Transcript Chapter 15 Diseases Resulting from Fungi and Yeasts

Diseases Resulting from
Fungi and Yeasts
Kristy P. Gilbert, D.O.
February 8, 2005
Superficial mycoses
 AKA dermatophytes
 Cause only stratum corneum, hair and nail
infection
 Three genera: Microsporum, Trichophyton,
Epidermophyton
 Division into: 1) tinea capitis, 2) tinea barbae,
3) tinea faciei, 4) tinea corporis, 5) tinea
manus, 6) tinea pedis, 7) tinea cruris,
8)onychomycosis
Host factors
 Immunosuppressed pts- cancer, diabetes
 AIDS, connective tissue disorders
 Genetic susceptibility may be related to types of keratin
or degree/mix of cutaneous lipids produced, cutaneous
barrier compromise
 Surface antigens-ABO system-one study of 108 culture
proven dermatophytosis pts noted type A blood prone to
chronic disease
 Human steroid hormones can inhibit growth of
dermatophytes (androgens like androstenedione)
 One group believes this high susceptibility of
Trichophyton rubrum & Epidermophyton floccosum to
intrafollicular androstenedione is a reason why these
species do not cause tinea capitis
Imidazoles
 Clotrimazole, miconazole, sulconazole, oxiconazole,
and ketoconazole
 Mostly used for topical tx
 Inhibit cytochrome P450 14-alpha-demethylase (an
essential enzyme in ergosterol synthesis)
 Ketaconazole has wide spectrum against
dermatophytes, yeasts, and some systemic
mycoses
 Ketaconazole has the potential for serious drug
interactions and a higher incidence of hepatotoxicity
during long-term daily therapy
Allylamines
 Naftifine, terbinafine, butenafine
 Inhibites squalene epoxydation
 Terbinafine has less activity against Candida
species in vitro studies then triazoles, but is effective
clinically
 Terbinafine is ineffective in the oral tx of tinea
versicolor but is effective topically
 Few drug interactions have been reported
 Bioavailability is unchanged in food
 Hepatotoxicity, leukopenia, severe exanthems, and
taste disturbances uncommon, but should be
monitored for clinically and by lab testing if
continuous dosing over 6 weeks
Polyene
 Nystatin
 Irreversibly binding to ergosterol-an
essential component of fungal cell
membranes
Triazoles
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Itraconazole, Fluconazole
Affect P450 system
Numerous drug interactions occur
Need to know pt’s current meds
Broadest spectrum to dermatophytes and Candida
species, and Malassezia furfur
 Itraconazole is fungistatic- food increases its
absorption , antacids and gastric acid secretion
suppressors produce erratic or lowered absorption
 Pulse dosing limits concern over lab abnormalities
 Fluconazole’s absorption is unaffected by food
Tinea Capitis
 Occurs chiefly in schoolchildren
 Boys more frequently than girls; except epidemics
caused by Trichophyton tonsurans where there is
equal frequency
 Divided into inflammatory and non-inflammatory
 Tinea capitis can be caused by all pathogenic
dermatophytes except Epidermophyton floccosum
and T. concentricum
 In U.S. most caused by T. tonsurans
Tinea Capitis
Noninflammatory
 M. audouinii infections present as the classic
form
 Characterized by multiple scaly lesions
(“gray-patch”), stubs of broken hair
 Over past 30 yrs, M. audouinii infections are
being replaced by increasing numbers of
“black-dot” ringworm, caused primarily by T.
tonsurans and occasionally by T. violaceum
 In the U.S. T. tonsurans is the most common
cause
Noninflammatory Tinea Capitis
 “Black dot” ringworm, caused by T.
tonsurans & occasionally T. violaceum
presents as multiple areas of alopecia
studded with black dots representing
infected hairs broken off at or below the
surface of the scalp
 Black dot tinea
 Black dot ringworm caused by
Trichophyton tonsurans
Inflammatory
 Usually caused by M. canis
 Can be caused by T. mentagrophytes, T. tonsurans,
M. gypsem, or T. verrucosum
 M. canis begin as scaly, erythematous, papular
eruptions with loose and broken-off hairs, followed
by varying degrees of inflammation
 A localized spot accompanied by pronounced
swelling, with developing bogginess and induration
exuding pus develops- kerion celsii
– A delayed type hypersensitivity reaction to fungal
elements
 With extensive lesions fever, pain, and regional
lymphadenopathy may occur
Kerion
 Kerion may be followed by scarring and
permanent alopecia in areas of inflammation and
suppuration
 Systemic steroids for short periods will greatly
diminish the inflammatory response and reduce
the risk of scarring
 Kerion: inflammatory rxn of tinea capitis caused by
Microsporum canis or Trichophyton mentagrophytes
 Permanent scarring alopecia post-kerion
 Kerion: red,
oozing,
hairless
plaque
Favus
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Rare in the U.S.
Most severe form of dermatophyte hair infection
Most frequently cause by T. schoenleinii
Hyphae and air spaces seen within hair shaft
Bluish white fluorescence under Wood’s light
Thick, yellow crusts composed of hyphae and skin
debris (‘scutula’)
 Scarring alopecia may develop
Favus with scarring alopecia and
scutula
 Scarring after favus infection
Etiology
 Tinea capitis can be cause by any one of
several species: T. tonsurans, M. audouinii
(human to human), and M. canis (animals to
human)
 Endothrix types-T. tonsurans (black-dot
ringworm) and T. violaceum
 Ectothrix found on scalp are T. verrucosum &
T. mentagrophytes, M. canis
Diagnosis
 Wood’s light
– Ultraviolet of 365 nm wavelength is obtained by passing a
beam through a Wood’s filter composed of nickel oxidecontaining glass
– A simple form is the 125-volt purple bulb
 Fluorescent-positive infections are caused by :T.
schoenleinii, M. canis, M. audouinii, M. distortum, M.
ferrugineum
 Hairs infected with T. tonsurans, T. verrucosum, & T.
violaceum and others of endothrix do not fluoresce
 The fluorescent substance is pteridine
Diagnosis
 KOH
– Two or three loose hairs are removed
– Hairs are placed on slide with a drop of 10-20%
solution of KOH
– A cover slip is applied, specimen is warmed until
hairs are macerated
– Examine under low, then high power
 Scales or hairs cleared with it can still be
cultured
DTM
 DTM contains cycloheximide to reduce growth of
contaminants and a colored pH indicator to denote
the alkali-producing dermatophytes
 Some clinically relevant nondermatophyte fungi
are cycloheximide sensitive (Candida tropicalis,
Scopulariopsis brevicaulis, Cryptococcus
neoformans, Pseudoallescheria boydii,
Trichosporon beigelii and Aspergillus spp.)
 Ectothrix type in Microsporum canis-note small
spores around hair shaft
 Endothrix spores in hair with Trichophyton tonsurans
 Endothrix in T. scoenleinii showing
characteristic bubbles of air
 Endothrix infection, (low-power KOH
mount): arthroconidia noted within hair shaft
 Endothrix infection (high-power KOH mount)
showing total hair shaft involvement
T. tonsurans
 This microoraganism grows slowly in culture
to produce a granular or powdery yellow to
red, brown, or buff colony
 Crater formation with radial grooves may be
produced
 Microconidia may be seen regularly
 Dx confirmed by the fact that cultures grow
poorly or not at all without thiamine
T. mentagrophytes
 Culture growth is velvety or granular or fluffy, flat
or furrowed, light buff, white, or sometimes pink
 Back of the culture can vary from buff to dark red
 Round microconidia borne laterally and in clusters
confirm dx within 2 weeks
 Spirals are sometimes present
 Macroconidia may be seen
T. verrucosum
 Growth is slow and cannot be observed well
for at least 3 weeks
 Colony is compact, glassy, velvety, heaped
or furrowed, and usually white, but may be
yellow or gray
 Chlamydospores (round swellings along the
hyphal structures) are present in early
cultures
 Microconidia may be seen
M. audouinii
 Gross appearance shows a slowly growing,
matted, velvety, light brown colony
 Back of which is reddish brown to orange
 Under microscope a few large multiseptate
macroconidia (macroaleuriospores) are seen
 Microconidia (microaleuriospores) in a lateral
position on hyphae are clavate
 Racquet mycelium, chlamydospores, and
pectinate hyphae are seen sometimes
M. canis
 Culture shows profuse, fuzzy, cottony, aerial
mycelia tending to become powdery in the center
 Color is buff to light brown
 Back of colony is lemon to orange-yellow
 Numerous spindle-shaped multiseptate
microconidia and thick-walled macroconidia are
present
 Clavate microconidia are found along with
chlamydospores and pectinate bodies
Treatment
 Griseofulvin of ultramicronized form, 10 mg/kg/day,
is the daily dose recommended for children
 Grifulvin V is the only oral suspension available for
children unable to swallow tablets-dose is 20
mg/kg/day
 Tx should continue for 2-4 months, or for at least 2
weeks after negative microscopic and culture
examinations are obtained
 Griseofulvin does not primarily affect the delayed
type hypersensitivity reaction responsible for the
inflammation in kerion
 For this, systemic steroids, to minimize scarring,
can be given simultaneously
Treatment
 Terbinafine
-effective for Trichophyton infections
-3-6mg/kg/day for 1 to 4 weeks
-Microsporum infections may require larger doses and longer courses
of therapy
 Itraconazole
 Fluconazole
 Selenium Sulfide or Ketoconazole shampoo as an
adjunct
Tinea Barbae
AKA Tinea sycosis, barber’s itch
Uncommon
Occurs chiefly among those in agriculture
Involvement is mostly one-sided on neck or
face
 Two clinical types are: deep, nodular,
suppurative lesions; and superficial, crusted,
partially bald patches with folliculitis
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Tinea Barbae
 Superficial crusted type
– mild pustular folliculitis with broken-off hairs (T.
violaceum) or without broken-off hairs (T.
rubrum)
– Affected hairs are loose, dry, and brittle
– When extracted bulb appears intact
Tinea Barbae
 Deep type
– Caused mostly by T. mentagrophytes or T.
verrucosum
– Swellings are usually confluent and form diffuse
boggy infiltrates with abscesses
– Pus may be expressed
– Lesions are limited to one part of face or neck in
men
Diagnosis-Tinea Barbae
 Clinical
 Confirmed by microscopic findings and by
standard culture techniques
 Rarely, Epidermophyton floccosum may
cause widespread verrucous lesions known
as verrucous epidermophytosis
 Verrucous epidermophytosis from Epidermphyton
floccosum
 Complete resolution after 48 days of Griseofulvin
Differential Diagnosis
 Sycosis vulgaris (staphlococcal folliculitis)lesions are pustules and papules, pierced in
the center by a hair, which is loose and
easily extracted after suppuration has
occurred
 Contact dermatitis
 Herpes infections
 Tinea barbae-Trichophyton
mentagrophytes
Treatment-Tinea Barbae
 Oral antifungals are required
 Topical agents as adjunctive therapy
 Micronized or ultramicronized
griseofulvin orally: dosage of 500–1000
mg or 350-700 mg respectively
 Tx usually for 4-6 weeks
Treatment-Tinea Barbae
 Other orals that have been effective: ketoconazole,
fluconazole, itraconazole, and terbinafine
 Topical antifungals should be applied from the
beginning of tx
 Affected parts should be bathed thoroughly in soap
and water
 Healthy areas that are not epilated may be shaved
or clipped
 When kerion is present a short course of systemic
steriod therapy may help reduce inflammation and
risk of scarring
Tinea Faciei
 Fungal infection of the face (apart from the beard)
 Must have high index of suspicion
– Mistaken for seborrheic dermatitis, contact dermatitis,
lupus, or photosensitive dermatosis
 Erythematous, slightly scaling, indistinct borders
are usually seen (best location for KOH scrapings)
 Typical annular rings are usually lacking & lesions
are exquisitely photosensitive
 Usually caused by T. rubrum, T. mentagrophytes,
or M. canis
 Tinea faciei
(Microsporum canis)
in a child
Treatment
 Topical antifungals
 If fungal folliculitis is present, oral medication is
required
 Oral griseofulvin administered for 2-4 weeks, as
well as fluconazole, itraconazole, or terbinafine are
all effective particularly in combination with topical
therapy
Tinea Corporis(Tinea Circinata)
 All superficial dermatophyte infections of the skin
except the scalp, beard, face, hands, feet, and
groin
 Sites of predilection are neck, upper and lower
extremities, and trunk
 Characterized by one or more circular, sharply
circumscribed, slightly erythematous, dry, scaly,
usually hypopigmented patches
 Advancing scaling edge is usually prominent
 Tinea corporis in a
child, caused by
Microsporum canis
 Tinea corporis
(Trichophyton rubrum)
 Note sharp margins
and central clearing
Tinea Corporis
 In some cases concentric circles form rings in
one another, making intricate patterns (tinea
imbricata)
 Widespread tinea corporis may be the
presenting sign of AIDS
 Tinea corporis: large gyrate plaque with
advancing border, perhaps worsened by
diapering
Histopathology
 Better ways to make diagnosis
 But if compact orthokeratosis is found in a
section, a search for fungal hyphae should
be performed
 This is diagnostic
Etiology-Tinea Corporis
 Microsporum canis, T. rubrum, T.
mentagrophytes- most common
 T. rubrum is is the most common
dermatophyte in the U.S. and worldwide
 T. tonsurans has experienced a dramatic
rise as a cause of tinea corporis as it has for
tinea capitis
 In children, M. canis is the cause of the
“moist” type of tinea circinata
Epidemiology
 Tinea corporis is frequently seen in childrenparticularly those exposed to animals with
ringworm (M. canis), especially CATS, dogs and
less commonly, horses and cattle
 In adults excessive perspiration is the most
common factor
– Personal history or close contact with tinea capitis or
tinea pedis is another important factor
 Incidence is especially high in hot, humid areas of
the world
Treatment-Tinea Corporis
 When tinea corporis is caused by T. tonsurans, M.
canis, T. mentagrophytes, or T. rubrum; griseofulvin,
terbinafine, itraconazole, and fluconazole are all
effective
 The ultra-micronized form may be used at a dose of
350-750 mg once/day for 4-6 weeks
 This dose may be increased to twice daily if needed
 Terbinafine, itraconazole, and fluconazole are
effective
 Terbinafine at 250 mg/day for two weeks
 Itraconazole 200 mg B.I.D. for one week
 Fluconazole 150 mg once/week for 4 weeks
Treatment
 When only 1-2 patches occur, topical tx
is effective
 Most are between 2-4 weeks with twice
daily use
 Econazole, ketaconazole, oxiconazole,
and terbinafine may be used once daily
 With terbinafine the course can be
shortened to 1 week
Treatment
 Creams are more effective than lotions
 Sulconazole may be less irritating in folded
areas
 Castellani paint (which is colorless if made
without fuchin) is very effective
 Salicylic acid 3-5%, or half-strength Whitfield’s
ointment, both standbys 30 yrs ago, are rarely
used today
 Addition of a low-potency steroid cream
during the initial 3-5 days of therapy can
decrease irritation rapidly without
compromising the effectiveness of the
antifungal
Other Forms of Tinea Corporis
 Trichophytic Granuloma or Perifollicular
Granuloma or Majocchi’s Granuloma or Tinea
Incognito
 A deep, pustular type of tinea circinata resembling
a carbuncle or kerion observed on the glabrous
skin
 A circumscribed, annular, raised, crusty, and
boggy granuloma
 Follicles are distended with viscid purulent
material
 Most frequently on the shins or wrists
 Majocchi’s granuloma H&E pale blue-staining
fungal hyphae within hair shaft
 Majocchi’s granuloma: PAS reveals multiple
organisms that have replaced a fragment of hair
shaft embedded in a sea of neutrophils
Tinea Imbricata (Tokelau)
 Superficial fungal infection limited to southwest
Polynesia, Melanesia, Southeast Asia, India, and
Central America
 Characterized by concentric rings of scales forming
extensive patches with polycyclic borders
 Small macular patch splits in center and forms large,
flaky scales attached at the periphery
 Resultant ring spreads peripherally and another
brownish macule appears in the center and
undergoes the process again
Tinea Imbricata
 When fully developed the eruption is characterized
by concentrically arranged rings or parallel
undulating lines of scales overlapping each other like
shingles on a roof (imbrex means shingle)
 Causative fungus is T. concentricum
 TOC is griseofulvin- in same form as for tinea
corporis
 Other options are terbinafine, fluconazole, and
itraconazole
 Several courses of therapy may be needed
 May need to remove patient from hot, humid
environment
 Tinea imbricata in New Guinea native
 Tinea imbricata: concentric rings of scale
caused by T. concentricum
Tinea Cruris
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AKA jock itch
Most common in men
On upper and inner thighs
Begins as a small erythematous and scaling or
vesicular and crusted patch
 Spreads peripherally and partly clears in the center
 Penoscrotal fold or sides of scrotum are seldom
involved; penis not involved
 Tinea cruris in a man
 Tinea cruris in a woman
Etiology-Tinea Cruris
 T. mentagrophytes & E. floccosum & T.
rubrum usual cause
 Frequently associated with tinea pedis b/c of
contaminated clothing
 Heat and high humidity
 Tight jockey shorts!
Treatment
 Reduce perspiration and enhance evaporation from
crural area
 Keep as dry as possible by wearing loose
underclothing
 Plain talcum powder or antifungal powders
 Specific topical and oral treatment is same as that
described under tinea corporis
 Tinea in diaper area
Tinea Pedis
 AKA athlete’s foot
 Most common fungal disease(by far)
 Primary lesions often are macerated with
occasional vesiculation, and fissures between
the toes
 Extreme pruritus
 Tinea pedis showing interdigital scalping
 T. mentagrophytes
 Interdigital scaling with vesiculation
caused by T. mentagrophytes
 Dermatophytosis
of the soles
 Trichophyton
mantagrophytes
 Acute
vesiculobullous
eruption on sole
caused by
Trichophyton
mentagrophytes
TP-Trichophyton rubrum
 T. rubrum causes the
majority of cases
 Produces a relatively
noninflammatory type of
dermatophytosis
characterized by a dull
erythema and pronounced
scaling involving the entire
sole and sides of feet
 Producing a moccasin or
sandal appearance
 Tinea pedis and
onychomycosis in
father/son pair.
 Father shows classic
moccasin distribution of
tinea pedis and son
shows distal subungual
onychomycosis
Tinea manus
 Tinea infection of hands
that is dry, scaly, and
erythematous may occur
 Suggestive of infection
with T. rubrum
 Other areas are frequently
affected at the same time
 Trichophyton rubrum infections
Differential diagnosis
 Allergic contact or irritant dermatitis-especially
occupational
 Pompholyx
 Atopic dermatitis
 Psoriasis
 Lamellar dyshidrosis
 Eczematoid or dyshidrotic lesions of unknown
cause on hands should prompt a search for
clinical evidence of dermatophytosis of feet etc.
 Fungus filaments under KOH mount
 Mosaic fungus
Prophylaxis
 Hyperhidrosis is a predisposing factor
 Dry toes after bathing
 Tolnaftate powder or Zeasorb medicated powders
for feet
 Plain talc, cornstartch, or rice powder may be
dusted into socks and shoes to keep feet dry
Treatment
 Topical antifungals
 With significant maceration wet dressings or
soaks with solutions such as aluminum
acetate, one part to 20 parts of water
 Anti-inflammatory effects of corticosteroids
are markedly beneficial
 Topical antibiotic ointments effective against
gram-negative organisms (gentamicin), in tx
of the moist type of interdigital lesions
 In ulcerative type of gram-negative toe web
infections, systemic floxins are needed
Treatment
 Keratolytic agents, such as salicylic acid,
lactic acid lotions, and Carmol are therapeutic
when fungus is protected by a thick layer of
overlying skin (i.e. soles)
 Griseofulvin is only effective against
dermatophytes
 When infection is caused by T.
mentagrophytes, griseofulvin does not
decrease inflammatory reaction
Treatment- dosing
 Griseofulvin in ultramicronized particles taken
orally in doses of 350-750 mg daily
 Dosage for children is 10 mg/kg/day
 Period of treatment depends on response
 Repeated KOH scrapings and culture should be
negative
 Recommended adult doses for newer agents:
terbinafine, 250 mg/day for 2 weeks; itraconazole,
200 mg twice daily for 1 week; fluconazole, 150
mg once weekly for 4 weeks
Onychomycosis
(Tinea Unguium)
 Onychomycosis encompasses both dermatophyte
and non-dermatophyte nail infections
 Represents up to 30% of diagnosed superficial
fungal infections
 Etiologic agents are: Epidermophyton,
Microsporum, and Trichophyton fungi
Onychomycosis
 Four classic types:
 1) distal subungual onychomycosis: primarily
involves distal nail bed and hyponychium, with
secondary involvement of underside of nail plate
of fingernails and toenails
 Onychomycosis caused by Trichophyton
rubrum
Trichophyton mentagrophytes
 2) white superficial
onychomycosis (leukonychia
trichophytica.) This is an
invasion of the toenail plate
on the surface of the nail
 It is produced by
T.mentagrophytes, species
of Cephalosporium and
Aspergillus, and Fusarium
oxysporum fungus
Onychomycosis
 3) Proximal subungual onychomycosis: involves
the nail plate mainly from proximal nail fold
 It is produced by T. rubrum & T. megninii and may
be an indication of HIV infection
 4) Candida onychomycosis involves all the nail
plate; it is due to Candida albicans and is seen in
patients with chronic mucocuataneous candidiasis
– Associated paronychia
– Adjacent cuticle is pink, swollen, and tender
– Fingernails > toenails
 Onychomycosis caused by Candida albicans
in mucocutaneous candidiasis
Onychomycosis
 Onychomycosis caused by
T. rubrum is usually a deep
infection
 Disease usually starts at
distal corner of nail and
involves the junction of nail
and its bed
 First a yellowish
discoloration occurs, which
may spread until entire nail
is affected
 Beneath discoloration nail
plate becomes loose from
nail bed
 Gradually entire nail becomes brittle and separated
from its bed due to piling up of keratin subungually
 Nail may break off, leaving an undermined remnant
that is black and yellow from dead nail and fungi that
are present
 A: Distal subungal, onychomycosis
occurring simultaneously with superficial
white onychomycosis
 B: Superficial white onychomycosis
Differential
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Allergic contact dermatitis
Psoriasis
Lichen planus
20 nail dystrophy
Darier’s disease
Reiter’s disease
Norwegian scabies
Non-dermatophyte onychomycosis
Treatment
 PO terbinafine, fluconazole, and itraconazole
 Griseofulvin continued until nails are clinically
normal
 Low success rates 15-30% for toenails and
50-70% for fingernails
 Griseofulvin does not tx nail disease caused
by candida
 3% Thymol in EtOH
Candidiasis
 Candida proliferates in both budding and mycelial
forms in outer layers of the stratum corneum
where horny cells are desquamating
 It does not attack hair, rarely involves nail, and is
incapable of breaking up the stratum corneum
 It is largely an opportunisitic organism
 Moisture promotes its growth
– Lip corners
– Body folds
Diagnosis
 Demonstration of the pathogenic yeast C.
albicans establishes the diagnosis
 Under microscope KOH prep may show
spores and pseudomycelium
 Culture on Sabouraud’s glucose agar shows
a growth of creamy, grayish, moist colonies in
about 4 days
 In time colonies form small, root-like
penetrations into agar
 Mycelium and spores of Candida albicans
Candidiasis
 KOH mount from infant with thrush showing
pseudohyphae and yeast forms
Topical Anti-candidal Agents
 These include, but are not limited to: clotrimazole
(Lotrimin, Mycelex), econazole (Spectazole),
ketaconazole (Nizoral), miconazole (MonistatDerm
Lotion, Micatin), oxiconazole (Oxistat),
sulconazole (Exelderm), naftifine (Naftin),
terconazole (vaginal candidiasis only), cicloprox
olamine (Loprox), butenafine (Mentax), nystatin,
and topical amphotericin B lotion
 Terbinafine has been reported to be less active
against Candida species by some authors
Oral Candidiasis (Thrush)
 Newborn infection may be acquired from
contact with vaginal tract of mother
 Grayish white membranous plaques are
found on surface
 Base of plaques are moist, reddish, and
macerated
 Diaper areas is especially susceptible to this
 Most of intertriginous areas and even
exposed skin may be involved
Oral candidiasis (Thrush)
 Frequently infection extends onto angles of
the mouth to form perleche (seen in elderly,
debilitated, and malnourished patients, and
diabetics)
 It is often the first manifestation of AIDS
 Is present in nearly 100% of all untreated
patients with full-blown AIDS
 “Thrush” in an adult with no known
predisposing factors warrants a search for
other evidence of infection with HIV, such as
lymphadenopathy, leukopenia, or HIV
antibodies in serum
 Thrush with extension to vermilion border
Treatment
 Babies with thrush may be allowed to suck on
a clotrimazole suppository inserted into the
slit tip of a pacifier four times a day for 2-3
days
 An adult can let tablets of clotrimazole or
Mycelex troches dissolve in the mouth
 Fluconazole, 100-200 mg/day for 5-10 days
with doubling the dose if it fails, or
Itraconazole, 200 mg daily for 5-10 days with
doubling the dose if it fails-both are available
in liquid forms
Perleche
 AKA angular cheilitis
 Maceration with transverse fissuring of oral
commissures
 Soft, pinhead-sized papules may appear
 Involvement is bilateral-usually
Perleche
Perleche
 Analogous to intertrigo elsewhere
 Similar changes may be seen in riboflavin
deficiency, and iron deficiency anemia
 Identical fissuring occurs in persons with
malocclusion caused by ill-fitting dentures and
in the aged whom atrophy of alveolar ridges
has occurred
 Seen in children who drool, lick their lips, or
suck their thumb
Treatment
 If due to C. albicans, anti-candidal creams and lotions
can be used
 Glycemic control in diabetes
 Antibiotic topical meds are used when a bacterial;
infection is present
 If due to vertical shortening of lower third of the face,
dental or oral surgical intervention may help
 Injection of collagen into depressed sulcus at the oral
commissure may be helpful
 Vytone!!
Candidal Vulvovaginitis
 Pruritus, irritation, and extreme burning
 Labia may be erythemtous, moist, and macerated and
cervix hyperemic, swollen, and eroded, showing small
vesicles on its surface
 Vaginal discharge is not usually profuse but is
frequently thick and tenacious
 May develop during pregnancy, in diabetes, or
secondary to therapy with a broad- spectrum antibiotic
 Recurrent vulvovaginal candidiasis has been
associated with long-term tamoxifen tx
Candidal Vulvovaginitis
 Candidal balanitis may be present in an
uncircumcised sexual partner
 If not recognized, repeated reinfection of a partner
may occur
 Diagnosis is by clinical symptoms and findings as
well as demonstration of fungus via KOH microscopic
exam & culture
 Tx is frustrating & disappointing due to recurrences
 Oral fluconazole 150 mg times 1 dose; Fluconazole,
100mg/day for 5-7 days, itraconazole, 200 mg/day for
2-3 days are other options
Treatment
 Topical options include miconizole (Monistat
cream), nystatin vaginal suppositories or
tablets (Mycostatin), or clotrimazole (GyneLotrimin or Mycelex G) vaginal tablets
inserted once daily for 7 days
Candidal Intertrigo
 Pinkish intertriginous moist patches are
surrounded by a thin, overhanging fringe of
somewhat macerated epidermis (“collarette”
scale)
 May resemble tinea cruris, but usually there
is less scaliness and a greater tendency to
fissuring
 Topical anti-candidal preparations are usually
effective
 Recurrence is common
Pseudo Diaper Rash
 In infants, C. albicans infection may start in perianal
region and spread over entire area
 Dermatitis is enhanced by maceration produced by
wet diapers
 Diaper friction may contribute to skin irritation and
compromised function of stratum corneum
 Suspected by finding involvement of folds and
occurrence of many small erythematous
desquamating “satellite” or “daughter” lesions
scattered around edges
Congenital Cutaneous
Candidiasis
 Infection of an infant during passage through birth
canal
 Eruption usually noted within first few hrs of delivery
 Erythematous macules progress to thin-walled
pustules, which rupture, dry, and desquamate within a
week
 Lesions are usually widespread, involving trunk, neck,
and head, at times palms and soles, including nail
folds
 Oral cavity and diaper area are spared
Congenital Cutaneous
Candidiasis
 Differential dx: listeriosis, syphilis, staphylococcal
and herpes infections, ETN, transient neonatal
pustular melanosis, miliaria rubra , drug eruption,
congenital icthyosiform erythroderma (neonatal
pustular disorders)
 If suspected early amniotic fluid, placenta, and
cord should be examined for evidence of infection
 Infants with disease limited to skin have favorable
outcomes
Congenital Cutaneous
Candidiasis
 Disseminated infection is suggested by (1) birth
weight <1500g (2) evidence of respiratory distress or
labs indicating neonatal sepsis (3) tx with broadspectrum antibiotics (4) extensive instrumentation
during delivery or invasive procedures in neonatal
period (5) positive systemic cultures, or (6) evidence
of an altered immune response
 Infants with congenital cutaneous candidiasis with
any of these 6 criteria would be considered for
systemic antifungal therapy
Perianal Candidiasis
 Frequently entire GI tract is involved
 Can be precipitated by oral antibiotic therapy
 Perianal dermatitis with erythema, oozing, and
maceration is present
 Psychogenic etiology is more common than is
candidiasis
 Differential dx: psoriasis, seborrheic dermatitis,
streptococcal and staphylococcal infections, contact
dermatitis, and extramammary Paget’s disease
 Fungicides, meticulous cleansing of perianal region
after bowel movements, topical corticosteroids and
antipruritics (Atarax)
Candidal Paronychia
 Cushion-like thickening of paronychial tissue, slow
erosion of lateral borders of nails, gradual thickening
and brownish discoloration of nail plates, and
development of pronounced transverse ridges
 Frequently only one nail
 A secondary mixed bacterial infection can occur with
those who frequently have hands in water or who
handle moist objects; cooks, dishwashers, bartenders,
nurses, canners, etc
Candidal Paronychia
 Manicuring nails sometimes is responsible for
mechanical or chemical injuries leading to
infection
 Ingrown toenails with chronic paronychia
 Seen in pts with diabetes
 Avoid chronic moisture exposure; get diabetes
under control
 Oral fluconazole once weekly or pulse dose
itraconazole should be effective
 Topical therapy should continue for 2-3 months
to prevent recurrence
Erosia Interdigitalis
Blastomycetica
 Oval-shaped area of macerated white skin on web
between and extending onto sides of fingers
 With progression macerated skin peels off, leaving
painful, raw,denuded area surrounded by a collar of
overhanging white epidermis
 Nearly always affects third web
 Moisture beneath rings macerates skin and
predisposes to infection
 Also seen in diabetics, those who do housework,
launderers, and others exposed to macerating effects
of water and strong alkalis
Chronic Mucocutaneous
Candidiasis
 A heterogeneous group of patients whose infection
with Candida is chronic but superficial
 Onset before age 6
 Onset in adult life may herald the occurrence of
thymoma
 When inherited an endocrinopathy is often found
 Most cases have well-defined limited defects of cellimmunity
 Oral lesions are diffuse and perleche and lip fissures
are common
Systemic Candidiasis
 High risk pts: pts with malignancies, AIDS, transplant
pts requiring immunosuppressive drugs, pts on oral
cortisone, pts who have had multiple surgical
operations especially cardiac, pts with indwelling
catheters, and heroin addicts
 Initial sign is varied: FUO, pulmonary infiltrates, GI
bleeding, endocarditis, renal failure, meningitis,
osteomyelitis, endophthalmitis, peritonitis, or a
disseminated maculopapular eruption
Systemic Candidiasis
 Cutaneous findings are erythematous macules that
become papular, pustular, and hemorrhagic, and may
progress to necrotic, ulcerating lesions resembling
ecthyma gangrenosum
 Deep abscesses may occur
 Trunk and extremities are usual sites of involvement
 Proximal muscle tenderness is a common finding
Systemic Candidiasis
 If candida is cultured within the first week of life
there is a high rate of systemic disease
 There is a 50% chance of systemic disease if 1 or
more cultures is positive
 Mortality has declined from 80% in the 1970’s to
40% in the 1990’s because of early empiric
antifungals and better prophylaxis
THE END