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Fungal Infections of the Skin and Nails

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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 – PowerPoint PPT presentation

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Title: Fungal Infections of the Skin and Nails


1
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

2
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

3
Sorry but .
4
Superficial Fungal Infections
  • 4.1 million visits -82 nondermatologists
  • 3 types of fungi-dermatophytes
  • Epidermophyton
  • Trichophyton
  • Microsporum
  • Named by location
  • Similar treatments Varied presentations

5
If they do this to food..
6
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)

7
KOH
8
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.

9
ID Reaction
10
Tinea capitis
  • Trichophyton or Microsporum species
  • Disease of children
  • Exposure from other children
    or pets
  • Highly variable presentation

11
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

12
Kerion
13
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

14
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

15
The diagnosis please..
16
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

17
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

18
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

19
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20
Tinea barbae
  • Characteristics
  • Inflammation in the
    beard/hair
  • Pseudofolliculitis
  • Frequently failed
    antibiotics
  • Positive S.Aureus culture does
    not rule out T. barbae

21
T. barbae
  • Diagnosis
  • Nodular, boggy lesions with
    exudate
  • Sinus tract formation
  • Scarring if untreated
  • KOH or culture may confirm

22
T. barbae
  • Differential diagnosis
  • Bacterial folliculitis
  • Pseudofolliculitis barbae
  • Contact dermatitis
  • Herpes
  • Syphilis
  • Acne
  • Candida

23
T. barbae
  • Treatment
  • Griseofulvin 0.5-1 g/day
  • Itraconazole or terbinafine for resistant cases
  • Local care

24
Tinea corporis
  • Papules or plaques with erythema and scale
  • Look for annular lesions with central clearing
  • Well-demarcated edges

25
T. corporis
  • Diagnosis
  • KOH from leading edge
  • Prior steroid use alters response/appearance
  • Majocchis granuloma pluck
    hairs for hyphae

26
T. corporis vs. Majocchis granuloma
27
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

28
T. corporis Differential diagnosis
29
The diagnosis please...
Lichen simplex chronicus
Nummular eczema
30
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

31
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32
Tinea cruris
  • Thrives in humid environments
  • Diagnosis
  • Spares scrotum
  • Pruritus burning clues
  • Look for feet as possible
    infection source
  • KOH hyphae

33
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

34
T. cruris
  • Treatment
  • Topical agents for 2-3 weeks
  • Mild topical steroid for inflammatory
    component
  • Pruritus relief
  • Look for infection source

35
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

36
Tinea manus
  • Diagnosis
  • Often unilateral, but
    with bilateral feet
  • May have only scant
    scaling, vesicles
  • Differential Diagnosis Eczema,
    contact dermatitis
  • Treatment Topical agents

37
The diagnosis is ...
38
Tinea pedis
  • Diagnosis
  • Extremely variable presentation
  • Be aware of id reaction and bacterial infection

39
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
40
The diagnosis is ..
41
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42
Tinea Versicolor
  • Diagnosis macules, plaques fine scale after
    scraping KOH

43
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

44
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

45
The diagnosis is...
46
Onychomycosis
47
Onychomycosis
  • Why should we treat? (cosmetically disfiguring,
    painful, entry for cellulitis)
  • Diff Dx Psoriasis, Lichen Planus, Trauma
  • Diagnosing vs. treating

48
  • Diagnosis?
  • Culture?
  • Treatment?

49
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50
CaseWhich of the following, if any, is
onychomycosis?
51
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

52
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

53
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)

54
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)
55
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)

56
Summary
  • Do a KOH when possible or doubtful
  • Avoid brand name combination steroid/antifungal
    products
  • Remember patient education strategies

57
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

58
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59
  • Whats the diff dx?
  • How to dx?
  • Use combo meds?
  • How to tx?

60
  • 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

61
A few unknowns
62
A few unknowns
63
A few unknowns
64
A few unknowns
65
Thank You .
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