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Adult Cutaneous Fungal Infections UCSF Dermatology Last updated 8.30.2010

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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

    Aly R and Maibach H. 1999. Atlas of Infections of the Skin. Churchill Livingstone.

    De Kock CA, Sampers GH, Knottnerus JA. Diagnosis and management of cases of

    suspected dermatomycosis in The Netherlands: influence of general practice based

    potassium hydroxide testing. Br J Gen Pract. 1995 Jul;45(396):349-51.

    Erbagci Z. Topical therapy for dermatophytoses: should corticosteroids be included?

    Am J Clin Dermatol. 2004;5(6):375-84.

    Gupta AK, Kogan N, Batra R. Pityriasis versicolor: a review of pharmacological

    treatment options. Expert Opin Pharmacother. 2005 Feb;6(2):165-78.

    Havlickova B, Czaika VA, Friedrich M. Epidemiological trends in skin mycoses

    worldwide. Mycoses. 2008 Sep;51 Suppl 4:2-15.

    Huang DB, Ostrosky-Zeichner L, Wu JJ, Pang KR, Tyring SK. Therapy of common

    superficial fungal infections. Dermatol Ther. 2004;17(6):517-22.

    Weinberg JM, Koestenblatt EK, Tutrone WD, Tishler HR, Najarian L. Comparison of

    diagnostic methods in the evaluation of onychomycosis. J Am Acad Dermatol. 2003

    Aug;49(2):193-7.

    Welsh O, Vera-Cabrera L, Welsh E. Onychomycosis. Clin Dermatol. 2010 Mar

    4;28(2):151-9.