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Clinical Therapeutics > Cutaneous Fungal Infections > Flashcards

Cutaneous Fungal Infections Flashcards

1
Q

What are the two common type of cutaneous fungal infections?

A

Dermatophytes
Yeast

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2
Q

What are 3 types of dermatophytes fungal infections?
(dermatophytes are NOT on mucosal tissue)

-tinea affects upper layer, dermatophytes eat dead keratin cell layer

A

tinea corporis - ringworm of the body
(no actual worm involved)
tinea cruris - jock itch
tinea pedis - athletes foot

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3
Q

What are two types of yeast fungal infections?
(these might occur on mucosal layers)

A

cutaneous candidiasis - occurs in intertriginous areas-groin, axillae, interdigital spaces, under the breast
pityriasis versicolor (malazzezia)

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4
Q

what are 5 goals of therapy

A
  1. eradicate existing infection - inhibit fungal growth (cure the infection)
  2. provide symptomatic relief (itching, burning and other discomforts)
  3. stop infection from spreading
  4. stop complications (such as secondary bacterial infection)
  5. avoid recurrences
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5
Q

What are 4 non prescription treatments?

A

clotrimazole 1% or miconazole 2%
tolnaftate 1%
undecylenic acid
nystatin 100 000 units/g

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6
Q

NON P - Clotrimazole 1% (canesten + generics) or Miconazole 2% (micatin + generics)
classification
mechanism of action
effective in treatment of ____ and ____
adverse effects:
nonprescription preparations currently available in Canada
Cure rate?

A

C: Azoles
Mech of action: Fungistatic, concentration may lead to fungicidal effects and blocks production of ergosterol, triglycerides and phospholipids by fungi
-broad spectrum
AE = local skin irritation, (erythema, pruritus, rash, stinging, and rarely hypersensitivity)
NonP: clotrimazole 1% (canesten + generics) cream
NonP: Miconazole nitrate 2% (micatin+generics) cream, spray, powder
cure rate = 80-90%
fast onset of action, 1-2 weeks but can stop the itch in 1-2 days

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7
Q

NON P - Tolnaftate 1% (Tinactin + generics)
classification
mechanism of action
effective in treatment of ____ and ____
adverse effects:
nonprescription preparations currently available in Canada

A

C: thiocarbamate
Mech of action: narrow spectrum antifungal (specific mechanism is unknown)
-effective in treatment of dermatophyte infections
-ineffective in treatment of cutaneous candidiasis
AE = local skin irritation
Available as a cream, aerosol, topical powder
-good option for prevention
-effects are seen after 2 weeks

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8
Q

NON P - Undecylenic acid (fungicure and generics)
classification
mechanism of action
effective in treatment of ____ and ____
adverse effects:
nonprescription preparations currently available in Canada

A

-mechanism of action is unknown
-lowest efficacy, low cure rate
effective in treatment of dermatophyte infections
-ineffective in treatment of cutaneous
AE: itching, burning, stinging
available as gel, liquid, cream, ointment, powder or spray

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9
Q

NON P - Nystatin 100 000 units/g
classification
mechanism of action
effective in treatment of ____ and ____
adverse effects:
nonprescription preparations currently available in Canada

A

C: polyene
-fungistatic or fungicidal, binds to sterols in cell membrane
-effective for candidal infections
-ineffective in treatment of dermatophyte infections
-available as cream or ointment
-AE: rarely irritation

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10
Q

What are 3 prescription products?

A

Topical Ciclopirox
Terbinafine
Ketoconazole

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11
Q

Topical ciclopirox
classification
mechanism of action
effective in treatment of ____ and ____
adverse effects:
available as”

A

C: hydroxypyridone
Broad spectrum agent: effective against dermatophytes and yeast
Fungicidal in vitro, exact mechanism of action unknown
AE: pruritus, burning, stinging, skin sensitivity, contact dermatitis
Available as Loprox 1% cream or lotion, Stieprox 1.5% shampoo
slightly more effective than clotrimazole/miconazole

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12
Q

Terbinafine
classification
mechanism of action
effective in treatment of ____ and ____
adverse effects:
available as”

A

C: allylamine
Broad spectrum fungicidal agent: topical: fungicidal to dermatophytes but only fungistatic to candida
AE: for topical treatment: redness, irritation/bnurning, contact dermatitis
after terbinafine is topically applied, has a half life of 14 to 35 hours and <5% is absorbed
available as: oral tablet, cream or spray
-continues to work even after patient stops taking it
(important to note that 1 week terbinafine = 4 weeks clotrimazole/miconazole)

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13
Q

Ketoconazole
classification
mechanism of action
effective in treatment of ____ and ____
adverse effects:
available as”

A

C: azole
Broad spectrum: effective in treatment of dermatophyte and yeast infections
Prescription products include cream, oral tablets
shampoo is available without a prescritpion
Oral dosage - risk of potentially fatal liver toxicity and therefore should only be used for serious or life threatening systemic fungal infections
Oral dosage - risk of potentially Fatal liver toxicity and therefor should only be used for life threatening systemic fungal infections

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14
Q

Dermatophytes generally refers to the various ____infections
requires ____keratin for growth/proliferation
affect ___layer of the epidermis, hair, skin, and nails
generally spread by
1.
2.

A

tinea
dead
top
direct contact through person to person or person to famine
soil to human or animal to human (unlikely)

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15
Q

How do you put the cream on the area infected by a dermatophyte?

A

1-2 cm outside the affected area

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16
Q

What are the three most common dermatophytes pathogens in skin infections?

A

trichophyton
microsporum
epidermophyton

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17
Q

Tinea Corporis - ringworm of the body
what are the signs and symptoms?

A

affected area often occurs on skin of the trunk, face, and extremeties
annular (ring like), circular, erythematous, flat, scaly patches
reddened, raised edges with vesicles and with margins that clearly transition from abnormal to normal skin, with an inner area clear
itching is variable and dependent on patient
(or in easy words, there are edges with clear margins, a clear area between infected skin and non infected skin)

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18
Q

The fungus generally likes…(think temperature)

A

warm, moist areas, tight clothing

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19
Q

Tinea Corporis (ringworm of the body)
differential diagnosis consider

A

psoriasis
contact dermatitis
seborrheic dermatitis
nummular eczema
Lyme disease
pityriasis rosea

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20
Q

How can you distinguish between psoriasis and tinea corporis?

A

in tinea corporis there are fine scales, not as silvery whereas in psoriasis, they are thick and grey/silvery

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21
Q

Tinea corporis - management
what are some non pharmacological suggestions?

A
  1. skin hygiene (clean) and dry
  2. avoid excessive irritation by towels
  3. wear loose fitting cotton clothes
  4. wash clothes and linens separately from non-infected individuals laundry
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22
Q

Tinea corporis - management
what are some non prescription topical options?
What is an important thing to mention when counselling patients on how to use these products?

A

-clotrimazole or miconazole - 1st line
apply to affected area for 4 weeks
-tolnaftate is less effective than azalea options
-Undecyclenic acid lacks comparative evidence of efficacy compared to other options, may be helpful

with the non prescription, treat until the area is clear, then 1 week beyond that to prevent reoccurrence

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23
Q

Tinea corporis - management
what are some prescription topical options?

A

Ketoconazole, terbinafine, ciclopirox
-treatment duration is less with terbinafine (once daily for 1 week)

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24
Q

Tinea cruris (Jock Itch)
affected areas?
often concurrent with ?

A

bilateral upper inner thigh
groin/pubic area
gluteal (anal) cleft
scrotum and penis are not usually affected
often concurrent with tinea pedis

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25
Q

Tinea cruris (Jock Itch) signs and symptoms
Characterisitcs of the lesions?

A

well marginated with defined, raised borders
erythematous ring shaped
quite pruritic (itchy)
lesions are red brown, scaly
small vesicles (little bumps fluid filled) may be seen at the margin

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26
Q

Tinea cruris (Jock itch) risk factors
name 4

A

warm and humid condition
wearing wet or tight clothes
immunocompromised individuals
genetics

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27
Q

Differentiate between Jock Itch and Pubic lice infections

A

jock itch and pubic lice are both in the groin area. In jock itch, there would be no lice present (consider history). in pubic lice infections, there would be a “spotted appearance” and lice present appearing as yellow/brown and skin may appear bluish and spotted

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28
Q

when would you refer a patient?

A

see online section: patient assessment

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29
Q

Tinea cruris - management
topical anti fungal non prescription?

A

clotrimaozole or miconazole (either or is ok) for 2 to 4 weeks. once the area is clear, apply for 1 week to prevent reinfection
apply to affected area, + 1-2cm

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30
Q

Tinea cruris - management
topical prescription options

A

terbinafine, ketoconazole, ciclopirox
treatment duration less with terbinafine (once daily for 1 week)

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31
Q

Tinea cruris - management
what are 4 non pharmacological suggestions?

A

wear loose fitting cotton clothes
powder to reduce moisture
avoid excessive irritation with towels
wash clothes and linens separately from non-infected individuals

32
Q

Monitoring of therapy
when should we see relief of itching?

A

See table 3.
in 1-2 days there should be improvement or relief of itching
if no improvement in 1-2 weeks, refer

33
Q

Tinea Pedis (athletes foot)
Prevalence?
Most common in?
-and what’s a sign for referral?

A

will affect up to 70% of the population
most common in teenage and adult males
<16 years is a sign for referral

34
Q

Tinea Pedis transmission

A

direct (contact with infected individual)
indirect (contact with contaminated surface)
auto inoculation (spread to other parts of the body)
think sharing shoes, pool, shower, etc

35
Q

Tinea pedis risk factors

A

warmth and dampness creating moist conditions
occlusive foot wear
diabetes
immunosuppression
peripheral vascular diseases
occluded skin
poor hygiene
obesity
trauma

36
Q

Tinea Pedis subtypes
4 subtypes

A

chronic interdigital
vesicular
moccasin type
acute ulcerative disease

37
Q

Tinea Pedis subtype Chronic Interdigital

A

Most common type of infection - fissures, scaling, maceration - generally self treatable
occurs between the 4/5th and or 3/4 toes
moist and warmth conditions contribute to worsening

38
Q

Tinea Pedis Vesicular

A

small vesicles on the instep of one or both feet
some scales between toe webs
most prevalent during the summer months

39
Q

Tinea Pedis Moccasin type

A

chronic
diffuse scaling with mild inflammation on the soles of the feet - generally found on both feet
often involve nails (refer)

40
Q

Tinea Pedis Acute Ulcerative Disease

A

Macerated, weepy lesions on soles of foot
hyperkeratosis and strong odour often present
may involve secondary infection with gram negative bacteria (refer)

41
Q

When do you refer for Tinea…

A

-patient is at risk of delayed wound healing
-child <16 years old
-lesion: weeping and severely inflamed or oozing pus or eczematous or painful
-toenail affected

42
Q

Tinea Pedis - non pharmacological suggestions

A

emphasize proper footcare/hygiene (wash feet daily, dry between toes)
avoid occlusive and tight fitting footwear
change to dry socks 2-3 times a day
change or alternate shoes
avoid being barefoot in public areas
do not share personal items

43
Q

Tinea Pedis management - topical anti fungal
non-prescription

A

clotrimazole or miconazole BID for up to 4 weeks (including 1 to 2 weeks after skin has cleared to prevent recurrences)
-apply to affected area

44
Q

Treatment of Tinea Pedis ONLY
prescription options

A

Ciclopirox: apply to affected area twice daily for 4 weeks
Terbinafine (cream or spray): 1 week up to 4 weeks
(has a higher cure rate versus other topical antifungals)

45
Q

What is the importance of treating tinea fungal infections?

A

without it, can lead to ulceration
complications can be secondary bacterial infections

46
Q

what is Onychomycosis?

A

fungal nail infections
toe nail infections are more common than fingernail infections

47
Q

Onychomycosis
___% nail issues

A

cause of about 50% of nail issues
infection rate for toenails is approx 6/4% of the Canadian population, incidence increases with age
more frequently toenails than fingernails
quality of life can be affected (can be painful, nail can separate)

48
Q

Onchomycosis Pathophysiology
most commonly due to? Acute or chronic?

A

most commonly due to dermatophytes (trichophyton, epidermophyton, microsporum)
chronic infection

49
Q

What are the 3 subtypes of onychomycosis?
what are the signs and symptoms associated with each subtype?

A
50
Q

Onychomycosis risk factors?

A

increased age
family history or genetics
immunodeficiency
co morbid conditions such as diabetes, peripheral vascular disease, psoriasis
smoking
tinea pedis
frequent nail trauma
sport participation

51
Q

Onychomycosis differential diagnosis of fungal nail infections

A
52
Q

Onychomycosis, a referral is required. why?

A

diagnosis confirmed through microscopy, biopsy or culture. often combination of culture and microscopy used

53
Q

For onychomycosis, what are appropriate non-pharmacologic suggestions that can be provided?

A
54
Q

Onychomycosis treatment endoints

A

mycological cure (fungus gone) or clinical cure/efficacy (nail has returned to normal)
toenails generally need longer duration of treatments compared to fingernails

55
Q

Onychomycosis oral vs topical options

A

oral therapy has higher efficacy
formulations such as creams, ointments, powders and solutions do not pass through the nail plate
topical nail lacquer delivers the medication by evaporating and producing an occlusive film that contains a high concentration of the medication

56
Q

What are onychomycosis oral treatments?

A

terbinafine > itraconazole&raquo_space; fluconazole

57
Q

Oral treatment terbinafine for onychomycosis?
mechanism of action?
treatment duration?
risk of severe ____ injury, requires close monitoring including baseline and mid treatment ___function ____level
drug interaction ____

A

drug of choice for dermatophyte onychomycosis
-is the most effective treatment
mycological cure 70%
clinical cure rate 38%
blocks biosynthesis of ergosterol by inhibiting squalene expoxidase
toenails 12 to 24 weeks
fingernails 6 to 12 weeks
liver injury, liver function, aminotransferase level
CYP2D6 inhibitor

58
Q

Onychomycosis prescription topical treatment options
what are the two?

A

ciclopirox 8% nail lacquer
-requires daily application for 48 weeks
33% mycological cure and 7% cure rate
adverse effects: local skin irritation, temporary alteration to nail appearance
49$/6g

efinaconazole 10% topical solution
-drops applied once daily for 48 weeks, no removal
54% mycological cure and 17% cure rate
adverse effects: irritation of the skin around application site
80$/6ml

59
Q

Onychomycosis what are non prescription options? name 1

A

propylene glycol urea lactic acid
once daily application for up to 24 weeks
mycological cure rate about 27% (in those with <50% affected nail)
adverse effects: local skin irritation, pain, onycholysis (separation of nail) and frequent whitening and opacity of the nail
must wash solution from unaffected skin and hands

60
Q

Onychomycosis monitoring
normal appearance of nail may take up to ___months
____recurrence rate, approximately ___% of patients will have infection again within ___ years of treatment

A

18 months
high, 20, 2

61
Q

what are two other types of tinea infections that you would refer for treatment

A

Tinea Capitis (on scalp)
Tinea Barbae (on beard)

62
Q

Pityriasis Versicolor Fungal infection is caused by an infection of the stratum corner by

A

Malassezia

63
Q

What is the pathophysiology of pityriasis versicolore?

A

it is an infection of the stratum corner by mallassezia
upper trunk common area of occurrence (sebaceous glands are the food source)
highest incidence in warm, humid environment, adolescents and young adults
refer if causation is unclear, patients may require further assessment

64
Q

What is a visible distinguishable sign of pityriasis versicolor or what does the name mean

A

scaly pigmentation that is either hypopigmented or hyper pigmented

65
Q

what are signs and symptoms of pityriasis versicolore?

A

change in cutaneous pigmentation, lesions may be hypo pigmented or hyper pigmented
lesions occur on the back, chest and upper arms
individual lesions are small but can coalesce to form larger patches
scraping lead to slight scale forming
generally only a cosmetic issue
itching is rare
NOT contagious
NOT a result of poor hygiene
-generally a part of our natural skin flora

66
Q

Pityriasis versicolor
non pharmacological suggestion

A

reduce moist environments and avoid oil on infected skin

67
Q

Pityriasis versicolor
what are non prescription treatment options?

A
  1. keotoconazole 2% shampoo (used like a lotion)
    -applied to affected area, leave on for 5 minutes then wash off
    -one time application or once daily for 3 days
    -clinical cure rate approx 70%
  2. topical azalea creams (clotrimazole or miconazole): apply twice a day for 2 weeks
    -similar efficacy to keoconazole
  3. Selenium sulfide 2.5% suspension
    -apply to affected area and lather with a little water, leave on skin for 10 minutes then wash off. use once daily for 7 to 14 days
    You can use it for prevention: use once or twice a month for prevention (reduces recurrence to 15%)

Note recurrence Is common

68
Q

Pityriasis versicolor
what are prescription treatment options?

A

topical ciclopirox (efficacy similar to topical ketoconazole)
topical ketoconazole cream formulation
topical terbinafine (less evidence of efficacy)

69
Q

Cutaneous Candidiasis Cause?

A

most frequently due to Candida albicans leading to an intertrigo infection
infections occur when pH of the skin is increased, other normal flora (bacteria) is removed due to antibiotics, increased glucose in sweat and/or moist, warm conditions
note that Candida albicans is a part of the normal flora, but it can overgrow

70
Q

What are risk factors of cutaneous candidiasis?

A

diabetes mellitus
malignancy
obesity
tropical environent
medical conditions such as neutropenia, HIV infection, psoriasis
use of corticosteroids (because they suppress the immune system)
individuals who have hands in water excessively can experience candida paronychia

71
Q

Cutaneous Candidiasis signs and symptoms
affected areas?
presentation?

A

affected areas is where moisture can gather, skin folds such as groin, axillae, gluteal region, under breasts, skin folds, hands
presentation is bright red, moist skin surface, irregular scalloped borders and satellite papule or pustules outside of border
itching and soreness

72
Q

When do you refer cutaneous candidiasis?

A

-unsuccessful initial treatment
-condition extensive or widespread
-recurrent infection
-ssytemic symptoms (fever? fatigue?)
-signs of secondary infections
-immunocompromised

73
Q

Cutaneous Candidiasis management - what are some non pharmacological therapy approaches?

A

keeping the area dry
bathe daily
avoid tight clothing
cool water compresss and then allow area to air dry

74
Q

Cutaneous Candidiasis management - what are topical anti fungal non prescription options?

A

clotrimazole or miconazole (apply twice a day for 3 weeks)
-nystatin cream/ointment (apply twice a day for 2-3 weeks)

75
Q

cutaneous candidiasis management - what are topical prescription options?

A

ketoconazole, ciclopirox, terbinafine

Clinical Therapeutics (2 decks)

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