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

Superficial mycoses AKA dermatophytes Cause only stratum corneum, hair and nail infection 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

Host factors Immunosuppressed pts- cancer, diabetes AIDS, connective tissue disorders 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 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

Imidazoles Clotrimazole, miconazole, sulconazole, oxiconazole, and ketoconazole Mostly used for topical tx Inhibit cytochrome P450 14-alpha-demethylase (an essential enzyme in ergosterol synthesis) 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

Allylamines Naftifine, terbinafine, butenafine Inhibites squalene epoxydation 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 Few drug interactions have been reported 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

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

Triazoles Itraconazole, Fluconazole Affect P450 system Numerous drug interactions occur Need to know pt’s current meds 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 Pulse dosing limits concern over lab abnormalities Fluconazole’s absorption is unaffected by food

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

Tinea Capitis

Noninflammatory M. audouinii infections present as the classic form 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 In the U.S. T. tonsurans is the most common cause

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 tinea

Black dot ringworm caused by Trichophyton tonsurans

Inflammatory Usually caused by M. canis 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 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

Kerion 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

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

Permanent scarring alopecia post-kerion

Kerion: red, oozing, hairless plaque

Favus Rare in the U.S. Most severe form of dermatophyte hair infection Most frequently cause by T. schoenleinii Hyphae and air spaces seen within hair shaft Bluish white fluorescence under Wood’s light Thick, yellow crusts composed of hyphae and skin debris (‘scutula’) Scarring alopecia may develop

Favus with scarring alopecia and scutula

Scarring after favus infection

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) Endothrix types-T. tonsurans (black-dot ringworm) and T. violaceum Ectothrix found on scalp are T. verrucosum & T. mentagrophytes, M. canis

Diagnosis Wood’s light Ultraviolet of 365 nm wavelength is obtained by passing a beam through a Wood’s 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 Hairs infected with T. tonsurans, T. verrucosum, & T. violaceum and others of endothrix do not fluoresce The fluorescent substance is pteridine

Diagnosis KOH Scales or hairs cleared with it can still be cultured 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

DTM 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.)

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

Endothrix spores in hair with Trichophyton tonsurans

Endothrix in T. scoenleinii showing characteristic bubbles of air

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

T. tonsurans 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 Microconidia may be seen regularly Dx confirmed by the fact that cultures grow poorly or not at all without thiamine

T. mentagrophytes 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 Round microconidia borne laterally and in clusters confirm dx within 2 weeks Spirals are sometimes present Macroconidia may be seen

T. verrucosum 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 Chlamydospores (round swellings along the hyphal structures) are present in early cultures Microconidia may be seen

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

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

Treatment 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 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 For this, systemic steroids, to minimize scarring, can be given simultaneously

Treatment 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 Fluconazole Selenium Sulfide or Ketoconazole shampoo as an adjunct

Tinea Barbae AKA Tinea sycosis, barber’s itch Uncommon Occurs chiefly among those in agriculture 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

Tinea Barbae 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

Tinea Barbae 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

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

Verrucous epidermophytosis from Epidermphyton floccosum

Complete resolution after 48 days of Griseofulvin

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 Contact dermatitis Herpes infections

Tinea barbae-Trichophyton mentagrophytes

Treatment-Tinea Barbae Oral antifungals are required Topical agents as adjunctive therapy Micronized or ultramicronized griseofulvin orally: dosage of 500–1000 mg or 350-700 mg respectively Tx usually for 4-6 weeks

Treatment-Tinea Barbae Other orals that have been effective: ketoconazole, fluconazole, itraconazole, and terbinafine Topical antifungals should be applied from the beginning of tx Affected parts should be bathed thoroughly in soap and water 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

Tinea Faciei Fungal infection of the face (apart from the beard) 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) Typical annular rings are usually lacking & lesions are exquisitely photosensitive Usually caused by T. rubrum, T. mentagrophytes, or M. canis

Tinea faciei (Microsporum canis) in a child

Treatment Topical antifungals 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

Tinea Corporis(Tinea Circinata) 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 Characterized by one or more circular, sharply circumscribed, slightly erythematous, dry, scaly, usually hypopigmented patches Advancing scaling edge is usually prominent

Tinea corporis in a child, caused by Microsporum canis

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

Tinea Corporis 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

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

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

Etiology-Tinea Corporis Microsporum canis, T. rubrum, T. mentagrophytes- most common 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 In children, M. canis is the cause of the “moist” type of tinea circinata

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 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

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 The ultra-micronized form may be used at a dose of 350-750 mg once/day for 4-6 weeks This dose may be increased to twice daily if needed Terbinafine, itraconazole, and fluconazole are effective Terbinafine at 250 mg/day for two weeks Itraconazole 200 mg B.I.D. for one week Fluconazole 150 mg once/week for 4 weeks

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

Treatment Creams are more effective than lotions Sulconazole may be less irritating in folded areas Castellani paint (which is colorless if made without fuchin) is very effective Salicylic acid 3-5%, or half-strength Whitfield’s 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

Other Forms of Tinea Corporis Trichophytic Granuloma or Perifollicular Granuloma or Majocchi’s Granuloma or Tinea Incognito 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 Follicles are distended with viscid purulent material Most frequently on the shins or wrists

Majocchi’s granuloma H&E pale blue-staining fungal hyphae within hair shaft

Majocchi’s granuloma: PAS reveals multiple organisms that have replaced a fragment of hair shaft embedded in a sea of neutrophils

Tinea Imbricata (Tokelau) 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 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

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) Causative fungus is T. concentricum TOC is griseofulvin- in same form as for tinea corporis Other options are terbinafine, fluconazole, and itraconazole Several courses of therapy may be needed May need to remove patient from hot, humid environment

Tinea imbricata in New Guinea native

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

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

Tinea cruris in a man

Tinea cruris in a woman

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

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

Tinea in diaper area

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

Tinea pedis showing interdigital scalping T. mentagrophytes

Interdigital scaling with vesiculation caused by T. mentagrophytes

Dermatophytosis of the soles Trichophyton mantagrophytes

Acute vesiculobullous eruption on sole caused by Trichophyton mentagrophytes

TP-Trichophyton rubrum 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 Producing a moccasin or sandal appearance

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

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

Trichophyton rubrum infections

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

Fungus filaments under KOH mount

Mosaic fungus

Prophylaxis Hyperhidrosis is a predisposing factor Dry toes after bathing 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

Treatment Topical antifungals 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 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

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) Griseofulvin is only effective against dermatophytes When infection is caused by T. mentagrophytes, griseofulvin does not decrease inflammatory reaction

Treatment- dosing Griseofulvin in ultramicronized particles taken orally in doses of 350-750 mg daily Dosage for children is 10 mg/kg/day Period of treatment depends on response 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

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

Onychomycosis 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

Onychomycosis caused by Trichophyton rubrum

Trichophyton mentagrophytes 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

Onychomycosis 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 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

Onychomycosis caused by Candida albicans in mucocutaneous candidiasis

Onychomycosis 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 First a yellowish discoloration occurs, which may spread until entire nail is affected Beneath discoloration nail plate becomes loose from nail bed

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

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

Differential Allergic contact dermatitis Psoriasis Lichen planus 20 nail dystrophy Darier’s disease Reiter’s disease Norwegian scabies Non-dermatophyte onychomycosis

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

Candidiasis 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 is largely an opportunisitic organism Moisture promotes its growth Lip corners Body folds

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

Mycelium and spores of Candida albicans

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

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 Terbinafine has been reported to be less active against Candida species by some authors

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

Oral candidiasis (Thrush) 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 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 with extension to vermilion border

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 An adult can let tablets of clotrimazole or Mycelex troches dissolve in the mouth Fluconazole, 100-200 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

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

Perleche

Perleche Analogous to intertrigo elsewhere 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 Seen in children who drool, lick their lips, or suck their thumb

Treatment If due to C. albicans, anti-candidal creams and lotions can be used Glycemic control in diabetes 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 Injection of collagen into depressed sulcus at the oral commissure may be helpful Vytone!!

Candidal Vulvovaginitis Pruritus, irritation, and extreme burning 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 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

Candidal Vulvovaginitis Candidal balanitis may be present in an uncircumcised sexual partner 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 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

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

Candidal Intertrigo 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 Topical anti-candidal preparations are usually effective Recurrence is common

Pseudo Diaper Rash In infants, C. albicans infection may start in perianal region and spread over entire area Dermatitis is enhanced by maceration produced by wet diapers 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

Congenital Cutaneous Candidiasis Infection of an infant during passage through birth canal Eruption usually noted within first few hrs of delivery 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 Oral cavity and diaper area are spared

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) If suspected early amniotic fluid, placenta, and cord should be examined for evidence of infection Infants with disease limited to skin have favorable outcomes

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 Infants with congenital cutaneous candidiasis with any of these 6 criteria would be considered for systemic antifungal therapy

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

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 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

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

Erosia Interdigitalis Blastomycetica 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 Nearly always affects third web 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

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

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 Initial sign is varied: FUO, pulmonary infiltrates, GI bleeding, endocarditis, renal failure, meningitis, osteomyelitis, endophthalmitis, peritonitis, or a disseminated maculopapular eruption

Systemic Candidiasis 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 Trunk and extremities are usual sites of involvement Proximal muscle tenderness is a common finding

Systemic Candidiasis 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 Mortality has declined from 80% in the 1970’s to 40% in the 1990’s because of early empiric antifungals and better prophylaxis

THE END