Transcript Chapter 15 Diseases Resulting from Fungi and Yeasts

Chapter 15
Diseases Resulting from
Fungi and Yeasts
Andrews’ Diseases of the Skin
Adam Wray, D.O.
February 8, 2005
Superficial mycoses
► AKA
dermatophytes
► Three genera: Microsporum, Trichophyton,
Epidermophyton
► Division
into seven types (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
AIDS
Genetic susceptibility may be related to types of
keratin or degree/mix of cutaneous lipids produced
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-alphademethylase (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
► 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
► Fluconazoles’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
noninflammatory
► Tinea capitis can be caused by all
pathogenic dermatophytes except
Epidermophyton floccosum and T.
concentricum
► In
U.S. most caused by T. tonsurans
Noninflammatory
► M.
audouinii infections present as the classic
form
► Characterized by multiple scaly lesions (“graypatch”), 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
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
► Black
dot tinea
► Black
dot ringworm caused by
Trichophyton tonsurans
Inflammatory
► Usually
► Can be
caused by M. canis
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
► Kerion
by
caused
Microsporum
canis
► Kerion:
heavily crusted, hairless plaque
► Permanent
scarring alopecia post kerion
► Kerion:
red,
oozing,
hairless
plaque
Favus
► 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
of scalp showing scutulae
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
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. 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.)
type in Microsporum canisnote small spores around hair shaft
► Ectothrix
► Endothrix
tonsurans
spores in hair with Trichophyton
in T. scoenleinii showing
characteristic bubbles of air
► Endothrix
► 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 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 a 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
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
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-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
mentagorphytes
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 seb derm, contact derm, lupus, or
photosensitive dermatosis
► Erythematous,
slightly scaling, indistinct
borders are usually seen
► Usually caused by T. rubrum. T.
mentagrophytes, or M. canis
► Tinea
faciei
(Microsporum canis)
in a child
► Tinea
corporis
involving
the face
(tinea
faciei)
Treatment
► Topical
antifungals
► 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
circumcsribed, slightly erythematous, dry, scaly,
usually hypopigmented patches
► Tinea
corporis in a
child, caused by
Microsporum canis
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
(Trichophyton rubrum)
► Note sharp margins
and central clearing
► 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 hx or close contact with tinea capitis or tinea
pedis is another important factor
► Incidence
the world
is especially high in hot, humid areas of
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(cont)
► 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 little used today
► Addition of a low-potency steroid cream
during the initial 3-5 days of therapy will
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
► Tichophyton
mentagrophytes
infection on lower leg
of American soldier in
Vietnam
► Majocchi’s
granuloma H&E pale bluestaining 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 pt from hot, humid
environment
► Tinea
imbricata in New Guinea native
► Tinea
imbricata: concentric rings of scale
caused by T. concentricum
Tinea Cruris
► 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 tx is same as that
described under tinea corporis
► Tinea
in diapered 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
► T.
pedis showing interdigital scalping
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-neg toe web
infections, systemic floxins are needed
Tx
► Keratolytic
agents, such as salicylic acid, lactic
acid lotions, and Carmol are therapeutic when
fungus is protected by a thick layer of
overlying skin (ie soles)
► Griseofulvin is only effective against
dermatophytes
► When infection is caused by T.
mentagrophytes griseofulvin does not
decrease inflammatory rx
Tx-doses
► Griseovulvin
in ultramicronized particles taken
orally in doses of 350-750 mg daily
► Dosage for children is 10 mg/kg/day
► Period of tx depends on response
► Repeated KOH scrapings and culture should be
neg
► 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 nondermatophyte 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
rubrum
caused by Trichophyton
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
pts with chronic mucocuataneous candidiasis
 Associated paronychia
 Adjacent cuticle is pink, swollen, and tender
 Fingernails > toenails
caused by Candida
albicans in mucocutaneous candidiasis
► Onychomycosis
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, onchomycosis occurring
simulataneously with superficial white
onchmycosis
► B: Superficial white onchomycosis
Differential
► Allergic
contact dermatitis
► Psoriasis
► Lichen planus
► 20 nail dystrophy
► Darier’s disease
► Reiter’s disease
► Norwegian scabies
► Nondermatophyte 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
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
► Demonstration
► Mycelium
albicans
and spores of Candida
Candidiasis
► KOH
mount from infant with thrush showing
pseudohyphae and yeast forms
Topical Anticandidal 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 pts, and
diabetics)
► It is often the first manifestation of AIDS
► Is present in nearly 100% of all untreated pts
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
Tx
► 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
Tx
due to C. albicans anticandidal creams and
lotions
► 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!!
► If
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..other
options
Tx
► 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 anticandidal preparations are usually
effective
► Recurrence is common
Pseudo Diaper Rash
infants, C. albicans infection may start in
perianal region and spread over entire area
► Dermatits 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
► In
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 thinwalled 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
CCC
► Disseminated
infection is suggested by (1) bw
<1500g (2) evidence of respiratory distress or
labs indicating neonatal sepsis (3) tx with
broad-spectrum 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 dermatits, and extramammary Paget’s
disease
► Fungicides, meticulous cleansing of perianal
region after bowel movements, topical
corticosteroids and antipruritics (Atarax)
Candidal Paronychia
► Cushionlike
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
CP
► 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 pts 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
cell-immunity
► 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
SC
► 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
SC
► 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
Thank You