FUNGAL SKIN INFECTIONS SEEN CLINICALLY

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DERMATOPHYTOSIS

TREATMENT

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FUNGAL SKIN INFECTIONS SEEN CLINICALLY

• TINEA

, OR DERMATOPHYTE INFECTION.

“

RINGWORM

.”

• TINEA VERSICOLOR

, A CUTANEOUS YEAST

INFECTION WITH MALASSEZIA FURFUR

• CUTANEOUS CANDIDIASIS

, A CUTANEOUS YEAST

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CLINICAL MANIFESTATIONS OF RINGWORM INFECTIONS BASED ON LOCATION OF INFECTION SITES

• TINEA CAPITIS - HEAD, SCALP, EYEBROWS, EYELASHES

• TINEA FAVOSA - SCALP (CRUSTY HAIR)

• TINEA CORPORIS - BODY (SMOOTH SKIN)

• TINEA CRURIS - GROIN (JOCK ITCH)

• TINEA UNGUIUM - NAILS

• TINEA BARBAE - BEARD

• TINEA MANUUM - HAND

(4)

SPECIES FOUND IN DIFFERENT

ANAMORPHIC GENERA

• MICROSPORUM _{- INFECTIONS ON SKIN AND HAIR (NOT THE CAUSE OF}

TINEA UNGUIUM)

• EPIDERMOPHYTON _{- INFECTIONS ON SKIN AND NAILS (NOT THE CAUSE}

OF TINEA CAPITIS)

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• CLINICAL FEATURES • ASYMMETRICAL

• ACTIVE MARGIN WITH CENTRAL CLEARING

• FUNGAL INFECTION ELSEWHERE

• INVESTIGATION

• SKIN SCRAPING

• NAIL CLIPPING

• MICROSCOPY, CULTURE OR HISTOLOGY

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TINEA CORPORIS

• CLASSIC “RINGWORM”

• TRUNK, EXTREMITIES, FACE

• ELEVATED, SCALY, PRURITIC LESIONS WITH ERYTHEMATOUS EDGE

• ANTHROPOPHILIC AND ZOOPHILIC CAUSES

• T. RUBRUM _{MOST COMMON}

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TINEA CAPITIS

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TINEA UNGUIUM

• DISTAL AND LATERAL SUBUNGUAL ONYCHOMYCOSIS (DLSO):

• DISCOLOURATION, SUBUNGUAL HYPERKERATOSIS, DISTAL ONYCHOLYSIS START AT THE HYPONYCHIUM SPREADING PROXIMALLY

• PROXIMAL SUBUNGUAL ONYCHOMYCOSIS (PSO):

• INVASION OF THE NAIL UNIT UNDER THE PROXIMAL NAIL FOLD AND SPREAD DISTALLY

• USUALLY ASSOCIATED WITH IMMUNOSUPPRESSED CONDITIONS, E.G. HIV INFECTION

• SUPERFICIAL WHITE ONYCHOMYCOSIS (SWO):

• INVASION OF THE SUPERFICIAL LAYERS OF THE NAIL PLATE BUT DO NOT PENETRATE IT LEADING TO A WHITE, CRUMBLY NAIL SURFACE

• TOTAL DYSTROPHIC ONYCHOMYCOSIS

• COMPLETE DYSTROPHY OF THE NAIL PLATE

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DIAGNOSIS

• WOOD’S LAMP EXAMINATION

• DETECTS FLUORESCENCE

• POTASSIUM HYDROXIDE MICROSCOPY

• DETECTS HYPHAE AND CONIDIA IN SKIN SCRAPINGS OR HAIR

• FUNGAL CULTURES

• REQUIRED TO IDENTIFY ORGANISM

• SKIN OR NAIL BIOPSIES

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INVESTIGATIONS

• KOH 10%

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MANAGEMENT OF SUPERFICIAL FUNGAL INFECTION:

GERNERAL PRINCIPLES

• GENERAL ADVICE: E.G AVOID SHARING OF TOWELS AND CLOTHING; KEEP THE AFFECTED AREAS COOL AND DRY; FREQUENT WASHING OF CLOTHES, LINEN; ETC.

• TOPICAL ANTIFUNGALS

• ADVANTAGES OF TOPICAL ANTIFUNGALS VS ORAL ANTIFUNGALS • LESS RISK OF ADVERSE EFFECTS

• FEWER DRUG INTERACTIONS

• LABORATORY TESTS NOT NEEDED TO MONITOR TREATMENT

• PROLONGED USE OF A STEROID-ANTIFUNGAL CREAM

• MAY NOT CURE THE INFECTION

• MAY CAUSE STRIAE

• SYSTEMIC TREATMENT

• TINEA CAPTITIS & TINEA UNGUIUM

• SEVERE OR EXTENSIVE DISEASE

• FAILED TOPICAL TREATMENT

(15)

TOPICAL PREPARATIONS FOR FUNGAL INFECTIONS

• APPLIED TO THE AFFECTED AREA FOR 2-4 WEEKS

• INCLUDING A MARGIN OF SEVERAL CENTIMETRES OF NORMAL SKIN

• CONTINUE FOR 1 OR 2 WEEKS AFTER THE LAST VISIBLE RASH HAS CLEARED

• AZOLES

• BIFONAZOLE

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TINEA CAPITIS: TREATMENT

• MICROSCOPY / CULTURE OF SKIN SCRAPINGS RECOMMENDED BEFORE STARTING TREATMENT

• GRISEOFULVIN

• 500 MG ONCE DAILY OR 250 MG BD; 10-25 MG/KG/D X 8–10WK

• STANDARD TREATMENT IN THE PEDIATRIC POPULATION

• TERBINAFINE

• 250 MG ONCE DAILY X 4/52

• NOT LICENSED FOR TINEA CAPITIS IN THE UK

• FDA APPROVED FOR CHILDREN > 4 YR ( < 25 KG: 125 MG/D; 25-35 KG: 187.5MG/D; > 35KG: 250MG/D)

• ADJUNCTIVE TREATMENT

• TOPICAL ANTIFUNGAL TREATMENT 2X/WEEK

• KETOCONAZOLE SHAMPOO, SELENIUM SULPHIDE SHAMPOO, OR TOPICAL TERBINAFINE CREAM

• DURING THE FIRST 2 WEEKS OF TREATMENT TO REDUCE TRANSMISSION.

• ORAL ANTIBIOTIC E.G. FLUCLOXACILLIN & AN ANTIFUNGAL CREAM ACTIVE AGAINST GRAM (+) ORGANISMS (E.G. MICONAZOLE, CLOTRIMAZOLE, ECONAZOLE)

• FOR SECONDARY INFECTION

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• SEVEN STUDIES, 2163 SUBJECTS

• SUBGROUP ANALYSIS

• TERBINAFINE WAS MORE EFFICACIOUS THAN GRISEOFULVIN IN TREATING TRICHOPHYTON SPECIES (1.616; 95% CI = 1.274- 2.051; P < 0.001)

• GRISEOFULVIN WAS MORE EFFICACIOUS THAN TERBINAFINE IN TREATING MICROSPORUM SPECIES (0.408; 95% CI = 0.254-0.656; P < 0.001)

• BOTH GRISEOFULVIN AND TERBINAFINE DEMONSTRATED GOOD

SAFETY PROFILES IN THE STUDIES.

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• SEVEN STUDIES, 2163 SUBJECTS

• SUBGROUP ANALYSIS

• TERBINAFINE WAS MORE EFFICACIOUS THAN GRISEOFULVIN IN TREATING TRICHOPHYTON SPECIES (1.616; 95% CI = 1.274- 2.051; P < 0.001)

• GRISEOFULVIN WAS MORE EFFICACIOUS THAN TERBINAFINE IN TREATING MICROSPORUM SPECIES (0.408; 95% CI = 0.254-0.656; P < 0.001)

• BOTH GRISEOFULVIN AND TERBINAFINE DEMONSTRATED GOOD SAFETY

PROFILES IN THE STUDIES.

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TINEA CORPORIS / CRURIS

• TOPICAL TERBINAFINE (MODERATE EVIDENCE) & TOPICAL IMIDAZOLES (WEAK

EVIDENCE)

• EFFICACIOUS IN THE TREATMENT OF FUNGAL INFECTIONS OF THE GROIN AND BODY

• INSUFFICIENT TRIAL EVIDENCE: SUPERIORITY OF ONE PREPARATION OVER ANOTHER

• IMIDAZOLES CURRENTLY THE MOST COMMONLY USED TOPICAL TREATMENTS FOR FUNGAL INFECTIONS OF THE SKIN

• FOR INFLAMED LESIONS

• TOPICAL ANTIFUNGAL COMBINED WITH A MILDLY POTENT CORTICOSTEROID: <= 1 WK

• DO NOT GIVE A CORTICOSTEROID PREPARATION ALONE

• COMBINATION PREPARATION:

• BEWARE OF THE INCREASED RISK OF ADVERSE EFFECTS WITH TOPICAL CORTICOSTEROIDS IN OCCLUDED AREAS E.G. GROINS

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TINEA PEDIS: TREATMENT

• ALLYLAMINES, AZOLES, BUTENAFINE, CICLOPIROXOLAMINE, TOLCICLATE & TOLNAFTATE

• ALL EFFICACIOUS RELATIVE TO PLACEBO IN THE TREATMENT OF TINEA PEDIS

• ALLYLAMINES

• GREATER EFFECTIVENESS WHEN USED FOR LONGER

• THE EFFECTIVENESS OF AZOLES IMPROVED OVER TIME

• NO DIFFERENCE IN TREATMENT FAILURE RATES BETWEEN ANY OF THE INDIVIDUAL AZOLES

• ALLYLAMINES MORE EFFICACIOUS THAN AZOLES

• THE META ANALYSIS OF 8 TRIALS AND OUTCOMES FROM 962 PARTICIPANTS SUPPORTS THE FINDING THAT ALLYLAMINES ARE MORE EFFECTIVE THAN AZOLES WHEN APPLIED FOR BETWEEN 4 TO 6 WEEKS

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• TERBINAFINE AND ITRACONAZOLE

• MORE EFFECTIVE THAN NO TREATMENT (PLACEBO) • TERBINAFINE (TWO WEEKS TREATMENT)

• MORE EFFECTIVE THAN ITRACONAZOLE (TWO WEEKS TREATMENT) • TERBINAFINE

• MORE EFFECTIVE THAN GRISEOFULVIN

• NO SIGNIFICANT DIFFERENCE IN EFFECTIVENESS FOUND BETWEEN: • TWO WEEKS OF TERBINAFINE VS FOUR WEEKS OF ITRACONAZOLE • FLUCONAZOLE VS EITHER ITRACONAZOLE OR KETOCONAZOLE • GRISEOFULVIN AND KETOCONAZOLE

• DIFFERENT DOSES OF FLUCONAZOLE

RECOMMENDATION:

• TO TREAT INITIALLY WITH TOPICAL AZOLES AND USE TOPICAL ALLYLAMINES FOR AZOLE TREATMENT FAILURES

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TINEA UNGUIUM: TREATMENT

• CONFIRM THE DIAGNOSIS BEFORE TREATMENT

• POSITIVE MICROSCOPY OR CULTURE

• TOPICAL TX WITH AMOROLFINE 5% NAIL LACQUER

• 6 /12 WK (FINGERNAIL)

• 9–12 /12 WK (TOENAIL)

• AMOROLFINE 5% NAIL LACQUER 1X/WK

• NOT APPROVED IN THE USA

• 6% TREATMENT FAILURE RATES FOUND AFTER 1 MONTH OF TREATMENT • DATA COLLECTED ON A VERY SMALL SAMPLE OF PEOPLE

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TINEA UNGUIUM: TREATMENT

• CICLOPIROXOLAMINE 8% NAIL LACQUER: QD

• COMBINING DATA FROM 2 TRIALS OF CICLOPIROXOLAMINE VERSUS PLACEBO:

• TREATMENT FAILURE RATES: 61% & 64% FOR CICLOPIROXOLAMINE

• THESE OUTCOMES FOLLOWED LONG TREATMENT TIMES (48 WEEKS)

• CICLOPIROXOLAMINE -> A POOR CHOICE FOR NAIL INFECTIONS

• BUTENAFINE 2%:

• TREATMENT FAILURE RATE: 20%

• USED IN COMBINATION WITH ORAL TREATMENT: INCREASE CURE RATES

• NO GOOD EVIDENCE FROM RANDOMIZED CONTROLLED TRIALS ON OTHER TOPICAL TREATMENTS FOR DERMATOPHYTE NAIL INFECTIONS:

• TOPICAL TIOCONAZOLE / SALICYLIC ACID/ UNDECENOATES.

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TINEA UNGUIUM: TREATMENT

• ORAL TERBINAFINE

• 250 MG DAILY: 6/52 FOR F/N, 12/52 X T/N

• ORAL TERBINAFINE MAY BE MORE EFFECTIVE THAN ORAL ITRACONAZOLE (WEAK EVIDENCE FROM RCTS)

• A META-ANALYSIS OF 18 STUDIES: A MYCOLOGICAL CURE RATE OF 76%.

• FEWER DRUG INTERACTIONS VS. AZOLE ANTIFUNGALS

• CYP2D6 INHIBITOR: INC. EFFECT OF TCA; BETA BLOCKERS & ANTIPSYCHOTICS (POSSIBLE)

• ADVERSE EFFECTS: USUALLY MILD AND TRANSIENT

• ORAL ITRACONAZOLE

• 200 MG BD X 1 WK PER PULSE, 2 TO 3 PULSES

• ORAL ITRACONAZOLE MAY BE LESS EFFECTIVE THAN ORAL TERBINAFINE (WEAK EVIDENCE FROM RCTS)

• A META-ANALYSIS OF 6 STUDIES ON PULSE ITRACONAZOLE: MYCOLOGICAL CURE RATE OF 63%

• PULSED THERAPY RECOMMENDED:

• NO GOOD EVIDENCE THAT IT IS LESS EFFECTIVE THAN CONTINUOUS THERAPY;

• RISKS OF ADVERSE EFFECTS MAY BE REDUCED

• N.B. THIS DOSING REGIMEN IS NOT LICENSED

• TAKE WITH FATTY MEAL/ ACIDIC BEVERAGE

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TREATMENT PITYRIASIS VERSICOLOR

• CONSIDER PROPHYLACTIC TREATMENT

• E.G. PRIOR TO EXPOSURE WARM HUMID ENVIRONMENTS OR SUNSHINE

• KETOCONAZOLE 2% SHAMPOO ONCE DAILY X A MAXIMUM OF 3 DAYS PRIOR TO SUN EXPOSURE

• LIMITED EVIDENCE THAT WEEKLY OR MONTHLY DOSES OF ORAL ANTIFUNGALS ARE EFFECTIVE IN PREVENTING RECURRENCE, BUT OPTIMAL REGIMENS HAVE NOT BEEN ESTABLISHED

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 Treat with shampoo

 Ketoconazole 2% shampoo once-daily to affected areas for 5/7

 Lather and leave it on for 5’ then rinse off

 Selenium sulphide 2.5% shampooonce-daily

to the affected areas for 7 days.  off-label indication

 may cause skin dryness and irritation

 Smell: unpleasant

 Lather and leave it on for 10’ then rinse off

 For small affected areas:

 Imidazole creams 2–3 weeks

 e.g. clotrimazole, econazole, ketoconazole, or miconazole

 Systemic Treatment:

 itraconazole 200 mg once daily for 7 days

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CANDIDIASIS MANAGEMENT

• GENERAL:

• DRYING, WEIGHT REDUCTION, AIR-CONDITIONING

• NYSTATIN CREAM OR TOPICAL IMIDAZOLE CREAM BD

• IF PERIANAL SKIN INVOLVED: + NYSTATIN 100,000 UNITS QID FOR 5/7

• ORAL FLUCONAZOLE TREATMENT 50 MG DAILY FOR 2 WEEKS

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