Fungal infections

Question 1

Fungal infections:

Id reaction?

Answer 1

Eruption of sterile vesicles distant to infected site of acute inflammatory fungal infections

Question 2

Fungal infections:

Tinea types?

Answer 2

Pedis (Foot)

• trichophyton commonly
• acute = uni/bilateral blistering/scaling that is itchy and can be painful - often self limiting
• Chronic = slow, progressive erosions/scales of toe webbing
• often is a common cause of lower limb cellulitis

Mannum (Hand)

• classically palms
• asymmetric lesions with defined edge
• itchy/burning
• ‘2 feet, one hand syndrome’ - referring to classic presentations

Cruris (Groin)

• M > F
• typically upper inner thigh and sparing scrotum

Unguium (nail) aka Onychomycosis

• acts as a reservoir
• toenails > fingernails
• multiple colours
• distal nail usually affected first
• rarely involves all nails (unlike eg psoriasis)

Capitis (scalp)

• almost exclusively in children
• single or multiple patches of patchy alopecia

Corporis (trunk/limbs)
-scaly, annular or curved rash, with central clearing and defined borders

Faciei (face)

• children and women
• chin, upper lip

Barbae (beard)

• most common in men and farmers as usually acquired from animals (horses, cattle)
• more severe
• can result in kerion and abscess formation

Incognito

• clinical appearance altered by use of immunosuppressant creams
• typically less erythemic, lack scaly border

Question 3

Fungal infections:

Yeast types?

Answer 3

Pityriasis versicolour

• typically Malassezia
• adolescence and young adults typically
• typically chest, back, face, scalp and groin
• well demarcated hypo/hyperpigmented lesions that can coalesce
• mild itch

Candidiasis
-typically albicans

Oral candidiasis

• immunosuppressed
• not rinsing mouth after inhaled corticosteroids
• white plaques with pseudomembranes
• often asymptomatic

Vulvovaginal candidiasis

• thick white discharge
• itch, burning and sometime dysuria
• chronic infections can be subtle
• occurs in elevated oestrogen state (premenstrual, pregnancy, exogenous oestrogens)

Male genital candidiasis

• glans mainly affected
• usually sexually transmitted
• more prevalent in uncircumcised males

Question 4

Fungal infections:

Approach?

Answer 4

If any doubt of diagnosis then obtain specimen

• skin scrapings (clean with alcohol, scrape scale from advancing border)
• nail clippings (clean with alcohol, clip, then scrape subungal tissue also)
• hair follicle (pluck with tweezers - need hair bulb, scrape scalp also)

Question 5

Fungal infections:

Management?

Answer 5

General:

• dry adequately
• non occlusive clothing
• wash regularly
• wash towels regularly
• drying powder when required

Tinea
1) Topical
Terbinafine 1% BD for 2 weeks
Clotrimazole 1% BD for 2 weeks (vaginal candida)
Nystatin 100000 unit/g cream BD for 2 weeks (vaginal candida)

Pityriasis versicolour
Ketoconazole 2% shampoo - topically to wet skin leaving for 10minutes then wash off - for 5 days

2) Oral
Terbinafine 250mg daily 
-skin 4 weeks
-scalp 6 weeks
-fingernails 6 weeks
-toenails 12 weeks
-monitor LFT 4 weekly

Fluconazole

• skin 150mg weekly for 6 weeks
• nails 150 - 300mg weekly for 3 - 6 months
• monitor LFT 4 weekly
• pityriasis versicolour 400mg single dose

Oral Candida
Nystatin 100000 unit/ml 1ml QID after meals or 2 weeks
Amphoteracin B lozenge 1 QID after meals for 2 weeks