Fungal Infections of the Skin and Nails

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Fungal Infections of the Skin and Nails

• Adam O. Goldstein, MD, MPH
• Associate Professor
• Department of Family Medicine
• University of North Carolina at Chapel Hill
• aog_at_med.unc.edu

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Fungal Infections of the Skin and Nails

• Objectives
• 1. To distinguish common fungal infections from
  similar appearing lesions e.g. eczema
• 2. Improved dx of fungal lesions with a KOH
  scraping
• 3. Know at least 2 tx options for common fungal
  infections of the skin nails
• 4. Know common errors in fungal dx and tx
• 5. Know when to suspect how to dx ID reaction

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Sorry but .
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Superficial Fungal Infections

• 4.1 million visits -82 nondermatologists
• 3 types of fungi-dermatophytes
• Epidermophyton
• Trichophyton
• Microsporum
• Named by location
• Similar treatments Varied presentations

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If they do this to food..
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Superficial Fungal Infections

• Common Denominator Do KOH, Do KOH, Do KOH ..
• Nondermatologists (34) were more likely than
  dermatologists (5) to prescribe combination
  products for the treatment of common fungal skin
  infections savings 10-25 million.
• (Smith, JAAD,1998)

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KOH
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ID Reaction

• Severe inflammatory skin reaction
• Immunologically mediated
• Appearance may be very different from original
  lesion
• Fungal infections if severe enough may provoke ID
  reaction. If you do not think about it, you will
  not diagnose it.

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ID Reaction
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Tinea capitis

• Trichophyton or Microsporum species
• Disease of children
• Exposure from other children
  or pets
• Highly variable presentation

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T. capitis

• Primary lesions plaques, papules, pustules or
  nodules
• Secondary lesions scale, alopecia,
  erythema, exudate and edema
• Kerion Severe T. capitis-
  inflamed, boggy nodule with
  hair loss

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Kerion
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T. capitis

• Diagnosis
• Overdiagnosed in adults, underdiagnosed in
  children
• Direct microscopic exam of hairs looking for
  hyphae/spores
• Woods lamp bright green
  fluorescence in hair shafts d/t
  Microsporum infection (lt 20 time)
• Culture If KOH is negative but strong clinical
  suspicion

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T. capitis

• Differential Diagnosis
• Seborrheic dermatitis- rare in children, KOH -
• Cellulitis- may coexist, KOH -
• Alopecia areata-discrete, nonscaling areas hair
  loss
• Syphilis- mothball eaten areas

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The diagnosis please..
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T. capitis

• Treatment
• Systemic therapy needed
• Griseofulvin at least 8 wks
  (Or 2 wks beyond cure)
• Itraconazole- 3-5mg/kg/day 1x/week 3 weeks
• Fluconazole- 3-6 mg/kg children (10, 40 ml)
• Terbinafine - 3-6mg/kg/day X 4 weeks

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Griseofulvin

• Microsize 250, 500 mg tabs, 125 mg/5 cc susp
• 500-1000 mg/day adults
• 15-20 mg/kg/day children
• SEs photosensitivity, H/A, GI
  upset, hypersensitivity, leukopenia
• Active only against dermatophytes, not yeasts

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T. capitis

• Patient education
• Compliance for 2 weeks beyond cure to prevent
  relapse
• Look for sources of infections
• Clean contaminated objects
• Reassure caretakers that it may take 1 month for
  improvement

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Tinea barbae

• Characteristics
• Inflammation in the
  beard/hair
• Pseudofolliculitis
• Frequently failed
  antibiotics
• Positive S.Aureus culture does
  not rule out T. barbae

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T. barbae

• Diagnosis
• Nodular, boggy lesions with
  exudate
• Sinus tract formation
• Scarring if untreated
• KOH or culture may confirm

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T. barbae

• Differential diagnosis
• Bacterial folliculitis
• Pseudofolliculitis barbae
• Contact dermatitis
• Herpes
• Syphilis
• Acne
• Candida

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T. barbae

• Treatment
• Griseofulvin 0.5-1 g/day
• Itraconazole or terbinafine for resistant cases
• Local care

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Tinea corporis

• Papules or plaques with erythema and scale
• Look for annular lesions with central clearing
• Well-demarcated edges

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T. corporis

• Diagnosis
• KOH from leading edge
• Prior steroid use alters response/appearance
• Majocchis granuloma pluck
  hairs for hyphae

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T. corporis vs. Majocchis granuloma
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T. corporis

• Differential diagnosis
• Nummular eczema KOH neg
• Pityriasis rosea KOH neg, multiple
  papules/plaques
• Psoriasis KOH neg, thick,
  silvery scales
• Granuloma annulare KOH neg, no scale
• Lyme disease KOH neg, no scale

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T. corporis Differential diagnosis
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The diagnosis please...
Lichen simplex chronicus
Nummular eczema
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T. corporis

• Treatment
• Avoid Lotrisone type combos
• Topical agents for mild/moderate disease
• Oral agents for extensive/resistant disease
• Continue topical medication 7-14 days beyond
  cure

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Tinea cruris

• Thrives in humid environments
• Diagnosis
• Spares scrotum
• Pruritus burning clues
• Look for feet as possible
  infection source
• KOH hyphae

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T.cruris

• Differential Diagnosis
• Candida Beefy red with poorly defined
  borders
• Intertrigo KOH negative, irritant
  dermatitis
• Erythrasma Asymmetric velvety patches,
  Neg KOH
• Psoriasis Thick silvery scales,Neg
  KOH
• Seb derm Borders less defined,
  distribution different, Neg KOH

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T. cruris

• Treatment
• Topical agents for 2-3 weeks
• Mild topical steroid for inflammatory
  component
• Pruritus relief
• Look for infection source

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T. cruris

• Patient education
• Use topical meds 7-14 days beyond cure
• Avoid prolonged topical steroids
• Avoid self-medicating preps
• Avoid baths and tight fitting
  underwear
• Use mild soaps or soap substitute
• Antifungal powders
• Keep area dry

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Tinea manus

• Diagnosis
• Often unilateral, but
  with bilateral feet
• May have only scant
  scaling, vesicles
• Differential Diagnosis Eczema,
  contact dermatitis
• Treatment Topical agents

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The diagnosis is ...
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Tinea pedis

• Diagnosis
• Extremely variable presentation
• Be aware of id reaction and bacterial infection

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T. pedis
Differential Diagnosis Eczema, Contact,
Psoriasis, Keratolysis Treatment and Patient
Education Limited Antifungal creams X 1-4
weeks Severe Oral therapy Griseofulvin 500 mg
microsize bid X 4-8 weeks Terbinafine 250 mg/day
X 2-6 weeks
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The diagnosis is ..
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Tinea Versicolor

• Diagnosis macules, plaques fine scale after
  scraping KOH

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Tinea Versicolor

• Treatment
• Limited disease Topical agents
• Widespread Ketoconazole
• 200 mg X 2 one dose, repeat
  1 week
• (Not griseofulvin)
• Prevention and Patient Education
• Selenium sulfide 2.5 overnight 1X/month

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Candidiasis

• Diagnosis Beefy red lesions, satellite papules
  and pustules
• Differential Dx Tinea, Intertrigo
• Treatment and Patient education
• Topical antifungal creams
• Oral therapy for extensive (not Griseofulvin)
• Environmental Zeasorb powder or Burows
• Mild topical steroids

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The diagnosis is...
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Onychomycosis
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Onychomycosis

• Why should we treat? (cosmetically disfiguring,
  painful, entry for cellulitis)
• Diff Dx Psoriasis, Lichen Planus, Trauma
• Diagnosing vs. treating

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• Diagnosis?
• Culture?
• Treatment?

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CaseWhich of the following, if any, is
onychomycosis?
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Onychomycosis- treatments

• 8 Ciclopirox (Penlac)
• Topical therapy FDA approved (2/00)
• 2 studies X 48 weeks
• 219 5.5 cc 6.5 ac vs. .9 placebo
• 235 8.5 cc 12 ac vs. .9 placebo
• se erythema 5
• 1x/day for seven days, remove w/alcohol and begin
  again

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Onychomycosis- systemic

• Oral meds
• Terbinafine- 250 mg qd X 6 wks Fingernails
• X 12 wks
  Toenails
• Itraconazole- 200 mg bid 1 wk/month
• X 2-3
  months Fingernails
• X 3-4
  months Toenails
• Fluconazole- 150-300 mg 1x/week x 6-9 months
• Side effects GI, Skin, H/A, LFT, Drugs

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Onychomycosis- oral meds

• RCT-DB, PC-
• 72 week f/u
• 496 patients
• Continuous terbinafine vs. pulsed itraconazole
• No diff. SEs
• T3 T4 I8 I4
• MC 76 81 38 49
• CC 54 60 32 32
• (BMJ, 4/99, 318 1031-1035)

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Evidence-based reviews- Fungal

• Pooled analysis trials comparing mycological cure
  rates
• Continuous treatment with terbinafine (250 mg/d
  for 12 weeks) continuous treatment with
  itraconazole (200 mg/d for 12 weeks)
• Statistically significant difference in 1 year
  outcomes in favor of terbinafine (risk
  difference, -0.23 95 confidence interval, -0.32
  to -0.15 number needed to treat, 5 95
  confidence interval, 4 to 8).

(Crawford, Arch Dermatol, 2002)
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Evidence-based review- Fungal

• Oral treatments for T. Pedis
• Twelve trials, 700 participants
• 2 trials comparing terbinafine and griseofulvin
• A pooled risk difference of 52 (95 confidence
  intervals 33 to 71) in favor of terbinafine's
  ability to cure infection
• (The Cochrane Library, 2003, http//www.update
  software.com/abstracts/ab003584.htm)

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Summary

• Do a KOH when possible or doubtful
• Avoid brand name combination steroid/antifungal
  products
• Remember patient education strategies

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Pearls

• T. capitis- overdiagnosed in adults/under in
  children oral therapy needed
• T. cruris- spares scrotum
• T. manus- often unilateral
• T. Pedis- highly variable presentation
• T. versicolor- oral therapy effective
• Onychomycosis- oral meds needed

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• Whats the diff dx?
• How to dx?
• Use combo meds?
• How to tx?

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• Diff dx
• SCCa, Eczema, Tinea
• How to dx
• KOH, KOH, KOH
• Use combo meds NO
• wrong 30
• unclear length of time
• more difficult for subsequent dx
• potent steroids
• Tx Lidex 0.05 bid

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A few unknowns
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A few unknowns
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A few unknowns
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A few unknowns
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Thank You .