Fungal Infection Dr. Shirsat Fungal Infection Objective Understand different types of fungal infections. Understand reasons for their occurrence. 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 Epidermophyton. Fungal Infections Candidiasis. Malassezia furfur (yeast). Tinea Corporis Common in childhood. Etiologic agents *Trichophyton tonsurance. Microsporum canis. * Trichophyton rubrum. Epidermophyton. 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. rubrum,T.mentagrophytes,T.tonsurans, T.violaceum. 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 pattern. Central clearing. Tinea Corporis Resolution of redness and edema followed by scaling on the papules and plaques. Vesilces, pustules or blisters. Itching is mild. Tinea Corporis Diagnosis Clinical. KOH examination 1) Place scale on a glass slide,add 20% KOH in dimethyl sulfoxide add cover slip. 2) Place the slide under microscope and dim the light source. 3)Fungal spores,hyphae and pseudohyphae (refractive) Tinea Corporis Treatment Topical—Allylamines Butenafine,Naftifine,Terbinafine Hydroxypyridinone. Ciclopirox. Imidazoles. Clotrimazole,Econozole,Ketoconazole,Micon azole,Oxiconazole. Tinea Corporis Treatment Polyene---Nystatin. Trizoles—Itraconazole,Fluconazole. Tinea Corporis Indications for Oral Treatment Lack of response to topical treatment. Lesions extensive involving hair follicles. 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 Pathogenesis Trichophyton Tonsuranse—fill the interior of the endoshaft with spores (endospores) hair fragility, breakage close to the scalp.Negative wood light test. 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 crusting. Significant inflammatory response—large tender boggy masses, draining sinuses. Alopecia –discrete, diffuse, severe or subtle. Posterior occipital lymphadenopathy. Inflammatory changes –host immune response. Tinea Capitis Clinical Presentation Highly inflammatory reaction with drainage does not indicate bacterial infection. Long standing inflammation can result in scar formation. Tinea Capitis Differential Diagnosis Alopecia areata. Atopic Dermatitis. Xerosis. Folliculitis. Seborrheic dermatitis. Psoriasis SLE Tinea Corposis Diagnosis 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 medium. Tine Capitis Treatment 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 Treatment 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 Treatment 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 Treatment Fluconazol: 6mg/kg/day once daily for 6wk 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 Treatment 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), antihistamine. Tinea Pedis And Tinea Manum Etiologic agent: T.rubrum,T.mantagrophytes,and Epidermiphyton. 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 circles. 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 occur. 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 common. Uncomplicated Tinea Pedis Treatment 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 Treatment Econazole (Spectazole) apply BID. Ciclopirox apply BID. Oral treatment if toenails are involved. Tinea Unguium (onychomycosis) Etiologic agents are Dermatophytes such as T.rubrum,T.mentagrophytes,and Epidermophyton floccosum,yeast such as candida species, and saprophytic fungi. Tinea Unguium Clinical Manifestation Invasion of nailplate from the distal underside of the nail resulting in discoloration,ridging,thickening,fragility, 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 Treatment 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 Treatment 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 6mg/kg/day. Tinea Unguium Treatment Itraconazol 100mg BID (saprophytic fungi). Terbinafen is superior and better tolerated. 250mg daily for 3 to 4 months (dermaphyte infection) 3 to 5mg/kg/day. 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 abdomen. 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 Treatment 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 Treatment In epidemic: Wrestling equipment should be cleaned. Candidiasis 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. Candidiasis Monilial diaper dermatitis. 90% children with oral candidias. Associated with antibiotic use, specially penicillin. Treatment: Nystatin cream, miconazile, econozole, and oxyconazole are also effective. Mupirocin (perianal rash) Intertrigo Inflammatory dermatitis with secondary candida infection. Common in obese children. Treatment: Topical nystatin, Imidazole, terbinafin. Tinea (Pityriasis)Versicolor Etiologic agent; Malassezia furfur. Common in tropical area, part of skin flora. Predisposing factors are warmth, humidity and immunosuppression. Tinea Versicolor Pathogenesis. 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 Diagnosis KOH preparation shows, short hyphae and spores(macaroni and meatballs). Culture is not helpful since organism is a normal commensal. Tinea Versicolor Treatment 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 Complication Chronic paronychia: may be fungal infection of chronic dermatitis.