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Clinical Pharmacy 1 - Term 1 > Lecture 5 - Cutaneous Fungal Infections > Flashcards

Lecture 5 - Cutaneous Fungal Infections Flashcards

1
Q

What are the 2 common types of cutaneous fungal infections?

A

1) Dermatophytes

2) Yeast

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2
Q

What are the 5 infections that are caused by dermatophytes?

A

1) Tinea corporis - ringworm of body
2) Tinea cruris - jock itch
3) Tinea pedia - athlete’s foot
4) Tinea capitis - scalp
5) Tinea unguium - toenails

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3
Q

What are the 2 infections caused by yeast?

A

1) Cutaneous candidiasis - occurs in intertriginous areas

2) Pityriasis versicolor

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4
Q

What are the objectives of self-treatment?

A
  • Provide symptomatic relief (itching, burning, and other discomforts)
  • Eradicate existing infection and inhibit fungal growth
  • Prevent future recurrent infections
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5
Q

When should you refer a cutaneous fungal infection?

A

If widespread, systemic, recurrent, or persistent

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6
Q

What is the classification of clotrimazole 1%?

A

Imidazole or azoles

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7
Q

What is the classification of miconazole 2%?

A

Imidazole or azoles

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8
Q

Are clotrimazole and miconazole fungistatic or fungicidal and what does this mean for treatment?

A
  • Fungistatic

- Will need a longer time-frame for treatment

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9
Q

What are clotrimazole and miconazole used to treat?

A

Dermatophyte and yeast infection

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10
Q

What is the dosage for clotrimazole and miconazole?

A

Apply a thin layer morning and evening

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11
Q

What are some adverse effects of clotrimazole and miconazole?

A

Local skin irritation or hypersensitivity

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12
Q

When should improvement be seen when using clotrimazole and miconazole?

A

1-2 weeks

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13
Q

Which preparations of clotrimazole and miconazole are most effective?

A

Cream

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14
Q

What is the classification of tolnaftate?

A

Thiocarbamate

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15
Q

What is thiocarbamate?

A

Narrow spectrum antifungal

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16
Q

What is thiocarbamate used to treat?

A
  • Dermatophyte infections

- Ineffective in treatment of cutaneous candidiasis

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17
Q

What is the dosage of thiocarbamate?

A

Apply morning and evening

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18
Q

What is an adverse effect from thiocarbamate?

A

Local skin irritation

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19
Q

When should improvement be seen when using tolnaftate?

A

Greater than 2 weeks

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20
Q

What kinds of preparations is tolnaftate available as?

A

Cream, gel, aerosol, topical powder, topical solution

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21
Q

What is undecylenic acid used to treat?

A

Dermatophyte infections

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22
Q

What is the dosage for undecylenic acid?

A

Apply twice daily

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23
Q

What are some adverse effects experienced from undecylenic acid?

A

Itching, burning, stinging

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24
Q

What kinds of preparations is undecylenic acid available as?

A

Ointment, powder, or spray

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25
Q

What is the classification of nystatin?

A

Polyene

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26
Q

In nystatin fungistatic or fungicidal?

A

Both

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27
Q

What kinds of preparations is nystatin available as?

A

Cream or ointment

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28
Q

What is nystatin used to treat?

A

Candidal infections

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29
Q

What is the dosage for nystatin?

A

Apply 2-3 times daily

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30
Q

What is an adverse effect experienced from nystatin?

A

Rarely irritation

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31
Q

What is the classification of ciclopirox?

A

Hydroxypyridone

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32
Q

What is ciclopirox?

A
  • Broad spectrum agent

- Antimycotic agent effective against dermatophytes, yeast, and some bacteria

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33
Q

What are some adverse effects experienced from ciclopirox?

A

Pruritus, burning, erythema

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34
Q

What is the dosage for topical ciclopirox?

A

Apply to affected area twice daily for 4 weeks

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35
Q

When should improvement be seen when using topical ciclopirox?

A
  • After 1 week, relief of itching and other symptoms should occur
  • If after 2 weeks there is no clinical improvement, re-evaluate diagnosis
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36
Q

What kinds of preparations is ciclopirox available as?

A
  • Loprox - 1% cream/lotion

- Stieprox - 1.5% shampoo used 2-3 times/week for treatment of fungal infections associated w/ seborrheic dermatitis

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37
Q

What is the classification of terbinafine?

A

Allylamine

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38
Q

What is terbinafine?

A
  • Broad spectrum fungicidal agent

- Fungicidal to dermatophytes but only fungistatic to candida

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39
Q

What kinds of preparations is terbinafine available as?

A

Oral tablet, cream, or spray

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40
Q

What is the advantage to topical terbinafine?

A
  • Generally shorter treatment regimens

- Results in slightly higher cure rate than other topical options

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41
Q

What is the dose for topical terbinafine?

A

Apply to affected area once daily for 1 week

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42
Q

What are some adverse effects experienced from topical terbinafine?

A

Pruritus, irritation/burning, rash, dryness

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43
Q

What is oral terbinafine used for?

A

Fungal nail infections, or severe tinea skin infections where topical treatment has failed

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44
Q

What is a disadvantage to oral terbinafine?

A

Tablets may interfere w/ cytochrome P450

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45
Q

What are some adverse effects to oral terbinafine?

A
  • Headache
  • GI disturbances
  • Hepatic failure
  • Rash
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46
Q

What is the classification of ketoconazole?

A

Imidazole

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47
Q

Is ketoconazole broad or narrow spectrum?

A

Broad

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48
Q

What is a disadvantage to oral ketoconazole?

A

Risk of potentially fatal liver toxicity, and therefore should only be used for serious or life threatening systemic fungal infections

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49
Q

What does a ringworm infection look like?

A
  • Inner skin appears healthy

- Outer ring is inflamed, red, and scaly

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50
Q

What are some characteristics of dermatophytes?

A
  • Require keratin for growth/proliferation

- Restricted to scalp, nails, and superficial skin

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51
Q

Where is keratin found?

A

In the cornified human epidermis-stratum corneum

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52
Q

Do dermatophytes have mucosal involvement?

A

No

53
Q

How are dermatophytes generally spread?

A
  • Person to person contact
  • Soil to human
  • Animal to human
  • Indirectly from formites (ex: furniture, hairbrushes, hats)
54
Q

What are the most common dermatophyte pathogens in skin infections?

A
  • Trichophyton
  • Microsporum
  • Epidermophyton
55
Q

What age group does tinea pedis generally occur in?

A
  • Adults 15-40

- Children under 12 is unusual and requires referral

56
Q

Does tinea pedis affect men or women more often?

A

Men

57
Q

What are the risk factors for tinea pedis?

A
  • Heat and dampness
  • Occlusive foot wear
  • Use of public bathing facilities (pools, gyms, dorms)
  • High impact sports; marathon runners
  • Sharing footwear
  • Prolonged application of topical steroid b/c blocks immune response
  • Hyperhidrosis (excessive sweating)
58
Q

What are the common affected areas of tinea pedis?

A
  • Toe webs, especially between 4th and 5th toes b/c generally have most squishing and friction
  • May spread between 3rd and 4th toes or to soles of feet
59
Q

What are the signs and symptoms of tinea pedis?

A
  • Interdigital maceration at web space
  • Fissuring and scaling
  • Pruritus and/or stinging sensation
  • Malodour
60
Q

When should a patient be referred for tinea pedis?

A
  • Patient is at risk of delayed wound healing (diabetes, cancer, PVD< immunocompromised, elderly, malnourised)
  • Child less than 12 years old
  • Lesion is weeping or severely inflamed, oozing, eczematous, or painful
  • Toenail is affected
61
Q

What are the subtypes of tinea pedis?

A
  • Chronic interdigital type - most common type; generally self-treatable
  • Vesicular type - pruritic vesicles on instep of one or both feet; may be painful; most common in summer months
  • Mocassin - off-white scaling lesion of soles and sides of feet; generally found on both feet and often involves nails
  • Acute ulcerative type - macerated, weepy lesions on soles of foot; often involving secondary infection w/ gram neg bacteria
62
Q

What some non-pharms for tinea pedis?

A
  • Proper footcare/hygiene
  • Avoid occlusive and tight-fitting footwear
  • Change to dry socks 2-3 times/day
  • Allow shoes to dry for 48-72 hours
63
Q

What is the pharmacological treatment for tinea pedis?

A
  • Topical antifungal (1st line is OTC imidazoles)
  • BID for up to 4 weeks
  • Apply to area and 1-2 cm surrounding
  • Refractory cases (or nail infection) require Rx treatment
64
Q

Which prescription products can pharmacists prescribe for tinea pedis?

A
  • Ciclopirox and terbinafine

- Salicylic acid and tolnaftate are available OTC and are not first line treatment

65
Q

Why is prompt treatment important for tinea pedis?

A

To prevent individuals from developing tinea unguium or infections in toenails

66
Q

Is there any OTC treatment for onychomycosis?

A

No

67
Q

When should you refer for onychomycosis?

A

Immediately

68
Q

How is the diagnosis of onychomycosis confirmed?

A

Nail clippings, scrapings under the nail, and deep nail samples

69
Q

What is the prescription treatment for onychomycosis?

A
  • Oral terbinafine for 12-16 weeks for toenail, or 6 weeks for fingernail
  • Ciclopirox nail lacquer, daily application for 48 weeks
70
Q

What is a side effect to oral terbinafine for onychomycosis?

A

Risk of severe liver injury

71
Q

What is a disadvantage to ciclopirox nail lacquer?

A

Limited penetration into the nail

72
Q

What are the areas affected by tinea cruris?

A
  • Bilateral thighs
  • Inguinal folds
  • Buttocks
  • Gluteal cleft (less common)
  • Can affect external vaginal area in females, but less common
73
Q

What are the risk factors for tinea cruris?

A
  • Warm, humid condition or increased sweating
  • Wearing wet or multiple layers of clothing
  • Immunocompromised individuals
  • Prevalence greater in men than women
74
Q

Can one partner transmit tinea cruris to another?

A

Yes

75
Q

What are the signs and symptoms of tinea cruris?

A
  • Well marginated erthymatous half-moon plaque
  • Small vesicles may be seen
  • Quite pruritic
  • Acute lesions are bright red
  • Chronic cases tend to have more hyperpigmented appearance
76
Q

What is the differential diagnosis for tinea cruris?

A
  • Pubic lice
  • Both appear as itchy and erythematous
  • For pubic lice, skin may appear bluish and spotted
  • For tinea cruris, round or irregular shaped patches will appear
77
Q

When would you refer a patient for tinea cruris or tinea corporis?

A
  • Infection has unknown origin
  • Immunocompromised
  • Responding poorly to topical therapy
  • Disease is extensive, disabling, multifocal, or inflammatory
78
Q

What is tinea corporis?

A

Ringworm of the body

79
Q

What are common risk factors for tinea corporis?

A
  • Most commonly seen in pre-pubescent individuals (children in daycares, schools)
  • Exposure to contaminated soils
  • Exposure to infected animals or people
  • Warm and moist environments
  • Shared towels or clothing
80
Q

What are the signs and symptoms of tinea corporis?

A
  • Often occurs on skin of trunk, face, and extremities
  • Oval, ring-like, erythematous, scaly patches
  • Reddened edges and sharp margins
  • Itching is variable
81
Q

What is the differential diagnosis for fungal skin infections?

A
  • Contact dermatitis or bacterial skin infections

- Fungal skin infections occur on areas w/ excess moisture, which the others occur anywhere on the body

82
Q

How can tinea corporis be prevented and managed?

A
  • Use general non-drug measures (loose fitting clothing, powder to reduce moisture)
  • Topical antifungal (imidazoles are 1st line treatment)
  • For refractory or resistant cases - allylamines or oral Rx agents
83
Q

What is the dosing for imidazoles in the treatment of tinea corporis?

A
  • Twice daily for 4 weeks (in the morning and at bedtime)
  • Apply to normal skin 2 cm beyond the affected area
  • Tolnaftate and undecylenic acid are also options
84
Q

What is tinea capitis?

A
  • Fungal infection involving scalp hair follicles
  • May extend to eyebrows, eye lashes, and beard
  • Occurs most often in children
  • Visible “black dots”
85
Q

Why aren’t corticosteroids used for treatment of fungal skin infections?

A

They will suppress the immune system and allow fungus to overgrow

86
Q

What is pityriasis versicolor?

A

Infection of stratum corneum by Malassezia

87
Q

Where and in who does pityriasis versicolor occur most often?

A
  • Upper trunk (sebaceous glands)

- Highest incidence in tropical environments, adolescents, and young adults

88
Q

When would you refer pityriasis versicolor?

A

If causation unclear

89
Q

What are the signs and symptoms of pityriasis versicolor?

A
  • Change in cutaneous pigmentation, lesions may be hyper or hypopigmented
  • Lesions occur on back, chest, and upper arms
  • Individual lesions small but can coalesce to form
  • No itching
90
Q

What is the OTC treatment for pityriasis versicolor?

A
  • Selenium sulfide 2.5% shampoo (apply for 10 mins, then wash off once daily for 7-14 days; use 1-2 times/month for prevention)
  • Topical azole cream (apply BID for 2 weeks)
  • Ketoconazole 2% shampoo (leave on for 5 mins then wash off once daily for 3 days)
91
Q

Is recurrence common for pityriasis versicolor?

A

Yes

92
Q

What causes candidiasis?

A

Candida albicans

93
Q

What are risk factors for candidiasis?

A
  • Diabetes
  • Immunosuppression
  • Tropical environment
  • Poor hygiene
  • Psoriasis/contact dermatitis
  • Obesity
  • Individuals w/ hands in water excessively
94
Q

What are the typical affected areas of candidiasis?

A
  • Groin
  • Armpit
  • Gluteal region
  • Under breasts
  • Skin folds (abdominal region)
  • Hands
95
Q

What is the presentation of candidiasis?

A
  • Bright red
  • Moist skin surface
  • Scaling borders and satellite (no clear border) papules or pustules
96
Q

When would you refer for candidiasis?

A
  • Unsuccessful initial treatment or condition worsens
  • Condition extensive, seriously inflamed, or debilitating
  • Systemic or recurrent infection
  • Signs of secondary bacterial infection
  • Immunocompromised
  • Patient less than 2 years old
97
Q

What is the management for candidiasis?

A
  • Keep area dry (non-medicated powder; avoid cornstarch)
  • Topical antifungal OTC (imidazoles BID for 2-3 weeks or nystatin cream BID-TID for 2-3 weeks)
  • In more severe cases, may use combination therapy - OTC topical antifungal and topical corticosteroid, Rx topical or oral antifungal therapy
98
Q

When can imidazoles be used?

A
  • Superficial dermatophyte infections

- Candida/mixed

99
Q

When should nystatin be used?

A

Candida infections

100
Q

What is a monitoring parameter for cutaneous fungal infections?

A

1-2 week improvement w/ relief of pruritus

101
Q

What is Desenex in Canada?

A

Undecylenic acid

102
Q

What is Lotriderm in Canada?

A

Clotrimazole and betamethasone (Rx)

103
Q

What is fungi-cure/fungi-nail product used for?

A

Athlete’s foot or ringworm of body/groin

104
Q

What is the downside to tea tree oil as a treatment for cutaneous fungal infections?

A

Needs to be used as BID application for 6 months, which is not practical and not entirely guaranteed

105
Q

Can clotrimazole be used in pregnancy and breastfeeding?

A

Yes

106
Q

Can miconazole be used in pregnanacy?

A

No

107
Q

Can miconazole be used in breastfeeding?

A

Yes

108
Q

Can nystatin be used in pregnancy and breastfeeding?

A

Yes

109
Q

What is the minimum age of used for clotrimazole, miconazole, tolnaftate, and undecylenic acid?

A

2 years

110
Q

How can a patient prevent the spreading of a cutaneous fungal infection to other parts of the body?

A
  • Use separate wash cloth and towel to wash/day affected area
  • Use hair dryer at low heat to dry intertriginous spaces that towel can’t reach
  • Put socks on before underwear to avoid spreading tinea pedis to groin
  • Avoid wearing clothing and shoes that allow the skin to stay wet
  • Allow shoes to dry thoroughly before wearing them again
111
Q

When should tinea pedis be completely treated?

A

4 weeks

112
Q

What is the treatment guideline for tinea cruris?

A

BID for 2-4 weeks

113
Q

What is the treatment guideline for tinea corporis?

A

BID for 4 weeks

114
Q

What is the treatment for candida intertrigo?

A

BID for 2-3 weeks

115
Q

What is an important note to mention to patients being treated for cutaneous fungal infections?

A

Continue treatment for 1-2 weeks after symptom resolution to ensure full eradication and prevent relapse

116
Q

What are tolnaftate and undecylenic acid used to treat?

A

Tinea pedis only

117
Q

What is diaper dermatitis?

A

A form of contact dermatitis due to disruption of normal skin barrier from moisture, friction, urine, and feces

118
Q

What are the signs and symptoms of irritant diaper dermatitis?

A
  • Shiny red patches in diaper area
  • Folds of skin are not affected (this can help differentiate btwn candidiasis which is almost always seen in skin folds)
119
Q

What are the risk factors for diaper dermatitis?

A
  • Irritants and friction
  • Comorbid conditions - atopic dermatitis
  • Chemicals
  • Type of diaper used
  • Occlusion and humidity
120
Q

When would you refer for diaper dermatitis?

A
  • Lack of improvement after 7 days of treatment
  • Pain, itching, or inflammation increases
  • Area shows signs of infection
121
Q

What are the goals of therapy for diaper dermatitis?

A
  • Relief of symptoms
  • Resolution of dermatitis
  • Prevention of complications and recurrences
122
Q

What are some non-pharms for diaper dermatitis?

A
  • Bathe daily in lukewarm water
  • Use fragrance free soap
  • Dry diaper area by patting gently
  • Fragrance and alcohol free baby wipes
  • Increase frequency of diaper changes
  • Do not use talc powders
123
Q

What are the pharmacological treatment options for diaper dermatitis?

A
  • Barrier products

- Zinc oxide

124
Q

____ are desirable as barriers

A

Pastes w/ more than 10% zinc oxide, titanium dioxide, starch, or talc

125
Q

What are the 2 types of barrier products?

A

1) Water impermeable

2) Barrier and water-absorptive

126
Q

What are some water impermeable barrier products?

A
  • Petrolatum
  • Dimethicone or dimethylpolysiloxane
  • Anhydrous lanolin or anhydrous eucerin
127
Q

Which concentrations of zinc oxide are used for which purpose in diaper dermatitis treatment?

A
  • Lower concentrations (15%) used for prevention

- High concentrations (>25%) used for treatment

128
Q

When would antifungal treatment be used for diaper dermatitis?

A
  • Moderate to severe cases
  • Apply first and then apply barrier cream
  • Apply twice daily for 1 week, stop when clear
129
Q

When would topical corticosteroids be used for treatment of diaper dermatitis?

A
  • Under supervision of a physician for children under 2 years old
  • Used in cases where allergic contact dermatitis is suspected

Clinical Pharmacy 1 - Term 1 (18 decks)

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