DERMATOLOGY EXIMIUS

FUNGAL INFECTIONS 2021

DR. HERALUZ LIQUIGAN-DAMO FEBRUARY 2020
Risk for fungal infections:
Major Predisposing factors
• Hematopoietic stem cell transplant (particularly 1st 30days) • Moist areas
• Induction chemotherapy for hematologic malignancies • Local environmental factors:
• Solid organ transplantation ° Heat
Minor ° Humidity
• Any chemotherapy ° Occlusion
• Critical illness • Immunocompromised patients
• Mechanical ventilation • Genetic predisposition
• Indwelling central venous catheter
• Hemodialysis Classification according to area of infection
• Tpn Tinea corporis
• Malnutrition • Trichophyton sp. (t. Circinata)
• Aids • Body (trunk, legs and arms)
• Mucositis • Face ( tinea faceii)
• Recent use of broad spectrum antibiotics
• Diabetes
• Intra- abdominal surgery

Classification of fungal infections:

• Superficial
• Mucocutaneous Lesions
• Subcutaneous • Primary
• Deep • secondary
° Primary • Degree of inflammation varies:
° Opportunistic ° Erythema and scaling
° Single
Dermatophytic infections ° Multiple or coalescing
• Dermatophytoses
° Central clearing +/-
• Tinea (latin for worm): charc. Ringshaped lesions.
• Variant forms: nummular scaling patches studded with
• Ringworm fungi: 3 genera
small papules or pustules
° Trichophyton ( t. Rubrum) Ddx:
° Microsporum
• Pityriasis rosea
° Epidermophyton
• Drug eruptions
• Most common sources:
• Nummular dermatitis
° Skin scales shed fr. Lesions on the foot onto a changing • Erythema multiforme
room floor. • Tinea versicolor
° T. Mentagrophytes stay alive for 36 months. • Erythrasma
° Infected hairs from household pets • Sporiasis
° Infected hairs from farm animals • Secondary syphilis
° • Granuloma annulare
Diagnosis • Impetigo or echthyma
Clinical signs & symptoms
• Pruritus Treatment: mild to moderate
• Burning or stinging sensations • Topical antifungal creams
• Erythematous areas with fine scales ° 2cm-3cm margin
often in circular pattern ° One month therapy
• White scales • Use of low to medium potent corticosteroids after one
• Spread peripherally with a central clearing month therap yfor pih.
• Erythematous ring, sharply marginated elevated rolled
borders and scaly with a clear center.

TRANSCRIBERS Group 7 1 of 6
 DERMATOLOGY EXIMIUS
FUNGAL INFECTIONS 2021
DR. HERALUZ LIQUIGAN-DAMO FEBRUARY 2020
Extensive lesions: oral anti fungals. • Vesicles, pustules and papules
Itraconazole (sporanox/canditral) • May extend to buttocks and inner thighs.
• Description fungistatic activity. Synthetic triazole antifungal
agent that slows fungal-cell growth by inhibiting Signs & symptoms
cytochrome p-450–dependent synthesis of ergosterol, a • Ringed lesions extend to crural fold over the adjacent inner
vital component of fungal-cell membranes. thigh.
• Adult dose200 mg po qid for 1 wk; not to exceed 400 mg/d; • Both sides
increase in 100-mg increments if no improvement • Lichenification, weeping
(administer >200 mg/d in divided doses) • Maceration with areas of pustulation.

Terbinafine (lamisil, daskil)

• Description : second generation allyamine. Inhibits
squalene epoxidase, which decreases ergosterol synthesis,
causing death of fungal cells.
• Adult dose250 mg po qid for 1-2 wk Differential diagnosis:
• Pediatric doseweight-based dosing (po): • Contact dermatitis
° 12-20 kg: 62.5 mg/d • Psoriasis
20-40 kg: 125 mg/d • Candidiasis
>40 kg: 250 mg/d
treatment duration as in adults. Treatment:
1. Avoidance of synthetic fabric underwear and tight fitting
Ketoconazole (nizoral ) clothing can help reduce susceptibility.
• Description: a broad-spectrum imidazole anifungal which 2. Topical theraphy with cream or lotion as tinea corporis.
is excreted in eccrine sweat glands. Interferes with enzyme, 3. Extensive lesions oral anti fungals.
17-demythylase, therefore, prevent synthesis of ergosterol
a part of the fungal cell membrane. Tinea pedis/manum(atheletes foot, fungal infection of hand)
• Adult: 200-400 mg po qid • More in men
• Pediatric dose3.3-6.6 m/kg po qid for 4 wk, not to exceed • Person to person
400 mg/dose • 4th and 5th toes
• Pruritus
Fluconazole (diflucan) • Burning or stinging
• Description synthetic oral antifungal (broad-spectrum Two types
bistriazole) that selectively inhibits fungal cytochrome p- 1. T. Mentagrophytes (inflammatory type)
450 and sterol c-14 alpha-demethylation acute type
• Adult dose150-300 mg po qid for up to 4 wk • vesicobulous eruption, clear tenacious fluid firm with bluish
• Pediatric dose3-6 mg/kg po qid for 14-28 d or 6-12 mg/kg tint.
qid, depending on severity of infection • Dries up--- yellowish brown crust.
• + lymphangitis
Griseofulvin (fulvicin) • + inguinal adenitis
• Adult dose: 500 mg microsize (330-375 mg ultramicrosize) • + hyperhidrosis
po in single or divided daily doses
• Pediatric dose: 20 mg microsize/kg/d (5 mg/lb/d) po or 7.3 2. T. Rubrum (non-inflammatory type)
mg ultramicrosize/kg/d (3.3 mg/lb/d) po • Erythema
• Scaling
Tinea cruris ( jock itch, crotch itch) • Fissuring
• E. Flocolosum, t. Rubrum, t. Mentagrophytes • Spread to soles or side of the feet
• 9x more prevalent in men
• Young people and obese ***chronic form: moccasin
• Tight clothing pedis or sandal appearance.
Lesions:
• Usually pruritic Complications:
• Erythematous • Secondary bacterial
• Sharply marginated edges raised and scaly infection
• Small erythematous scaling vesicular and crusted patch • Cellulitis
spread peripherally with central clearing • Lympangitis

TRANSCRIBERS Group 7 2 of 6
 DERMATOLOGY EXIMIUS
FUNGAL INFECTIONS 2021
DR. HERALUZ LIQUIGAN-DAMO FEBRUARY 2020
Differential diagnosis • Inflammatory changes from pustular folliculitis to kerion; an
• Allergic contact dermatitis inflammatory, boggy mass studded with broken hairs
• Irritant dermatitis oozing with purulent materials.
• Atopic dermatitis
• Psoriasis
• Xerosis

Treatment
Macerated interdigital:
• K permanganate
• Castellanis paint
• Topical antifungals:
° E.g. Ketoconazole 1% cream. Rub gently into affected Ddx:
area bid/qid for 2-4 wk. - Impetigo Syphilis
• Topical antibacterials - Lupus erythematosus Trichotillomania
• Oral antibiotics - Subacute cutaneous psoriasis Alopecia areata
• Anti fungal powders - Plaque psoriasis, Pyoderma
- Pustular seborrheic dermatitis Secondary syphilis
Moccasin type:
• Salicylic acid Treatment:
• Lactic acid Griseofulvin
• Benzoyl peroxide • Treatment of choice in all ringworm infections of the scalp.
• Urea creams • The effective dosage 20-25 mg/kg/d for 6-8 weeks.
• Anti fungal creams hs with occlusion • Adult:500 mg to 1 g microsize (330-375 mg ultramicrosize)
• Whitfields ointment : salicylic 3% and benzoic acid 6% in po in single or divided daily doses
lanolin or vaselin base. • Pedia:20-25 mg microsize/kg/d (5 mg/lb/d) po or 7.3 mg
ultramicrosize/kg/d (3.3 mg/lb/d) for 6-8 wk
Bullous type:
• Drain Itraconazole (sporanox)
• Drying agents : tap water , k permanganate • Adult dose: 200 mg po qd; not to exceed 400 mg/d
• Oral anti fungals if necessary. increase in 100-mg increments if no improvement
(administer >200 mg/d in divided doses)
Tinea capitis (scalp ringworm) 200 mg iv bid for 4 doses, followed by 200 mg/d
• T. Tonsurans, m. Canis, p. Ovale • Pediatric dose3-5 mg/kg/d po for 4-6 wk
• Over crowding
• Poor hygeine Ketoconazole (nizoral)
• Low socio economic condition • Initial: 200 mg/d in single tab
• Protein malnutrition in serious infections, may increase to 400 mg/d
• Pediatric dose not established
Clinical patterns:
1. Non-inflammatory, human epidemic type Fluconazole (diflucan)
• m. Auddoinii, m. Ferruggineum • 6 mg/kg po for 20 d (reported effective) or 3-6 mg/kg po
• Gray patch ring worm- small for 6 wk (offers excellent antifungal results)
eryhtematous papules spreads • Pediatric dose<6 months: not established
centrifugally involving all hairs on its >6 months: 5 mg/kg/d po for 4-6 wk or 6 mg/kg/d po for
path. 20 d
• Gray hair-lusterless, large solitary
annular patches. Terbinafine (lamisil)
• Scaling, minimal inflammation, well • 250 mg/d po pediatric doseweight-based dosing (po):
demarcated patches at occiput or posterior of neck. 10-20 kg: 62.5 mg/d for 2-4 wk
2. Inflammatory 20-40 kg: 125 mg/d for 2-4 wk
• M. Canis, m. Gypseum >40 kg: administer as in adults
• Scarring alopecia, pruritus, fever, pain, regional • Anti fungal shampoos.
lymphadenopathy

TRANSCRIBERS Group 7 3 of 6
 DERMATOLOGY EXIMIUS
FUNGAL INFECTIONS 2021
DR. HERALUZ LIQUIGAN-DAMO FEBRUARY 2020
Tinea unguim (onycomycosis) Candidal paronychia
• Epidermophyton, microsporum, • Housekeepers, bakers, fisherman, bartenders.
candida • Lesion: redness, swelling, tenderness with persistent
• Adult females retraction of the cuticle and proximal nail fold. Onycholysis,
• Occupation transverse ridging of nail plate with brownish green
• most common fungal infection of discoloration of lateral borders.
the nails
Treatment
Pathophysiology 1. Topical imidazole
1. DLSO(distal subungal onychomycosis) 2. Oral ketoconazole
• The most common form of om, the fungus spreads from 3. Surgical avulsion
plantar skin and invades the underside of the nail via the
hyponychium or the distal lateral nail bed. Inflammation
occurring in these areas of the nail apparatus causes the Chronic mucocutaneous candidiasis
typical physical signs of dlso. • Persistent, recurrent candidal infection of oropharynx, skin
Clinical features: and nail apparatus. Immunocomprised.
• Dlso presents as a thickened and opacified nail plate, • Onset infancy early childhood
subungual hyperkeratosis, and onycholysis. Discoloration • Treatment:
ranges from white to brown. The edge of the involved area 1. Amphotericin b
is often dystrophic, while the edge of the nail itself becomes 2. 5 flucytosine
severely eroded.

Co(candidal onychomycosis)
• Onycholysis, paronychia, or chronic mucocutaneous
2. PSO(proximal subungal onychomycosis),
disease.
• The least common subtype, fungi invade the cuticle and the
• Onycholysis may be caused primarily by yeast, or the
proximal nail fold and then penetrate the dorsum of the nail
organism may secondarily colonize onycholytic nails.
plate.
• Candidal paronychia is usually secondary to trauma of the
Clinical features
nail fold.
• Pso presents as an area of leukonychia in the proximal nail
• Chronic mucocutaneous candidiasis affects the nail plate
fold, and it may extend to deeper layers of the nail. The nail
and eventually infects the proximal and lateral nail folds.
plate becomes white proximally and remains normal
• Total dystrophic om involves the entire nail unit and may
distally.
include permanent scarring of the nail matrix
• May involve both the toenails and the fingernails.
• it can manifest as an erythematous swelling of the nail
fold (paronychia) or as a separation of the nail plate from
its bed (onycholysis).
• Gross subungual hyperkeratosis and inflammation of the
3. WSO(white subungual onychomycosis) nail fold is observed in patients with chronic
• Is a rarer presentation caused by direct invasion of the mucocutaneous disease
surface of the nail plate and by secondary infection of the • The digits may take on a bulbous or drumstick appearance,
nail bed and the hyponychium. and the entire thickness of nail may be affected.
Clinical features • Total dystrophic om presents as a thickened, opaque, and
• Wso is usually confined to the toenails and manifests as yellow-brown nail and involves the entire nail plate and
small, white speckled or powdery patches on the surface of matrix.
the nail plate. The nail becomes roughened and crumbles Ddx:
easily. • Contact dermatitis, irritant
• Lichen planus
• Malignant melanoma
• Psoriasis, nails

TRANSCRIBERS Group 7 4 of 6
 DERMATOLOGY EXIMIUS
FUNGAL INFECTIONS 2021
DR. HERALUZ LIQUIGAN-DAMO FEBRUARY 2020
Treatment: • Macules tend to coalesce, forming irregularly shaped
• Topical azoles patches of pigmentary alteration.
• Castallani paint • Characteristically reveals a variance in skin hue.
• Surgical avulsion of nails • The condition is more noticeable during the summer
• Locetar nail lacquer months when the discrepancy in color from the normal skin
becomes more apparent.
Oral treatment: • Light scraping of the involved skin with a scalpel blade
• 1st line: terbinafine 250mg/d x 6 wks fingernails x 12 wks characteristically yields a copious amount of keratin.
toenails. Form 2
• Itraconazole 100mg/d x 6 wks fingernails x12 wks toenails. • Inverse form
• Entirely different distribution, affecting the flexural regions,
Pulse treatment the face, or isolated areas of the extremities
• 200mg bid 7 days x 2 months to 3-4 months. • More often seen in hosts who are immunocompromised.
• Fluconazole 150-400 mg/d/week or 100-200mg/d until • Can be confused with candidiasis, seborrheic dermatitis,
nails grow back normally. psoriasis, erythrasma, and dermatophyte infections.

Prophylaxis: Form 3
1. Benzoyl peroxide • Involves the hair follicle
2. Anti-fungal creams • Localized to the back, the chest, and the extremities.
3. Miconazole lotion/ powder daily • This form can be clinically difficult to differentiate from
4. Anti-fungal sprays bacterial folliculitis. The presentation of pityrosporum
folliculitis is a perifollicular, erythematous papule or
Pityriasis versicolor pustule.
• Malassezia furfur or pitysporum ovale • Predisposing factors include diabetes, high humidity,
• Late adolescent to early adults steroid or antibiotic therapy, and immunosuppressant
• High humidity, high rate of sebum production, high levels of therapy.
cortisol. • Additionally, several reports reveal that m furfur also plays
• Can persist to months to years. a role in seborrheic dermatitis.

Predisposing factors
• Genetic predisposition;
• warm, humid environments;
• Immunosuppression;
• Malnutrition;
Pathogenesis
• And cushing disease
• Dimorphic, lipophilic organism
• dicarboxylic acids formed by enzymatic oxidation of fatty
Differentials
acids in skin surface inhibits tyrosinase in epidermal
• Leprosy
melanocytes and thereby lead to hypomelanosis.
• Pityriasis alba
• Hyperpigmented macules in tinea versicolor, the organism
• Psoriasis, guttate
induces an enlargement of melanosomes made by
• Seborrheic dermatitis
melanocytes at the basal layer of the epidermis.
• Tinea corporis
• Vitiligo
Symptoms
Diagnosis
• Ocassionally none
• Potassium hydroxide (koh) 10%
• Most common complain of cosmetically disturbing,
• short, cigar-butt hyphae that are
abnormal pigmentation.
present in the diseased state.
• Mild pruritus.
• Spores with short mycelium –
• Spaghetti and meatballs
Lesions
• bacon and eggs
Form 1
• The ultraviolet black (wood) light
• *most common - numerous, well-marginated, finely scaly,
-coppery-orange fluorescence however, in some cases, the
oval-to-round macules scattered over the trunk and/or the
lesions appear darker than the unaffected skin under the
chest, with occasional extension to the lower part of the
wood light, but they do not fluoresce.
abdomen, the neck, and the proximal extremities

TRANSCRIBERS Group 7 5 of 6
 DERMATOLOGY EXIMIUS
FUNGAL INFECTIONS 2021
DR. HERALUZ LIQUIGAN-DAMO FEBRUARY 2020
Treatment Diagnosis:
Selenium sulfide • KOH
• Lotion is liberally applied to affected areas of the skin daily Treatment
for 2 weeks; each application is allowed to remain on the 1. Miconazole (monistat 2% 5g cream) intravaginal x 7days.
skin for at least 10-15 minutes prior to being washed off. Vaginal supp. 200mg x 3 days 100mg x 7 days.
• 3 nights no shower. 2. Nystatin vag. Supp. Od x 7 days.
• In resistant cases, overnight application can be helpful. 3. Clotrimazole 2 tab hs x 3 days.
4. Gentian violet 10%.
Topical creams 5. Fluconazole 150mg po sd
• Terbinafine (lamisil) apply bid x 2-4 weeks. Recurrent:
• Butenafine (funcid) od x 1 month • Clotrimazole 500mg vag. Tab
• Topical azole every night for 2-4 weeks • Fluconazole 150mg po sd
• Clotrimazole (canesten) bid or tid x 2 weeks to 1 month. • Itraconazole 100mg po bid x 7 days
• Miconazole (defungin) od x 1mo.
Ballinitis
Ø Ketoconazole shampoo daily 1% 10-15 min shower • Men
Ø Terbinafine solution 1% bid x 7 days • Symptoms: burning, itching in glans and preputial sac.
Ø Sulfur soap • Lesion: maculapapular lesion with diffuse erythema,
Ø Sastid soap edema, ulcerations, fissuring of prepuce, white plaques
Ø Benzoyl peroxide wash under foreskin.
Ddx :
Extensive lesion - Psoriasis, Eczema,Herpes,
• ketoconazole 400mg oral sd - Molluscum contagiosum, condylomata acumnatum
• ketoconazole 200mg od 2-4 weeks
• fluconazole od 150- to 300-mg weekly dose for 2-4 week Treatment:
• itraconazole 200 mg/d for 7 days.
• Clotrimazole topical cream bid x 7 to 14 days
• Fluconazole 150mg sd
Prophylaxis
• Ketoconazole shampoo
Intertrigo candida
• Selinium sulfide • Glaborous skin: genitor crural, subaxillary, gluteal,
• Sulfur soap once a month interdigital, submammary.
Symptoms:
Cutaneous candidiasis
• Pruritus,
C. Albican
• Erythematous macerated area of the skin,
• Body flora, mouth gi tract, vagina
• Fragile satellite vesicopustule breaks
• Systemic, oral, cutaneous
• And macular base with colarette of detachable necrotic
• Superficial, moist, occluded cutaneous sites like groin,
epidermis.
axillae, submammary areas ,buttocks of infants.

Predisposing factors:
Predisposing factors:
• Obesity
- Dm - Obesity
• Occlusive dressing
- Hyperhydrosis - Heat
• Moist environment
- Maceration - Chronic debilitation
Systemic and topical glucocorticosteroids
Ddx:
• Tinea
Vaginal/vulvovaginal candidiasis
• Eczema
• 2/3 of women with dm, steroids use, immunosuppression,
• S.dermatitis
antibiotics use, douche, and sexual promiscuity.
• Psoriasis
• Onset: abrupt, a week before menstruation, recur before
• Erythrasma
each menstruation.
Treatment:
• Symptoms: pruritus, vaginal discharge, soreness, vulvar
• Castellani paint od 7-14days
burning, dysparunia, external dysparunia.
• Topical steroids and azoles
• Pe: erosions, pustules, erthema, swelling, curd-like
material, white discharge, edema,white plaques that can
wipe off.

TRANSCRIBERS Group 7 6 of 6