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Management of
Common Common
Fungal Skin Infections
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• Superficial fungal infections of
the skin are one of the most
common dermatologic
conditions seen in clinical conditions seen in clinical
practice.
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Fungi: Common Groups
1. Dermatophytes: Superficial Ring
worm type
2. Candida Albacans: Yeast infection2. Candida Albacans: Yeast infection
3. Pityrosporium: Yeast, present in
normal flora of skin, esp. scalp &
trunk.
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CLASSIFICATION OF
FUNGAL INFECTION
1.Superficial
2.Cutaneous
3.Subcutaneous3.Subcutaneous
4.Systemic
5.Opportunistic
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1. Superficial mycoses- Pityriasis versicolor – pigmented lesion
on torso (trunk of the human body). ( Dubo? )
- Tinea nigra – gray to black macular lesion
on palms.
- Black piedra – dark gritty deposits on hair.
- White piedra – soft whitish granules along
hair shaft.
- All diagnosed by microscopy and easily
treated by topical preparation.
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2. Cutaneous infections
• Infections of skin and its appendages (nails, hair)
20 Spp. of dermatophytes cause • 20 Spp. of dermatophytes cause ringworm.
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3. Subcutaneous mycoses
-Subcutaneous infections, over 35 spp.
Produce chronic inflammatory disease
of subcutaneous tissue & lymphatics, of subcutaneous tissue & lymphatics,
e.g. sporotrichosis (Ulcerated lesion at
site of inculasion followed by multiple
nodules)
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4. Systemic fungal infections
- Uncommon: if Natural immunity is high
- Physiologic barriers include:
- Skin and mucus membranes
- Tissue temperature: fungi grow better at- Tissue temperature: fungi grow better at
less than 37°C
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5. Opportunistic Mycoses
- Do not normally cause disease in healthy people.
- Cause disease in immuno-compromised people.
- Weakened immune function may occure due to:
▪ Inherited immunodeficiency disease▪ Inherited immunodeficiency disease
▪ Drugs that suppress immune system:
cancer chemotherapy, corticosteroids, drugs
to prevent organ transplant Rejection.
▪ Radiation therapy
▪ Infection (HIV)
▪ Cancer, diabetes, advanced age and mal-nutrition.
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Most common opportunistic mycotic
infections: (commonly seen in PLWHA)
1. Candidiasis
2. Aspergillosis2. Aspergillosis
3. Cryptococcosis
4. Zygomycosis/mucormycosis
5. Pneumocystis carinii
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Superficial Fungal
Infections
• Tinea infections• Tinea infections
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TINEA Infection
• T.Corporis- ringworm of body
• T.Cruris- groin• T.Cruris- groin
• T.Pedis- foot
• T.Unguium- nail
• T.Capitis scalp
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T.Corporis (ring of the body)
• Superficial skin infection
• Itchy
• Annular patch (ring shaped)• Annular patch (ring shaped)
• Well defined edge
• Scaling more obvious at
edges(central clearing)
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Tinea Corporis
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Tinea corporis – body ringworm
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Tinea corporis
Tinea Corporis Tinea of the face
Psoriasis Tinea corporis(Scaly lesion)Psoriasis (for differential diagnosis)
Tinea corporis(Scaly lesion)
TineaManum (hand) Tinea Corporis
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• Often assoc with T.pedis
• “Jock itch”
TINEA CRURIS (groin)
• “Jock itch”
• Tight hot sweaty groin e.g. athletes, obese
• Infection of groin, genitalia, perinium
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Tinea Cruris – Jock Itch
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Tinea Pedis –
Athlete’s Foot Infection
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Tinea Pedis�Clinical features
• Dermatitis
• Peeling • Peeling
• Maceration
• Fissuring
Sites
Toe clefts
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Tinea Unguium – Nail Infection
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Tinea Unguium (nail)
1. Disto-lateral
subungual
onychomycosis
1
onychomycosis
2. Superficial white
onychomycosis
3. Total dystrophic
onychomycosis
2
3
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Regimes-Tinea Unguium
• TERBINAFINE
– Terbinafine250mg od
• ITRACONAZOLE• ITRACONAZOLE
– Pulse rx Itraconazole - 1wk/mth 200mg bid
– Itraconazole 200mg od
• FLUCANAZOLE
– Fluconazole 150mg once weekly
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T.Pedis
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TINEA CAPITIS - KERION
Ringworm of the scalp
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TINEA CAPITIS – Black dot
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Tinea Capitis
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Tinea Capitis
Gray Patch
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Rx-Tinea Capitis
• MUST use oral Rx- prolonged course
–Griseofulvin-20mg/kg/od x 6-8/52 –Griseofulvin-20mg/kg/od x 6-8/52
Terbinafine-250mg od x 4/52
–Flucanazole-50mg-150mg/wk x 4-6/52
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Rx-Tinea Capitis
Adjunctive Measures
• Shampoo- antifungal/ antiseptic/antidandruff
• Antibiotics
• NO STEROIDS
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Other Fungal InfectionsOther Fungal Infections
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Tinea Manuum
�Dry hyperkeratotic
Palmer aspect
Dorsal aspect
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Tinea Barbae
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Tinea Faciei
• Infection of the
skin of the face
excluded excluded
moustache &beard
areas
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Peri-oral dermatophytosis
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Investigation:
- Microscopy of scrapings
KOH preparation and looking KOH preparation and looking for the fungal elements from skin scraping, nail or hair.
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Management
• General Measures
• Non-specific Keratolytics
-eg Whitfield’s ointment
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Specific Antifungal Rx
• Griseofulvin
• Azoles-
-Imidazole eg ketoconazole (liver toxicity: oral prep)
topical prepstopical preps
-Triazole eg itraconazole,fluconazole
• Allylamines eg terbinafine, naftifine
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TOPICAL Rx
• Localized disease of skin
– extend rx for 3-5/7 after apparent cure
– 1% clotrimazole less effective
• Sprays & solutions
– tinea pedis /hairy areas
• Limited nail disease
– Batrafen nail lacquer
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ORAL Rx• Extensive disease
• Nail disease
• Tinea Capitis
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FDA approved drugs for empirical therapy
Drug Dosing regimen used in controlled trials
Ampho B 0.6 – 1.0 mg/kg/day (IV)
__________________________________________________
Liposomal 3 mg/kg/day (IV)
Ampho B
For Systemic Fungal Infections
Ampho B
________________________________________________
Itraconazole 400 mg/day/or two days then 200 mg/d for
5-12 days (IV), followed by oral solution
400 mg/day for 14 days
__________________________________________________
Caspofungin 70 mg day 1, then 50 mg/daily
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In BPKIHS D-OPDCOMMON FUNGAL PROBLEMS: All types
Rx: prescribed:
1. Hygiene teaching.
2. Antifungal: 2. Antifungal:
a. Topical: Ketaconazole, Clotrimazole,
Butrinazole
b. Oral: Fluconazole, Ketaconazole, itrazole
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Thank YouThank You
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7. Yeasts• Pityrosporum.
• Candida.
• Ordinarily commensals.
• Can become pathogens under favourable conditions.
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Pityriasis Versicolor
• Asymptomatic
scaly maculeshypopigmented
• Chest, back, face
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P.Versicolor• Hyperpigmented
Like Dubi
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Pityriasis Versicolor
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8. Tinea Versicolor
(In Head)(In Head)
Dandruff
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Tinea Versicolor
�Skin infection caused by a yeast
�Warm and humid environment
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Tinea Versicolor� S/S
- oval or irregularly shaped spots
- pale, dark , or pink in color
- sharp border- sharp border
- itching, worsens with heating and
sweating
� Tx
- Topical antifungal medications
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Management• Many Rx
• No Rx eradicates yeast permanently
• NONSPECIFIC
• Keratolytics • Keratolytics
– whitfield onit, sulphur
• Antiseptics
– selenium sulphide, Na thiosulphate
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Antifungal Rx
Azoles-oral/topical
• Ketoconazole 200mg od x7
• Itraconazole 200mg od x 7• Itraconazole 200mg od x 7
• Fluconazole 300mg-400mg stat
• Terbinafine tabs for P.V
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9. Candidiasis
o Candida sp- commensal of GIT
o Precipitating Factors
�Endocrinopathy�Endocrinopathy
�Immunosuppression
�Fe/Zn deficiency
�Oral antibiotic Rx
o Oropharyngeal candidiasis is marker for AIDS
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Candidiasis
• Oropharnygeal
• Candidal intertrigo-breasts, groin
• Chronic Paronychia - nail fold infection• Chronic Paronychia - nail fold infection
• Vaginitis/balanitis
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Risk Factors for Candidiasis:
▪ Post-operative status
▪ Cytotoxic cancer chemotherapy
▪ Antibiotic therapy▪ Antibiotic therapy
▪ Burns
▪ Drug abuse
▪ GI damage
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Candidal Intertrigo
• Moist folds
• Erythematous patch • Erythematous patch
with satellite lesions
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Management
• Rx underlying disorder
• Reduce moisture-
– Wt loss, cotton underwear
– Absorbent/antifungal powder eg Zeasorb AF
• Rx partner in recurrent genital candidiasis• Rx partner in recurrent genital candidiasis
• Rx-Nystatin
Azoles
• Oral antifungal (itraconazole): immune suppressed
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10. Chronic Paronychia
• Infection of nail fold
• Wet alkaline work
Excess manicuring
• Damage to cuticle • Damage to cuticle
• Swelling of nail fold
(bolstering)
• Nail dystrophy
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Chronic Paronychia
• Keep hands dry /Wear gloves
• Long term Rx
• Oral Azoles
• Antifungal solution-(high alcohol content)• Antifungal solution-(high alcohol content)
• +/-Broad spectrum antibiotics-cover staph
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Rx Summary
• Tinea capitis should be treated with
systemic therapy.
• Griseofulvin in a dose of 10-20 mg per
kg for six weeks to 8weeks is the first-kg for six weeks to 8weeks is the first-
line treatment of Tinea capitis.
• Ketoconazole 2-4mg per kg for ten
days, itraconazole and terbinafine
(Lamisil) are good alternatives.
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• Griseofulvin should be taken after fatty meal.
• Topical treatment can be added to decrease
the transmission and accelerate resolution.
• Whitefield ointment is preferred in the
absence of secondary bacterial infection.
• Other family members should also be • Other family members should also be
examined and treated.
• Small and single lesion can be treated with
topical agents. Clotrimazole 1%, ketoconazole
2%, meconazole 1%. BID for two weeks
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• Systemic: ketoconazole 2-4mg per kg
of weight for 10 days. Itraconazole and
fluconazole are choices if available.
Griseofulvin is also effective for the Griseofulvin is also effective for the
treatment of Tinea corporis.
• Topical anti fungal creams or
ointments applied regularly for 4 - 6
wks.
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• Systemic treatments provide better skin
penetration than most topical preparations,
Itraconazole, terbinafine and griseofulvin
are good choices for oral therapy.
• Itraconazole and terbinafine are more
effective than griseofulvin. Once-weekly effective than griseofulvin. Once-weekly
dosing with fluconazole is another option,
especially in noncompliant patients.
• Personal hygiene (foot hygiene) is highly
advised.
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Thank YouThank You