Fungal Infections

Treatment of foot lesions with inflammation

Aluminum acetate solution 1:40 2-3 times/day for up to 1 wk as foot soaks or compresses Follow with antifungal treatment 2x/day for 4 weeks and nonpharm measures

Tinea

Dermatophyte infection

Tinea pedis treatment

If wet, dry; if dry, wet If small vesicles and scaling without inflammation, use antifungal and non-pharm If lesions with inflammation or wet athlete's foot, resolve inflammation or moisture before treating with antifungal and nonpharm If unsure lesions are fungal, refer

Terbinafine gel

1x day/1 wk (between toes only, not for whole foot infections)

Butenafine cream

2x day/1 wk (for infection between toes only)

Terbinafine spray

2x day/1 wk (for infection between toes only, not for whole foot)

Terbinafine cream

2x day/1 wk for infection between toes 2x day/2 wk for infection of whole foot

Clotrimazole cream

2x day/4 wk for infection between toes or on whole foot

Miconazole powder

2x day/4 wk for infection between toes or on whole foot

Miconazole spray

2x day/4 wk for infection between toes or on whole foot

Tolnaftate cream

2x day/4 wk for infection between toes or on whole foot

Tolnaftate powder

2x day/4 wk for infection between toes or on whole foot

Tolnaftate spray

2x day/4 wk for infection between toes or on whole foot

Clotrimazole and miconazole nitrate

Imidazole derivatives- inhibition of sterol synthesis, damage fungal cell wall membrane, inhibit enzyme activity of sub cellular organelles Fungistatic Side effects include irritation, burning, stinging (possible contact dermatitis with miconazole use) Used for treatment of tinea pedis, cruris, and corporis

Tinea manuum

Presents similarly to tinea pedis but on hands Inflamed red rash w/w/o vesicles, white flaking, dryness, itching, mocassin scaling Tinea pedis likely also present Prevent transmission via scratching

Chronic intertriginous tinea pedis

S/S: fissuring, scaling, maceration (skin breakdown), malodor, pruritus, stinging Most common presentation Hyperhidrosis must be treated if present

Treatment of foot lesions in wet, soggy athlete's foot with deep fissures

Aluminum chloride 10% 2x/day for up to 1 wk until fissures healed Next, aluminum chloride 20-30% 2x/day until odor, wetness, whiteness subside Then, 1x/day Next, antifungal 2x/day after aluminum chloride treatment for 4 weeks with nonpharm measures

Treatment of foot lesions in wet, soggy type of athlete's foot without fissures

Aluminum chloride 20-30% 2x/day for up to 1 wk until odor, wetness, whiteness subside, then 1x/day Antifungal 2x/day after aluminum chloride treatment for 4 wk with nonpharm measures

Treatment of foot lesions with small vesicles and scaling without inflammation

Antifungal 2x/day for 4 weeks and nonpharm measures

Barbae

Beard

Corporis

Body

Tinea corporis

Can occur on any part of body Begin as small, circular, erythematous, scaly areas and spread peripherally Borders may contain vesicles or pustules Pruritus can occur

Fungal infection self-care exclusions

Causative factor unclear, unsuccessful initial treatment or worsening of condition, nails or scalp involved, face/mucous membranes/genitalia involved, signs of possible secondary bacterial infection, excessive and continuous exudation, debilitating state, immune deficiency, systemic infection, or DM, fever, malaise

Tinea pedis types

Chronic intertriginous, chronic papulosquamous pattern, vesicular, acute ulcerative

Tinea barbae

Erythematous patches Papules and vesicles at border Hair may be broken or loose May be bacterial infection and/or inflammation

Tolnaftate 1%

Exact mechanism not understood Used for prevention and treatment of athlete's foot (dry and scaly athlete's foot) Well-tolerated and no drug-drug interactions with topical use (may sting if applied to broken skin)

Hyperhidrosis

Excessive sweating

Pedis

Feet

Aluminum acetate (Domeboro or Burow's solution)

For treatment of tinea pedis with inflammation Generally diluted with 10-40 parts of water Immerse whole foot in solution for 20 min up to TID or apply solution to affected area in form of wet dressing Treat with antifungal after inflammation is resolved (~1 wk)

Onychomycosis

Fungal infection of the fingernails or toenails

Dermatophytosis

Fungal infection of the foot

Dermatomycoses

Fungal infection of the integumentary system Often ring-shaped with clear center and red, scaly borders Symptoms may vary greatly

Undecylenic acid

Fungistatic Mild superficial fungal infections Excludes nails or hairy parts of body Product has strong odor Relatively nonirritating, burning may occur due to alcohol concentrations in solutions

Cruris

Groin

Manuum

Hands

Tinea capitis

Inflammatory or non-inflammatory Often presents with loss of hair in patches

Terbinafine hydrochloride 1%

Inhibition of squalene epoxidase results in ergosterol deficiency and eventual fungal cell death (fungicidal) Low incidence of side effects (irritation, burning/stinging and itching/dryness most common) No drug-drug interactions Used for tinea pedis (dependent on formulation), tinea cruris, tinea corporis

Fungal infection non-pharmacologic therapy

Intended to complement effects of OTC antifungals and prevent future infection Keep skin clean and dry, use separate towel to dry affected area or dry last Wash clothing and towels in hot water Avoid sharing towels, clothing, shoes Throw away shoes if they cannot be washed Minimize scratching

Pruritus

Itching

Acute ulcerative tinea pedis S/S

Macerated, denuded, weeping ulcerations on sole of foot White hyperkeratosis, pungent odor (due to secondary infection), extremely painful, rare

Garlic

May have antifungal properties Possible effectiveness in tinea pedis, corporis, cruris

Tinea cruris

Medial and upper parts of thighs and pubic area Bilateral, spares scrotum and penis (if not, refer) Elevated, demarcated margins that are erythematous Small vesicles can occur on margins Scaling, pruritus, pain when sweating, skin can become macerated

Chronic papulosquamous pattern tinea pedis S/S

Mild inflammation, moccasin scaling of soles, usually on both feet, tinea unguium may be present Nail must be treated with drugs or surgically removed if infected (nails must be treated first)

Tinea unguium (onychomycosis)

Nail becomes thick, yellow, opaque, friable and can separate from nail bed Can lead to more severe infections

Unguium

Nails

Salts of aluminum

No direct antifungal activity Relief of inflammatory conditions such as athlete's foot Possible astringent effect May cause stinging, itching, skin irritation Do not use for more than 1 wk without doctor consult (prolonged use may produce severe tissue necrosis) Useful in combination with antifungal drugs Must dilute for deep fissures D/C if lesions appear/worsen

Pathogenic fungal transmission

Occurs through contact with infected individuals (athrophilic), animals (zoophilic), soil (geophilic), or fomites Individuals with weakened immune systems, chronic health problems, or repeated trauma to feet are at increased risk of infection

Aluminum chloride

Often advertised as "no sweat" products Used to treat wet, soggy type of athlete's foot 20-30% used to treat without fissures 10% used to treat with fissures Use twice daily until S/S disappear, then once daily to control symptoms Treat with antifungal and nonpharm after this

Hyperkeratosis

Overgrowth of skin

Fungal infection treatment goals

Provide symptomatic relief, eradicate existing infection, prevent future infections

Fungal infection S/S

Pruritic is most common complaint Fissures between toes, painful burning and stinging of fissures, weeping, pain, scaling of dry skin, brittle and discolored nail Small vesicles may form larger bullies eruption with pain and irritation Weeps clear fluid, not pus

Pathophysiology of fungal infections

Remains within stratum corneum Immunologic and nonimmunologic mechanisms limit the spread of infection to stratum corneum Type IV delayed hypersensitivity response Normal resident anaerobic diphtheroids may be involved

Which fungal infection cannot be treated OTC?

Ringworm if >2 lesions

Capitis

Scalp

Butenafine hydrochloride 1% cream

Squalene epoxidase inhibitor Minimal side effects (burning, stinging most common) Relieves itching, burning, cracking, scaling of athlete's foot between toes, jock itch, ringworm Fungicidal Athlete's foot on whole foot cannot be treated with this

Dermatomycoses fungi

Trichophyton, microsporum, epidermophyton

T/F: The only true determinant of a fungal infection is lab evaluation of tissue scrapings from affected area (PCP only)

True Pharmacists triage only- importance of follow-up

Vesicular tinea pedis S/S

Vesicles, vesicopustules, skin scaling, involves instep and mid-anterior plantar surface Symptomatic in summer months