Presentation on theme: "Fungal Infections of the Skin and Nails"— Presentation transcript:
1 Fungal Infections of the Skin and Nails Adam O. Goldstein, MD, MPHAssociate ProfessorDepartment of Family MedicineUniversity of North Carolina at Chapel Hill
2 Fungal Infections of the Skin and Nails Objectives1. To distinguish common fungal infections from similar appearing lesions; e.g. eczema2. Improved dx of fungal lesions with a KOH scraping3. Know at least 2 tx options for common fungal infections of the skin & nails4. Know common errors in fungal dx and tx5. Know when to suspect & how to dx ID reaction
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)
8 ID Reaction Severe inflammatory skin reaction Immunologically mediated Appearance may be very different from original lesionFungal infections if severe enough may provoke ID reaction. If you do not think about it, you will not diagnose it.
13 T. capitisDiagnosisOverdiagnosed in adults, underdiagnosed in childrenDirect microscopic exam of hairs looking for hyphae/sporesWoods lamp: bright green fluorescence in hair shafts d/t Microsporum infection (< 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 lossSyphilis- “mothball eaten” areas
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 weeksFluconazole- 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 mg/day adults15-20 mg/kg/day childrenSE’s: photosensitivity, H/A, GI upset, hypersensitivity, leukopeniaActive only against dermatophytes, not yeasts
18 T. capitis Patient education Compliance for 2 weeks beyond “cure” to prevent relapseLook for sources of infectionsClean contaminated objectsReassure caretakers that it may take 1 month for improvement
50 Case Which of the following, if any, is onychomycosis?
51 Onychomycosis- treatments 8% Ciclopirox (Penlac)Topical therapy: FDA approved (2/00)2 studies X 48 weeks:% cc 6.5% ac vs. .9% placebo% cc 12% ac vs. .9% placebose: erythema 5%1x/day for seven days, remove w/alcohol and begin again
53 Onychomycosis- oral meds RCT-DB, PC-72 week f/u496 patientsContinuous terbinafine vs. pulsed itraconazoleNo diff. SE’sT3 T I I4MC % 81% 38% 49%CC % 60% 32% 32%(BMJ, 4/99, 318: )
54 Evidence-based reviews- Fungal Pooled analysis trials comparing mycological cure ratesContinuous 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, [95% confidence interval, to ]; number needed to treat, 5 [95% confidence interval, 4 to 8]).(Crawford, Arch Dermatol, 2002)
55 Evidence-based review- Fungal Oral treatments for T. PedisTwelve trials, 700 participants2 trials comparing terbinafine and griseofulvinA 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)
56 Summary Do a KOH when possible or doubtful Avoid brand name combination steroid/antifungal productsRemember patient education strategies
57 PearlsT. capitis- overdiagnosed in adults/under in children; oral therapy neededT. cruris- spares scrotumT. manus- often unilateralT. Pedis- highly variable presentationT. versicolor- oral therapy effectiveOnychomycosis- oral meds needed
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