fugal infections

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By: familydoctor (103 month(s) ago)

thanks alot ,,

By: familydoctor (103 month(s) ago)

thanks alot

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thanks alot

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FUNGAL INFECTIONS OF THE SKIN AND NAILS : 

FUNGAL INFECTIONS OF THE SKIN AND NAILS MAJ ASHER AHMED MASHHOOD MBBS, FCPS (Dermatology) ASSISTANT PROFESSOR MH RAWALPINDI

WHAT IS A FUNGUS : 

WHAT IS A FUNGUS A FUNGUS IS A EUKARYOTIC CELL WITH THICK CELL WALL CONTAINING GLYCAN AND MANNANS TWO BASIC FORMS: MOULDS & YEASTS MOULDS INCLUDE DERMATOPHYTES AND YEASTS INCLUDE CANDIDA AND MALASSEZIA REPRODUCE BY SEXUAL AND ASEXUAL MEANS

HOW FUNGAL INFECTIONS ARE ACQUIRED : 

HOW FUNGAL INFECTIONS ARE ACQUIRED BY CLOSE CONTACT

HOW FUNGAL INFECTIONS ARE ACQUIRED : 

HOW FUNGAL INFECTIONS ARE ACQUIRED

HOW FUNGAL INFECTIONS ARE ACQUIRED : 

HOW FUNGAL INFECTIONS ARE ACQUIRED SOIL SWIMMING POOLS

HOW FUNGAL INFECTIONS ARE ACQUIRED : 

HOW FUNGAL INFECTIONS ARE ACQUIRED

FUNGUS CAN EFFECT ANY ONE : 

FUNGUS CAN EFFECT ANY ONE MALES FEMALES ADULTS CHILDREN EXECUTIVES WORKERS FARMERS

WHICH PARTS OF THE SKIN ARE EFFECTED BY RASH OF FUNGAL INFECTION : 

WHICH PARTS OF THE SKIN ARE EFFECTED BY RASH OF FUNGAL INFECTION TINEA CAPITIS TINEA FACEI TINEA MANNUM TINEA OF NAIL TINEA CORPORIS TINEA CRURIS TINEA PEDIS CANDIDIASIS PITY. VERSICOLOR

OBJECTIVES : 

OBJECTIVES TO DISTINGUISH COMMON FUNGAL INFECTIONS FROM SIMILAR APPEARING LESIONS; E.G. ECZEMA TO KNOW COMMON ERRORS IN FUNGAL DIAGNOSIS AND TREATMENT TO KNOW WHEN TO SUSPECT AND HOW TO DIAGNOSIS ID REACTION TO DISCUSS THE TREATMENT OPTIONS OF COMMON FUNGAL INFECTIONS OF THE SKIN AND NAILS

DERMATOPHYTES : 

DERMATOPHYTES THREE ASEXUAL GENERA: Trichophyton Microsporum Epidermophyton Distinguished by macroconidias DIVIDED ECOLOGICALLY INTO ZOOPHILIC (HAVING ANIMAL ORIGIN), GEOPHILIC (ORIGIN FROM SOIL) AND ANTHROPOPHILIC (RESTRICTED TO HUMANS) DISEASE THEY CAUSED ARE NAMED AFTER THE LOCATION VARIED PRESENTATIONS SIMILAR TREATMENTS BUT THE DOSE SCHEDULES ARE DIFFERENT

IF THEY DO THIS TO FOOD….. : 

IF THEY DO THIS TO FOOD…..

DIAGNOSIS OF DERMATOPHYTES : 

DIAGNOSIS OF DERMATOPHYTES DIRECT MICROSCOPY OF SKIN SCRAPINGS IN KOH MOUNTS FUNGAL CULTURE IN SABOURAUD’S AGAR

DIRECT MICROSCOPY : 

DIRECT MICROSCOPY

FUNGAL CULTURES AND COLONIES : 

FUNGAL CULTURES AND COLONIES MICROSPORUM TRICHOPHYTON EPIDERMOPHYTON

ITCHING AND RASH ARE THE MAIN COMPLAINTS : 

ITCHING AND RASH ARE THE MAIN COMPLAINTS

TINEA CAPITIS : 

TINEA CAPITIS It is the invasion of hair shafts by dermatophyte fungus Disease of children Exposure from other children or pets Highly variable presentation Trichophyton or Microsporum species

TINEA CAPITIS : 

TINEA CAPITIS Small-spored ectothrix: partial alopecia, mild inflammation and scaling Kerion: painful inflammatory mass, pus discharge, hair loss, thick crusting Agminate folliculitis: plaque studded with follicular pustules Endothrix: Black dots at scalp surface, partial hair loss, mild inflammation Favus: mild hair loss, yellowish cup shaped crusts surrounding hair follicles

KERION : 

KERION

Slide 19: 

ENDO AND ECTOTHRIX VARIETY OF TINEA CAPITIS

T. CAPITISDIAGNOSIS : 

T. CAPITISDIAGNOSIS Over diagnosed in adults and under diagnosed in children Direct microscopic exam of hairs: Look for hyphae Woods lamp Examination: bright green fluorescence in hair shafts in Microsporum infection Culture: If KOH is negative

DIFFERENTIAL DIAGNOSIS : 

DIFFERENTIAL DIAGNOSIS CELLULITIS ALOPECIA AREATA SEB ECZEMA SEC SYPHILIS

TINEA BARBAE : 

TINEA BARBAE Ringworm of the beard & moustaches Zoophilic dermatophytes Kerion type, highly inflamed pustular folliculitis & hair loss

TINEA BARBAE : 

TINEA BARBAE Diagnostic features Nodular, boggy lesions with pus exudate Sinus tract formation Scarring if untreated KOH or culture may confirm

TINEA BARBAE : 

TINEA BARBAE Differential diagnosis Bacterial folliculitis Pseudofolliculitis barbae Contact dermatitis Herpes Simplex Syphilis Acne

TINEA FACIEI : 

TINEA FACIEI Infection of non-hairy areas of face Especially in children and women Annular lesion with central clearing and peripheral spread Itching and burning

TINEA CORPORIS : 

TINEA CORPORIS Ringworm of glabrous skin Characteristic lesions are circular, sharply marginated, raised borders and central clearing Single or multiple Degree of inflammation is variable In inflamed lesions pustules or vesicles predominate

T.CORPORIS : 

T.CORPORIS

TINEA CIRCINATA : 

TINEA CIRCINATA Caused by T. concentricum AR susceptibility Multiple concentric rings Severe pruritis

T. CORPORIS : 

T. CORPORIS Differential diagnosis Nummular eczema KOH –ve, erythematous scaling Pityriasis rosea KOH -ve, multiple papules/plaques, peripheral scales Psoriasis KOH -ve, thick, silvery scales Granuloma annulare KOH -ve, no scale

THE DIAGNOSIS PLEASE... : 

THE DIAGNOSIS PLEASE...

TINEA CRURIS : 

TINEA CRURIS Infection of groins Thrives in humid environments T.rubrum, T. mentagrophytes, and Epidermophyton floccosum Autoinfection from foot, sharing of towels and sport clothing Erythematous plaque with curved and sharp margins Extends down the thighs and buttocks Itching is very intense

TINEA CRURIS : 

TINEA CRURIS Diagnostic features: Spares scrotum Severe pruritus & burning Well defined border Central clearance Mild scaling Look for feet as possible infection source KOH + hyphae

TINEA CRURIS : 

TINEA CRURIS Differential Diagnosis: Candida Beefy red with poorly defined borders, numerous satellite lesions Intertrigo Erythematous lesions in the fold with out any characteristic feature Erythrasma Asymmetric scaly patches, Pink fluorescence on woods light exam Psoriasis Thick silvery scales Seb derm Borders less defined, distribution different

TINEA INCOGNITOSTEROID-MODIFIED TINEA : 

TINEA INCOGNITOSTEROID-MODIFIED TINEA Ringworm infection modified by the use of oral or topical steroids The clinical picture is modified to a variable extent The inflammation may subside and the typical border may be lost The lesion tends to improve initially, but later on the disease gets aggravated On careful inspection some reminiscence of the typical border can be appreciated

TINEA PEDIS : 

TINEA PEDIS Infection of feet or toes Species involved are Trichophyton rubrum, T. mentagrophytes, and Epidermophyton floccosum THREE TYPES OF T. PEDIS Intertriginous dermatitis Squamous hyperkeratotic Vesicobullous reaction

INTERTRIGINOUS DERMATITIS : 

INTERTRIGINOUS DERMATITIS Peeling, maceration and fissuring of inter-digital clefts

SQUAMOUS HYPERKERATOTIC : 

SQUAMOUS HYPERKERATOTIC Chronic, affects soles Erythamatous skin with silvery scales and accentuated creases, Commonly caused by T. rubrum

VESICOBULLOUS REACTION : 

VESICOBULLOUS REACTION Vesicles and pustules over one of the foot Commonly caused by T. mentagrophytes

DIFFERENTIAL DIAGNOSIS OF T. PEDIS : 

DIFFERENTIAL DIAGNOSIS OF T. PEDIS Palmoplantar Keratoderma Psoriasis Plantar Eczema

TINEA MANUM : 

TINEA MANUM Fungal infection of palmar aspect of hands Chronic lesion Unilateral, rarely bilateral Characterized by hyperkeratosis and scaling Accentuation of palmar creases Dry scales (KOH +ve) Differential Diagnosis: Eczema, contact dermatitis

ID ERUPTION : 

ID ERUPTION Allergic rash Proven dermatophyte infection which usually becomes highly inflamed Characterized by small follicular papules on the trunk or vesicular lesions over the hands Distant eruptions are free of the fungus Spontaneous disappearance once the fungal infection is treated

ONYCHOMYCOSIS : 

ONYCHOMYCOSIS Invasion of nail plate by species of dematophytes Commonly associated with T. pedis or T. manum Caused by the same species which cause the above infections Asymmetrical nail involvement

DISTAL AND LATERAL SUBUNGUAL ONYCHOMYCOSIS : 

DISTAL AND LATERAL SUBUNGUAL ONYCHOMYCOSIS Most common pattern Whitish or yellowish discoloration at distal or lateral edge of a nail plate Nail plate gets thickened and cracked

PROXIMAL SUBUNGUAL ONYCHOMYCOSIS : 

PROXIMAL SUBUNGUAL ONYCHOMYCOSIS Uncommon Invasion of nail plate from posterior nail fold Produce white nails with only marginal increase in thickness

SUPERFICIAL WHITE ONYCHOMYCOSIS : 

SUPERFICIAL WHITE ONYCHOMYCOSIS Less common Dorsal surface of nail plate is eroded in well-circumscribed powdery white patches, away from the free edge

ENDONYX ONYCHOMYCOSIS : 

ENDONYX ONYCHOMYCOSIS Nail plate is scarred with pits and lamellar splits Invasion occurs from the top surface and penetrates deeply into the nail plate

TOTAL DYSTROPHIC ONYCHOMYCOSIS : 

TOTAL DYSTROPHIC ONYCHOMYCOSIS Complete and massive destruction of the nail plate

PITYRIASIS VERSICOLOR : 

PITYRIASIS VERSICOLOR Infection caused by an yeast Malassezia furfur Sharply demarcated macules which are brownish or whitish in colour with fine scales Mostly asymptomatic. Sometimes mild irritation Chronic and present for months Mainly involve the trunk

PITYRIASIS VERSICOLOR : 

PITYRIASIS VERSICOLOR KOH Mount examination Coarse mycelia and spherical thick walled yeasts (Spegitti and meat-ball appearance) Woods light Examination Pale yellow fluorescence under woods light

CANDIDIASIS : 

CANDIDIASIS Infection caused by the yeast Candida albicans Candida are normal inhabitants of oral mucosa, GIT, GUT and skin Causes oral infection if the body resistance is low; in diabetes, Sjőgren’s syndrome, retention of food debris, poor oral hygiene and local tissue damage Oral lesion are associated with creamy curd-like pseudo-membrane which when removed reveal an erythematous base Intertriginous lesions are caused by maceration in body folds The lesions are well demarcated, beefy red and moist along with satellite papules and pustules

ACUTE PSEUDOMEMBRANOUS AND CHRONIC HYPERPLASTIC CANDIDIASIS : 

ACUTE PSEUDOMEMBRANOUS AND CHRONIC HYPERPLASTIC CANDIDIASIS

ANGULAR CHELITIS : 

ANGULAR CHELITIS

CANDIDAL INTERTRIGO : 

CANDIDAL INTERTRIGO

INTERDIGITAL CANDIDIASIS : 

INTERDIGITAL CANDIDIASIS

THE DIAGNOSIS IS... : 

THE DIAGNOSIS IS... Nappy dermatitis Tinea cruris

TREATMENT : 

TREATMENT TOPICAL ORAL

TOPICAL TREATMENT : 

TOPICAL TREATMENT Benzoic acid compound ointment (Whitfield ointment) ½ strength Imidazole creams/lotions e.g. Stiemazol, Travogen, Canasten, Mycospor, Spike Vaginal creams; Trvogen, Daktarin 1% Terbinafine cream (Lamisil) Polyene antibiotics e.g. Nystatin oral drops and vaginal tablets Oral imidazole cream; Daktarin oral gel Steroid / anti-fungal combination e.g. Hydrozole, Travocort, Daktacort Anti-fungal shampoos e.g. Stiprox, Spike, Selsun brown

ORAL TREATMENT : 

ORAL TREATMENT GRISEOFULVIN Inhibit the formation of intracellular microtubules Fungistatic Available in 250 & 500 mg tabs and 125 mg / 5 ml suspension Dose is 10-20 mg/kg/day SE’s: photosensitivity, headache, GI upset, hypersensitivity, leukopenia Active only against dermatophytes, not yeasts Nowadays it is used primarily in T. capitis

ORAL TREATMENT : 

ORAL TREATMENT TERBINAFINE (Lamisil, Terbiderm) Inhibit squalene epoxidase in the formation of fungal cell membrane Fungicidal Available as 125 mg tablets Dose is ½ tablet daily for children < 6 years, 1 tablet daily for children between 6 and 12 years and 1 tablet twice daily for adults Duration of treatment for dermatophytes is for 2-4 weeks For onychomycosis 6-12 weeks

ORAL TREATMENT : 

ORAL TREATMENT ITRACONAZOLE (Sporanox, Icon, Rolac) Orally active azole Inhibit cytochrome P-450 dependent demethylation stage in fungal cell membrane formation Affective against dermatophytes, yeasts and fungi causing systemic infection Available in 100 mg capsules. Given as once a day dose Duration of treatment is 2-4 weeks For Onychomycosis given as pulse therapy for 2-3 months

ORAL TREATMENT : 

ORAL TREATMENT FLUCONAZOLE (Zolanix) Orally active azole Similar mechanism of action as Itraconazole Available as 150 mg capsules Used for treatment of dermatophytes, candidiasis and systemic mycosis Longer half life and hence given in a convenient weekly doses. Side effects are rare One capsule stat is sufficient for vaginal candidiasis and balanitis Duration of treatment for dermatophyte infection is 2-4 weeks and for onychomycosis 6-8 months

POINTS TO REMEMBER : 

POINTS TO REMEMBER Asymmetry, well-defined border, central clearing and itching T. capitis:- over diagnosed in adults/under in children; oral therapy needed T. cruris:- spares scrotum T. manum:- often unilateral T. pedis:- highly variable presentation, unilateral involvement is diagnostic P. versicolor:- topical therapy alone is effective Onychomycosis:- oral treatment is must

Slide 63: 

GRISEOFULVIN Dose is 10-20 mg/kg/day Nowadays it is used primarily in T. capitis TERBINAFINE Fungicidal Dose is 1 tablet twice daily for adults ITRACONAZOLE Available in 100 mg capsules. Given as once a day dose FLUCONAZOLE (Zolanix)

THANK YOU : 

THANK YOU

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