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Diseases Resulting from Fungi and Yeasts Kristy P. Gilbert, D.O. February 8, 2005.

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Presentation on theme: "Diseases Resulting from Fungi and Yeasts Kristy P. Gilbert, D.O. February 8, 2005."— Presentation transcript:

1 Diseases Resulting from Fungi and Yeasts Kristy P. Gilbert, D.O. February 8, 2005

2 Superficial mycoses AKA dermatophytes AKA dermatophytes Cause only stratum corneum, hair and nail infection Cause only stratum corneum, hair and nail infection Three genera: Microsporum, Trichophyton, Epidermophyton Three genera: Microsporum, Trichophyton, Epidermophyton Division into: 1) tinea capitis, 2) tinea barbae, 3) tinea faciei, 4) tinea corporis, 5) tinea manus, 6) tinea pedis, 7) tinea cruris, 8)onychomycosis Division into: 1) tinea capitis, 2) tinea barbae, 3) tinea faciei, 4) tinea corporis, 5) tinea manus, 6) tinea pedis, 7) tinea cruris, 8)onychomycosis

3 Host factors Immunosuppressed pts- cancer, diabetes Immunosuppressed pts- cancer, diabetes AIDS, connective tissue disorders AIDS, connective tissue disorders Genetic susceptibility may be related to types of keratin or degree/mix of cutaneous lipids produced, cutaneous barrier compromise Genetic susceptibility may be related to types of keratin or degree/mix of cutaneous lipids produced, cutaneous barrier compromise Surface antigens-ABO system-one study of 108 culture proven dermatophytosis pts noted type A blood prone to chronic disease Surface antigens-ABO system-one study of 108 culture proven dermatophytosis pts noted type A blood prone to chronic disease Human steroid hormones can inhibit growth of dermatophytes (androgens like androstenedione) Human steroid hormones can inhibit growth of dermatophytes (androgens like androstenedione) One group believes this high susceptibility of Trichophyton rubrum & Epidermophyton floccosum to intrafollicular androstenedione is a reason why these species do not cause tinea capitis One group believes this high susceptibility of Trichophyton rubrum & Epidermophyton floccosum to intrafollicular androstenedione is a reason why these species do not cause tinea capitis

4 Imidazoles Clotrimazole, miconazole, sulconazole, oxiconazole, and ketoconazole Clotrimazole, miconazole, sulconazole, oxiconazole, and ketoconazole Mostly used for topical tx Mostly used for topical tx Inhibit cytochrome P alpha-demethylase (an essential enzyme in ergosterol synthesis) Inhibit cytochrome P alpha-demethylase (an essential enzyme in ergosterol synthesis) Ketaconazole has wide spectrum against dermatophytes, yeasts, and some systemic mycoses Ketaconazole has wide spectrum against dermatophytes, yeasts, and some systemic mycoses Ketaconazole has the potential for serious drug interactions and a higher incidence of hepatotoxicity during long-term daily therapy Ketaconazole has the potential for serious drug interactions and a higher incidence of hepatotoxicity during long-term daily therapy

5 Allylamines Naftifine, terbinafine, butenafine Naftifine, terbinafine, butenafine Inhibites squalene epoxydation Inhibites squalene epoxydation Terbinafine has less activity against Candida species in vitro studies then triazoles, but is effective clinically Terbinafine has less activity against Candida species in vitro studies then triazoles, but is effective clinically Terbinafine is ineffective in the oral tx of tinea versicolor but is effective topically Terbinafine is ineffective in the oral tx of tinea versicolor but is effective topically Few drug interactions have been reported Few drug interactions have been reported Bioavailability is unchanged in food Bioavailability is unchanged in food Hepatotoxicity, leukopenia, severe exanthems, and taste disturbances uncommon, but should be monitored for clinically and by lab testing if continuous dosing over 6 weeks Hepatotoxicity, leukopenia, severe exanthems, and taste disturbances uncommon, but should be monitored for clinically and by lab testing if continuous dosing over 6 weeks

6 Polyene Nystatin Nystatin Irreversibly binding to ergosterol-an essential component of fungal cell membranes Irreversibly binding to ergosterol-an essential component of fungal cell membranes

7 Triazoles Itraconazole, Fluconazole Itraconazole, Fluconazole Affect P450 system Affect P450 system Numerous drug interactions occur Numerous drug interactions occur Need to know pts current meds Need to know pts current meds Broadest spectrum to dermatophytes and Candida species, and Malassezia furfur Broadest spectrum to dermatophytes and Candida species, and Malassezia furfur Itraconazole is fungistatic- food increases its absorption, antacids and gastric acid secretion suppressors produce erratic or lowered absorption Itraconazole is fungistatic- food increases its absorption, antacids and gastric acid secretion suppressors produce erratic or lowered absorption Pulse dosing limits concern over lab abnormalities Pulse dosing limits concern over lab abnormalities Fluconazoles absorption is unaffected by food Fluconazoles absorption is unaffected by food

8 Tinea Capitis Occurs chiefly in schoolchildren Occurs chiefly in schoolchildren Boys more frequently than girls; except epidemics caused by Trichophyton tonsurans where there is equal frequency Boys more frequently than girls; except epidemics caused by Trichophyton tonsurans where there is equal frequency Divided into inflammatory and non-inflammatory Divided into inflammatory and non-inflammatory Tinea capitis can be caused by all pathogenic dermatophytes except Epidermophyton floccosum and T. concentricum Tinea capitis can be caused by all pathogenic dermatophytes except Epidermophyton floccosum and T. concentricum In U.S. most caused by T. tonsurans In U.S. most caused by T. tonsurans

9 Tinea Capitis

10 Noninflammatory M. audouinii infections present as the classic form M. audouinii infections present as the classic form Characterized by multiple scaly lesions (gray-patch), stubs of broken hair Characterized by multiple scaly lesions (gray-patch), stubs of broken hair Over past 30 yrs, M. audouinii infections are being replaced by increasing numbers of black-dot ringworm, caused primarily by T. tonsurans and occasionally by T. violaceum Over past 30 yrs, M. audouinii infections are being replaced by increasing numbers of black-dot ringworm, caused primarily by T. tonsurans and occasionally by T. violaceum In the U.S. T. tonsurans is the most common cause In the U.S. T. tonsurans is the most common cause

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

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13 Black dot tinea Black dot tinea

14 Black dot ringworm caused by Black dot ringworm caused by Trichophyton tonsurans

15 Inflammatory Usually caused by M. canis Usually caused by M. canis Can be caused by T. mentagrophytes, T. tonsurans, M. gypsem, or T. verrucosum Can be caused by T. mentagrophytes, T. tonsurans, M. gypsem, or T. verrucosum M. canis begin as scaly, erythematous, papular eruptions with loose and broken-off hairs, followed by varying degrees of inflammation M. canis begin as scaly, erythematous, papular eruptions with loose and broken-off hairs, followed by varying degrees of inflammation A localized spot accompanied by pronounced swelling, with developing bogginess and induration exuding pus develops- kerion celsii A localized spot accompanied by pronounced swelling, with developing bogginess and induration exuding pus develops- kerion celsii –A delayed type hypersensitivity reaction to fungal elements With extensive lesions fever, pain, and regional lymphadenopathy may occur With extensive lesions fever, pain, and regional lymphadenopathy may occur

16 Kerion Kerion may be followed by scarring and permanent alopecia in areas of inflammation and suppuration Kerion may be followed by scarring and permanent alopecia in areas of inflammation and suppuration Systemic steroids for short periods will greatly diminish the inflammatory response and reduce the risk of scarring Systemic steroids for short periods will greatly diminish the inflammatory response and reduce the risk of scarring

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

18 Permanent scarring alopecia post-kerion Permanent scarring alopecia post-kerion

19 Kerion: red, oozing, hairless plaque Kerion: red, oozing, hairless plaque

20 Favus Rare in the U.S. Rare in the U.S. Most severe form of dermatophyte hair infection Most severe form of dermatophyte hair infection Most frequently cause by T. schoenleinii Most frequently cause by T. schoenleinii Hyphae and air spaces seen within hair shaft Hyphae and air spaces seen within hair shaft Bluish white fluorescence under Woods light Bluish white fluorescence under Woods light Thick, yellow crusts composed of hyphae and skin debris (scutula) Thick, yellow crusts composed of hyphae and skin debris (scutula) Scarring alopecia may develop Scarring alopecia may develop

21 Favus with scarring alopecia and scutula

22 Scarring after favus infection Scarring after favus infection

23 Etiology Tinea capitis can be cause by any one of several species: T. tonsurans, M. audouinii (human to human), and M. canis (animals to human) Tinea capitis can be cause by any one of several species: T. tonsurans, M. audouinii (human to human), and M. canis (animals to human) Endothrix types-T. tonsurans (black-dot ringworm) and T. violaceum Endothrix types-T. tonsurans (black-dot ringworm) and T. violaceum Ectothrix found on scalp are T. verrucosum & T. mentagrophytes, M. canis Ectothrix found on scalp are T. verrucosum & T. mentagrophytes, M. canis

24 Diagnosis Woods light Woods light –Ultraviolet of 365 nm wavelength is obtained by passing a beam through a Woods filter composed of nickel oxide- containing glass –A simple form is the 125-volt purple bulb Fluorescent-positive infections are caused by :T. schoenleinii, M. canis, M. audouinii, M. distortum, M. ferrugineum Fluorescent-positive infections are caused by :T. schoenleinii, M. canis, M. audouinii, M. distortum, M. ferrugineum Hairs infected with T. tonsurans, T. verrucosum, & T. violaceum and others of endothrix do not fluoresce Hairs infected with T. tonsurans, T. verrucosum, & T. violaceum and others of endothrix do not fluoresce The fluorescent substance is pteridine The fluorescent substance is pteridine

25 Diagnosis KOH KOH –Two or three loose hairs are removed –Hairs are placed on slide with a drop of 10-20% solution of KOH –A cover slip is applied, specimen is warmed until hairs are macerated –Examine under low, then high power Scales or hairs cleared with it can still be cultured Scales or hairs cleared with it can still be cultured

26 DTM DTM contains cycloheximide to reduce growth of contaminants and a colored pH indicator to denote the alkali-producing dermatophytes DTM contains cycloheximide to reduce growth of contaminants and a colored pH indicator to denote the alkali-producing dermatophytes Some clinically relevant nondermatophyte fungi are cycloheximide sensitive (Candida tropicalis, Scopulariopsis brevicaulis, Cryptococcus neoformans, Pseudoallescheria boydii, Trichosporon beigelii and Aspergillus spp.) Some clinically relevant nondermatophyte fungi are cycloheximide sensitive (Candida tropicalis, Scopulariopsis brevicaulis, Cryptococcus neoformans, Pseudoallescheria boydii, Trichosporon beigelii and Aspergillus spp.)

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

29 Endothrix spores in hair with Trichophyton tonsurans Endothrix spores in hair with Trichophyton tonsurans

30 Endothrix in T. scoenleinii showing characteristic bubbles of air Endothrix in T. scoenleinii showing characteristic bubbles of air

31 Endothrix infection, (low-power KOH mount): arthroconidia noted within hair shaft Endothrix infection, (low-power KOH mount): arthroconidia noted within hair shaft Endothrix infection (high-power KOH mount) showing total hair shaft involvement Endothrix infection (high-power KOH mount) showing total hair shaft involvement

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33 T. tonsurans This microoraganism grows slowly in culture to produce a granular or powdery yellow to red, brown, or buff colony This microoraganism grows slowly in culture to produce a granular or powdery yellow to red, brown, or buff colony Crater formation with radial grooves may be produced Crater formation with radial grooves may be produced Microconidia may be seen regularly Microconidia may be seen regularly Dx confirmed by the fact that cultures grow poorly or not at all without thiamine Dx confirmed by the fact that cultures grow poorly or not at all without thiamine

34 T. mentagrophytes Culture growth is velvety or granular or fluffy, flat or furrowed, light buff, white, or sometimes pink Culture growth is velvety or granular or fluffy, flat or furrowed, light buff, white, or sometimes pink Back of the culture can vary from buff to dark red Back of the culture can vary from buff to dark red Round microconidia borne laterally and in clusters confirm dx within 2 weeks Round microconidia borne laterally and in clusters confirm dx within 2 weeks Spirals are sometimes present Spirals are sometimes present Macroconidia may be seen Macroconidia may be seen

35 T. verrucosum Growth is slow and cannot be observed well for at least 3 weeks Growth is slow and cannot be observed well for at least 3 weeks Colony is compact, glassy, velvety, heaped or furrowed, and usually white, but may be yellow or gray Colony is compact, glassy, velvety, heaped or furrowed, and usually white, but may be yellow or gray Chlamydospores (round swellings along the hyphal structures) are present in early cultures Chlamydospores (round swellings along the hyphal structures) are present in early cultures Microconidia may be seen Microconidia may be seen

36 M. audouinii Gross appearance shows a slowly growing, matted, velvety, light brown colony Gross appearance shows a slowly growing, matted, velvety, light brown colony Back of which is reddish brown to orange Back of which is reddish brown to orange Under microscope a few large multiseptate macroconidia (macroaleuriospores) are seen Under microscope a few large multiseptate macroconidia (macroaleuriospores) are seen Microconidia (microaleuriospores) in a lateral position on hyphae are clavate Microconidia (microaleuriospores) in a lateral position on hyphae are clavate Racquet mycelium, chlamydospores, and pectinate hyphae are seen sometimes Racquet mycelium, chlamydospores, and pectinate hyphae are seen sometimes

37 M. canis Culture shows profuse, fuzzy, cottony, aerial mycelia tending to become powdery in the center Culture shows profuse, fuzzy, cottony, aerial mycelia tending to become powdery in the center Color is buff to light brown Color is buff to light brown Back of colony is lemon to orange-yellow Back of colony is lemon to orange-yellow Numerous spindle-shaped multiseptate microconidia and thick-walled macroconidia are present Numerous spindle-shaped multiseptate microconidia and thick-walled macroconidia are present Clavate microconidia are found along with chlamydospores and pectinate bodies Clavate microconidia are found along with chlamydospores and pectinate bodies

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39 Treatment Griseofulvin of ultramicronized form, 10 mg/kg/day, is the daily dose recommended for children Griseofulvin of ultramicronized form, 10 mg/kg/day, is the daily dose recommended for children Grifulvin V is the only oral suspension available for children unable to swallow tablets-dose is 20 mg/kg/day Grifulvin V is the only oral suspension available for children unable to swallow tablets-dose is 20 mg/kg/day Tx should continue for 2-4 months, or for at least 2 weeks after negative microscopic and culture examinations are obtained Tx should continue for 2-4 months, or for at least 2 weeks after negative microscopic and culture examinations are obtained Griseofulvin does not primarily affect the delayed type hypersensitivity reaction responsible for the inflammation in kerion Griseofulvin does not primarily affect the delayed type hypersensitivity reaction responsible for the inflammation in kerion For this, systemic steroids, to minimize scarring, can be given simultaneously For this, systemic steroids, to minimize scarring, can be given simultaneously

40 Treatment Terbinafine Terbinafine -effective for Trichophyton infections -3-6mg/kg/day for 1 to 4 weeks -Microsporum infections may require larger doses and longer courses of therapy Itraconazole Itraconazole Fluconazole Fluconazole Selenium Sulfide or Ketoconazole shampoo as an adjunct Selenium Sulfide or Ketoconazole shampoo as an adjunct

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42 Tinea Barbae AKA Tinea sycosis, barbers itch AKA Tinea sycosis, barbers itch Uncommon Uncommon Occurs chiefly among those in agriculture Occurs chiefly among those in agriculture Involvement is mostly one-sided on neck or face Involvement is mostly one-sided on neck or face Two clinical types are: deep, nodular, suppurative lesions; and superficial, crusted, partially bald patches with folliculitis Two clinical types are: deep, nodular, suppurative lesions; and superficial, crusted, partially bald patches with folliculitis

43 Tinea Barbae Superficial crusted type Superficial crusted type –mild pustular folliculitis with broken-off hairs (T. violaceum) or without broken-off hairs (T. rubrum) –Affected hairs are loose, dry, and brittle –When extracted bulb appears intact

44 Tinea Barbae Deep type Deep type –Caused mostly by T. mentagrophytes or T. verrucosum –Swellings are usually confluent and form diffuse boggy infiltrates with abscesses –Pus may be expressed –Lesions are limited to one part of face or neck in men

45 Diagnosis-Tinea Barbae Clinical Clinical Confirmed by microscopic findings and by standard culture techniques Confirmed by microscopic findings and by standard culture techniques Rarely, Epidermophyton floccosum may cause widespread verrucous lesions known as verrucous epidermophytosis Rarely, Epidermophyton floccosum may cause widespread verrucous lesions known as verrucous epidermophytosis

46 Verrucous epidermophytosis from Epidermphyton floccosum Verrucous epidermophytosis from Epidermphyton floccosum

47 Complete resolution after 48 days of Griseofulvin Complete resolution after 48 days of Griseofulvin

48 Differential Diagnosis Sycosis vulgaris (staphlococcal folliculitis)- lesions are pustules and papules, pierced in the center by a hair, which is loose and easily extracted after suppuration has occurred Sycosis vulgaris (staphlococcal folliculitis)- lesions are pustules and papules, pierced in the center by a hair, which is loose and easily extracted after suppuration has occurred Contact dermatitis Contact dermatitis Herpes infections Herpes infections

49 Tinea barbae-Trichophyton mentagrophytes Tinea barbae-Trichophyton mentagrophytes

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52 Treatment-Tinea Barbae Oral antifungals are required Oral antifungals are required Topical agents as adjunctive therapy Topical agents as adjunctive therapy Micronized or ultramicronized griseofulvin orally: dosage of 500–1000 mg or mg respectively Micronized or ultramicronized griseofulvin orally: dosage of 500–1000 mg or mg respectively Tx usually for 4-6 weeks Tx usually for 4-6 weeks

53 Treatment-Tinea Barbae Other orals that have been effective: ketoconazole, fluconazole, itraconazole, and terbinafine Other orals that have been effective: ketoconazole, fluconazole, itraconazole, and terbinafine Topical antifungals should be applied from the beginning of tx Topical antifungals should be applied from the beginning of tx Affected parts should be bathed thoroughly in soap and water Affected parts should be bathed thoroughly in soap and water Healthy areas that are not epilated may be shaved or clipped Healthy areas that are not epilated may be shaved or clipped When kerion is present a short course of systemic steriod therapy may help reduce inflammation and risk of scarring When kerion is present a short course of systemic steriod therapy may help reduce inflammation and risk of scarring

54 Tinea Faciei Fungal infection of the face (apart from the beard) Fungal infection of the face (apart from the beard) Must have high index of suspicion Must have high index of suspicion –Mistaken for seborrheic dermatitis, contact dermatitis, lupus, or photosensitive dermatosis Erythematous, slightly scaling, indistinct borders are usually seen (best location for KOH scrapings) Erythematous, slightly scaling, indistinct borders are usually seen (best location for KOH scrapings) Typical annular rings are usually lacking & lesions are exquisitely photosensitive Typical annular rings are usually lacking & lesions are exquisitely photosensitive Usually caused by T. rubrum, T. mentagrophytes, or M. canis Usually caused by T. rubrum, T. mentagrophytes, or M. canis

55 Tinea faciei (Microsporum canis) in a child Tinea faciei (Microsporum canis) in a child

56 Treatment Topical antifungals Topical antifungals If fungal folliculitis is present, oral medication is required If fungal folliculitis is present, oral medication is required Oral griseofulvin administered for 2-4 weeks, as well as fluconazole, itraconazole, or terbinafine are all effective particularly in combination with topical therapy Oral griseofulvin administered for 2-4 weeks, as well as fluconazole, itraconazole, or terbinafine are all effective particularly in combination with topical therapy

57 Tinea Corporis(Tinea Circinata) All superficial dermatophyte infections of the skin except the scalp, beard, face, hands, feet, and groin All superficial dermatophyte infections of the skin except the scalp, beard, face, hands, feet, and groin Sites of predilection are neck, upper and lower extremities, and trunk Sites of predilection are neck, upper and lower extremities, and trunk Characterized by one or more circular, sharply circumscribed, slightly erythematous, dry, scaly, usually hypopigmented patches Characterized by one or more circular, sharply circumscribed, slightly erythematous, dry, scaly, usually hypopigmented patches Advancing scaling edge is usually prominent Advancing scaling edge is usually prominent

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

59 Tinea corporis (Trichophyton rubrum) Tinea corporis (Trichophyton rubrum) Note sharp margins and central clearing Note sharp margins and central clearing

60 Tinea Corporis In some cases concentric circles form rings in one another, making intricate patterns (tinea imbricata) In some cases concentric circles form rings in one another, making intricate patterns (tinea imbricata) Widespread tinea corporis may be the presenting sign of AIDS Widespread tinea corporis may be the presenting sign of AIDS

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

62 Histopathology Better ways to make diagnosis Better ways to make diagnosis But if compact orthokeratosis is found in a section, a search for fungal hyphae should be performed But if compact orthokeratosis is found in a section, a search for fungal hyphae should be performed This is diagnostic This is diagnostic

63 Etiology-Tinea Corporis Microsporum canis, T. rubrum, T. mentagrophytes- most common Microsporum canis, T. rubrum, T. mentagrophytes- most common T. rubrum is is the most common dermatophyte in the U.S. and worldwide T. rubrum is is the most common dermatophyte in the U.S. and worldwide T. tonsurans has experienced a dramatic rise as a cause of tinea corporis as it has for tinea capitis T. tonsurans has experienced a dramatic rise as a cause of tinea corporis as it has for tinea capitis In children, M. canis is the cause of the moist type of tinea circinata In children, M. canis is the cause of the moist type of tinea circinata

64 Epidemiology Tinea corporis is frequently seen in children- particularly those exposed to animals with ringworm (M. canis), especially CATS, dogs and less commonly, horses and cattle Tinea corporis is frequently seen in children- particularly those exposed to animals with ringworm (M. canis), especially CATS, dogs and less commonly, horses and cattle In adults excessive perspiration is the most common factor In adults excessive perspiration is the most common factor –Personal history or close contact with tinea capitis or tinea pedis is another important factor Incidence is especially high in hot, humid areas of the world Incidence is especially high in hot, humid areas of the world

65 Treatment-Tinea Corporis When tinea corporis is caused by T. tonsurans, M. canis, T. mentagrophytes, or T. rubrum; griseofulvin, terbinafine, itraconazole, and fluconazole are all effective When tinea corporis is caused by T. tonsurans, M. canis, T. mentagrophytes, or T. rubrum; griseofulvin, terbinafine, itraconazole, and fluconazole are all effective The ultra-micronized form may be used at a dose of mg once/day for 4-6 weeks The ultra-micronized form may be used at a dose of mg once/day for 4-6 weeks This dose may be increased to twice daily if needed This dose may be increased to twice daily if needed Terbinafine, itraconazole, and fluconazole are effective Terbinafine, itraconazole, and fluconazole are effective Terbinafine at 250 mg/day for two weeks Terbinafine at 250 mg/day for two weeks Itraconazole 200 mg B.I.D. for one week Itraconazole 200 mg B.I.D. for one week Fluconazole 150 mg once/week for 4 weeks Fluconazole 150 mg once/week for 4 weeks

66 Treatment When only 1-2 patches occur, topical tx is effective When only 1-2 patches occur, topical tx is effective Most are between 2-4 weeks with twice daily use Most are between 2-4 weeks with twice daily use Econazole, ketaconazole, oxiconazole, and terbinafine may be used once daily Econazole, ketaconazole, oxiconazole, and terbinafine may be used once daily With terbinafine the course can be shortened to 1 week With terbinafine the course can be shortened to 1 week

67 Treatment Creams are more effective than lotions Creams are more effective than lotions Sulconazole may be less irritating in folded areas Sulconazole may be less irritating in folded areas Castellani paint (which is colorless if made without fuchin) is very effective Castellani paint (which is colorless if made without fuchin) is very effective Salicylic acid 3-5%, or half-strength Whitfields ointment, both standbys 30 yrs ago, are rarely used today Salicylic acid 3-5%, or half-strength Whitfields ointment, both standbys 30 yrs ago, are rarely used today Addition of a low-potency steroid cream during the initial 3-5 days of therapy can decrease irritation rapidly without compromising the effectiveness of the antifungal Addition of a low-potency steroid cream during the initial 3-5 days of therapy can decrease irritation rapidly without compromising the effectiveness of the antifungal

68 Other Forms of Tinea Corporis Trichophytic Granuloma or Perifollicular Granuloma or Majocchis Granuloma or Tinea Incognito Trichophytic Granuloma or Perifollicular Granuloma or Majocchis Granuloma or Tinea Incognito A deep, pustular type of tinea circinata resembling a carbuncle or kerion observed on the glabrous skin A deep, pustular type of tinea circinata resembling a carbuncle or kerion observed on the glabrous skin A circumscribed, annular, raised, crusty, and boggy granuloma A circumscribed, annular, raised, crusty, and boggy granuloma Follicles are distended with viscid purulent material Follicles are distended with viscid purulent material Most frequently on the shins or wrists Most frequently on the shins or wrists

69 Majocchis granuloma H&E pale blue-staining fungal hyphae within hair shaft Majocchis granuloma H&E pale blue-staining fungal hyphae within hair shaft

70 Majocchis granuloma: PAS reveals multiple organisms that have replaced a fragment of hair shaft embedded in a sea of neutrophils Majocchis granuloma: PAS reveals multiple organisms that have replaced a fragment of hair shaft embedded in a sea of neutrophils

71 Tinea Imbricata (Tokelau) Superficial fungal infection limited to southwest Polynesia, Melanesia, Southeast Asia, India, and Central America Superficial fungal infection limited to southwest Polynesia, Melanesia, Southeast Asia, India, and Central America Characterized by concentric rings of scales forming extensive patches with polycyclic borders Characterized by concentric rings of scales forming extensive patches with polycyclic borders Small macular patch splits in center and forms large, flaky scales attached at the periphery Small macular patch splits in center and forms large, flaky scales attached at the periphery Resultant ring spreads peripherally and another brownish macule appears in the center and undergoes the process again Resultant ring spreads peripherally and another brownish macule appears in the center and undergoes the process again

72 Tinea Imbricata When fully developed the eruption is characterized by concentrically arranged rings or parallel undulating lines of scales overlapping each other like shingles on a roof (imbrex means shingle) When fully developed the eruption is characterized by concentrically arranged rings or parallel undulating lines of scales overlapping each other like shingles on a roof (imbrex means shingle) Causative fungus is T. concentricum Causative fungus is T. concentricum TOC is griseofulvin- in same form as for tinea corporis TOC is griseofulvin- in same form as for tinea corporis Other options are terbinafine, fluconazole, and itraconazole Other options are terbinafine, fluconazole, and itraconazole Several courses of therapy may be needed Several courses of therapy may be needed May need to remove patient from hot, humid environment May need to remove patient from hot, humid environment

73 Tinea imbricata in New Guinea native Tinea imbricata in New Guinea native

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

75 Tinea Cruris AKA jock itch AKA jock itch Most common in men Most common in men On upper and inner thighs On upper and inner thighs Begins as a small erythematous and scaling or vesicular and crusted patch Begins as a small erythematous and scaling or vesicular and crusted patch Spreads peripherally and partly clears in the center Spreads peripherally and partly clears in the center Penoscrotal fold or sides of scrotum are seldom involved; penis not involved Penoscrotal fold or sides of scrotum are seldom involved; penis not involved

76 Tinea cruris in a man Tinea cruris in a man

77 Tinea cruris in a woman Tinea cruris in a woman

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79 Etiology-Tinea Cruris T. mentagrophytes & E. floccosum & T. rubrum usual cause T. mentagrophytes & E. floccosum & T. rubrum usual cause Frequently associated with tinea pedis b/c of contaminated clothing Frequently associated with tinea pedis b/c of contaminated clothing Heat and high humidity Heat and high humidity Tight jockey shorts! Tight jockey shorts!

80 Treatment Reduce perspiration and enhance evaporation from crural area Reduce perspiration and enhance evaporation from crural area Keep as dry as possible by wearing loose underclothing Keep as dry as possible by wearing loose underclothing Plain talcum powder or antifungal powders Plain talcum powder or antifungal powders Specific topical and oral treatment is same as that described under tinea corporis Specific topical and oral treatment is same as that described under tinea corporis

81 Tinea in diaper area Tinea in diaper area

82 Tinea Pedis AKA athletes foot AKA athletes foot Most common fungal disease(by far) Most common fungal disease(by far) Primary lesions often are macerated with occasional vesiculation, and fissures between the toes Primary lesions often are macerated with occasional vesiculation, and fissures between the toes Extreme pruritus Extreme pruritus

83 Tinea pedis showing interdigital scalping Tinea pedis showing interdigital scalping T. mentagrophytes T. mentagrophytes

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

85 Dermatophytosis of the soles Dermatophytosis of the soles Trichophyton mantagrophytes Trichophyton mantagrophytes

86 Acute vesiculobullous eruption on sole caused by Trichophyton mentagrophytes Acute vesiculobullous eruption on sole caused by Trichophyton mentagrophytes

87 TP-Trichophyton rubrum T. rubrum causes the majority of cases T. rubrum causes the majority of cases Produces a relatively noninflammatory type of dermatophytosis characterized by a dull erythema and pronounced scaling involving the entire sole and sides of feet Produces a relatively noninflammatory type of dermatophytosis characterized by a dull erythema and pronounced scaling involving the entire sole and sides of feet Producing a moccasin or sandal appearance Producing a moccasin or sandal appearance

88 Tinea pedis and onychomycosis in father/son pair. Tinea pedis and onychomycosis in father/son pair. Father shows classic moccasin distribution of tinea pedis and son shows distal subungual onychomycosis Father shows classic moccasin distribution of tinea pedis and son shows distal subungual onychomycosis

89 Tinea manus Tinea infection of hands that is dry, scaly, and erythematous may occur Tinea infection of hands that is dry, scaly, and erythematous may occur Suggestive of infection with T. rubrum Suggestive of infection with T. rubrum Other areas are frequently affected at the same time Other areas are frequently affected at the same time

90 Trichophyton rubrum infections Trichophyton rubrum infections

91 Differential diagnosis Allergic contact or irritant dermatitis-especially occupational Allergic contact or irritant dermatitis-especially occupational Pompholyx Pompholyx Atopic dermatitis Atopic dermatitis Psoriasis Psoriasis Lamellar dyshidrosis Lamellar dyshidrosis Eczematoid or dyshidrotic lesions of unknown cause on hands should prompt a search for clinical evidence of dermatophytosis of feet etc. Eczematoid or dyshidrotic lesions of unknown cause on hands should prompt a search for clinical evidence of dermatophytosis of feet etc.

92 Fungus filaments under KOH mount Fungus filaments under KOH mount

93 Mosaic fungus Mosaic fungus

94 Prophylaxis Hyperhidrosis is a predisposing factor Hyperhidrosis is a predisposing factor Dry toes after bathing Dry toes after bathing Tolnaftate powder or Zeasorb medicated powders for feet Tolnaftate powder or Zeasorb medicated powders for feet Plain talc, cornstartch, or rice powder may be dusted into socks and shoes to keep feet dry Plain talc, cornstartch, or rice powder may be dusted into socks and shoes to keep feet dry

95 Treatment Topical antifungals Topical antifungals With significant maceration wet dressings or soaks with solutions such as aluminum acetate, one part to 20 parts of water With significant maceration wet dressings or soaks with solutions such as aluminum acetate, one part to 20 parts of water Anti-inflammatory effects of corticosteroids are markedly beneficial Anti-inflammatory effects of corticosteroids are markedly beneficial Topical antibiotic ointments effective against gram-negative organisms (gentamicin), in tx of the moist type of interdigital lesions Topical antibiotic ointments effective against gram-negative organisms (gentamicin), in tx of the moist type of interdigital lesions In ulcerative type of gram-negative toe web infections, systemic floxins are needed In ulcerative type of gram-negative toe web infections, systemic floxins are needed

96 Treatment Keratolytic agents, such as salicylic acid, lactic acid lotions, and Carmol are therapeutic when fungus is protected by a thick layer of overlying skin (i.e. soles) Keratolytic agents, such as salicylic acid, lactic acid lotions, and Carmol are therapeutic when fungus is protected by a thick layer of overlying skin (i.e. soles) Griseofulvin is only effective against dermatophytes Griseofulvin is only effective against dermatophytes When infection is caused by T. mentagrophytes, griseofulvin does not decrease inflammatory reaction When infection is caused by T. mentagrophytes, griseofulvin does not decrease inflammatory reaction

97 Treatment- dosing Griseofulvin in ultramicronized particles taken orally in doses of mg daily Griseofulvin in ultramicronized particles taken orally in doses of mg daily Dosage for children is 10 mg/kg/day Dosage 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 negative Repeated KOH scrapings and culture should be negative Recommended adult doses for newer agents: terbinafine, 250 mg/day for 2 weeks; itraconazole, 200 mg twice daily for 1 week; fluconazole, 150 mg once weekly for 4 weeks Recommended adult doses for newer agents: terbinafine, 250 mg/day for 2 weeks; itraconazole, 200 mg twice daily for 1 week; fluconazole, 150 mg once weekly for 4 weeks

98 Onychomycosis (Tinea Unguium) Onychomycosis encompasses both dermatophyte and non-dermatophyte nail infections Onychomycosis encompasses both dermatophyte and non-dermatophyte nail infections Represents up to 30% of diagnosed superficial fungal infections Represents up to 30% of diagnosed superficial fungal infections Etiologic agents are: Epidermophyton, Microsporum, and Trichophyton fungi Etiologic agents are: Epidermophyton, Microsporum, and Trichophyton fungi

99 Onychomycosis Four classic types: Four classic types: 1) distal subungual onychomycosis: primarily involves distal nail bed and hyponychium, with secondary involvement of underside of nail plate of fingernails and toenails 1) distal subungual onychomycosis: primarily involves distal nail bed and hyponychium, with secondary involvement of underside of nail plate of fingernails and toenails

100 Onychomycosis caused by Trichophyton rubrum Onychomycosis caused by Trichophyton rubrum

101 Trichophyton mentagrophytes 2) white superficial onychomycosis (leukonychia trichophytica.) This is an invasion of the toenail plate on the surface of the nail 2) white superficial onychomycosis (leukonychia trichophytica.) This is an invasion of the toenail plate on the surface of the nail It is produced by T.mentagrophytes, species of Cephalosporium and Aspergillus, and Fusarium oxysporum fungus It is produced by T.mentagrophytes, species of Cephalosporium and Aspergillus, and Fusarium oxysporum fungus

102 Onychomycosis 3) Proximal subungual onychomycosis: involves the nail plate mainly from proximal nail fold 3) Proximal subungual onychomycosis: involves the nail plate mainly from proximal nail fold It is produced by T. rubrum & T. megninii and may be an indication of HIV infection It is produced by T. rubrum & T. megninii and may be an indication of HIV infection 4) Candida onychomycosis involves all the nail plate; it is due to Candida albicans and is seen in patients with chronic mucocuataneous candidiasis 4) Candida onychomycosis involves all the nail plate; it is due to Candida albicans and is seen in patients with chronic mucocuataneous candidiasis –Associated paronychia –Adjacent cuticle is pink, swollen, and tender –Fingernails > toenails

103 Onychomycosis caused by Candida albicans in mucocutaneous candidiasis Onychomycosis caused by Candida albicans in mucocutaneous candidiasis

104 Onychomycosis Onychomycosis caused by T. rubrum is usually a deep infection Onychomycosis caused by T. rubrum is usually a deep infection Disease usually starts at distal corner of nail and involves the junction of nail and its bed Disease usually starts at distal corner of nail and involves the junction of nail and its bed First a yellowish discoloration occurs, which may spread until entire nail is affected First a yellowish discoloration occurs, which may spread until entire nail is affected Beneath discoloration nail plate becomes loose from nail bed Beneath discoloration nail plate becomes loose from nail bed

105 Gradually entire nail becomes brittle and separated from its bed due to piling up of keratin subungually Gradually entire nail becomes brittle and separated from its bed due to piling up of keratin subungually Nail may break off, leaving an undermined remnant that is black and yellow from dead nail and fungi that are present Nail may break off, leaving an undermined remnant that is black and yellow from dead nail and fungi that are present

106 A: Distal subungal, onychomycosis occurring simultaneously with superficial white onychomycosis A: Distal subungal, onychomycosis occurring simultaneously with superficial white onychomycosis B: Superficial white onychomycosis B: Superficial white onychomycosis

107 Differential Allergic contact dermatitis Allergic contact dermatitis Psoriasis Psoriasis Lichen planus Lichen planus 20 nail dystrophy 20 nail dystrophy Dariers disease Dariers disease Reiters disease Reiters disease Norwegian scabies Norwegian scabies Non-dermatophyte onychomycosis Non-dermatophyte onychomycosis

108 Treatment PO terbinafine, fluconazole, and itraconazole PO terbinafine, fluconazole, and itraconazole Griseofulvin continued until nails are clinically normal Griseofulvin continued until nails are clinically normal Low success rates 15-30% for toenails and 50-70% for fingernails Low success rates 15-30% for toenails and 50-70% for fingernails Griseofulvin does not tx nail disease caused by candida Griseofulvin does not tx nail disease caused by candida 3% Thymol in EtOH 3% Thymol in EtOH

109

110 Candidiasis Candida proliferates in both budding and mycelial forms in outer layers of the stratum corneum where horny cells are desquamating Candida proliferates in both budding and mycelial forms in outer layers of the stratum corneum where horny cells are desquamating It does not attack hair, rarely involves nail, and is incapable of breaking up the stratum corneum It does not attack hair, rarely involves nail, and is incapable of breaking up the stratum corneum It is largely an opportunisitic organism It is largely an opportunisitic organism Moisture promotes its growth Moisture promotes its growth –Lip corners –Body folds

111 Diagnosis Demonstration of the pathogenic yeast C. albicans establishes the diagnosis Demonstration of the pathogenic yeast C. albicans establishes the diagnosis Under microscope KOH prep may show spores and pseudomycelium Under microscope KOH prep may show spores and pseudomycelium Culture on Sabourauds glucose agar shows a growth of creamy, grayish, moist colonies in about 4 days Culture on Sabourauds glucose agar shows a growth of creamy, grayish, moist colonies in about 4 days In time colonies form small, root-like penetrations into agar In time colonies form small, root-like penetrations into agar

112

113 Mycelium and spores of Candida albicans Mycelium and spores of Candida albicans

114 Candidiasis KOH mount from infant with thrush showing pseudohyphae and yeast forms KOH mount from infant with thrush showing pseudohyphae and yeast forms

115 Topical Anti-candidal Agents These include, but are not limited to: clotrimazole (Lotrimin, Mycelex), econazole (Spectazole), ketaconazole (Nizoral), miconazole (MonistatDerm Lotion, Micatin), oxiconazole (Oxistat), sulconazole (Exelderm), naftifine (Naftin), terconazole (vaginal candidiasis only), cicloprox olamine (Loprox), butenafine (Mentax), nystatin, and topical amphotericin B lotion These include, but are not limited to: clotrimazole (Lotrimin, Mycelex), econazole (Spectazole), ketaconazole (Nizoral), miconazole (MonistatDerm Lotion, Micatin), oxiconazole (Oxistat), sulconazole (Exelderm), naftifine (Naftin), terconazole (vaginal candidiasis only), cicloprox olamine (Loprox), butenafine (Mentax), nystatin, and topical amphotericin B lotion Terbinafine has been reported to be less active against Candida species by some authors Terbinafine has been reported to be less active against Candida species by some authors

116 Oral Candidiasis (Thrush) Newborn infection may be acquired from contact with vaginal tract of mother Newborn infection may be acquired from contact with vaginal tract of mother Grayish white membranous plaques are found on surface Grayish white membranous plaques are found on surface Base of plaques are moist, reddish, and macerated Base of plaques are moist, reddish, and macerated Diaper areas is especially susceptible to this Diaper areas is especially susceptible to this Most of intertriginous areas and even exposed skin may be involved Most of intertriginous areas and even exposed skin may be involved

117 Frequently infection extends onto angles of the mouth to form perleche (seen in elderly, debilitated, and malnourished patients, and diabetics) Frequently infection extends onto angles of the mouth to form perleche (seen in elderly, debilitated, and malnourished patients, and diabetics) It is often the first manifestation of AIDS It is often the first manifestation of AIDS Is present in nearly 100% of all untreated patients with full-blown AIDS Is present in nearly 100% of all untreated patients with full-blown AIDS Thrush in an adult with no known predisposing factors warrants a search for other evidence of infection with HIV, such as lymphadenopathy, leukopenia, or HIV antibodies in serum Thrush in an adult with no known predisposing factors warrants a search for other evidence of infection with HIV, such as lymphadenopathy, leukopenia, or HIV antibodies in serum Oral candidiasis (Thrush)

118 Thrush with extension to vermilion border Thrush with extension to vermilion border

119 Treatment Babies with thrush may be allowed to suck on a clotrimazole suppository inserted into the slit tip of a pacifier four times a day for 2-3 days Babies with thrush may be allowed to suck on a clotrimazole suppository inserted into the slit tip of a pacifier four times a day for 2-3 days An adult can let tablets of clotrimazole or Mycelex troches dissolve in the mouth An adult can let tablets of clotrimazole or Mycelex troches dissolve in the mouth Fluconazole, mg/day for 5-10 days with doubling the dose if it fails, or Itraconazole, 200 mg daily for 5-10 days with doubling the dose if it fails-both are available in liquid forms Fluconazole, mg/day for 5-10 days with doubling the dose if it fails, or Itraconazole, 200 mg daily for 5-10 days with doubling the dose if it fails-both are available in liquid forms

120

121 Perleche AKA angular cheilitis AKA angular cheilitis Maceration with transverse fissuring of oral commissures Maceration with transverse fissuring of oral commissures Soft, pinhead-sized papules may appear Soft, pinhead-sized papules may appear Involvement is bilateral-usually Involvement is bilateral-usually

122 Perleche

123 Perleche Analogous to intertrigo elsewhere Analogous to intertrigo elsewhere Similar changes may be seen in riboflavin deficiency, and iron deficiency anemia Similar changes may be seen in riboflavin deficiency, and iron deficiency anemia Identical fissuring occurs in persons with malocclusion caused by ill-fitting dentures and in the aged whom atrophy of alveolar ridges has occurred Identical fissuring occurs in persons with malocclusion caused by ill-fitting dentures and in the aged whom atrophy of alveolar ridges has occurred Seen in children who drool, lick their lips, or suck their thumb Seen in children who drool, lick their lips, or suck their thumb

124 Treatment If due to C. albicans, anti-candidal creams and lotions can be used If due to C. albicans, anti-candidal creams and lotions can be used Glycemic control in diabetes Glycemic control in diabetes Antibiotic topical meds are used when a bacterial; infection is present Antibiotic topical meds are used when a bacterial; infection is present If due to vertical shortening of lower third of the face, dental or oral surgical intervention may help If due to vertical shortening of lower third of the face, dental or oral surgical intervention may help Injection of collagen into depressed sulcus at the oral commissure may be helpful Injection of collagen into depressed sulcus at the oral commissure may be helpful Vytone!! Vytone!!

125 Candidal Vulvovaginitis Pruritus, irritation, and extreme burning Pruritus, irritation, and extreme burning Labia may be erythemtous, moist, and macerated and cervix hyperemic, swollen, and eroded, showing small vesicles on its surface Labia may be erythemtous, moist, and macerated and cervix hyperemic, swollen, and eroded, showing small vesicles on its surface Vaginal discharge is not usually profuse but is frequently thick and tenacious Vaginal discharge is not usually profuse but is frequently thick and tenacious May develop during pregnancy, in diabetes, or secondary to therapy with a broad- spectrum antibiotic May develop during pregnancy, in diabetes, or secondary to therapy with a broad- spectrum antibiotic Recurrent vulvovaginal candidiasis has been associated with long-term tamoxifen tx Recurrent vulvovaginal candidiasis has been associated with long-term tamoxifen tx

126 Candidal Vulvovaginitis Candidal balanitis may be present in an uncircumcised sexual partner Candidal balanitis may be present in an uncircumcised sexual partner If not recognized, repeated reinfection of a partner may occur If not recognized, repeated reinfection of a partner may occur Diagnosis is by clinical symptoms and findings as well as demonstration of fungus via KOH microscopic exam & culture Diagnosis is by clinical symptoms and findings as well as demonstration of fungus via KOH microscopic exam & culture Tx is frustrating & disappointing due to recurrences Tx is frustrating & disappointing due to recurrences Oral fluconazole 150 mg times 1 dose; Fluconazole, 100mg/day for 5-7 days, itraconazole, 200 mg/day for 2-3 days are other options Oral fluconazole 150 mg times 1 dose; Fluconazole, 100mg/day for 5-7 days, itraconazole, 200 mg/day for 2-3 days are other options

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

129 Candidal Intertrigo Pinkish intertriginous moist patches are surrounded by a thin, overhanging fringe of somewhat macerated epidermis (collarette scale) Pinkish intertriginous moist patches are surrounded by a thin, overhanging fringe of somewhat macerated epidermis (collarette scale) May resemble tinea cruris, but usually there is less scaliness and a greater tendency to fissuring May resemble tinea cruris, but usually there is less scaliness and a greater tendency to fissuring Topical anti-candidal preparations are usually effective Topical anti-candidal preparations are usually effective Recurrence is common Recurrence is common

130

131 Pseudo Diaper Rash In infants, C. albicans infection may start in perianal region and spread over entire area In infants, C. albicans infection may start in perianal region and spread over entire area Dermatitis is enhanced by maceration produced by wet diapers Dermatitis is enhanced by maceration produced by wet diapers Diaper friction may contribute to skin irritation and compromised function of stratum corneum Diaper friction may contribute to skin irritation and compromised function of stratum corneum Suspected by finding involvement of folds and occurrence of many small erythematous desquamating satellite or daughter lesions scattered around edges Suspected by finding involvement of folds and occurrence of many small erythematous desquamating satellite or daughter lesions scattered around edges

132 Congenital Cutaneous Candidiasis Infection of an infant during passage through birth canal Infection of an infant during passage through birth canal Eruption usually noted within first few hrs of delivery Eruption usually noted within first few hrs of delivery Erythematous macules progress to thin-walled pustules, which rupture, dry, and desquamate within a week Erythematous macules progress to thin-walled pustules, which rupture, dry, and desquamate within a week Lesions are usually widespread, involving trunk, neck, and head, at times palms and soles, including nail folds Lesions are usually widespread, involving trunk, neck, and head, at times palms and soles, including nail folds Oral cavity and diaper area are spared Oral cavity and diaper area are spared

133 Congenital Cutaneous Candidiasis Differential dx: listeriosis, syphilis, staphylococcal and herpes infections, ETN, transient neonatal pustular melanosis, miliaria rubra, drug eruption, congenital icthyosiform erythroderma (neonatal pustular disorders) Differential dx: listeriosis, syphilis, staphylococcal and herpes infections, ETN, transient neonatal pustular melanosis, miliaria rubra, drug eruption, congenital icthyosiform erythroderma (neonatal pustular disorders) If suspected early amniotic fluid, placenta, and cord should be examined for evidence of infection If suspected early amniotic fluid, placenta, and cord should be examined for evidence of infection Infants with disease limited to skin have favorable outcomes Infants with disease limited to skin have favorable outcomes

134 Congenital Cutaneous Candidiasis Disseminated infection is suggested by (1) birth weight <1500g (2) evidence of respiratory distress or labs indicating neonatal sepsis (3) tx with broad- spectrum antibiotics (4) extensive instrumentation during delivery or invasive procedures in neonatal period (5) positive systemic cultures, or (6) evidence of an altered immune response Disseminated infection is suggested by (1) birth weight <1500g (2) evidence of respiratory distress or labs indicating neonatal sepsis (3) tx with broad- spectrum antibiotics (4) extensive instrumentation during delivery or invasive procedures in neonatal period (5) positive systemic cultures, or (6) evidence of an altered immune response Infants with congenital cutaneous candidiasis with any of these 6 criteria would be considered for systemic antifungal therapy Infants with congenital cutaneous candidiasis with any of these 6 criteria would be considered for systemic antifungal therapy

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136

137 Perianal Candidiasis Frequently entire GI tract is involved Frequently entire GI tract is involved Can be precipitated by oral antibiotic therapy Can be precipitated by oral antibiotic therapy Perianal dermatitis with erythema, oozing, and maceration is present Perianal dermatitis with erythema, oozing, and maceration is present Psychogenic etiology is more common than is candidiasis Psychogenic etiology is more common than is candidiasis Differential dx: psoriasis, seborrheic dermatitis, streptococcal and staphylococcal infections, contact dermatitis, and extramammary Pagets disease Differential dx: psoriasis, seborrheic dermatitis, streptococcal and staphylococcal infections, contact dermatitis, and extramammary Pagets disease Fungicides, meticulous cleansing of perianal region after bowel movements, topical corticosteroids and antipruritics (Atarax) Fungicides, meticulous cleansing of perianal region after bowel movements, topical corticosteroids and antipruritics (Atarax)

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139 Candidal Paronychia Cushion-like thickening of paronychial tissue, slow erosion of lateral borders of nails, gradual thickening and brownish discoloration of nail plates, and development of pronounced transverse ridges Cushion-like thickening of paronychial tissue, slow erosion of lateral borders of nails, gradual thickening and brownish discoloration of nail plates, and development of pronounced transverse ridges Frequently only one nail Frequently only one nail A secondary mixed bacterial infection can occur with those who frequently have hands in water or who handle moist objects; cooks, dishwashers, bartenders, nurses, canners, etc A secondary mixed bacterial infection can occur with those who frequently have hands in water or who handle moist objects; cooks, dishwashers, bartenders, nurses, canners, etc

140 Candidal Paronychia Manicuring nails sometimes is responsible for mechanical or chemical injuries leading to infection Manicuring nails sometimes is responsible for mechanical or chemical injuries leading to infection Ingrown toenails with chronic paronychia Ingrown toenails with chronic paronychia Seen in pts with diabetes Seen in pts with diabetes Avoid chronic moisture exposure; get diabetes under control Avoid chronic moisture exposure; get diabetes under control Oral fluconazole once weekly or pulse dose itraconazole should be effective Oral fluconazole once weekly or pulse dose itraconazole should be effective Topical therapy should continue for 2-3 months to prevent recurrence Topical therapy should continue for 2-3 months to prevent recurrence

141 Erosia Interdigitalis Blastomycetica Oval-shaped area of macerated white skin on web between and extending onto sides of fingers Oval-shaped area of macerated white skin on web between and extending onto sides of fingers With progression macerated skin peels off, leaving painful, raw,denuded area surrounded by a collar of overhanging white epidermis With progression macerated skin peels off, leaving painful, raw,denuded area surrounded by a collar of overhanging white epidermis Nearly always affects third web Nearly always affects third web Moisture beneath rings macerates skin and predisposes to infection Moisture beneath rings macerates skin and predisposes to infection Also seen in diabetics, those who do housework, launderers, and others exposed to macerating effects of water and strong alkalis Also seen in diabetics, those who do housework, launderers, and others exposed to macerating effects of water and strong alkalis

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143 Chronic Mucocutaneous Candidiasis A heterogeneous group of patients whose infection with Candida is chronic but superficial A heterogeneous group of patients whose infection with Candida is chronic but superficial Onset before age 6 Onset before age 6 Onset in adult life may herald the occurrence of thymoma Onset in adult life may herald the occurrence of thymoma When inherited an endocrinopathy is often found When inherited an endocrinopathy is often found Most cases have well-defined limited defects of cell- immunity Most cases have well-defined limited defects of cell- immunity Oral lesions are diffuse and perleche and lip fissures are common Oral lesions are diffuse and perleche and lip fissures are common

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146 Systemic Candidiasis High risk pts: pts with malignancies, AIDS, transplant pts requiring immunosuppressive drugs, pts on oral cortisone, pts who have had multiple surgical operations especially cardiac, pts with indwelling catheters, and heroin addicts High risk pts: pts with malignancies, AIDS, transplant pts requiring immunosuppressive drugs, pts on oral cortisone, pts who have had multiple surgical operations especially cardiac, pts with indwelling catheters, and heroin addicts Initial sign is varied: FUO, pulmonary infiltrates, GI bleeding, endocarditis, renal failure, meningitis, osteomyelitis, endophthalmitis, peritonitis, or a disseminated maculopapular eruption Initial sign is varied: FUO, pulmonary infiltrates, GI bleeding, endocarditis, renal failure, meningitis, osteomyelitis, endophthalmitis, peritonitis, or a disseminated maculopapular eruption

147 Systemic Candidiasis Cutaneous findings are erythematous macules that become papular, pustular, and hemorrhagic, and may progress to necrotic, ulcerating lesions resembling ecthyma gangrenosum Cutaneous findings are erythematous macules that become papular, pustular, and hemorrhagic, and may progress to necrotic, ulcerating lesions resembling ecthyma gangrenosum Deep abscesses may occur Deep abscesses may occur Trunk and extremities are usual sites of involvement Trunk and extremities are usual sites of involvement Proximal muscle tenderness is a common finding Proximal muscle tenderness is a common finding

148 Systemic Candidiasis If candida is cultured within the first week of life there is a high rate of systemic disease If candida is cultured within the first week of life there is a high rate of systemic disease There is a 50% chance of systemic disease if 1 or more cultures is positive There is a 50% chance of systemic disease if 1 or more cultures is positive Mortality has declined from 80% in the 1970s to 40% in the 1990s because of early empiric antifungals and better prophylaxis Mortality has declined from 80% in the 1970s to 40% in the 1990s because of early empiric antifungals and better prophylaxis

149 THE END


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