Transcript Adult Cutaneous Fungal Infections

Adult Cutaneous Fungal
Infections
Medical Student Core Curriculum
in Dermatology
Last updated May 23, 2011
1
Module Instructions
 The following module contains a number
of blue, underlined terms which are
hyperlinked to the dermatology glossary,
an illustrated interactive guide to clinical
dermatology and dermatopathology.
 We encourage the learner to read all the
hyperlinked information.
2
Goals and Objectives
 The purpose of this module is to help medical students
develop a clinical approach to the evaluation and initial
management of patients presenting with cutaneous fungal
infections.
 By completing this module, the learner will be able to:
• Identify and describe the morphologies of superficial fungal infections
• Describe the correct procedure for performing a KOH examination
and interpreting the results
• Recognize the use and limitations of KOH examination and fungal
cultures to diagnose fungal infections
• Recommend an initial treatment plan for an adult with tinea pedis,
tinea versicolor, candidal intertrigo, and seborrheic dermatitis
3
Superficial Fungal Infections:
The Basics
 Dermatophytoses are estimated to affect 20-25% of people
worldwide, making them one of the most common infections.
 Superficial cutaneous fungal infections are limited to the
epidermis, as opposed to systemic fungal infections (e.g.
endemic mycoses and opportunistic infections).
 Three groups of cutaneous fungi cause superficial infections:
dermatophytes, Malassezia spp., and Candida spp.
 Dermatophytes (which include Trichophyton spp., Microsporum
spp., and Epidermophyton spp.) infect keratinized tissues: the
stratum corneum (outermost epidermal layer), the nail or the hair.
 The term tinea is used for dermatophytoses and is modified
according to the anatomic site of infection, e.g. tinea pedis
4
Case One
Mr. Eugene Brown
5
Case One: History
 HPI: Eugene Brown is a 62-year-old healthy man who
presents to his primary care physician with a one-year
history of itching and burning of his feet.
 PMH: no chronic illnesses or prior hospitalizations
 Medications: none
 Allergies: no known allergies
 Family history: noncontributory
 Social history: lives with wife, works as a banker
 Health-related behaviors: reports no alcohol, tobacco or
drug use
 ROS: increased nocturia, otherwise negative
6
Case One: Skin Exam
 How would you
describe these exam
findings?
7
Case One: Skin Exam
 Erythema and scaling
are present on the
plantar surface and
between the toes
8
Case One, Question 1
 Which of the following is Mr. Brown’s most
likely diagnosis?
a.
b.
c.
d.
e.
Atopic dermatitis
Candidal intertrigo
Onychomycosis
Psoriasis
Tinea pedis
9
9
Case One, Question 1
Answer: e
 Which of the following is Mr. Brown’s most likely
diagnosis?
a. Atopic dermatitis (Characterized by red patches and plaques
± scale. Lichenification may also result)
b. Candida intertrigo (Erythematous, eroded areas with satellite
papules. Less likely location)
c. Onychomycosis (Fungal infection of the nail)
d. Psoriasis (The interdigital and plantar surfaces of the toes
are unusual locations for psoriasis. Would expect a welldemarcated plaque with a thick silvery scale)
e. Tinea Pedis
10
Tinea Pedis: The Basics
 Tinea pedis (“athlete’s foot”) is the most common fungal
infection seen in developed countries, and is most
commonly caused by the fungus Trichophyton rubrum
 Shoes provide an ideal environment for fungus to grow
due to moisture
 Public showers, gyms, and swimming pools are common
sources of infection
 It is difficult to permanently cure and may often recur
 There are three clinical patterns of infection: interdigital,
moccasin, and vesiculobullous type
11
Tinea Pedis: Interdigital Type
 Most common, presents
with scaling and
redness between the
toes and may have
associated maceration.
12
Tinea Pedis: Moccasin Type
 Also known as chronic
hyperkeratotic type.
 Sharply marginated scale,
distributed along lateral
borders of feet, heels, and
soles.
 At times, vesicles and
erythema are present at the
margins.
 Often associated with
onychomycosis (nail fungal
infection).
13
Tinea Pedis: Moccasin Type
 Moccasin type may present as
“one hand, two feet” syndrome.
 Affected hand shows unilateral
fine scaling, particularly in the
creases (see below), and nails
are often involved.
14
Tinea Pedis: Vesiculobullous Type
 Grouped, 2-3 mm
vesicles or bullae are
seen, often on the arch
or instep. They may be
itchy or painful.
 Vesiculobullous type
tinea pedis represents a
delayed hypersensitivity
immune response to a
dermatophyte.
15
Back to Case One
Eugene Brown
16
Case One, Question 2
 Which of the following is the most appropriate
next step in diagnosis?
a.
b.
c.
d.
Begin empiric treatment with antifungals.
KOH exam
Skin biopsy
Wood’s light
17
Case One, Question 2
Answer: b
 Which of the following is the most appropriate next
step in diagnosis?
a. Begin empiric treatment with antifungals (First need a
diagnosis. There are many scaly eruptions that can
occur on the foot)
b. KOH exam
c. Skin biopsy (This is too invasive when a simpler test is
available)
d. Wood’s light (Organisms will not fluoresce on wood’s
light)
18
Case One: KOH Exam
What are the diagnostic features in this KOH exam?
Magnification 40x
19
Case One: KOH Exam
What are the diagnostic features in this KOH exam?
 Parallel walls
throughout the
entire length
 Septated and
branching
hyphae
Magnification 40x
20
KOH Exam: Basic Facts
 KOH microscopy is the easiest and most cost
effective method used to diagnose fungal
infections of the hair, skin, and nail.
 Proper technique requires training.
• Sensitivity is dependent on the operator’s
experience.
 KOH dissolves keratinocytes to allow easy viewing
of hyphae.
 Heat is used to accelerate this reaction.
21
The KOH Exam Procedure
1. Clean and moisten skin with
alcohol swab
2. Collect scale with #15 scalpel
blade
3. Put scale on center of glass
slide
4. Add drop of KOH and
coverslip; heat slide gently with
flame to adequately dissolve
keratin
5. Microscopy: scan at 10X to
locate hyphae; then study in
detail at 40X if needed
Click here to watch the video
Make sure to turn on your computer volume
(video length 8min 41sec)
22
Case One, Question 3
 Which of the following are possible pitfalls
of KOH prep?
a. False negative KOH due to prior partial
treatment with antifungals
b. Misidentification of clothing fibers or lint as
hyphae
c. Possibility of mistaking lipid or cell membranes
for hyphae
d. All of the above are limitations
23
Case One, Question 3
Answer: d
 Which of the following are possible pitfalls of KOH
prep?
a. False negative KOH due to prior partial treatment with
antifungals
b. Misidentification of clothing fibers or lint as hyphae
(clothing fibers or lint are tapered, while hyphae have
parallel walls throughout)
c. Possibility of mistaking lipid or cell membranes for hyphae
(hyphae have parallel walls throughout and tend to be
longer)
d. All of the above are limitations
24
Treatment of Tinea Pedis: Hygiene
 For all types of tinea pedis, hygiene and
topical antifungals are effective first-line
therapies
 Hygiene:
•
•
•
•
Dry the area after bathing
Change socks daily and alternate shoes worn
Consider wearing open shoes such as sandals
Use foot powder (available over the counter) to
keep feet dry
25
Topical Antifungals
 There are several classes of topical antifungal
medications
 Some classes are fungistatic (stop fungi from
growing), others are fungicidal (they kill fungi)
 Not all conditions are treatable with topical
antifungals (specifically, hair infections and nail
infections do not respond to topical treatment
and require systemic treatment)
26
Treatment of Tinea Pedis: Topical
 Topical antifungals: apply until tinea shows resolution,
then continue treatment for a minimum of two weeks
• Imidazoles: Fungistatic
Examples: clotrimazole, miconazole, sulconazole,
oxiconazole, ketoconazole (least activity against
dermatophytes)
• Allylamines: Fungicidal
Examples: terbinafine, butenafine, naftifine
• Ciclopirox: Fungicidal and fungistatic
Example: Ciclopirox olamine
27
Treatment of Tinea Pedis By Type
 Interdigital:
• Topical imidazoles, ciclopirox olamine, and allylamines
 Plantar Moccasin/Chronic Hyperkeratotic:
• Topical allylamines and imidazoles
• Keratolytics are also useful: e.g. salicylic acid, benzoic acid
(Whitfield’s ointment)*, urea, and lactic acid

Vesiculobullous:
• Compresses in conjunction with antifungal agents
• May require an oral agent such as terbinafine or itraconazole
* Whitfield’s
ointment is a combination of salicylic and benzoic acid. In US can be
bought through online pharmacies or compounded.
28
Case One, Question 5
 Which of the following are common
complications of tinea pedis? You may choose
more than one answer.
a.
b.
c.
d.
e.
Deep vein thrombosis
Furunculosis of the lower leg
Lower leg cellulitis
Peripheral neuropathy
Tinea corporis
29
Case One, Question 5
Answer: c & e
 Which of the following are common complications of
tinea pedis?
a. Deep vein thrombosis
b. Furunculosis of the lower leg
c. Lower leg cellulitis (the most common risk factor for
lower leg cellulitis in immunocompetent non-diabetics is
tinea pedis, which creates a portal of entry for bacteria)
d. Peripheral neuropathy
e. Tinea corporis (from autoinoculation)
30
30
Onychomycosis
 Another complication of tinea
pedis is onychomycosis, a
chronic fungal infection of the
nailbed that tends to spread to
other nails.
 Responds very poorly to topical
antifungals
 First line treatments are oral
terbinafine or itraconazole
31
Onychomycosis
 Identification of fungus in the affected nail (at
minimum a positive KOH prep or nail biopsy) is
necessary before treatment, for several reasons:
• May mimic other conditions (e.g. psoriasis, lichen
planus)
• Treatment is expensive, of long duration, and with
potential side effects
• Oral antifungals also have drug-drug interactions
32
Case Two
Mr. Daniel Green
33
Case Two: History
 HPI: Daniel Green is a healthy 18-year-old who presents
with a lesion on his right leg that has been present for 2
weeks. The lesion is itchy and is growing in size.
 PMH: no major illnesses or hospitalizations
 Medications: none
 Allergies: none
 Family history: noncontributory
 Social history: Lives with his parents and sister. The family
adopted a puppy 3 months ago. No history of recent travel.
 Health-related behaviors: no tobacco, alcohol or drug use.
34
Case Two: Skin Exam
 How would you describe
these exam findings?
35
Case Two: Skin Exam
 This is a sharply
marginated, erythematous
annular lesion with central
clearing and raised
papulovesicular border with
scaling.
36
Case Two, Question 1
 Which of the following is the most
appropriate next step in diagnosis?
a.
b.
c.
d.
Biopsy
KOH exam
Wood’s light exam
All of the above
37
Case Two, Question 1
Answer: b
 Which of the following is the most appropriate
next step in diagnosis?
a.
b.
c.
d.
Biopsy
KOH exam
Wood’s light exam
All of the above
38
Case Two, Question 2
 Which of the following is the most likely
diagnosis?
a.
b.
c.
d.
e.
Atopic dermatitis
Psoriasis
Seborrheic dermatitis
Tinea corporis
Tinea cruris
39
Case Two, Question 2
Answer: d
 Which of the following is the most likely diagnosis?
a. Atopic dermatitis (Poorly defined erythematous
patches without central clearing)
b. Psoriasis (Well-demarcated erythematous plaques
with silvery scale)
c. Seborrheic dermatitis (Inflammatory reaction to yeast
typically affecting face, chest, and/or scalp, often with
scaling)
d. Tinea corporis
e. Tinea cruris (Dermatophyte infection in the groin)
40
Tinea Corporis
 Tinea corporis, “ringworm”, refers to dermatophytosis
of the skin, usually affecting the trunk and limbs
•
•
•
•
Affects all age groups
Most prominent symptom is itching
Asymmetric distribution
The margin of the lesion is the most active; central
area tends to heal
• Scrapings should be taken from the red scaly margin
for KOH exam
• A variant of this is tinea cruris or “jock itch”, which has
a similar presentation but appears in the groin
41
Tinea Corporis
 Annular lesion
with central
clearing is typical
of tinea corporis
42
Why Perform A Fungal Culture?
 Cultures identify the specific species of fungi
causing the infection
 As opposed to tinea pedis, tinea corporis is caused
by different fungal species with different
environmental sources
• Animals (cats/dogs), tinea capitis, tinea pedis
 Using a fungal culture to identify the species will
help identify the source and guide treatment
 Even if the KOH prep is negative, a culture may be
positive
43
Tinea Corporis: Treatment
 Begin with topical treatment
 Topical antifungals are applied until tinea shows
resolution, then continue treatment for a minimum of two
weeks
• Imidazoles (fungistatic)
• Allylamines (fungicidal)
• Ciclopirox (fungicidal and fungistatic)
 Oral antifungals are indicated in the following situations:
• If there is a poor response to topical agents
• If an animal is the source of infection
• If eruptions involve a large surface area
44
Case Three
Ms. Anna Jones
45
Case Three: History
 HPI: Ms. Jones is a 27-year-old woman who presents with
mild itchiness of her back which began mid summer. She is
also concerned about areas on her back that do not tan.
 PMH: asthma
 Medications: occasional multivitamin
 Allergies: no known drug allergies
 Social history: spends her summer months in Florida. Is an
avid runner.
 Health-related behaviors: occasional glass of wine 1-2
times per month, no tobacco or drug use
 ROS: negative
46
Case Three: Skin Exam
 How would you describe
these exam findings?
47
Case Three: Skin Exam
 Well-demarcated, pink
and tan, macules and
patches, across the
back.
48
Case Three, Question 1
 Which of the following is the most likely
diagnosis?
a.
b.
c.
d.
e.
Pityriasis alba
Seborrheic dermatitis
Tinea corporis
Tinea versicolor
Vitiligo
49
Case Three, Question 1
Answer: d
 Which of the following is the most likely diagnosis?
a. Pityriasis alba (noninfectious, asymptomatic poorlydefined areas of hypopigmentation; self-limited)
b. Seborrheic dermatitis (abnormal immune response to
normal skin yeast causing scaling and crusting)
c. Tinea corporis (fungal skin infection, presents as
erythematous annular lesions with central clearing)
d. Tinea versicolor
e. Vitiligo (autoimmune loss/dysfunction of melanocytes
causing areas of complete depigmentation)
50
Diagnosis: Tinea Versicolor
 Tinea versicolor (aka Pityriasis versicolor) is
not a dermatophytosis
 It is an infection caused by species of
Malassezia, a lipophilic yeast that is a normal
resident in the keratin of the skin and hair
follicles of individuals at puberty and beyond
 Tends to recur annually in the summer months
51
Tinea Versicolor
 Characterized by well-demarcated, tan, salmon, or
hypopigmented patches, occurring most commonly
on the trunk (facial involvement is rare)
 Macules will grow, coalesce and various shapes and
sizes are attained in an asymmetric distribution
 Visible scale is not often present, but when rubbed
with a finger or scalpel blade, scale is readily seen
• This is a diagnostic feature of tinea versicolor
• Evoked scale will disappear after treatment
52
52
A Closer Look at Tinea Versicolor
53
Case Three, Question 2
 Which of the following is the most
appropriate next step in management?
a.
b.
c.
d.
Fungal culture
KOH exam
Skin biopsy
Wood’s light exam
54
Case Three, Question 2
Answer: b
 Which of the following is the most appropriate
next step in management?
a. Fungal culture (Malassezia spp. are easily
identified by a KOH exam but are not easily
cultured)
b. KOH exam
c. Skin biopsy
d. Wood’s light exam
55
Microscopy
Spores (yeast forms)
Short
Hyphae
The KOH exam shows short hyphae and small round spores.
Characteristic “spaghetti and meatball” pattern.
56
Microscopy with dye added to the
specimen
Magnification 40x
Characteristic “spaghetti and meatball” pattern corresponding to
hyphae and spores.
57
Tinea Versicolor: Morphology
 It’s called “versicolor” because it can be light,
dark, or pink to tan.
• In untanned Caucasians, the lesions may be salmoncolored or brown.
• In tanned Caucasians, the lesions may appear pale in
comparison to the surrounding skin.
• In darker skinned individuals, lesions may appear
hyper- or hypopigmented.
 Let’s look at some examples of the various colors
of tinea versicolor.
58
Tinea Versicolor: lighter
59
Tinea Versicolor: darker
60
Tinea Versicolor: pink or tan
61
Case Three, Question 3
 Which of the following treatments would
you recommend for Ms. Jones?
a.
b.
c.
d.
Antifungal shampoo
Ketoconazole cream
Nystatin cream
Oral terbinafine
62
Case Three, Question 3
Answer: a
 Which of the following treatments would you
recommend for Ms. Jones?
a. Antifungal shampoo
b. Ketoconazole cream (effective for limited
areas, but not widespread infections)
c. Nystatin cream (not effective)
d. Oral terbinafine (in contrast to topical
terbinafine, oral terbinafine is not effective)
63
Case Three, Question 4
 What is true about treatment of tinea
versicolor?
a. Normal pigmentation should return within a
week of treatment
b. Oral azoles should be used in most cases
c. When using shampoos as body wash, leave
on for ten minutes before rinsing
64
Case Three, Question 4
Answer: c
 What is true about treatment of tinea versicolor?
a. Normal pigmentation should return within a week
of treatment (usually takes weeks to months to
return to normal)
b. Oral azoles should be used in most cases (mild
cases can be treated with topicals)
c. When using shampoos as body wash, leave
on for ten minutes before rinsing
65
Tinea Versicolor: Topical Treatment
 Shampoos: selenium sulfide 2% shampoo,
ketoconazole shampoo, pyrithione zinc shampoo
• Apply daily to affected areas, lather, and rinse
• Spreads easily to cover larger areas
 Azole creams: ketoconazole, econazole, miconazole,
clotrimazole
• Apply daily or bid for 2 weeks
• Can be effective for limited areas, but infections tend to be
widespread, so local topical treatment associated with high
relapse rate
• More expensive than shampoos
66
Tinea Versicolor: Oral treatment
 Oral medication should be used when a large area is
involved.
 Oral medications of choice include:
• Ketoconazole
• Fluconazole
• Itraconazole
 Ketoconazole can be given as a one-time dose.
• Take on an empty stomach, exercise until perspiring
(medication is delivered via sweat), and avoid shower
six hours after taking medication.
67
Tinea Versicolor:
Maintenance Therapy
 Many patients relapse
 If the patient has had more than one previous
episode then recommend maintenance therapy
 Maintenance therapy: topicals are used 1-2x/week
•
•
•
•
Ketoconazole shampoo
Selenium sulfide (2.5%) lotion or shampoo
Salicylic acid/sulfur bar
Pyrithione zinc (bar or shampoo)
 Refer patients who fail maintenance therapy to
dermatology
68
Case Four
Ms. Betty Raskin
69
Case Four: History
 HPI: Ms. Raskin is a 62-year-old woman who presents
with a red itchy rash beneath her breasts
 PMH: Type 2 diabetes (last hemoglobin A1c 9.2%),
obesity
 Medications: Metformin, which she says she often does
not remember to take
 Family history: noncontributory
 Social history: lives in Texas part-time
 Health-related behaviors: no tobacco, alcohol or drug use
 ROS: negative
70
Case Four, Question 1
 Which of the following best describe these
characteristic exam findings?
a. Well-demarcated red
plaques with overlying
thick silvery scale
b. Grouped vesicles on an
erythematous base
c. Sharply defined red
plaques involving the skin
folds with surrounding
satellite papules
d. Inflammatory nodules
71
Case Four, Question 1
Answer: c
 Which of the following best describe these characteristic
exam findings?
a. Well-demarcated red plaques
with overlying thick silvery
scale
b. Grouped vesicles on an
erythematous base
c. Sharply defined red
plaques involving the skin
folds with surrounding
satellite papules
d. Inflammatory nodules
72
72
Case Four, Question 2
 Which of the following is the most likely
diagnosis?
a.
b.
c.
d.
e.
Atopic dermatitis
Candidal intertrigo
Psoriasis
Seborrheic dermatitis
Tinea cruris
73
Case Four, Question 2
Answer: b
 Which of the following is the most likely diagnosis?
a. Atopic dermatitis (chronic eruption of pruritic, erythematous, oozing
papules and plaques, usually with secondary lichenification and
excoriation)
b. Candidal intertrigo
c. Psoriasis (characterized by well-demarcated, erythematous
papules and plaques with overlying silvery scale)
d. Seborrheic dermatitis (typical skin findings range from fine white
scale to erythematous patches and plaques with greasy, yellowish
scale)
e. Tinea cruris (dermatophytosis of the groin, genitalia, pubic area,
perineal, and perianal skin, usually appears as multiple
erythematous papulovesicles with a well-marginated, raised border)
74
Candidal Intertrigo: Basic Facts
 Candidal intertrigo = candidiasis of large skin
folds
 May arise in the following areas:
•
•
•
•
Groin or armpits
Between the buttocks
Under large pendulous breasts
Under overhanging abdominal folds
 KOH exam reveals pseudohyphae
 Burns more than itches
75
Case Four, Question 3
 Which of the following factors predispose to
candidal intertrigo?
a.
b.
c.
d.
e.
Diabetes mellitus
Hot, humid weather
Limited mobility
Obesity
All of the above
76
Case Four, Question 3
Answer: e
 Which of the following factors predispose to
candidal intertrigo?
a.
b.
c.
d.
e.
Diabetes mellitus
Hot, humid weather
Limited mobility
Obesity
All of the above
77
77
Case Four, Question 4
 Which of the following is the most
appropriate next step in management?
a. Barrier creams or ointments (e.g.
petroleum jelly, zinc oxide paste, etc.)
b. Nystatin ointment
c. Oral antifungal agent
d. Oral glucocorticoid
78
Case Four, Question 4
Answer: b
 Which of the following is the most appropriate
next step in management?
a. Barrier creams or ointments (useful as
adjunct/preventive therapy, but does not eradicate
candida)
b. Nystatin ointment (useful for candida, ointment
base prevents maceration in moist areas)
c. Oral antifungal agent (usually can be treated with
topical agent)
d. Oral glucocorticoid (may worsen the infection)
79
79
Candidal Intertrigo: Management
 Topical antifungal agents
• Polyenes and Imidazoles: nystatin,
miconazole, clotrimazole, or econazole
• Allylamines are not used to treat candida
 Prevention
• Keep intertriginous areas dry, clean, and cool
• Encourage weight loss for obese patients
• Washing with benzoyl peroxide bar may
reduce Candida colonization
80
Candidal Intertrigo: Management
 Topical anti-inflammatory
• Low strength glucocorticoid preparations
rapidly improves the itching and burning, but
should be stopped after one week
 Systemic antifungal agents (used for
infections resistant to topical treatment)
• Oral fluconazole, itraconazole, or ketoconazole
81
Take Home Points
 Cutaneous fungal infections are extremely common.
 There are three clinical patterns of tinea pedis infection:
interdigital, moccasin, and vesiculobullous type.
 If it scales, scrape it! KOH examination is the easiest and
most cost effective method used to diagnose fungal infections
of the hair, skin, and nails.
 Fungal culture is important because it may be positive when
KOH prep is negative, and is the only easily available method
to definitively identify the organism.
 Culture is especially helpful in tinea corporis when the source
of infection is not obvious (as opposed to tinea pedis).
82
Take Home Points
 Tinea versicolor is characterized by well-demarcated, tan,
salmon, or hypopigmented patches, occurring most commonly
on the trunk.
 Topical treatment is usually appropriate as a first-line agent for
tinea pedis, tinea corporis, and candidal intertrigo, however oral
medications are called for when involvement is extensive, when
tinea corporis is thought to have been transmitted by an animal,
and in fungal infections of the nails.
 Fungal infections have high rates of recurrence after treatment,
but maintaining a dry, clean skin environment is helpful for
prevention.
 Monitoring for recurrence and maintenance treatments may be
helpful in patients with recurrent infection.
83
Acknowledgements
 This module was developed by the American Academy
of Dermatology Medical Student Core Curriculum
Workgroup from 2008-2012.
 Primary authors: Iris Ahronowitz, MD; Ronda Farah,
MD; Sarah D. Cipriano, MD, MPH; Raza Aly, PhD,
MPH; Timothy G. Berger, MD, FAAD.
 Peer reviewers: Heather Woodworth Wickless, MD,
MPH; Daniel S. Loo, MD, FAAD.
 Revisions and editing: Sarah D. Cipriano, MD, MPH;
John Trinidad. Last revised July, 2011.
84
References
 Aly R and Maibach H. 1999. Atlas of Infections of the Skin.
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