Dandruff, Seborrhea, and Tinea

Question 1

What is Dandruff?

Answer 1

Dry, powdery scales (minimal scales) to yellow oily greasy scales (inflammation)

Once scales become yellow, might be time to see doctor

Caused by a yeast-like/ fungal organism (Malassezia)

worse in…
males
HIV patients
psoriasis patients

Question 2

How to differentiate tinea from dandruff?

Answer 2

Typical cases of tinea are characterized by circular red spots within a clearing of hair.

Dandruff on the other hand is more diffuse

Question 3

How to differentiate psoriasis from dandruff?

Answer 3

In psoriasis, hypergrowth of skin cells causes skin to become elevated. Silver scales form

Dandruff tends to be flush to surrounding tissue

Question 4

What is the first thing people should try for dandruff?

Answer 4

Start with unmedicated shampoo, but people expect something medicated if they ask a pharmacist for a reccomendation

selenium sulfide, zinc pyrithione, and ketoconazole are common agents found in medicated shampoos

Question 5

Is coal tar an antifungal agent?

Answer 5

No, coal tar and salicylic acid are not antifungal.

Selenium, zinc pyrithione, and ketoconazole(strongest) are all antifungals

Question 6

How often should dandruff shampoos be used?

Answer 6

Up to 2 times per week

Question 7

Are topical (scalp) steroids a valid option for dandruff?

Answer 7

No, it is most likely overkill if there is inflammation. It also does not treat the fungal infection.

Topical steroids are indicated more for seborrhea vs. dandruff

Question 8

How does seborrhea/seborrheic dermatitis present itself?

Answer 8

Yellow-ish scales
Possibly some redness
Found more often in men

Chest, armpits, face are common regions affected

Question 9

Where does seborrhea appear attypically?

Answer 9

Eyelid

ear canal

scalp (cradle cap)

Referral is key in this situation

Question 10

What are some conditions that may look like seborrhea?

Answer 10

Eczema
Psoriasis
Tinea corporis
Perioral dermatitis

Question 11

How to differentiate between Rosacea and seborrhea?

Answer 11

Rosacea is characterized by acne type lesions with redness

Seborrhea on the other hand has scales, while rosacea does not show scaling

Question 12

What is the treatment for seborrhea/

Answer 12

anti-fungal products:
ketconazole topical cream 2% (once daily-BID) for 4 weeks

Topical steroids (for inflammation)

Pimecrolimus cream (non-steroid anti-inflammatory)

Topical steroids and pimecrolimus do not treat the fungus itself, they just dial down the body’s reaction

Apply agent to affected area

Question 13

What is diagnosis by treatment?

Answer 13

Sometimes diagnoses are not 100% confirmed, but we can start patients on therapy and confirm diagnosis if treatment works. If treatment works, try agent for adifferent diagnosis

Question 14

What is cradle cap?

Answer 14

Incidence is between 3rd-4th week of infancy

Scales on baby’s scalp and no oozing or weeping.

disappears within 8 months

use baby oil/vaseline to soften scales

Probably a different form of seborrhea

Question 15

What are the different types of tinea?

Answer 15

Tinea….

capitis (ringworm of the scalp)

corporis (ringworm)

cruris (jock itch)

pedis (Athelete’s foot)

finger/toenail (Onychommychosis)

versicolor (done later in suntan material)

Question 16

Describe the presentation and treatment of tinea capitis (scalp)?

Answer 16

Characteristic circular lesion is not visible nor is redness. Need dermatologist to diagnose this condition after testing. Tinea capitis is characterized by small patches of itchy, scaly scalp

Highly contagious

Hard to treat scalp issues due to concerns with ability of agents to penetrate (topical agents are ineffective)

Therapy is not under pharmacist’s realm, there are no OTC products

common agents:
griseofulvin
terbfinare hydrochloride

Question 17

Describe the presentation and treatment of tinea corporis (body)?

Answer 17

People can catch tinea corposis from animals like cats, dogs, and horses

Itchiness and burning sensation is common, but mild compared to eczema or hives

Men are more affected than women

usually found on smooth, hairless areas, but it isn’t a hard rule

antifungals work great on all species that cause tinea corporis

common agents:
clomitrazole 1% (OTC)
ketoconazole (Rx)
terbinafine (Rx)

Question 18

Is ketoconazole prescribed?

Answer 18

Yes, it is prescribed. But it doesn’t mean that it is a much better agent for tinea compared to OTC -azole agents like clotrimazole

Question 19

How long should tinea treatments last?

Answer 19

Massage cream into area BID for at least 4 weeks. Once tinea has cleared up, use agent for at least 1 week to prevent recurrent infection

Question 20

Is Canesten(offcially indicated for vaginitis) a valid agent for tinea treatment?

Answer 20

Yes, the active ingredient (clotrimazole) is perfectly fine for tinea

Question 21

How long does terbinafine 1% cream/spray treatment for tinea last?

Answer 21

Once daily for 7 days

Treatment lasts shorter vs. clottimazole or ketoconazole

This can be prescribed by pharmacists.

Question 22

Should steroids or steroid/antifungal combination products be used to treat tinea?

Answer 22

Steroids mask the severity of a case of tinea. The medsask resources do not reccomend use of steroids in tinea.

Just use an antifungal alone

Question 23

Describe the presentation and treatment of tinea pedis?

Answer 23

Athlete’s foot

Most commonly found between the toes, but it can spread to the instep or sole

if athlete’s foot is very widespread, scales might have to be removed physically before treatment

OTC -azole (clotrimazole) BID for 4 weeks

Question 24

What conditions look like tinea pedis (Athlete’s Foot)?

Answer 24

Allergic contact dermatitis

Erythasma (bacterial infection between toes)

Candidiasis (yeast infection on the feet is quite rare)

Seborrheic dermatitis (not common on foot)

Question 25

When should pharmacists refer tinea pedis (Athlete’s Foot)?

Answer 25

Extensive (both top and bottom of foot affected)

No improvement after 1 week

Patient has diabetes

Onychomycosis (toenail infection)

Question 26

Are antifungal powders better than creams?

Answer 26

No, creams are better because they have better contact with the skin.

Sprays and powders are better for oozing lesions and as preventative agents

Question 27

Describe the presentation and treatment of tinea cruris?

Answer 27

The areas affected are the insides of the upper thigh (groin area), but the genitals are spared

The patient will report burning, itching, and skin colour change

Can affect men and women

Often co-morbid with tinea pedis and onychomycosis

Skin should be kept dry to help stop spread

Regular antifungal agents are totally fine
ex. prescribed (Terbinafine 1% Cream once daily for 7 days)
OTC (clotrimazole BID for 4 weeks)

Question 28

What conditions can look like tinea cruris?

Answer 28

Candida (yeast infection that covers genitals, in tinea cruris genitals are spared)

Erythasma (common in tropical areas and is a chronic superficial bacterial infection)

Psoriasis

Seborrheic dermatitis

Question 29

What are some non-pharmacological treatments for tinea cruris?

Answer 29

Skin should be kept dry

Launder items used by infected person

Une of non-medicated powders to help absorb moisture

Question 30

Should corn starch be used for tinea cruris?

Answer 30

No, cornstarch could be used as a food source by the fungus that causes tinea cruris?

Question 31

Why is talcum powder no longer in baby powder?

Answer 31

Talc was suggested to cause pulmonary issues due to application technique (dropping powder from distance, baby inhales in talc)

Question 32

What is teh benefit of steroid and antifungal combination products?

Answer 32

These combination products are great for reducing inflammation and infection. The downside of these products is that a steroid is only needed for a few days, but it is usually used for the entire antifungal treatment duration (4 weeks)

Question 33

Is erythasma a bacterial infection?

Answer 33

Erythasma are caused by bacterial and fungal pathogens. It is hard to determine between the two, so a diagnosis by treatment approach is used. If initial treatment approach doesn’t work, try the other agent

Question 34

Describe the presentation of onychomychosis?

Answer 34

Initially, complaints about the appearance of the nail, with no physical symptoms

As the disease progresses, interference with standing, walking, and exercise

Paresthesia (burning/prickling sensation in limbs), pain, discomfort, and loss of dexterity

Onychomycosis accounts for 50-60% of cases of abnormal appearing nails

Question 35

When should pharmacists refer onychomychosis?

Answer 35

More than 3 nails affected

More than 50% of any nail affected

Lunula involvement (Affects base of nail/white crescent)

Question 36

What are some therapy options available to pharmacists for onychomychosis?

Answer 36

OTC: proplyene glycol/urea/lactic acid topical solution

Rx: Efinconazole 10% solution
(apply 1 drop once daily for up to 48 weeks)

Question 37

How effective are onychomychosis treatments?

Answer 37

45-60% of cases treated with oral treatments (terbinafine) resolve in one year

6-23% of cases treated with efinaconazole resolve in one year

less than 10% of cases in placebo group resolved, therefore topical treatment should be resereved only for minimal cases (20-40% nail affected)

Question 38

What are the different types of nail fungus?

Answer 38

DSO & DSLO: distal subungal lateral onychomychosis (can be treated with topical agents) This is also the most common form (75-85% of cases)

PSO: proximal subungal onychomychosis (more severe, need MD attention and oral agents)

WSO: white superficial onychomychosis (more severe, need MD and oral agents)

Candidal Onychomychosis: starts in the soft tissues before spreading to the nail (most common on fingernails)