Fungal Infections of the Skin and Nails

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.

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

20. Tinea barbae Characteristics Inflammation in the beard/hair Pseudofolliculitis Frequently �failed� antibiotics Positive S.Aureus culture does not rule out T. barbae

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

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

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

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

25. T. corporis Diagnosis KOH from leading edge Prior steroid use alters response/appearance Majocchi�s granuloma: pluck hairs for hyphae

26. T. corporis vs. Majocchi�s granuloma

27. 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

28. T. corporis: Differential diagnosis

29. The diagnosis please...

30. 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�

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

33. 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

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

35. 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

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

37. The diagnosis is ...

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

39. T. pedis

40. The diagnosis is �..

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

43. 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

44. 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

45. The diagnosis is...

46. Onychomycosis

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

48. Diagnosis? Culture? Treatment?

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

51. 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% placebo 235 8.5% cc 12% ac vs. .9% placebo se: erythema 5% 1x/day for seven days, remove w/alcohol and begin again

52. 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

53. Onychomycosis- oral meds RCT-DB, PC- 72 week f/u 496 patients Continuous terbinafine vs. pulsed itraconazole No diff. SE�s T3 T4 I8 I4 MC 76% 81% 38% 49% CC 54% 60% 32% 32% (BMJ, 4/99, 318: 1031-1035)

54. 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]).

55. 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)

56. Summary Do a KOH when possible or doubtful Avoid brand name combination steroid/antifungal products Remember patient education strategies

57. 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

59. What�s the diff dx? How to dx? Use combo meds? How to tx?

60. 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

65. Thank You ��.