Fungi are eukaryotic organisms that can live in air, soil, on plants, and in water. Fungal infections occur when the immune system cannot fight off invading fungi. There are many types of fungi including yeasts, molds, and dimorphic fungi. Risk factors for fungal infections include weak immune systems, medications, obesity, and sweaty conditions. Common fungal infections include athlete's foot, ringworm, and onychomycosis. They are typically diagnosed by microscopic examination and treated with topical antifungal creams or oral antifungal medications.

2. Presented by:-
M. Talha Afzal
Pharm-D

3. What is a Fungi?
 Fungi are eukaryotic organisms; i.e., their cells contain
membrane-bound organelles and clearly defined nuclei.
 The study of fungi is known as mycology.
 Fungi can live everywhere in the air, in the soil, on plants
and in water.
 Fungal infections are common throughout much of the
natural world. In humans, fungal infections occur when an
invading fungus takes over an area of the body and is too
much for the immune system to handle.

4.  Like many microbes, there are helpful fungi and harmful
fungi. However, where fungal infections are concerned,
once treated, reinfections can easily occur, as fungi can
be a tad difficult to kill.
Fungi can be divided into (based on morphology)
1) yeasts
(e.g. Candida and Cryptococcus)
2) Filamentous fungi or moulds
(i.e. Aspergillus, Trichophyton and Alternaria).
3) Dimorphic fungi have more than one form being both
yeasts and filamentous. (i.e. Histoplasma).

5. How does fungal infection occur?
Fungal outbreaks have been linked to a variety of
sources, including exposure to disease-causing fungi in the
natural environment or injections with contaminated
medication. Because fungal spores are often present in the air
or in the soil, one can inhale the spores or they can land on a
person. Thus fungal infections often start off in the lungs or
on the skin.
• In people with weak immune systems, these fungi are
more likely to cause an infection.
• Infections that happen because a person’s immune system
is weak are called opportunistic infections.

6. Factors increasing the risk of getting Fungal
infection:
 People are born with a weak immune system.
 People with weakened immune systems such as children,
elderly people, people suffering AIDS, HIV infection,
cancer, diabetes.
 Medications, like corticosteroids or cancer chemotherapy,
can also lower the body’s ability to fight infections.
 Organ transplant patients.
 Stem cells transplant patients.

7.  People with a genetic predisposition toward fungal
infections.
 People who sweat a lot since sweaty clothes and shoes can
enhance fungus growth on the skin.
 People who come in contact with a person suffering from a
fungal infection.
 People who frequent communal areas with moisture, such
as locker rooms and showers, since fungi require moisture
to grow and reproduce.
 People who are obese as they have excessive skin folds

8. Classification of Fungal Infections

9. Mycosis
Skin Mycosis
Superficial
Mycosis
Cutaneous
Mycosis
Subcutaneous
Mycosis
Systemic
Mycosis
Due to
primary
(dimorphic)
pathogens
Due to
opportunistic
pathogen.

10. Skin Mycosis
1). Superficial Mycosis (or tineas) mostly occur in the tropics
and are restricted to the outer surface of the hair and skin.
Examples are:
• Piedraia hortae, it causes black piedra, a disease of the hair
shaft characterized by brown/black nodules on the scalp
hair.
• Trichosporon cutaneum, it causes white piedra, a superficial
infection of the skin, scalp and pubic hair.

11. 2). Cutaneous Mycosis.
These genera commonly cause disease in the non-
living tissues of skin, hair, or nails/claws of people and
animals, by growing in a zone just above where the protein
keratin is deposited. These genera are Microsporum,
Trichophyton and Epidermophyton and they are often labeled
‘dermatophytes’ or dermatomycosis.
Examples of such infections include
• Onychomycosis
• Athlete's foot
• Ringworm

12. 3). Subcutaneous Mycosis
These are generally caused by fungi that are normally
inhabitants of soil, which become infective by being introduced
through wounds in the skin. Most infections involve people
who normally walk barefoot.
Examples of such fungi include
• Madurella mycetomatis
• Madurella grisea

13. Systemic mycosis
These are the infections that affect the whole body.
1). Systemic Mycosis due to primary pathogens.
These infections are usually acquired by inhalation of
virulent spores originating from soil or related substrata, so
the disease starts off primarily in the lungs and can spread to
other organ systems.
The four prime examples are
• Coccidioidomycosis
• Cryptococcosis
• Histoplasmosis
• Blastomycosis.

14. 2). Systemic mycosis due to opportunistic pathogens.
These are the infections caused by fungi with low inherent
virulence. The opportunistic pathogens are usually commensal
organisms that become pathogenic when the opportunity
offered by a weakened immune system is presented.
The examples of such infections include
• Candidiasis
• Aspergillosis

15. Laboratory Diagnosis of Fungal Infections

16. Specimens Examination
Microscopy
Potassium hydroxide
(KOH) mount
Direct
immunofluorescence
Staining technique:
Histology
Antigen detection
Culture and isolation Findings

17. Indirect methods based on host immune response:
(a) Skin testing:
Skin test once a popular diagnostic test is now almost
abandoned because of false-positive results. However, those
tests are useful to study patient’s immune status.
(b) Serologic tests:
Serologic tests like ELISA for histoplasmosis, latex
agglutination test and CFT have been devised.

18. Fungal Diseases of medical importance
1. Athletes foot
2. Ringworm
3. Tinea capitis
4. Onychomycosis
5. Tinea verisicolor
6. Cutaneous candidiasis

19. ATHLETE’S FOOT:-
Athlete's foot, also called tinea pedis, is a fungal
infection of the foot. It causes peeling, redness ,
itching, burning, and sometimes blisters and sores.

20. Athlete's foot is a very common infection.
• The fungus grows best in a warm, moist
environment such as shoes, socks, swimming pools,
locker rooms, and the floors of public showers.
• It is most common in the summer and in warm,
humid climates.
• It occurs more often in people who wear tight shoes
and who use community baths and pools.

21. Causes of Athlete's Foot?
Athlete's foot is caused by a
microscopic fungus that lives on dead tissue of
the hair, toenails and outer skin layers. There are at
least four kinds of fungus that can cause athlete's
foot. The most common of these fungi is
Trichophyton rubrum.

22. What Are the Symptoms of Athlete's
Foot?
Signs and symptoms of athlete's foot vary from
person to person. However, common symptoms
include:
Peeling, cracking, and scaling of the feet ,
Redness, blisters, or softening and breaking down
of the skin, Itching, burning, or both.

23. Types of Athlete's Foot:-
•Interdigital: Also called toe web infection, this is the
most common kind of athlete's foot. It usually occurs
between the two smallest toes. This form of athlete's foot
can cause itching, burning, and scaling and the infection
can spread to the sole of the foot.
•Moccasin: A moccasin-type infection of athlete's foot
can begin with a minor irritation, dryness, itching, or scaly
skin. As it develops, the skin may thicken and crack. This
infection can involve the entire sole of the foot and extend
onto the sides of the foot.

24. •Vesicular:
This is the least common kind of athlete's
foot. The condition usually begins with a sudden
outbreak of fluid-filled blisters under the skin.
Most often, the blisters develop on the underside
of the foot. However, they also can appear
between the toes, on the heel, or on the top of
the foot.

25. Diagnosis:-
Not all itchy, scaly feet have athlete's foot. The
best way to diagnose the infection is that doctor
should scrape the skin and examine the scales
under a microscope for evidence of fungus.

26. Home Remedies for Athlete's Foot:-
•Many over-the-counter antifungal
medications can be applied to the affected
area.
•These creams should be used sparingly
but regularly, at least once a day. An
application of this cream should be
adequate to cover the entire bottom of
foot.

27. •It is important to keep feet clean and dry. Wear clean,
absorbent socks made of natural fibers, such as cotton, and
change them during the day if feet become moist or sweaty.
•If possible, remove the insoles of shoes and sneakers to
allow them to dry out over night.
•Dusting the inside of shoes and socks with talcum powder
or a medicated powder will help to decrease the moisture
level.
•If a patient plans to see physician for diagnosis and
treatment of athlete's foot, it would be desirable to stop
using any antifungal medication for at least two weeks as it
could inhibit an accurate diagnosis.

28. Treatment:-
Athlete's foot is treated with topical
antifungal medication in most cases.
Severe cases may require oral drugs.
• Antifungal creams are sufficient for treating most
cases of athlete's foot. Common brands include:
 * Clotrim (Clotrimazole)
 **Lamisil (1% terbinafine)
**Novartis pharma. *Zafa pharma.

29. • If the topical antifungal medications do not clear up the
infection, doctor may prescribe an oral antifungal
medication.
• If patient is unsure of his diagnosis and/or his plan to
visit a physician within the next month, the application
of 1% hydrocortisone cream would be a reasonable
therapeutic tactic.
• Since many of the causes of foot dermatitis are not
infections, they may respond to this medication.
Moreover, it will enhance doctor's ability to find fungal
organism should they be the cause.

30. Prevention:-
Steps to prevent athlete's foot include:
• wearing shower sandals in public showering
areas,
• wearing shoes that allow the feet to breathe,
and daily washing of the feet with soap and
water.
• Drying the feet thoroughly and using a quality
foot powder can also help prevent athlete's
foot.

31. Ringworm
Ringworm, also called tinea corporis, is not a
worm, but a fungal infection of the skin.
It can appear anywhere on the body and it looks like a
circular, red, flat sore.
It is often accompanied by scaly skin.
The outer part of the sore can be raised while the skin in
the middle appears normal.
Ringworm can be unsightly, but it is usually not a serious
condition.

32. Is Ringworm Contagious?
Ringworm can spread by
• direct contact with infected people or animals.
• It also may be spread on clothing or furniture.
• Heat and humidity may help to spread the
infection.

33. Symptoms of Ringworm:
Ringworm appears as a red, circular, flat sore that
is sometimes accompanied by scaly skin. There may be
more than one patch of ringworm on the skin, and
patches or red rings of rash may overlap. It is possible to
have ringworm without having the common red ring of
rash.

34. Diagnosis:-
A doctor can diagnose ringworm based on the
appearance of the rash or reported symptoms. The
patient will ask about possible exposure to people
or animals with ringworm. The doctor may take
skin scrapings or samples from the infected area
and look at them under a microscope to confirm
the diagnosis.

35. Causes of Ringworm:-
Ringworm is highly contagious. You can catch it
in any of the following ways:
•From another person.
Ringworm often spreads by skin-to-skin
contact.
•From your pets.
Rubbing or grooming Sparky. Wash hands
properly. It’s also very common in cows.

36. •By touching objects.
The fungus that causes ringworm can
linger on surfaces, clothes, towels, and in
combs and brushes.
•From soil.
If patient is working or standing barefoot in
soil that’s infected with the fungus that
causes ringworm, he can get it, too.

37. Treatment:-
Treatment for ringworm usually consists of
antifungal medications that are applied to the skin.
Many ringworm infections respond well to over-
the-counter creams, including:
•Terbinafine ( Lamisil)
•Clotrimazole (Clotrim)
Oral drugs can be prescribed for more severe cases
of ringworm.
• Terbinafine:
250 mg/day PO in single dose or divided
q12hr for 2-6 weeks

38. Onychomycosis is a fungal infection of the toenails or
fingernails.
Consequences:
Onychomycosis causes fingernails or toenails to
thicken, discolor, disfigure, and split.
• Finger nail infection may cause:
psychological, social, or employment related problems.

40. •usually symptomless unless the nail becomes so thick it
causes pain when wearing shoes.
•As the nail thickens, onychomycosis may interfere with
standing, walking, and exercising.
•Severe cases of Candida infections can disfigure the
fingertips and nails.

41. Dermatophytes can be treated either topically or systemically.
commonly used topical agents :
1.imidazoles:
(Clotrimazole , econazole , Miconazole, sulconazole
and thioconazole)
 These are fungi static drugs.
MOA:
they inhibit C-14 α demethylase (a cytochrome p450
enzyme) , thus blocking the demethylation of lanosterol to
ergosterol, this disrupts membrane structure and function, and
thereby inhibits fungal cell growth.

42. 2. Terbinafine:
Drug of choice for treating dermatophytes
especially onychomycosis.
Dose:- 250 mg (1 tablet) PO daily for 6 weeks
(fingernail) or 12 weeks (toenail)
 MOA: terbinafine inhibits fungal squalene epoxidase,
thereby decreasing the synthesis of ergosterol ,and also
the accumulation of toxic product amount of squalene
results in death of fungal cell.
 Contraindicated in pregnancy

43. 3.Griesofulvin;
First orally administered treatment for dermatophytes.
MOA: It cause disruption of the mitotic spindle and
inhibition of fungal mitosis.
 Dose : 500-1000mg daily, given in one dose or
divided dose if required.
 Treatment lasts for 6 to 12 months
 Duration of treatment :
Skin or hair infection: 4-12 weeks.
Finger nail infection: 6 month.
Toe nail infection : more than one year.

44.  Tinea versicolor is a common fungal infection of the
skin. The fungus interferes with the normal
pigmentation of the skin, resulting in small, discolored
patches. These patches may be lighter or darker in color
than the surrounding skin and most commonly affect
the trunk and shoulders.
 Tinea versicolor occurs most frequently in teens and
young adults. Sun exposure may make tinea versicolor
more apparent. Tinea versicolor, which is also called
pityriasis versicolor, is not painful or contagious. But it
can lead to emotional distress or self-consciousness.

45. Symptoms:
Tinea versicolor signs and symptoms include:
•Patches of skin discoloration, usually on the back, chest,
neck and upper arms, which may appear lighter or darker
than usual
•Mild itching
•Scaling
When to see a doctor?
consult doctor if:
• skin doesn't improve with self-care measures
•The fungal infection returns
•The patches cover large areas of body

47. The fungus that causes tinea versicolor can be found on
healthy skin. It only starts causing problems when the
fungus overgrows. A number of factors may trigger this
growth, including:
 Hot, humid weather
 Oily skin
 Hormonal changes
 Weakened immune system

48. Treatment :
Non pharmacologic therapy:
Sunlight accelerates repigmentation of
hypopigmented areas .
Pharmacological treatment:
Topical treatment:
selenium sulfide 2.5% (Selsun) suspension,
lotion or shampoo applied daily for 10 minutes for 7
consecutive days.

49.  Antifungal topical agents:
Miconazole,
Clotrimazole.
 Oral treatment:
ketoconazole 200mg qd/5days
Fluconazole: 150mg single dose weekly for
2-6 weeks
Itraconazole: 200mg/od/5days

50. What is ringworm of the scalp?
 Ringworm of the scalp is not really a worm, but a
fungal infection. It gets the name ringworm because
the fungus makes circular marks on the skin, often
with flat centers and raised borders. Also called Tinea
capitis, this infection affects your scalp and hair
shafts, causing small patches of itchy, scaly skin.
 Ringworm is a highly contagious infection that’s
usually spread through person-to-person contact or by
sharing combs, towels, hats, or pillows. Ringworm is
most common in children, but can infect a person of
any age.

51.  Fungi called dermatophytes cause ringworm of the scalp.
Fungi are organisms that thrive on dead tissue, such as
fingernails, hair, and the outer layers of your skin.
Dermatophytes prefer warmth and moisture, so they thrive
on sweaty skin. Overcrowding and poor hygiene increase
the spread of ringworm.
 Ringworm spreads easily, especially among children. You
can get ringworm from touching the skin of an infected
person.
 House pets, such as cats and dogs, can spread ringworm,
too. Farm animals like goats, cows, horses, and pigs can
also be carriers.

52.  The most common symptom of ringworm is itchy
patches on the scalp. Sections of hair may break off
near the scalp, leaving scaly, red areas or bald spots.
You may see black dots where the hair has broken
off. Left untreated, these areas can gradually grow
and spread.
Other symptoms include:
 brittle hair swollen lymph nodes
 low-grade fever painful scalp

53.  A visual exam is often enough for a doctor to diagnose
ringworm of the scalp. Doctor may use a special light
called a Wood’s lamp to illuminate patient’s scalp and
determine signs of infection.
 Doctor may also take a skin or hair sample to confirm
the diagnosis. The sample is then sent to a lab to
determine the presence of fungi. This involves looking
at your hair or a scraping from a scaly patch of scalp
under a microscope. This process may take up to three
weeks.

54. Antifungal medication:
 The leading antifungal medications for ringworm are
griseofulvin (Grifulvin V, Gris-PEG) and terbinafine
hydrochloride(Lamisil). Doctor may recommend
taking these medications with a high-fat food such as
peanut butter or ice cream.
 Griseofulvin: 500 mg/day PO for 4-6 weeks.
 Terbinafine: 250 mg/day PO in single dose or divided
q12hr for 2-6 weeks

55. Medicated shampoo:
Doctor may prescribe a medicated shampoo to remove
fungus and prevent the spread of infection. The shampoo
contains the active antifungal ingredient ketoconazole or
selenium sulfide (selsun blue). Medicated shampoo helps
prevent the fungus from spreading, but it doesn’t kill
ringworm. Doctor may advise to use this shampoo a
couple times per week for a month. Leave the shampoo on
for five minutes, then rinse.

56.  Ringworm heals very slowly. It can take more than a
month to see any improvement.
 Doctor may want to check patient or child in 4 to 6
weeks to make sure the infection is clearing up. It can be
difficult to get rid of ringworm, and it’s possible to get
the infection more than once. However, recurrences often
stop at puberty. Long-term effects include possible bald
patches or scarring.
 Child can usually return to school once they start
treatment for ringworm, but ask the doctor when it’s safe
for them to return.

57. • Pets and other family members should be
examined and treated if necessary. This will help
prevent reinfection.
• Do not share towels, combs, hats, or other
personal items with other family members.
• sterilize combs and brushes that belong to the
infected person by soaking them in bleach water.

58. Cutaneous Candidiasis:-
It can involve almost any skin area of the body, but
mostly occurs in warm, moist, creased areas such as the
armpits and groin.
 Candida is the most common cause of nappy rash in
infants.
 The rash can affect various parts the body, but it’s most
likely to develop in the folds of the skin because
Candida fungi thrive and grow in warm, moist areas. This
includes areas in the armpits, in the groin, between the
fingers, and under the breasts.

59.  Candida can also cause infections in the nails, edges of the
nails, and corners of the mouth.
Symptoms of candidiasis of the skin.
• Rash
• Redness
• Intense itching
• Infection can cause the skin to become cracked and sore
• Blisters and pustules may also occur

60. What causes candidiasis of the skin?
Candidiasis of the skin develops when the skin
becomes infected with Candida. A small amount of Candida
fungi naturally live on the skin. When this type of fungus
begins to multiply uncontrollably, however, it can cause an
infection.
This may occur because of:
• Warm weather
• Tight clothing
• Poor hygiene
• Infrequent undergarment changes
• Obesity
• Use of antibiotics that kill harmless bacteria that
• Keep Candida under control

61. • the use of corticosteroids or other medications that affect
the immune system
• a weakened immune system as a result of diabetes,
pregnancy, or another medical condition
• incomplete drying of damp or wet skin
 Babies can also develop candidiasis of the skin, especially
on the buttocks. A diaper tends to provide an ideal
environment for Candida.
 Candidiasis of the skin usually isn’t contagious. However,
people with weakened immune systems may develop the
condition after touching the skin of an infected person.
Those with compromised immune systems are also more
likely to develop a severe infection as a result of
candidiasis.

62. Prevention of candidiasis of the skin:
• Candidiasis of the skin can usually be prevented with
home remedies, the most important of which is proper
hygiene.
• Washing the skin regularly and drying the skin thoroughly
can prevent the skin from becoming too moist.
• Quickly change out of damp clothing, such as swimsuits or
sweaty workout clothes.
• Change the socks and undergarments regularly.
• Wear loose-fitting clothing.
• Use gentle and scent-free soap on affected areas.
• Reduce the amount of sugar in your diet.

63. Treatment:
Topical antifungal agents including
• Miconazole nitrate (Daktarin oral gel, Mycon)
• Clotrimazole (Clozox)
Oral therapy with
Fluconazole (Flunaz) (150 mg) OD
or
Itraconazole (Rolac) (100 mg) OD
In case of oral infection:
Treatment with a topical agent
Nystatin (Nysta) 5 mL oral rinse and swallow qid)
Reserve oral fluconazole, 100 mg once daily for 2 weeks,
for patients with more severe disease.

65. Role of Pharmacist:
Pharmacist should counsel the patient regarding the symptoms of
disease, its prevention and treatment. The counselling points should
include.
• Practice good personal hygiene.
• Always dry the skin completely after bath.
• Antiperspirants are used to reduce sweating which makes the skin
drier and less likely to grow fungi.
• Keep and use own towels and face cloths to prevent contamination,
especially in communal areas.
• Use antifungal powders in shoes or socks to prevent proliferation
of the remaining spores.
• Pharmacist should look out for other pathophysiological states
such as renal dysfunction (especially for Fluconazole and
Flucytosine) as well as the drug interaction should also be
overviewed.