• Superficial fungal infections of the skin are one of the most common dermatologic conditions seen in clinical practice.
Fungi: Common Groups1. Dermatophytes: Superficial Ring worm type2. Candida Albacans: Yeast infection3. Pityrosporium: Yeast, present in normal flora of skin, esp. scalp & trunk.
CLASSIFICATION OF FUNGAL INFECTION1.Superficial2.Cutaneous3.Subcutaneous4.Systemic5.Opportunistic
1. Superficial mycoses - Pityriasis versicolor – pigmented lesion on torso (trunk of the human body). ( Dubo? ) - Tinea nigra – gray to black macular lesion on palms. - Black piedra – dark gritty deposits on hair. - White piedra – soft whitish granules along hair shaft. - All diagnosed by microscopy and easily treated by topical preparation.
2. Cutaneous infections• Infections of skin and its appendages (nails, hair)• 20 Spp. of dermatophytes cause ringworm.
3. Subcutaneous mycoses -Subcutaneous infections, over 35 spp. Produce chronic inflammatory disease of subcutaneous tissue & lymphatics, e.g. sporotrichosis (Ulcerated lesion at site of inculasion followed by multiple nodules)
4. Systemic fungal infections - Uncommon: if Natural immunity is high - Physiologic barriers include: - Skin and mucus membranes - Tissue temperature: fungi grow better at less than 37°C
5. Opportunistic Mycoses - Do not normally cause disease in healthy people.- Cause disease in immuno-compromised people.- Weakened immune function may occure due to: ▪ Inherited immunodeficiency disease ▪ Drugs that suppress immune system: cancer chemotherapy, corticosteroids, drugs to prevent organ transplant Rejection. ▪ Radiation therapy ▪ Infection (HIV) ▪ Cancer, diabetes, advanced age and mal-nutrition.
Most common opportunistic mycoticinfections: (commonly seen in PLWHA) 1. Candidiasis 2. Aspergillosis 3. Cryptococcosis 4. Zygomycosis/mucormycosis 5. Pneumocystis carinii
TOPICAL Rx• Localized disease of skin – extend rx for 3-5/7 after apparent cure – 1% clotrimazole less effective• Sprays & solutions – tinea pedis /hairy areas• Limited nail disease – Batrafen nail lacquer
ORAL Rx• Extensive disease• Nail disease• Tinea Capitis
For Systemic Fungal InfectionsFDA approved drugs for empirical therapyDrug Dosing regimen used in controlled trialsAmpho B 0.6 – 1.0 mg/kg/day (IV)__________________________________________________Liposomal 3 mg/kg/day (IV)Ampho B________________________________________________Itraconazole 400 mg/day/or two days then 200 mg/d for 5-12 days (IV), followed by oral solution 400 mg/day for 14 days__________________________________________________Caspofungin 70 mg day 1, then 50 mg/daily
In BPKIHS D-OPDCOMMON FUNGAL PROBLEMS: All typesRx: prescribed:1. Hygiene teaching.2. Antifungal: a. Topical: Ketaconazole, Clotrimazole, Butrinazole b. Oral: Fluconazole, Ketaconazole, itrazole
Rx Summary• Tinea capitis should be treated with systemic therapy.• Griseofulvin in a dose of 10-20 mg per kg for six weeks to 8weeks is the first- line treatment of Tinea capitis.• Ketoconazole 2-4mg per kg for ten days, itraconazole and terbinafine (Lamisil) are good alternatives.
• Griseofulvin should be taken after fatty meal.• Topical treatment can be added to decrease the transmission and accelerate resolution.• Whitefield ointment is preferred in the absence of secondary bacterial infection.• Other family members should also be examined and treated.• Small and single lesion can be treated with topical agents. Clotrimazole 1%, ketoconazole 2%, meconazole 1%. BID for two weeks
• Systemic: ketoconazole 2-4mg per kg of weight for 10 days. Itraconazole and fluconazole are choices if available. Griseofulvin is also effective for the treatment of Tinea corporis.• Topical anti fungal creams or ointments applied regularly for 4 - 6 wks.
• Systemic treatments provide better skin penetration than most topical preparations, Itraconazole, terbinafine and griseofulvin are good choices for oral therapy.• Itraconazole and terbinafine are more effective than griseofulvin. Once-weekly dosing with fluconazole is another option, especially in noncompliant patients.• Personal hygiene (foot hygiene) is highly advised.