Dermatophyte infection
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Transcript Dermatophyte infection
Superficial fungal infection
15 October 2011
Dr. Cheng Tin-sik 鄭天錫醫生
Specialist in Dermatology & Venereology
(Social Hygiene Service, CHP, DH)
Clinical Assistant Professor (Hon.), CUHK
1
Superficial fungal
infections
2
Prevalence: ~ 29.4 million cases
Annual economic burden
USD$1,953,000,000 in expenses
USD$450,000,000 in indirect costs
Ranked 4th among 22 skin disease groups
evaluated in terms of direct costs
USD$1.7 billion with 74% of costs attributable to
prescription drugs
an estimated average of 4,124,038 ± 202,977 annual
visits during the study period
(N.B. 2010: 308 million)
•
Dermatophyte infection
•
Superficial candidosis
•
one of the most common human infectious diseases in the
world
3 genera: Trichophyton, Microsporum, Epidermophyton
Involving the skin, nails, and mucous membranes of the mouth
& vagina
Candida albicans 80-90%
Pityriasis versicolor
Superficial fungal infection:
Dermatophytosis
4
Practical tips for management
(Dermatophyte infection)
5
Clinical features
asymmetrical
active margin with central
clearing
fungal infection elsewhere
Investigation
skin scraping
nail clipping
microscopy, culture or
histology
Direct examination
6
microscopy of skin, nail and hair specimens with 10%
KOH
simplest
cheapest
immediate identification of spores and hyphae
e.g. confirms the dx of tinea capitis
Differentiates btw endothrix or ectothrix infection
Drawbacks of KOH microscopy
Sensitivity:
tinea capitis: 67 to 91%
tinea pedis 73.3% (95% CI: 66.3 to 79.5%)
Onychomycosis: 80%
Low specificity: 42.5% (36.6 to 48.6%); 72% (onychomycosis)
Unable to differentiate between dermatophytic /
Nondermatophytic infections
Direct examination - Stains
7
Staining increases sensitivity of direct examination
by facilitating the visualization of fungal structures
Stains that can be associated to clearing agents
Chlorazol black E (CBE)
stains only the fungal structures & excludes many artefacts
KOH–CBE as sensitive as histopathologic analysis using PAS stain
94.3% vs. 98.8%, NS
Blue–Black Ink permanent (Parker Quink)
stains fungal elements in deep blue
Congo red
binds to polysaccharides of the fungal cell wall, particularly beta-D-glucans
Fluorochromes
Calcofluor white
Most convenient
binds to chitin
may be used in KOH
Fungal elements appear blue or green
sensitivity significantly higher with calcofluor than with KOH
fluorescence microscope
88% and 72%, respectively, P = 0.0116 (Abdelrahman et al)
Tinea capitis
8
occurs predominantly in prepubertal children
Source:
infected puppies & kittens
close contact with infected children
Usually caused by Trichophyton tonsurans, Microsporum
canis, Microsporum audouinii
The causative agent varies in different geographical areas.
In the USA and in some cities in the UK, T. tonsurans is the most common cause
In Hong Kong, tinea capitis is usually caused by M. canis
Pet exposure: associated with M. canis
Tinea capitis
9
Three patterns of invasion:
Ectothrix
Arthroconidia found around the hair shaft
Endothrix
Arthroconidia within the hair shaft
Favus
Hyphae and air spaces found within the hair shafts
caused by T. schoenleinii infection
results in a honeycomb destruction of the hair shaft
fluorescence under Wood’s light
presence of pteridine
Many species producing a small spore ectothrix pattern
T. schoenleinii
Tinea capitis
10
Clinical features:
Itch
Scalp scaling
Irregular, patchy hair loss
Lymphadenopathy
More severe inflammatory responses:
Erythema
Pustules / Pustular boggy masses
Crusting
Scarring alopecia
Id reaction: itchy papules around the outer helix of the ear
Tinea capitis
11
Seborrhoeic pattern
dandruff-like scaling on the scalp
Prepubertal children p/w suspected seborrhoeic dermatitis
on the scalp: presumed to have tinea capitis until proven
otherwise
Black dot pattern
patchy alopecia with black stumps of broken hair shaft:
due to breakage of hair near the scalp
Kerion
boggy masses covered with pustular folliculitis
scarring may ensue afterwards
Favus
most frequently caused by T. schoenleinii
yellow saucer-shaped adherent crusts made up of hyphae
and spores occur around the hairs
Tinea capitis
12
DDx
Seborrhoeic dermatitis
scaling of the scalp without significant hair loss
Alopecia areata
usually complete alopecia in the affected areas (vs patchy alopecia in T.
capitis)
little or no scaling or inflammation
Exclamation mark hair
Psoriasis
usually more scaling is present.
Traction alopecia
stress on the hair & hair shaft by tight braiding
Trichotillomania
obsessive compulsive disorder of pulling one's own hair
hair of various lengths & no scalp involvement
Tinea capitis - Ix
13
scrape affected areas with a blunt scalpel
blade
to collect affected hairs, broken-off hair stubs, and scalp
scale
also pluck hairs from affected areas if possible
not suitable for detecting carriers
No abnormal areas to take scrapings
Store at room temperature. No need to refrigerate
If not possible / in an asymptomatic carrier
brush with an unused toothbrush or cytobrush
passing the brush through the hair ten times in the affected
area
in suspected carriers: different areas of the scalp
send the brush for culture
Tinea faciei
14
Asymmetric erythematous eruption
Affecting the glabrous skin of the face
the redness & the scaling border usu. less pronounced
typical annular pattern frequently absent
+/- pustules
Clue: the presence of red borders which are well demarcated and
are often serpiginous.
Usually caused by T. rubrum or T. mentagrophytes var.
mentagrophytes.
Tinea faciei: DDX
15
Seborrhoeic dermatitis
usually symmetrical and the lesions are not well demarcated.
Photodermatitis
usually symmetrical
sparing areas that are relatively protected from the sun
Perioral and contact dermatitis
Rosacea
Lupus erythematosus
Acne vulgaris
Psoriasis
Tinea manuum
16
Diffuse hyperkeratosis of the palms and digits
Involvement of palmar creases
Usually affecting only one hand
usually in a patient with tinea pedis resulting in ‘two
feet and one hand syndrome’.
+/- Tinea unguium of the involved hand
Dermatophytes involved:
the same as those for tinea pedis and tinea cruris
T. rubrum, T. mentagrophytes, and E. floccosum
Tinea manuum
17
Conditions confused with tinea manuum
xerosis, eczema & chronic irritant contact dermatitis
chronic scaling of the palms
both palms usually involved & the border not well demarcated
Psoriasis affecting the palms
presence of well demarcated scaling plaques occurring
bilaterally
plaques more elevated & erythematous
+/- lesions of psoriasis in other parts of the body
Tinea corporis
18
dermatophyte infection of the glabrous skin of the
trunk and extremities
T. rubrum and T. mentagrophytes
Pink-to-red annular or arciform patches and plaques
scaly or vesicular borders
expanding peripherally with a tendency for central clearing
Inflammatory follicular papules may be present at the active border
19
Majocchi’s granuloma
follicular epithelium grossly involved resulting in folliculitis
in the setting of immunosuppression
localized (e.g. a potent topical steroid)
systemic immunosuppression
Mainly caused by T. rubrum
C/F: inflammatory papular, pustular or nodular lesions mainly on the limbs or
face
Tinea gladiatorum
transmission of a dermatophyte infection from close skin-to-skin contact of
athletes
Tinea incognito
Topical steroids modify the presentations of fungal infections
the inflammatory response decreased
well defined margins or scaling absent
diffuse erythema +/- scales
papules and pustules may be found
T. corporis:
20 DDx
Nummular eczema
the coin-shaped lesions usually multiple & located on the extremities
usually no central clearing
Pityriasis rosea
The herald patch is frequently mistaken for tinea
Usu. followed by a generalized eruption within a few weeks
Annular psoriasis
usually thicker and more scaling than those of fungal infections
Erythema annuulare centrifugum
the scale is inside the elevated border
Granuloma annulare
no scaling and the border is more indurated
Tinea cruris
Flexural tinea usu. occurs in the groin
N.B. 3 major causes of a groin rash:
tinea cruris, candidiasis, intertrigo
Rare in axillae or submammary folds
Rare to extend onto the scrotum
Infection from patient’s own feet
Well defined patch with leading scaly edge
Asymmetrical
May extend to gluteal fold & buttocks
21
T. cruris: DDx
Candidiasis
Erythrasma
Intertrigo
Flexural psoriasis
Seborrhoeic dermatitis
Contact dermatitis
Pseudoacanthosis nigricans
Hailey-Hailey disease
Extramammary Paget’s disease
Langerhan’s cell histiocytosis
22
Tinea pedis
23
Interdigital type:
erythema, scaling and maceration with fissures found in
the web spaces
Esp.between the 4th and 5th toes
Moccasin type:
diffuse scaling on the soles extending to the sides of
the feet
Ulcerative type:
begins in the 2 lateral interdigital spaces
extends to the lateral dorsum and the plantar surface of
the arch
The lesions of the toe webs are usually macerated and
have scaling borders
Vesiculobullous type
vesicular eruptions on the arch or side of the feet are
found
Pompholyx like lesions on the hands are the classic
dermatophytid reaction
Tinea pedis
24
Dyshidrotic eczema & contact dermatitis
frequently confused with the vesiculopustular type of tinea pedis
the vesicles are usually smaller and rarely progress to pustules
Other differential diagnoses
eczema, soft corn
juvenile plantar dermatosis
Erythrasma
bacterial infections e.g. pseudomonas
Psoriasis/pustular psoriasis
secondary syphilis
Tinea unguium
25
dermatophytes & non-dermatophytes can cause
onychomycosis
yeasts or non-dermatophyte moulds: <10%
Dermatophytes: ~90% of cases
Toenail >fingernail infections
usually tinea pedis +ve
Tinea unguium
Clinical presentations:
26
Distal and lateral subungual onychomycosis (DLSO):
Discolouration, subungual hyperkeratosis, distal onycholysis start at
the hyponychium spreading proximally
Proximal subungual onychomycosis (PSO):
Invasion of the nail unit under the proximal nail fold and spread distally
usually associated with immunosuppressed conditions, e.g. HIV
infection
Superficial white onychomycosis (SWO):
Invasion of the superficial layers of the nail plate but do not penetrate it
leading to a white, crumbly nail surface
Total dystrophic onychomycosis
complete dystrophy of the nail plate
Tinea unguium: specimen collection
27
Wipe with 70% alcohol before sampling.
Superficial infection:
scrape the surface of the nail with scalpel
Nail clipping:
sample the full thickness of the nail as proximal as possible
Include the scrapings of s/u debris
Put the samples into folded dark paper squares and store at
room temperature
Tinea unguium: investigations
28
Nail clippings / scrapings x fungal microscopy and culture
Positive results:
Dermatophytes: if either microscopy or culture is positive.
Candida species: if both microscopy and culture are positive.
Non-dermatophytes: if both microscopy and culture are positive on at least two samples taken at different times.
Non-dermatophyte moulds:
microscopy of nail specimens with 10% KOH
rare causes of nail infection
usually colonize nails as a secondary infection following trauma or an underlying dermatophyte infection.
Sensitivity: 80%; Specificity: 72%
Unable to differentiate between dermatophytic / Nondermatophytic infections
Culture
a few weeks for definite identification
Sensitivity: 59%; Specificity: 82%
false negative common
culture identification complicated
High false-negative rates
Based on macroscopic & microscopic morphology and pigmentation
dermatophyte isolates from patients on antifungal treatment generally do not show characteristic morphology on culture
A negative test cannot definitively exclude fungal nail infection.
Repeat if clinical suspicion high
Periodic acid schiff (PAS) stain for the presence of dermatophytes
higher sensitivity (vs. KOH preparations)
Karimzadegan-Nia et al, 2007; Lawry et al, 2000; Weinberg et al, 2005
Non-dermatophyte moulds
29
comprise a large group of heterogeneous filamentous fungi
usually considered saprophytic
under suitable conditions, some of these species may cause true infections
Nail invasion by NDM considered uncommon
prevalence rates: ranging from 1.45% to 17.6%
only a few species of moulds are regularly identified as causing onychomycosis
Acremonium sp, Aspergillus sp, Fusarium sp, Onychocola canadiensis, Scytalidium sp and Scopulariopsis
brevicaulis
NDM: sensitive to cycloheximide
use the Sabouraud’s dextrose agar without cycloheximide
The criteria for establishing a diagnosis of NDM nail infection:
1) repeated isolation of the fungus on direct examination of well-sampled specimens
2) repeated positive culture of a species of fungus consistent with the finding on direct microscopic
examination
3) failure to isolate dermatophytes in the culture
Management of superficial fungal infection: Gerneral
30
principles
General advice: e.g avoid sharing of towels and clothing; keep the affected
areas cool and dry; frequent washing of clothes, linen; etc.
Topical antifungals
Advantages of topical antifungals vs oral antifungals
Less risk of adverse effects
Fewer drug interactions
Laboratory tests not needed to monitor treatment
Prolonged use of a steroid-antifungal cream
may not cure the infection
May cause striae
Systemic treatment
Tinea captitis & tinea unguium
severe or extensive disease
Failed topical treatment
topical treatment may be tried in most other superficial fungal infections.
Topical preparations for fungal infections
31
applied to the affected area
for 2-4 weeks
including a margin of several
centimetres of normal skin
Continue for 1 or 2 weeks after
the last visible rash has cleared
Azoles
Bifonazole
Clotrimazole (Canesten,
Lotremin)
Econazole
Ketoconazole
Miconazole (Daktarin)
Sulconazole
Tioconazole (Trosyd)
Allylamine
Terbinafine
Naftifine
Ciclopiroxolamine
Polyenes
Nystatin
Thiocarbamates
Tolnaftate
Tolciclate
Others
Whitfield's ointment
Undecylenic alkanolamide
Tinea capitis: treatment
32
A +ve microscopy / +ve culture of skin scrapings recommended before starting
treatment
Griseofulvin
500 mg once daily or 250 mg BD; 10-25
mg/kg/d x 8–10/52;
standard treatment in the pediatric population
Terbinafine
250 mg once daily x 4/52
not licensed for tinea capitis in the UK
FDA approved for children > 4 yr ( < 25 kg: 125 mg/d; 25-35 kg: 187.5mg/d; > 35kg: 250mg/d)
Adjunctive treatment
topical antifungal treatment 2x/week
ketoconazole shampoo, selenium sulphide shampoo, or topical terbinafine cream
during the first 2 weeks of treatment to reduce transmission.
oral antibiotic e.g. flucloxacillin & an antifungal cream active against Gram (+) organisms (e.g. miconazole,
clotrimazole, econazole)
For secondary infection
33
Seven studies, 2163 subjects
Subgroup analysis
terbinafine was more efficacious than griseofulvin in treating Trichophyton
species (1.616; 95% CI = 1.274- 2.051; P < 0.001)
griseofulvin was more efficacious than terbinafine in treating Microsporum
species (0.408; 95% CI = 0.254-0.656; P < 0.001)
Both griseofulvin and terbinafine demonstrated good safety
profiles in the studies.
J Am Acad Dermatol 2011;64:663-70
Tinea capitis: Management of contacts
34
Contacts screened for clinically silent fungal carriage on
the scalp:
household members
people closely associated with the infected person
screening in schools is not necessary
Asymptomatic carriers should be detected and treated
Take samples for microscopy and culture
Management:
treat with
selenium sulphide
ketoconazole shampoo
povidone iodine shampoo (shown to be more efficacious)
people with a heavy growth / high spore count on brush culture
may require oral antifungal treatment
Tinea corporis / cruris
35
topical terbinafine (moderate evidence) & topical imidazoles (weak
evidence)
Efficacious in the treatment of fungal infections of the groin and body
Insufficient trial evidence: superiority of one preparation over another
imidazoles currently the most commonly used topical treatments for fungal infections of the
skin
For inflamed lesions
topical antifungal combined with a mildly potent corticosteroid: <= 1 wk
Do not give a corticosteroid preparation alone
Combination preparation:
beware of the increased risk of adverse effects with topical corticosteroids in occluded areas e.g.
groins
Tinea pedis: treatment
36
Allylamines, azoles, butenafine, ciclopiroxolamine, tolciclate & tolnaftate
all efficacious relative to placebo in the treatment of tinea pedis
Allylamines
greater effectiveness when used for longer
The effectiveness of azoles improved over time
No difference in treatment failure rates between any of the individual azoles
allylamines more efficacious than azoles
The meta analysis of 8 trials and outcomes from 962 participants supports the finding that
allylamines are more effective than azoles when applied for between 4 to 6 weeks
37
Terbinafine and itraconazole
Terbinafine (two weeks treatment)
more effective than itraconazole (two weeks treatment)
Terbinafine
more effective than no treatment (placebo)
more effective than griseofulvin
No significant difference in effectiveness found between:
two weeks of terbinafine vs four weeks of itraconazole
fluconazole vs either itraconazole or ketoconazole
griseofulvin and ketoconazole
different doses of fluconazole
Recommendation:
to treat initially with topical azoles and use topical allylamines for azole treatment failures
Tinea unguium: treatment
38
Confirm the diagnosis before treatment
positive microscopy or culture
Mild and superficial TU:
Superficial onychomycosis
Mild distal onychomycosis
Lateral onychomycosis
topical tx with amorolfine 5% nail lacquer
6 /12 (fingernail)
9–12 /12 (toenail)
Amorolfine 5% nail lacquer 1x/wk
not approved in the USA
6% treatment failure rates found after 1 month of treatment
data collected on a very small sample of people
these high rates of success might be unreliable.
Tinea unguium: treatment
Ciclopiroxolamine 8% nail lacquer: QD
Combining data from 2 trials of ciclopiroxolamine versus placebo:
Treatment failure rates: 61% & 64% for ciclopiroxolamine
These outcomes followed long treatment times (48 weeks)
ciclopiroxolamine -> a poor choice for nail infections
Butenafine 2%:
treatment failure rate: 20%
Used in combination with oral treatment: increase cure rates
No good evidence from randomized controlled trials on other topical
treatments for dermatophyte nail infections:
Topical tioconazole / salicylic acid/ undecenoates.
Topical treatments for fungal infections of the skin and nails of the foot. (Review) 22
Copyright © 2009 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Tinea unguium: treatment
40
Oral terbinafine
250 mg daily: 6/52 for F/N, 12/52 x T/N
oral terbinafine may be more effective than oral itraconazole (weak evidence from RCTs)
A meta-analysis of 18 studies: a mycological cure rate of 76%.
fewer drug interactions vs. azole antifungals
CYP2D6 inhibitor: inc. effect of TCA; Beta blockers & antipsychotics (possible)
adverse effects: usually mild and transient
Oral itraconazole
200 mg bd x 1 wk per pulse, 2 to 3 pulses
oral itraconazole may be less effective than oral terbinafine (weak evidence from RCTs)
A meta-analysis of 6 studies on pulse itraconazole: mycological cure rate of 63%
Pulsed therapy recommended:
no good evidence that it is less effective than continuous therapy;
risks of adverse effects may be reduced
N.B. this dosing regimen is not licensed
Take with fatty meal/ acidic beverage
Pityriasis versicolor
41
Commensal yeast: Malassezia species
occurs most frequently in hot and humid tropical climates
also prevalent in temperate climates
Malassezia has an oil requirement for growth
increased incidence in adolescents
predilection for sebum-rich areas of the skin
use of bath oils and skin lubricants may enhance disease
development
Pityriasis versicolor occurs
when the budding yeast form transforms to the mycelial form
Various factors implicated:
e.g. hot and humid environment, oily skin and excessive sweating.
42
Multiple white, pink to brown, oval to round coalescing macules and
patches
mild and fine scaling
mainly found on the seborrhoeic areas
especially the upper trunk and shoulders
also found on the face, scalp, antecubital fossae, submammary regions and groins
often confluent and quite extensive
Flexural areas: sometimes referred to as ‘inverse’ pityriasis versicolor
Associated scale may be shown by scratching of the skin surface
Produce chemicals that reduce the pigment in the skin, causing whitish
patches
azelaic acid, pityriacitrin and malassezin
ability of the fungus to filter sunlight and the screening effect of
tryptophan-dependent metabolites
absence of pigmentation in exposed areas
43
Wood's light:
a yellow-green fluorescence may be observed in affected
areas
due to pityrialactone
Skin scrapings x microscopy (KOH):
clusters of yeast cells and long hyphae
like "spaghetti and meatballs“
Malassezia species: difficult to grow in the
laboratory
scrapings may be reported as "culture negative“
grows best if a lipid such as olive oil added to Littman agar
culture medium
Malassezia species
44
Pityriasis versicolor
not considered to be contagious
Infection not due to poor hygiene
Inhabit the skin of about 90% of adults without causing harm
suppresses the expected immune response to it in some:
allowing it to proliferate & cause a skin disorder
often without any inflammatory response.
Malassezia
45
Members of the genus Malassezia
formerly classified as Pityrosporum
species
P. ovale (oval cells) and P. orbiculare (round
cells)
Malassezia is the correct name for this
genus
Identification of isolates from pityriasis
versicolor (PV) using the new
nomenclature:
the causal species more likely to be M.
globosa or M. sympodialis
Malassezia furfur believed to be the
causal organism of PV prior to the
description of the new species in 1996
Malassezia furfur
Malassezia sympodialis
Malassezia globosa
Malassezia restricta
Malassezia obtusa
Malassezia slooffiae
Malassezia pachydermatis
Malassezia yamatoensis
Malassezia dermatis
Malassezia nana
Malassezia japonica
Treatment
46
Treat with shampoo
Ketoconazole 2% shampoo once-daily to
affected areas for 5/7
Selenium sulphide 2.5% shampoo once-daily
to the affected areas for 7 days.
off-label indication
may cause skin dryness and irritation
Smell: unpleasant
Lather and leave it on for 10’ then rinse off
For small affected areas:
Imidazole creams 2–3 weeks
Lather and leave it on for 5’ then rinse off
e.g. clotrimazole, econazole, ketoconazole, or
miconazole
Systemic Treatment:
itraconazole 200 mg once daily for 7 days
fluconazole 50 mg once daily for 2–4 weeks
(licensed) or a 300 mg dose once weekly for
4 weeks (off-label).
consider prophylactic treatment
e.g. prior to exposure warm humid
environments or sunshine
ketoconazole 2% shampoo once daily x a
maximum of 3 days prior to sun exposure
limited evidence that weekly or monthly doses of
oral antifungals are effective in preventing
recurrence, but optimal regimens have not been
established
Candidiasis
Cutaneous candidosis less common than
dermatophytosis
Candida species
capable of producing skin and mucous membrane infections
~200 species
~20 of them associated with human or animal infections
e.g. C. albicans, C. tropicalis, C. glabrata, C. parapsilosis, C. krusei, C.
guilliermondii
C. albicans accounting for most of the infections
found among the commensal flora of the
diseased skin, mouth, vaginal tract, and
gastrointestinal tract
48
Become a pathogen in predisposed conditions
e.g. infancy, pregnancy, occluded sites, diabetes, Cushing’s syndrome,
immunosuppression, imbalance in the normal microbial flora, etc
Predisposing factors:
Large skin folds retain heat & moisture:
environment suited for yeast infection
E.g. older women with pendulous breasts, obese patients with overhanging skinfolds
Hot, humid weather; tight or abrasive underclothing; DM, poor hygiene.
Inflammatory diseases in skinfolds
e.g. psoriasis and the use of topical steroids favour yeast growth within fold areas
49
Rash:
red, macerated and well demarcated
surrounded by satellite papules and pustules
A fringe of moist scale might be found at the border
In the skin, pustules are formed
dissect under the stratum corneum peeling it away resulting in a red, denuded/macerated, glistening surface
with a long, cigarette paper-like, scaling and advancing border
Pustules rupture to form a superficial collarette of scale
Rash: sore rather than itchy.
Usually found in the intertriginous skin folds and other moist, occluded sites
genital area / area covered by diaper
flexures, e.g. the groin, axillae, finger & toe webs
In diaper dermatitis caused by Candida
bright red plaques in the inguinal and gluteal folds and satellite pustules may be found
Candidal infection is a frequent cause of chronic paronychia
manifesting as painful periungual erythema and swelling
associated with secondary nail thickening, ridging and discoloration.
Oropharyngeal candidiasis
50
white plaques and pustules on oral mucosal surface
leaving a raw, bleeding base when removed mechanically
Candida balanitis
more commonly found in the uncircumcised
usually presents with red patches, swelling and tiny pustules
Candida vulvovaginitis
usually causing itchiness and soreness, a curd-like discharge, pustules,
erythema and oedema of the vagina and vulva are found
Perianal candidiasis:
Pruritus ani & maceration usually found
Chronic mucocutaneous candidiasis
associated with a hetererogeneous group of autoimmune, immunologic and endocrinologic
diseases
characterized by recurrent or persistent superficial candidal infections
due to an impaired cell-mediated immunity against Candida species
51
DDX of cutaneous candidiasis
includes tinea, intertrigo, erythrasma, seborrhoeic dermatitis,
psoriasis, etc.
Investigations
Microscopy:
pseudohyphae and yeast forms
Isolation of the fungus in culture & its identification
In patients with recurrent candidiasis
Test for diabetes mellitus & other conditions producing
immunosuppression
Candidiasis: management
General:
drying, weight reduction, air-conditioning
Nystatin cream or topical imidazole cream BD
If perianal skin involved: + Nystatin 100,000 units
QID for 5/7
oral fluconazole treatment 50 mg daily for
2 weeks
Useful in resisitant cases and for extensive or severe candidiasis
52
THE53END
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