ANTIFUNGAL THERAPY Tinea Infection Treatment By SUDIPTO HALDAR
Cause Of Fungal InfectionSuperficial Fungal Infections may be caused by differenttypes of Fungi, like - Dermatophytes Molds YeastsThe most common fungal infections are caused by theDermatophytes, which are the most abundant in theirdistributionSuch infections are commonly termed as TINEA Infections
Tinea Infection: The common TINEA Infections are : Tinea corporis Tinea cruris Tinea pedis Tinea capitis Tinea versicolor Tinea unguium (Onychomycosis caused by dermatophytes) Common Superficial infections caused by oher species include Onychomycosis (caused by Candida) Cutaneous candidiasis
Tinea Corporis Cause: Tinea corporis is a common skin disorder among children. However, it may occur in people of all ages. It is caused by mold-like fungi called dermatophytes. Fungi thrive in warm, moist areas. The following raise your risk for a fungal infection: Long-term wetness of the skin (such as from sweating) Minor skin and nail injuries Poor hygiene Tinea corporis can spread easily to other people. You can catch the condition if you come into direct contact with an area of ringworm on someones body, or if you touch contaminated items such as: Clothing Combs Pool surfaces Shower floors and walls The fungi can also be spread by pets (cats are common carriers).
Tinea Corporis Symptoms Symptoms may include itching. The rash begins as a small area of red, raised spots and pimples. The rash slowly becomes ring-shaped, with a red- colored, raised border and a clearer center. The border may look scaly. The rash may occur on the arms, legs, face, or other exposed body areas.
Tinea CorporisSigns and tests The health care provider can often diagnose tinea corporis by how the skin looks. In some cases, the following tests may be done: Looking at a skin scraping of the rash under the microscope using a KOH (potassium hydroxide) test Skin lesion biopsy
Treatment TOPICAL THERAPY: Topical therapy should be applied to the lesion and at least 2 cm beyond this area once or twice a day for at least 2 weeks, depending on which agent is used. Topical azoles and allylamines show high rates of clinical efficacy. These agents inhibit the synthesis of ergosterol, a major fungal cell membrane sterol. SYSTEMIC THERAPY: Systemic therapy may be indicated for tinea corporis that includes extensive skin infection, immunosuppression, resistance to topical antifungal therapy. Use of oral agents requires attention to potential drug interactions and monitoring for adverse effects.
Tinea Cruris Tinea cruris, a pruritic superficial fungal infection of the groin and adjacent skin, is the second most common clinical presentation for dermatophytosis. Tinea cruris is a common and important clinical problem that may, at times, be a diagnostic and therapeutic challenge.
PATHOPHYSIOLOGY The most common etiologic agents for tinea cruris include Trichophyton rubrum and Epidermophyton floccosum; less commonly Trichophyton mentagrophytes and Trichophyton verrucosum are involved. Tinea cruris is a contagious infection transmitted by fomites, such as contaminated towels or hotel bedroom sheets, or by autoinoculation from a reservoir on the hands or feet (tinea manuum, tinea pedis, tinea unguium). The etiologic agents in tinea cruris produce keratinases, which allow invasion of the cornified cell layer of the epidermis. The host immune response may prevent deeper invasion. Risk factors for initial tinea cruris infection or reinfection include wearing tight-fitting or wet clothing or undergarments.
Tinea Cruris Treatment Clinical cure of an uncomplicated tinea cruris infection usually can be achieved using topical antifungal agents of the imidazole or allylamine family. Consider patients unable to use topical treatments consistently or with extensive or recalcitrant infection as candidates for systemic administration of antifungal therapy, which has been proven safe in immunocompetent persons. Prevention of tinea cruris reinfection is an essential component of disease management. Patients with tinea cruris often have concurrent dermatophyte infections of the feet and hands. Treat all active areas of tinea cruris infection simultaneously to prevent reinfection of the groin from other body sites. Advise patients with tinea pedis to put on their socks before their undershorts to reduce the possibility of direct contamination. Advise patients with tinea cruris to dry the crural folds completely after bathing and to use separate towels for drying the groin and other parts of the body.
Tinea Pedis Tinea pedis is the term used for a dermatophyte infection of the soles ofthe feet and the interdigital spaces. Tinea pedis is most commonly causedbyTrichophyton rubrum, a dermatophyte initially endemic only to a smallregion of Southeast Asia and in parts of Africa and Australia. Interestingly,tinea pedis was not noted in these areas then, possibly because thesepopulations did not wear occlusive footwear. The colonization of the Trubrum –endemic regions by European nations helped to spread the fungusthroughout Europe. Wars with accompanying mass movements of troopsand refugees, the general increase in available means of travel, and the risein the use of occlusive footwear have all combined to make T rubrum theworlds most prevalent dermatophyte
Tinea Pedis Causes: Athletes foot occurs when a certain fungus grows on your skin in your feet. In addition to the toes, it may also occur on the heels, palms, and between the fingers. Athletes foot is the most common type of tinea fungal infections. The fungus thrives in warm, moist areas. Your risk for getting athletes foot increases if you: Wear closed shoes, especially if they are plastic-lined Keep your feet wet for prolonged periods of time Sweat a lot Develop a minor skin or nail injury Athletes foot is contagious, and can be passed through direct contact, or contact with items such as shoes, stockings, and shower or pool surfaces.
Symptoms The most common symptom is cracked, flaking, peeling skin between the toes or side of the foot. Other symptoms can include: Red and itchy skin Burning or stinging pain Blisters that ooze or get crusty If the fungus spreads to your nails, they can become discolored, thick, and even crumble. Athletes foot may occur at the same time as other fungal skin infections such as ringworm or jock itch.
Tinea Pedis Treatment Tinea pedis can be treated with topical or oral antifungals or a combination of both. Topical agents are used for 1-6 weeks, depending on manufacturers recommendations. A patient with chronic hyperkeratotic (moccasin) tinea pedis should be instructed to apply medication to the bottoms and sides of his or her feet. For interdigital tinea pedis, even though symptoms may not be present, a patient should apply the topical agent to the interdigital areas and to the soles because of the likelihood of plantar-surface infection.
Tinea Versicolor A fungal infection of the skin caused by Malassezia furfur and characterized by finely desquamating, pale tan patches on the upper trunk and upper arms that may itch and do not tan. In dark-skinned people the lesions may be depigmented. The fungus fluoresces under Woods light and may be easily identified in scrapings viewed under a microscope. Topical and oral antifungal agents may be used, as well as repeated applications of selenium sulfide. The pale patches may persist for up to 1 year after successful treatment, and recurrence is common.
Tinea Versicolor Signs & Symptoms: Acidic bleach from the growing yeast causes areas of skin to be a different color than the skin around them. These can be individual spots or patches. Specific signs and symptoms of the infection include: Patches that may be white, pink, red, or brown and can be lighter or darker than the skin around them. Spots that do not tan the way the rest of your skin does. Spots that may occur anywhere on your body but are most commonly seen on your neck, chest, back, and arms. The spots may disappear during cool weather and get worse during warm and humid weather. They may be dry and scaly and may itch or hurt, although this is not common.
Treatment Of Tinea Versicolor Treatment of tinea versicolor can consist of creams, lotions, or shampoos that are put on the skin. It can also include medication given as pills. The type of treatment will depend on the size, location, and thickness of the infected area. Treatment options include: Topical anti-fungals:These products are applied directly to your skin and may be in the form of lotions, shampoos, creams, or soaps. They keep the growth of the yeast under control. Over-the-counter anti-fungal topical products containing ingredients such as selenium sulfide, miconazole, clotrimazole, and terbinafine are available. But sometimes prescription medications may be needed.
Treatment Of Tinea Versicolor Anti-fungal pills: These may be used to treat more serious or recurrent cases of tinea versicolor. Or in some cases they may be used because they can provide a simpler and quicker resolution of the infection. These medicines are given by prescription and can have side effects. So its important to be monitored by your doctor while using anti-fungal pills. Treatment usually eliminates the fungal infection. However, the discoloration of the skin may take up to several months to resolve.
Onychomycosis Onychomycosis is a fungal infection of the toenails or fingernails. Cause: Onychomycosis causes fingernails or toenails to thicken, discolor, disfigure, and split. At first, onychomycosis appears to be only a cosmetic concern. Without treatment, however, the toenails can become so thick that they press against the inside of the shoes, causing pressure, irritation, and pain. Fingernail infection may cause psychological, social, or employment-related problems.
Onychomycosis Symptoms & Signs Onychomycosis usually does not cause any symptoms unless the nail becomes so thick it causes pain when wearing shoes. People with onychomycosis usually go to the doctor for cosmetic reasons, not because of physical pain or problems related to onychomycosis. As the nail thickens, onychomycosis may interfere with standing, walking, and exercising. Paresthesia (a sensation of pricking, tingling, or creeping on the skin having noobjective cause and usually associated with injury or irritation of a nerve), pain, discomfort, and loss of agility (dexterity) may occur. Loss of self-esteem, embarrassment, and social problems can also develop. Severe cases of Candida infections can disfigure the fingertips and nails.
Treatment on Onychomycosis In the past, medicines used to treat onychomycosis (OM) were not very effective. OM is difficult to treat because nails grow slowly and receive very little blood supply. However, recent advances in treatment options, including oral (taken by mouth) and topical (applied on the skin or nail surface) medications, have been made. Newer oral medicines have revolutionized treatment of onychomycosis. However, the rate of recurrence is high, even with newer medicines. Treatment is expensive, has certain risks, and recurrence is possible.
Dosage & Administration Of Terbinafine to Eradicate Tinea The Oral dose of Terbinafine is a constant 250 mg O.D. in adults The duration can vary considerably, depending on the condition (severity, area of distribution and duration of the disease) ADULT DOSAGE Tinea Corporis : Topical application once or twice daily, for 1 to 2 wks; Orally 250 mg O.D. for up to 4 weeks Tinea Cruris : Topical application once or twice daily for 1 to 2 weeks; Orally 250 mg O.D. for 2 to 4 weeks Tinea Pedis : Topical application once or twice daily for 1 week; Orally 250 mg O.D. for up to 6 weeks Tinea Capitis : Orally 250 mg O.D. for 4 weeks (rarely found in adults) Tinea Versicolor : Topical application once or twice daily for 1 to 2 weeks, suitable oral antimycotic drug may be co-prescribed, like Terbinafine itself, or Fluconazole.
Dosage & Administration Of Terbinafine PAEDIATRIC DOSAGE Terbinafine can be safely used in children over 1 year of age, for Tinea infections, Onychomycosis, and especially Tinea Capitis, in the following per kg body wt. dose: 10 - 20 kg - 62.5 mg O.D. 20 - 40 kg - 125 mg O.D. >40 kg - 250 mg O.D. The indication-wise dosage in children is as follows : Tinea Capitis - 2 weeks to 4 weeks Tinea Cruris - 2 to 4 weeks Tinea Corporis - 4 weeks Onychomycosis - Up to 6 weeks, in case of fingernail, or longer Up to 12 weeks, in case of toenail, or longer
Adjuvant therapy with Ketoconazole in Tinea Infection2% Ketoconazole w/w offers freedom from and protects against Tinea Versicolor, and also effective as an adjuvant therapy along with topical and oral antifungal drugs to treat tinea and candida skin infections.