Fungal skin infection

Fungal skin infections are commonly affect the outer layer of the skin, nails and hair. Most of the fungi causing infections are usually dermatophytes (tinea), yeast (candida) and molds

1. FUNGAL SKIN INFECTION By Dr NDAYISABA CORNEILLE INTERNATIONAL HEALTH SCIENCE UNIVERSITY 2/19/2019 6:17:04 PM DR NDAYISABA CORNEILLE

2. What to expect/topic outline Introduction Key terms in fungal skin infections The different fungal skin infections Causes of the different fungal skin infections Clinical features/manifestations of fungal skin infections Management /treatment of fungal skin infections

3. Introduction Fungal skin infections are commonly affect the outer layer of the skin, nails and hair. Most of the fungi causing infections are usually dermatophytes ( tinea ), yeast (candida) and molds. The sign and symptoms depends on the type of the organisms that cause the infections. Most of the time, fungal skin infections may appear red, scaly and itchy. The rashes present have a well-defined border and sometimes it appear like a dry skin .

4. Fungi usually make their homes in moist areas of the body where skin surfaces meet; between the toes, in the genital area, and under the breasts. Fungi can live in the air, soil, water, plants and some live naturally in the human body. Fungal infections of the skin includes : 1.Dermatophytes infection which affect skin and nail ( epidermophyton ), hair ,skin and nail ( Trichophyto n ), skin and hair( Microsporum ) ; 2.Pityriasis versicolor , 3.Sporotrichosis c 4.Candidal infection 5.mycetoma. Introduction Cont ……

5. Key terms in fungal skin infections Fungi any of a group of unicellular, multicellular, or syncytial spore-producing organisms feeding on organic matter, including moulds , yeast, mushrooms, and toadstools. Mould : multi cellular fungus that produces superficial growth on various kinds of damp or decaying organic matter. Yeast : single celled fungi that produce asexually by budding or division. • Zoophilic fungi (those transmitted to humans by animals) cause a more severe inflammation • Anthropophilic fungi (spread from person to person) cause less inflammation . Dermatomycoses refers to any fungal infection of the skin or hair. These are caused by many different species and are generally named after the infected area rather than the species that cause it. Dermatophytosis refers an infection with fungi (organisms with high affinity for keratinized tissue such as the skin, nails and hair). These fungi may be acquired from animals (especially pets), other humans (especially among children) or soil (mainly among adults).

6. 1.Dermatophyte infection Dermatophytes are fungal organisms that require keratin for growth. These fungi can cause superficial infections of the skin, hair and nails . Dermatophytes are spread by direct contact from other people, animals, soil and from fomites. It coused by fungi which is responsible for invading : 1.Skin 2.Mucosal sites 3.These fungi are commensural organisms that frequently colonize normal epithelium. 4.Infections can extend more deeply in the immunocompromise d host.

7. The dermatophyte infections can be defined by the part of the body affected as listed below: Foot: Tinea Pedis Body: Tinea Corporis Scalp: Tinea capitis Nails: Tinea unguium Inguinal area: Tinea cruris Classification of dermatophyte infections

8. Tinea Pedis It is Dermatophytic infection of the feet which is Most commonly known: athlete’s foot, kulat air, “kaki makan air” it Occurs at the area between toes and around the foot below ankle level, Predisposing Factors : Hot, humid weather ; occlusive footwear; excessive sweating . • Most cases are caused by one of three dermatophytes organisms: 1. Trichophyton rubrum (the most common and the most stubborn) 2. Trichophyton mentagrophytes var. interdigitale 3. Epidermophyton floccosum .

9. Risk factors . Wearing closed shoes, especially if they are plastic-lined Having wet feet for prolonged periods of time Sweating a lot. Developing a minor skin or nail injury. NB ; Athlete's foot is contagious, and can be passed through direct contact, or contact with items such as shoes, stockings, and shower or pool surfaces . Clinical Manifestation . Skin Symptoms : • Usually Asymptomatic • Pruritus • Red and itchy skin • Burning or stinging pain • Blisters that ooze or get crusty • If the fungus spreads to nails, they become discolored(white or yellow), thick, and even crumble

10. There 4 Types : 1. Interdigital Type Two patterns: • Dry scaling • Maceration, peeling, fissuring of toe webs . Hyperhidrosis common. • Most common site : between fourth and fifth toes. Infection may spread to adjacent areas of feet . Usually is caused by all three organisms. Tinea pedis : interdigital dry type Skin Lesions 2 . Ulcerative Type : Extension of interdigital tinea pedis onto dorsal and plantar foot. Tinea pedis : Ulcerative Type

11. 3 . Moccasin Type : • Well-demarcated erythema with minute papules on margin, fine white scaling , and hyperkeratosis (confined to heels, soles, lateral borders of feet ). 4 . Inflammatory/Bullous Type : • Vesicle s or bullae filled with clear fluid . • Pus usually indicates superinfection with S.aureus infection or GAS. Usually is caused by T. mentagrophytes var. interdigitale or E. floccosum Tinea pedis : Inflammatory/Bullous Type Tinea pedis : Moccasin Type

12. MANAGEMENT - Tinea pedis can be treated with topical or oral antifungals or a combination of both.topical agents are used for 1-6 weeks. • Prophylaxis :Important in preventing recurrence T.pedis . Daily washing of feet while bathing with benzoyl peroxide bar is effective and inexpensive. Antifungal powders, alcohol gels . Keep the space in-between the toes dry by drying the skin thoroughly after washing, exposing to air, wearing cotton socks and not wearing shoes that are too tight or hot. Changing socks daily will help prevent re-infection

13. Subacute or chronic dermatophytosis of the groin , pubic regions , thighs and buttocks as scaling annular plaques . It is “Always ” associated with tinea pedis , the source of the infection.It is more common in men and typically spares the scrotum . It is the ‘second’ most common clinical presentation for dermatophytosis Most cases are caused by one of two dermatophytes organisms: 1. Trichophyton rubrum ; 2 . Trichophyton mentagrophytes Tinea Cruris (jock itch)

14. Predisposing Factors: 1)Warm, humid environment. 2) tight clothing worn by men. 3) obesity 4)Chronic topical glucocorticoid application. Clinical Manifestation . Skin Symptoms : Often none. In some persons pruritus .Skin Lesions: 1.Large , scaling, well-demarcated dull red /brown plaques Papules, pustules may be present at margins Tinea cruris : pruritus Tinea cruris : Brown plaques

15. Management Wash the groin skin two to three times a day. Keep the groin area dry. Avoid excess groin skin irritation by wearing 100% cotton underwear. Avoid fabric softeners, bleaches, or harsh laundry detergents. Apply a mix of over-the-counter hydrocortisone cream and clotrimazole cream one to two times a day to the affected area and covering this liberally with zinc oxide ointment.

16. TINEA CORPORIS Fungal infection of the skin, most common on the exposed surfaces of the body, namely the face, arms and shoulders. Are more common in children Etiology : dermatophytes which include trichophyton rubrum and microsporum canis 2.Predisposing Factors : . Animal exposure . chronic topical application of glucocorticoids .

17. Clinical Manifestation Skin Symptoms :Most commonly asymptomatic. •At times, pruritus and photosensitivity . Skin Lesions 1. Well-circumscribed macule to plaque of variable size; elevated border and central regression 2. Scaling is often minimal but can be pronounced. 3. Pink to red. 4. In black patients, hyperpigmentation .

18. - An Imidazole cream or Whitfield’s ointment twice daily for a minimum of 4 weeks. - Continue treatment until one week after symptoms have cleared. Multiple, widespread lesions may be treated systemically : - Griseofulvin 500 mg once daily for 2 to 6 weeks in adults or griseofulvin 10 –15 mg/kg once daily for 2 to 6 weeks in children or - Ketaconazole 200 mg once or twice daily or itraconazole 200 mg (2 tabs) once daily for 2 to 4 weeks in adults. When there is severe itching a mild steroid may be added . Clotrimazole 1% cream twice a day Or miconazole 2% cream 12 hourly for 2-3 weeks Management

19. TINEA INCOGNITO This is the term used for unrecognized fungal infection in patients treated with steroids (topical or systemic ). The normal response to infection (leading to erythema, scaling, a raised margin, and itching) is diminished, particularly with local steroid creams or ointments. The infecting organism flourishes, however, because of the host’s impaired immune response shown by the enlarging, persistent skin lesions . The groins, hands, and face are sites where this is most likely to occur . Lesions are usually asymptomatic but may be very pruritic or even painful .

20. Tinea Capitis Or Ringworm of the scalp Dermatophytic trichomycosis of the scalp . In Endothrix breaks at the mouth of follicle,Black dot, ( T.tonsurans,T.violaceum ) .In Ectothrix breaks hair 2-3 mm from mouth of the follicle . ( Microsporum,T.verucosum . ) but Mixed infections do occur . Etiology 90% of cases of tinea capitis caused by T . tonsurans . most cases were caused by: M. audouinii . Less commonly : M . gypseum , T. rubrum . T.mentagrophytes , Transmission • Person-to-person, animal to-person, via fomites. • Spores are present on asymptomatic carriers , animals, or inanimate objects . Risk Factors : For favus : debilitation,malnutrition , chronic disease

21. Epidemiology of tinea capitis Ringworm is a highly contagious infection and can spread through person-to-person contact or by sharing combs, towels, hats, or pillows. Fungi are organisms that thrive on dead tissue, such as fingernails, hair, and the outer layers of the skin. Dermatophytes prefer warmth and moisture thus they thrive on sweaty skin. Overcrowding and poor hygiene increase the spread of ringworm. House pets, such as cats and dogs, and Farm animals like goats, cows, horses, and pigs can also be carriers

22. Epidemiology of tinea capitis The high prevalence of superficial mycolic infections shows that 20-25% of the world’s population has skin mycoses making these one of the most frequent forms of infection. Pathogens responsible for skin mycoses are primarily anthropophillic and zophilicdermatophytes from the genera trishophyton (t) microsporum (m) and epidermophyton (e ) . the attack rates incidence of occurrence of specific mycoses can vary according to local socio-economic conditions and cultural practices for example tinea pedis is more prevalent in developed countries than in emerging economies. Poorer countries tinea capitis caused by t soudanese and m.audouinii are more prevalent . Microsporum,trichophyton and epidermophyton are restricted to the keratin layer of the epidermis, nail plate and hair shaft Fungi are organisms that thrive on dead tissue, such as fingernails, hair, and the outer layers of the skin. Dermatophytes prefer warmth and moisture thus they thrive on sweaty skin. Overcrowding and poor hygiene increase the spread of ringworm. House pets, such as cats and dogs, and Farm animals like goats, cows, horses, and pigs can also be carriers

23. Clinical Manifestation Skin Symptoms : 1.Inflammatory tinea capitis : •Pain, tenderness •± Alopecia 2.• Noninflammatory infection: • Scaling •Scalp pruritus •Diffuse or circumscribed alopecia •Occipital or posterior auricular adenopathy

24. Skin Lesions 1 . Small- Spored Ectothrix Tinea Capitis :’ ’Gray patch ” tinea capitis 2. Endothrix Tinea Capitis : “ Black dot ” tinea capitis : Broken-off hairs near surface give appearance of “dots” (swollen hair shafts) in dark-haired patients. Dots occur as affected hair breaks at surface of scalp. Tends to bediffuse and poorly circumscribed. ( Endothrix Tinea Capitis Ectothrix Tinea Capitis

25. Kerion : ( fig 1 ) • Inflammatory mass in which remaining hairs are loose. This Characterized by boggy, purulent,inflamed nodules and plaques • Usually extremely painful; drains pus frommultiple openings, like honeycomb. Tinea capitis : ( fig 2 ) • favus Extensive hair loss with atrophy,scarring , and so-called scutula , i.e., yellowish adherent crusts present on the scalp; remaining hairs pierce the scutula . ( fig 1 ) • ( fig 2 ) •

26. Management - Griseofulvin 500 mg once daily for 8-12 weeks in adults. - Griseofulvin 10-15 mg/kg once daily for 8-12 weeks in children. - Add Whitfield’s ointment or miconazole twice daily topically for 4 weeks. - Continue treatment after 12 weeks if the infection has not cleared completely. - Alternative: Ketaconazole 200 mg twice daily or terbinafine 250 mg once daily or itraconazole 200 mg (2 tabs) once daily for 4-8 weeks in adults. - Ask for signs of infection in siblings or friends of affected children or in pets or farm animals (bald patches, rash) and have these treated. - In case of bacterial superinfection : antiseptics and / or antibiotics. Systemic treatment is necessary to prevent scarring leading to permanent bald patches

27. Tinea Unguium / Onychomycosis is a fungal infection of the nail . This condition may affect toenails or fingernails, but toenail infections are particularly common. Etiology : • Between 95 and 97% caused by T. rubrum and T. mentagrophytes . Much less common : Epidermophyton floccosum , T. violaceum , T. schoenleinii , T. verrucosum ( usually infects only fingernails ).

28. Clinical Manifestation Approximately 80% of onychomycosis occurs on the feet, especially on the big toes . 3 Types : 1 . DLSO : (distal and lateral subungual type) White patch is noted on the distal or lateral undersurface of the nail and nail bed, usually with sharply demarcated borders. In time, whitish color can become discolored to a brown or black hue.

29. 2. SWO : (superficial white Onychomycosis ) A white chalky plaque is seen on the proximal nail plate, which may become eroded with loss of the nail plate 3 . PSO : (proximal subungual onychomycosis ) A white spot appears from beneath proximal nail fold. In time, white discoloration fills lunula , eventually moving distally to involve much of undersurface of the nail.

30. Management Debridement :is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue . Systemic agents :such as itraconazole appear effective in the treatment of onychomycosis . Itraconazole : 200 mg/d for 6 weeks (fingernails), 12 weeks (toenails) (continuous therapy).

31. Indications for Systemic Therapy  Fingernail involvement ,  limitation of function ,  pain ( thickened great toenails with pressure on nail bed , ingrowing toe nails ).  physical disability .  potential for secondary bacterial infection.  difficulty in trimming nails .

32. 2.Cutaneous candidiasis. Candida infection may occur in the flexures of infants and elderly or immobilized patients, especially below the breasts and folds of abdominal skin. Risk factor : - Immunity suppression e.g. HIV-infected and cancer patients or by systemic steroids, cytotoxic drugs, and radiotherapy. - Pregnancy and contraceptive pill use. - Warmth and moisture (babies’ nappy area, groins, under breasts, between toes). - Use of broad-spectrum antibiotics which kill resident non-pathogenic bacteria. - Diabetes mellitus. Diaper rash is also a cutaneous candida infection seen in the perineum of infants, in the region of contact with wet diapers .

33. Clinical Presentation The infection presents with itching, soreness, and a mild discharge. Skin : Red macules often with small pustules on their periphery which break down as the lesion spreads outwards. Oral and vulvo -vaginal: Itchy and painful mucosa redness, superficial erosions and white adherent plaques. Infection of lips / corners of the mouth also occurs. Severe mucosal candidiasis is seen often in HIV infection. NOTE: It needs to be differentiated from: (a) Psoriasis, which does not itch; (b) Seborrhoeic dermatitis, a common cause of a flexural rash in infants; and (c) Contact dermatitis and discoid eczema, which do not have the scaling margin. Candida intertrigo is symmetrical and “satellite” pustules or papules outside the outer rim of the rash are typical .

34. Management - Treat large oozing lesions with potassium permanganate dressings or baths for 10 minutes twice daily. Keep lesional skin dry. - Paint mucosal or smaller wet lesions with Gentian Violet solution once daily until healed. - Nystatin ointment or cream twice daily for skin, nystatin oral suspension (1 ml) swirled around mouth four times daily until two days after clinical cure for oral candidiasis, nystatin pessaries nightly for 2 weeks for vaginal candidiasis. - An imidazole cream twice daily for skin infections, miconazole oral gel 5 ml 4 times daily for 1 week for oral thrush, imidazole pessaries 1-3 nights for vaginal thrush. - Nappy rash: apply an imidazole cream and cover with zinkoxide cream or ointment. - In severe cases e.g. oesophageal thrush ketoconazole 200 mg twice daily for 1-2 weeks or itraconazole 100 mg once daily for 2 weeks or fluconazole 50-200 mg once daily for 1-2 weeks. Treatment duration may need to be extended in immunocompromised patients . NOTE: Griseofulvin is not an effective treatment for candida infections .

35. PARONYCHIA Chronic paronychia is a chronic inflammation of the skin around the nail caused by mixed or yeast infections. The cause is Candida albicans (a yeast) together with secondary bacterial infection. Chronic paronychia occurs in the fingers of individualls whose work demands repeated wetting of the hands: housewives, barmen, dentists, cleaners, laundry and laundry staff, nurses, and mushroom growers, for example. Other predisposing factors include diabetes, poor peripheral circulation, and removal of the cuticle. Presentation There is erythema and swelling of the nail fold, often on one side with brownish discoloration of the nail. Pus may be exuded.

36. Management Keep dry! Work conditions may need adapting. Bathe in betadine or potassium permanganate solution followed by application of an imidazole cream or Gentian Violet paint twice daily. Pushing back the cuticles should be avoided—this is commonly a long term condition, lasting for years. The hands should be kept as dry as possible, an azole lotion applied regularly around the nail fold, and in acute flares a course of erythromycin prescribed. Massaging the nailfold with a mild steroid helps decrease swelling .

37. 3.Tinea Versicolor ( Pityriasis Versicolor (PV ) ) A fungal infection of the skin caused a yeast called   Malassezia furfur previously known as Pityrosporumovale , P. orbiculare . This affects the trunk, usually of fair skinned individuals exposed to the sun. It affects mainly the upper back, chest, and arms. The fungus fluoresces under Wood's light and may be easily identified in scrapings viewed under a microscope . Predisposing Factors 1)Warm season or climates ; tropical climate 2) Hyperhidrosis ; aerobic exercise 3) Oily skin 4) Glucocorticoid treatment 5) Immunodeficiency 6)Application of lipids such as cocoa butter 7) predisposes young children to PV

38. Clinical Manifestation Skin Symptoms: ▪ Well-demarcated scaling patches ▪ Variable pigmentation: hypo- and hyperpigmented ; pink Most commonly on the trunk. Well defined macular lesions with fine scales develop, which tend to be white in suntanned areas and brown on pale skin. It may be confused with seborrhoeic dermatitis, pityriasis rosea , and vitiligo - itching, worsens with heating and sweating Skin Lesions 1• Macules, sharply marginated round or oval in shape, varying in size. 2. Hyperpigmented Sharply marginated brown scaling macules on the left side of the neck.

39. Management Non pharmacologic therapy: -Sunlight accelerates repigmentation of hypopigmented areas. Pharmacological treatment: -Topical treatment: selenium sulfide2.5% suspension, applied daily for 10 minutes for 7 consecutive days. -Antifungal topical agents: miconazole , clotrimazole 2% Oral treatment: -Ketoconazole 200mg qd /5days or single 400mg- dose Fluconazole: 400mg single dose, Triconazole : 200mg/od/5days

40. 4. sporotrichosis Sporotrichosis is a rare infection caused by a fungus called Sporothrix . This fungus lives throughout the world in soil and on plant matter such as sphagnum moss, rose bushes, and hay. Epidemiology Sporotrichosis by coming in contact with the fungal spores in the environment. Some cases of sporotrichosis have been associated with scratches or bites from animals, particularly cats.

41. Clinical features A nodule or warty plaque forms at the site of injury. Nodule appear along local lymphatic's Investigation Mycological culture Histological examination Treatment Oral potassium iodide

42. 5. Mycetoma A chronic localized infection caused by various species of fungi or actinomycetes and characterized by the formation of clusters of organism within abscesses. Mycetoma is a disease caused by certain types of bacteria and fungi found in soil and water. These bacteria and fungi may enter the body through a break in the skin, often on the person’s foot. . Mycetoma can be caused by bacteria ( actinomycetoma ) or fungi ( eumycetoma ). Clinical features Lesions on the lower leg. Serious deformity and gross swelling of the limb. Swollen skin with discharging sinuses

43. Investigations Gram colour and microscopy Culturing of the causative organism Treatment Systemic antifungal or antibiotics such as rifampicin, dapsone , streptomycin and clotrimoxazole .

44. REFERENCES ABC of Dermatology, 4 th Edition, Paul K Buxton, 2003, BMJ Books . Fitzpatrick’s color atlas and synopsis of clinical dermatology sixth edition, Klaus Wolf,r.Allen Johnson Therapeutic Guidelines: Dermatology