tinea and dermatitis

Jeremy McCourt, Pharm.D. 04/21/2011

Distinguish the clinical presentation and predisposing factors for tinea and dermatitis.

Determine when should be treated with self-care management or referred due to exclusions.

Determine the type of skin disorder and develop an appropriate treatment plan, when given specific patient information.

Penetration of keratinous structures of body by dermatophytes

3 most common dermatophytes Trichophyton Microsporum Epidermophyton

Can be contracted through contact with infected people, animals, soil, or fomites

Inoculation of dermatophyte into skin Incubation

Grows in stratum corneum Minimal signs of infection

Enlargement Size and duration of infection depend on fungal growth rate

and epithelial turnover rate Dermatophytes produce keratinases that cause allergic

reactions in living epidermis Refractory period

Time preceding cell-mediated immune response Inflammation and pruritis are at their peak

Involution Symptoms diminish, infection may clear spontaneously

Impairment of immune system Poor nutrition and

hygiene Impaired circulation Immune system

depression Diabetes mellitus

and other debilitating diseases

Promotion of fungal growth Skin occlusion Warm, humid

climates Skin trauma

Presenting symptoms vary depending on site of infection

Ranges from mild itching and scaling to severe, exudative inflammatory process Denudation Fissuring Crusting Discoloration of affected skin

Secondary infections Permanent hair loss Scarring

“Athlete’s foot” Malodor, pruritis, and/or stinging

sensation on the feet Typically involves lateral toe webs,

usually between 3rd and 4th, or 4th and 5th toes

Infection may spread to sole or instep of the foot, but rarely to the dorsum

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- Fissuring, scaling, or maceration of interdigital spaces

“Onychomycosis” Nails lose normal, shiny luster and

become opaque Can NOT be treated with topical non-

prescription drugs

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- Thick, rough, yellow, opaque, and friable

- Nail may separate from nail bed, and may be lost altogether

“Ringworm of the body” Most common in prepubescent individuals Frequently transmitted among children in

day care centers Increased risk in hot, humid environments Stress and overweight also increase risk

of infection Can occur on any part of the body, on

smooth bare skin May have diverse presentation

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- Begin as small, circular, scaly, erythematous areas- Spread peripherally - Borders may contain vesicles or pustules

“Jock itch” More common in males Affects medial and upper parts of

thighs and pubic area Penis and scrotum are usually not affected

Generally occurs bilaterally with significant pruritis

Well-demarcated margins

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- Slightly elevated, more erythematous than central area; fine scaling and small vesicles may be seen - Acute lesions are more bright red, where

chronic cases have more of a hyperpigmented appearance

“Ringworm of the scalp” More common in children Occurs more frequently in black females

than black males and white children Can be spread by direct contact, but

more commonly through contact with infected fomites

Can be spread through contact with infected cats or dogs

Non-inflammatory Small papules surrounding hair shafts, spread

centrifugally Little inflammation, hair in lesions is dull gray in

color, usually breaks off at level of scalp Inflammatory

Inflammation with weeping, crusty patches on scalp Black-Dot

Infected areas of scalp from breakage of hair shafts Favus

Patchy area of hair loss with yellowish crusts and scales

Can lead to scalp atrophy, scarring, and permanent hair loss

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“Barber’s itch”, “Ringworm of the beard” Affects the hairs and follicles of beards and

mustaches Removal of the beard or mustache is

recommended

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QUickly and accurately assess the patient SCHOLAR – Symptoms, characteristics,

history, onset, location, aggravating factors, remitting factors)

Establish that the patient is appropriate for self-care

Suggest appropriate self-care strategies Talk with the patient

Causative factor unclear Unsuccessful initial treatment, or worsening of

condition Nails or scalp involved Face, mucous membranes, or genitalia involved Signs of possible secondary bacterial infection

(oozing purulent material) Excessive and continuous exudation Condition extensive, seriously inflamed, or

debilitating Diabetes, systemic infection, asthma, immune

deficiency Fever, malaise, or both

Provide symptomatic relief Eradicate existing infection Prevent future infections

Avoid occlusive clothing and fabrics Keep area clean and dry Limit exposure to affected area Do not share or re-use clothing, towels,

or other personal items

Topical antifungals can be used to treat most infections and are considered first line Available in creams, ointments, powders,

and solutions Systemic (oral) therapy may be needed

for infections involving nails or hair

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Medication Frequency

Clotrimazole (Lotrimin) Twice Daily

Ketoconazole (Nizoral) Daily

Miconazole (Zeasorb-AF) Twice Daily

Terbinafine (Lamisil AT) Twice Daily

Tolnaftate (Tinactin) Twice Daily

Selenium Sulfide (Selsun blue)

Daily for 2 weeks

Medication Dose Duration

Fluconazole (Diflucan)

150mg weekly 1-4 weeks

Ketoconazole (Nizoral)

200mg daily 4 weeks

Itraconazole (Sporanox)

200-400mg daily 1 week

Terbinafine (Lamisil)

250mg daily 2 weeks

Medication Dose Duration

Terbinafine (Lamisil)

250mg daily 4-8 weeks

Ketoconazole (Nizoral)

200mg daily 4 weeks


100-200mg daily 4-6 weeks

Griseofulvin (Grifulvin V)

500mg daily 4-6 weeks

Medication Fingernail Dose Toenail Dose

Terbinafine (Lamisil) 250mg daily x 6 weeks

250mg daily x 12 weeks


200mg BID x 1 week per month for two months


200mg BID x 1 week per month for three months


Fluconazole (Diflucan)

50mg daily x 6 months

300mg weekly x 6 months

50mg daily x 12 months

300mg weekly x 12 months

Common: GI, dermatologic, headache Less common: taste disturbance, fatigue,

inability to concentrate, abnormal liver enzymes

Terbinafine Avoid in patients with chronic or active liver

disease May cause Stevens-Johnson’s Syndrome

Itraconazole Avoid in patients with active liver disease Avoid in patients with ventricular dysfunction (CHF)

Terbinafine Inhibits CYP 2D6 Medications: tricyclic antidepressants,

psychotropic drugs, cimetidine, rifampin, cyclosporine, caffeine, theophylline, terfenadine

“Azoles” Inhibit CYP 3A4 Medications: benzodiazepines, warfarin,

simvastatin

Proper application technique for topical agents to prevent over- or under-medication

Patient should know the expected duration of therapy

Apply medication regularly throughout the complete course of treatment

Methods to prevent recurrent infections

• A.B. is a 21 y/o WM college student who complains of burning, itching sensation between the toes of his left foot. His symptoms are worse each day, and are worse at bedtime. The area between his toes is very red and becomes worse after showering. He describes his toenails as normal in appearance; no discoloration or brittleness. He has no concurrent medical conditions or medications. A.B. showers daily in his residence hall and at the gym after workouts. He also reports that his feet sweat a lot.

What type of infection is A.B. likely suffering?

What are the exclusions for self-treatment for this patient?

What should you do to correct A.B.’s current problem?

What counseling would you provide to A.B.?

Inflammation of the skin Creates a vicious cycle of itching and

scratching Condition is chronic and relapsing No absolute known cause

Believed to be caused by genetic, environmental, and immunologic mechanisms

Intense itching Erythematous inflamed lesions Papules and vesicles present Lesions associated with scratching,

which leads to excoriations and exudates Most commonly extensor surfaces of

extremities, trunk, face, scalp, and neck

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Pruritus with three or more of the following: History of flexural dermatitis of the face in

children < 10 years of age Self and/or family history of asthma or allergic

rhinitis History of generalized xerosis within the past

year Visible flexural eczema History of rash at younger than 2 years of age

Allergen triggers Food allergens

Especially in younger patients with severe condition

Aeroallergens Various other allergens (pet dander, dust

mites, grass, pollen)

Increased susceptibility to microbial skin infections (Staph. aureus)

Increased risk of herpes simplex infection

Eyelid dermatitis (blepharitis), nipple dermatitis, cheilitis of the lips

Blepharitis may result in visual impairment due to corneal scarring

Identify and eliminate potential allergens Reduce frequency of bathing to every other day Use tepid water in baths Avoid irritating soaps, washcloths, or scrubs Air dry skin and gently pat dry Apply emollient within 3 minutes of drying Keep fingernails short and clean to prevent

scratching Consider wearing cotton gloves at night Use cotton sheets and pajamas Avoid harsh laundry detergents Moisturize at lease twice a day

Topical Steroids Various strengths and formulations High potency steroids should be used for short

periods of time (< 3 weeks) Do NOT use on the face, mucous membranes,

eyelids, or skin-fold areas Moderate potency agents can be used for more

chronic dermatitis of the trunk or extremities Low potency agents are typically used for

children

Adapted from LexiComp,Inc.

Antipruritics Local anesthetics

Pramoxine, lidocaine, benzocaine Antihistimines

May be due to sedative effects or antihistamine activity

Topical agents (diphenhydramine) should not be used OTC for more than 7 consecutive days.

Topical Immunomodulators Long-term option Can be used on all body locations for

prolonged periods w/out skin atrophy Reduces the inflammatory process of

dermatitis through inhibition of calcineurin Agents:

Tacrolimus 0.03% and 0.1% ointment Used for moderate to severe dermatitis 0.03% approved for children > 2 years old

Pimecrolimus 1% cream

Coal Tar Preparations Contain both antipruritic and

antiinflammatory properties Used in combination with corticosteroids to

reduce the strength of steroid needed Should not be used on oozing lesions due

to stinging and irritation Limiting factors include strong odor and

staining

Phototherapy Potent topical steroids Cyclosporine Methotrexate Oral steroids Azathioprine Psychotherapeutic

• F.M. is a 47 y/o WM with persistent itching in the flexural areas of the knees and elbows. The affected areas appear erythematous, excoriated, and lichenified, with fine scaling. His symptoms seem to worsen during the winter and summer months. Sweating seems to make the condition worse. Washing with soap and water regularly after workouts and use of Jergens Lotion as not helped to date. Current medications include Claritin 10mg daily for relief of allergic rhinitis. He reports allergies to house dust, cats, and grass pollen. He states that he experienced drowsiness when using Benadryl in the past. He is reported to have had atopic dermatitis rashes as a child.

What condition is F.M. most likely suffering?

What exclusions to self-treatment does he have?

What can you do to provide acute relief of F.M.’s symptoms?

What additional information would you provide F.M. to prevent recurrence of symptoms?

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T.F. brings her 9 year old son into the pharmacy. She reports that he has had an itchy rash on his forehead for the past 4 or 5 days.

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A.G. is a 32 y.o. male who presents to your pharmacy and shows you a rash that has been “itching him like crazy”. The rash developed after showering at a local pool. He has not tried anything to treat the rash yet.

F.E. is an elderly gentleman who reports to the pharmacy complaining that his left foot has been stinging and itching between and around his toes. He also states that the skin and toenails of this foot “look different than they used to.” He shows you his foot in your private counseling area. library.med.utah.edu

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M.J. is a 24 y.o. male who reports to your pharmacy complaining of a rash on his chin and lip. He states that he is “not sure what he should use to put on the rash.”

A loyal customer of yours brings her 13 month old into the pharmacy. She is concerned about a rash that has developed on his chest and face.

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Brown T, Chin T. Superficial Fungal Infections (Ch. 124). In: DiPiro JT, Talbert RL, Yee GC, et al. Pharmacotherapy: A Pathophysiologic Approach, 7th Ed. New York; McGraw Hill; 2008. Accessed 04/01/11 via www.accesspharmacy.com

Cheigh N. Atopic Dermatitis (Ch. 102). In: DiPiro JT, Talbert RL, Yee GC, et al. Pharmacotherapy: A Pathophysiologic Approach, 7th Ed. New York; McGraw Hill; 2008. Accessed 04/01/11 via www.accesspharmacy.com

Corticosteroids. Lexi-Comp (Lexi-Drugs) [Internet database]. Lexi-Comp, Inc; April 6, 2011.

Newton G, Popovich N. Fungal Skin Infections (Ch. 43). In: Bernardi R, Kroon L, McDermott J. et al. Handbook of Nonprescription Drugs, 15th Ed. Washington DC; American Pharmacists Association; 2006: 889-905.

Scott S, Martin R. Atopic Dermatitis and Dry Skin (Ch. 33). In: Bernardi R, Kroon L, McDermott J. et al. Handbook of Nonprescription Drugs, 15th Ed. Washington DC; American Pharmacists Association; 2006: 711-728.

tinea and dermatitis

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