Chapter 13: Fungal Skin Infections

Follow up and referral

The patient should be seen for initial follow-up 2 weeks after the start of therapy. For resistant cases, the clinician should confirm the diagnosis with a fungal culture or the diagnosis should be reevaluated. Resistant cases should be referred to a dermatologist for reevaluation or for more aggressive treatment with systemic antifungals. If the patient was initially placed on topical therapy only, systemic therapy can be considered.

Risk factors for serious disease if infected with candida?

- include conditions that alter cellular immunity, such as AIDS, diabetes mellitus, corticosteroid treatment, bone marrow transplant, chemotherapy, and invasive parenteral catheterization (parenteral feeding catheters are considered high risk), and invasive monitoring devices in intensive care units. -Broad-spectrum antibiotic therapy, including antibiotics following major surgery in normal hosts, can increase the risk of candida infection.

Candidiasis (also known as moniliasis and candidosis)

-An infection by the organism Candida. -Candida is an opportunistic pathogen that causes not only superficial mucocutaneous infections but also serious disease that can be fatal, especially in immunocompromised patients. -Candida belongs to the yeast family of fungi.

Pathophysiology of candida infection

-Candida organisms cause a strong inflammatory response on the skin, which accounts for the intense erythema and pruritus commonly seen with this infection. -Normal commensal flora and intact cellular immunity mediated primarily by cytotoxic T cells are the body's primary defenses against fungal overgrowth and invasive candidal infection. -The use of systemic antibiotics has the potential for clearing normal microbial skin flora, and both oral and inhaled corticosteroids, HIV infection and AIDS, malignancy, chemotherapy and other immunosuppressant drugs, diabetes mellitus, and senescence all contribute to decreased helper and cytotoxic T-cell function, increasing the likelihood of candidal skin infection.

Vulvovaginitis candida infection treatment

-For topical treatment of severe cases of candidal vulvovaginitis, cream formulations often yield better results than vaginal suppositories. -Women should be cautioned that topical treatments may weaken latex condoms and diaphragms. - For mild to moderate cases, suppositories work well and are available as 3-day treatment regimens. - recurrent vulvovaginitis candida infection should be treated with 7 day suppository - diflucan discouraged due to increased resistance to systemic antifungals

candidal paronychia treatment

-In candidal paronychia, a warm compress on the affected fingertip will enhance drainage of purulent discharge and help relieve the pain. -Incision and drainage of purulent material may speed resolution and provide relief. Candidal infections of the nailbed (subungual candida) are best treated with systemic antifungals.

Candidiasis infections in men

-Men with diabetes, especially if uncircumcised, are at higher risk for candidal infections of the glans penis (balanitis). -The uncircumcised foreskin holds heat and moisture and increases the risk of candidal overgrowth.

Diagnostic testing for candida infection

-Skin infections caused by Candida are generally diagnosed by their classic appearance. -Candida yeasts are normally present in the mouth, vagina, sputum, or stool. Candidal cultures can be obtained from the skin or mucous membranes with a Culturette. Because Candida is part of the normal flora, a positive culture from the mouth or vagina is of limited value unless confirming signs and symptoms accompany it.

Follow up and referral for candida infection

-The patient should be seen in 2 weeks to monitor response to treatment. If there is no response to treatment, the initial diagnosis should be reconsidered, or the patient should be referred to a dermatologist. -If a partial response is seen, treatment can be continued for another 1 to 2 weeks and the patient is reevaluated. If there is poor response at that time, the patient needs a referral to a dermatologist.

Diagnostic testing for vaginal candial infections

-a saline wet mount, pH paper, and potassium hydroxide (KOH) test are helpful in the diagnosis -The whiff test will be negative, and the vaginal pH is normal (acidic) at 4.5 or less.

Causative organisms of onychomycosis

1. can be caused by the yeast C. albicans. 2. Dermatophytic species of fungi: Trichophyton species: T. rubrum, T. mentagrophytes, T. schoenleinii

KOH Examination

A laboratory examination using KOH is necessary for diagnosis, because only 50% of dystrophic nails are due to dermatophytosis. A drop of 10% KOH is placed on the sample of nail clippings and is heated gently with a lighter or match. The heating accelerates the effect of the KOH on the keratinized cell walls, but the slide should not be placed too close to the flame, or the KOH will get too hot and boil off. When the sample is ready, the hyphae will be easier to see because the cell walls will have been lysed by the KOH.

Dermatophytid (Id) Reaction

Acute id eruptions are caused by a hypersensitivity reaction to the fungus. The id eruption presents as vesicles on the sides of the fingers and/or the palms of the hands. The vesicles do not contain fungus but rather are sterile. The patient may or may not be aware of a concurrent tinea pedis infection.

Chronic tinea pedis vs acute tinea pedis

Acute tinea pedis is caused by Trichophyton mentagrophytes var. interdigitale chronic tinea pedis, which is more common, is caused by Trichophyton rubrum.

Follow up and referral for onychomycosis

After initiation of therapy, liver function tests should be rechecked every 4 weeks. The first follow-up visit is scheduled during the fourth week to monitor for symptoms of hepatoxicity, adverse reactions, and compliance with treatment and to obtain a liver function panel. Thereafter, the patient should be seen for follow-up every 4 to 6 weeks with liver function tests done. Resistant cases of onychomycosis should be referred to a dermatologist. Nail growth should be monitored until the nails become clinically normal

Diagnostic Test for onychomycosis

All cases of presumed onychomycosis must be confirmed by laboratory findings. Findings of the KOH examination typical of fungal infection are hyphae and spores with a classic "spaghetti and meatballs" appearance. Under the microscope, hyphae appear as long translucent tubes with septae (separate sections), while spores are small round to ovoid shapes.

epidemiology of candida infections

Although C. albicans is the most common (60% to 90%) of all yeast isolates found in the oropharynx and on the genitalia, other types of Candida coexist in the body, including C. tropicalis, C. glabrata, C. krusei, C. rugosa, and other yeast strains.

Kerion

An extremely painful and inflammatory presentation of tinea capitis known as a kerion. A kerion appears as a large, bright red, boggy "bump" on the scalp with alopecia. Purulent drainage can be expressed out of the kerion by gentle pressure, and pus can be seen oozin

Candidal paronychia (tissue surrounding the nail) DDx

Bacterial paronychia (Pseudomonas, Proteus) Herpetic whitlow

What is the most common species of candida that causes infections in humans?

Candida albicans

Intertrigo (skinfolds) DDx

Contact dermatitis Bacterial intertrigo (erythrasma)

Medication list for the different Tinea infections (HOLY CRAP THERE ARE A LOT!!)

Drugs Commonly Prescribed 13.1: Tinea Infections (pg 179)

What are the two most important factors contributing to candidal infections?

Favorable environmental factors and a weakened immune system.

Environmental and Host factors that increase risk of Tinea

Favorable environmental factors that increase the risk of tinea infection include heat, moisture, and poor air circulation. Host factors include age, broken skin, broken hair shafts, and excessive moisture on the skin or nails.

Warnings for patients taking Griseofuulvin

Female patients must be cautioned that oral contraceptives may be less effective with griseofulvin and to use alternate birth control during treatment and for 1 month after treatment. Male patients on griseofulvin should be advised that this drug affects sperm (it is teratogenic) and to avoid fathering a child for at least 6 months after stopping the drug.

Oral candidiasis infection treatment

First-line treatment for mild oral candidiasis is --> clotrimazole troches 10 mg five times a day or --> miconazole 50 mg buccal tablet once a day for 7 to 14 days, applied to the upper gum over the incisor. Oral candidiasis (thrush) may also be treated with nystatin, which is available in suspension, pastilles, or troches. Nystatin is available in a 100,000 units/mL suspension, and 4 to 6 mL (or one teaspoon) is given (one-half dose on each side of the mouth) four to five times daily. --> Clotrimazole (Mycelex) troches are also indicated for prophylaxis of thrush at a dosage of one troche three times daily. --> Oral fluconazole 100 to 200 mg daily for 7 to 14 days is recommended for the treatment of moderate to severe oropharyngeal candidiasis. --> Itraconazole solution (10 mg/mL) is indicated for oral candidiasis that is unresponsive to fluconazole and is available in cherry and caramel flavors. The patient is instructed to swish 10 mL (100 mg) twice daily in the mouth for several seconds before swallowing; treatment should continue for 2 to 4 weeks. *Itraconazole oral antifungal medications are contraindicated in women who are pregnant or could become pregnant. Relapse frequently occurs after treatment of thrush in immunocompromised patients.

Balanitis (glans of penis) DDx

Flat genital warts Erythroplasia of Queyrat (Bowen's disease of the penis) Contact dermatitis Balanitis plasma cellularis (Zoon's balanitis)

Systemic Therapy for treatment of onychomycosis

For patients who desire treatment for onychomycosis, most authorities recommend systemic therapy. If concurrent tinea pedis, tinea manuum, or tinea corporis is present, it should be treated with topical antifungals, so that the source of infection is eradicated. Fingernails are easier to treat than toenails and have a higher cure rate from 50% to 70% Itraconazole and terbinafine are better choices for toenail infections, which are more difficult to treat. Patients who are on H2 blockers can also take these drugs. There is no role for griseofulvin in the treatment of toenail onychomycosis because up to 80% to 90% of patients will relapse with this drug.

Fungal Culture

Fungal cultures done on Sabouraud's agar or with Dermatophyte test medium produce results in up to 3 days. The area where the samples are to be taken should be cleansed with 70% alcohol and allowed to dry before specimen collection. -Skin should be taken from the active border of the lesion. -Nail samples should be taken from the subsurface of the infected nail. (To obtain samples from underneath the nail, a scalpel can be used to scrape the underside of the infected nail.)

Cellulitis infection secondary to tinea infection treatment

If the clinician suspects that a secondary bacterial skin infection (cellulitis) is complicating tinea infection, a culture should be done on the purulent discharge. Empiric therapy for mild cellulitis, which is usually caused by gram-positive bacteria such as Staphylococcus or group A beta-hemolytic Streptococcus is: --> oral antibiotics such as cephalexin or dicloxacillin for 7 to 14 days.

What is more at risk for tinea and yeast infections?

Individuals with diabetes

Diagnostic testing for Tinea ungium (Onychomycosis)

Microscopy is the most useful diagnostic tool for tinea in the primary-care setting. A small piece of skin from the active edge of the lesion or a nail fragment is placed on a glass slide. A drop of 10% KOH is placed on the sample, which is then heated gently with a lighter or match. A Wood's light examination should be used on any area of alopecia and hypopigmentation. Some fungi fluoresce when examined under Wood's light, which emits ultraviolet light (black light). The examining room should be darkened for this examination. A characteristic color that is associated with two minor causes of tinea capitis is a blue-green or bright green color from M. canis or M. audouinii. T. tonsurans, the most common cause of tinea capitis, does not fluoresce under a Wood's light examination.

Pathophysiology of tinea infection

Microsporum and Epidermophyton species both cause infections of the skin and nails. Trichophyton species cause infections not only of skin and nails but also of the hair. These fungal infections are superficial because all three types metabolize keratin, the protein that comprises the topmost layer of body surface epithelium, which normally serves as a protective barrier against microbial infection.

Thrush (oral candidiasis) DDx

Milk curd (infants) Pharyngeal exudate (bacteria/viral)

Management of Tinea infections

Most cases of tinea infections (except tinea infections of the scalp and nails) respond well to a 2- to 4-week course of topical treatment with azole-class drugs. These agents should be continued for at least 1 week after the lesions have cleared. They should be applied a few centimeters beyond the edges of the skin lesions.

Subjective symptoms of Tinea Versicolor

Most cases of tinea versicolor are recognized in the summer because the hypopigmented spots become more visible at that time of year, as they do not tan. Tinea versicolor is asymptomatic and has a gradual onset. Rarely, a patient will complain of mild pruritus. The typical patient is a teen or young adult, although tinea can occur at any age. People of African descent with tinea will complain of either light-colored (hypopigmented) or dark-colored (hyperpigmented) spots. In adults, the usual sites are on the back, upper chest, arms, and sometimes the neck and face. In children, the rash is more likely to be on the face or forehead.

Subjective symptoms of onychomycosis

Onychomycosis is an asymptomatic infection, and there should be no pain involved. Some patients report having tried several OTC remedies with no result. The patient may complain of thickened dystrophic nails or nails with cloudy, white-colored patches. Some report nail discoloration, ranging from yellow to green or brown to black.

Classification of onychomycosis

Onychomycosis is classified as either a primary or secondary infection 1. Primary infection = involves invasion of the healthy nail plate. 2. or secondary onychomycosis= diseased nails (e.g., from psoriasis or trauma) which are predisposed to developing infection.

Epidemiology of onychomycosis

Onychomycosis is more common in adults and elderly patients than in children. The combination of poor circulation in the lower extremities as a result of peripheral vascular disease and the immunocompromising effects of advanced age makes this a common problem in older adults.

Balanitis

Subjective: -The typical patient is a sexually active adult man who complains of a reddish rash and itching on the glans penis (sometimes accompanied by burning after intercourse) although no burning is usually felt with urination. Objective: The glans penis has small erythematous and eroded patches that are tender to touch. A different presentation demonstrates small white round lesions with a red base on the glans.

Intertriginous Candidiasis

Subjective: -The typical patient is an obese adult who complains of a red, itchy rash that is occasionally "weepy" (draining tissue fluid) and moist (It is sometimes accompanied by burning) -The location of the rash may be in the inframammary area, the groin, the perianal area, or the interdigital spaces of both the hands and feet. Objective: Any area of skin on the body where there is maceration (i.e., skin rubbing against skin) or increased heat and moisture can become easily colonized by Candida. The lesions appear as bright red patches with satellite lesions. The skin will appear eroded and moist and is tender to touch.

Subungual Candida

Subjective: No pain or itching is associated with this infection. The typical patient is an adult who reports one or several discolored, yellow fingernails for several weeks to months. Objective: The nail is discolored and yellow in color. The nail may be deformed and partially or totally separated from the nailbed.

Oral Candidiasis (Thrush)

Subjective: The patient will complain of a severe sore throat, dysphagia (especially with acidic foods such as citrus). Objective: The anterior and posterior pharynx (including the tongue) is frequently involved. White creamy patches are seen and can be easily scraped off with a tongue blade, leaving behind erythematous patches.

Vaginal Candidiasis

Subjective: The patient, usually ranging in age from adolescence to middle age, typically complains of burning, itching, and irritation, either on the vulva or both the vulva and vagina (vulvovaginitis). Burning may be noted during intercourse (dyspareunia) or urination (dysuria). The vaginal discharge is reported as white in color, with a "cottage-cheese" or thick texture Objective: The vulva and, in some patients, the surrounding area appear erythematous and irritated. During speculum examination, the vaginal tissue appears erythematous, with white, curdlike patches pasted on the vaginal walls. The posterior fornix of the vagina may be full of thick white discharge.

Candidal Paronychia

Subjective: The typical patient is an adult who complains of an extremely painful fingertip that is red, hot, and swollen. A history of frequent water immersion of the hands is common. Objective: The area around the nail (the paronychium) is bright red, swollen, and extremely tender. A purulent pocket of discharge is sometimes present; when fluctuant, this abscess will rupture and drain pus.

Objective symptoms of Onychomycosis

Superficial white onychomycosis involves only the nail surface but may occur with either distal or lateral subungual onychomycosis. Subungual onychomycosis may involve distal, lateral, and proximal sites of infection. The first or fifth toenail is more likely to become infected than the other toes. The infected nail typically appears dry and has an opaque white patch with sharp borders that start on the distal, lateral, or proximal subungual portion, or is limited to the nail surface (superficial white onychomycosis). In some patients, the white opaque areas become discolored—either yellow or brown. A green-black color suggests complication with a bacterial Pseudomonas infection.

WARNING about systemic antifungals to treat onychomycosis

The decision to treat onychomycosis aggressively must be considered carefully because it is predominantly a benign cosmetic infection. Other important factors include the presence of any preexisting medical problems and the past medical history. Patients who have liver disease should avoid systemic antifungal drugs because of the high risk of hepatoxicity and liver failure. A history of infection with viral hepatitis can result in chronic infection with hepatitis B or C, and a history of excessive alcohol use can result in cirrhosis of the liver or elevations in liver function tests—all of which are considered high-risk conditions for starting systemic antifungal therapy.

DDx of onychomycosis

The differential diagnosis of onychomycosis includes psoriasis of the nail, reactive arthritis (postinfectious), trauma to the nail, and congenital nail abnormalities.

Objective symptoms of Tinea Pedis

The most common presentation of tinea pedis is macerated white skin between the web spaces of the toes; the infection is pruritic with occasional painful fissures and can be accompanied by an unpleasant foot odor.

What is the most contagious tinea?

The most contagious of all dermatophytoses is tinea capitis (scalp ringworm).

Subjective symptoms of Tinea Cruris

The typical patient is an obese adult man who complains of a pruritic rash on the groin that spreads to the medial inner aspect of the upper thigh. Sometimes, the rash is not associated with pruritus.

Subjective symptoms of Tinea Pedis

The typical patient is usually a male teenage athlete or an adult who comes to the clinic complaining of "athlete's foot" and strong foot odor. Most patients do not have pain with this infection unless it becomes secondarily infected with bacteria, causing cellulitis. The patient reports areas of macerated soft, whitened skin between the toes. Some patients will complain of concurrent infections on the hand (tinea manuum), on the body (tinea corporis), or under the toenails (tinea unguium).

Subjective symptoms of Tinea Corporis

The typical patient will report a history of an erythematous round and elevated pruritic lesion that grows in size and starts to clear in the center—the classic shape of "ringworm." Sometimes, there is a history of another family member with the same infection, and patients may report a history of prior infection.

Subjective symptoms of Tinea Capitis

The typical patient with tinea capitis is a toddler or school-age child. The parent often reports a painless bald spot. If kerion formation accompanies the infection, the child will show signs of discomfort or will complain of pain. Systemic symptoms such as fever or malaise are not associated with kerion formation.

Objective symptoms of Tinea Corporis

This infection presents as the classic "ringworm" infection—it is easy to recognize in the clinical setting. The patient will present with ringlike lesions with a bright red elevated border (collarette) that is covered with scales. The lesions are usually very pruritic, but sometimes they are asymptomatic.

Objective symptoms of Tinea Capitis

Three clinical presentations are seen with tinea capitis infections. 1. One presentation is "black dot" tinea capitis caused by T. tonsurans. The child with "black dot" tinea capitis presents with painless patchy alopecia (either in single or multiple patches). The skin on the scalp does not have erythema; the "black dot" appearance results from broken hair stubbles that remain on the scalp. 2. Another presentation is called "gray patch" tinea capitis. The child with this condition also presents with patchy alopecia, but the bald patches are covered with fine gray-white scales. The patch is made up of thick, keratinized skin that is grayish-white in color. Broken hair shafts of different lengths are present on the surface. 3. Third presentation is an extremely painful and inflammatory presentation of tinea capitis known as a kerion. A kerion appears as a large, bright red, boggy "bump" on the scalp with alopecia.

Diagnostic testing for Tinea Infections

Tinea infections are usually diagnosed by their clinical presentation. The classic "ringworm" lesions are easy to recognize. The diagnosis can be confirmed via microscopy in the clinic or a specimen (skin scraping) can be sent to the laboratory in a sterile plastic cup. A fungal culture is recommended for onychomycosis (tinea unguium) and for tinea capitis. Because these two tinea infections require long-term therapy with systemic antifungals (with a high potential for serious side effects), physician consultation is recommended.

Management of Tinea Capitis

Tinea infections of the hair and nails do not respond to topical treatment, unlike other tinea infections. Tinea capitis should be treated with oral systemic antifungals, along with a topical antifungal for localized scalp lesions. The treatment of choice: --> griseofulvin (Grifulvin V) 250 to 500 mg by mouth twice per day for severe cases in adults or once per day for children weighing more than 50 pounds. For children who weigh 30 to 50 pounds, --> griseofulvin (Grifulvin V) 125 to 250 mg daily is recommended. Treatment duration is from 2 to 4 months or at least 2 weeks after negative cultures are obtained. Concurrent treatment with selenium sulfide shampoo three times per week is used as adjunctive therapy to systemic antifungals.

What is the most common fungal infection in the USA?

Tinea pedis, or "athlete's foot"

Subungual Candida (under nail) DDx

Tinea unguium (onychomycosis)

Treatment of tinea versicolor

Tinea versicolor is treated with topical selenium sulfide lotion (Selsun) applied daily for 7 days from neck to waist daily ("lathered" on with a small amount of water and left on for 10 minutes) before rinsing thoroughly. Treatment is repeated once a week for 1 month and then once a month for maintenance. Ketoconazole (Nizoral) shampoo can also be used weekly for maintenance. The clinician should advise patients that treatment will eradicate the infection but will not remove the hypopigmented spots from the skin, which take longer to resolve. For patients who want more aggressive treatment, fluconazole and itraconazole are the drugs of choice. --> Fluconazole 150 to 300 mg weekly for 2 to 4 weeks OR --> itraconazole may be prescribed at 200 mg daily for 7 days.

Diagnostic testing for Tinea Capitis

To obtain a fungal culture for suspected tinea capitis, the clinician should use a dry toothbrush to brush the areas of alopecia and then impregnate the culture media with the bristles. Another method is to use a wet cotton swab, wipe it over the areas of alopecia, and then implant it on the media. Growth is usually seen in 10 to 14 days of culture. In addition, hair bulbs and broken hair, along with scales from the active lesion, should be cultured. It is important to look for spores and hyphae on the hair shaft, inside the hair shaft (endothrix), and outside the hair shaft (ectothrix) using microscopy. A Wood's light examination should be done in all cases of scalp alopecia. Although some infections will fluoresce (M. canis, M. audouinii), others do not (T. tonsurans, T. violaceum).

Ulcerative Tinea Pedis treatment

Toe web infection (ulcerative type) can be due to gram-negative bacterial infection (e.g., Pseudomonas aeruginosa, Escherichia coli, Proteus) and must be treated with systemic fluoroquinolones (e.g., ciprofloxacin).

Pharmocologic therapy for candida infections

Topical antifungals such as nystatin (Nyamyc, Pedi-Dri, Nystop; effective for Candida only), clotrimazole (Lotrimin), miconazole (Monistat-Derm), naftifine (Naftin), terbinafine (Lamisil), and ciclopirox (Loprox) are effective. --> Most topical antifungal creams are applied twice per day for at least 2 weeks (and up to 4 weeks) --> The patient should be instructed to apply creams sparingly because too much cream will cause skin maceration, especially in intertriginous areas. --> The cream is massaged gently into the rash and the surrounding area. The patient is advised that mild improvement in the rash may be seen in a week, but it frequently takes 2 to 4 weeks until the rash is cleared.

Tinea corporis/cruris and pedis treatment

Topical medications should be the first line of treatment. Topical terbinafine and all azoles have been shown to be safe and effective for treatment of tinea corporis, cruris, and pedis. Oral medications should be reserved for severe cases or when topical treatments have failed. Oral itraconazole, fluconazole, and terbinafine are safe and effective for the treatment of tinea corporis, cruris, and pedis. Concomitant short-term treatment with a mild corticosteroid such as hydrocortisone 1% (OTC) is effective in helping to relieve itch and inflammation.

Topical Therapy treatment for onychomycosis:

Topical treatment of onychomycosis is generally not very effective (cure rates of 10% or less), but it is worth an attempt because it is not typically associated with any serious side effects. -->ciclopirox nail lacquer 8% (Penlac) applied twice daily for 6 to 18 months or --> efinaconazole 10% topical once daily for 48 weeks or --> tavaborole 0.5% solution applied once daily for 48 weeks . Penlac should be applied evenly on the affected nail and surrounding 5 mm of skin once daily, preferably at bedtime. It should be applied over previous coats, then removed with alcohol once a week. Nail polish should not be used during treatment. Efinaconazole and tavaborole should be applied once daily over the entire nail surface and under the nail. **Initial improvement may take up to 6 months, and treatment can continue up to 48 weeks.

Transmission of tinea

Transmission occurs primarily through direct contact with an infected person or animal (dogs, cats). Other modes of transmission include contact with asymptomatic carriers who can infect family members and close contacts, or contact with soil.

Treatment of Tinea Pedis

Treatment of tinea pedis should emphasize moisture control; drying foot powders (miconazole, tolnaftate) are very helpful. If weeping areas are present, compresses made from Burow's solution are beneficial. The feet should be exposed to air as much as possible; during warm weather, the use of airy sandals or going barefoot is helpful. If socks are worn, cotton or a synthetic "wicking" blend is the best material. Socks should be changed once a day; changing socks twice a day is indicated if the patient's feet become wet within the next 4 hours. An antiperspirant spray on the soles of the feet (to be applied on normal skin only) can help patients with excessively sweaty feet. Severe tinea pedis can be treated with oral agents such as itraconazole or terbinafine daily. After a short course of systemic therapy, the patient should be placed on maintenance topical therapy with an antifungal powder or a spray (miconazole, tolnaftate) to prevent recurrences.

Vaginal candidiasis

Trichomoniasis Bacterial vaginosis Contact dermatitis

Ulcerative Tinea Pedis objective presentation

Ulcers and erosions in web spaces with secondary bacterial infection (Most commonly staph aureus)

dermatophytoses (tinea)

are superficial skin infections caused predominantly by three fungal species: Trichophyton, Epidermophyton, and Microsporum.

Management of Tinea infections requiring systemic antifungal treatment

for all patients who are on systemic antifungals, physician consultation is recommended because systemically absorbed antifungal drugs can cause hepatotoxicity. A baseline liver function profile should be done initially and repeated again in 4 weeks and periodically thereafter during the course of treatment. A baseline complete blood count (CBC) and another repeated in 4 weeks are recommended. Thereafter, a follow-up CBC can be done at 4- to 6-week intervals.

In distal and lateral subungual onychomycosis

infection starts at the distal or lateral margins of the nail. The infection then moves toward the center of the nail until the entire nail is affected. Distal subungual onychomycosis is almost always caused by T. rubrum. Superficial white onychomycosis involves infection of the nail surface only and is caused mainly by T. mentagrophytes.

Onychomycosis (Tinea unguium)

is a benign superficial infection of the toenails and fingernails, which negatively affects their appearance and may lead to dystrophic changes.

Total dystrophic onychomycosis

is associated mostly with chronic candidiasis, which is seen in severely immunodeficient states such as AIDS.

T. mentagrophytes tinea pedis

is associated with burning pruritus and sometimes pain. It is more likely to flare up during warm weather, forming multiple vesicles and bullae. It can become secondarily infected with bacteria, resulting in cellulitis or even lymphangitis.

Vaginal infection with C. albicans

is common; it occurs in up to 75% of women at some point in their lifetime (pregnant women and patients with diabetes are at increased risk).

Which patient population is likely to have Tinea capitis (ringworm of the scalp)

is more common in children until puberty when, for unknown reasons, the incidence markedly decreases.

Objective symptoms of Tinea Cruris

is more common in men in the summer or during warm weather. It is usually extremely pruritic, and most lesions will show some lichenification from chronic scratching. The typical lesion is round to a half-circle and will spread to the inner medial upper thigh but spare the scrotum. The color of the lesion, depending on whether it is chronic or acute, can vary from bright red to a dull discoloration. The lesions can become macerated from infection and scratching; they may become secondarily infected with bacteria or C. albicans.

Which patient population is more likely to have Tinea cruris (jock itch)

is more common in men, and T. rubrum is the typical agent. Tinea unguium (onychomycosis) occurs more frequently in adults and elderly patients.

moccasin type tinea pedis objective presentation

is seen more often with T. rubrum infection. Scaling and thickening of the skin is seen in a moccasin distribution on both feet.

Tinea Versicolor objective symptoms

is usually asymptomatic; it is not associated with pruritus. The patient will present with oval to round, pink or hypopigmented or hyperpigmented macules, located mainly on the back, chest, arms, and sometimes the neck and face.

Who is more likely to have Tinea unguium (onychomycosis)

occurs more frequently in adults and elderly patients.

proximal subungual onychomycosis

the pathogen enters the nailbed through the posterior nail and cuticle area, then migrates to the proximal nailbed. This form of onychomycosis is most commonly seen in immunocompromised individuals who exhibit suboptimal T-cell function.

Factors that increase the risk of onychomycosis include:

wearing occlusive shoes, diabetes mellitus, participation in sports, increasing age, and poor circulation of the lower extremities.

Who has a higher prevalence of vulvovaginal candidiasis?

women of reproductive age and African American ethnicity.

Cutaneous infections caused by Candida include the following:

• Infections of infancy: thrush, diaper dermatitis • Oral infections: oral candidiasis (thrush), angular cheilitis • Genital infections: vulvovaginitis, balanitis • Intertriginous (skinfold) infections: cutaneous candidiasis of the inframammary area, groin, axillae, web spaces of the fingers or toes, perianal area • Other infections: folliculitis, candidal paronychia, subungual candidiasis (beneath the nail)

Tinea infections are classified by their location on the body; different types include the following:

• Tinea capitis/ringworm of the scalp • Tinea corporis/ringworm of the body,(AKA: tinea circinata) • Tinea cruris or ringworm of the groin, also known as "jock itch" • Tinea pedis or "athlete's foot" • Tinea manuum or tinea of the hands • Tinea versicolor, also known as pityriasis versicolor • Tinea unguium (onychomycosis)