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Transcript of Fungal infectionsacademic.sun.ac.za/stellmed/CourseMaterial/Annual GP...T capitis • HAIR LOSS -...
Fungal infections
Dr. W.I. Visser / KannenbergDivision of DermatologyDepartment of Medicine
Faculty of Health SciencesUniversity of Stellenbosch
Tygerberg Hospital
Objectives
1. Dermatophyte infections
2. Candida infection
3. Malassezia infections
Clinical picture & Treatment
Fungal skin infections
dermatophytes non-dermatophytes
• Yeast-like fungus – Candida albicans
• Molds
KOH
• Dermatophyte
septate hyphae
• Candida
round or oval cells
pseudohyphae
septate hyphae
Candida
Dermatophyte
If it scales scrape it!
Terms
• ‘ringworm’
• ‘tinea’
• grow only in keratin
dermatophyte
infection
stratum corneum
hair
nail
DERMATOPHYTE INFECTION
Microsporum canis
Trichophyton violaceum
Epidermophyton floccosum
T. capitis
T. barbae
T. corporis
T. cruris
T. faciei
T. manuum
T. pedis
T. unguium
DERMATOPHYTE INFECTION
OF THE SCALP
• mostly childhood
• sebum contains fungistatic fatty acids
• Trichophyton violaceum
T capitis
• HAIR LOSS - patchy
• grey patch
• yellow patch (= impetigo)
• alopecia areata – like
• black dot type
• seborrheic dermatitis – like
• kerion (abscess-like) [antibiotics / surgery]
• favus
• pustular
Favus
Kerion
Moth eaten
Grey patch
Black dot
Alopecia areata-like
IMPETIGO OF SCALP
primary impetigo vs. secondary impetigo
• head lice
• dermatophyte infection
• scabies
DERMATOPHYTE INFECTION
OF THE
FACE AND BEARD
T faciale
T barbae
DERMATOPHYTE INFECTION
OF THE
BODY
T corporis
• annular lesions with active border, red and
scaly, central clearance
• adults : from feet
• child : from scalp
T corporis
Differential diagnosis
• Dermatitis
• Psoriasis
• Dermatophyte
• Medication
• Syphilis
• T-cell lymphoma
DERMATOPHYTE INFECTION
OF THE
GROIN AREA
T cruris
• men > women
• annular lesions with active border, red
and scaly
• central clearance
• look for DF infection of feet / nails
T cruris
DERMATOPHYTE INFECTION
OF THE
HAND
T manuum
• usually unilateral
• red & scaly
• vesicopustular
• annular lesions with active border, red and scaly, central clearance
• Source : feet
T manuum
DERMATOPHYTE INFECTION
OF THE NAILS
Tinea unguium
• toenails > fingernails
• especially adults
• aspecially great toenail
• thickened
• discoloured : yellowish / white
• subungal hyperkeratosis
• onycholysis
• paronychia
T unguium
DERMATOPHYTE INFECTION
OF THE
FOOT
T pedis
• between toe’s (athlete’s foot) [swimming pool / shower]
• annular lesions with active border, red and scaly,
• central clearance
• vesicopustular
• red and scaly (mocassin)
• Diabetic patients at risk
• TWO FEET, ONE HAND!
T pedis
WOOD’S LIGHT
• Microsporum canis
• yellow-green
M. canis
TINEA INCOGNITO
• dermatophyte infection
• topical steroids
• altered appearance
• erythema with scaling and pustules
• no active border!
T incognito
‘IDE’ REACTIONS
• dermatophyte infection (athlete’s foot)
• reaction at a distance
• vesicular, papular
• immunological
• no fungi
Id reaction
Learning point
If your patients’s “asymmerical eczema” is
spreading despite local steroids
– think of a dermatophyte infection
DIAGNOSIS
• clinical
• KOH and microscopy
• culture
• skin biopsy
• therapeutic trial
Scalpel blade
Scalpel blade
KOH
Glass slide
Microscope
KOH microscopy
Treatment
localized infection
• topical imidazole (eg. clotrimazole)
- fungistatic
• topical allylamine (eg. terbinafine)
- fungicidal
Treatment
Systemic treatment for dermatophyte
infection of the scalp, onychomycosis of
many nails, and, widespread infection
elsewhere (eg. body)
TREATMENT
• scalpGriseofulvin 10 – 20mg/kg with a meal for 6 weeks
• many nailsterbinafine (Lamisil)itraconazole (Sporanox)fingernails : 6 weekstoenails : 8 - 12 weeks
• all other widespread infection
itraconazole (Sporanox)terbinafine (Lamisil)griseofulvin
Treatment
MYCETOMA
• Direct inoculation
• Soil fungi
• Deep infection
• Abscesses and draining sinuses
• GRAINS/ GRANULES
Mycetoma (Madura foot)
Treatment
• Refer
• Surgery
• Systemic therapy
Onychomycosis
• Encompasses all fungal infections of the
nail – dermatophytes/non-dermatophytes
• (nail dystrophy presentation)
CANDIDA INFECTIONS
Intertriginous candidiasis
of major flexures
Candida granuloma of
Scalp (rare)
Oral candidiasis
Interdigital candidiasis
Chronic paronychia and
nail plate
candidiasis
Genital candidiasis
Candida albicans
• topical steroids
• systemic steroids
• immunity (HIV / AIDS, malignancy, CT)
• broad-spectrum antibiotics
• DM
• warmth, friction & moisture
CandidaORAL MUCOSA
• erythema & white curd-like plaques
ANGULAR CHEILITIS (hoekstomatitis)(perlèche)
• age
• ill-fitting dentures
• Staphylococcus aureus
CHRONIC PARONYCHIA
• water immersionhousewivesbarstafffloristsfishmongers
• erythema, edema & nail dystrophy
Chronic Paronychia
BALANITIS / VULVOVAGINITIS
• poor hygiene
• pregnancy, OCP
• erythema
• small white patches
• erosions
INTERTRIGO
• = intertriginous areasincluding abdominal fat apron
• obesitypoor hygienered & scaly‘satellite’ pustules
DIAGNOSIS
• clinical
• KOH and microscopy
• culture
• skin biopsy
• therapeutic trial
TREATMENT
• nystatin (Mycostatin®)
• amphotericin B (Fungizone®)
• topical imidazole
• topical allylamine
• Lamisil® / Sporanox® po
• griseofulvin : effective Θ
• PVC / latex gloves with cotton lining
Learning points
• Alwys check the urine for sugar.
• Remember that griseofulvin has no action
against Candida.
PITYRIASIS VERSICOLOR
• Pityrosporum ovale (Malassezia furfur)
• young adults
• tropical climates
• macules with fine scaling
• hypopigmented
• hyperpigmented
• trunk and upper arms
• asymptomatic / cosmetic
• KOH & microscopy : “meatballs & spaghetti”
P versicolor
P versicolor
P versicolor
“meatballs & spaghetti”
TREATMENT• selenium sulphide shampoo (Selsun®)
• Ketoconazole shampoo (Niz® shampoo)
• topical imidazole
• ketoconazole (Nizoral®)
400mg / day x 2 days
• Sporanox®
400mg stat
or 200mg / day x 7 days
Important!
• residual hypopigmentation
1 – 2 years to repigment
• recurrence common
Learning points
• This is not a dermatophyte infection, do
not try griseofulvin or terbinafine.
• Patients think the treatment has not
worked if their pale patches do not
disappear straight away
- Warn them about this in advance.
Cryptococcus
Histoplasmosis
Sporotrichosis
What must you know
• Dermatophyte infections
• Candida
• Malassezia
• Know about systemic fungi can effect skin
Test