Tinea: Head to Toe - UCSF Medical Education · Tinea: Head to Toe A dermatophyte tour of human skin...
Transcript of Tinea: Head to Toe - UCSF Medical Education · Tinea: Head to Toe A dermatophyte tour of human skin...
Tinea: Head to ToeA dermatophyte tour of human skin
Renee Howard, MDAssistant Clinical Professor of
Dermatology, UCSF
Tour de Tinea Head to Toe
CapitisFacieiCorporisPedisUnguim (onychomycosis)
Tips for Tinea Head to Toe
DiagnosticTherapeutic
Non-inflammatory Tinea CapitisSeborrheic dermatitis: thick greasy scale frontal scalp & vertexAtopic dermatitis: fine scale all over; itchyPsoriasis: thick silvery-white scale sticks to hair– Williams JV et al Pediatrics
2005;115:e1-6.
Psoriasis
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Psoriasis
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Tinea?
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No, Langerhans cell histiocytosis
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Inflammatory Tinea Capitis
DDx Inflammatory Tinea Capitis
Folliculitis: just pustules with no scaleDiscoid lupus: scarring “skating rink”alopecia with scale in hair follicle openingsAlopecia areata: smooth pink-orange discrete patches with no scale
Tinea Capitis Diagnostic Tip
See the scaleDo fungal culture!
Tinea Capitis Rx
First line still Griseofulvin 20-25mg/kg micronized for 6-8 weeks with fatty meal.Second line agents for griseofulvin failure or intolerance are not FDA approved– Lamisil 6 mg/kg/day– Itraconazole 5 mg/kg/day– Fluconazole 6 mg/kg/day
• Sethi A, Antaya R. Pediatr Infect Dis J 2006;25:643
Tinea Capitis Treatment Tip
Must use systemic therapy; topical is adjunctive onlyIf patient fails griseofulvin– Check compliance– Treat family members with antifungal
shampoo; look for school contacts– If inflammatory check history carefully for
animal source (rabbits, guinea pigs, horses, puppies, kittens)
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Rash for a month; failed topical tolnaftate
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Tinea facei Dx TipCan appear seborrheicdermatitis-like– Gorani et al Pediatr
Dermatol 2005;22:243.
Look for tinea capitis or corporisLook for animal contact
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Tinea facei?
Tinea corporis? Neonatal lupus erythematosus
Granuloma annulare Annular urticaria Tinea Corporis Diagnostic Tips
All that is annular is not fungalIf it scales, scrape it!If KOH negative, do fungal cultureRemember pustular, vesicular and crusted plaques can also be tinea
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Leismaniasis? Leishmaniasis? I think not
17 year old just back from summer trip to Costa RicaItchy rash on feet came up the last few days there“OMG I have leishmaniasis,” says she in a panic
Tinea Corporis Diagnostic TipScrape edge for KOHDo fungal culture if KOH negative or in an outbreak e.g. tinea gladiatorumUse moist cotton swab or toothbrush and rub scaliest area, usually borderSwab media & send
Tinea Corporis Treatment TipTopicals: terbinafine, clotrimazole, miconazole, butenifine cream BID for 2 weeksAvoid combination topical steroid/antifungal creams– Alston et al Pediatrics 2003;111:201
Nystatin for candida; not effective for dermatophyteIf fails topical, use oral griseofulvin15-20mg/kg for 3 weeks
The many feet of tinea pedis
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Tinea Pedis Diagnostic Tip
Do fungal culture if KOH negative or fails antifungal topical therapyIf negative, consider inflammatory dermatoses such as psoriasis, atopic dermatitis, allergic contact dermatitis and juvenile plantar dermatosis.
Juvenile Plantar Dermatosis
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Tinea Pedis Therapeutic TipAvoid potent topical steroid/antifungal combinations– Greenberg et al Pediatr Dermatol 2002;19:78.
If treating chronic inflammatory dermatosis such as psoriasis with topical steroids, monitor for fungal superinfection and addseparate antifungal cream to regimenAddress hyperhidrosis
Onychomycosis: distal subungual⌃
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Onychomycosis Diagnostic Tip
Scrape under nail with 15 blade or curetteKOH and fungal culture of scaleClip affected distal nail plate and send to pathology for special stains
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Onychomycosis Rx TipSystemic terbinafine 6 mg/kg/day for 3 monthsPulse itraconazole 5 mg/kg one week of every month for 3 monthsFluconazole 3-6 mg/kb once weekly for 5 mos.Do baseline LFT’s & repeat after 1 month.All off-label for children <18 years– Sethi A, Antaya R. Pediatr Infect Dis J 2006;25:643
Onychomycosis in a 10 year old
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Onychomycosis Rx Tip
Topical therapy worth a try in young children because their nail plates are thinnerCombine keratolytic with antifungal cream– 40% urea cream and terbinafine cream
Better topical treatments on the horizonUsually are treating parents…
Tour de Tinea
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