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Fungal Infections of the Skin and Nails

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 aog@med.unc.edu. Fungal Infections of the Skin and Nails. Objectives

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Fungal Infections of the Skin and Nails

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  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 aog@med.unc.edu

  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 • 4.1 million visits -82% nondermatologists • 3 types of fungi-dermatophytes: Epidermophyton Trichophyton Microsporum • Named by location • Similar treatments; Varied presentations

  5. If they do this to food…..

  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)

  7. KOH

  8. 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.

  9. ID Reaction

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

  11. 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

  12. Kerion

  13. 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

  14. 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

  15. The diagnosis please…..

  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 weeks • Fluconazole- 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 • 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

  18. 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

  19. Tinea barbae Characteristics • Inflammation in the beard/hair • Pseudofolliculitis • Frequently “failed” antibiotics • Positive S.Aureus culture does not rule out T. barbae

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

  21. T. barbae Differential diagnosis • Bacterial folliculitis • Pseudofolliculitis barbae • Contact dermatitis • Herpes • Syphilis • Acne • Candida

  22. T. barbae Treatment • Griseofulvin 0.5-1 g/day • Itraconazole or terbinafine for resistant cases • Local care

  23. Tinea corporis • Papules or plaques with erythema and scale • Look for annular lesions with central clearing • Well-demarcated edges

  24. T. corporis Diagnosis • KOH from leading edge • Prior steroid use alters response/appearance • Majocchi’s granuloma: pluck hairs for hyphae

  25. T. corporis vs. Majocchi’s granuloma

  26. 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

  27. T. corporis:Differential diagnosis

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

  29. 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”

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

  31. T.cruris Differential 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

  32. T. cruris Treatment • Topical agents for 2-3 weeks • Mild topical steroid for inflammatory component • Pruritus relief • Look for infection source

  33. 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

  34. Tinea manus • Diagnosis: • Often unilateral, but with bilateral feet • May have only scant scaling, vesicles • Differential Diagnosis: Eczema, contact dermatitis • Treatment: Topical agents

  35. The diagnosis is ...

  36. Tinea pedis • Diagnosis: • Extremely variable presentation • Be aware of id reaction and bacterial infection

  37. 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

  38. The diagnosis is …..

  39. Tinea Versicolor • Diagnosis: macules, plaques; fine scale after scraping; KOH +

  40. 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

  41. 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

  42. The diagnosis is...

  43. Onychomycosis

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

  45. Diagnosis? • Culture? • Treatment?

  46. CaseWhich of the following, if any, is onychomycosis?

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