Fungal Infections and Warts PDF

Fungal Infections - Most fungal infections are caused by a barrier breakdown in either the skin or nail - Usually superficial - tinea= dermatophyte infections Tinea capitis= scalp Tinea cruris= groin Tinea corporis= body Tinea pedis= feet Tinea unguium= nails - T...

Fungal Infections - Most fungal infections are caused by a barrier breakdown in either the skin or nail - Usually superficial - tinea= dermatophyte infections Tinea capitis= scalp Tinea cruris= groin Tinea corporis= body Tinea pedis= feet Tinea unguium= nails - Trauma to the skin infected is significantly more important/ worse than just exposure to pathogens - Environmental factors can affect - Such as shoes - Climate: humidity - Sweating and wearing wet clothes make it worse - Public pools; Bathing facilities - Diabetes, autoimmune diseases, immunosuppressive drugs, impaired circulation, poor hygiene and poor nutrition are associated with tinea infections - More prone to tinea infections - Most prevalent cases are tinea pedis - Athletes foot - More common in adults - Can be transmitted through foot to foot contact - High impact sports can cause chronic trauma to the foot - Long distance running - Soccer - Those who wear sandals are less likely to develop athlete's foot - Tinea unguium= ringworm of the nails= onychomycosis - EXCLUSION FOR SELF CARE - Associated with tinea pedis - NO APPROVED TOPICAL SELF-TREATMENT FOR ONYCHOMYCOSIS - Must be treated with systemic Rx therapy, Rx combo topical and systemic oral therapy or removal of infected nail - 2 most common infections= tinea corporis and tinea cruris - Tinea corporis= ringworm of the body - Most common in prepubescent age - Wrestling is commonly transmitted - Prevalent in adults and children who live in hot, humid climates - Those under stress, overweight or immunosuppressed are at most risk - Tinea cruris= jock itch - Red rash, pruritic, most common during warm weather - Sweating, prolonged contact with wet clothing  - 3x more common in men than women - Women are much less likely to get infected than men - Tinea capitis= ringworm of the scalp - Mostly in children/ most common dermatophyte infection in children - Black female children are the most likely to get it - Spread by direct contact - Mostly spreads by infected combs, brushes, toys, telephones, towels, linens - Can be through cats and dogs - Cannot be managed with non-Rx - NEED AN RX - Trichophyton is the most common species of pathogenic fungi - Red, scaly borders, clear centers and ring-shaped - Stages of Infection - Incubation period - Dermatophyte grows in stratum corneum - Minimal signs of infection - Adherence and penetration - Refractory period - Involution Size & duration of lesions= growth rate of the organism and epidermal turnover rate The fungal growth rate must equal or exceed the epidermal growth turnover rate; otherwise the organism will be quickly shed Criterion Fungal Skin Infection Contact Dermatitis Bacterial Skin Infection Location On or in areas of the body where Any area of the body Anywhere on the body excess moisture accumulates, exposed to the such as the feet, groin, scalp, and allergen/irritant; hands, underarms face, legs, ears, eyes, and anogenital area most often involved Signs Manifests either as soggy Manifests as a variety of Manifests as a variety of malodorous, thickened skin; acute lesions: raised wheals, lesions, from macules to vesicular rash; or fine scaling of fluid-filled vesicles, or both pustules to ulcers with affected area with a variable surrounding redness; degree of inflammation; cracks lesions often warmer than and fissures in more severe cases surrounding, unaffected skin Symptoms Itching and pain Itching and pain Irritation and pain Distribution Usually localized to a single Affects all areas of Usually localized to a single region of the body but can spread exposed skin but does not region of the body but can spread spread  Timing Variable onset after exposure Variable onset from Variable onset after immediately after exposure exposure to 3 weeks after contact Cause Superficial fungal infection Exposure to skin irritants Superficial bacterial or allergens infection Modifying factors Treated with nonprescription Treated with topical Treated with prescription astringents, antifungals, and antipruritics, skin antibiotics nondrug measures to keep the protectants, astringents, area clean and dry and nondrug measures to avoid reexposure Tinea Pedis Tinea Unguium Tinea Corporis Tinea Cruris Tinea Capitis Species/ Chronic interdigital Non-inflammatory Types Chronic Inflammatory hyperkeratotic Black Dot Vesicular Favus Acute Ulcerative Presentation Chronic - lose their shiny - lesions involve - more common in Non-inflammatory interdigital luster and become glabrous (smooth males - legions begin as - fissuring, scaling opaque and bare) skin - occurs on medial small papules or maceration in - if left untreated → - begin as small, and upper parts of surrounding hair between fingers nail becomes thick, circular scaly areas thighs and pubic shafts - sole of foot or rough, yellow, and - lesions spread areas - scaling of the instep of foot friable peripherally and - small vesicles scalp Chronic - nail may separate may contain seen at crevices - little inflammation hyperkeratotic from nail bed vesicles or pustules - acute lesions are - dull in grey color, - both feet involved - nail may need to - very itchy bright red, fine usually break off of - mild inflammation be removed - occurs any area of scaling is pregnant scalp - scaling - things getting the body - bilateral condition Inflammatory - soles and lateral/ under the nails may - location of - do NOT spread to - pustules to kerion medial of feet be a problem for dermatophyte can penis/ scrotum formation - one or more infection lead to what caused - pain is very - weeping lesions toenails often occur the infection common - Form thick crust Vesicular on the scalp - T. mentagrophytes Black dot - small vesicles hair breaks off shaft - near instep and - black dots on the mid-anterior of foot scalp - scaling on toe - hair loss webs - inflammation - SUMMER! - challenging to Acute Ulcerative diagnose - least common Favus - Weeping - patchy areas of ulcerations of the hair loss sole of foot - yellow crust and - ODOR scales (scutula)  - thickening of outer - can take over a layer of skin major part of the - overgrowth of scalp gram negative - secondary - extremely painful, bacterial infections erosive and are very common impedes the ability Such as scarring to walk and permanent hair loss Aggravating Hyperhidrosis Dirt getting under Bad body hygiene Excess sweating Bad hygiene factors Sweaty feet the nails Bad hygiene Treatment Goals - Do not have significant impact on mortality - Can be difficult to treat and can cause chronic lesions and decrease quality of life 1. Provide symptomatic relief 2. Eradicate existing infection 3. Prevent future infections - Tinea pedis, Tinea corporis, and Tinea cruris can be treated with NON RX antifungal and non Rx measures - Tinea unguium and Tinea capitis NEED to be referred - ADHERENCE IS KEY - Most treatments take 2-6 weeks to work Pharmacologic Therapy - Clotrimazole, miconazole, nitrate, terbinafine hydrochlorate, butenafine HCl, tolnaftate and undecylenic acid are SAFE for non- Rx topical agents for treatment of skin fungal infections - Rare cases of burning, mild skin irritation, and stinging have occurred w/ use of non-Rx topical antifungals - Nystatin (Rx only) is only effective for yeasts, NOT tinea infections Clotrimazole and Miconazole Nitrate - Imidazole derivatives - Act by inhibiting the biosynthesis of ergosterol and other sterols by damaging fungal cell wall membrane - 1% clotrimazole and 2% miconazole nitrate are safe and effective for topical non-Rx - Treats tinea pedis, tinea cruris and tinea coproris - Apply twice daily - For ringworm and athletes foot, apply twice daily for 4 weeks - For jock itch, apply twice daily for 2 weeks - Do not coadminister miconazole and warfarin  Terbinafine Hcl - 1% strength - Allylamine antifungal agent that inhibits squalene epoxidase - Causes fungal cell death - Treats tinea pedis, tinea cruris and tinea coproris - Apply twice daily to affected area - Cures tinea pedis within 1 week - Complete resolution of symptoms can be shown in 4 weeks - Athletes foot on toes= apply twice daily for 1 week - Athletes foot on bottom of feet= apply twice daily for 2 weeks - Jock itch and ringworm= apply once daily for 1 week Side effects= irritation, burning and itchy/ dryness Butenafine HCl - 1% - MOA same as terbinafine - Treats tinea pedis between toes, tinea cruris and tinea corporis - Relieves itching, burning, cracking and scaling - Tinea pedis= apply thin layer between toes twice daily for 1 week or once daily for 4 weeks - Tinea cruris and tinea coproris= apply a thin film to affected area once daily for 2 weeks Side effects= burning and itching Tolnaftate - Treatment of tinea pedis, tinea cruris and tinea corporis - Only non Rx approved for preventing and treating tinea infections - Valuable in treating dry, scaly lesions - Adherence is key for this medication as relapse is common - polyethylene glycol 400 - 1% - Superficial fungal therapy - Applied twice daily - Takes 2-4 weeks - Tinea cruris within 2 weeks - Tinea pedis and tinea corpus may take 4-6 weeks - Can be applied to broken skin - May sting Undecylenic - Reduces redness and irritation - 25% - Tinea pedis and corporis= twice daily for 2 weeks - Tinea cruris= applied twice daily for 2 weeks  Adverse effects= local skin irritation, burning Salts of Aluminum - Not FDA approved for fungal infections - Provide relief for inflammatory conditions of the skin, such as tinea pedis - Good for acute, inflammatory type and the wet, soggy type of tinea pedis - Not a cure for athlete's foot but useful - Changes to dry athlete's foot so other medications can be used - Whole foot can be immersed in solution for 20 mins up to 3x a day - Or as a wet dressing - Can be dissolved in water - 20-30% Creams and solutions are the most efficient Complementary Therapies - Bitter orange - Least evidence - Tea tree oil - Neutral results - Garlic - Positive results Self-Care Exclusions - Cause unclear - Unsuccessful initial treatment - Worsening condition - Nails or scalp involves - Signs of secondary infection - Serious inflammation - Bleeding - Diabetes, systemic infection, immunocompromised - Fever, malaise or both Trade Name Active Ingredient Indications for Use Directions for Use Desenex Antifungal Miconazole 2% For adults and children older For jock itch and ringworm, apply Powder than 2 years of age twice daily for 2 weeks. For athlete’s foot, apply twice daily for 4 weeks. Lotrimin AF Jock Miconazole 2% For adults and children older For athlete’s foot and ringworm, Itch Antifungal than 2 years of age apply twice daily for 4 weeks. Powder Spray For jock itch, apply twice daily for 2 weeks. Micatin Antifungal Miconazole 2% For adults and children 2 years For athlete’s foot and ringworm, Cream of age and older apply twice daily for 4 weeks. For jock itch, apply twice daily for 2 weeks. Lotrimin AF Clotrimazole 1% For adults and children 2 years For athlete’s foot and ringworm, Clotrimazole Jock of age and older apply twice daily for 4 weeks. Itch Cream For jock itch, apply daily for 2 weeks. Lotrimin Ultra Jock Butenafine 1% For adults and children 12 years For athlete's foot between the toes, Itch Cream and older apply twice daily for 1 week, or once daily for 4 weeks. For jock itch and ringworm, apply once daily for 2 weeks. Lamisil AT (cream, Terbinafine 1% For adults and children 12 years For athlete’s foot between the toes, spray) and older apply twice daily for 1 week. For jock itch and ringworm, apply once daily for 1 week. Tinactin Athlete’s Tolnaftate 1% For adults and children 2 years For athlete’s foot and ringworm, Foot Cream of age and older apply daily for 4 weeks. For jock itch, apply daily for 2 weeks. Tinactin Powder Tolnaftate 1% For adults and children 2 years For athlete’s foot and ringworm, Spray of age and older spray twice daily for 4 weeks. For prevention, spray 1–2 times daily. Fungicure (solution, Undecylenic acid 10%, 22%, 25% For adults 18 years of age and For ringworm and athlete’s foot, cream) older apply twice daily for 4 weeks. Hypercare Aluminum chloride For adults with hyperhidrosis Apply daily at bedtime; once excessive sweating has stopped, decrease to once or twice weekly or as needed. Domeboro Aluminum acetate Temporary relief of minor skin Soak: Soak affected area in irritation solution for 15–30 minutes as needed. May repeat 3 times daily. Wet dressing: Soak a clean, soft, white cloth in solution and apply loosely to affected area for 15–30 minutes; may repeat as needed for 4 to 8 hours. Non- Pharm Therapy - Keep the skin clean and dry - Avoid sharing personal articles - Avoid contact w infected areas or other fungal infections - Odor controlling insoles  Key Points - Tinea corporis, tinea cruris and tinea pedis can be treated with non prescription drugs - Ex. clotrimazole, miconazole nitrate, terbinafine HCl, butenafine HCl, tolnaftate and undecylenic acid - Effectiveness of topical antifungals will be limited unless the pt eliminates other predisposing factors prior to tinea infections - Drugs are effective in all available delivery vehicles but powders are for extremely mild conditions of adjunctive therapy - Because solutions and creams can be spread beyond affected area, they should be used sparingly - Suspected and actual dermatophytosis= once or twice daily for 1-4 weeks - Adherence is key - To tell pt that recurrence is common and it will not go away overnight - Dermatophytes in diabetic patients and immunocompromised need to be watched by professional - The only antifungal approved for athletes foot is tolnaftate Warts - Caused by HPV pathogen - More common in adolescents within 12-16 years of age - Person to person contact, contaminated surfaces - Incubation period may be months - Risk for: immunocompromised, chronic skin condition, barefoot, swimming pools, public showers, meat-handling facilities and biting the nails - HPV 2,4 and 27 are common on the hands - HPV 1 is most common on the feet Wart Type Common Location Population(s) Characteristics Self-Treatable Commonly Affected Common (verruca Hands Children and Skin-colored or brown, Yes vulgaris) adolescents dome-shaped, hyperkeratotic papules with a rough surface Flat (verruca plana) Face Children Smooth, flat-topped, No yellow-brown papules; common in children but rare in adults Plantar (verruca Feet Adolescents and young Skin-colored, flat, Yes plantaris) adults callus-like, hyperkeratotic lesions with disruption of normal  skin markings; located on the feet Mosaic Feet Adolescents and young Multiple, closely grouped No adults plantar warts Periungual Nails Persons who bite their Thickened, fissured, No nails cauliflower-textured skin around the nail plate Filiform Face Flesh-colored, rapidly No growing, with threadlike projections Treatment - Not universal - There is NO CURE Goals 1. Eliminate associated signs and symptoms 2. Remove lesion without scarring 3. Prevent recurrence of the warts 4. Prevent spread of HPV through autoinoculation or transmission to others Optimal treatment depends on the patients age, type, number, size, location duration of lesions, immune status, cost of therapy, access to therapy, adverse effects and treatment preference Non-Pharmacological Therapy - Focuses on preventing the spread - Avoid cutting, shaving, or picking at warts - Wash hands before and after touching other parts of the body - Avoid sharing towels, razors, socks, shoes - Keep wart covered - Don’t walk barefoot - Lambs wool or moleskin can help with plantar warts Pharmacological Therapy Salicylic Acid - Common and plantar warts - 17% liquid - common - 40% plastar, pads, strips and sticks  - Plantar Trade Name Primary Ingredient(s) Compound W One Step Pads Salicylic acid 40% Curad Mediplast Pads Salicylic acid 40% Dr. Scholl’s Clear Away One Step Clear Strips Salicylic acid 40% DuoFilm Wart Remover Patch Salicylic acid 40% WartStick Salicylic acid 40% Compound W Fast Acting Wart Removal Gel Salicylic acid 17% Compound W Fast Acting Wart Removal Liquid Salicylic acid 17% Dr. Scholl’s Clear Away Fast-Acting Liquid Salicylic acid 17% DuoFilm Liquid Wart Remover Salicylic acid 17% Compound W Freeze Off Wart Removal System Cryotherapy: Dimethyl ether; propane Compound W Freeze Off Advanced Cryotherapy: Dimethyl ether; propane Dr. Scholl’s Freeze Away Wart Remover Cryotherapy: Dimethyl ether; propane Wartner Cryogenic Wart Removal System Cryotherapy: Dimethyl ether; propane Compound W NitroFreeze Cryotherapy: Nitrous oxide - Salicylic acid destroys virus-infected cells - Disadvantage = constant and frequent application - Skin irritation - Potential of damaged skin around the wart - Potential for systemic toxicity - Warts decrease in size within the first few weeks - Do not exceed past 12 weeks of treatment  General Guidelines Wash hands before and after use. Before treatment, soak the affected area in warm water for 5 minutes. Wash and dry the affected area thoroughly. Salicylic Acid 40% Plasters/Pads/Strips/Sticks14 Trim a plaster to fit the wart, apply plaster, and cover with an occlusive tape; apply disc of appropriate size to wart and cover with pad; apply strip to wart, making sure the disc in the strip does not touch healthy tissue; or apply stick to wart, making sure the stick is not on healthy tissue, and bandage or cover. Remove plaster/pad/strip/stick after 48 hours. Repeat procedure every 48 hours as needed until the wart resolves. These products may be used for up to 12 weeks. Salicylic Acid 17% Liquid/Gel15,16 Apply 1 drop at a time to cover the wart. Protect adjacent healthy skin from coming into contact with the gel. Let solution dry completely. Cover wart with self-adhesive discs or an occlusive tape. Repeat procedure 1–2 times a day until the wart resolves. This product may be used for up to 12 weeks. Cryotherapy - Liquid nitrogen - Freezes the tissue and destroys the HPV keratinocytes - Causes local inflammation - The preparation is applied directly to the wart - A blister will form under the wart and it will fall off in 10 days - Cannot use an applicator more than once - Not any more effective than salicylic acid - More effective for hands than salicylic acid - Treat warts every 2-3 weeks for best results - Max 3 sessions in 12 weeks General Guidelines Wash hands before and after use. Before treatment, soak the affected area in warm water for 5 minutes. Wash and dry the affected area thoroughly. May use a file or pumice stone to lightly abrade the surface of plantar warts. Do not hold the cryotherapy product canister close to the face, body, or clothing. These products are flammable. Do not use near heat sources. Application:  ​ – Prepare the device (refer to product-specific instructions). ​ – Activate the device (refer to product-specific instructions). ​ – Apply to the wart until a “halo” appears around the wart (refer to instructions). ​ – Approximately 20 seconds for common warts ​ – Approximately 40 seconds for plantar warts Discard single-use applicators after one use. Repeat after 2 weeks if needed. This product may be used for up to 3 treatments. Special populations Pregnancy - Do not use salicylic acid - Refer to MD Lactation - Do not use in lactation - Refer to MD Children - NOT FOR UNDER 3 YEARS OLD - Salicylic Acid should not be used in those recovering from flu or chicken pox - Reyes syndrome - Cryotherapy should not be used in those UNDER 4 YEARS OLD Geriatrics - Apply cautiously in those w/ advanced age - Avoid normal skin tissue around the wart Comorbid Conditions - Pt w/ diabetes and poor circulation should not use either product Complementary Therapy - Folklore - Warts are resolved spontaneously without treatment - Not much evidence - Vitamin A - Interferes w/ HPV replication - Not much evidence - Dietary Zinc - Improves immune response - Inhibit HPV replication - 10mg/kg/day - Garlic  - Allium sativum - Inhibit proliferation of infected cells - Resolution of 2-3 weeks and no recurrence - Occlusion w/ Duct Tape - Inexpensive - Less painful - Local irritation - Conflicting results - Good for young children Self Care Exclusions - Under 3 years old for salicylates - Under 4 years old for cryotherapy - Pregnancy or breastfeeding - Mental or physical conditions that limit or affect pt from following product direction - Chronic debilitating conditions - Poor blood circulation - Diabetes - Neuropathy - Immunocompromised - Large or multiple all over body - Bleeding, pain or discolored warts - Painful plantar warts - Warts located on the face, breasts, armpits, fingernails, toenails, anus, genitalia, or mucous membranes - Warts that are not resolved after 12 weeks - Salicylate allergy - Immunosuppressive medications or medications that contradict the use of salicylic acid Key Points - Wait and see approach may be an option - Refer if there are multiple warts - Plantar warts should be treated with 40% salicylic acid - Warts on the hand should be treated with 17% salicylic acid - Nitric oxide and dimethyl ethyl propane are at home treatments - Follow directions carefully - Adverse effects? => refer to MD