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Diseases Resulting from Fungi and Yeasts

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					      Chapter 15
Diseases Resulting from
   Fungi and Yeasts
  Andrews’ Diseases of the Skin
       Adam Wray, D.O.
       February 8, 2005
             Superficial mycoses
► AKA dermatophytes
► Three genera: Microsporum, Trichophyton,
  Epidermophyton
► Division into seven types (1)tinea capitis,
  (2)tinea barbae, (3)tinea faciei, (4)tinea
  corporis, (5) tinea manus, (6) tinea pedis, (7)
  tinea cruris, (8)onychomycosis
                Host factors

► Immunosuppressed pts
► AIDS
► Genetic susceptibility may be related to types of
  keratin or degree/mix of cutaneous lipids produced
► Surface antigens-ABO system-one study of 108
  culture proven dermatophytosis pts noted type A
  blood prone to chronic disease
► Human steroid hormones can inhibit growth of
  dermatophytes (androgens like androstenedione)
► One group believes this high susceptibility of
    Trichophyton rubrum & Epidermophyton floccosum to
    intrafollicular androstenedione is a reason why these
    species do not cause tinea capitis
          Imidazoles
► Clotrimazole, miconazole, sulconazole,
  oxiconazole, and ketoconazole
► Mostly used for topical tx
► Inhibit cytochrome P450 14-alpha-
  demethylase (an essential enzyme in
  ergosterol synthesis)
► Ketaconazole has wide spectrum against
  dermatophytes, yeasts, and some systemic
  mycoses
► Ketaconazole has the potential for serious
  drug interactions and a higher incidence of
  hepatotoxicity during long-term daily therapy
               Allylamines
► Naftifine, terbinafine, butenafine
► Inhibites squalene epoxydation
► Terbinafine has less activity against Candida
  species in vitro studies then triazoles, but is
  effective clinically
► Terbinafine is ineffective in the oral tx of tinea
  versicolor but is effective topically
► Few drug interactions have been reported
► Bioavailability is unchanged in food
► Hepatotoxicity, leukopenia, severe exanthems,
  and taste disturbances uncommon, but should
  be monitored for clinically and by lab testing if
  continuous dosing over 6 weeks
                  Polyene
► Nystatin
                   to ergosterol-an
► Irreversibly binding
 essential component of fungal cell
 membranes
             Triazoles
► Itraconazole, Fluconazole
► Affect P450 system
► Numerous drug interactions occur
► Need to know pt’s current meds
► Broadest spectrum to dermatophytes and
  Candida species, and Malassezia furfur
► Itraconazole is fungistatic-food increases its
  absorption , antacids and gastric acid secretion
  suppressors produce erratic or lowered
  absorption
► Pulse dosing limits concern over lab
  abnormalities
► Fluconazoles’s absorption is unaffected by
  food
           Tinea Capitis

► Occurs  chiefly in schoolchildren
► Boys more frequently than girls; except
  epidemics caused by Trichophyton tonsurans
  where there is equal frequency
► Divided into inflammatory and
  noninflammatory
► Tinea capitis can be caused by all
  pathogenic dermatophytes except
  Epidermophyton floccosum and T.
  concentricum
► In   U.S. most caused by T. tonsurans
            Noninflammatory

► M.   audouinii infections present as the classic
  form
► Characterized by multiple scaly lesions (“gray-
  patch”), stubs of broken hair
► Over past 30 yrs, M. audouinii infections are
  being replaced by increasing numbers of
  “black-dot” ringworm, caused primarily by T.
  tonsurans and occasionally by T. violaceum
► In the U.S. T. tonsurans is the most common
  cause
  Noninflammatory Tinea Capitis
► “Blackdot” ringworm, caused by T.
 tonsurans & occasionally T. violaceum
 presents as multiple areas of alopecia
 studded with black dots representing
 infected hairs broken off at or below the
 surface of the scalp
► Black   dot tinea
► Black   dot ringworm caused by
 Trichophyton tonsurans
            Inflammatory
► Usuallycaused by M. canis
► Can be caused by T. mentagrophytes, T.
  tonsurans, M. gypsem, or T. verrucosum
► M. canis begin as scaly, erythematous,
  papular eruptions with loose and broken-off
  hairs, followed by varying degrees of
  inflammation
► A localized spot accompanied by pronounced
  swelling, with developing bogginess and
  induration exuding pus develops-kerion celsii
   A delayed type hypersensitivity reaction to fungal
    elements
► With extensive lesions fever, pain, and
  regional lymphadenopathy may occur
                     Kerion
► Kerion  may be followed by scarring and
  permanent alopecia in areas of inflammation and
  suppuration
► Systemic steroids for short periods will greatly
  diminish the inflammatory response and reduce
  the risk of scarring
► Kerion:   inflammatory rxn of tinea capitis caused by
  Microsporum canis or Trichophyton
  mentagrophytes
► Kerion   caused
 by
 Microsporum
 canis
► Kerion:   heavily crusted, hairless plaque
► Permanent scarring   alopecia post kerion
► Kerion:
 red,
 oozing,
 hairless
 plaque
              Favus
► Rare  in the U.S.
► Most severe form of dermatophyte hair
  infection
► Most frequently cause by T. schoenleinii
► Hyphae and air spaces seen within hair shaft
► Bluish white fluorescence under Wood’s light
► Thick, yellow crusts composed of hyphae and
  skin debris (‘scutula’)
► Scarring alopecia may develop
► Favus   of scalp showing scutulae
Favus with scarring alopecia and
            scutula
► Scarring after   favus infection
                Etiology

► Tinea capitis can be cause by any one of
  several species: T. tonsurans, M. audouinii
  (human to human), and M. canis (animals to
  human)
► Endothrix types-T. tonsurans (black-dot
  ringworm) and T. violaceum
► Ectothrix found on scalp are T. verrucosum &
  T. mentagrophytes
                       Diagnosis

►   Wood’s light
     Ultraviolet of 365 nm wavelength is obtained by passing a
      beam through a Wood’s filter composed of nickel oxide-
      containing glass
     A simple form is the 125-volt purple bulb
►   Fluorescent-positive infections are caused by :T.
    schoenleinii, M. canis, M. audouinii, M. distortum, M.
    ferrugineum
►   Hairs infected with T. tonsurans & T. violaceum and
  others of endothrix do not fluoresce
► The fluorescent substance is pteridine
                 Diagnosis

► KOH
   Two or three loose hairs are removed
   Hairs are placed on slide with a drop of 10-20%
    solution of KOH
   A cover slip is applied, specimen is warmed until
    hairs are macerated
   Examine under low, then high power
► Scales or hairs cleared with it can still be
  cultured
                       DTM
► DTM  contains cycloheximide to reduce growth of
  contaminants and a colored pH indicator to denote
  the alkali-producing dermatophytes
► Some clinically relevant nondermatophyte fungi
  are cycloheximide sensitive (Candida tropicalis,
  Scopulariopsis brevicaulis, Cryptococcus
  neoformans, Pseudoallescheria boydii,
  Trichosporon beigelii and Aspergillus spp.)
         type in Microsporum canis-
► Ectothrix
 note small spores around hair shaft
► Endothrix   spores in hair with Trichophyton
  tonsurans
► Endothrixin T. scoenleinii showing
 characteristic bubbles of air
► Endothrix infection, (low-power KOH
  mount): arthroconidia noted within hair
  shaft
► Endothrix infection (high-power KOH
  mount) showing total hair shaft involvement
              T. tonsurans
► This microoraganism grows slowly in culture
  to produce a granular or powdery yellow to
  red, brown, or buff colony
► Crater formation with radial grooves may be
  produced
► Microconidia may be seen regularly
► Dx confirmed by the fact that cultures grow
  poorly or not at all without thiamine
            T. mentagrophytes
► Culture  growth is velvety or granular or fluffy, flat
  or furrowed, light buff, white, or sometimes pink
► Back of the culture can vary from buff to dark red
► Round microconidia borne laterally and in clusters
  confirm dx within 2 weeks
► Spirals are sometimes present
► Macroconidia may be seen
             T. verrucosum
► Growth   is slow and cannot be observed well
  for at least 3 weeks
► Colony is compact, glassy, velvety, , heaped
  or furrowed, and usually white, but may be
  yellow or gray
► Chlamydospores are present in early
  cultures
► Microconidia may be seen
               M. audouinii
► Gross  appearance shows a slowly growing,
  matted, velvety, light brown colony
► Back of which is reddish brown to orange
► Under microscope a few large multiseptate
  macroconidia (macroaleuriospores) are seen
► Microconidia (microaleuriospores) in a lateral
  position on hyphae are clavate
► Racquet mycelium, chlamydospores, and pectinate
  hyphae are seen sometimes
                   M. canis
► Culture  shows profuse, fuzzy, cottony, aerial
  mycelia tending to become powdery in the center
► Color is buff to light brown
► Back of colony is lemon to orange-yellow
► Numerous spindle-shaped multiseptate
  microconidia and thick-walled macroconidia are
  present
► Clavate microconidia are found along with
  chlamydospores and pectinate bodies
           Treatment
► Griseofulvin  of ultramicronized form, 10
  mg/kg/day, is the daily dose recommended
  for children
► Grifulvin V is the only oral suspension
  available for children unable to swallow
  tablets-dose is 20 mg/kg/day
► Tx should continue for 2-4 months, or for at
  least 2 weeks after a negative microscopic
  and culture examinations are obtained
► Griseofulvin does not primarily affect the
  delayed type hypersensitivity reaction
  responsible for the inflammation in kerion
► For this, systemic steroids, to minimize
  scarring, can be given simultaneously
          Tinea Barbae

► AKA  Tinea sycosis, barber’s itch
► Uncommon
► Occurs chiefly among those in agriculture
► Involvement is mostly one-sided on neck or
  face
► Two clinical types are: deep, nodular,
  suppurative lesions; and superficial , crusted,
  partially bald patches with folliculitis
                Tinea Barbae
► Superficial crusted   type
   mild pustular folliculitis with broken-off hairs (T.
    violaceum) or without broken-off hairs (T.
    rubrum)
   Affected hairs are loose, dry, and brittle
   When extracted bulb appears intact
                Tinea Barbae

► Deep   type
   Caused mostly by T. mentagrophytes or T.
    verrucosum
   Swellings are usually confluent and form diffuse
    boggy infiltrates with abscesses
   Pus may be expressed
   Lesions are limited to one part of face or neck in
    men
       Diagnosis-Tinea Barbae
► Clinical
► Confirmed by  microscopic findings and by
  standard culture techniques
► Rarely, Epidermophyton floccosum may
  cause widespread verrucous lesions known
  as verrucous epidermophytosis
► Verrucous   epidermophytosis from
 Epidermphyton floccosum
► Complete  resolution after 48 days of
 griseofulvin
        Differential Diagnosis
► Sycosis vulgaris-lesions are pustules and
  papules, pierced in the center by a hair,
  which is loose and easily extracted after
  suppuration has occurred
► Contact dermatitis
► Herpes infections
► Tinea   barbae-Trichophyton
 mentagorphytes
Treatment-Tinea Barbae
► Oral antifungals are required
► Topical agents as adjunctive therapy
► Micronized or ultramicronized
  griseofulvin orally: dosage of 500–1000
  mg or 350-700 mg respectively
► Tx usually for 4-6 weeks
 Treatment-Tinea Barbae
► Other  orals that have been effective:
  ketoconazole, fluconazole, itraconazole, and
  terbinafine
► Topical antifungals should be applied from
  the beginning of tx
► Affected parts should be bathed thoroughly in
  soap and water
► Healthy areas that are not epilated may be
  shaved or clipped
► When kerion is present a short course of
  systemic steriod therapy may help reduce
  inflammation and risk of scarring
                  Tinea Faciei

► Fungal   infection of the face (apart from the
  beard)
► Must have high index of suspicion
    Mistaken for seb derm, contact derm, lupus, or
     photosensitive dermatosis
► Erythematous,  slightly scaling, indistinct
  borders are usually seen
► Usually caused by T. rubrum. T.
  mentagrophytes, or M. canis
► Tinea   faciei
  (Microsporum canis)
  in a child
► Tinea
 corporis
 involving
 the face
 (tinea
 faciei)
                   Treatment
► Topical  antifungals
► Oral griseofulvin administered for 2-4 weeks, as
  well as fluconazole, itraconazole, or terbinafine are
  all effective particularly in combination with topical
  therapy
  Tinea Corporis(Tinea Circinata)
► All superficial dermatophyte infections of the skin
  except the scalp, beard, face, hands, feet, and
  groin
► Sites of predilection are neck, upper and lower
  extremities, and trunk
► Characterized by one or more circular, sharply
  circumcsribed, slightly erythematous, dry, scaly,
  usually hypopigmented patches
► Tinea  corporis in a
  child, caused by
  Microsporum canis
              Tinea Corporis


► In some cases concentric circles form rings in
  one another, making intricate patterns (tinea
  imbricata)
► Widespread tinea corporis may be the
  presenting sign of AIDS
► Tinea   corporis
  (Trichophyton rubrum)
► Note sharp margins
  and central clearing
► Tineacorporis: large gyrate plaque with
 advancing border, perhaps worsened by
 diapering
             Histopathology
► Better  ways to make diagnosis
► But if compact orthokeratosis is found in a
  section, a search for fungal hyphae should
  be performed
► This is diagnostic
       Etiology-Tinea Corporis
► Microsporum canis,   T. rubrum, T.
  mentagrophytes-most common
► T. rubrum is is the most common
  dermatophyte in the U.S. and worldwide
► T. tonsurans has experienced a dramatic
  rise as a cause of tinea corporis as it has for
  tinea capitis
► In children, M. canis is the cause of the
  “moist” type of tinea circinata
                 Epidemiology
► Tinea  corporis is frequently seen in children-
  particularly those exposed to animals with
  ringworm(M. canis), especially CATS, dogs and
  less commonly, horses and cattle
► In adults excessive perspiration is the most
  common factor
   Personal hx or close contact with tinea capitis or tinea
    pedis is another important factor
► Incidence   is especially high in hot, humid areas of
  the world
Treatment-Tinea Corporis
► When   tinea corporis is caused by T.
  tonsurans, M. canis, T. mentagrophytes, or T.
  rubrum , griseofulvin, terbinafine,
  itraconazole, and fluconazole are all effective
► The ultra-micronized form may be used at a
  dose of 350-750 mg once/day for 4-6 weeks
► This dose may be increased to twice daily if
  needed
► Terbinafine, itraconazole, and fluconazole are
  effective
► Terbinafine at 250 mg/day for two weeks
► Itraconazole 200 mg B.I.D. for one week
► Fluconazole 150 mg once/week for 4 weeks
            Treatment(cont)

► When   only 1-2 patches occur, topical tx
  is effective
► Most are between 2-4 weeks with twice
  daily use
► Econazole, ketaconazole, oxiconazole,
  and terbinafine may be used once daily
► With terbinafine the course can be
  shortened to 1 week
               Treatment
► Creams    are more effective than lotions
► Sulconazole may be less irritating in folded
  areas
► Castellani paint (which is colorless if made
  without fuchin) is very effective
► Salicylic acid 3% -5%, or half-strength
  Whitfield’s ointment, both standbys 30 yrs
  ago, are little used today
► Addition of a low-potency steroid cream
  during the initial 3-5 days of therapy will
  decrease irritation rapidly without
  compromising the effectiveness of the
  antifungal
  Other Forms of Tinea Corporis
► Trichophytic  Granuloma or Perifollicular Granuloma
  or Majocchi’s Granuloma or Tinea Incognito
► A deep, pustular type of tinea circinata resembling
  a carbuncle or kerion observed on the glabrous
  skin
► A circumscribed, annular, raised, crusty, and
  boggy granuloma
► Follicles are distended with viscid purulent material
► Tichophyton
 mentagrophytes
 infection on lower leg
 of American soldier in
 Vietnam
► Majocchi’sgranuloma H&E pale blue-
 staining fungal hyphae within hair
 shaft
► Majocchi’sgranuloma: PAS reveals multiple
  organisms that have replaced a fragment of hair
  shaft embedded in a sea of neutrophils
Tinea Imbricata (Tokelau)
► Superficial fungal infection limited to
  southwest Polynesia, Melanesia, Southeast
  Asia, India, and Central America
► Characterized by concentric rings of scales
  forming extensive patches with polycyclic
  borders
► Small macular patch splits in center and
  forms large, flaky scales attached at the
  periphery
► Resultant ring spreads peripherally and
  another brownish macule appears in the
  center and undergoes the process again
           Tinea Imbricata
► When   fully developed the eruption is
  characterized by concentrically arranged
  rings or parallel undulating lines of scales
  overlapping each other like shingles on a
  roof (imbrex means shingle)
► Causative fungus is T. concentricum
► TOC is griseofulvin- in same form as for
  tinea corporis
► Other options are terbinafine, fluconazole,
  and itraconazole
► Several courses of therapy may be needed
► May need to remove pt from hot, humid
  environment
► Tinea   imbricata in New Guinea native
      imbricata: concentric rings of scale
► Tinea
 caused by T. concentricum
           Tinea Cruris
► AKA  jock itch
► Most common in men
► On upper and inner thighs
► Begins as a small erythematous and scaling
  or vesicular and crusted patch
► Spreads peripherally and partly clears in the
  center
► Penoscrotal fold or sides of scrotum are
  seldom involved; penis not involved
► Tinea   cruris in a man
► Tinea   cruris in a woman
         Etiology-Tinea Cruris
   mentagrophytes & E. floccosum & T.
► T.
 rubrum usual cause
► Frequently associated with tinea pedis b/c
  of contaminated clothing
► Heat and high humidity
► Tight jockey shorts!
                 Treatment

► Reduce   perspiration and enhance evaporation
  from crural area
► Keep as dry as possible by wearing loose
  underclothing
► Plain talcum powder or antifungal powders
► Specific topical and oral tx is same as that
  described under tinea corporis
► Tinea   in diapered area
           Tinea Pedis
► AKA  athlete’s foot
► Most common fungal disease(by far)
► Primary lesions often are macerated with
  occasional vesiculation, and fissures between
  the toes
► Extreme pruritus
► Tinea   pedis showing interdigital scalping
► T.   mentagrophytes
                   with vesiculation
► Interdigital scaling
  caused by T. mentagrophytes
► Dermatophytosis
 of the soles
► Trichophyton
 mantagrophytes
► Acute
 vesiculobullous
 eruption on sole
 caused by
 Trichophyton
 mentagrophytes
TP-Trichophyton rubrum
           ►   T. rubrum causes the
             majority of cases
           ► Produces a relatively
             noninflammatory type of
             dermatophytosis
             characterized by a dull
             erythema and pronounced
             scaling involving the entire
             sole and sides of feet
           ► Producing a moccasin or
             sandal appearance
► Tinea pedis and
  onychomycosis in
  father/son pair.
► Father shows classic
  moccasin distribution of
  tinea pedis and son
  shows distal subungual
  onychomycosis
                  Tinea manus
► Tinea infection of hands
  that is dry, scaly, and
  erythematous may occur
► Suggestive of infection
  with T. rubrum
► Other areas are frequently
  affected at the same time
► Trichophyton   rubrum infections
             Differential diagnosis
► Allergiccontact or irritant dermatitis-especially
  occupational
► Pompholyx
► Atopic dermatitis
► Psoriasis
► Lamellar dyshidrosis
► Eczematoid or dyshidrotic lesions of unknown
  cause on hands should prompt a search for clinical
  evidence of dermatophytosis of feet etc.
► Fungus   filaments under KOH mount
► Mosaic   fungus
                  Prophylaxis
► Hyperhidrosis   is a predisposing factor
► Dry toes after bathing
► Tolnaftate powder or Zeasorb medicated powders
  for feet
► Plain talc, cornstartch, or rice powder may be
  dusted into socks and shoes to keep feet dry
                 Treatment

► Topical  antifungals
► With significant maceration wet dressings or
  soaks with solutions such as aluminum
  acetate, one part to 20 parts of water
► Anti-inflammatory effects of corticosteroids
  are markedly beneficial
► Topical antibiotic ointments effective against
  gram-negative organisms (gentamicin), in tx
  of the moist type of interdigital lesions
► In ulcerative type of gram-neg toe web
  infections, systemic floxins are needed
                         Tx

► Keratolytic agents, such as salicylic acid, lactic
  acid lotions, and Carmol are therapeutic when
  fungus is protected by a thick layer of
  overlying skin (ie soles)
► Griseofulvin is only effective against
  dermatophytes
► When infection is caused by T.
  mentagrophytes griseofulvin does not
  decrease inflammatory rx
                   Tx-doses
► Griseovulvin  in ultramicronized particles taken
  orally in doses of 350-750 mg daily
► Dosage for children is 10 mg/kg/day
► Period of tx depends on response
► Repeated KOH scrapings and culture should be
  neg
► Recommended adult doses for newer agents:
  terbinafine, 250 mg/day for 2 weeks; itraconazole,
  200 mg twice daily for 1 week; fluconazole, 150
  mg once weekly for 4 weeks
 Onychomycosis(Tinea Unguium)
► Onychomycosis    encompasses both dermatophyte
  and nondermatophyte nail infections
► Represents up to 30% of diagnosed superficial
  fungal infections
► Etiologic agents are: Epidermophyton,
  Microsporum, and Trichophyton fungi
              Onychomycosis
► Four  classic types:
► 1.) distal subungual onychomycosis: primarily
  involves distal nail bed and hyponychium, with
  secondary involvement of underside of nail plate
  of fingernails and toenails
► Onychomycosis   caused by Trichophyton
 rubrum
Trichophyton mentagrophytes
              ► 2.) white superficial
                onychomycosis(leukonychia
                trichophytica):this is an
                invasion of the toenail plate
                on the surface of the nail
              ► It is produced by
                T.mentagrophytes, species
                of Cephalosporium and
                  Aspergillus, and Fusarium
                  oxysporum fungus
                Onychomycosis
► 3.)  Proximal subungual onychomycosis: involves
  the nail plate mainly from proximal nail fold
► It is produced by T. rubrum & T. megninii and
  may be an indication of HIV infection
► 4.) Candida onychomycosis involves all the nail
  plate; it is due to Candida albicans and is seen in
  pts with chronic mucocuataneous candidiasis
    Associated paronychia
    Adjacent cuticle is pink, swollen, and tender
    Fingernails > toenails
► Onychomycosis  caused by Candida
 albicans in mucocutaneous candidiasis
             Onychomycosis
► Onychomycosis caused
  by T. rubrum is usually a
  deep infection
► Disease usually starts at
  distal corner of nail and
  involves the junction of
  nail and its bed
► First a yellowish
  discoloration occurs,
  which may spread until
  entire nail is affected
► Beneath discoloration
  nail plate becomes loose
  from nail bed
► Gradually entire nail becomes brittle and separated
  from its bed due to piling up of keratin subungually
► Nail may break off, leaving an undermined remnant
  that is black and yellow from dead nail and fungi that
  are present
► A: Distal subungal, onchomycosis occurring
  simulataneously with superficial white
  onchmycosis
► B: Superficial white onchomycosis
             Differential

► Allergic contact dermatitis
► Psoriasis
► Lichen planus
► 20 nail dystrophy
► Darier’s disease
► Reiter’s disease
► Norwegian scabies
► Nondermatophyte onychomycosis
                Treatment

► PO  terbinafine, fluconazole, and itraconazole
► Griseofulvin continued until nails are clinically
  normal
► Low success rates 15-30% for toenails and
  50-70% for fingernails
► Griseofulvin does not tx nail disease caused
  by candida
► 3% thymol in EtOH
                   Candidiasis
► Candida   proliferates in both budding and mycelial
  forms in outer layers of the stratum corneum
  where horny cells are desquamating
► It does not attack hair, rarely involves nail, and is
  incapable of breaking up the stratum corneum
► It is largely an opportunisitic organism
► Moisture promotes its growth
    Lip corners
    Body folds
               Diagnosis

► Demonstration   of the pathogenic yeast C.
  albicans establishes the diagnosis
► Under microscope KOH prep may show
  spores and pseudomycelium
► Culture on Sabouraud’s glucose agar shows a
  growth of creamy, grayish, moist colonies in
  about 4 days
► In time colonies form small, root-like
  penetrations into agar
► Mycelium   and spores of Candida
 albicans
               Candidiasis




► KOHmount from infant with thrush showing
 pseudohyphae and yeast forms
     Topical Anticandidal Agents
► These  include, but are not limited to: clotrimazole
  (Lotrimin, Mycelex), econazole (Spectazole),
  ketaconazole (Nizoral), miconazole (MonistatDerm
  Lotion, Micatin), oxiconazole (Oxistat), sulconazole
  (Exelderm), naftifine (Naftin), terconazole (vaginal
  candidiasis only), cicloprox olamine (Loprox),
  butenafine (Mentax), nystatin, and topical
  amphotericin B lotion
► Terbinafine has been reported to be less active
  against Candida species by some authors
   Oral Candidiasis (Thrush)

► Newborn   infection may be acquired from
  contact with vaginal tract of mother
► Grayish white membranous plaques are found
  on surface
► Base of plaques are moist, reddish, and
  macerated
► Diaper areas is especially susceptible to this
► Most of intertriginous areas and even
  exposed skin may be involved
    Oral candidiasis (Thrush)
► Frequently   infection extends onto angles of
  the mouth to form perleche(seen in elderly,
  debilitated, and malnourished pts, and
  diabetics)
► It is often the first manifestation of AIDS
► Is present in nearly 100% of all untreated pts
  with full-blown AIDS
► “Thrush” in an adult with no known
  predisposing factors warrants a search for
  other evidence of infection with HIV, such as
  lymphadenopathy, leukopenia, or HIV
  antibodies in serum
► Thrush   with extension to vermilion border
                       Tx
► Babies   with thrush may be allowed to suck on
  a clotrimazole suppository inserted into the
  slit tip of a pacifier four times a day for 2-3
  days
► An adult can let tablets of clotrimazole or
  Mycelex troches dissolve in the mouth
► Fluconazole, 100-200 mg/day for 5-10 days
  with doubling the dose if it fails, or
  itraconazole, 200 mg daily for 5-10 days with
  doubling the dose if it fails-both are available
  in liquid forms
                   Perleche

► AKA  angular cheilitis
► Maceration with transverse fissuring of oral
  commissures
► Soft, pinhead-sized papules may appear
► Involvement is bilateral-usually
Perleche
              Perleche
► Analogous    to intertrigo elsewhere
► Similar changes may be seen in riboflavin
  deficiency, and iron deficiency anemia
► Identical fissuring occurs in persons with
  malocclusion caused by ill-fitting dentures
  and in the aged whom atrophy of alveolar
  ridges has occurred
► Seen in children who drool, lick their lips, or
  suck their thumb
                       Tx
► If due to C. albicans anticandidal creams and
  lotions
► Glycemic control in diabetes
► Antibiotic topical meds are used when a
  bacterial; infection is present
► If due to vertical shortening of lower third of
  the face, dental or oral surgical intervention
  may help
► Injection of collagen into depressed sulcus at
  the oral commissure may be helpful
► Vytone!!
   Candidal Vulvovaginitis
► Pruritus,  irritation, and extreme burning
► Labia may be erythemtous, moist, and
  macerated and cervix hyperemic, swollen, and
  eroded, showing small vesicles on its surface
► Vaginal discharge is not usually profuse but is
  frequently thick and tenacious
► May develop during pregnancy, in diabetes, or
  secondary to therapy with a broad- spectrum
  antibiotic
► Recurrent vulvovaginal candidiasis has been
  associated with long-term tamoxifen tx
  Candidal Vulvovaginitis
► Candidal  balanitis may be present in an
  uncircumcised sexual partner
► If not recognized, repeated reinfection of a
  partner may occur
► Diagnosis is by clinical symptoms and findings
  as well as demonstration of fungus via KOH
  microscopic exam & culture
► Tx is frustrating & disappointing due to
  recurrences
► Oral fluconazole 150 mg times 1 dose;
  Fluconazole, 100mg/day for 5-7 days,
  itraconazole, 200 mg/day for 2-3 days..other
  options
                    Tx
► Topicaloptions include miconizole (Monistat
 cream), nystatin vaginal suppositories or
 tablets (Mycostatin), or clotrimazole (Gyne-
 Lotrimin or Mycelex G) vaginal tablets
 inserted once daily for 7 days
         Candidal Intertrigo

► Pinkish intertriginous moist patches are
  surrounded by a thin, overhanging fringe of
  somewhat macerated epidermis (“collarette”
  scale)
► May resemble tinea cruris, but usually there is
  less scaliness and a greater tendency to
  fissuring
► Topical anticandidal preparations are usually
  effective
► Recurrence is common
          Pseudo Diaper Rash
► In  infants, C. albicans infection may start in
  perianal region and spread over entire area
► Dermatits is enhanced by maceration
  produced by wet diapers
► Diaper friction may contribute to skin
  irritation and compromised function of
  stratum corneum
► Suspected by finding involvement of folds and
  occurrence of many small erythematous
  desquamating “satellite” or “daughter” lesions
  scattered around edges
  Congenital Cutaneous
      Candidiasis
► Infection  of an infant during passage through
  birth canal
► Eruption usually noted within first few hrs of
  delivery
► Erythematous macules progress to thin-
  walled pustules, which rupture, dry, and
  desquamate within a week
► Lesions are usually widespread, involving
  trunk, neck, and head, at times palms and
  soles, including nail folds
► Oral cavity and diaper area are spared
          Congenital Cutaneous
              Candidiasis
► Differentialdx: listeriosis, syphilis, staphylococcal
  and herpes infections, ETN, transient neonatal
  pustular melanosis, miliaria rubra , drug eruption,
  congenital icthyosiform erythroderma (neonatal
  pustular disorders)
► If suspected early amniotic fluid, placenta, and
  cord should be examined for evidence of infection
► Infants with disease limited to skin have favorable
  outcomes
                     CCC
► Disseminated   infection is suggested by (1) bw
  <1500g (2) evidence of respiratory distress or
  labs indicating neonatal sepsis (3) tx with
  broad-spectrum antibiotics (4) extensive
  instrumentation during delivery or invasive
  procedures in neonatal period (5) positive
  systemic cultures, or (6) evidence of an altered
  immune response
► Infants with congenital cutaneous candidiasis
  with any of these 6 criteria would be
  considered for systemic antifungal therapy
     Perianal Candidiasis
► Frequently   entire GI tract is involved
► Can be precipitated by oral antibiotic therapy
► Perianal dermatitis with erythema, oozing, and
  maceration is present
► Psychogenic etiology is more common than is
  candidiasis
► Differential dx: psoriasis, seborrheic
  dermatitis, streptococcal and staphylococcal
  infections, contact dermatits, and
  extramammary Paget’s disease
► Fungicides, meticulous cleansing of perianal
  region after bowel movements, topical
  corticosteroids and antipruritics (Atarax)
      Candidal Paronychia
► Cushionlike thickening of paronychial tissue,
  slow erosion of lateral borders of nails, gradual
  thickening and brownish discoloration of nail
  plates, and development of pronounced
  transverse ridges
► Frequently only one nail
► A secondary mixed bacterial infection can occur
  with those who frequently have hands in water
  or who handle moist objects; cooks,
  dishwashers, bartenders, nurses, canners, etc
                   CP
► Manicuring  nails sometimes is responsible for
  mechanical or chemical injuries leading to
  infection
► Ingrown toenails with chronic paronychia
► Seen in pts with diabetes
► Avoid chronic moisture exposure; get diabetes
  under control
► Oral fluconazole once weekly or pulse dose
  itraconazole should be effective
► Topical therapy should continue for 2-3 months
  to prevent recurrence
      Erosia Interdigitalis
        Blastomycetica
► Oval-shaped   area of macerated white skin on
  web between and extending onto sides of
  fingers
► With progression macerated skin peels off,
  leaving painful, raw,denuded area surrounded
  by a collar of overhanging white epidermis
► Nearly always affects third web
► Moisture beneath rings macerates skin and
  predisposes to infection
► Also seen in diabetics, those who do
  housework, launderers, and others exposed to
  macerating effects of water and strong alkalis
     Chronic Mucocutaneous
           Candidiasis
►A   heterogeneous group of pts whose infection
  with Candida is chronic but superficial
► Onset before age 6
► Onset in adult life may herald the occurrence of
  thymoma
► When inherited an endocrinopathy is often
  found
► Most cases have well-defined limited defects of
  cell-immunity
► Oral lesions are diffuse and perleche and lip
  fissures are common
    Systemic Candidiasis
► High   risk pts: pts with malignancies, AIDS,
  transplant pts requiring immunosuppressive
  drugs, pts on oral cortisone, pts who have had
  multiple surgical operations especially cardiac,
  pts with indwelling catheters, and heroin
  addicts
► Initial sign is varied: FUO, pulmonary
  infiltrates, GI bleeding, endocarditis, renal
  failure, meningitis, osteomyelitis,
  endophthalmitis, peritonitis, or a disseminated
  maculopapular eruption
                    SC

► Cutaneous   findings are erythematous
  macules that become papular, pustular, and
  hemorrhagic, and may progress to necrotic,
  ulcerating lesions resembling ecthyma
  gangrenosum
► Deep abscesses may occur
► Trunk and extremities are usual sites of
  involvement
► Proximal muscle tenderness is a common
  finding
                         SC
► Ifcandida is cultured within the first week of life
  there is a high rate of systemic disease
► There is a 50% chance of systemic disease if 1 or
  more cultures is positive
► Mortality has declined from 80% in the 1970’s to
  40% in the 1990’s because of early empiric
  antifungals and better prophylaxis
THE END
 Thank You

				
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