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					Fungal Infection

    Dr. Shirsat
   Fungal Infection Objective
 Understand different types of fungal
 Understand reasons for their
 Identify skin signs.
 Initiate treatment.
         Fungal infections
         Causative agents
 Plant like organisms who survive in
  Keratinaceous tissue.
 Dermatophytes and yeast
  Dermatophytes 40 fungal species
  Trichophyton, Microsporum, and
         Fungal Infections

 Candidiasis.
 Malassezia furfur (yeast).
           Tinea Corporis
 Common in childhood.
 Etiologic agents
  *Trichophyton tonsurance.
  Microsporum canis.
  * Trichophyton rubrum.
 Transmission direct contact with human
  or animal, and inanimate object.
           Tinea Corporis

 Skin lesion pink-red, scaly, annular
  patch with expanding border.
 Bullous Tinea –tinea rubrum
 Majocchis granuloma—T.
Tinea Corporis
 Rash in occluded areas—
  anthropophillic organism.
 Rash on exposed areas such as face,
  neck, and arms—Zoophilic species
  (Microsporum canis) Tinea capitis can
  shower down from the scalp and
  produce multiple lesions.
          Tinea Incognita

 Lesion treated with steroid, delayed
 response to anti-fungal treatment.
          Tinea Corporis
 Skin rash individual and grouped red
 scaly papules and small plaques
 sometimes with mild edema.
 Progressively enlarge and migrate to
 form expanding rings,arcs or annular
 Central clearing.
          Tinea Corporis

 Resolution of redness and edema
  followed by scaling on the papules and
 Vesilces, pustules or blisters.
 Itching is mild.
              Tinea Corporis
 Clinical.
 KOH examination
      1) Place scale on a glass slide,add 20%
         KOH in dimethyl sulfoxide add cover
      2) Place the slide under microscope and
         dim the light source.
      3)Fungal spores,hyphae and
         pseudohyphae (refractive)
           Tinea Corporis
 Topical—Allylamines

   Tinea Corporis Treatment

 Polyene---Nystatin.
 Trizoles—Itraconazole,Fluconazole.
        Tinea Corporis
Indications for Oral Treatment

 Lack of response to topical treatment.
 Lesions extensive involving hair
 Immunocompromised.
 Co-existant Tinea capites present.
           Tinea Capitis
 Common in inner city population.
 Common in African American.
 Etiologic agent –Trichophyton
  Tonsurans 90%
     Microsporum canis 10%
 Colonization may be present.
 Transmission –direct contact,fomites.
           Tinea Capitis
 Trichophyton Tonsuranse—fill the
  interior of the endoshaft with spores
  (endospores) hair fragility, breakage
  close to the scalp.Negative wood light
 Microsporum—spores on the exterior
  aspect of the shaft (exospores)
      Positive wood light test.
           Tinea Capitis
       Clinical Presentation

 Common presentation-thin, fine, dry,or
  greasy scales
 Black-dot hair with discrete hair loss.
 Subtle findings-resembling seborrheic
  dermatitis,atopic dermatitis with little or
  no hair loss.
               Tinea Capitis
 Inflammatory response—patulous,pustules,or
   Significant inflammatory response—large
    tender boggy masses, draining sinuses.
   Alopecia –discrete, diffuse, severe or subtle.
   Posterior occipital lymphadenopathy.
   Inflammatory changes –host immune
          Tinea Capitis
      Clinical Presentation

 Highly inflammatory reaction with
  drainage does not indicate bacterial
 Long standing inflammation can result
  in scar formation.
             Tinea Capitis
        Differential Diagnosis
 Alopecia areata.
 Atopic Dermatitis.
 Xerosis.
 Folliculitis.
 Seborrheic dermatitis.
 Psoriasis
           Tinea Corposis

 Clinical—any child with scaling, hair
  loss, or erythema of the scalp.
 Woods light examination.
 Gold standard is culture.
           Hair,scalp scraping with blade
  or toothbrush, or cotton swab method.
          Tinea Capitis
       Culturing the Lesion

 1) Moisten a standard cotton swab with
  tap water.
 2) Roll the swab over all four quadrants
  of scalp.
 3) Put the swab in transport container or
  innoculate on dermatophyte test
             Tine Capitis
 Topical treatment is not effective.
 Griseofulvine 20 to 25 mg/kg/day of
  microsize formulation for 6 to 8 weeks.
  Two weeks following resolution of
  symptoms.Relative resistance has been
  noted requiring high dosing.M.Canis is
  resistant to treatment and may require
  treatment for months.
            Tinea Capitis
 Sporicidal shampoo such as 2.5%
  selenium sulfide or Ketoconazole
  should be used twice a week to reduce
  infectious risk, for 2 weeks.
 Re-evaluate after 4 weeks of treatment
  and reculture at the end of treatment .
 Family members and close contacts
  may receive topical treatment.
              Tinea Capitis
 Careful hygiene-combs, brushes, headgear
  should not be shared.
 Other oral anti-fungal for patients who do not
  tolerate or respond to Griseofulvin.
      Terbinafin (Lamisil) 3 to 6mg/kg once a
  day for 2 to 4 weeks.< 20kg=63.5mg/day,20
  to 40 kg =125mg/day.>40 mg=250 mg/day.
            Tinea Capitis
 Fluconazol: 6mg/kg/day once daily for
 Itraconazole: 5mg/kg/day,once daily or
  divided into two doses,for 2 to 4 weeks
  continuous dosing, or pulse dosing(1
  week of therapy a month for 1-3 pulses
  as clinically indicated)
 Not approved by FDA for tinea capitis.
             Tinea Capitis

 Indication for steroids.
      Lack of response after two weeks of
  anti-fungal treatment.
      Prednisone 1 to 2 mg/kg once daily
  for 10 to 14 days.
        Tinea Capitis
  Complications of Treatment
 Dermatophitid or id reaction (hypersensitivity
 reaction to fungal antigen).
 Clinical manifestation of ID reaction.
 Superficial edema and scaling.
 Pityriasis rosea like rash.
 Treatment –Short course of topical or
 systemic steroid (1 to 2 weeks),
     Tinea Pedis And Tinea
 Etiologic agent:
 T.pedis: secondary infection with skin
  flora such as
  micrococci,corynebacteria,and gram-
  negative bacteria.
 Predisposition –warmth and moisture.
            Tinea Pedis
         Clinical Features
 Web spaces become red scaly and
  macerated,occasionally with edema.
 Spreads to palms and soles with
  minimal scaling appears in 1 to 3 mm
 Vesicle and blister formation with
  redness and edema.
             Tinea Pedis
          Clinical Features

 Secondary bacterial infection, cellulitis,
  deep soft tissue infection, and
  sometimes systemic infection can
 Vigorous immune response is rare.
          Tinea Manuum
       Clinical Presentation

 Primarily involves the palm with dry
  scale, small circular areas of scale.
 Infection of one hand with both feet is
  Uncomplicated Tinea Pedis

 Keep the area cool and dry.
 Anti-fungal powders and sprays
 Topical Imidazole for four weeks.
 Topical allylamine for one to two weeks.
    Complicated Tinea Pedis

 Econazole (Spectazole) apply BID.
 Ciclopirox apply BID.
 Oral treatment if toenails are involved.
          Tinea Unguium

 Etiologic agents are Dermatophytes
 such as
 Epidermophyton floccosum,yeast such
 as candida species, and saprophytic
         Tinea Unguium
      Clinical Manifestation

 Invasion of nailplate from the distal
  underside of the nail resulting in
  breakage and accumulation of the
  debris without inflammation (common).
         Tinea Unguium
      Clinical Manifestation

 Superficial growth on the surface of the
 nail, resulting in fragile powdery white
 grayish opaque discoloration, no
 subungual infection.
          Tinea Unguium

 Topical treatment may be effective for
 superficial fungal infection.
    Ciclopirox in a lacquer form used for
 48 weeks, 30% cure rate.
    Also useful in potentiating effect of
 oral treatment.
           Tinea Unguium
 Griseofulvin and Ketoconazole have
  proved unsatisfactory after 12 to 18
  months of treatment.
 Itraconazole daily treatment for one
  week followed by three week period
  without treatment for three months is
  highly effective 78% clinical cure, 4 to
          Tinea Unguium
 Itraconazol 100mg BID (saprophytic
 Terbinafen is superior and better
  tolerated. 250mg daily for 3 to 4
  months (dermaphyte infection) 3 to
 Fluconazol 150mg once a week for 3 to
  6 months (candida).
            Tinea Cruris

 Etiologic agent E.floccosum rash limited
  to groin or perineal area.
 T.rubrum patches spreading to the
 Common in summer and tropical areas.
           Tinea Cruris
      Clinical Manifestation

 Rash: annular lesions in the groin and
  perineal area.
 Confluent patches spreading to the
  thigh buttocks and abdomen.
           Tinea Cruris
      Differential Diagnosis

 Contact dermatitis.
 Psoriasis.
 Seborrheic.
            Tinea Cruris

 Diagnosis by clinical appearance, KOH
  or culture.
 Treatment: topical anti-fungal Imidazole
  for two weeks.
  Allylmine for 1 week.
  Decrease moisture by using powder
  and loose clothing.
        Tinea Gladiatorum

 Tinea corporis in athletes.
 Etiologic agent: Trichophyton tonsurans.
 Lesions on the neck, back ,and arms.
         Tinea Gladiatorum

 Topical treatment 1 week after the clearance
  of the rash.
 Infected Wrestler and teammates may be
  treated with Itraconazole or fluconazole, but it
  is not FDA approved yet.
 Athlete must be removed from the
  competition or lesions must be covered.
        Tinea Gladiatorum

 In epidemic: Wrestling equipment
 should be cleaned.
 Oral candidiasis: Infants and
  immunocompromised patients.
 Scattered white patches on the oral and
  buccal mucosa, tongue, or palate.
  Progressing to esophagitis
     Treatment ; Nystatin oral suspension.
     Fluconazole has been used in HIV
     Remove reservoir like, pacifiers.
 Monilial diaper dermatitis.
 90% children with oral candidias.
 Associated with antibiotic use, specially
 Treatment: Nystatin cream, miconazile,
 econozole, and oxyconazole are also
 effective. Mupirocin (perianal rash)

 Inflammatory dermatitis with secondary
  candida infection.
 Common in obese children.
 Treatment: Topical nystatin, Imidazole,
  Tinea (Pityriasis)Versicolor

 Etiologic agent; Malassezia furfur.
 Common in tropical area, part of skin
 Predisposing factors are warmth,
  humidity and immunosuppression.
         Tinea Versicolor

 Yeast grows in stratum corneum,
 sebum reached areas.
         Tinea Versicolor
       Clinical Manifestions
 Skin rash: oval lesions white, brown,
  pink or tan, discrete and coalescent with
  fine faint scale.
 Distribution : most common area is
  trunk, sometimes face forehead, and
  temple. Rarely arms, neck and axila.
 Common in healthy adolescence.
          Tinea Versicolor

 Pityrosporum folliculitis.
 Cathetor related infections.
 Seborrhea.
 Flares of atopic dermatitis and neonatal
  cephalic pustulosis.
Tinea Versicolar
Differential Diagnosis

 Pityriasis alba.
 Vitiligo.
 Pityriasis rosea.
 Seborrheic dermatitis.
          Tinea Versicolor

 KOH preparation shows, short hyphae
  and spores(macaroni and meatballs).
 Culture is not helpful since organism is
  a normal commensal.
         Tinea Versicolor
 Ketoconazole shampoo for 3 to 5
  minutes for three consecutive days.
 Systemic treatment for extensive or
  recurrent disease.
  Itraconazole, Ketoconazole, and
  Fluconazole are effective.
  Terbinafin spray (Griseofulvin and
  turbinafin oral not effective).
           Tinea Pedis

 Chronic paronychia: may be fungal
 infection of chronic dermatitis.