Diseases Resulting from Diseases Resulting from Fungi and YeastsFungi and Yeasts

Kristy P. Gilbert, D.O.Kristy P. Gilbert, D.O.

February 8, 2005February 8, 2005

Superficial mycosesSuperficial mycoses

AKA dermatophytesAKA dermatophytes Cause only stratum corneum, hair and nail Cause only stratum corneum, hair and nail

infectioninfection Three genera: Three genera: Microsporum, Trichophyton, Microsporum, Trichophyton,

EpidermophytonEpidermophyton Division into: 1) tinea capitis, 2) tinea barbae, Division into: 1) tinea capitis, 2) tinea barbae,

3) tinea faciei, 4) tinea corporis, 5) tinea 3) tinea faciei, 4) tinea corporis, 5) tinea manus, 6) tinea pedis, 7) tinea cruris, manus, 6) tinea pedis, 7) tinea cruris, 8)onychomycosis8)onychomycosis

Host factorsHost factors

Immunosuppressed pts- cancer, diabetesImmunosuppressed pts- cancer, diabetes AIDS, connective tissue disordersAIDS, connective tissue disorders Genetic susceptibility may be related to types of keratin Genetic susceptibility may be related to types of keratin

or degree/mix of cutaneous lipids produced, cutaneous or degree/mix of cutaneous lipids produced, cutaneous barrier compromise barrier compromise

Surface antigens-ABO system-one study of 108 culture Surface antigens-ABO system-one study of 108 culture proven dermatophytosis pts noted type A blood prone to proven dermatophytosis pts noted type A blood prone to chronic diseasechronic disease

Human steroid hormones can inhibit growth of Human steroid hormones can inhibit growth of dermatophytes (androgens like androstenedione)dermatophytes (androgens like androstenedione)

One group believes this high susceptibility of One group believes this high susceptibility of Trichophyton rubrum & Epidermophyton floccosum Trichophyton rubrum & Epidermophyton floccosum to to intrafollicular androstenedione is a reason why these intrafollicular androstenedione is a reason why these species do not cause tinea capitisspecies do not cause tinea capitis

ImidazolesImidazoles Clotrimazole, miconazole, sulconazole, oxiconazole, Clotrimazole, miconazole, sulconazole, oxiconazole,

and ketoconazoleand ketoconazole Mostly used for topical txMostly used for topical tx Inhibit cytochrome P450 14-alpha-demethylase (an Inhibit cytochrome P450 14-alpha-demethylase (an

essential enzyme in ergosterol synthesis)essential enzyme in ergosterol synthesis) Ketaconazole has wide spectrum against Ketaconazole has wide spectrum against

dermatophytes, yeasts, and some systemic mycosesdermatophytes, yeasts, and some systemic mycoses Ketaconazole has the potential for serious drug Ketaconazole has the potential for serious drug

interactions and a higher incidence of hepatotoxicity interactions and a higher incidence of hepatotoxicity during long-term daily therapyduring long-term daily therapy

AllylaminesAllylamines Naftifine, terbinafine, butenafineNaftifine, terbinafine, butenafine Inhibites squalene epoxydationInhibites squalene epoxydation Terbinafine has less activity against Terbinafine has less activity against CandidaCandida

species in vitro studies then triazoles, but is effective species in vitro studies then triazoles, but is effective clinicallyclinically

Terbinafine is ineffective in the oral tx of tinea Terbinafine is ineffective in the oral tx of tinea versicolor but is effective topicallyversicolor but is effective topically

Few drug interactions have been reportedFew drug interactions have been reported Bioavailability is unchanged in foodBioavailability is unchanged in food Hepatotoxicity, leukopenia, severe exanthems, and Hepatotoxicity, leukopenia, severe exanthems, and

taste disturbances uncommon, but should be taste disturbances uncommon, but should be monitored for clinically and by lab testing if monitored for clinically and by lab testing if continuous dosing over 6 weekscontinuous dosing over 6 weeks

PolyenePolyene

NystatinNystatin Irreversibly binding to ergosterol-an Irreversibly binding to ergosterol-an

essential component of fungal cell essential component of fungal cell membranesmembranes

TriazolesTriazoles Itraconazole, FluconazoleItraconazole, Fluconazole Affect P450 systemAffect P450 system Numerous drug interactions occurNumerous drug interactions occur Need to know pt’s current medsNeed to know pt’s current meds Broadest spectrum to dermatophytes and Broadest spectrum to dermatophytes and Candida Candida

species, and species, and Malassezia furfurMalassezia furfur Itraconazole is fungistatic- food increases its Itraconazole is fungistatic- food increases its

absorption , antacids and gastric acid secretion absorption , antacids and gastric acid secretion suppressors produce erratic or lowered absorptionsuppressors produce erratic or lowered absorption

Pulse dosing limits concern over lab abnormalitiesPulse dosing limits concern over lab abnormalities Fluconazole’s absorption is unaffected by foodFluconazole’s absorption is unaffected by food

Tinea CapitisTinea Capitis

Occurs chiefly in schoolchildrenOccurs chiefly in schoolchildren Boys more frequently than girls; except epidemics Boys more frequently than girls; except epidemics

caused by caused by Trichophyton tonsuransTrichophyton tonsurans where there is where there is equal frequencyequal frequency

Divided into inflammatory and non-inflammatoryDivided into inflammatory and non-inflammatory Tinea capitis can be caused by all pathogenic Tinea capitis can be caused by all pathogenic

dermatophytes except dermatophytes except Epidermophyton floccosumEpidermophyton floccosum and and T. concentricumT. concentricum

In U.S. most caused by In U.S. most caused by T. tonsuransT. tonsurans

Tinea CapitisTinea Capitis

Noninflammatory Noninflammatory

M. audouiniiM. audouinii infections present as the classic infections present as the classic form form

Characterized by multiple scaly lesions Characterized by multiple scaly lesions (“gray-patch”), stubs of broken hair(“gray-patch”), stubs of broken hair

Over past 30 yrs, Over past 30 yrs, M. audouinii M. audouinii infections are infections are being replaced by increasing numbers of being replaced by increasing numbers of “black-dot” ringworm, caused primarily by “black-dot” ringworm, caused primarily by T. T. tonsuranstonsurans and occasionally by and occasionally by T. violaceumT. violaceum

In the U.SIn the U.S. T. tonsurans . T. tonsurans is the most common is the most common cause cause

Noninflammatory Tinea CapitisNoninflammatory Tinea Capitis

““Black dot” ringworm, caused by Black dot” ringworm, caused by T. T. tonsurans & tonsurans & occasionally occasionally T. violaceumT. violaceum presents as multiple areas of alopecia presents as multiple areas of alopecia studded with black dots representing studded with black dots representing infected hairs broken off at or below the infected hairs broken off at or below the surface of the scalpsurface of the scalp

Black dot tineaBlack dot tinea

Black dot ringworm caused by Black dot ringworm caused by Trichophyton tonsuransTrichophyton tonsurans

Inflammatory Inflammatory Usually caused by Usually caused by M. canisM. canis Can be caused by Can be caused by T. mentagrophytes, T. tonsurans, T. mentagrophytes, T. tonsurans,

M. gypsem, or T. verrucosumM. gypsem, or T. verrucosum M. canisM. canis begin as scaly, erythematous, papular begin as scaly, erythematous, papular

eruptions with loose and broken-off hairs, followed eruptions with loose and broken-off hairs, followed by varying degrees of inflammationby varying degrees of inflammation

A localized spot accompanied by pronounced A localized spot accompanied by pronounced swelling, with developing bogginess and induration swelling, with developing bogginess and induration exuding pus develops- exuding pus develops- kerion celsiikerion celsii– A delayed type hypersensitivity reaction to fungal A delayed type hypersensitivity reaction to fungal

elementselements With extensive lesions fever, pain, and regional With extensive lesions fever, pain, and regional

lymphadenopathy may occurlymphadenopathy may occur

KerionKerion

Kerion may be followed by scarring and Kerion may be followed by scarring and permanent alopecia in areas of inflammation and permanent alopecia in areas of inflammation and suppurationsuppuration

Systemic steroids for short periods will greatly Systemic steroids for short periods will greatly diminish the inflammatory response and reduce diminish the inflammatory response and reduce the risk of scarringthe risk of scarring

Kerion: inflammatory rxn of tinea capitis caused by Kerion: inflammatory rxn of tinea capitis caused by Microsporum canis or Trichophyton mentagrophytesMicrosporum canis or Trichophyton mentagrophytes

Permanent scarring alopecia post-kerionPermanent scarring alopecia post-kerion

Kerion: red, Kerion: red, oozing, oozing, hairless hairless plaqueplaque

FavusFavus

Rare in the U.S.Rare in the U.S. Most severe form of dermatophyte hair infectionMost severe form of dermatophyte hair infection Most frequently cause by Most frequently cause by T. schoenleiniiT. schoenleinii Hyphae and air spaces seen within hair shaftHyphae and air spaces seen within hair shaft Bluish white fluorescence under Wood’s lightBluish white fluorescence under Wood’s light Thick, yellow crusts composed of hyphae and skin Thick, yellow crusts composed of hyphae and skin

debris (‘scutula’)debris (‘scutula’) Scarring alopecia may developScarring alopecia may develop

Favus with scarring alopecia and Favus with scarring alopecia and scutulascutula

Scarring after favus infectionScarring after favus infection

EtiologyEtiology

Tinea capitis can be cause by any one of Tinea capitis can be cause by any one of several species: several species: T. tonsurans, M. audouinii T. tonsurans, M. audouinii (human to human)(human to human), and M. canis , and M. canis (animals to (animals to human)human)

Endothrix types-Endothrix types-T. tonsurans T. tonsurans (black-dot (black-dot ringworm) and ringworm) and T. violaceumT. violaceum

Ectothrix found on scalp are Ectothrix found on scalp are T. verrucosum & T. verrucosum & T. mentagrophytes, M. canisT. mentagrophytes, M. canis

DiagnosisDiagnosis

Wood’s lightWood’s light– Ultraviolet of 365 nm wavelength is obtained by passing a Ultraviolet of 365 nm wavelength is obtained by passing a

beam through a Wood’s filter composed of nickel oxide-beam through a Wood’s filter composed of nickel oxide-containing glasscontaining glass

– A simple form is the 125-volt purple bulbA simple form is the 125-volt purple bulb Fluorescent-positive infections are caused by :Fluorescent-positive infections are caused by :T. T. sschoenleinii, M. choenleinii, M. ccanis, M. anis, M. aaudouinii, M. udouinii, M. ddistortum, M. istortum, M. fferrugineumerrugineum

Hairs infected with Hairs infected with T. tonsurans, T. verrucosum, & T. T. tonsurans, T. verrucosum, & T. violaceum violaceum and others of endothrix do not fluoresceand others of endothrix do not fluoresce

The fluorescent substance is The fluorescent substance is pteridinepteridine

DiagnosisDiagnosis

KOHKOH– Two or three loose hairs are removedTwo or three loose hairs are removed– Hairs are placed on slide with a drop of 10-20% Hairs are placed on slide with a drop of 10-20%

solution of KOHsolution of KOH– A cover slip is applied, specimen is warmed until A cover slip is applied, specimen is warmed until

hairs are maceratedhairs are macerated– Examine under low, then high powerExamine under low, then high power

Scales or hairs cleared with it can still be Scales or hairs cleared with it can still be culturedcultured

DTMDTM

DTM contains cycloheximide to reduce growth of DTM contains cycloheximide to reduce growth of contaminants and a colored pH indicator to denote contaminants and a colored pH indicator to denote the alkali-producing dermatophytesthe alkali-producing dermatophytes

Some clinically relevant nondermatophyte fungi Some clinically relevant nondermatophyte fungi are cycloheximide sensitive (are cycloheximide sensitive (Candida tropicalis, Candida tropicalis, Scopulariopsis brevicaulis, Cryptococcus Scopulariopsis brevicaulis, Cryptococcus neoformans, Pseudoallescheria boydii, neoformans, Pseudoallescheria boydii, Trichosporon beigelii Trichosporon beigelii and and Aspergillus Aspergillus spp.)spp.)

Ectothrix type in Ectothrix type in Microsporum canis-Microsporum canis-note small note small spores around hair shaftspores around hair shaft

Endothrix spores in hair with Endothrix spores in hair with Trichophyton tonsuransTrichophyton tonsurans

Endothrix inEndothrix in T. scoenleinii T. scoenleinii showing showing characteristic bubbles of aircharacteristic bubbles of air

Endothrix infection, (low-power KOH Endothrix infection, (low-power KOH mount): arthroconidia noted within hair shaftmount): arthroconidia noted within hair shaft

Endothrix infection (high-power KOH mount) Endothrix infection (high-power KOH mount) showing total hair shaft involvementshowing total hair shaft involvement

T. tonsuransT. tonsurans

This microoraganism grows slowly in culture This microoraganism grows slowly in culture to produce a granular or powdery yellow to to produce a granular or powdery yellow to red, brown, or buff colonyred, brown, or buff colony

Crater formation with radial grooves may be Crater formation with radial grooves may be producedproduced

Microconidia may be seen regularlyMicroconidia may be seen regularly Dx confirmed by the fact that cultures grow Dx confirmed by the fact that cultures grow

poorly or not at all without thiaminepoorly or not at all without thiamine

T. mentagrophytesT. mentagrophytes

Culture growth is velvety or granular or fluffy, flat Culture growth is velvety or granular or fluffy, flat or furrowed, light buff, white, or sometimes pinkor furrowed, light buff, white, or sometimes pink

Back of the culture can vary from buff to dark redBack of the culture can vary from buff to dark red Round microconidia borne laterally and in clusters Round microconidia borne laterally and in clusters

confirm dx within 2 weeksconfirm dx within 2 weeks Spirals are sometimes presentSpirals are sometimes present Macroconidia may be seenMacroconidia may be seen

T. verrucosumT. verrucosum

Growth is slow and cannot be observed well Growth is slow and cannot be observed well for at least 3 weeksfor at least 3 weeks

Colony is compact, glassy, velvety, heaped Colony is compact, glassy, velvety, heaped or furrowed, and usually white, but may be or furrowed, and usually white, but may be yellow or grayyellow or gray

Chlamydospores (round swellings along the Chlamydospores (round swellings along the hyphal structures) are present in early hyphal structures) are present in early culturescultures

Microconidia may be seenMicroconidia may be seen

M. audouiniiM. audouinii

Gross appearance shows a slowly growing, Gross appearance shows a slowly growing, matted, velvety, light brown colonymatted, velvety, light brown colony

Back of which is reddish brown to orangeBack of which is reddish brown to orange Under microscope a few large multiseptate Under microscope a few large multiseptate

macroconidia (macroaleuriospores) are seenmacroconidia (macroaleuriospores) are seen Microconidia (microaleuriospores) in a lateral Microconidia (microaleuriospores) in a lateral

position on hyphae are clavateposition on hyphae are clavate Racquet mycelium, chlamydospores, and Racquet mycelium, chlamydospores, and

pectinate hyphae are seen sometimespectinate hyphae are seen sometimes

M. canisM. canis

Culture shows profuse, fuzzy, cottony, aerial Culture shows profuse, fuzzy, cottony, aerial mycelia tending to become powdery in the centermycelia tending to become powdery in the center

Color is buff to light brownColor is buff to light brown Back of colony is lemon to orange-yellowBack of colony is lemon to orange-yellow Numerous spindle-shaped multiseptate Numerous spindle-shaped multiseptate

microconidia and thick-walled macroconidia are microconidia and thick-walled macroconidia are presentpresent

Clavate microconidia are found along with Clavate microconidia are found along with chlamydospores and pectinate bodieschlamydospores and pectinate bodies

TreatmentTreatment Griseofulvin of ultramicronized form, 10 mg/kg/day, is the daily Griseofulvin of ultramicronized form, 10 mg/kg/day, is the daily

dose recommended for childrendose recommended for children Grifulvin V is the only oral suspension available for children unable Grifulvin V is the only oral suspension available for children unable

to swallow tablets-dose is 20 mg/kg/dayto swallow tablets-dose is 20 mg/kg/day Tx should continue for 2-4 months, or for at least 2 weeks after Tx should continue for 2-4 months, or for at least 2 weeks after

negative microscopic and culture examinations are obtainednegative microscopic and culture examinations are obtained Griseofulvin does not primarily affect the delayed type Griseofulvin does not primarily affect the delayed type

hypersensitivity reaction responsible for the inflammation in kerionhypersensitivity reaction responsible for the inflammation in kerion For this, systemic steroids, to minimize scarring, can be given For this, systemic steroids, to minimize scarring, can be given

simultaneouslysimultaneously

TreatmentTreatment

TerbinafineTerbinafine-effective for Trichophyton infections-effective for Trichophyton infections

-3-6mg/kg/day for 1 to 4 weeks-3-6mg/kg/day for 1 to 4 weeks-Microsporum infections may require larger doses and longer courses -Microsporum infections may require larger doses and longer courses of therapy of therapy

ItraconazoleItraconazole FluconazoleFluconazole Selenium Sulfide or Ketoconazole shampoo as an Selenium Sulfide or Ketoconazole shampoo as an

adjunctadjunct

Tinea BarbaeTinea Barbae

AKA Tinea sycosis, barber’s itchAKA Tinea sycosis, barber’s itch UncommonUncommon Occurs chiefly among those in agricultureOccurs chiefly among those in agriculture Involvement is mostly one-sided on neck or Involvement is mostly one-sided on neck or

faceface Two clinical types are: deep, nodular, Two clinical types are: deep, nodular,

suppurative lesions; and superficial, crusted, suppurative lesions; and superficial, crusted, partially bald patches with folliculitispartially bald patches with folliculitis

Tinea BarbaeTinea Barbae

Superficial crusted type Superficial crusted type – mild pustular folliculitis with broken-off hairs (mild pustular folliculitis with broken-off hairs (T. T.

violaceum) violaceum) or without broken-off hairs (or without broken-off hairs (T. T. rubrum)rubrum)

– Affected hairs are loose, dry, and brittleAffected hairs are loose, dry, and brittle– When extracted bulb appears intactWhen extracted bulb appears intact

Tinea BarbaeTinea Barbae

Deep typeDeep type– Caused mostly by Caused mostly by T. mentagrophytes T. mentagrophytes or or T. T.

verrucosumverrucosum – Swellings are usually confluent and form diffuse Swellings are usually confluent and form diffuse

boggy infiltrates with abscessesboggy infiltrates with abscesses– Pus may be expressed Pus may be expressed – Lesions are limited to one part of face or neck in Lesions are limited to one part of face or neck in

menmen

Diagnosis-Tinea BarbaeDiagnosis-Tinea Barbae

ClinicalClinical Confirmed by microscopic findings and by Confirmed by microscopic findings and by

standard culture techniques standard culture techniques Rarely, Rarely, Epidermophyton floccosumEpidermophyton floccosum may may

cause widespread verrucous lesions known cause widespread verrucous lesions known as as verrucous epidermophytosisverrucous epidermophytosis

Verrucous epidermophytosis from Verrucous epidermophytosis from Epidermphyton Epidermphyton floccosumfloccosum

Complete resolution after 48 days of GriseofulvinComplete resolution after 48 days of Griseofulvin

Differential DiagnosisDifferential Diagnosis

Sycosis vulgaris (staphlococcal folliculitis)-Sycosis vulgaris (staphlococcal folliculitis)-lesions are pustules and papules, pierced in lesions are pustules and papules, pierced in the center by a hair, which is loose and the center by a hair, which is loose and easily extracted after suppuration has easily extracted after suppuration has occurredoccurred

Contact dermatitisContact dermatitis Herpes infectionsHerpes infections

Tinea barbae-Tinea barbae-Trichophyton mentagrophytesTrichophyton mentagrophytes

Treatment-Tinea BarbaeTreatment-Tinea Barbae

Oral antifungals are requiredOral antifungals are required Topical agents as adjunctive therapyTopical agents as adjunctive therapy Micronized or ultramicronized Micronized or ultramicronized

griseofulvin orally: dosage of 500–1000 griseofulvin orally: dosage of 500–1000 mg or 350-700 mg respectively mg or 350-700 mg respectively

Tx usually for 4-6 weeksTx usually for 4-6 weeks

Treatment-Tinea BarbaeTreatment-Tinea Barbae

Other orals that have been effective: ketoconazole, Other orals that have been effective: ketoconazole, fluconazole, itraconazole, and terbinafinefluconazole, itraconazole, and terbinafine

Topical antifungals should be applied from the beginning Topical antifungals should be applied from the beginning of txof tx

Affected parts should be bathed thoroughly in soap and Affected parts should be bathed thoroughly in soap and waterwater

Healthy areas that are not epilated may be shaved or Healthy areas that are not epilated may be shaved or clippedclipped

When kerion is present a short course of systemic steriod When kerion is present a short course of systemic steriod therapy may help reduce inflammation and risk of scarringtherapy may help reduce inflammation and risk of scarring

Tinea FacieiTinea Faciei

Fungal infection of the face (apart from the beard)Fungal infection of the face (apart from the beard) Must have high index of suspicionMust have high index of suspicion

– Mistaken for seborrheic dermatitis, contact dermatitis, Mistaken for seborrheic dermatitis, contact dermatitis, lupus, or photosensitive dermatosislupus, or photosensitive dermatosis

Erythematous, slightly scaling, indistinct borders Erythematous, slightly scaling, indistinct borders are usually seen (best location for KOH scrapings)are usually seen (best location for KOH scrapings)

Typical annular rings are usually lacking & lesions Typical annular rings are usually lacking & lesions are exquisitely photosensitiveare exquisitely photosensitive

Usually caused by Usually caused by T. rubrum, T. mentagrophytes, T. rubrum, T. mentagrophytes, or M. canisor M. canis

Tinea faciei Tinea faciei ((Microsporum canisMicrosporum canis) )

in a childin a child

TreatmentTreatment

Topical antifungalsTopical antifungals If fungal folliculitis is present, oral medication is If fungal folliculitis is present, oral medication is

requiredrequired Oral griseofulvin administered for 2-4 weeks, as Oral griseofulvin administered for 2-4 weeks, as

well as fluconazole, itraconazole, or terbinafine are well as fluconazole, itraconazole, or terbinafine are all effective particularly in combination with topical all effective particularly in combination with topical therapytherapy

Tinea Corporis(Tinea Circinata)Tinea Corporis(Tinea Circinata)

All superficial dermatophyte infections of the skin All superficial dermatophyte infections of the skin except the scalp, beard, face, hands, feet, and except the scalp, beard, face, hands, feet, and groingroin

Sites of predilection are neck, upper and lower Sites of predilection are neck, upper and lower extremities, and trunkextremities, and trunk

Characterized by one or more circular, sharply Characterized by one or more circular, sharply circumscribed, slightly erythematous, dry, scaly, circumscribed, slightly erythematous, dry, scaly, usually hypopigmented patchesusually hypopigmented patches

Advancing scaling edge is usually prominentAdvancing scaling edge is usually prominent

Tinea corporis in a Tinea corporis in a child, caused by child, caused by Microsporum canisMicrosporum canis

Tinea corporis Tinea corporis ((Trichophyton rubrum)Trichophyton rubrum)

Note sharp margins Note sharp margins and central clearingand central clearing

Tinea CorporisTinea Corporis

In some cases concentric circles form rings in In some cases concentric circles form rings in one another, making intricate patterns (tinea one another, making intricate patterns (tinea imbricata)imbricata)

Widespread tinea corporis may be the Widespread tinea corporis may be the presenting sign of AIDSpresenting sign of AIDS

Tinea corporis: large gyrate plaque with Tinea corporis: large gyrate plaque with advancing border, perhaps worsened by advancing border, perhaps worsened by

diaperingdiapering

HistopathologyHistopathology

Better ways to make diagnosisBetter ways to make diagnosis But if compact orthokeratosis is found in a But if compact orthokeratosis is found in a

section, a search for fungal hyphae should section, a search for fungal hyphae should be performedbe performed

This is diagnosticThis is diagnostic

Etiology-Tinea CorporisEtiology-Tinea Corporis

Microsporum canis, T. rubrum, T. Microsporum canis, T. rubrum, T. mentagrophytesmentagrophytes- most common- most common

T. rubrum T. rubrum is is the most common is is the most common dermatophyte in the U.S. and worldwidedermatophyte in the U.S. and worldwide

T. tonsuransT. tonsurans has experienced a dramatic has experienced a dramatic rise as a cause of tinea corporis as it has for rise as a cause of tinea corporis as it has for tinea capitistinea capitis

In children, In children, M. canisM. canis is the cause of the is the cause of the “moist” type of tinea circinata“moist” type of tinea circinata

EpidemiologyEpidemiology

Tinea corporis is frequently seen in children-Tinea corporis is frequently seen in children-particularly those exposed to animals with particularly those exposed to animals with ringworm (ringworm (M. canis)M. canis), especially , especially CATSCATS, dogs and , dogs and less commonly, horses and cattleless commonly, horses and cattle

In adults excessive perspiration is the most In adults excessive perspiration is the most common factorcommon factor– Personal history or close contact with tinea capitis or Personal history or close contact with tinea capitis or

tinea pedis is another important factortinea pedis is another important factor

Incidence is especially high in hot, humid areas of Incidence is especially high in hot, humid areas of the worldthe world

Treatment-Tinea CorporisTreatment-Tinea Corporis When tinea corporis is caused by When tinea corporis is caused by T. tonsurans, M. canis, T. T. tonsurans, M. canis, T.

mentagrophytes, or T. rubrummentagrophytes, or T. rubrum; griseofulvin, terbinafine, ; griseofulvin, terbinafine, itraconazole, and fluconazole are all effectiveitraconazole, and fluconazole are all effective

The ultra-micronized form may be used at a dose of 350-750 The ultra-micronized form may be used at a dose of 350-750 mg once/day for 4-6 weeksmg once/day for 4-6 weeks

This dose may be increased to twice daily if neededThis dose may be increased to twice daily if needed Terbinafine, itraconazole, and fluconazole are effectiveTerbinafine, itraconazole, and fluconazole are effective Terbinafine at 250 mg/day for two weeksTerbinafine at 250 mg/day for two weeks Itraconazole 200 mg B.I.D. for one weekItraconazole 200 mg B.I.D. for one week Fluconazole 150 mg once/week for 4 weeksFluconazole 150 mg once/week for 4 weeks

Treatment Treatment When only 1-2 patches occur, topical tx When only 1-2 patches occur, topical tx

is effectiveis effective Most are between 2-4 weeks with twice Most are between 2-4 weeks with twice

daily usedaily use Econazole, ketaconazole, oxiconazole, Econazole, ketaconazole, oxiconazole,

and terbinafine may be used once dailyand terbinafine may be used once daily With terbinafine the course can be With terbinafine the course can be

shortened to 1 weekshortened to 1 week

Treatment Treatment Creams are more effective than lotionsCreams are more effective than lotions Sulconazole may be less irritating in folded Sulconazole may be less irritating in folded

areasareas Castellani paint (which is colorless if made Castellani paint (which is colorless if made

without fuchin) is very effectivewithout fuchin) is very effective Salicylic acid 3-5%, or half-strength Whitfield’s Salicylic acid 3-5%, or half-strength Whitfield’s

ointment, both standbys 30 yrs ago, are rarely ointment, both standbys 30 yrs ago, are rarely used todayused today

Addition of a low-potency steroid cream Addition of a low-potency steroid cream during the initial 3-5 days of therapy can during the initial 3-5 days of therapy can decrease irritation rapidly without decrease irritation rapidly without compromising the effectiveness of the compromising the effectiveness of the antifungalantifungal

Other Forms of Tinea CorporisOther Forms of Tinea Corporis

Trichophytic Granuloma or Perifollicular Trichophytic Granuloma or Perifollicular Granuloma or Majocchi’s Granuloma or Tinea Granuloma or Majocchi’s Granuloma or Tinea IncognitoIncognito

A deep, pustular type of tinea circinata resembling A deep, pustular type of tinea circinata resembling a carbuncle or kerion observed on the glabrous a carbuncle or kerion observed on the glabrous skinskin

A circumscribed, annular, raised, crusty, and A circumscribed, annular, raised, crusty, and boggy granulomaboggy granuloma

Follicles are distended with viscid purulent Follicles are distended with viscid purulent materialmaterial

Most frequently on the shins or wristsMost frequently on the shins or wrists

Majocchi’s granuloma H&E pale blue-staining Majocchi’s granuloma H&E pale blue-staining fungal hyphae within hair shaftfungal hyphae within hair shaft

Majocchi’s granuloma: PAS reveals multiple organisms that have Majocchi’s granuloma: PAS reveals multiple organisms that have replaced a fragment of hair shaft embedded in a sea of neutrophilsreplaced a fragment of hair shaft embedded in a sea of neutrophils

Tinea Imbricata (Tokelau)Tinea Imbricata (Tokelau)

Superficial fungal infection limited to southwest Superficial fungal infection limited to southwest Polynesia, Melanesia, Southeast Asia, India, and Polynesia, Melanesia, Southeast Asia, India, and Central AmericaCentral America

Characterized by concentric rings of scales forming Characterized by concentric rings of scales forming extensive patches with polycyclic bordersextensive patches with polycyclic borders

Small macular patch splits in center and forms large, Small macular patch splits in center and forms large, flaky scales attached at the peripheryflaky scales attached at the periphery

Resultant ring spreads peripherally and another Resultant ring spreads peripherally and another brownish macule appears in the center and brownish macule appears in the center and undergoes the process againundergoes the process again

Tinea ImbricataTinea Imbricata

When fully developed the eruption is characterized by When fully developed the eruption is characterized by concentrically arranged rings or parallel undulating lines of concentrically arranged rings or parallel undulating lines of scales overlapping each other like shingles on a roof scales overlapping each other like shingles on a roof (imbrex means shingle)(imbrex means shingle)

Causative fungus is Causative fungus is T. concentricumT. concentricum TOC is griseofulvin- in same form as for tinea corporisTOC is griseofulvin- in same form as for tinea corporis Other options are terbinafine, fluconazole, and itraconazoleOther options are terbinafine, fluconazole, and itraconazole Several courses of therapy may be neededSeveral courses of therapy may be needed May need to remove patient from hot, humid environmentMay need to remove patient from hot, humid environment

Tinea imbricata in New Guinea nativeTinea imbricata in New Guinea native

Tinea imbricata: concentric rings of scale Tinea imbricata: concentric rings of scale caused by caused by T. concentricumT. concentricum

Tinea CrurisTinea Cruris

AKA jock itchAKA jock itch Most common in menMost common in men On upper and inner thighsOn upper and inner thighs Begins as a small erythematous and scaling or Begins as a small erythematous and scaling or

vesicular and crusted patch vesicular and crusted patch Spreads peripherally and partly clears in the centerSpreads peripherally and partly clears in the center Penoscrotal fold or sides of scrotum are seldom Penoscrotal fold or sides of scrotum are seldom

involved; penis not involvedinvolved; penis not involved

Tinea cruris in a manTinea cruris in a man

Tinea cruris in a womanTinea cruris in a woman

Etiology-Tinea CrurisEtiology-Tinea Cruris

T. mentagrophytes T. mentagrophytes && E. floccosum & T. E. floccosum & T. rubrumrubrum usual cause usual cause

Frequently associated with tinea pedis b/c of Frequently associated with tinea pedis b/c of contaminated clothing contaminated clothing

Heat and high humidityHeat and high humidity Tight Tight jockey shortsjockey shorts!!

TreatmentTreatment

Reduce perspiration and enhance evaporation from Reduce perspiration and enhance evaporation from crural area crural area

Keep as dry as possible by wearing loose Keep as dry as possible by wearing loose underclothing underclothing

Plain talcum powder or antifungal powdersPlain talcum powder or antifungal powders Specific topical and oral treatment is same as that Specific topical and oral treatment is same as that

described under tinea corporisdescribed under tinea corporis

Tinea in diaper areaTinea in diaper area

Tinea PedisTinea Pedis

AKA athlete’s footAKA athlete’s foot Most common fungal disease(by far)Most common fungal disease(by far) Primary lesions often are macerated with Primary lesions often are macerated with

occasional vesiculation, and fissures between occasional vesiculation, and fissures between the toesthe toes

Extreme pruritusExtreme pruritus

Tinea pedis showing interdigital scalpingTinea pedis showing interdigital scalping T. mentagrophytesT. mentagrophytes

Interdigital scaling with vesiculation Interdigital scaling with vesiculation caused by T. mentagrophytescaused by T. mentagrophytes

Dermatophytosis Dermatophytosis of the solesof the soles

Trichophyton Trichophyton mantagrophytesmantagrophytes

Acute Acute vesiculobullous vesiculobullous eruption on sole eruption on sole

caused by caused by Trichophyton Trichophyton

mentagrophytesmentagrophytes

TP-TP-Trichophyton rubrumTrichophyton rubrum

T. rubrumT. rubrum causes the causes the majority of cases majority of cases

Produces a relatively Produces a relatively noninflammatory type of noninflammatory type of dermatophytosis dermatophytosis characterized by a dull characterized by a dull erythema and pronounced erythema and pronounced scaling involving the entire scaling involving the entire sole and sides of feetsole and sides of feet

Producing a moccasin or Producing a moccasin or sandal appearancesandal appearance

Tinea pedis and Tinea pedis and onychomycosis in onychomycosis in father/son pair.father/son pair.

Father shows classic Father shows classic moccasin distribution of moccasin distribution of tinea pedis and son tinea pedis and son shows distal subungual shows distal subungual onychomycosisonychomycosis

Tinea manusTinea manus

Tinea infection of hands Tinea infection of hands that is dry, scaly, and that is dry, scaly, and erythematous may occurerythematous may occur

Suggestive of infection Suggestive of infection with with T. rubrumT. rubrum

Other areas are frequently Other areas are frequently affected at the same timeaffected at the same time

Trichophyton rubrum Trichophyton rubrum infectionsinfections

Differential diagnosisDifferential diagnosis

Allergic contact or irritant dermatitis-especially Allergic contact or irritant dermatitis-especially occupationaloccupational

PompholyxPompholyx Atopic dermatitisAtopic dermatitis PsoriasisPsoriasis Lamellar dyshidrosisLamellar dyshidrosis Eczematoid or dyshidrotic lesions of unknown Eczematoid or dyshidrotic lesions of unknown

cause on hands should prompt a search for cause on hands should prompt a search for clinical evidence of dermatophytosis of feet etc.clinical evidence of dermatophytosis of feet etc.

Fungus filaments under KOH mountFungus filaments under KOH mount

Mosaic fungusMosaic fungus

Prophylaxis Prophylaxis

Hyperhidrosis is a predisposing factorHyperhidrosis is a predisposing factor Dry toes after bathingDry toes after bathing Tolnaftate powder or Zeasorb medicated powders Tolnaftate powder or Zeasorb medicated powders

for feetfor feet Plain talc, cornstartch, or rice powder may be Plain talc, cornstartch, or rice powder may be

dusted into socks and shoes to keep feet drydusted into socks and shoes to keep feet dry

TreatmentTreatment

Topical antifungalsTopical antifungals With significant maceration wet dressings or With significant maceration wet dressings or

soaks with solutions such as aluminum soaks with solutions such as aluminum acetate, one part to 20 parts of wateracetate, one part to 20 parts of water

Anti-inflammatory effects of corticosteroids Anti-inflammatory effects of corticosteroids are markedly beneficialare markedly beneficial

Topical antibiotic ointments effective against Topical antibiotic ointments effective against gram-negative organisms (gentamicin), in tx gram-negative organisms (gentamicin), in tx of the moist type of interdigital lesionsof the moist type of interdigital lesions

In ulcerative type of gram-negative toe web In ulcerative type of gram-negative toe web infections, systemic floxins are neededinfections, systemic floxins are needed

TreatmentTreatment Keratolytic agents, such as salicylic acid, Keratolytic agents, such as salicylic acid,

lactic acid lotions, and Carmol are therapeutic lactic acid lotions, and Carmol are therapeutic when fungus is protected by a thick layer of when fungus is protected by a thick layer of overlying skin (i.e. soles)overlying skin (i.e. soles)

Griseofulvin is only effective against Griseofulvin is only effective against dermatophytesdermatophytes

When infection is caused by When infection is caused by T. T. mentagrophytes,mentagrophytes, griseofulvin does not griseofulvin does not decrease inflammatory reactiondecrease inflammatory reaction

Treatment- dosingTreatment- dosing

Griseofulvin in ultramicronized particles taken Griseofulvin in ultramicronized particles taken orally in doses of 350-750 mg dailyorally in doses of 350-750 mg daily

Dosage for children is 10 mg/kg/dayDosage for children is 10 mg/kg/day Period of treatment depends on response Period of treatment depends on response Repeated KOH scrapings and culture should be Repeated KOH scrapings and culture should be

negativenegative Recommended adult doses for newer agents: Recommended adult doses for newer agents:

terbinafine, 250 mg/day for 2 weeks; itraconazole, terbinafine, 250 mg/day for 2 weeks; itraconazole, 200 mg twice daily for 1 week; fluconazole, 150 200 mg twice daily for 1 week; fluconazole, 150 mg once weekly for 4 weeksmg once weekly for 4 weeks

OnychomycosisOnychomycosis(Tinea Unguium)(Tinea Unguium)

Onychomycosis encompasses both dermatophyte Onychomycosis encompasses both dermatophyte and non-dermatophyte nail infectionsand non-dermatophyte nail infections

Represents up to 30% of diagnosed superficial Represents up to 30% of diagnosed superficial fungal infectionsfungal infections

Etiologic agents are: Etiologic agents are: Epidermophyton, Epidermophyton, Microsporum, and Trichophyton Microsporum, and Trichophyton fungifungi

OnychomycosisOnychomycosis

Four classic types:Four classic types: 1) distal subungual onychomycosis: primarily 1) distal subungual onychomycosis: primarily

involves distal nail bed and hyponychium, with involves distal nail bed and hyponychium, with secondary involvement of underside of nail plate secondary involvement of underside of nail plate of fingernails and toenailsof fingernails and toenails

Onychomycosis caused by Onychomycosis caused by Trichophyton Trichophyton rubrumrubrum

Trichophyton mentagrophytesTrichophyton mentagrophytes

2) white superficial 2) white superficial onychomycosis (leukonychia onychomycosis (leukonychia trichophytica.) This is an trichophytica.) This is an invasion of the toenail plate invasion of the toenail plate on the surface of the nailon the surface of the nail

It is produced by It is produced by T.mentagrophytes, T.mentagrophytes, species species of of Cephalosporium and Cephalosporium and Aspergillus, and Fusarium Aspergillus, and Fusarium oxysporum oxysporum fungusfungus

OnychomycosisOnychomycosis

3) Proximal subungual onychomycosis: involves 3) Proximal subungual onychomycosis: involves the nail plate mainly from proximal nail foldthe nail plate mainly from proximal nail fold

It is produced by It is produced by T. rubrum & T. megniniiT. rubrum & T. megninii and may and may be an indication of HIV infectionbe an indication of HIV infection

4) Candida onychomycosis involves all the nail 4) Candida onychomycosis involves all the nail plate; it is due to plate; it is due to Candida albicansCandida albicans and is seen in and is seen in patients with chronic mucocuataneous candidiasis patients with chronic mucocuataneous candidiasis – Associated paronychiaAssociated paronychia– Adjacent cuticle is pink, swollen, and tenderAdjacent cuticle is pink, swollen, and tender– Fingernails > toenailsFingernails > toenails

Onychomycosis caused by Onychomycosis caused by Candida albicansCandida albicans in mucocutaneous candidiasisin mucocutaneous candidiasis

OnychomycosisOnychomycosis

Onychomycosis caused by Onychomycosis caused by T. rubrum T. rubrum is usually a deep is usually a deep infectioninfection

Disease usually starts at Disease usually starts at distal corner of nail and distal corner of nail and involves the junction of nail involves the junction of nail and its bedand its bed

First a yellowish First a yellowish discoloration occurs, which discoloration occurs, which may spread until entire nail may spread until entire nail is affectedis affected

Beneath discoloration nail Beneath discoloration nail plate becomes loose from plate becomes loose from nail bednail bed

Gradually entire nail becomes brittle and separated Gradually entire nail becomes brittle and separated from its bed due to piling up of keratin subungually from its bed due to piling up of keratin subungually

Nail may break off, leaving an undermined remnant Nail may break off, leaving an undermined remnant that is black and yellow from dead nail and fungi that that is black and yellow from dead nail and fungi that

are presentare present

A: Distal subungal, onychomycosis A: Distal subungal, onychomycosis occurring simultaneously with superficial occurring simultaneously with superficial

white onychomycosiswhite onychomycosis B: Superficial white onychomycosisB: Superficial white onychomycosis

DifferentialDifferential

Allergic contact dermatitisAllergic contact dermatitis PsoriasisPsoriasis Lichen planusLichen planus 20 nail dystrophy20 nail dystrophy Darier’s diseaseDarier’s disease Reiter’s diseaseReiter’s disease Norwegian scabiesNorwegian scabies Non-dermatophyte onychomycosisNon-dermatophyte onychomycosis

TreatmentTreatment

PO terbinafine, fluconazole, and itraconazolePO terbinafine, fluconazole, and itraconazole Griseofulvin continued until nails are clinically Griseofulvin continued until nails are clinically

normalnormal Low success rates 15-30% for toenails and Low success rates 15-30% for toenails and

50-70% for fingernails50-70% for fingernails Griseofulvin does not tx nail disease caused Griseofulvin does not tx nail disease caused

by candidaby candida 3% Thymol in EtOH3% Thymol in EtOH

CandidiasisCandidiasis

Candida Candida proliferates in both budding and mycelial proliferates in both budding and mycelial forms in outer layers of the stratum corneum forms in outer layers of the stratum corneum where horny cells are desquamatingwhere horny cells are desquamating

It does not attack hair, rarely involves nail, and is It does not attack hair, rarely involves nail, and is incapable of breaking up the stratum corneumincapable of breaking up the stratum corneum

It is largely an opportunisitic organismIt is largely an opportunisitic organism Moisture promotes its growthMoisture promotes its growth

– Lip cornersLip corners– Body foldsBody folds

DiagnosisDiagnosis

Demonstration of the pathogenic yeast Demonstration of the pathogenic yeast C. C. albicansalbicans establishes the diagnosis establishes the diagnosis

Under microscope KOH prep may show Under microscope KOH prep may show spores and pseudomyceliumspores and pseudomycelium

Culture on Sabouraud’s glucose agar shows Culture on Sabouraud’s glucose agar shows a growth of creamy, grayish, moist colonies in a growth of creamy, grayish, moist colonies in about 4 days about 4 days

In time colonies form small, root-like In time colonies form small, root-like penetrations into agarpenetrations into agar

Mycelium and spores of Mycelium and spores of Candida albicansCandida albicans

CandidiasisCandidiasis

KOH mount from infant with thrush showing KOH mount from infant with thrush showing pseudohyphae and yeast formspseudohyphae and yeast forms

Topical Anti-candidal AgentsTopical Anti-candidal Agents

These include, but are not limited to: clotrimazole These include, but are not limited to: clotrimazole (Lotrimin, Mycelex), econazole (Spectazole), (Lotrimin, Mycelex), econazole (Spectazole), ketaconazole (Nizoral), miconazole (MonistatDerm ketaconazole (Nizoral), miconazole (MonistatDerm Lotion, Micatin), oxiconazole (Oxistat), Lotion, Micatin), oxiconazole (Oxistat), sulconazole (Exelderm), naftifine (Naftin), sulconazole (Exelderm), naftifine (Naftin), terconazole (vaginal candidiasis only), cicloprox terconazole (vaginal candidiasis only), cicloprox olamine (Loprox), butenafine (Mentax), nystatin, olamine (Loprox), butenafine (Mentax), nystatin, and topical amphotericin B lotionand topical amphotericin B lotion

Terbinafine has been reported to be less active Terbinafine has been reported to be less active against against Candida Candida species by some authorsspecies by some authors

Oral Candidiasis (Thrush)Oral Candidiasis (Thrush)

Newborn infection may be acquired from Newborn infection may be acquired from contact with vaginal tract of mothercontact with vaginal tract of mother

Grayish white membranous plaques are Grayish white membranous plaques are found on surfacefound on surface

Base of plaques are moist, reddish, and Base of plaques are moist, reddish, and maceratedmacerated

Diaper areas is especially susceptible to thisDiaper areas is especially susceptible to this Most of intertriginous areas and even Most of intertriginous areas and even

exposed skin may be involvedexposed skin may be involved

Frequently infection extends onto angles of Frequently infection extends onto angles of the mouth to form perleche (seen in elderly, the mouth to form perleche (seen in elderly, debilitated, and malnourished patients, and debilitated, and malnourished patients, and diabetics)diabetics)

It is often the first manifestation of AIDSIt is often the first manifestation of AIDS Is present in nearly 100% of all untreated Is present in nearly 100% of all untreated

patients with full-blown AIDSpatients with full-blown AIDS ““Thrush” in an adult with no known Thrush” in an adult with no known

predisposing factors warrants a search for predisposing factors warrants a search for other evidence of infection with HIV, such as other evidence of infection with HIV, such as lymphadenopathy, leukopenia, or HIV lymphadenopathy, leukopenia, or HIV antibodies in serumantibodies in serum

Oral candidiasis (Thrush)Oral candidiasis (Thrush)

Thrush with extension to vermilion borderThrush with extension to vermilion border

TreatmentTreatment Babies with thrush may be allowed to suck on Babies with thrush may be allowed to suck on

a clotrimazole suppository inserted into the a clotrimazole suppository inserted into the slit tip of a pacifier four times a day for 2-3 slit tip of a pacifier four times a day for 2-3 daysdays

An adult can let tablets of clotrimazole or An adult can let tablets of clotrimazole or Mycelex troches dissolve in the mouthMycelex troches dissolve in the mouth

Fluconazole, 100-200 mg/day for 5-10 days Fluconazole, 100-200 mg/day for 5-10 days with doubling the dose if it fails, or with doubling the dose if it fails, or Itraconazole, 200 mg daily for 5-10 days with Itraconazole, 200 mg daily for 5-10 days with doubling the dose if it fails-both are available doubling the dose if it fails-both are available in liquid formsin liquid forms

PerlechePerleche

AKA angular cheilitisAKA angular cheilitis Maceration with transverse fissuring of oral Maceration with transverse fissuring of oral

commissurescommissures Soft, pinhead-sized papules may appearSoft, pinhead-sized papules may appear Involvement is bilateral-usuallyInvolvement is bilateral-usually

PerlechePerleche

PerlechePerleche

Analogous to intertrigo elsewhereAnalogous to intertrigo elsewhere Similar changes may be seen in riboflavin Similar changes may be seen in riboflavin

deficiency, and iron deficiency anemiadeficiency, and iron deficiency anemia Identical fissuring occurs in persons with Identical fissuring occurs in persons with

malocclusion caused by ill-fitting dentures and malocclusion caused by ill-fitting dentures and in the aged whom atrophy of alveolar ridges in the aged whom atrophy of alveolar ridges has occurredhas occurred

Seen in children who drool, lick their lips, or Seen in children who drool, lick their lips, or suck their thumbsuck their thumb

TreatmentTreatment

If due to If due to C. albicans,C. albicans, anti-candidal creams and lotions anti-candidal creams and lotions can be usedcan be used

Glycemic control in diabetesGlycemic control in diabetes Antibiotic topical meds are used when a bacterial; Antibiotic topical meds are used when a bacterial;

infection is presentinfection is present If due to vertical shortening of lower third of the face, If due to vertical shortening of lower third of the face,

dental or oral surgical intervention may helpdental or oral surgical intervention may help Injection of collagen into depressed sulcus at the oral Injection of collagen into depressed sulcus at the oral

commissure may be helpfulcommissure may be helpful Vytone!!Vytone!!

Candidal VulvovaginitisCandidal Vulvovaginitis

Pruritus, irritation, and extreme burningPruritus, irritation, and extreme burning Labia may be erythemtous, moist, and macerated and Labia may be erythemtous, moist, and macerated and

cervix hyperemic, swollen, and eroded, showing small cervix hyperemic, swollen, and eroded, showing small vesicles on its surfacevesicles on its surface

Vaginal discharge is not usually profuse but is Vaginal discharge is not usually profuse but is frequently thick and tenaciousfrequently thick and tenacious

May develop during pregnancy, in diabetes, or May develop during pregnancy, in diabetes, or secondary to therapy with a broad- spectrum antibioticsecondary to therapy with a broad- spectrum antibiotic

Recurrent vulvovaginal candidiasis has been Recurrent vulvovaginal candidiasis has been associated with long-term tamoxifen txassociated with long-term tamoxifen tx

Candidal VulvovaginitisCandidal Vulvovaginitis

Candidal balanitis may be present in an uncircumcised sexual Candidal balanitis may be present in an uncircumcised sexual partnerpartner

If not recognized, repeated reinfection of a partner may occurIf not recognized, repeated reinfection of a partner may occur Diagnosis is by clinical symptoms and findings as well as Diagnosis is by clinical symptoms and findings as well as

demonstration of fungus via KOH microscopic exam & culturedemonstration of fungus via KOH microscopic exam & culture Tx is frustrating & disappointing due to recurrencesTx is frustrating & disappointing due to recurrences Oral fluconazole 150 mg times 1 dose; Fluconazole, Oral fluconazole 150 mg times 1 dose; Fluconazole,

100mg/day for 5-7 days, itraconazole, 200 mg/day for 2-3 100mg/day for 5-7 days, itraconazole, 200 mg/day for 2-3 days are other optionsdays are other options

TreatmentTreatment

Topical options include miconizole (Monistat Topical options include miconizole (Monistat cream), nystatin vaginal suppositories or cream), nystatin vaginal suppositories or tablets (Mycostatin), or clotrimazole (Gyne-tablets (Mycostatin), or clotrimazole (Gyne-Lotrimin or Mycelex G) vaginal tablets Lotrimin or Mycelex G) vaginal tablets inserted once daily for 7 daysinserted once daily for 7 days

Candidal IntertrigoCandidal Intertrigo Pinkish intertriginous moist patches are Pinkish intertriginous moist patches are

surrounded by a thin, overhanging fringe of surrounded by a thin, overhanging fringe of somewhat macerated epidermis (“collarette” somewhat macerated epidermis (“collarette” scale)scale)

May resemble tinea cruris, but usually there is May resemble tinea cruris, but usually there is less scaliness and a greater tendency to less scaliness and a greater tendency to fissuringfissuring

Topical anti-candidal preparations are usually Topical anti-candidal preparations are usually effectiveeffective

Recurrence is commonRecurrence is common

Pseudo Diaper RashPseudo Diaper Rash

In infants, In infants, C. albicans C. albicans infection may start in perianal infection may start in perianal region and spread over entire arearegion and spread over entire area

Dermatitis is enhanced by maceration produced by Dermatitis is enhanced by maceration produced by wet diaperswet diapers

Diaper friction may contribute to skin irritation and Diaper friction may contribute to skin irritation and compromised function of stratum corneumcompromised function of stratum corneum

Suspected by finding involvement of folds and Suspected by finding involvement of folds and occurrence of many small erythematous occurrence of many small erythematous desquamating “satellite” or “daughter” lesions desquamating “satellite” or “daughter” lesions scattered around edgesscattered around edges

Congenital Cutaneous Congenital Cutaneous CandidiasisCandidiasis

Infection of an infant during passage through birth Infection of an infant during passage through birth canalcanal

Eruption usually noted within first few hrs of deliveryEruption usually noted within first few hrs of delivery Erythematous macules progress to thin-walled Erythematous macules progress to thin-walled

pustules, which rupture, dry, and desquamate within a pustules, which rupture, dry, and desquamate within a weekweek

Lesions are usually widespread, involving trunk, neck, Lesions are usually widespread, involving trunk, neck, and head, at times palms and soles, including nail and head, at times palms and soles, including nail foldsfolds

Oral cavity and diaper area are sparedOral cavity and diaper area are spared

Congenital Cutaneous Congenital Cutaneous CandidiasisCandidiasis

Differential dx: listeriosis, syphilis, staphylococcal Differential dx: listeriosis, syphilis, staphylococcal and herpes infections, ETN, transient neonatal and herpes infections, ETN, transient neonatal pustular melanosis, miliaria rubra , drug eruption, pustular melanosis, miliaria rubra , drug eruption, congenital icthyosiform erythroderma (neonatal congenital icthyosiform erythroderma (neonatal pustular disorders)pustular disorders)

If suspected early amniotic fluid, placenta, and If suspected early amniotic fluid, placenta, and cord should be examined for evidence of infectioncord should be examined for evidence of infection

Infants with disease limited to skin have favorable Infants with disease limited to skin have favorable outcomesoutcomes

Congenital Cutaneous Congenital Cutaneous CandidiasisCandidiasis

Disseminated infection is suggested by (1) birth Disseminated infection is suggested by (1) birth weight <1500g (2) evidence of respiratory distress or weight <1500g (2) evidence of respiratory distress or labs indicating neonatal sepsis (3) tx with broad-labs indicating neonatal sepsis (3) tx with broad-spectrum antibiotics (4) extensive instrumentation spectrum antibiotics (4) extensive instrumentation during delivery or invasive procedures in neonatal during delivery or invasive procedures in neonatal period (5) positive systemic cultures, or (6) evidence period (5) positive systemic cultures, or (6) evidence of an altered immune responseof an altered immune response

Infants with congenital cutaneous candidiasis with Infants with congenital cutaneous candidiasis with any of these 6 criteria would be considered for any of these 6 criteria would be considered for systemic antifungal therapysystemic antifungal therapy

Perianal CandidiasisPerianal Candidiasis Frequently entire GI tract is involvedFrequently entire GI tract is involved Can be precipitated by oral antibiotic therapyCan be precipitated by oral antibiotic therapy Perianal dermatitis with erythema, oozing, and Perianal dermatitis with erythema, oozing, and

maceration is presentmaceration is present Psychogenic etiology is more common than is Psychogenic etiology is more common than is

candidiasiscandidiasis Differential dx: psoriasis, seborrheic dermatitis, Differential dx: psoriasis, seborrheic dermatitis,

streptococcal and staphylococcal infections, contact streptococcal and staphylococcal infections, contact dermatitis, and extramammary Paget’s diseasedermatitis, and extramammary Paget’s disease

Fungicides, meticulous cleansing of perianal region Fungicides, meticulous cleansing of perianal region after bowel movements, topical corticosteroids and after bowel movements, topical corticosteroids and antipruritics (Atarax)antipruritics (Atarax)

Candidal ParonychiaCandidal Paronychia

Cushion-like thickening of paronychial tissue, slow Cushion-like thickening of paronychial tissue, slow erosion of lateral borders of nails, gradual thickening erosion of lateral borders of nails, gradual thickening and brownish discoloration of nail plates, and and brownish discoloration of nail plates, and development of pronounced transverse ridgesdevelopment of pronounced transverse ridges

Frequently only one nailFrequently only one nail A secondary mixed bacterial infection can occur with A secondary mixed bacterial infection can occur with

those who frequently have hands in water or who those who frequently have hands in water or who handle moist objects; cooks, dishwashers, bartenders, handle moist objects; cooks, dishwashers, bartenders, nurses, canners, etcnurses, canners, etc

Candidal ParonychiaCandidal Paronychia Manicuring nails sometimes is responsible for Manicuring nails sometimes is responsible for

mechanical or chemical injuries leading to mechanical or chemical injuries leading to infectioninfection

Ingrown toenails with chronic paronychia Ingrown toenails with chronic paronychia Seen in pts with diabetesSeen in pts with diabetes Avoid chronic moisture exposure; get diabetes Avoid chronic moisture exposure; get diabetes

under controlunder control Oral fluconazole once weekly or pulse dose Oral fluconazole once weekly or pulse dose

itraconazole should be effectiveitraconazole should be effective Topical therapy should continue for 2-3 months Topical therapy should continue for 2-3 months

to prevent recurrenceto prevent recurrence

Erosia Interdigitalis Erosia Interdigitalis BlastomyceticaBlastomycetica

Oval-shaped area of macerated white skin on web Oval-shaped area of macerated white skin on web between and extending onto sides of fingersbetween and extending onto sides of fingers

With progression macerated skin peels off, leaving With progression macerated skin peels off, leaving painful, raw,denuded area surrounded by a collar of painful, raw,denuded area surrounded by a collar of overhanging white epidermisoverhanging white epidermis

Nearly always affects third webNearly always affects third web Moisture beneath rings macerates skin and Moisture beneath rings macerates skin and

predisposes to infectionpredisposes to infection Also seen in diabetics, those who do housework, Also seen in diabetics, those who do housework,

launderers, and others exposed to macerating effects launderers, and others exposed to macerating effects of water and strong alkalisof water and strong alkalis

Chronic Mucocutaneous Chronic Mucocutaneous CandidiasisCandidiasis

A heterogeneous group of patients whose infection A heterogeneous group of patients whose infection with with Candida Candida is chronic but superficialis chronic but superficial

Onset before age 6Onset before age 6 Onset in adult life may herald the occurrence of Onset in adult life may herald the occurrence of

thymomathymoma When inherited an endocrinopathy is often foundWhen inherited an endocrinopathy is often found Most cases have well-defined limited defects of cell-Most cases have well-defined limited defects of cell-

immunityimmunity Oral lesions are diffuse and perleche and lip fissures Oral lesions are diffuse and perleche and lip fissures

are commonare common

Systemic CandidiasisSystemic Candidiasis

High risk pts: pts with malignancies, AIDS, transplant High risk pts: pts with malignancies, AIDS, transplant pts requiring immunosuppressive drugs, pts on oral pts requiring immunosuppressive drugs, pts on oral cortisone, pts who have had multiple surgical cortisone, pts who have had multiple surgical operations especially cardiac, pts with indwelling operations especially cardiac, pts with indwelling catheters, and heroin addictscatheters, and heroin addicts

Initial sign is varied: FUO, pulmonary infiltrates, GI Initial sign is varied: FUO, pulmonary infiltrates, GI bleeding, endocarditis, renal failure, meningitis, bleeding, endocarditis, renal failure, meningitis, osteomyelitis, endophthalmitis, peritonitis, or a osteomyelitis, endophthalmitis, peritonitis, or a disseminated maculopapular eruptiondisseminated maculopapular eruption

Systemic CandidiasisSystemic Candidiasis

Cutaneous findings are erythematous macules that Cutaneous findings are erythematous macules that become papular, pustular, and hemorrhagic, and may become papular, pustular, and hemorrhagic, and may progress to necrotic, ulcerating lesions resembling progress to necrotic, ulcerating lesions resembling ecthyma gangrenosumecthyma gangrenosum

Deep abscesses may occurDeep abscesses may occur Trunk and extremities are usual sites of involvementTrunk and extremities are usual sites of involvement Proximal muscle tenderness is a common findingProximal muscle tenderness is a common finding

Systemic CandidiasisSystemic Candidiasis

If candida is cultured within the first week of life If candida is cultured within the first week of life there is a high rate of systemic diseasethere is a high rate of systemic disease

There is a 50% chance of systemic disease if 1 or There is a 50% chance of systemic disease if 1 or more cultures is positivemore cultures is positive

Mortality has declined from 80% in the 1970’s to Mortality has declined from 80% in the 1970’s to 40% in the 1990’s because of early empiric 40% in the 1990’s because of early empiric antifungals and better prophylaxisantifungals and better prophylaxis

THE ENDTHE END