Fungal Infections Updated - PPT

FUNGAL INFECTIONS Dr.Barzan Khalid Sharaf. Lecturer in College of Medicine / University of Duhok Fungal Infection Most common type of infection 20 – 25 % worlds population Predisposing Factors  Tropical climate  Manual labour population  Low socioeconomic status  P...

FUNGAL INFECTIONS Dr.Barzan Khalid Sharaf. Lecturer in College of Medicine / University of Duhok Fungal Infection Most common type of infection 20 – 25 % worlds population Predisposing Factors  Tropical climate  Manual labour population  Low socioeconomic status  Profuse sweating  Friction with clothes, synthetic innerwear  Malnourishment  Immunosuppressed patients HIV, Congenital Immunodeficiencies, patients on corticosteroids, immunosuppressive drugs, Diabetes  Superficial Cutaneous Fungal Infection Deep Fungal Infection 3 Genera : Microsporum Trichophyton Epidermophyton Superficial Infections: I. T. Capitis II. T. Barbae III. T. Faciei IV. T. Corporis V. T. Manuum VI. T. Pedis VII. T. Cruris VIII. Onychomycosis I Tinea Capitis ( Scalp Ringworm Invasion ) a dermatophyte fungus of a hair shaft by Mainly in children; rare after puberty because sebum is fungistatic Boys > Girls Wide spectrum of lesions: few dull grey broken off hairs, with little scaling to severe, painful inflammatory mass Partial hair loss is common in all type 4 Varieties Gray Patch (Ectothrix ) Black Dot ( Endothrix ) Favus Kerion I Tinea Capitis - Grey Patch ( Ectothrix ) Non inflammatory type Etiology: Microsporum spp Patches of partial hair loss- often circular in shape Hairs – dull and grey – easily pluckable Tinea Capitis - Grey Patch ( Ectothrix ) I Tinea Capitis - Black Dot ( Endothrix ) Endothrix organisms Hair shaft is brittle Broken off hairs – black dot Inflammation is minimal Wood’s Lamp examination: green fluorescence Tinea Capitis - Black Dot ( Endothrix ) I Tinea Capitis - Kerion Inflammatory type Painful, boggy swelling with purulent discharge Vesicles and pustules Thick crusting with matting of hair Lymphadenopathy Secondary bacterial infection Heals with scarring I Tinea Capitis - Favus Inflammatory type Begins early in life Yellow, cup shaped crust – scutulum Concavity faces upwards Mousy odor Hair may be matted Extensive patchy hairloss with cicatricial alopecia II Tinea Barbae – T.Sycosis, Barber’s Itch Ringworm of beard & moustache area Disease of adult males Invasion of coarse hairs Inflammatory papulopustules, seropurulent discharge Hairs- easily epilated Simulate bacterial folliculitis Diagnosis- confirmed by KOH mount Tinea Barbae III Tinea Faciei Dermatophyte infection on non bearded area of face Burning, itching & photosensitivity Erythematous scaly patches Extends peripherally- raised border Central area- hypopigmented or brown Seen often in immunocompromised patients IV Tinea Corporis Dermatophyte infections of skin other than those involving the scalp, beard, face, hands, feet and groin The fungus enters the stratum corneum and spreads centrifugally Tinea Corporis Typical lesion- annular / polycyclic Borders – erythematous, vesicular or scaly Centre – clear, hyperpigmentation Concentric rings may be seen Sites: Waist, under breasts, abdomen, thighs, etc. Differential Diagnosis of T. Corporis Psoriasis Lichen Simplex Chronicus Pityriaisis Rosea Candidiasis Nummular eczema Tertiary Syphilis Annular lesions of Leprosy V Tinea Manuum Ringworm of palmar skin Commonly occurs in adults, in males 2 main clinical types: (1) Non inflammatory squamous form  Most common clinical presentation  Hyperkeratosis of palms and fingers  Accentuation of flexural creases  Association – hyperhidrosis (2) Inflammatory vesicular / dyshidrotic / eczematous form:  Uncommon in temperate climates  Vesicles occur-mainly on palms  Itchy  Heal spontaneously VI Tinea Pedis ( Athlete’s Foot ) Dermatophyte infection of the feet Most common fungal infection worldwide 30-70 % of population in developed countries Wearing of shoes and resultant maceration Adult males commonest VI Tinea Pedis ( Athlete’s Foot ) 4 clinically accepted variants: (1) The chronic intertriginous type commonest type fissuring, scaling or maceration lateral 3rd & 4th toe webs (2) Chronic papulosquamous type inflammation patchy ‘mocassin like’ scaling over soles (3)Vesicular or vesiculobullous type small vesicles/ vesiculopustules- seen at instep and mid anterior plantar surface Associated with scaling (4) Acute ulcerative variant Maceration, weeping and ulceration of the soles often complicated by secondary infections VI Tinea Pedis-Prevention  Keeping toes dry  Not walking barefoot on the floors of communal changing rooms  Avoiding swimming baths.  Avoid closed shoes  Avoid nylon socks  Use of antifungal powders VII Tinea Cruris ( Dhobi’s itch, Jock itch ) Dermatophytic infection of the groins Itching Sharply demarcated, erythematous advancing annular skin rash Extends from groins to the thighs  Scaling is variable, and occasionally may mask the inflammatory changes.  Vesiculation is rare VIII Onychomycosis Infection of nail caused by fungus Common infection 20 % of all nail diseases Incidence is increasing Dirty, dull, dry, pitted, ridged, split, discoloured, thick, uneven, nails with subungual hyperkeratosis Onychomycosis 4 Clinical types ( 1 ) Distal and lateral sunungual Onychomycosis ( 2 ) Proximal Subungual Onychomycosis ( 3 ) White Superficial Onychomycosis ( 4 ) Total Dystrophic Onychomycosis  Distal and lateral sunungual Onychomycosis Most common type 90 % of all fungal nail infection Etiology: T.rubrum Toe nails > finger nails Infection starts in distal nailbed or lateral nailfold, then moves proximally White Superficial Onychomycosis 2nd most common Well circumscribed powdery white patches o nail plate- easily scraped way Surface of nail- rough & friable Proximal Subungual Onychomycosis Least common variant Etiology: T.rubrum 1st clinical sign is a whitish-brownish area on proximal part of nail Early indicator of HIV infection Treatment of Dermatophyte Infections- Topical  Bifonazole, Oxiconazole, Clotrimazole, Miconazole, Butenafine, Terbinafine.  Vehicle: Lotions, creams, powders, gels are available. Treatment of Dermatophyte Infections- Systemic Griseofulvin 250 mg BD Fluconazole 150 mg weekly Terbinafine 250 mg OD Itraconazole 200 mg OD Duration  T.capitis - 6 weeks  T.faciei - 4 weeks  T.cruris - 2-4 weeks  T.corporis - 4-6 weeks  T.manuum/pedis - 6-8 weeks Treatment of Onychomycosis  The same line of Treatment for 3 months (fingernail) 6 months (toenails)  8% Ciclopirox olamine lotions for local application  Amorolfine lacquer painted weekly  Pulse Therapy Terbinafine: 250mg given 1BD 1week / per month Itraconazole: 200mg given 1BD 1week/month 3 pulses for fingernails 4 pulses for toenails. Treatment Principles Dermatophytosis will take 3-4 weeks to resolve and patient should be told about the need for complete treatment. Treat 1 week beyond apparent cure. Need for hygiene, proper clothing. Onychomycosis requires 3-6 months of treatment. Treat 4 weeks beyond apparent cure. Temporary relief should not be mistaken for cure Candidiasis Causative organism: Candida albicans Candida tropicalis Candida pseudotropicalis Sites of affection: Mucous membrane Skin Nails Candidiasis : Mucosal  Oral thrush: Creamy, curd-like, white pseudomembrane, on erythematous base  Sites: Immunocompetent patient: cheeks, gums or the palate. Immunocompromised patients: affection of tongue with extension to pharynx or oesophagus  Angular cheilitis (angular stomatitis / perleche) Soreness at the angles of the mouth Candidiasis : Mucosal Vulvovaginitis (vulvovaginal thrush) Itching and soreness with a thick, creamy white discharge Balanoposthitis: Tiny papules on the glans penis after intercourse, evolve as white pustules or vesicles and rupture. Radial fissures on glans penis in diabetics. Vulvovaginitis in conjugal partner Candidiasis - Flexural Intertrigo (Flexural candidiasis): Erythema and maceration in the folds, axilla, groins and webspaces. Napkin rash: Pustules, with an irregular border and satellite lesions Candidiasis: Nail Chronic Paronychia: Swelling of the nail fold with pain and discharge of pus. Chronic, recurrent. Superadded bacterial infection Onychomycosis: Destruction of nail plate. Treatment of candidiasis Treat predisposing factors like poor hygiene, diabetes, AIDS, conjugal infection Topical Clotrimazole Miconazole Ciclopirox olamine Oral: Itraconazole 100-200mg Fluconazole 150mg Pityriasis versicolor Etiologic agent: Malassezia furfur Common among youth Genetic predisposition, familial occurrence Multiple, discrete, discoloured, macules. Fawn, brown, grey or hypopigmented Pinhead sized to large sheets of discolouration Seborrheic areas, upper half of body: trunk, arms, neck, abdomen. P.versicolor - Investigations Wood’s Lamp examination: Yellow fluorescence KOH preparation: Spaghetti and meatball appearance Coarse mycelium, fragmented to short filaments 2-5 micron wide and up to 2-5 micron long, together with spherical, thick-walled yeasts 2-8 micron in diameter, arranged in grape like fashion. Treatment P. versicolor - Topical Topical Clotrimazole Miconazole Bifonazole, Oxiconazole, Butenafine,Terbinafine, Selenium sulfide, Sodium thiosulphate Oral Fluconazole 400mg single dose Griseofulvin is NOT effective. Hypopigmentation will take weeks to fade Scaling will disappear soon THANK YOU