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Adult Cutaneous
Fungal Infections
UCSF Dermatology
Last updated 8.30.2010
Module Instructions
The following module contains a number of
green, underlined terms which are
hyperlinked to the dermatology glossary,
an illustrated interactive guide to clinical
dermatology and dermatopathology.
We encourage the learner to read all the
hyperlinked information.
http://missinglink.ucsf.edu/lm/DermatologyGlossary/index.html
Goals and Objectives
The purpose of this module is to help medical students develop a clinical approach to the evaluation and initial management of patients presenting with cutaneous fungal infections.
After completing this module, the medical student will be able to: Identify and describe the morphologies of superficial fungal infections.
Describe the correct procedure for performing a KOH examination
and interpreting results.
Recognize the use and limitations of KOH examination and fungal
cultures to diagnose fungal infections.
Explain basic principles of treatment for superficial dermatomycoses,
including fungistatic and fungicidal topical and systemic agents.
Superficial Fungal Infections: The Basics
Superficial cutaneous fungal infections are limited to the epidermis, as opposed to systemic fungal infections (i.e. endemic mycoses and opportunistic infections).
Three groups of cutaneous fungi cause superficial infections: dermatophytes, Malassezia spp., and Candida spp.
Dermatophytes (which include Trichophyton spp., Microsporum spp., and Epidermophyton spp.) infect keratinized tissues: the stratum corneum (outermost epidermal layer), the nail or the hair.
The term tinea is used for dermatophytoses and is modified according to the anatomic site of infection, e.g., tinea pedis
Dermatophytoses are estimated to affect 20-25% of people worldwide, making them one of the most common infections.
http://missinglink.ucsf.edu/lm/DermatologyGlossary/epidermis.html
Case One
Mr. Eugene Brown
Case One: History
HPI: Eugene Brown is a 62 year-old healthy gentleman who presents to his primary care physician with a one-year history of itching and burning of his feet.
PMH: no chronic illnesses or prior hospitalizations
Medications: none
Allergies: no known allergies
Family history: noncontributory
Social history: lives with wife, works as a banker
Health-related behaviors: reports no alcohol, tobacco or drug use
ROS: increased nocturia, otherwise negative
Case One: Skin Exam
How would you describe these exam findings?
Case One: Skin Exam
Erythema and scaling are
present on the plantar
surface and between the
toes.
Case One, Question 1
Which of the following is Mr. Browns most
likely diagnosis?
a. Tinea pedis
b. Psoriasis
c. Candidal intertrigo
d. Atopic dermatitis
e. Onychomycosis
9
Case One, Question 1
Answer: a
Which of the following is Mr. Browns most likely diagnosis?
a. Tinea Pedis
b. Psoriasis (The interdigital and plantar surface of the toes are an unusual location for psoriasis. Would expect a well-demarcated plaque with a thick silvery scale)
c. Candida intertrigo (More erythema, less likely location)
d. Atopic dermatitis (Characterized by red patches and plaques scale. Lichenification may also result)
e. Onychomycosis (Fungal infection of nail)
http://missinglink.ucsf.edu/lm/DermatologyGlossary/psoriasis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/atopic_dermatitis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/onychomycosis.html
Tinea Pedis: The Basics
Tines pedis (athletes foot) is the most common fungal infection seen in developed countries, and is most commonly caused by the fungus Trichophytonrubrum.
Shoes provide an ideal environment due to high humidity.
Public showers, gyms, and swimming pools are common sources of infection.
Difficult to permanently cure; may recur in hot seasons.
Three clinical patterns of infection: interdigital, moccasin, and vesiculobullous type.
Tinea Pedis: Interdigital Type
Most common, presents with scaling and redness between
the toes and may have associated maceration.
Tinea Pedis: Moccasin Type
Also known as chronic hyperkeratotic type.
Sharply marginated scale, distributed along lateral borders of feet, heels, and soles.
At times, vesicles and erythema are present at the margins.
Often associated with onychomycosis(nail fungal infection).
Tinea Pedis: Moccasin Type
Moccasin type may present as
one hand, two feet syndrome.
Affected hand shows unilateral
fine scaling, particularly in the
creases (see below), and nails
are often involved.
Tinea Pedis: Vesiculobullous Type
Vesiculobullous type
tinea pedis represents
a delayed
hypersensitivity
immune response to a
dermatophyte.
Grouped, 2-3 mm
vesicles or bullae are
seen, often on the arch
or instep.
May be itchy or painful.
Back to Case One
Eugene Brown
Case One, Question 2
Which of the following is the most
appropriate next step in diagnosis?
a. Woods lamp
b. KOH exam
c. Skin biopsy
d. Diagnostic testing not necessary at this time.
Begin empiric treatment with antifungals.
Case One, Question 2
Answer: b
Which of the following is the most
appropriate next step in diagnosis?
a. Woods lamp
b. KOH exam (potassium hydroxide
preparation)
c. Skin biopsy
d. Diagnostic testing not necessary at this time.
Begin empiric treatment with antifungals.
http://missinglink.ucsf.edu/lm/DermatologyGlossary/woods_light_examination.html
Case One: KOH Exam
What are the diagnostic features in this KOH exam?
Case One: KOH Exam
What are the diagnostic features in this KOH exam?
Parallel walls
throughout
the entire length
Septated and
branching
hyphae
KOH Exam: Basic Facts
Easiest and most cost effective method
used to diagnose fungal infections of the
hair, skin, and nail
Proper technique requires training and
repetition
KOH dissolves keratinocytes to allow
easy viewing of hyphae
Heat is used to accelerate this reaction
The KOH Exam Procedure
1. Clean and moisten skin with
alcohol swab
2. Collect scale with 15 scalpel
blade
3. Put scale on center of glass
slide
4. Add drop of KOH and
coverslip; heat slide gently
with flame to adequately
dissolve keratin
5. Microscopy: scan at 10X to
locate hyphae; then study in
detail at 40X if needed
Click here to watch the KOH video.
Make sure to turn on your computer volume
(video length 8min 41sec)
http://www.dermatology.ucsf.edu/pdf/KOH Prep Video.wmv
Case One, Question 3
Which of the following are possible pitfalls of KOH prep?
a. False negative KOH due to prior partial treatment with antifungals
b. Possibility of mistaking lipid or cell membranes for hyphae
c. Misidentification of clothing fibers or lint as hyphae
d. All of the above are limitations
Case One, Question 3
Answer: d Which of the following are possible pitfalls
of KOH prep?a. False negative KOH due to prior partial treatment
with antifungals
b. Possibility of mistaking lipid or cell membranes for hyphae (hyphae have parallel walls throughout and tend to be longer)
c. Misidentification of clothing fibers or lint as hyphae(clothing fibers or lint are tapered, while hyphaehave parallel walls throughout)
d. All of the above are limitations
Treatment of Tinea Pedis: Hygiene
For all types of tinea pedis, hygiene and
topical antifungals are effective first-line
therapies
Hygiene: Dry the area after bathing
Change socks daily and alternate shoes worn
Consider wearing open shoes such as sandals
Use foot powder (available over the counter) to
keep feet dry
Treatment of Tinea Pedis: Topical
Topical antifungals: Apply until tinea shows
resolution, then continue treatment for a minimum of
two weeks
Imidazoles: Fungistatic (inhibit the growth of fungi)Examples: clotrimazole, miconazole, sulconazole,
oxiconazole, ketoconazole (least activity against
dermatophytes)
Allylamines: Fungicidal (kill fungi)Examples: terbinafine, butenafine, naftifine
Ciclopirox: Fungicidal and fungistaticExample: Ciclopirox olamine
Treatment of Tinea Pedis By Type
Interdigital: Antifungal agents with broad spectrum antibacterial activity
such as imidazoles, ciclopirox olamine, and allylamines.
Plantar Moccasin/Chronic Hyperkeratotic: Topical allylamines and imidazoles
Keratolytics are also useful: ie salicylic acid, benzoic acid
(Whitfields ointment)*, urea, and lactic acid
Vesiculobullous: Compresses in conjunction with antifungal agents
May require an oral agent such as terbinafine or
itraconazole.
* Whitfields ointment is a combination of salicylic and benzoic acid. In US can be bought
through online pharmacies or compounded.
Case One, Question 5
Which of the following are common
complications of tinea pedis?
a.Lower leg cellulitis
b.Furuncolosis of the lower leg
c. Peripheral neuropathy
d.Deep vein thrombosis
e.Tinea corporis
29
Case One, Question 5
Answer: a and e Which of the following are common
complications of tinea pedis?a. Lower leg cellulitis (the most common risk
factor for lower leg cellulitis in immunocompetent non-diabetics is tinea pedis, which creates a portal of entry for bacteria)
b. Furuncolosis of the lower legc. Peripheral neuropathyd. Deep vein thrombosise. Tinea corporis (from autoinoculation)
Onychomycosis
May mimic other conditions (e.g. psoriasis, lichen planus)
Treatment is expensive, of long duration, and with potential side effects
Oral antifungals also have drug-drug interactions
Responds very poorly to topical antifungals first line treatments are oral terbinafine or itraconazole.
Another complication of tinea pedis is
onychomycosis, a chronic fungal
infection of the nailbed that tends to
spread to other nails.
Identification of fungus in the affected
nail (at minimum a positive KOH prep or
nail biopsy) is necessary before
treatment, for several reasons:
Case Two
Mr. Daniel Green
Case Two: History
HPI: Daniel Green is a healthy 18 year-old who presents with a lesion on his right leg that has been present for 2 weeks. The lesion is itchy and is growing in size.
PMH: no major illnesses or hospitalizations
Medications: None
Allergies: None
Family history: noncontributory
Social history: Lives with his parents and 12 year-old sister. The family adopted a puppy approximately 3 months ago. No history of recent travel.
Health-related behaviors: no tobacco, alcohol or drug use.
Case Two: Skin Exam
How would you describe these
exam findings?
Case Two: Skin Exam
Sharply marginated,
erythematous annular lesion
with central clearing and raised
papulovesicular border with
scaling.
Case Two, Question 1
Which of the following is the most
appropriate next step in diagnosis?
a. Woods lamp exam
b. KOH exam
c. Biopsy
d. All of the above
Case Two, Question 1
Answer: b
Which of the following is the most
appropriate next step in diagnosis?
a. Woods lamp exam
b. KOH exam
c. Biopsy
d. All of the above
Case Two, Question 2
Which of the following is the most likely
diagnosis?
a. Tinea cruris
b. Tinea corporis
c. Atopic dermatitis
d. Psoriasis
e. Seborrheic dermatitis
Case Two, Question 2
Answer: b
Which of the following is the most likely diagnosis?
a. Tinea cruris (Dermatophyte infection in the groin)
b. Tinea corporis
c. Atopic dermatitis (Poorly defined erythematouspatches without central clearing)
d. Psoriasis (Well-demarcated erythematous plaques with silvery scale)
e. Seborrheic dermatitis (Yeast infection typically affecting face, chest, and/or scalp, often with scaling)
http://missinglink.ucsf.edu/lm/DermatologyGlossary/tinea.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/atopic_dermatitis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/psoriasis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/seborrheic_dermatitis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/seborrheic_dermatitis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/seborrheic_dermatitis.html
Basic Facts: Tinea Corporis
Tinea corporis, ringworm, refers to dermatophytosis
of the skin, usually affecting the trunk and limbs Affects all age groups
Most prominent symptom is itching
Asymmetric distribution
The margin of the lesion is the most active; central area
tends to heal
Scrapings should be taken from the red scaly margin for
KOH exam
A variant of this is tinea cruris or jock itch, which has a
similar presentation but appears in the groin
Tinea Corporis
Annular lesion with
central clearing is
typical of tinea
corporis
When To Perform A Fungal Culture?
Cultures identify the specific species of fungi causing the infection.
Even if KOH prep is negative, a culture may be positive.
As opposed to tinea pedis, tinea corporis is caused by different fungal species with different environmental sources (i.e. animals, tinea capitis, tinea pedis). Using a fungal culture to identify the species will
help identify the source and guide treatment
Tinea Corporis: Treatment
Begin with topical treatment
Topical antifungals are applied until tinea shows
resolution, then continue treatment for a minimum of two
weeks
Imidazoles (fungistatic)
Allylamines (fungicidal)
Ciclopirox (fungicidal and fungistatic)
Oral antifungals are indicated in the following situations:
If there is a poor response to topical agents
If an animal is the source of infection
If eruptions involve a large surface area
Ms. Anna Jones
Case Three
Case Three: History
HPI: Ms Jones is a 27 year-old woman who presents with
mild itchiness of her back which began mid summer. She is
also concerned about areas on her back that do not tan.
PMH: asthma
Medications: occasional multivitamin
Allergies: no known drug allergies
Social History: spends her summer months in Florida. Is an
avid runner.
Health-related behaviors: occasional glass of wine 1-2
times per month, no tobacco or drug use
ROS: negative
Case Three: Skin Exam
How would you describe these exam findings?
Case Three: Skin Exam
Hypopigmented macules and patches
Tan surrounding skin
Case Three, Question 1
Which of the following is the most likely
diagnosis?
a. Tinea versicolor
b. Seborrheic dermatitis
c. Pityriasis alba
d. Vitiligo
e. Tinea corporis
Case Three, Question 1
Answer: a
Which of the following is the most likely diagnosis?a. Tinea versicolor
b. Seborrheic dermatitis (abnormal immune response to normal skin yeast causing scaling and crusting)
c. Pityriasis alba (noninfectious, asymptomatic poorly-defined areas of hypopigmentation; self-limited)
d. Vitiligo (autoimmune loss/dysfunction of melanocytescausing areas of complete depigmentation)
e. Tinea corporis (fungal skin infection, presents as erythematous annular lesions with central clearing)
http://missinglink.ucsf.edu/lm/DermatologyGlossary/seborrheic_dermatitis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/seborrheic_dermatitis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/seborrheic_dermatitis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/pityriasis_alba.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/pityriasis_alba.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/pityriasis_alba.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/vitiligo.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/tinea_corporis.html
Diagnosis: Tinea Versicolor
Tinea versicolor (aka Pityriasis versicolor) is
not a dermatophytosis
It is an infection caused by species of
Malassezia, a lipophilic yeast that is a normal
resident in the keratin of the skin and hair
follicles of individuals at puberty and beyond
Tends to recur annually in the summer months
Tinea Versicolor
Characterized by well-demarcated, tan, salmon, or
hypopigmented patches, occurring most commonly
on the trunk (facial involvement is rare)
Macules will grow, coalesce and various shapes
and sizes are attained in an asymmetric
distribution
Visible scale is not often present, but when rubbed
with a finger or scalpel blade, scale is readily seen.
This is a diagnostic feature of tinea versicolor
Evoked scale will disappear after treatment50
Case Three, Question 2
Which of the following is the most
appropriate next step in management?
a. Fungal culture
b. KOH exam
c. Woods light exam
d. Skin biopsy
Case Three, Question 2
Answer: b
Which of the following is the most
appropriate next step in management?
a. Fungal culture (Malassezia spp. are easily
identified by a KOH exam but are not easily
cultured)
b. KOH exam
c. Woods light exam
d. Skin biopsy
Microscopy
Characteristic spaghetti and meatball pattern corresponding
to hyphae and spores. (Dye added to this specimen)
Tinea Versicolor: Morphology
In untanned Caucasians, the
lesions may be salmon-
colored or brown.
In tanned Caucasians, the
lesions may appear pale in
comparison to the
surrounding skin.
In darker skinned individuals,
lesions may appear hyper- or
hypopigmented.
Case Three, Question 3
Which of the following treatments would
you recommend for Ms Jones?
a. Ketoconazole cream
b. Antifungal shampoo
c. Oral terbinafine
d. Nystatin cream
Case Three, Question 3
Answer: b
Which of the following treatments would you
recommend for Ms Jones?
a. Ketoconazole cream
b. Antifungal shampoo
c. Oral terbinafine
d. Nystatin cream
Tinea Versicolor: Topical Treatment
Shampoos: selenium sulfide 2% shampoo,
ketoconazole shampoo, pyrithione zinc shampoo
Apply daily to affected areas, lather, and rinse
Spreads easily to cover larger areas
Azole creams: ketoconazole, econazole, miconazole,
clotrimazole
Apply daily or bid for 2 weeks
Can be effective for limited areas, but infections tend to be
widespread, so local topical treatment associated with high
relapse rate
More expensive than shampoos
Tinea Versicolor: Oral treatment
Oral medication should be used when a large
area is involved.
Oral medications of choice include: ketoconazole (can be given as one-time dose)
fluconazole
itraconazole
Ketoconazole can be given as a one-time dose. Take on an empty stomach, exercise until perspiring
(medication is delivered via sweat), and avoid shower
six hours after taking medication.
Tinea Versicolor: Maintenance Therapy
Many patients relapse
If the patient has had more than one previous episode then recommend maintenance therapy
Maintenance therapy: topicals are used 1-2x/week Ketoconazole shampoo
Selenium sulfide (2.5%) lotion or shampoo
Salicylic acid/sulfur bar
Pyrithione zinc (bar or shampoo)
Ketoconazole 400mg PO monthly
Ms. Betty Raskin
Case Four
Case Four: History
HPI: Ms. Raskin is a 62 year-old woman who
presents with a red itchy rash beneath her breasts
PMH: type 2 diabetes (last hemoglobin A1c 9.2%),
obesity
Medications: metformin, which she says she often
does not remember to take
Family history: noncontributory
Social history: lives in Texas part-time
Health-related behaviors: no tobacco, alcohol or drug
use
ROS: negative
Case Four, Question 1
a. Well demarcated red
plaques with overlying
thick silvery scale
b. Grouped vesicles on an
erythematous base
c. Sharply defined red
plaques involving the
skin folds with
surrounding satellite
papules
d. Inflammatory nodules
Which of the following best describe these characteristic
exam findings?
63
Case Four, Question 1
a. Well demarcated red
plaques with overlying thick
silvery scale
b. Grouped vesicles on an
erythematous base
c. Sharply defined red
plaques involving the
skin folds with
surrounding satellite
papules
d. Inflammatory nodules
Answer: c
Which of the following best describe these characteristic
exam findings?
Case Four, Question 2
Which of the following is the most likely
diagnosis?
a. Psoriasis
b. Candidal intertrigo
c. Seborrheic dermatitis
d. Eczema
e. Tinea cruris
Case Four, Question 2
Answer: b
Which of the following is the most likely
diagnosis?
a. Psoriasis
b. Candidal intertrigo
c. Seborrheic dermatitis
d. Eczema
e. Tinea cruris
http://missinglink.ucsf.edu/lm/DermatologyGlossary/psoriasis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/seborrheic_dermatitis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/seborrheic_dermatitis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/seborrheic_dermatitis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/eczema.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/tinea.html
Candidal Intertrigo: Basic Facts
Candidal intertrigo = Candidiasis of large skin folds
May arise in the following areas:
Groin or armpits
Between the buttocks
Under large pendulous breasts
Under overhanging abdominal folds
KOH exam reveals pseudohyphae
Burns more than itches
Case Four, Question 3
Which of the following factors predispose to
candidal intertrigo?
a. Hot, humid weather
b. Limited mobility
c. Obesity
d. Diabetes mellitus
e. All of the above
68
Case Four, Question 3
Answer: e
Which of the following factors predispose to candidal intertrigo?
a. Hot, humid weather
b. Limited mobility
c. Obesity
d. Diabetes mellitus
e. All of the above
Case Four, Question 4
Which of the following is the most
appropriate next step in management?
a. Nystatin ointment and topical low strength
glucocorticoid
b. Oral antifungal agent and topical low strength
glucocorticoid
c. Oral glucocorticoid
d. Barrier creams or ointments (e.g. petroleum
jelly, zinc oxide paste, etc.)
70
Case Four, Question 4
Answer: a
Which of the following is the most appropriate next step in management?
a. Nystatin ointment and topical low strength glucocorticoid
b. Oral antifungal agent and topical low strength glucocorticoid
c. Oral glucocorticoid
d. Barrier creams or ointments (e.g. petroleum jelly, zinc oxide paste, etc.)
Candidal Intertrigo: Management
Prevention Keep intertriginous areas dry, clean, and cool Encourage weight loss for obese patients Washing with benzoyl peroxide bar may reduce Candida
colonization
Topical antifungal agents Nystatin, miconazole, clotrimazole, or econazole
Topical anti-inflammatory Low strength glucocorticoid preparations rapidly improves
the itching and burning, but should be stopped after one week
Systemic antifungal agents (used for infections resistant to topical treatment) Oral fluconazole, itraconazole, or ketoconazole
Take Home Points
Cutaneous fungal infections are extremely common Three clinical patterns of tinea pedis infection: interdigital,
moccasin, and vesiculobullous type Lower leg cellulitis is a potentially life-threatening complication of
tinea pedis; therefore in people at elevated risk (e.g. diabetics, immunocompromised) it is essential to treat tinea pedis.
If it scales, scrape it! KOH examination is the easiest and most cost effective method used to diagnose fungal infections of the hair, skin, and nails.
In tinea corporis and tinea cruris, the margin of the lesion is the most active, and is the preferred site for skin scraping for KOH exam.
Fungal culture is important because it may be positive when KOH prep is negative, and is the only easily available method to definitively identify the organism. Culture is especially helpful in tinea corporis when the source of infection is not obvious (as opposed to tinea pedis).
Take Home Points
Tinea versicolor is tan-or salmon-colored in light-colored skin Tinea versicolor may appear relatively hypopigmented in
tanned individuals or darker brown in people with naturally pigmented skin.
Topical treatment is usually appropriate as a first-line agent for tinea pedis, tinea corporis, and candidal intertrigo, however oral medications are called for when involvement is extensive, when tinea corporis is thought to have been transmitted by an animal, and in fungal infections of the nails.
Fungal infections have high rates of recurrence after treatment, but maintaining a dry, clean skin environment is helpful for prevention.
Monitoring for recurrence and maintenance treatments may be helpful in patients with recurrent infection.
End of the Module
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