FUNGAL SKIN INFECTIONS SEEN CLINICALLY

  DERMATOPHYTOSIS TREATMENT

DR. PUTU SISKA VIRGAYANTI, SPKK

  

FUNGAL SKIN INFECTIONS SEEN CLINICALLY

• TINEA, OR DERMATOPHYTE INFECTION.

  “RINGWORM.”

• TINEA VERSICOLOR, A CUTANEOUS YEAST

INFECTION WITH MALASSEZIA FURFUR

• • CUTANEOUS CANDIDIASIS, A CUTANEOUS YEAST

  INFECTION WITH CANDIDA SPECIES.

CLINICAL MANIFESTATIONS OF RINGWORM INFECTIONS BASED ON LOCATION OF INFECTION SITES

• TINEA CAPITIS - HEAD, SCALP, EYEBROWS, EYELASHES
• TINEA FAVOSA - SCALP (CRUSTY HAIR)
• TINEA CORPORIS - BODY (SMOOTH SKIN)
• TINEA CRURIS - GROIN (JOCK ITCH)
• TINEA UNGUIUM - NAILS
• TINEA BARBAE - BEARD
• TINEA MANUUM - HAND
• TINEA PEDIS - FOOT (ATHLETE'S FOOT)

SPECIES FOUND IN DIFFERENT ANAMORPHIC GENERA

• • MICROSPORUM - INFECTIONS ON SKIN AND HAIR (NOT THE CAUSE OF

  TINEA UNGUIUM)

• • EPIDERMOPHYTON - INFECTIONS ON SKIN AND NAILS (NOT THE CAUSE

  OF TINEA CAPITIS) • TRICHOPHYTON - INFECTIONS ON SKIN, HAIR, AND NAILS.

  (Dermatophyte infection)

5 Practical tips for management

• ^{CLINICAL FEATURES}
• ASYMMETRICAL
• ACTIVE MARGIN WITH CENTRAL CLEARING
• FUNGAL INFECTION ELSEWHERE
• ^{INVESTIGATION}
• SKIN SCRAPING
• NAIL CLIPPING
• ^{MICROSCOPY, CULTURE OR HISTOLOGY}

TINEA PEDIS

• – ATHLETE’S FOOT INFECTION

TINEA CORPORIS

• CLASSIC “RINGWORM”
• TRUNK, EXTREMITIES, FACE
• ELEVATED, SCALY, PRURITIC LESIONS WITH ERYTHEMATOUS EDGE
• ANTHROPOPHILIC AND ZOOPHILIC CAUSES

  MOST COMMON

• T. RUBRUM

  Center for Food Security and Public Health, Iowa State University, 2011

TINEA CORPORIS

• – BODY RINGWORM

TINEA CRURIS

• – JOCK ITCH

TINEA CAPITIS

  

Gray Patch

TINEA UNGUIUM

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• DISTAL AND LATERAL SUBUNGUAL ONYCHOMYCOSIS (DL
• DISCOLOURATION, SUBUNGUAL HYPERKERATOSIS, DISTAL ONYCHOLYSIS

  START AT THE HYPONYCHIUM SPREADING PROXIMALLY

• PROXIMAL SUBUNGUAL ONYCHOMYCOSIS (P
• INVASION OF THE NAIL UNIT UNDER THE PROXIMAL NAIL FOLD AND SPREAD

  DISTALLY

• USUALLY ASSOCIATED WITH IMMUNOSUPPRESSED CONDITIONS, E.G. HIV

  INFECTION

• SUPERFICIAL WHITE ONYCHOMYCOSIS (S
• INVASION OF THE SUPERFICIAL LAYERS OF THE NAIL PLATE BUT DO NOT

  PENETRATE IT LEADING TO A WHITE, CRUMBLY NAIL SURFACE

• TOTAL DYSTROPHIC ONYCHOMYC
• COMPLETE DYSTROPHY OF THE NAIL PLATE

  DIAGNOSIS

• WOOD’S LAMP EXAMINA>DETECTS FLUORESC>POTASSIUM HYDROXIDE MICROS>DETECTS HYPHAE AND CONIDIA IN SKIN SCRAPINGS OR >FUNGAL CULT>REQUIRED TO IDENTIFY ORGA
• SKIN OR NAIL BIOPSIES

  Center for Food Security and Public Health, Iowa State University, 2011

  INVESTIGATIONS

• KOH 10%
• DERMATOPHYTES APPEAR AS TRANSLUCENT BRANCHING, ROD- SHAPED FILAMENTS (HYPHAE) OF UNIFORM WIDTH WITH LINES OF

  SEPARATION (SEPTA) SPANNING THE WIDTH AND APPEARING AT

  IRREGULAR INTERVALS.

MANAGEMENT OF SUPERFICIAL FUNGAL INFECTION:

14 GERNERAL PRINCIPLES

• GENERAL ADVICE: E.G AVOID SHARING OF TOWELS AND CLOTHING; KEEP THE AFFECTED AREAS COOL AND DRY; FREQUENT WASHING OF CLOTHES, LINEN; ETC.
• TOPICAL ANTIFUN>ADVANTAGES OF TOPICAL ANTIFUNGALS VS ORAL ANTIFUNGALS
• LESS RISK OF ADVERSE EFFECTS
• FEWER DRUG INTERACTIONS
• LABORATORY TESTS NOT NEEDED TO MONITOR TREAT>PROLONGED USE OF A STEROID-ANTIFUNGAL CREAM
• _{• MAY CAUSE STRIAE} • MAY NOT CURE THE INFECTION
• SYSTEMIC TREAT>TINEA CAPTITIS & TINEA UNGUIUM
• SEVERE OR EXTENSIVE DISEASE
• FAILED TOPICAL TREATMENT

TOPICAL PREPARATIONS FOR FUNGAL INFECTIONS

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• APPLIED TO THE AFFECTED AREA FOR 2-4 W
• ALLYLAMINE
• TERBINAFINE
• NAFTIFINE
• INCLUDING A MARGIN OF

  SEVERAL CENTIMETRES OF NORMAL SKIN

• CICLOPIROXOLAMINE
• CONTINUE FOR 1 OR 2 WEEKS

  AFTER THE LAST VISIBLE RASH HAS CLEARED

• POLYENES
• NYSTATIN
>AZ>THIOCARBAMATES
• TOLNAFTATE
• TOLCIC
• BIFONAZOLE
• CLOTRIMAZOLE (CANESTEN,

  LOTREMIN)

• ECONAZOLE
• KETOCONAZOLE
• MICONAZOLE (DAKTARIN)
• SULCONAZOLE
>OT
• WHITFIELD'S OINTMENT
• UNDECYLENIC ALKANOLAMIDE

TINEA CAPITIS: TREATMENT

• MICROSCOPY / CULTURE OF SKIN SCRAPINGS RECOMMENDED BEFORE STARTING TREATMENT

16 GRISEOFULVIN

• 500 MG ONCE DAILY OR 250 MG BD; 10-25 MG/KG/D X 8–10WK
• STANDARD TREATMENT IN THE PEDIATRIC POPULATION ^TERBINAFINE
• 250 MG ONCE DAILY X 4/52
• NOT LICENSED FOR TINEA CAPITIS IN THE UK
• FDA APPROVED FOR CHILDREN > 4 YR ( < 25 KG: 125 MG/D; 25-35 KG: 187.5MG/D; > 35KG: 250MG/D) ^{ADJUNCTIVE TREATMENT}
• ^{TOPICAL ANTIFUNGAL TREATMENT 2X/WEEK}
• KETOCONAZOLE SHAMPOO, SELENIUM SULPHIDE SHAMPOO, OR TOPICAL TERBINAFINE CREAM • DURING THE FIRST 2 WEEKS OF TREATMENT TO REDUCE TRANSMISSION. _{ORGANISMS (E.G. MICONAZOLE, CLOTRIMAZOLE, ECONAZOLE)}

  ^{ORAL ANTIBIOTIC E.G. FLUCLOXACILLIN & AN ANTIFUNGAL CREAM ACTIVE AGAINST GRAM (+)}

• FOR SECONDARY INFECTION

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• SEVEN STUDIES, 2163 SUBJECTS
• SUBGROUP ANAL>TERBINAFINE WAS MORE EFFICACIOUS THAN GRISEOFULVIN IN TREATING _{TRICHOPHYTON SPECIES (1.616; 95% CI = 1.274- 2.051; P < 0.001)}
• GRISEOFULVIN WAS MORE EFFICACIOUS THAN TERBINAFINE IN TREATING _{MICROSPORUM SPECIES (0.408; 95% CI = 0.254-0.656; P < 0.001)BOTH GRISEOFULVIN AND TERBINAFINE DEMONSTRATED GOOD SAFETY PROFILES IN THE STUDIES.}

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• SEVEN STUDIES, 2163 SUBJECTS
• SUBGROUP ANAL>TERBINAFINE WAS MORE EFFICACIOUS THAN GRISEOFULVIN IN TREATING TRICHOPHYTON _{SPECIES (1.616; 95% CI = 1.274- 2.051; P < 0.001)}
• GRISEOFULVIN WAS MORE EFFICACIOUS THAN TERBINAFINE IN TREATING MICROSPORUM _{SPECIES (0.408; 95% CI = 0.254-0.656; P < 0.001)BOTH GRISEOFULVIN AND TERBINAFINE DEMONSTRATED GOOD SAFETY PROFILES IN THE STUDIES.}

  TINEA CORPORIS / CRURIS

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• TOPICAL TERBINAFINE (MODERATE EVIDENCE) & TOPICAL IMIDAZOLES (WEAK

  EVIDENCE)

• EFFICACIOUS IN THE TREATMENT OF FUNGAL INFECTIONS OF THE GROIN AND >

  • INSUFFICIENT TRIAL EVIDENCE: SUPERIORITY OF ONE PREPARATION OVER

  ANO
• IMIDAZOLES CURRENTLY THE MOST COMMONLY USED TOPICAL TREATMENTS FOR FUNGAL
INFECTIONS OF THE SKIN<>FOR INFLAMED LES>TOPICAL ANTIFUNGAL COMBINED WITH A MILDLY POTENT CORTICOSTEROID: &lt;= 1 WK
• DO NOT GIVE A CORTICOSTEROID PREPARATION ALONE
• COMBINATION PREPARAT
• BEWARE OF THE INCREASED RISK OF ADVERSE EFFECTS WITH TOPICAL CORTICOSTEROIDS IN OCCLUDED _{AREAS E.G. GROINS}

TINEA PEDIS: TREATMENT

  

20

• • ALLYLAMINES, AZOLES, BUTENAFINE, CICLOPIROXOLAMINE, TOLCICLATE &amp; TOLNAFTATE

• ALL EFFICACIOUS RELATIVE TO PLACEBO IN THE TREATMENT OF TINEA P>ALLYLAMINES
• GREATER EFFECTIVENESS WHEN USED FOR LO>THE EFFECTIVENESS OF AZOLES IMPROVED OVER TIME
• NO DIFFERENCE IN TREATMENT FAILURE RATES BETWEEN ANY OF THE INDIVIDUAL AZ
• ALLYLAMINES MORE EFFICACIOUS THAN AZOLES
• THE META ANALYSIS OF 8 TRIALS AND OUTCOMES FROM 962 PARTICIPANTS SUPPORTS THE FINDING THAT _{ALLYLAMINES ARE MORE EFFECTIVE THAN AZOLES WHEN APPLIED FOR BETWEEN 4 TO 6 WEEKS}

  21

• TERBINAFINE AND ITRACONAZOLE
• MORE EFFECTIVE THAN NO TREATMENT (PLAC>TERBINAFINE (TWO WEEKS TREATMENT)
• MORE EFFECTIVE THAN ITRACONAZOLE (TWO WEEKS TREATM>TERBINAFINE
• MORE EFFECTIVE THAN GRISEOFU>NO SIGNIFICANT DIFFERENCE IN EFFECTIVENESS FOUND BETWEEN:
• TWO WEEKS OF TERBINAFINE VS FOUR WEEKS OF ITRACONAZOLE
• FLUCONAZOLE VS EITHER ITRACONAZOLE OR KETOCONAZOLE
• GRISEOFULVIN AND KETOCONAZOLE _{RECOMMENDATION:}
• DIFFERENT DOSES OF FLUCONAZOLE

TINEA UNGUIUM: TREATMENT

  22

• CONFIRM THE DIAGNOSIS BEFORE TREAT>POSITIVE MICROSCOPY OR CULTURE
• TOPICAL TX WITH AMOROLFINE 5% NAIL LACQUER
• 6 /12 WK (FINGERNAIL)
• 9–12 /12 WK (TOEN>AMOROLFINE 5% NAIL LACQUER 1>NOT APPROVED IN THE USA
• 6% TREATMENT FAILURE RATES FOUND AFTER 1 MONTH OF TREAT
• DATA COLLECTED ON A VERY SMALL SAMPLE OF PEOPLE • THESE HIGH RATES OF SUCCESS MIGHT BE UNRELIABLE.

TINEA UNGUIUM: TREATMENT

• CICLOPIROXOLAMINE 8% NAIL LACQUER>COMBINING DATA FROM 2 TRIALS OF CICLOPIROXOLAMINE VERSUS PLACEBO: _{• THESE OUTCOMES FOLLOWED LONG TREATMENT TIMES (48 WEEKS) • TREATMENT FAILURE RATES: 61% &amp; 64% FOR CICLOPIROXOLAMINE • CICLOPIROXOLAMINE -&gt; A POOR CHOICE FOR NAIL INFECTIONSBUTENAFINE>TREATMENT FAILURE RATE:>USED IN COMBINATION WITH ORAL TREATMENT: INCREASE CURE RATES}

• • NO GOOD EVIDENCE FROM RANDOMIZED CONTROLLED TRIALS ON OTHER

  TOPICAL TREATMENTS FOR DERMATOPHYTE NAIL INFECTIONS: • TOPICAL TIOCONAZOLE / SALICYLIC ACID/ UNDECENOATES.

TINEA UNGUIUM: TREATMENT

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• ORAL TERBINAFINE
• 250 MG DAILY: 6/52 FOR F/N, 12/52 X T/N _{• A META-ANALYSIS OF 18 STUDIES: A MYCOLOGICAL CURE RATE OF 76%.}

  _{• ORAL TERBINAFINE MAY BE MORE EFFECTIVE THAN ORAL ITRACONAZOLE (WEAK EVIDENCE FROM RCTS)}

• FEWER DRUG INTERACTIONS VS. AZOLE ANTIFUNGALS _{• CYP2D6 INHIBITOR: INC. EFFECT OF TCA; BETA BLOCKERS &amp; ANTIPSYCHOTICS (POSSIBLE)}
• ADVERSE EFFECTS: USUALLY MILD AND TRANSIENT _{•ORAL ITRACONAZOLE 200 MG BD X 1 WK PER PULSE, 2 TO 3 PULSES}
• ORAL ITRACONAZOLE MAY BE LESS EFFECTIVE THAN ORAL TERBINAFINE (WEAK EVIDENCE FROM RCTS)

• • A META-ANALYSIS OF 6 STUDIES ON PULSE ITRACONAZOLE: MYCOLOGICAL CURE RATE OF 63%

• PULSED THERAPY RECOMMENDED: _{• RISKS OF ADVERSE EFFECTS MAY BE REDUCED • NO GOOD EVIDENCE THAT IT IS LESS EFFECTIVE THAN CONTINUOUS THERAPY;N.B. THIS DOSING REGIMEN IS NOT LICENSED}
• TAKE WITH FATTY MEAL/ ACIDIC BEVERAGE

TREATMENT PITYRIASIS VERSICOLOR

   _{Lather and leave it on for 10’ then rinse off  For small affected areas:  Imidazole creams 2 –3 weeks}  e.g. clotrimazole, econazole, ketoconazole, or _{ miconazole Systemic Treatment:  } itraconazole 200 mg once daily for 7 days _{fluconazole 50 mg once daily for 2 –4 weeks (licensed) or a 300 mg dose once weekly for 4 weeks (off-label).}

  26 _{ Treat with shampoo}  _{Ketoconazole 2% shampoo once-daily to affected areas for 5/7  Lather and leave it on for 5’ then rinse off  Selenium sulphide 2.5% shampoo once-daily} to the affected areas for 7 days. _{ off-label indication  may cause skin dryness and irritation  Smell: unpleasant}

• CONSIDER PROPHYLACTIC TREATMENT _{• E.G. PRIOR TO EXPOSURE WARM HUMID ENVIRONMENTS OR SUNSHINE}
• ^{KETOCONAZOLE 2% SHAMPOO ONCE DAILY X A} _{MAXIMUM OF 3 DAYS PRIOR TO SUN EXPOSURE • LIMITED EVIDENCE THAT WEEKLY OR MONTHLY} DOSES OF ORAL ANTIFUNGALS ARE EFFECTIVE IN _{PREVENTING RECURRENCE, BUT OPTIMAL REGIMENS HAVE NOT BEEN ESTABLISHED}