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Chapter 15 Diseases Resulting from Fungi and Yeasts

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  • 1. Chapter 15 Diseases Resulting from Fungi and Yeasts Andrews‟ Diseases of the Skin Adam Wray, D.O. February 8, 2005
  • 2. Superficial mycoses ► AKA dermatophytes ► Three genera: Microsporum, Trichophyton, Epidermophyton ► Division into seven types (1)tinea capitis, (2)tinea barbae, (3)tinea faciei, (4)tinea corporis, (5) tinea manus, (6) tinea pedis, (7) tinea cruris, (8)onychomycosis
  • 3. Host factors ► Immunosuppressed pts ► AIDS ► Genetic susceptibility may be related to types of keratin or degree/mix of cutaneous lipids produced ► Surface antigens-ABO system-one study of 108 culture proven dermatophytosis pts noted type A blood prone to chronic disease ► Human steroid hormones can inhibit growth of dermatophytes (androgens like androstenedione) ► One group believes this high susceptibility of Trichophyton rubrum & Epidermophyton floccosum to intrafollicular androstenedione is a reason why these species do not cause tinea capitis
  • 4. Imidazoles ► Clotrimazole, miconazole, sulconazole, oxiconazole, and ketoconazole ► Mostly used for topical tx ► Inhibit cytochrome P450 14-alpha- demethylase (an essential enzyme in ergosterol synthesis) ► Ketaconazole has wide spectrum against dermatophytes, yeasts, and some systemic mycoses ► Ketaconazole has the potential for serious drug interactions and a higher incidence of hepatotoxicity during long-term daily therapy
  • 5. Allylamines ► Naftifine, terbinafine, butenafine ► Inhibites squalene epoxydation ► Terbinafine has less activity against Candida species in vitro studies then triazoles, but is effective clinically ► Terbinafine is ineffective in the oral tx of tinea versicolor but is effective topically ► Few drug interactions have been reported ► Bioavailability is unchanged in food ► Hepatotoxicity, leukopenia, severe exanthems, and taste disturbances uncommon, but should be monitored for clinically and by lab testing if continuous dosing over 6 weeks
  • 6. Polyene ► Nystatin ► Irreversiblybinding to ergosterol-an essential component of fungal cell membranes
  • 7. Triazoles ► Itraconazole, Fluconazole ► Affect P450 system ► Numerous drug interactions occur ► Need to know pt‟s current meds ► Broadest spectrum to dermatophytes and Candida species, and Malassezia furfur ► Itraconazole is fungistatic-food increases its absorption , antacids and gastric acid secretion suppressors produce erratic or lowered absorption ► Pulse dosing limits concern over lab abnormalities ► Fluconazoles‟s absorption is unaffected by food
  • 8. Tinea Capitis ► Occurs chiefly in schoolchildren ► Boys more frequently than girls; except epidemics caused by Trichophyton tonsurans where there is equal frequency ► Divided into inflammatory and noninflammatory ► Tinea capitis can be caused by all pathogenic dermatophytes except Epidermophyton floccosum and T. concentricum ► In U.S. most caused by T. tonsurans
  • 9. Noninflammatory ► M. audouinii infections present as the classic form ► Characterized by multiple scaly lesions (“gray- patch”), stubs of broken hair ► Over past 30 yrs, M. audouinii infections are being replaced by increasing numbers of “black-dot” ringworm, caused primarily by T. tonsurans and occasionally by T. violaceum ► In the U.S. T. tonsurans is the most common cause
  • 10. Noninflammatory Tinea Capitis ► “Blackdot” ringworm, caused by T. tonsurans & occasionally T. violaceum presents as multiple areas of alopecia studded with black dots representing infected hairs broken off at or below the surface of the scalp
  • 11. ► Black dot tinea
  • 12. ► Black dot ringworm caused by Trichophyton tonsurans
  • 13. Inflammatory ► Usually caused by M. canis ► Can be caused by T. mentagrophytes, T. tonsurans, M. gypsem, or T. verrucosum ► M. canis begin as scaly, erythematous, papular eruptions with loose and broken-off hairs, followed by varying degrees of inflammation ► A localized spot accompanied by pronounced swelling, with developing bogginess and induration exuding pus develops-kerion celsii  A delayed type hypersensitivity reaction to fungal elements ► With extensive lesions fever, pain, and regional lymphadenopathy may occur
  • 14. Kerion ► Kerion may be followed by scarring and permanent alopecia in areas of inflammation and suppuration ► Systemic steroids for short periods will greatly diminish the inflammatory response and reduce the risk of scarring
  • 15. ► Kerion: inflammatory rxn of tinea capitis caused by Microsporum canis or Trichophyton mentagrophytes
  • 16. ► Kerion caused by Microsporum canis
  • 17. ► Kerion: heavily crusted, hairless plaque
  • 18. ► Permanent scarring alopecia post kerion
  • 19. ► Kerion: red, oozin g, hairless plaque
  • 20. Favus ► Rare in the U.S. ► Most severe form of dermatophyte hair infection ► Most frequently cause by T. schoenleinii ► Hyphae and air spaces seen within hair shaft ► Bluish white fluorescence under Wood‟s light ► Thick, yellow crusts composed of hyphae and skin debris („scutula‟) ► Scarring alopecia may develop
  • 21. ► Favus of scalp showing scutulae
  • 22. Favus with scarring alopecia and scutula
  • 23. ► Scarring after favus infection
  • 24. Etiology ► Tinea capitis can be cause by any one of several species: T. tonsurans, M. audouinii (human to human), and M. canis (animals to human) ► Endothrix types-T. tonsurans(black-dot ringworm) and T. violaceum ► Ectothrix found on scalp are T. verrucosum & T. mentagrophytes
  • 25. Diagnosis ► Wood‟s light  Ultraviolet of 365 nm wavelength is obtained by passing a beam through a Wood‟s filter composed of nickel oxide- containing glass  A simple form is the 125-volt purple bulb ► Fluorescent-positive infections are caused by :T. schoenleinii, M. canis, M. audouinii, M. distortum, M. ferrugineum ► Hairs infected with T. tonsurans & T. violaceum and others of endothrix do not fluoresce ► The fluorescent substance is pteridine
  • 26. Diagnosis ► KOH  Two or three loose hairs are removed  Hairs are placed on slide with a drop of 10-20% solution of KOH  A cover slip is applied, specimen is warmed until hairs are macerated  Examine under low, then high power ► Scales or hairs cleared with it can still be cultured
  • 27. DTM ► DTM contains cycloheximide to reduce growth of contaminants and a colored pH indicator to denote the alkali-producing dermatophytes ► Some clinically relevant nondermatophyte fungi are cycloheximide sensitive (Candida tropicalis, Scopulariopsis brevicaulis, Cryptococcus neoformans, Pseudoallescheria boydii, Trichosporon beigelii and Aspergillus spp.)
  • 28. type in Microsporum canis- ► Ectothrix note small spores around hair shaft
  • 29. ► Endothrix spores in hair with Trichophyton tonsurans
  • 30. ► Endothrixin T. scoenleinii showing characteristic bubbles of air
  • 31. ► Endothrix infection, (low-power KOH mount): arthroconidia noted within hair shaft ► Endothrix infection (high-power KOH mount) showing total hair shaft involvement
  • 32. T. tonsurans ► This microoraganism grows slowly in culture to produce a granular or powdery yellow to red, brown, or buff colony ► Crater formation with radial grooves may be produced ► Microconidia may be seen regularly ► Dx confirmed by the fact that cultures grow poorly or not at all without thiamine
  • 33. T. mentagrophytes ► Culture growth is velvety or granular or fluffy, flat or furrowed, light buff, white, or sometimes pink ► Back of the culture can vary from buff to dark red ► Round microconidia borne laterally and in clusters confirm dx within 2 weeks ► Spirals are sometimes present ► Macroconidia may be seen
  • 34. T. verrucosum ► Growth is slow and cannot be observed well for at least 3 weeks ► Colony is compact, glassy, velvety, , heaped or furrowed, and usually white, but may be yellow or gray ► Chlamydospores are present in early cultures ► Microconidia may be seen
  • 35. M. audouinii ► Gross appearance shows a slowly growing, matted, velvety, light brown colony ► Back of which is reddish brown to orange ► Under microscope a few large multiseptate macroconidia (macroaleuriospores) are seen ► Microconidia (microaleuriospores) in a lateral position on hyphae are clavate ► Racquet mycelium, chlamydospores, and pectinate hyphae are seen sometimes
  • 36. M. canis ► Culture shows profuse, fuzzy, cottony, aerial mycelia tending to become powdery in the center ► Color is buff to light brown ► Back of colony is lemon to orange-yellow ► Numerous spindle-shaped multiseptate microconidia and thick-walled macroconidia are present ► Clavate microconidia are found along with chlamydospores and pectinate bodies
  • 37. Treatment ► Griseofulvin of ultramicronized form, 10 mg/kg/day, is the daily dose recommended for children ► Grifulvin V is the only oral suspension available for children unable to swallow tablets-dose is 20 mg/kg/day ► Tx should continue for 2-4 months, or for at least 2 weeks after a negative microscopic and culture examinations are obtained ► Griseofulvin does not primarily affect the delayed type hypersensitivity reaction responsible for the inflammation in kerion ► For this, systemic steroids, to minimize scarring, can be given simultaneously
  • 38. Tinea Barbae ► AKA Tinea sycosis, barber‟s itch ► Uncommon ► Occurs chiefly among those in agriculture ► Involvement is mostly one-sided on neck or face ► Two clinical types are: deep, nodular, suppurative lesions; and superficial , crusted, partially bald patches with folliculitis
  • 39. Tinea Barbae ► Superficial crusted type  mild pustular folliculitis with broken-off hairs (T. violaceum) or without broken-off hairs (T. rubrum)  Affected hairs are loose, dry, and brittle  When extracted bulb appears intact
  • 40. Tinea Barbae ► Deep type  Caused mostly by T. mentagrophytes or T. verrucosum  Swellings are usually confluent and form diffuse boggy infiltrates with abscesses  Pus may be expressed  Lesions are limited to one part of face or neck in men
  • 41. Diagnosis-Tinea Barbae ► Clinical ► Confirmed by microscopic findings and by standard culture techniques ► Rarely, Epidermophyton floccosum may cause widespread verrucous lesions known as verrucous epidermophytosis
  • 42. ► Verrucous epidermophytosis from Epidermphyton floccosum
  • 43. ► Complete resolution after 48 days of griseofulvin
  • 44. Differential Diagnosis ► Sycosis vulgaris-lesions are pustules and papules, pierced in the center by a hair, which is loose and easily extracted after suppuration has occurred ► Contact dermatitis ► Herpes infections
  • 45. ► Tinea barbae-Trichophyton mentagorphytes
  • 46. Treatment-Tinea Barbae ► Oral antifungals are required ► Topical agents as adjunctive therapy ► Micronized or ultramicronized griseofulvin orally: dosage of 500–1000 mg or 350-700 mg respectively ► Tx usually for 4-6 weeks
  • 47. Treatment-Tinea Barbae ► Other orals that have been effective: ketoconazole, fluconazole, itraconazole, and terbinafine ► Topical antifungals should be applied from the beginning of tx ► Affected parts should be bathed thoroughly in soap and water ► Healthy areas that are not epilated may be shaved or clipped ► When kerion is present a short course of systemic steriod therapy may help reduce inflammation and risk of scarring
  • 48. Tinea Faciei ► Fungal infection of the face (apart from the beard) ► Must have high index of suspicion  Mistaken for seb derm, contact derm, lupus, or photosensitive dermatosis ► Erythematous, slightly scaling, indistinct borders are usually seen ► Usually caused by T. rubrum. T. mentagrophytes, or M. canis
  • 49. ► Tinea faciei (Microsporum canis) in a child
  • 50. ► Tinea corporis involving the face (tinea faciei)
  • 51. Treatment ► Topical antifungals ► Oral griseofulvin administered for 2-4 weeks, as well as fluconazole, itraconazole, or terbinafine are all effective particularly in combination with topical therapy
  • 52. Tinea Corporis(Tinea Circinata) ► All superficial dermatophyte infections of the skin except the scalp, beard, face, hands, feet, and groin ► Sites of predilection are neck, upper and lower extremities, and trunk ► Characterized by one or more circular, sharply circumcsribed, slightly erythematous, dry, scaly, usually hypopigmented patches
  • 53. ► Tinea corporis in a child, caused by Microsporum canis
  • 54. Tinea Corporis ► In some cases concentric circles form rings in one another, making intricate patterns (tinea imbricata) ► Widespread tinea corporis may be the presenting sign of AIDS
  • 55. ► Tinea corporis (Trichophyton rubrum) ► Note sharp margins and central clearing
  • 56. ► Tineacorporis: large gyrate plaque with advancing border, perhaps worsened by diapering
  • 57. Histopathology ► Better ways to make diagnosis ► But if compact orthokeratosis is found in a section, a search for fungal hyphae should be performed ► This is diagnostic
  • 58. Etiology-Tinea Corporis ► Microsporum canis, T. rubrum, T. mentagrophytes-most common ► T. rubrum is is the most common dermatophyte in the U.S. and worldwide ► T. tonsurans has experienced a dramatic rise as a cause of tinea corporis as it has for tinea capitis ► In children, M. canis is the cause of the “moist” type of tinea circinata
  • 59. Epidemiology ► Tinea corporis is frequently seen in children- particularly those exposed to animals with ringworm(M. canis), especially CATS, dogs and less commonly, horses and cattle ► In adults excessive perspiration is the most common factor  Personal hx or close contact with tinea capitis or tinea pedis is another important factor ► Incidence is especially high in hot, humid areas of the world
  • 60. Treatment-Tinea Corporis ► When tinea corporis is caused by T. tonsurans, M. canis, T. mentagrophytes, or T. rubrum , griseofulvin, terbinafine, itraconazole, and fluconazole are all effective ► The ultra-micronized form may be used at a dose of 350-750 mg once/day for 4-6 weeks ► This dose may be increased to twice daily if needed ► Terbinafine, itraconazole, and fluconazole are effective ► Terbinafine at 250 mg/day for two weeks ► Itraconazole 200 mg B.I.D. for one week ► Fluconazole 150 mg once/week for 4 weeks
  • 61. Treatment(cont) ► When only 1-2 patches occur, topical tx is effective ► Most are between 2-4 weeks with twice daily use ► Econazole, ketaconazole, oxiconazole, and terbinafine may be used once daily ► With terbinafine the course can be shortened to 1 week
  • 62. Treatment ► Creams are more effective than lotions ► Sulconazole may be less irritating in folded areas ► Castellani paint (which is colorless if made without fuchin) is very effective ► Salicylic acid 3% -5%, or half-strength Whitfield‟s ointment, both standbys 30 yrs ago, are little used today ► Addition of a low-potency steroid cream during the initial 3-5 days of therapy will decrease irritation rapidly without compromising the effectiveness of the antifungal
  • 63. Other Forms of Tinea Corporis ► Trichophytic Granuloma or Perifollicular Granuloma or Majocchi‟s Granuloma or Tinea Incognito ► A deep, pustular type of tinea circinata resembling a carbuncle or kerion observed on the glabrous skin ► A circumscribed, annular, raised, crusty, and boggy granuloma ► Follicles are distended with viscid purulent material
  • 64. ► Tichophyton mentagrophytes infection on lower leg of American soldier in Vietnam
  • 65. ► Majocchi‟sgranuloma H&E pale blue- staining fungal hyphae within hair shaft
  • 66. ► Majocchi‟sgranuloma: PAS reveals multiple organisms that have replaced a fragment of hair shaft embedded in a sea of neutrophils
  • 67. Tinea Imbricata (Tokelau) ► Superficial fungal infection limited to southwest Polynesia, Melanesia, Southeast Asia, India, and Central America ► Characterized by concentric rings of scales forming extensive patches with polycyclic borders ► Small macular patch splits in center and forms large, flaky scales attached at the periphery ► Resultant ring spreads peripherally and another brownish macule appears in the center and undergoes the process again
  • 68. Tinea Imbricata ► When fully developed the eruption is characterized by concentrically arranged rings or parallel undulating lines of scales overlapping each other like shingles on a roof (imbrex means shingle) ► Causative fungus is T. concentricum ► TOC is griseofulvin- in same form as for tinea corporis ► Other options are terbinafine, fluconazole, and itraconazole ► Several courses of therapy may be needed ► May need to remove pt from hot, humid environment
  • 69. ► Tinea imbricata in New Guinea native
  • 70. ► Tinea imbricata: concentric rings of scale caused by T. concentricum
  • 71. Tinea Cruris ► AKA jock itch ► Most common in men ► On upper and inner thighs ► Begins as a small erythematous and scaling or vesicular and crusted patch ► Spreads peripherally and partly clears in the center ► Penoscrotal fold or sides of scrotum are seldom involved; penis not involved
  • 72. ► Tinea cruris in a man
  • 73. ► Tinea cruris in a woman
  • 74. Etiology-Tinea Cruris ► T.mentagrophytes & E. floccosum & T. rubrum usual cause ► Frequently associated with tinea pedis b/c of contaminated clothing ► Heat and high humidity ► Tight jockey shorts!
  • 75. Treatment ► Reduce perspiration and enhance evaporation from crural area ► Keep as dry as possible by wearing loose underclothing ► Plain talcum powder or antifungal powders ► Specific topical and oral tx is same as that described under tinea corporis
  • 76. ► Tinea in diapered area
  • 77. Tinea Pedis ► AKA athlete‟s foot ► Most common fungal disease(by far) ► Primary lesions often are macerated with occasional vesiculation, and fissures between the toes ► Extreme pruritus
  • 78. ► Tinea pedis showing interdigital scalping ► T. mentagrophytes
  • 79. ► Interdigital scaling with vesiculation caused by T. mentagrophytes
  • 80. ► Dermatophytosis of the soles ► Trichophyton mantagrophytes
  • 81. ► Acute vesiculobullous eruption on sole caused by Trichophyton mentagrophytes
  • 82. TP-Trichophyton rubrum ► T. rubrum causes the majority of cases ► Produces a relatively noninflammatory type of dermatophytosis characterized by a dull erythema and pronounced scaling involving the entire sole and sides of feet ► Producing a moccasin or sandal appearance
  • 83. ► Tinea pedis and onychomycosis in father/son pair. ► Father shows classic moccasin distribution of tinea pedis and son shows distal subungual onychomycosis
  • 84. Tinea manus ► Tinea infection of hands that is dry, scaly, and erythematous may occur ► Suggestive of infection with T. rubrum ► Other areas are frequently affected at the same time
  • 85. ► Trichophyton rubrum infections
  • 86. Differential diagnosis ► Allergiccontact or irritant dermatitis-especially occupational ► Pompholyx ► Atopic dermatitis ► Psoriasis ► Lamellar dyshidrosis ► Eczematoid or dyshidrotic lesions of unknown cause on hands should prompt a search for clinical evidence of dermatophytosis of feet etc.
  • 87. ► Fungus filaments under KOH mount
  • 88. ► Mosaic fungus
  • 89. Prophylaxis ► Hyperhidrosis is a predisposing factor ► Dry toes after bathing ► Tolnaftate powder or Zeasorb medicated powders for feet ► Plain talc, cornstartch, or rice powder may be dusted into socks and shoes to keep feet dry
  • 90. Treatment ► Topical antifungals ► With significant maceration wet dressings or soaks with solutions such as aluminum acetate, one part to 20 parts of water ► Anti-inflammatory effects of corticosteroids are markedly beneficial ► Topical antibiotic ointments effective against gram-negative organisms (gentamicin), in tx of the moist type of interdigital lesions ► In ulcerative type of gram-neg toe web infections, systemic floxins are needed
  • 91. Tx ► Keratolytic agents, such as salicylic acid, lactic acid lotions, and Carmol are therapeutic when fungus is protected by a thick layer of overlying skin (ie soles) ► Griseofulvin is only effective against dermatophytes ► When infection is caused by T. mentagrophytes griseofulvin does not decrease inflammatory rx
  • 92. Tx-doses ► Griseovulvin in ultramicronized particles taken orally in doses of 350-750 mg daily ► Dosage for children is 10 mg/kg/day ► Period of tx depends on response ► Repeated KOH scrapings and culture should be neg ► Recommended adult doses for newer agents: terbinafine, 250 mg/day for 2 weeks; itraconazole, 200 mg twice daily for 1 week; fluconazole, 150 mg once weekly for 4 weeks
  • 93. Onychomycosis(Tinea Unguium) ► Onychomycosis encompasses both dermatophyte and nondermatophyte nail infections ► Represents up to 30% of diagnosed superficial fungal infections ► Etiologic agents are: Epidermophyton, Microsporum, and Trichophyton fungi
  • 94. Onychomycosis ► Four classic types: ► 1.) distal subungual onychomycosis: primarily involves distal nail bed and hyponychium, with secondary involvement of underside of nail plate of fingernails and toenails
  • 95. ► Onychomycosis caused by Trichophyton rubrum
  • 96. Trichophyton mentagrophytes ► 2.) white superficial onychomycosis(leukonychia trichophytica):this is an invasion of the toenail plate on the surface of the nail ► It is produced by T.mentagrophytes, species of Cephalosporium and Aspergillus, and Fusarium oxysporum fungus
  • 97. Onychomycosis ► 3.) Proximal subungual onychomycosis: involves the nail plate mainly from proximal nail fold ► It is produced by T. rubrum & T. megninii and may be an indication of HIV infection ► 4.) Candida onychomycosis involves all the nail plate; it is due to Candida albicans and is seen in pts with chronic mucocuataneous candidiasis  Associated paronychia  Adjacent cuticle is pink, swollen, and tender  Fingernails > toenails
  • 98. ► Onychomycosis caused by Candida albicans in mucocutaneous candidiasis
  • 99. Onychomycosis ► Onychomycosis caused by T. rubrum is usually a deep infection ► Disease usually starts at distal corner of nail and involves the junction of nail and its bed ► First a yellowish discoloration occurs, which may spread until entire nail is affected ► Beneath discoloration nail plate becomes loose
  • 100. ► Gradually entire nail becomes brittle and separated from its bed due to piling up of keratin subungually ► Nail may break off, leaving an undermined remnant that is black and yellow from dead nail and fungi that are present
  • 101. ► A: Distal subungal, onchomycosis occurring simulataneously with superficial white onchmycosis ► B: Superficial white onchomycosis
  • 102. Differential ► Allergic contact dermatitis ► Psoriasis ► Lichen planus ► 20 nail dystrophy ► Darier‟s disease ► Reiter‟s disease ► Norwegian scabies ► Nondermatophyte onychomycosis
  • 103. Treatment ► PO terbinafine, fluconazole, and itraconazole ► Griseofulvin continued until nails are clinically normal ► Low success rates 15-30% for toenails and 50-70% for fingernails ► Griseofulvin does not tx nail disease caused by candida ► 3% thymol in EtOH
  • 104. Candidiasis ► Candida proliferates in both budding and mycelial forms in outer layers of the stratum corneum where horny cells are desquamating ► It does not attack hair, rarely involves nail, and is incapable of breaking up the stratum corneum ► It is largely an opportunisitic organism ► Moisture promotes its growth  Lip corners  Body folds
  • 105. Diagnosis ► Demonstration of the pathogenic yeast C. albicans establishes the diagnosis ► Under microscope KOH prep may show spores and pseudomycelium ► Culture on Sabouraud‟s glucose agar shows a growth of creamy, grayish, moist colonies in about 4 days ► In time colonies form small, root-like penetrations into agar
  • 106. ► Mycelium and spores of Candida albicans
  • 107. Candidiasis ► KOHmount from infant with thrush showing pseudohyphae and yeast forms
  • 108. Topical Anticandidal Agents ► These include, but are not limited to: clotrimazole (Lotrimin, Mycelex), econazole (Spectazole), ketaconazole (Nizoral), miconazole (MonistatDerm Lotion, Micatin), oxiconazole (Oxistat), sulconazole (Exelderm), naftifine (Naftin), terconazole (vaginal candidiasis only), cicloprox olamine (Loprox), butenafine (Mentax), nystatin, and topical amphotericin B lotion ► Terbinafine has been reported to be less active against Candida species by some authors
  • 109. Oral Candidiasis (Thrush) ► Newborn infection may be acquired from contact with vaginal tract of mother ► Grayish white membranous plaques are found on surface ► Base of plaques are moist, reddish, and macerated ► Diaper areas is especially susceptible to this ► Most of intertriginous areas and even exposed skin may be involved
  • 110. Oral candidiasis (Thrush) ► Frequently infection extends onto angles of the mouth to form perleche(seen in elderly, debilitated, and malnourished pts, and diabetics) ► It is often the first manifestation of AIDS ► Is present in nearly 100% of all untreated pts with full-blown AIDS ► “Thrush” in an adult with no known predisposing factors warrants a search for other evidence of infection with HIV, such as lymphadenopathy, leukopenia, or HIV antibodies in serum
  • 111. ► Thrush with extension to vermilion border
  • 112. Tx ► Babies with thrush may be allowed to suck on a clotrimazole suppository inserted into the slit tip of a pacifier four times a day for 2-3 days ► An adult can let tablets of clotrimazole or Mycelex troches dissolve in the mouth ► Fluconazole, 100-200 mg/day for 5-10 days with doubling the dose if it fails, or itraconazole, 200 mg daily for 5-10 days with doubling the dose if it fails-both are available in liquid forms
  • 113. Perleche ► AKA angular cheilitis ► Maceration with transverse fissuring of oral commissures ► Soft, pinhead-sized papules may appear ► Involvement is bilateral-usually
  • 114. Perleche
  • 115. Perleche ► Analogous to intertrigo elsewhere ► Similar changes may be seen in riboflavin deficiency, and iron deficiency anemia ► Identical fissuring occurs in persons with malocclusion caused by ill-fitting dentures and in the aged whom atrophy of alveolar ridges has occurred ► Seen in children who drool, lick their lips, or suck their thumb
  • 116. Tx ► If due to C. albicans anticandidal creams and lotions ► Glycemic control in diabetes ► Antibiotic topical meds are used when a bacterial; infection is present ► If due to vertical shortening of lower third of the face, dental or oral surgical intervention may help ► Injection of collagen into depressed sulcus at the oral commissure may be helpful ► Vytone!!
  • 117. Candidal Vulvovaginitis ► Pruritus, irritation, and extreme burning ► Labia may be erythemtous, moist, and macerated and cervix hyperemic, swollen, and eroded, showing small vesicles on its surface ► Vaginal discharge is not usually profuse but is frequently thick and tenacious ► May develop during pregnancy, in diabetes, or secondary to therapy with a broad- spectrum antibiotic ► Recurrent vulvovaginal candidiasis has been associated with long-term tamoxifen tx
  • 118. Candidal Vulvovaginitis ► Candidal balanitis may be present in an uncircumcised sexual partner ► If not recognized, repeated reinfection of a partner may occur ► Diagnosis is by clinical symptoms and findings as well as demonstration of fungus via KOH microscopic exam & culture ► Tx is frustrating & disappointing due to recurrences ► Oral fluconazole 150 mg times 1 dose; Fluconazole, 100mg/day for 5-7 days, itraconazole, 200 mg/day for 2-3 days..other options
  • 119. Tx ► Topicaloptions include miconizole (Monistat cream), nystatin vaginal suppositories or tablets (Mycostatin), or clotrimazole (Gyne- Lotrimin or Mycelex G) vaginal tablets inserted once daily for 7 days
  • 120. Candidal Intertrigo ► Pinkish intertriginous moist patches are surrounded by a thin, overhanging fringe of somewhat macerated epidermis (“collarette” scale) ► May resemble tinea cruris, but usually there is less scaliness and a greater tendency to fissuring ► Topical anticandidal preparations are usually effective ► Recurrence is common
  • 121. Pseudo Diaper Rash ► In infants, C. albicans infection may start in perianal region and spread over entire area ► Dermatits is enhanced by maceration produced by wet diapers ► Diaper friction may contribute to skin irritation and compromised function of stratum corneum ► Suspected by finding involvement of folds and occurrence of many small erythematous desquamating “satellite” or “daughter” lesions scattered around edges
  • 122. Congenital Cutaneous Candidiasis ► Infection of an infant during passage through birth canal ► Eruption usually noted within first few hrs of delivery ► Erythematous macules progress to thin- walled pustules, which rupture, dry, and desquamate within a week ► Lesions are usually widespread, involving trunk, neck, and head, at times palms and soles, including nail folds ► Oral cavity and diaper area are spared
  • 123. Congenital Cutaneous Candidiasis ► Differentialdx: listeriosis, syphilis, staphylococcal and herpes infections, ETN, transient neonatal pustular melanosis, miliaria rubra , drug eruption, congenital icthyosiform erythroderma (neonatal pustular disorders) ► If suspected early amniotic fluid, placenta, and cord should be examined for evidence of infection ► Infants with disease limited to skin have favorable outcomes
  • 124. CCC ► Disseminated infection is suggested by (1) bw <1500g (2) evidence of respiratory distress or labs indicating neonatal sepsis (3) tx with broad-spectrum antibiotics (4) extensive instrumentation during delivery or invasive procedures in neonatal period (5) positive systemic cultures, or (6) evidence of an altered immune response ► Infants with congenital cutaneous candidiasis with any of these 6 criteria would be considered for systemic antifungal therapy
  • 125. Perianal Candidiasis ► Frequently entire GI tract is involved ► Can be precipitated by oral antibiotic therapy ► Perianal dermatitis with erythema, oozing, and maceration is present ► Psychogenic etiology is more common than is candidiasis ► Differential dx: psoriasis, seborrheic dermatitis, streptococcal and staphylococcal infections, contact dermatits, and extramammary Paget‟s disease ► Fungicides, meticulous cleansing of perianal region after bowel movements, topical corticosteroids and antipruritics (Atarax)
  • 126. Candidal Paronychia ► Cushionlike thickening of paronychial tissue, slow erosion of lateral borders of nails, gradual thickening and brownish discoloration of nail plates, and development of pronounced transverse ridges ► Frequently only one nail ► A secondary mixed bacterial infection can occur with those who frequently have hands in water or who handle moist objects; cooks, dishwashers, bartenders, nurses, canners , etc
  • 127. CP ► Manicuring nails sometimes is responsible for mechanical or chemical injuries leading to infection ► Ingrown toenails with chronic paronychia ► Seen in pts with diabetes ► Avoid chronic moisture exposure; get diabetes under control ► Oral fluconazole once weekly or pulse dose itraconazole should be effective ► Topical therapy should continue for 2-3 months to prevent recurrence
  • 128. Erosia Interdigitalis Blastomycetica ► Oval-shaped area of macerated white skin on web between and extending onto sides of fingers ► With progression macerated skin peels off, leaving painful, raw,denuded area surrounded by a collar of overhanging white epidermis ► Nearly always affects third web ► Moisture beneath rings macerates skin and predisposes to infection ► Also seen in diabetics, those who do housework, launderers, and others exposed to macerating effects of water and strong alkalis
  • 129. Chronic Mucocutaneous Candidiasis ►A heterogeneous group of pts whose infection with Candida is chronic but superficial ► Onset before age 6 ► Onset in adult life may herald the occurrence of thymoma ► When inherited an endocrinopathy is often found ► Most cases have well-defined limited defects of cell-immunity ► Oral lesions are diffuse and perleche and lip fissures are common
  • 130. Systemic Candidiasis ► High risk pts: pts with malignancies, AIDS, transplant pts requiring immunosuppressive drugs, pts on oral cortisone, pts who have had multiple surgical operations especially cardiac, pts with indwelling catheters, and heroin addicts ► Initial sign is varied: FUO, pulmonary infiltrates, GI bleeding, endocarditis, renal failure, meningitis, osteomyelitis, endophthalmitis, peritonitis, or a disseminated maculopapular eruption
  • 131. SC ► Cutaneous findings are erythematous macules that become papular, pustular, and hemorrhagic, and may progress to necrotic, ulcerating lesions resembling ecthyma gangrenosum ► Deep abscesses may occur ► Trunk and extremities are usual sites of involvement ► Proximal muscle tenderness is a common finding
  • 132. SC ► Ifcandida is cultured within the first week of life there is a high rate of systemic disease ► There is a 50% chance of systemic disease if 1 or more cultures is positive ► Mortality has declined from 80% in the 1970‟s to 40% in the 1990‟s because of early empiric antifungals and better prophylaxis
  • 133. THE END Thank You