Presentation on theme: "Fungal Infections of the Skin and Nails Adam O. Goldstein, MD, MPH Associate Professor Department of Family Medicine University of North Carolina at Chapel."— Presentation transcript:
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
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
Sorry… but ….
Superficial Fungal Infections l 4.1 million visits -82% nondermatologists l 3 types of fungi-dermatophytes: Epidermophyton Trichophyton Microsporum l Named by location l Similar treatments; Varied presentations
If they do this to food…..
Superficial Fungal Infections l Common Denominator = Do KOH, Do KOH, Do KOH.. l 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)
ID Reaction l Severe inflammatory skin reaction l Immunologically mediated l Appearance may be very different from original lesion l Fungal infections if severe enough may provoke ID reaction. If you do not think about it, you will not diagnose it.
Tinea capitis l Trichophyton or Microsporum species l Disease of children l Exposure from other children or pets l Highly variable presentation
T. capitis l Primary lesions: plaques, papules, pustules or nodules l Secondary lesions: scale, alopecia, erythema, exudate and edema Kerion: Severe T. capitis- inflamed, boggy nodule with hair loss
T. capitis Diagnosis l Overdiagnosed in adults, underdiagnosed in children l Direct microscopic exam of hairs looking for hyphae/spores l Woods lamp: bright green fluorescence in hair shafts d/t Microsporum infection (< 20% time) l Culture: If KOH is negative but strong clinical suspicion
T. capitis Differential Diagnosis l Seborrheic dermatitis- rare in children, KOH - l Cellulitis- may coexist, KOH - l Alopecia areata-discrete, nonscaling areas hair loss l Syphilis- mothball eaten areas
The diagnosis please…..
T. capitis Treatment l Systemic therapy needed l Griseofulvin at least 8 wks (Or 2 wks beyond cure) l Itraconazole- 3-5mg/kg/day 1x/week 3 weeks l Fluconazole- 3-6 mg/kg children (10, 40 ml) l Terbinafine - 3-6mg/kg/day X 4 weeks
Griseofulvin l Microsize 250, 500 mg tabs, 125 mg/5 cc susp l mg/day adults l mg/kg/day children l SEs: photosensitivity, H/A, GI upset, hypersensitivity, leukopenia l Active only against dermatophytes, not yeasts
T. capitis Patient education l Compliance for 2 weeks beyond cure to prevent relapse l Look for sources of infections l Clean contaminated objects l Reassure caretakers that it may take 1 month for improvement
Tinea barbae Characteristics l Inflammation in the beard/hair l Pseudofolliculitis l Frequently failed antibiotics l Positive S.Aureus culture does not rule out T. barbae
T. barbae Diagnosis l Nodular, boggy lesions with exudate l Sinus tract formation l Scarring if untreated l KOH or culture may confirm
T. barbae Differential diagnosis l Bacterial folliculitis l Pseudofolliculitis barbae l Contact dermatitis l Herpes l Syphilis l Acne l Candida
T. barbae Treatment l Griseofulvin g/day l Itraconazole or terbinafine for resistant cases l Local care
Tinea corporis l Papules or plaques with erythema and scale l Look for annular lesions with central clearing l Well-demarcated edges
T. corporis Diagnosis l KOH from leading edge l Prior steroid use alters response/appearance l Majocchis granuloma: pluck hairs for hyphae
T. corporis vs. Majocchis granuloma
T. corporis Differential diagnosis l Nummular eczema KOH neg l Pityriasis rosea KOH neg, multiple papules/plaques l Psoriasis KOH neg, thick, silvery scales l Granuloma annulare KOH neg, no scale l Lyme disease KOH neg, no scale
T. corporis: Differential diagnosis
The diagnosis please... Lichen simplex chronicus Nummular eczema
T. corporis Treatment l Avoid Lotrisone type combos l Topical agents for mild/moderate disease l Oral agents for extensive/resistant disease l Continue topical medication days beyond cure
Tinea cruris l Thrives in humid environments l Diagnosis: »Spares scrotum; »Pruritus & burning clues »Look for feet as possible infection source »KOH + hyphae
T.cruris Differential Diagnosis: l Candida Beefy red with poorly defined borders l Intertrigo KOH negative, irritant dermatitis l Erythrasma Asymmetric velvety patches, Neg KOH l Psoriasis Thick silvery scales,Neg KOH l Seb derm Borders less defined, distribution different, Neg KOH
T. cruris Treatment l Topical agents for 2-3 weeks l Mild topical steroid for inflammatory component l Pruritus relief l Look for infection source
T. cruris Patient education l Use topical meds 7-14 days beyond cure l Avoid prolonged topical steroids l Avoid self-medicating preps l Avoid baths and tight fitting underwear l Use mild soaps or soap substitute l Antifungal powders l Keep area dry
Tinea manus l Diagnosis: »Often unilateral, but with bilateral feet »May have only scant scaling, vesicles l Differential Diagnosis: Eczema, contact dermatitis l Treatment: Topical agents
The diagnosis is...
Tinea pedis l Diagnosis: –Extremely variable presentation –Be aware of id reaction and bacterial infection
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
The diagnosis is …..
Tinea Versicolor l Diagnosis: macules, plaques; fine scale after scraping; KOH +
Tinea Versicolor l Treatment: Limited disease: Topical agents Widespread: Ketoconazole 200 mg X 2 one dose, repeat 1 week (Not griseofulvin) l Prevention and Patient Education: Selenium sulfide 2.5% overnight 1X/month
Candidiasis l Diagnosis: Beefy red lesions, satellite papules and pustules l Differential Dx: Tinea, Intertrigo l Treatment and Patient education : Topical antifungal creams Oral therapy for extensive (not Griseofulvin) Environmental: Zeasorb powder or Burows Mild topical steroids
The diagnosis is...
l Why should we treat? (cosmetically disfiguring, painful, entry for cellulitis) l Diff Dx: Psoriasis, Lichen Planus, Trauma l Diagnosing vs. treating
l Diagnosis? l Culture? l Treatment?
Case Which of the following, if any, is onychomycosis?
Onychomycosis- treatments l 8% Ciclopirox (Penlac) l Topical therapy: FDA approved (2/00) 2 studies X 48 weeks: % cc 6.5% ac vs..9% placebo % cc 12% ac vs..9% placebo se: erythema 5% 1x/day for seven days, remove w/alcohol and begin again
Onychomycosis- systemic l 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 mg 1x/week x 6-9 months l Side effects: GI, Skin, H/A, LFT, Drugs
Onychomycosis- oral meds l RCT-DB, PC- l 72 week f/u l 496 patients l Continuous terbinafine vs. pulsed itraconazole l No diff. SEs T3 T4 I8 I4 MC 76% 81% 38% 49% CC 54% 60% 32% 32% (BMJ, 4/99, 318: )
Evidence-based reviews- Fungal l Pooled analysis trials comparing mycological cure rates l Continuous treatment with terbinafine (250 mg/d for 12 weeks) & continuous treatment with itraconazole (200 mg/d for 12 weeks) l Statistically significant difference in 1 year outcomes in favor of terbinafine (risk difference, [95% confidence interval, to ]; number needed to treat, 5 [95% confidence interval, 4 to 8]). (Crawford, Arch Dermatol, 2002)
Evidence-based review- Fungal l Oral treatments for T. Pedis l Twelve trials, 700 participants l 2 trials comparing terbinafine and griseofulvin l 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, software.com/abstracts/ab htm)
Summary l Do a KOH when possible or doubtful l Avoid brand name combination steroid/antifungal products l Remember patient education strategies
Pearls l T. capitis- overdiagnosed in adults/under in children; oral therapy needed l T. cruris- spares scrotum l T. manus- often unilateral l T. Pedis- highly variable presentation l T. versicolor- oral therapy effective l Onychomycosis- oral meds needed
l Whats the diff dx? l How to dx? l Use combo meds? l How to tx?
l Diff dx: »SCCa, Eczema, Tinea l How to dx: »KOH, KOH, KOH l Use combo meds: NO »wrong 30% »unclear length of time »more difficult for subsequent dx »$$$ »potent steroids l Tx: Lidex 0.05% bid