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 [email protected]
Mar 31, 2015
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
4.1 million visits -82% nondermatologists 3 types of fungi-dermatophytes: Epidermophyton
Trichophyton
Microsporum
Named by location Similar treatments; Varied presentations
If they do this to food…..
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)
KOH
ID Reaction
Severe inflammatory skin reaction Immunologically mediated Appearance may be very different from
original lesion Fungal infections if severe enough may
provoke ID reaction. If you do not think about it, you will not diagnose it.
ID Reaction
Tinea capitis
Trichophyton or Microsporum species
Disease of children Exposure from other
children or pets Highly variable
presentation
T. capitis
Primary lesions: plaques, papules, pustules or nodules
Secondary lesions: scale, alopecia, erythema, exudate and edema
Kerion: Severe T. capitis- inflamed, boggy nodule with hair loss
Kerion
T. capitis
Diagnosis Overdiagnosed in adults,
underdiagnosed in children Direct microscopic exam of hairs
looking for hyphae/spores Woods lamp: bright green
fluorescence in hair shafts d/t Microsporum infection (< 20% time)
Culture: If KOH is negative but strong clinical suspicion
T. capitis
Differential Diagnosis Seborrheic dermatitis- rare in children, KOH - Cellulitis- may coexist, KOH - Alopecia areata-discrete, nonscaling areas
hair loss Syphilis- “mothball eaten” areas
The diagnosis please…..
T. capitis
Treatment Systemic therapy needed Griseofulvin at least 8 wks
(Or 2 wks beyond cure) Itraconazole- 3-5mg/kg/day
1x/week 3 weeks Fluconazole- 3-6 mg/kg children
(10, 40 ml) Terbinafine - 3-6mg/kg/day X 4
weeks
Griseofulvin
Microsize 250, 500 mg tabs, 125 mg/5 cc susp
500-1000 mg/day adults 15-20 mg/kg/day children SE’s: photosensitivity, H/A, GI
upset, hypersensitivity, leukopenia Active only against dermatophytes, not
yeasts
T. capitis
Patient education Compliance for 2 weeks beyond
“cure” to prevent relapse Look for sources of infections Clean contaminated objects Reassure caretakers that it may
take 1 month for improvement
Tinea barbae
Characteristics Inflammation in the
beard/hair Pseudofolliculitis Frequently “failed” antibiotics Positive S.Aureus culture does
not rule out T. barbae
T. barbae
Diagnosis Nodular, boggy lesions
with exudate
Sinus tract formation Scarring if untreated KOH or culture may
confirm
T. barbae
Differential diagnosis Bacterial folliculitis Pseudofolliculitis barbae Contact dermatitis Herpes Syphilis Acne Candida
T. barbae
Treatment Griseofulvin 0.5-1 g/day Itraconazole or terbinafine for resistant
cases Local care
Tinea corporis
Papules or plaques with erythema and scale Look for annular lesions with central clearing Well-demarcated edges
T. corporis
Diagnosis KOH from leading edge Prior steroid use alters
response/appearance Majocchi’s granuloma:
pluck hairs for hyphae
T. corporis vs. Majocchi’s granuloma
T. corporis
Differential diagnosis Nummular eczema KOH neg Pityriasis rosea KOH neg, multiple
papules/plaques Psoriasis KOH neg, thick, silvery
scales Granuloma annulare KOH neg, no scale
Lyme disease KOH neg, no scale
T. corporis: Differential diagnosis
The diagnosis please...
Lichen simplex chronicus Nummular eczema
T. corporis
Treatment Avoid “Lotrisone” type combos Topical agents for
mild/moderate disease Oral agents for
extensive/resistant disease Continue topical medication 7-
14 days beyond “cure”
Tinea cruris
Thrives in humid environments
Diagnosis: » Spares scrotum; » Pruritus & burning clues» Look for feet as possible
infection source» KOH + hyphae
T.crurisDifferential Diagnosis: Candida Beefy red with poorly defined
borders Intertrigo KOH negative, irritant
dermatitis Erythrasma Asymmetric velvety patches,
Neg KOH Psoriasis Thick silvery scales,Neg
KOH Seb derm Borders less defined,
distribution different, Neg KOH
T. cruris
Treatment Topical agents for 2-3
weeks Mild topical steroid for
inflammatory component Pruritus relief Look for infection source
T. cruris
Patient education Use topical meds 7-14 days beyond cure Avoid prolonged topical steroids Avoid self-medicating preps Avoid baths and tight fitting underwear Use mild soaps or soap substitute Antifungal powders Keep area dry
Tinea manus
Diagnosis: » Often unilateral, but
with bilateral feet» May have only scant
scaling, vesicles Differential Diagnosis:
Eczema, contact dermatitis Treatment: Topical agents
The diagnosis is ...
Tinea pedis
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 weeksTerbinafine 250 mg/day X 2-6 weeks
The diagnosis is …..
Tinea Versicolor
Diagnosis: macules, plaques; fine scale after scraping; KOH +
Tinea Versicolor
Treatment: Limited disease: Topical agents
Widespread: Ketoconazole
200 mg X 2 one dose, repeat 1 week
(Not griseofulvin) Prevention and Patient Education:
Selenium sulfide 2.5% overnight 1X/month
Candidiasis
Diagnosis: Beefy red lesions, satellite papules and pustules
Differential Dx: Tinea, Intertrigo
Treatment and Patient education : Topical antifungal creams
Oral therapy for extensive (not Griseofulvin)
Environmental: Zeasorb powder or Burow’s
Mild topical steroids
The diagnosis is...
Onychomycosis
Onychomycosis
Why should we treat? (cosmetically disfiguring, painful, entry for cellulitis)
Diff Dx: Psoriasis, Lichen Planus, Trauma
Diagnosing vs. treating
Diagnosis? Culture? Treatment?
CaseWhich of the following, if any, is
onychomycosis?
Onychomycosis- treatments
8% Ciclopirox (Penlac) Topical therapy: FDA approved (2/00)
2 studies X 48 weeks:219 5.5% cc 6.5% ac vs. .9% placebo235 8.5% cc 12% ac vs. .9% placebo
se: erythema 5%
1x/day for seven days, remove w/alcohol and begin again
Onychomycosis- systemic
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- 150-300 mg 1x/week x 6-9 months
Side effects: GI, Skin, H/A, LFT, Drugs
Onychomycosis- oral meds
RCT-DB, PC- 72 week f/u 496 patients Continuous terbinafine vs. pulsed itraconazole No diff. SE’s
T3 T4 I8 I4MC 76% 81% 38% 49%CC 54% 60% 32% 32%
(BMJ, 4/99, 318: 1031-1035)
Evidence-based reviews- Fungal
Pooled analysis trials comparing mycological cure rates
Continuous 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, -0.23 [95% confidence interval, -0.32 to -0.15]; number needed to treat, 5 [95% confidence interval, 4 to 8]).
(Crawford, Arch Dermatol, 2002)
Evidence-based review- Fungal
Oral treatments for T. Pedis Twelve trials, 700 participants 2 trials comparing terbinafine and griseofulvin 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, http://www.update software.com/abstracts/ab003584.htm)
Summary
Do a KOH when possible or doubtful Avoid brand name combination
steroid/antifungal products Remember patient education strategies
Pearls
T. capitis- overdiagnosed in adults/under in children; oral therapy needed
T. cruris- spares scrotum T. manus- often unilateral T. Pedis- highly variable presentation T. versicolor- oral therapy effective Onychomycosis- oral meds needed
What’s the diff dx?
How to dx? Use combo
meds? How to tx?
Diff dx:» SCCa, Eczema, Tinea
How to dx: » KOH, KOH, KOH
Use combo meds: NO» wrong 30% » unclear length of time» more difficult for subsequent dx » $$$» potent steroids
Tx: Lidex 0.05% bid
A few unknowns
A few unknowns
A few unknowns
A few unknowns
Thank You …….