Mycosis PDF

MYCOSIS  MYCOSIS Mycosis: A Fungal Infection Mycosis, also known as a fungal infection, is a disease caused by a fungus. Fungi are eukaryotic microorganisms that can be unicellular or multicellular. They are different from bacteria in that they have a cell wall made of chitin, not peptidog...

MYCOSIS  MYCOSIS Mycosis: A Fungal Infection Mycosis, also known as a fungal infection, is a disease caused by a fungus. Fungi are eukaryotic microorganisms that can be unicellular or multicellular. They are different from bacteria in that they have a cell wall made of chitin, not peptidoglycan. Classification of Mycoses Mycoses are typically classified based on the site of infection and the type of fungal organism involved. 1. Based on Site of Infection: Superficial Mycoses: These infections affect the outermost layer of the skin and hair. They are usually harmless and cosmetic in nature. Cutaneous Mycoses: These infections involve the deeper layers of the skin, hair, and nails. They can cause inflammation and discomfort. Subcutaneous Mycoses: These infections affect the deeper layers of the skin and subcutaneous tissues. They can be chronic and may require surgical intervention. Systemic Mycoses: These infections spread throughout the body and can affect multiple organs. They can be life-threatening, especially in immunocompromised individuals. MYCOSIS... 2. Based on Type of Fungal Organism: Dermatophytoses: Caused by dermatophytes, a group of fungi that thrive on keratinized tissues (skin, hair, nails). Candidiasis: Caused by Candida species, a type of yeast that is normally present on the skin and mucous membranes but can overgrow and cause infection. Aspergillosis: Caused by Aspergillus species, a type of mold that can cause respiratory infections and allergic reactions. MYCOSIS... Histoplasmosis: Caused by Histoplasma capsulatum, a dimorphic fungus found in soil contaminated with bird or bat droppings. Coccidioidomycosis: Caused by Coccidioides immitis and C. posadasii, dimorphic fungi found in arid and semi-arid regions of the southwestern United States and Mexico MAJOR CATEGORY OF MYCOSIS.. TYPE OF MYCOSIS DESCRIPTION/EXPLANATION SUPERFICIAL MYCOSIS Affect the outer most layer of the skin, hair and nails. Common example include tinea versicolor. CUTANEOUS MYCOSIS Involves deeper layer of the skin, include the epidemis,hairs and nails it can cause condition line athlete’s foot and ringworm. SUBCUTANEOUS MYCOSIS It affect the skin, subcutaneous tissue, and sometimes bone example include sporotrichosis. SYSTEMIC MYCOSIS Involves internal organs or the entire body. This type can be life-threatening and is typical caused by inhalation of fungal spores. Example histoplasmosis and candidiasis. OPPORTUNISTIC MYCOSIS Affect immunocompromised individual often in the form of systemic infections. Include aspergillosis and cryptococcosis. SUPERMYCOSIS... Superficial mycosis :refers to a group of fungal infections that primarily affect the outermost layers of the skin and hair. They are often characterized by minimal inflammation and are primarily cosmetic concerns. Causative Agents: Pityriasis versicolor: Caused by Malassezia furfur, a yeast-like fungus that colonizes the skin's surface. Black piedra: Caused by Piedraia hortae, a fungus that forms black nodules on hair shafts. White piedra: Caused by Trichosporon beigelii, a fungus that forms soft, white nodules on hair shafts. Tinea nigra: Caused by Phaeoannellomyces werneckii, a fungus that causes brown to black macules on the palms of the hands or soles of the feet. MYCOSIS... Transmission Pityriasis versicolor: Spread by person-to-person contact or through contaminated clothing and towels. Black piedra: Spread by direct contact with infected hair or through shared combs and brushes. White piedra: Spread through similar means as black piedra. Tinea nigra: Spread through contact with contaminated soil or surfaces in tropical and subtropical regions. Clinical Presentation/Signs and Symptoms: Pityriasis versicolor: Characterized by patches of discolored skin that may be lighter or darker than the surrounding skin. Cont… Black piedra: Presence of small, hard, black nodules on hair shafts.. Cont… White piedra: Presence of soft, white nodules on hair shafts. Cont… Tinea nigra: Brown to black macules on the palms of the hands or soles of the feet SUPERFICIAL MYCOSIS... Superficial mycoses are generally not life-threatening and rarely cause serious complications. However, some individuals may experience itching, discomfort, or cosmetic concerns. In rare cases, severe cases of pityriasis versicolor may lead to post- inflammatory hyperpigmentation, leaving behind darker patches on the skin. NOTE; Superficial mycoses are more common in warm and humid climates. People with oily skin or weakened immune systems may be more susceptible to these infections. Treatment typically involves antifungal medications applied topically to the affected areas. Maintaining good hygiene practices, such as washing hands and showering regularly, can help prevent the spread of superficial mycoses. CUTANEOUS MYCOSIS Cutaneous Mycosis Cutaneous mycoses are fungal infections that affect the deeper layers of the skin, hair, and nails. They can cause inflammation, itching, and discomfort, and can sometimes lead to more serious complications. Causative Agents Dermatophytes: A group of fungi that thrive on keratinized tissues (skin, hair, nails). Common examples include: Trichophyton species Microsporum species Epidermophyton species Candida species: A type of yeast that can overgrow and cause infection, especially in warm, moist areas of the body Transmission: * Direct contact: Touching an infected person or animal. * Indirect contact: Sharing contaminated items such as towels, clothing, or sports equipment. * Environmental sources: Contact with contaminated soil or surfaces.  Clinical Presentation/Signs and Symptoms Tinea corporis (ringworm): Round, scaly patches with a raised, red border.  Tinea cruris (jock itch): Itchy rash in the groin area.  Tinea pedis (athlete's foot): Itching, scaling, and cracking between the toes.  Tinea unguium (onychomycosis): Thickening, discoloration, and crumbling of the nails. Other fungi: Less common causes include non-dermatophytic molds and yeasts. Candidiasis: * Oral thrush: White patches on the tongue and inner cheeks. * Vaginal candidiasis: Itching, burning, and white discharge from the vagina. * Diaper rash: Red, irritated skin in the diaper area. * Other cutaneous mycoses: Can present with a variety of symptoms depending on the specific fungus involved. Complications: * Secondary bacterial infections: Scratching can break the skin and allow bacteria to enter, leading to infection. * Spread of infection: In some cases, the infection can spread to other parts of the body. * Psychological distress: Cutaneous mycoses can be unsightly and embarrassing, causing emotional distress for some individuals. CUTANEOUS MYCOSIS……. NOTE; 1.Cutaneous mycoses are among the most common of all communicable diseases. 2. Cutaneous fungal infections are caused by species of Malassezia, dermatophytes, or Candida (discussed later). 3. The growth of dermatophytes is inhibited by serum and body temperature, and these fungi rarely become invasive. 4. Geophilic and zoophilic dermatophytes usually cause acute, inflammatory lesions that respond to topical treatment within weeks and rarely recur. 5. Anthropophilic dermatophytes usually cause relatively mild, chronic lesions that may require months or years of treatment and frequently recur. SUBCUTANEOUS MYCOSIS….. Subcutaneous Mycosis Subcutaneous mycoses are fungal infections that affect the deeper layers of the skin and subcutaneous tissues. They are typically chronic infections that can be difficult to treat and may require surgical intervention. Causative Agents: Chromoblastomycosis: Caused by several species of fungi, including Fonsecaea pedrosoi, Fonsecaea compacta, Cladophialophora carrionii, and Phialophora verrucosa. Mycetoma: Caused by a variety of fungi and bacteria. Sporotrichosis: Caused by Sporothrix schenckii, a dimorphic fungus.  Clinical Presentation/Signs and Symptoms: Chromoblastomycosis: Characterized by verrucous (wart-like) lesions on the skin, often on the lower extremities.  Transmission Traumatic inoculation: The most common mode of transmission is through a puncture wound or cut in the skin, allowing the fungus to enter the deeper tissues. Direct contact: In some cases, the infection can spread from person to person through direct contact with open wounds.  Treatment and Prevention Surgical excision for small lesions. Chemotherapy with flucytosine or itraconazole for larger lesions The application of local heat is also beneficial. Relapse is common. Wearing shoes and protecting the legs probably would prevent infection. MYCETOMA Mycetoma is a chronic, slowly progressive granulomatous infection of the skin and subcutaneous tissues.  Agents of Mycetoma and types of grains they produce Eumycetoma Actinomycetoma 1.Blck granules 1.White to yellow granules Madurella mycetomatis Norcadia species Madurella grisea Streptomyces somaliensis Exophiala jeanselmei Antinomadura madural Curvularia species 2.White granules 2.Pink to red Granules Pseudallescheria boydii. Actinomadura pelletieri Aspergillus nidulans Acremonium species Fusarium sopecies  Clinical manifestation The causative agents enter the skin or subcutaneous tissue from the contaminated soil,ussually by the accidental trauma such as thorn prick or splinter injury. ❖Hallmark of mycetoma is the presence of clinical triad consisting of; Tumor like swelling i.e. tumefaction Discharging sinuses Discharge oozing from sinuses containing granules  Treatment Treatment of mycetoma consists of surgical removal of the lesion followed by the use of; Topical nystatin or miconazole, Itraconazole, ketoconazole for Pseudallescheria boydii. Amphotericin B for Madurella infections. Flucytosine for Exophiala jeanselmei. Chemotherapeutic agents must be given for long periods to adequately penetrate these lesions.  Sporotrichosis: Characterized by the development of nodules and ulcers along the lymphatic channels, often starting at the site of inoculation.  Treatment Oral administration of saturated solution of potassium iodide in milk is quite effective, it is difficult for many patients to tolerate. The treatment of choice is oral itraconazole or another azoles. Amphotericin B is recommended for systemic infections.  Subcutaneous mycoses are more common in tropical and subtropical regions. People who work outdoors or in agricultural settings are at increased risk of infection. Treatment typically involves long-term antifungal medications, sometimes in combination with surgery to remove infected tissue. Complications: Spread of infection: The infection can spread to deeper tissues, including bones and joints. Lymphatic involvement: In some cases, the lymphatic system can become involved, leading to lymphadenopathy. Cosmetic disfigurement: Subcutaneous mycoses can cause significant scarring and disfigurement.  SYSTEMIC MYCOSIS… Systemic Mycosis Systemic mycoses, also known as deep mycoses or invasive fungal infections, are serious fungal infections that spread throughout the body and can affect multiple organs. They are often life-threatening, especially in immunocompromised individuals. HISTOPLASMOSIS Histoplasma capsulatum is a dimorphic soil saprophyte that causes histoplasmosis. Histoplasmosis is initiated by inhalation of the conidia. Symptoms and Clinical Findings Immunocompetent persons who inhale a heavy inoculum, develop acute pulmonary histoplasmosis, which is a self-limited flu like syndrome with fever, chills, myalgias, headaches, and nonproductive cough. Symptoms and Clinical findings On radiographic examination, most patients will have hilar lymphadenopathy and pulmonary infiltrates or nodules. These symptoms resolve spontaneously without therapy, and the granulomatous nodules in the lungs or other sites heal with calcification. Chronic pulmonary histoplasmosis occurs most often in men and is usually a reactivation process,  TREATMENT Acute pulmonary histoplasmosis is managed with supportive therapy and rest. Itraconazole is the treatment for mild to moderate infection. In disseminated disease, systemic treatment with amphotericin B is often curative, though patients may need prolonged treatment and monitoring for relapses. Patients with AIDS typically relapse despite therapy that would be curative in other patients. Therefore, AIDS patients require maintenance therapy with itraconazole. COCCIDIOIDOMYCOSIS Causative agents are Coccidioides posadasii or C immitis. 40% of the infected individuals develop a self-limited influenza like illness with fever, malaise, cough, arthralgia, and headache. This condition is called valley fever, San Joaquin Valley fever, or desert rheumatism.  TREATMENT Itraconazole may reduce the symptoms. Amphotericin B, patients who have shown severe symptoms. Cases of coccidioidal meningitis have been treated with oral fluconazole, which has good penetration of BBB; However, long-term therapy is required, and relapses have occurred. Surgical resection of pulmonary cavities is sometimes necessary and often curative BLASTOMYCOSIS A chronic infection with granulomatous and suppurative lesions that is initiated in the lungs, whence dissemination may occur to any organ but preferentially to the skin and bones. Blastomycosis is caused by Blastomyces dermatitidis.  SYMPTOMS AND CLINICAL FINDINGS The most common clinical presentation is a pulmonary infiltrate in association with a variety of symptoms indistinguishable from other acute lower respiratory infections (fever, malaise, night sweats, cough, and myalgias). Patients can also present with chronic pneumonia. When dissemination occurs, skin lesions on exposed surfaces are most common. They may evolve into ulcerated verrucous granulomas with an advancing border and central scarring. The border is filled with micro abscesses and has a sharp, sloping edge. Lesions of bone, the genitalia (prostate, epididymis, and testis), and the central nervous system also occur.  TREATMENT Severe cases of blastomycosis are treated with amphotericin B. In patients with confined lesions, a 6-month course of itraconazole is very effective.  PARACOCCIDIOIDOMYCOSIS The disease is caused by Paracoccidioides brasiliensis. Paracoccidioides brasiliensis is inhaled, and initial lesions occur in the lung. Most patients are 30–60 years of age, and over 90% are men.  Clinical findings and Treatment In the usual case of chronic paracoccidioidomycosis, the yeasts spread from the lung to other organs, particularly the skin and mucocutaneous tissue, lymph nodes, spleen, liver, adrenals, and other sites. Many patients present with painful sores involving the oral mucosa Itraconazole appears to be most effective against paracoccidioidomycosis, but ketoconazole and trimethoprim-sulfamethoxazole are also efficacious. Severe disease can be treated with amphotericin B.  OPPORTUNISTIC MYCOSES Fungal infections that occur primarily in individuals with weak immune system and underlying health conditions. Candida and related yeasts are endogenous opportunists Candidiasis, cryptococcosis, aspergillosis, mucormycosis, Pneumocystis pneumonia, and penicilliosis are opportunistic mycosis. CRYPTOCOCCOSIS Caused by Cryptococcus neoformans and Cryptococcus gattii. Cryptococcus neoformans occurs in immunocompetent persons but more often in patients with HIV/AIDS, hematogenous malignancies, and other immunosuppressive conditions. Cryptococcosis due to C gattii is rarer and usually associated with apparently normal hosts Clinical findings The major clinical manifestation is chronic meningitis, which can resemble a brain tumor, brain abscess, degenerative central nervous system diseases. Cerebrospinal fluid pressure and protein may be increased and the cell count elevated, whereas the glucose is normal or low. Patients may complain of headache, neck stiffness, and disorientation. There may be lesions in skin, lungs, or other organs.  Treatment Combination therapy of amphotericin B and flucytosine has been considered the standard treatment for cryptococcal meningitis. Amphotericin B (with or without flucytosine) is curative in non-AIDS most patients. Inadequately treated AIDS patients will almost always relapse when amphotericin B is withdrawn and require suppressive therapy with fluconazole, which offers excellent penetration of the central nervous system. PNEUMOCYSTIS PNEUMONIA Pneumocystis jiroveci causes pneumonia in immunocompromised patients; dissemination is rare. Prior to the introduction of effective chemoprophylactic regimens, it was a major cause of death among AIDS patients. Chemoprophylaxis has resulted in a dramatic decrease in the incidence of pneumonia, but infections are increasing in other organs, primarily the spleen, lymph nodes, and bone marrow. Acute cases of Pneumocystis pneumonia are treated with trimethoprim- sulfamethoxazole or pentamidine isethionate. Prophylaxis can be achieved with daily trimethoprim sulfamethoxazole or aerosolized pentamidine.  Aspergillosis: Caused by Aspergillus species, a type of mold that can cause respiratory infections and allergic reactions. A fumigatus is the most common human pathogen, but many others, including A flavus, A niger, A terreus, and A lentulus may cause disease. The clinical findings are TREATMENT Aspergilloma is treated with itraconazole or amphotericin B and surgery. Invasive aspergillosis requires rapid administration of either the native or lipid formulation of amphotericin B or voriconazole. The less severe chronic necrotizing pulmonary disease may be treatable with voriconazole or itraconazole. Allergic forms of aspergillosis are treated with corticosteroids or disodium cromoglycate.  Candidiasis: Caused by Candida species, a type of yeast that is normally present on the skin and mucous membranes but can overgrow and cause infection, especially in immunocompromised individuals.  Transmission Inhalation: Most systemic mycoses are acquired through inhalation of fungal spores from the environment. Direct contact: In some cases, the infection can spread through direct contact with contaminated soil or surfaces. Immunocompromise: People with weakened immune systems are at increased risk of developing systemic mycoses. Clinical Presentation/Signs and Symptoms Fever: A common symptom of many systemic mycoses. Cough: Often present in pulmonary infections. Chest pain: May occur due to lung involvement. Skin lesions: Can develop in some cases.  Complications: Disseminated disease: The infection can spread to multiple organs, including the brain, kidneys, and liver. Organ failure: Severe infections can lead to organ failure and death. Chronic disease: Some systemic mycoses can cause chronic infections that require long-term treatment. NOTE 1. Subcutaneous mycoses may be caused by dozens of environmental molds associated with vegetation and soil. 2. These infections are usually acquired when minor cuts or scratches introduce soil or plant debris (eg, splinters, thorns) containing the pathogenic fungus. The ensuing infections are frequently chronic but rarely spread to deeper tissues. 3. Sporothrix schenckii, the cause of sporotrichosis, is a dimorphic fungus that converts from hyphal growth to yeast cells within the host. 4. The diagnostic feature of chromoblastomycosis is the microscopic observation of brownish (melanized), spherical sclerotic bodies within the lesions. 5. The diagnostic feature of phaeohyphomycosis is the presence of brownish (melanized), septate hyphae within the lesions. 6. The hallmark of a mycetoma is localized swelling and the formation of fistulae that contain hard granules composed of hyphae and inflammatory tissue (eg, macrophages, fibrin). Clinical Presentation/Signs and Symptoms: Candidiasis: Can affect various parts of the body, including the mouth (oral thrush), esophagus, vagina, and bloodstream. Aspergillosis: Can cause respiratory infections, including pneumonia and invasive aspergillosis. Zygomycosis: Can cause rapidly progressing infections, often affecting the sinuses, lungs, and brain. Cryptococcosis: Can cause pneumonia and meningitis. Pneumocystis pneumonia: Can cause severe respiratory symptoms, including shortness of breath and cough. Complications: Disseminated disease: The infection can spread to multiple organs. Organ failure: Severe infections can lead to organ failure and death.  Increased mortality: Opportunistic mycoses are a significant cause of morbidity and mortality in immunocompromised individuals. NOTE; 1. Opportunistic mycoses are caused by globally distributed fungi that are either members of the human microbiota, such as Candida species, or environmental yeasts and molds. Among the categories of fungal infections, the incidence, severity, and mortality of systemic opportunistic mycoses are the highest. 2. Innate host defences (e.g., neutrophils, monocytes) provide crucial protection from systemic candidiasis, invasive aspergillosis, and mucormycosis. Patients at risk include those with hematologic dyscrasias (eg, leukemia, neutropenia) as well as those treated with immunosuppressive (eg, corticosteroid) or cytotoxic drugs. 3. Most patients with HIV/AIDS develop mucosal candidiasis (eg, thrush, esophagitis). Those with CD4 counts less than 100 cells/μL are at risk for cryptococcosis, Pneumocystis pneumonia, aspergillosis, penicilliosis, endemic mycoses, and other infections. 4. The diagnosis of invasive aspergillosis or candidiasis is often difficult because blood cultures are invariably negative in patients with aspergillosis, and less than 50% are positive in patients with systemic candidiasis. 5. Successful management of opportunistic mycoses involves early diagnosis, rapid administration of appropriate antifungal therapy, and control of the underlying condition or disease MYCOTOXICOSIS…… Mycotoxicosis refers to illnesses caused by the ingestion of mycotoxins, which are toxic secondary metabolites produced by certain fungi. Causative agents Alfatoxins: Produced by aspergillus flavus and A. parasiticus. Found in contaminated food and feed, such as peanuts,corn and tree nuts.  Ochratoxins: Produced by Aspergillus and Penicillium species. Found in cereals, coffee, and wine. Ergot alkaloids: Produced by Claviceps purpurea. Found in contaminated grains, especially rye. Trichothecenes: Produced by Fusarium species. Found in grains, cereals, and feed. Zearalenone: Produced by Fusarium species. Found in corn and other grains.  Transmission Primarily through the ingestion of contaminated food or feed. Inhalation of contaminated dust or spores can also occur in occupational settings. Clinical Presentation/Signs and Symptoms Aflatoxicosis: Liver damage, cancer (liver, kidney), immunosuppression. Ochratoxicosis: Kidney damage, immunosuppression, neurotoxicity. Ergotism: Vasospasm, gangrene, hallucinations, convulsions. Trichothecenes: Vomiting, diarrhea, skin irritation, immunosuppression. Zearalenone: Estrogenic effects, reproductive problems. Complications: Liver damage Kidney damage Cancer Neurotoxicity Immunosuppression Reproductive problems  Other Important Information: Mycotoxins can contaminate a wide range of food and feed products. Proper food storage and handling practices are crucial to minimize mycotoxin contamination. Mycotoxins can pose a significant risk to human and animal health. Fungal Allergies…….. Fungal allergies:occur when the immune system overreact to exposure to fungal spores or other fungal components. Causative Agents: Mold spores: Common indoor and outdoor molds include Alternaria, Cladosporium, Penicillium, and Aspergillus. Yeast cells: Candida albicans is a common yeast that can cause allergies. Transmission: Inhalation of fungal spores from the air. Contact with mold-contaminated surfaces. Ingestion of certain fungi (less common). Clinical Presentation/Signs and Symptoms: Allergic rhinitis: Sneezing, runny nose, itchy eyes, nasal congestion. Asthma: Wheezing, coughing, shortness of breath. Skin allergies: Itchy rash, hives. Sinusitis: Sinus congestion, pain, and pressure. Complications: Chronic sinusitis Asthma exacerbations NOTE; Fungal allergies are common and can significantly impact a person's quality of life. Avoidance of mold exposure is key in managing fungal allergies. Allergy medications, such as antihistamines and corticosteroids, can help manage symptoms. In some cases, immunotherapy (allergy shots) may be beneficial. PHARMACOLOGICAL MANAGEMENT OF MYCOSIS…. 1 Tinea Corporis (Body Ringworm) Pharmacological Treatment A: benzoic acid compound ointment (topical) 12hourly up to 2weeks. OR C: miconazole cream (topical) 2%, apply thinly 12hourly a day. Continue for 5-7days after clearing of lesions. OR C: terbinafine cream (topical) 12hourly for 2weeks If extensive, use C: terbinafine (PO) 250mg 24hourly for 2weeks 2 Tinea Capitis Pharmacological Treatment C: miconazole cream (topical) 2%, apply thinly 12hourly for 2weeks. Continue for 5-7days after clearing of lesions AND A: griseofulvin (PO): Adult 500 mg; Paediatric 10- 20mg/kg 24hourly for 6-8weeks OR C: terbinafine (PO): Adult 250mg 24hourly 6- 8weeks; paediatric 62.5mg/ 10-20kg 24 hourly; 125mg/ 21-40 kg 24 hourly; 250mg/ 41kg 24hourly 3.Pityriasis Versicolor Pharmacological Treatment A: clotrimazole cream (topical) 12hourly for 2weeks OR C: miconazole nitrate cream (topical) 2% 12hourly for 2weeks OR C: ketoconazole shampoo 3times per week for 4weeks (if extensive) AND A: fluconazole (PO) 300mg stat OR D: itraconazole (PO)200mg 24hourly for 2weeks.4 Tinea Pedis (Athlete’s Foot) and Tinea Cruris Prevention and Non-Pharmacological Treatment Frequent change of socks/footwear, underwear. Use of cotton socks, underwear. Keep as dry as possible the spaces between toes after bathing always. Separating the opposing skin surfaces (e.g. with a piece of gauze) will help speeding healing. Pharmacological Treatment A: clotrimazole cream (topical) 1% apply 12hourly for 2weeks OR C: miconazole cream (topical) 2%apply 12hourly for 2weeks OR C: terbinafine cream (topical) 24hourly for 14days AND A: gentian violet 24hourly for 14days for bacterial super infection Alternatively C: terbinafine (PO) 250mg 24hourly for 2- 4weeks OR D: itraconazole (PO) 200mg 24hourly for 2-4weeks 5.Candidiasis Pharmacological Treatment Cutaneous candidiasis A: clotrimazole cream (topical) 1% apply 12hourly for 2weeks OR C: miconazole cream (topical) 2% apply 12hourly for 2weeks OR Oral candidiasis A: nystatin oral suspension - gurgle and swallow 6hourly a day Newborns: 200,000–400,000 Units for 24 hours 2 years old 1,000,000–2,000,000 Units for 24 hours OR C: miconazole 2 % oral gel apply every 8hourly for 7days Vaginal candidiasis A: clotrimazole vaginal pessaries; insert one at night for 6days OR C: miconazole vaginal pessaries insert one at night for 3day AND (if severe) A: fluconazole (PO) 150mg stat Gastrointestinal Tract (GIT) candidiasis A: fluconazole (PO) 150mg 24hourly for 14days.6 Onychomycosis Pharmacological Treatment A: fluconazole (PO) 150-300mg once weekly for 6– 12months OR C: terbinafine (PO) 250mg 24hourly for 6- 8weeks. For toe nails the duration of treatment is generally 12–16weeks. OR D: itraconazole (PO) 200mg 12hourly for 7days is given as pulsed dosing, of each month for 6months 7. Chromoblastomycosis Pharmacological Treatment D: itraconazole (PO) 200mg 24hourly for 6-9months.8 Mycetoma (Madura Foot) Treatment of Actinomycetoma (bacteria form) Pharmacological Treatment A: co-trimoxazole (PO) 480mg–960mg 12hourly for 5weeks AND S: amikacin 7.5mg/kg 12hourly for 5weeks Alternatively A: co-trimoxazole (PO) 480mg–960 mg 12hourly for 5weeks AND S: dapsone (PO): adult 100mg 24hourly for 2–4months; Paediatric 25–50mg 24hourly for 5weeks Treatment of Eumycetoma (Fungi form) Non-pharmacological Treatment Surgery where indicated Footwear and protective clothing in at-risk populations e.g. cattle herders Pharmacological Treatment D: itraconazole (PO) 200mg 12hourly for 5weeks or longer (up to a year) END