Fungal Infection

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Fungal Infection

• Dr. Shirsat

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Fungal Infection Objective

• Understand different types of fungal infections.
• Understand reasons for their occurrence.
• Identify skin signs.
• Initiate treatment.

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Fungal infectionsCausative agents

• Plant like organisms who survive in Keratinaceous
  tissue.
• Dermatophytes and yeast
• Dermatophytes 40 fungal species
• Trichophyton, Microsporum, and
  Epidermophyton.

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Fungal Infections

• Candidiasis.
• Malassezia furfur (yeast).

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Tinea Corporis

• Common in childhood.
• Etiologic agents
• Trichophyton tonsurance. Microsporum
  canis. Trichophyton rubrum.
  Epidermophyton.
• Transmission direct contact with human or animal,
  and inanimate object.

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Tinea Corporis

• Skin lesion pink-red, scaly, annular patch with
  expanding border.
• Bullous Tinea tinea rubrum
• Majocchis granulomaT. rubrum,T.mentagrophytes,T.t
  onsurans,T.violaceum.

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Tinea Corporis

• Rash in occluded areasanthropophillic organism.
• Rash on exposed areas such as face, neck, and
  armsZoophilic species (Microsporum canis)
  Tinea capitis can shower down from the scalp and
  produce multiple lesions.

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Tinea Incognita

• Lesion treated with steroid, delayed response to
  anti-fungal treatment.

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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.

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Tinea Corporis

• Resolution of redness and edema followed by
  scaling on the papules and plaques.
• Vesilces, pustules or blisters.
• Itching is mild.

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Tinea CorporisDiagnosis

• 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)

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Tinea CorporisTreatment

• TopicalAllylamines Butenafine,Naftifine,T
  erbinafine
  Hydroxypyridinone. Ciclopirox.
  Imidazoles. Clotrimazole,Econozole,Ketocon
  azole,Miconazole,Oxiconazole.

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Tinea Corporis Treatment

• Polyene---Nystatin.
• TrizolesItraconazole,Fluconazole.

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Tinea CorporisIndications for Oral Treatment

• Lack of response to topical treatment.
• Lesions extensive involving hair follicles.
• Immunocompromised.
• Co-existant Tinea capites present.

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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.

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Tinea CapitisPathogenesis

• Trichophyton Tonsuransefill the interior of the
  endoshaft with spores (endospores) hair
  fragility, breakage close to the scalp.Negative
  wood light test.
• Microsporumspores on the exterior aspect of the
  shaft (exospores) Positive wood light test.

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Tinea CapitisClinical 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.

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Tinea Capitis

• Inflammatory responsepatulous,pustules,or
  crusting.
• Significant inflammatory responselarge tender
  boggy masses, draining sinuses.
• Alopecia discrete, diffuse, severe or subtle.
• Posterior occipital lymphadenopathy.
• Inflammatory changes host immune response.

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Tinea CapitisClinical Presentation

• Highly inflammatory reaction with drainage does
  not indicate bacterial infection.
• Long standing inflammation can result in scar
  formation.

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Tinea CapitisDifferential Diagnosis

• Alopecia areata.
• Atopic Dermatitis.
• Xerosis.
• Folliculitis.
• Seborrheic dermatitis.
• Psoriasis
• SLE

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Tinea CorposisDiagnosis

• Clinicalany 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.

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Tinea CapitisCulturing 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.

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Tine CapitisTreatment

• 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.

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Tinea CapitisTreatment

• 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.

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Tinea CapitisTreatment

• 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. lt 20kg63.5mg/day,20 to 40 kg
  125mg/day.gt40 mg250 mg/day.

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Tinea CapitisTreatment

• 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.

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Tinea CapitisTreatment

• Indication for steroids. Lack of response
  after two weeks of anti-fungal treatment. Pred
  nisone 1 to 2 mg/kg once daily for 10 to 14 days.

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Tinea CapitisComplications 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.

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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.

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Tinea PedisClinical 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.

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Tinea PedisClinical Features

• Secondary bacterial infection, cellulitis, deep
  soft tissue infection, and sometimes systemic
  infection can occur.
• Vigorous immune response is rare.

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Tinea ManuumClinical Presentation

• Primarily involves the palm with dry scale, small
  circular areas of scale.
• Infection of one hand with both feet is common.

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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.

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Complicated Tinea Pedis Treatment

• Econazole (Spectazole) apply BID.
• Ciclopirox apply BID.
• Oral treatment if toenails are involved.

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Tinea Unguium (onychomycosis)

• Etiologic agents are Dermatophytes such as
  T.rubrum,T.mentagrophytes,and Epidermophyton
  floccosum,yeast such as candida species, and
  saprophytic fungi.

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Tinea UnguiumClinical Manifestation

• Invasion of nailplate from the distal underside
  of the nail resulting in discoloration,ridging,thi
  ckening,fragility, breakage and accumulation of
  the debris without inflammation (common).

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Tinea UnguiumClinical Manifestation

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

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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.

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Tinea UnguiumTreatment

• 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.

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Tinea UnguiumTreatment

• 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).

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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.

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Tinea CrurisClinical Manifestation

• Rash annular lesions in the groin and perineal
  area.
• Confluent patches spreading to the thigh buttocks
  and abdomen.

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Tinea CrurisDifferential Diagnosis

• Contact dermatitis.
• Psoriasis.
• Seborrheic.

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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.

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Tinea Gladiatorum

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

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Tinea GladiatorumTreatment

• 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.

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Tinea GladiatorumTreatment

• In epidemic Wrestling equipment should be
  cleaned.

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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.

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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)

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Intertrigo

• Inflammatory dermatitis with secondary candida
  infection.
• Common in obese children.
• Treatment Topical nystatin, Imidazole,
  terbinafin.

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Tinea (Pityriasis)Versicolor

• Etiologic agent Malassezia furfur.
• Common in tropical area, part of skin flora.
• Predisposing factors are warmth, humidity and
  immunosuppression.

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Tinea VersicolorPathogenesis.

• Yeast grows in stratum corneum, sebum reached
  areas.

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Tinea VersicolorClinical 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.

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Tinea Versicolor

• Pityrosporum folliculitis.
• Cathetor related infections.
• Seborrhea.
• Flares of atopic dermatitis and neonatal cephalic
  pustulosis.

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Tinea VersicolarDifferential Diagnosis

• Pityriasis alba.
• Vitiligo.
• Pityriasis rosea.
• Seborrheic dermatitis.

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Tinea VersicolorDiagnosis

• KOH preparation shows, short hyphae and
  spores(macaroni and meatballs).
• Culture is not helpful since organism is a normal
  commensal.

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Tinea VersicolorTreatment

• 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).

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Tinea Pedis Complication

• Chronic paronychia may be fungal infection of
  chronic dermatitis.