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Ms. Jones brings 6-week-old Sam to the clinic because of a bright red rash in the diaper area that has gotten worse since she started putting over-the-counter antibiotic cream on it 3 days ago. Sam is diagnosed with diaper Candida or a yeast infection. Clotrimazole (Lotrimin) topical TID for 14 days to the diaper area has been prescribed.
Develop a teaching plan for Ms. Jones including age-appropriate considerations for Sam. Chapter 12:
Fungal Infections of the Skin
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Fungal Infections of the Skin
• Tinea
• Tinea versicolor
• Candidiasis
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Types of Tinea Infections
• Tinea capitis: head
• Tinea corporis: body
• Tinea pedis: foot
• Tinea manus: hand
• Tinea unguium (onychomycosis): nails
• Tinea cruris: groin
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Factors Predisposing People to Fungal
Infections
• Warm, moist, occluded environments
• Family history
• Compromised immune system
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Five Species of Fungus Causing Most
Infections
• Trichophyton rubrum
• Trichophyton tonsurans
• Trichophyton mentagrophytes
• Microsporum canis
• Epidermophyton floccosum
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Diagnostic Criteria for Fungal Infections
• Symptoms
– Pruritus, burning, and stinging of the scalp or skin,
possible erythema and vesicles with inflammatory
dermal reactions.
• Diagnostic tests
– Microscopic evaluation of the stratum corneum with
10% potassium hydroxide (KOH) preparation
– Fungal culture
– Wood lamp (identifies only Microsporum)
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Tinea Capitis Presentation
• Inflamed, scaly, alopecic patches, especially in infants
• Diffuse scaling with multiple round areas with alopecia
secondary to broken hair shafts, leaving residual black
stumps
• “Gray patch” type with round, scaly plaques of alopecia
in which the hair shaft is broken off close to the surface
• Tender, pustular nodules
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Tinea Corporis
• Called “ringworm” when it affects the face, limbs, or
trunk but not the groin, hands, or feet
• Presentation: ring-shaped lesion with well-demarcated
margins, central clearing, and a scaly, erythematous
border
• Causes: contact with infected animals, human-to-human
transmission, and from infected mats in wrestling
• Organisms responsible: M. canis, T. rubrum, and T.
mentagrophytes
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Tinea Cruris
• Often referred to a “jock itch.”
• A fungal infection of the groin and inguinal folds, tinea
cruris spares the scrotum.
• Causes are T. rubrum or E. floccosum.
• Symptoms: lesions that are large, erythematous, and
macular, with a central clearing; a hallmark is pruritus or
a burning sensation.
• Often fungal infection of the feet is present.
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Three Types of Tinea Pedis
• Interdigital: scaling, maceration, and fissures between
the toes
• Plantar: diffuse scaling of the soles, usually on the entire
plantar surface
• Acute vesicular: vesicles and bullae on the sole of the
foot, the great toe, and the instep
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Characteristics of Tinea Manus
• Dermatophyte infection of the hand
• Always associated with tinea pedis and usually unilateral
• Lesions marked by mild, diffuse scaling of palmar skin
• Vesicles may be grouped on the palms or fingernails
involved
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Tinea Unguium
• Fungal infection of the nail; typically the toenails.
• Nails become thick and scaly with subungual debris.
• Onycholysis (nail separation from bed) may occur.
• Under the nail, a hyperkeratotic substance accumulates
that lifts the nail up.
• Organisms causing onychomycosis: dermatophytes, E.
floccosum, T. rubrum, T. mentagrophytes, Candida
albicans, Aspergillus, Fusarium, and Scopulariopsis.
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Question
• Upon physical examination, a practitioner notes a ringlike lesion with a scaly, erythematous border on the
trunk of a child. What fungal infection would the
practitioner suspect?
A. Tinea capitis
B. Tinea corporis
C. Tinea cruris
D. Tinea pedis
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Answer
• B. Tinea corporis
• Rationale: Tinea corporis is called “ringworm” when it
affects the face, limbs, or trunk. The typical presentation
of tinea corporis is a ring-shaped lesion with welldemarcated margins, central clearing, and a scaly,
erythematous border. Tinea capitis affects the scalp,
tinea cruris affects the groin, and tinea pedis affects the
feet.
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Initiating Drug Therapy for Fungal
Infections
• Prevention: applying powder containing miconazole
(Monistat) or tolnaftate (Tinactin) to areas prone to
fungal infections after bathing and blow drying on low
temperature
• Goals of drug therapy: directed against the offending
fungus and site of infection; may be topical or systemic
depending on location of lesions
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Topical Azole Antifungals
• Action: work by pairing the synthesis of ergosterol, the
main sterol of fungal cell membranes, allowing for
increased permeability and leakage of cellular
components, resulting in cell death.
• Uses: effective against tinea corporis, tinea cruris, and
tinea pedis as well as cutaneous candidiasis.
• Dosage: applied once or twice a day for 2 to 4 weeks.
Therapy should continue for 1 week after the lesions
clear.
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Topical Allylamine Antifungals
• Action: effective against dermatophyte infections but
have limited effectiveness against yeast
• Dosage: shorter treatment period with less likelihood of
relapse; applied twice daily
• Adverse events: burning and irritation
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Griseofulvin
• Action: deposits in keratin precursor cells increasing new
keratin resistance to fungal invasion.
• Adverse events: nausea, vomiting, diarrhea, headache,
or photosensitivity.
• Interactions: increases levels of warfarin (Coumadin) and
decreases levels of barbiturates and cyclosporine
(Sandimmune). It may decrease the efficacy of oral
contraceptives and may cause a serious and unpleasant
reaction with alcohol.
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Systemic Allylamine Antifungals
• Action: inhibits squalene epoxidase, a key enzyme in
fungal biosynthesis, causing a deficiency of ergosterol
causing fungal cell death
• Dosage: fingernail onychomycosis: 250 mg/d for 6
weeks; toenail onychomycosis: 250 mg/d for 12 weeks
• Adverse events: diarrhea, dyspepsia, rash, increase in
liver enzymes, and headache
• Interactions: potentiated by cimetidine (Tagamet) and
antagonized by rifampin (Rifadin)
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Systemic Azole Antifungals
• Action: inhibit cytochrome P-450 (CYP) enzymes and
fungal 14-a-demethylase, inhibiting synthesis of
ergosterol. Systemic therapy is required for tinea capitis
and tinea unguium.
• Dosage: dosage of itraconazole is 200 mg once daily for
12 weeks for toenail infection. For fingernail infection,
the dose is 200 mg twice daily for 1 week, then 3 weeks
off, and repeat dosing with 200 mg twice daily for 1
week.
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Question
• For which fungal infection would the practitioner use as
first-line therapy a systemic fungicide?
A. Tinea capitis
B. Tinea corporis
C. Tinea pedia
D. Tinea cruris
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Answer
• A. Tinea capitis
• Rationale: Topical agents work well for most tineas but
not for tinea capitis and tinea unguium. Topical therapy is
recommended for cases of tinea corporis, pedis, cruris, or
manus when the infection affects a limited area.
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Selecting the Appropriate Agent for Tinea
• Tinea capitis
– First line: griseofulvin (Grifulvin V) minimum 8 weeks
– Second line: terbinafine (Lamisil) or itraconazole
(Sporanox) 4 weeks
• Tinea corporis, tinea cruris, tinea pedia
– First line: topical azole antifungals for 2 to 4 weeks
(1 week past clinical cure), 2 weeks even after rash
is gone
– Second line: systemic therapy: terbinafine (Lamisil)
or fluconazole (Diflucan)
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Selecting the Appropriate Agent for Tinea
(cont.)
• Onychomycosis
– First line: itraconazole (Sporanox) or terbinafine
(Lamisil) 12 weeks with food; not recommended for
children
• Tinea versicolor
– First line: selenium sulfide solution 1% or 2.5%
topical azole cream or spray for localized lesions
– Second line: itraconazole (Sporanox)
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Question
• A clinician treated a patient who has tinea versicolor with
selenium sulfide solution without success. What is the
second line of therapy for this patient?
A. Topical azole
B. Terbinafine (Lamisil)
C. Fluconazole (Diflucan)
D. Itraconazole (Sporanox)
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Answer
• D. Itraconazole (Sporanox)
• Rationale: After trying selenium sulfide solution 1% or
2.5% topical azole cream or spray, the second line of
therapy for tinea versicolor is itraconazole (Sporanox).
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Patient Education for Tinea
• Teach hygiene and ways to avoid transferring fungal
infection to others.
• Complete the full course of treatment and do not stop
treatment when symptoms subside.
• Inform parents and other caregivers that children can
attend school while being treated.
• Dry areas susceptible to fungus with a hair dryer after
bathing.
• Use antifungal powder and sprays for prophylaxis.
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Tinea Versicolor (Pityriasis Versicolor)
• An opportunistic superficial yeast infection
• Causes: overgrowth of the hyphal form of Pityrosporum
ovale; occurs mostly in subtropical and tropical areas
• Action: an enzyme oxidizes fatty acids in the skin surface
lipids, forming dicarboxylic acids, which inhibit tyrosinase
in epidermal melanocytes and cause hypomelanosis
• Diagnostic criteria: well-defined skin lesions, round or
oval macules with an overlay of scales forming on the
trunk, upper arms, and neck with mild itching; confirmed
by positive KOH test
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Candidiasis
• Superficial fungal infection of the skin and mucous
membranes.
• Causes: C. albicans occurs on moist cutaneous sites in
people with infection or diabetes, or using systemic and
topical corticosteroids, and with immunosuppression.
• Action: C. albicans invades the epidermis when warm,
moist conditions prevail.
• Diagnostic criteria: red, moist papules, or pustules found
in the axillae, inframammary areas, groin, and between
the fingers and toes.
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Order of Treatment for Candidiasis
• First line: cool soaks with Burow solution, topical azole
for 10 days, oral nystatin
• Second line: itraconazole (Sporanox) or fluconazole
(Diflucan)
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Complementary and Alternative Medicine
• Apple cider vinegar
• Palin yogurt
• Tea tree oil
• Tea
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Summary
• Fungi live in the dead, horny outer layer of the skin.
• The organisms penetrate only the stratum corneum—the
surface layer of the skin.
• Fungi infect the skin, hair, and nails and cause tinea,
tinea versicolor, and candidiasis.
• An important role of the practitioner is to teach the
patient about hygiene and ways to avoid transferring
fungal infection to others.
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