Chapter 15 Diseases Resulting from Fungi and Yeasts

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Chapter 15Diseases Resulting from Fungi and
Yeasts

• Andrews Diseases of the Skin
• Adam Wray, D.O.
• February 8, 2005

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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

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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

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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

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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

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Polyene

• Nystatin
• Irreversibly binding to ergosterol-an essential
  component of fungal cell membranes

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Triazoles

• Itraconazole, Fluconazole
• Affect P450 system
• Numerous drug interactions occur
• Need to know pts 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
• Fluconazoless absorption is unaffected by food

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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

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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

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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

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• Black dot tinea

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• Black dot ringworm caused by Trichophyton
  tonsurans

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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

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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

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• Kerion inflammatory rxn of tinea capitis caused
  by Microsporum canis or Trichophyton
  mentagrophytes

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• Kerion caused by Microsporum canis

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• Kerion heavily crusted, hairless plaque

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• Permanent scarring alopecia post kerion

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• Kerion red, oozing, hairless plaque

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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 Woods light
• Thick, yellow crusts composed of hyphae and skin
  debris (scutula)
• Scarring alopecia may develop

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• Favus of scalp showing scutulae

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Favus with scarring alopecia and scutula
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• Scarring after favus infection

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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

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Diagnosis

• Woods light
• Ultraviolet of 365 nm wavelength is obtained by
  passing a beam through a Woods filter composed
  of nickel oxide-containing 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

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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

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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.)

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• Ectothrix type in Microsporum canis-note small
  spores around hair shaft

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• Endothrix spores in hair with Trichophyton
  tonsurans

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• Endothrix in T. scoenleinii showing
  characteristic bubbles of air

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• Endothrix infection, (low-power KOH mount)
  arthroconidia noted within hair shaft
• Endothrix infection (high-power KOH mount)
  showing total hair shaft involvement

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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

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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

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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

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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

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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

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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

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Tinea Barbae

• AKA Tinea sycosis, barbers 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

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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

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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

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• Verrucous epidermophytosis from Epidermphyton
  floccosum

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• Complete resolution after 48 days of griseofulvin

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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

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• Tinea barbae-Trichophyton mentagorphytes

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Treatment-Tinea Barbae

• Oral antifungals are required
• Topical agents as adjunctive therapy
• Micronized or ultramicronized griseofulvin
  orally dosage of 5001000 mg or 350-700 mg
  respectively
• Tx usually for 4-6 weeks

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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

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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

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• Tinea faciei (Microsporum canis) in a child

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• Tinea corporis involving the face (tinea faciei)

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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

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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

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• Tinea corporis in a child, caused by Microsporum
  canis

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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

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• Tinea corporis (Trichophyton rubrum)
• Note sharp margins and central clearing

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• Tinea corporis large gyrate plaque with
  advancing border, perhaps worsened by diapering

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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

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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

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Epidemiology

• Tinea corporis is frequently seen in
  children-particularly 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 is especially high in hot, humid areas
  of the world

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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

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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

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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
  Whitfields 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

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Other Forms of Tinea Corporis

• Trichophytic Granuloma or Perifollicular
  Granuloma or Majocchis 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

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• Tichophyton mentagrophytes infection on lower leg
  of American soldier in Vietnam

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• Majocchis granuloma HE pale blue-staining
  fungal hyphae within hair shaft

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• Majocchis granuloma PAS reveals multiple
  organisms that have replaced a fragment of hair
  shaft embedded in a sea of neutrophils

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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

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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

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• Tinea imbricata in New Guinea native

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• Tinea imbricata concentric rings of scale caused
  by T. concentricum

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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

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• Tinea cruris in a man

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• Tinea cruris in a woman

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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!

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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

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• Tinea in diapered area

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Tinea Pedis

• AKA athletes foot
• Most common fungal disease(by far)
• Primary lesions often are macerated with
  occasional vesiculation, and fissures between the
  toes
• Extreme pruritus

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• Tinea pedis showing interdigital scalping
• T. mentagrophytes

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• Interdigital scaling with vesiculation caused by
  T. mentagrophytes

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• Dermatophytosis of the soles
• Trichophyton mantagrophytes

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• Acute vesiculobullous eruption on sole caused by
  Trichophyton mentagrophytes

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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

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• Tinea pedis and onychomycosis in father/son pair.
• Father shows classic moccasin distribution of
  tinea pedis and son shows distal subungual
  onychomycosis

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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

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• Trichophyton rubrum infections

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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.

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• Fungus filaments under KOH mount

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• Mosaic fungus

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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

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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

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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

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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

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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

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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

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• Onychomycosis caused by Trichophyton rubrum

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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

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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 gt toenails

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• Onychomycosis caused by Candida albicans in
  mucocutaneous candidiasis

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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

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• 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

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• A Distal subungal, onchomycosis occurring
  simulataneously with superficial white
  onchmycosis
• B Superficial white onchomycosis

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Differential

• Allergic contact dermatitis
• Psoriasis
• Lichen planus
• 20 nail dystrophy
• Dariers disease
• Reiters disease
• Norwegian scabies
• Nondermatophyte onychomycosis

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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

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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

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Diagnosis

• Demonstration of the pathogenic yeast C. albicans
  establishes the diagnosis
• Under microscope KOH prep may show spores and
  pseudomycelium
• Culture on Sabourauds glucose agar shows a
  growth of creamy, grayish, moist colonies in
  about 4 days
• In time colonies form small, root-like
  penetrations into agar

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• Mycelium and spores of Candida albicans

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Candidiasis

• KOH mount from infant with thrush showing
  pseudohyphae and yeast forms

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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

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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

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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

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• Thrush with extension to vermilion border

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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

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Perleche

• AKA angular cheilitis
• Maceration with transverse fissuring of oral
  commissures
• Soft, pinhead-sized papules may appear
• Involvement is bilateral-usually

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Perleche
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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

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Tx

• If 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!!

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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

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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

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Tx

• Topical options include miconizole (Monistat
  cream), nystatin vaginal suppositories or tablets
  (Mycostatin), or clotrimazole (Gyne-Lotrimin or
  Mycelex G) vaginal tablets inserted once daily
  for 7 days

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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

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Pseudo Diaper Rash

• In 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

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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

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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

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CCC

• Disseminated infection is suggested by (1) bw
  lt1500g (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

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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
  Pagets disease
• Fungicides, meticulous cleansing of perianal
  region after bowel movements, topical
  corticosteroids and antipruritics (Atarax)

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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

143
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

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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

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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

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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

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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

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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 1970s to
  40 in the 1990s because of early empiric
  antifungals and better prophylaxis

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THE END

• Thank You