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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.

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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:

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

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 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

5 If they do this to food…..

6 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)


8 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.

9 ID Reaction

10 Tinea capitis l Trichophyton or Microsporum species l Disease of children l Exposure from other children or pets l Highly variable presentation

11 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

12 Kerion

13 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

14 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

15 The diagnosis please…..

16 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

17 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

18 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


20 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

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

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

23 T. barbae Treatment l Griseofulvin g/day l Itraconazole or terbinafine for resistant cases l Local care

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

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

26 T. corporis vs. Majocchis granuloma

27 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

28 T. corporis: Differential diagnosis

29 The diagnosis please... Lichen simplex chronicus Nummular eczema

30 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


32 Tinea cruris l Thrives in humid environments l Diagnosis: »Spares scrotum; »Pruritus & burning clues »Look for feet as possible infection source »KOH + hyphae

33 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

34 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

35 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

36 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

37 The diagnosis is...

38 Tinea pedis l 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 …..


42 Tinea Versicolor l Diagnosis: macules, plaques; fine scale after scraping; KOH +

43 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

44 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

45 The diagnosis is...

46 Onychomycosis

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

48 l Diagnosis? l Culture? l Treatment?


50 Case Which of the following, if any, is onychomycosis?

51 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

52 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

53 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: )

54 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)

55 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, htm)

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

57 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


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

60 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

61 A few unknowns




65 Thank You …….

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