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Chapter 33. Topical Fungal Infections Revised 8/15/10

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Presentation on theme: "Chapter 33. Topical Fungal Infections Revised 8/15/10"— Presentation transcript:

1 Chapter 33. Topical Fungal Infections Revised 8/15/10

2 Fungal Prevalence 20% of U.S. residents may be affected
Tinea pedis most common Tinea corporis, cruris next most common Tinea capitis incidence falling

3 Fungal Epidemiology: General
High temperature High humidity More common: tropical and subtropical areas Immunocompromised patients Those with mild skin trauma or maceration from occlusion

4 Tinea Pedis Epidemiology
Athlete’s foot; ringworm of foot White urban dwellers Adults ages 15-40; more common in males Those using communal bathing facilities, swimming pools, summer camps, sports clubs, gyms Marathon running: foot trauma

5 Tinea Corporis Epidemiology
Ringworm of the body From persons or animals (cat/dog) Transfer from tinea capitis Most common prepubertal tinea (day-care center spread common) Warm climates, overweight, stress Tinea corporis gladiatorum: wrestling transmission

6 Tinea Cruris Epidemiology
Jock itch Summer Intertriginous skin: maceration facilitates warm, moist environment More in males, scrotal skin folds Rare in prepubertal children Postpubertal males highest risk group

7 Tinea Capitis Epidemiology
Ringworm of scalp More in pediatrics; poorer hygiene Playing with infected brushes, combs, toys, telephones Contacting infected cat or dog Black children: occlusive hair dressings/ tight braids

8 Tinea Unguium Epidemiology
Onychomycosis 30% of those over the age of 60 Toenails of those who also have tinea pedis

9 Tinea Versicolor Epidemiology
Warm, humid weather Underlying immune deficiency Oily/greasy skin Hyperhidrosis: excessive foot sweating

10 Tinea Nigra Epidemiology
Temperate climates Younger patients Females Palms and soles

11 Causes of Superficial Tineas
Trichophyton, Microsporum, Epidermophyton Anthropophilic fungi: person-to-person (most common) Zoophilic fungi: animal-to-person Geophilic fungi: soil-to-person

12 Manifestations of Fungal Skin Infections
Anthropophilic: little inflammation From pets or soil: Acutely inflamed; allergies to fungal antigens

13 Manifestations: Tinea Pedis
3 forms Intertriginous: macerated, boggy, white, thick, odorous, pruritic between toes Acute vesicular: inflammation, fissuring; 2˚ bacterial infections; odorous, pruritic; extreme pain in walking Moccasin: chronic, nonvesicular, over plantar foot

14 T. Pedis

15 Manifestation: Tinea Pedis
Flares in the summer; abates in winter May cause tinea manuum: “one-hand, two-foot disease”; Hands are dry, red, scaly

16 Manifestations: Tinea Corporis
Glabrous skin (smooth and bare) Not on scalp, feet, hands, groin, ears, face Oval, scaly patch with inflamed border Centrally, skin often appears lighter or normal; thus, the lesion appears to be a ring circling beneath the skin surface 15-20 lesions over the body Lesions coalesce: polycyclic appearance

17 T. Corporis Presentations

18 T. Corporis Presentations

19 T. Corporis Presentations

20 T. Corporis Presentations

21 Manifestations: Tinea Cruris
Sharply defined lesions Inflamed borders, reddish-brown centers Begins in groin skinfolds Spreads to perineum, thighs, buttocks Intense pruritus Sweating causes overt pain 2˚ bacterial infection possible

22 T. Cruris Presentations

23 T. Cruris Presentations

24 Manifestations: Tinea Capitis
Circular patch of scaly skin Dry, noninflammatory dermatosis Patchy areas of hair loss Crown, parietal areas “Black dots”: hairs broken off at the scalp Kerion or favus: both worse involvement

25 T. Capitis Presentation

26 Manifestations: Other Tineas
Unguium: opaque, yellow nails; thickened; brittle, crumbled; nail lifts and may be lost Versicolor: lesions darken in winter, lighten in summer Nigra: black, brown discoloration on palms, lesions may coalesce; no scaling, nonpruritic, painless

27 T. Unguium Presentation

28 T. Versicolor Presentations

29 Tinea Incognito Inappropriate assumption that lesions are allergenic in etiology Treatment of the lesion with steroids Steroid decreases inflammatory barriers, allowing spread to accelerate As spread accelerates, patient increases use of steroids

30 Tinea Incognito

31 Tinea Treatment Guidelines
Be sure lesions are fungal Check for other medications or medical conditions causing lesions Ointments last longer than creams Aerosols easy to use on skin and in shoes Only self treat: pedis, cruris, corporis Continue for full course of therapy

32 Tinea Pedis Treatment If topicals ineffective, orals may be necessary
2˚ bacterial infections may require antibiotics May also need antiperspirants Recurs in 70% of patients

33 Tinea Corporis Treatment
If condition does not clear, may be Psoriasis Eczema Medication-induced eruptions More severe fungal pathogens

34 Tinea Cruris Treatment
Responds more readily to therapy than tinea pedis or tinea corporis Treatment times are shorter

35 Tineas Requiring Referral
Tinea capitis: Topical medications do not penetrate follicles Tinea Unguium: Forget Fungi-Nail; requires systemic therapy Tinea Versicolor: Requires Rx meds Tinea Nigra: Differentiate from other pigmentation such as melanoma: requires Rx meds

36 Self-Care Only pedis, corporis, cruris
Not for nails, scalp, vaginal yeast infections, diaper rash Supervise children External use only Keep from eyes Clean skin with mild soap first Apply morning and night

37 Therapeutic Choices: Classify By Cure Rates/Dosing
First Generation: Longest cure rates Second Generation: Shorter cure rates Third Generation: Shortest cure rates for tinea pedis coupled with once-daily dosing

38 First Generation (Oldest)
First Generation: use down to 2 years Undecylenic acid: around pre-1970s Tolnaftate: OTC in 1971 Miconazole: OTC in 1982 Clotrimazole: OTC in 1989 Use 4 weeks for corporis & pedis, 2 weeks for cruris Age limit is 2 years

39 Clotrimazole Occasional burning, stinging, peeling, other minor local reactions

40 Clotrimazole: Lotrimin AF Creams

41 Clotrimazole Products: Lotrimin AF for Her and Fungi Cure Intensive

42 Miconazole Nitrate Occasional burning and irritation
Otherwise, safe and effective ingredient

43 Miconazole Products: Micatin Cream

44 Miconazole Products: Neosporin AF, Desenex Powder, Cruex Spray

45 Miconazole Products: Lotrimin AF Powder and Aerosol Powders

46 Lotrimin AF Differences
Note that some dosage forms of Lotrimin AF are clotrimazole, where others are miconazole Evidently, clotrimazole cannot be produced in any aerosol form

47 Tolnaftate Irritation on excoriated skin
Only ingredient proven to prevent recurrences: apply to dry feet 1-2 times daily, at start of spring/summer

48 Tolnaftate Products: Tinactins
Tinea pedis spray Jock Itch spray

49 Tolnaftate Products: Tinactins

50 Tolnaftate Products: Lamisil Defense

51 Tolnaftate Products: Fungi Cure Gel

52 Undecylenic Acid Odor slightly unpleasant
Fungi Cure Liquid, Fungi Nail

53 Second Generation Newer Meds (Post-2000): Only 12 and over
Terbinafine: 1999 Butenafine: 2001

54 Terbinafine Lamisil AT Cream, Spray Pump, Solution
Only for those aged 12 and over Cures pedis between toes if used BID for 1 week Only Lamisil AT Cream has an indication for pedis on bottom/sides of feet: used twice daily for 2 weeks Cures cruris and corporis used once daily for 1 week

55 Lamisil AT Products

56 Butenafine Lotrimin Ultra Cream Only for those aged 12 and over
Cures pedis between toes if used BID for 1 week OR once daily for 4 weeks Efficacy on bottom and sides of feet unknown Cures cruris and corporis used once daily for 2 weeks

57 Lotrimin Ultra Tinea pedis box Jock Itch box

58 Third generation Newest Option: Lamisil AT Gel (terbinafine)
Innovative One large advantage that will cause it to rapidly become the nonprescription standard for tinea pedis treatment Requires only one application daily to achieve cure for tinea pedis between the toes in only one week Age cut-off is still 12 years

59 Lamisil AT Gel

60 Lamisil AT Gel Ability of patient to treat only once daily will increase adherence to dosage regimen and increase the chances of full cure Efficacy on bottom or sides of feet is unknown

61 Deceptive Product Fungi Nail: Only 25% undecylenic acid; cannot cure fungal nails; many consumers are misled

62 Deceptive Product Dr. Scholl’s Fungal Nail: Contains tolnaftate cream, revitalizer cream, a brush and file; cannot cure fungal nails and also misleads consumers

63 Deceptive Product Blue Star Ointment: Recommended for tinea cruris, pedis, and corporis; camphor 1.24%, methyl salicylate, salicylic acid; junk product; extreme pain if applied to broken skin

64 Prevention of Pedis Keep feet clean & dry
Dry thoroughly after bathing; use antifungal powder Go barefoot whenever possible Wear open sandals Use thongs when in communal bathing or showering facilities Change shoes/socks daily

65 Prevention of Pedis Never share footwear
See physician immediately if toenails infected Use preventive tolnaftate if recurrent If present elsewhere, don’t use same towel to dry the feet Wear several different shoes so they can dry Wear cotton socks

66 Prevention of Corporis
Wash/dry with different cloths than those used to wash/dry the feet Never play with strange cats/dogs Avoid contact with infected people Lose weight: less intertriginous skin Dry thoroughly after bathing, especially intertriginous skin (e.g., beneath breasts) Never garden in bare feet or knees

67 Prevention of Cruris Lose weight
Wash and dry groin with different towels/wash cloths Avoid sexual contact with infected individuals Wear underclothes that allow evaporation

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