Fungal Infections...10. Van Zuuren EJ, Fedorowicz Z, El-Gohary M. Evidence-based topical treatments...

Fungal InfectionsEugene Sanik, D.O.

3rd Year Dermatology Resident

Disclosures

• No financial relationships to disclose

Learning Objectives

• Understand the causes of fungal infections

• Illustrate and recognize their clinical presentations

• Review latest evidence-based treatment guidelines

Introduction to Mycology

• Fungi first appeared 1.5 billion years ago

• Among earliest organisms domesticated by humans

• Serious problem only since 20th century

• 1.5 million fungal species known

• Less than 100 are pathogenic to humans

• Except for dermatophytes, not contagious

Classification of Fungal Diseases

• Superficial- Do not have ability to invade skin, hair, or nails

• Cutaneous - Dermatophytes

• Deep- Localized subcutaneous (implantation or dermal spread)

- Dimorphic systemic (hematogenous spread)

- Opportunistic (immunocompromised patients)

Classification of Fungal Diseases

• Superficial- Do not have ability to invade skin, hair, or nails

• Cutaneous - Dermatophytes

• Deep- Localized subcutaneous (implantation or dermal spread)

- Dimorphic systemic (hematogenous spread)

- Opportunistic (immunocompromised patients)

Superficial Fungal Infections

• Pityriasis versicolor

• Tinea nigra

• Black piedra

• White piedra

Pityriasis Versicolor

Treatment of Pityriasis Versicolor

• Topical ketoconazole very effective against Malassezia

• Oral fluconazole and itraconazole as effective with lower recurrence

• Oral ketoconazole not recommended (FDA warning)

• Oral terbinafine not effective

Tinea Nigra

Hortaea werneckii (melanin-producing yeast)

Black Piedra and White Piedra

Piedra Hortae Trichosporon beigelii

Differential Diagnosis of Piedras

Trichomycosis axillaris

Corynebacterium

Head Lice

Pediculus humanus capitis

Classification of Fungal Diseases

• Superficial- Do not have ability to invade skin, hair, or nails

• Cutaneous - Dermatophytes

• Deep- Localized subcutaneous (implantation or dermal spread)

- Dimorphic systemic (hematogenous spread)

- Opportunistic (immunocompromised patients)

Cutaneous Mycoses

• Dermatophytoses of skin, hair, and nails

• Candidiasis of skin, mucous membranes, and nails

• Do not invade subcutaneous tissue

Dermatophytosis

• Microsporum, Trichophyton, and Epidermophyton

• Most common causes:• Tinea capitis – T. tonsurans

• Tinea faciei – T. rubrum

• Tinea corporis – T. rubrum

• Tinea pedis – T. rubrum

• Bullous tinea pedis – T. mentagrophytes

• White superficial onychomycosis – T. mentagrophytes

• Distal & proximal subungual onychomycosis – T. rubrum

• betamethasone did not compromise the antifungal effects of clotrimazole

• clinical endpoints consistently favored the combination drug, which relieved symptoms more rapidly

• Once daily application is as effective as twice daily, with better compliance

• Azoles, benzylamines, and allylamines show no difference in clinical effectiveness

• Azole-corticosteroid combination achieved higher clinical cure rates than azole monotherapy

• Duration inadequately addressed

• When given for 2 weeks, Terbinafine has statistically significantly better cure rates than Itrazonazole, Fluconazole, Ketoconazole, and Griseofulvin.

• Itraconazole for 4 weeks as effective as 2 weeks of Terbinafine

Tinea Treatment: Summary

TOPICAL

• Any topical antifungal, once daily for 2-4 weeks

- optional: add moderate potency topical steroid

ORAL

• Terbinafine 250mg once daily for 2 weeks

Fungal folliculitis

• Tinea capitis

• Tinea barbae

• Majocchi’s granuloma

• Require treatment with oral antifungals

• Fungi thought to have evolved to survive harsh winters and resist temperatures < 50°C, but authors conjecture:- Fungi may be secondarily destroyed as tissue necrosis occurs- Rapid cooling forms intracellular ice crystals and disrupts the

cell membrane- rewarming damages the cell membrane again and stimulates

the immune system

Dermatophytid (“id”) reaction

• Hypersensitivity reaction to dermatophyte antigens

• Classic presentation is vesicular eruption on the sides of fingers with inflammatory tinea pedis

• Examine the feet in all cases of suspected hand eczema!

• Eruptions can also be urticarial and panniculitic

Onychomycosis (Tinea Unguium)

• T. rubrum (most common), yeast, nondermatophyte molds

• Superficial white onychomycosis

• Distal lateral subungual onychomycosis

• Proximal subungual onychomycosis

Onychomycosis Treatment

Mycologic Cure Rate(negative KOH and culture)

Topical Ciclopirox (Penlac) 29%

Topical Tavaborole (Kerydin) 35%

Topical Efinaconazole (Jublia) 55%

Oral Fluconazole (Diflucan) 48%

Oral Itraconazole (Sporanox) 54%

Oral Terbinafine (Lamisil) 77%

Candidiasis

• C. albicans inhabits skin, GU, and GI tract

• Opportunistic pathogen

• Frequently infects intertriginous areas

• Predisposing factors include hygiene, diabetes, antibiotic use, and immunosuppression

• Clinical spectrum can range from short-lived superficial to overwhelming systemic infections

Candidiasis Treatment

TOPICAL

• Any topical antifungal for cutaneous candidiasis

• Rinse-and-spit with fluoconazole solution is superior to nystatin and amphotericin B for thrush

ORAL

• Fluconazole 50-100mg/day (95%+ success rate)

Classification of Fungal Diseases

• Superficial- Do not have ability to invade skin, hair, or nails

• Cutaneous - Dermatophytes

• Deep- Localized subcutaneous (implantation or dermal spread)

- Dimorphic systemic (hematogenous spread)

- Opportunistic (immunocompromised patients)

Deep Fungal Infections

Subcutaneous Systemic Opportunistic

SporotrichosisPhaeohyphomycosisChromomycosisMycetoma (Madura foot) Lobomycosis RhinosporidiosisZygomycosis

BlastomycosisHistoplasmosis CoccidioidomycosisParacoccidioidomycosis

CryptococcosisAspergillosisFusariosisMucormycosisPenicilliosis

Sporotrichosis

• DDX: Atypical mycobacterium, Nocardia, Leishmania, Tularemia

Chromomycosis

• Fonsecaea pedrosoi (most common cause)

Madura Foot (Mycetoma)

Lobomycosis

• Lacazia loboi

• “keloidal blastomycosis”

• Dolphins

Histoplasmosis Blastomycosis

Coccidiomycosis Paracoccidiomycosis

Opportunistic Systemic

• Disseminate in immunocompromised patients- Organ transplant, post-chemotherapy, HIV

• Candida species most common

Mucormycosis

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