superficial fungal infection Flashcards
what is the main pathogen responsible for vulvovaginal candidiasis ( yeast infection)?
1st- candida albicans**
2nd- candida glabrata (due to resistant VVC there gas been a shift)
what are the risk factors for VVC?
initial sexual activity
oral-genital contact
contraceptive agent
antibiotic use
DM -sglt2
immunosuppression
pregnancy
clinical presentation of VVC?
symptoms: intense inching, soreness, irritation, burning on urination, painful intercourse
signs: erythema, fissure, clumpy, thick, white cottage cheese like discharge with no foul odor, edema
normal pH (4-4.5)
culture only if reccurrent
non pharm treatment for VVC?
keep area dry and clean
avoid harsh or perfumed soaps and douching
avoid tight and constrictive clothing
discontinue any precipitating medications ( steroids)
when is self treatment recommended for uncomplicated VVC?
for women with multiple confirmed prior cases who report the same symptoms
Are there any difference in the cure rates between oral and topical azole for VVC?
no
what is the treatment day range for nonprescription patients in uncomplicated VVC?
1-7 days
pregnancy = 7 days
what dosage form is recommended for pregnant women and how many days if they have uncomplicated VCC?
topical 7days
avoid oral
uncomplicated VVC OTC products
Butoconazole
clotrimazole
miconazole (caution with warfarin)
tioconazole (ointment)
uncomplicated VVC prescription
nystatin 1 tab x 14d
terconazole
fluconazole 150mg 1 tabs x 1day (repeat in 3days if recurrent)
uncomplicated VCC number of tablets
one
complicated VCC treatment
oral fluconazole 150mg every 72hrs x 2-3 doses
what patients are included in complicated VVC
immunocompromised
uncontrolled DM
pregnancy
what is the duration of treatment for uncontrolled DM and immunocompromised (complicated )
10-14 days
what topical VVC should pregnant women receive ?
topical imidazole for 7days
can’t take fluconazole
bee honey and yogurt may beneficial as adjunct therapy
for pregnancy if VCC worsens and exceeds 7 days
IV amp B
recurrent VVC
having >= 3 episodes < 12 months
10- 14 days oral or topical followed by fluconazole 150 mg weekly x 6 months
antifungal resistent VVC infection
generally c. glabrata
boric acid 600 intravaginally daily x 14 days, followed by one capsule twice weekly
toxic if taken orally
new VCC treatment for acute VCC
ibrexafungerp (brexafemmeO
MOA: triterpenoid fungal that inhibits glucan synthase
SE: diarrhea, nausea, abdominal pain
CI pregnancy, strong CYP3A4 inhibitors
new VVC treatment for for reducing the incidence or recurrent VCC
oteseconazole (vivjoa)
MOA: antifunal that inhibits 14a demethylase
SE: Nausea, HA
CI: pregnancy and lactation
what is the most common pathogen in oropharyngeal and esophageal candidiasis (thrush)
c. albicans
risk factors of oropharyngeal and esophageal candidiasis
medications (corticosteroids, cytotoxic agents, PPI, antibiotics)
environmental changes
poor dental hygiene
xerostomia
smoking
immunosupressant therapy
young infants , elderly
HIV/AIDS
DM
thyroid, parathyroid, adrenal dysfunction
cancer and radiation therapy
nutritional deficiencies
treatment for mild for oropharyngeal candidiasis
clotrimazole troche 10 mg
-hold in the mouth for 15-20 mins until dissolve
miconazole mucoadhesive buccal tab 50 mg daily x 7-14days
nystatin suspenpension 1000 units/ml
- for dryer mouth
- nausea
- high in sugar (does not help DM pts)
-not preferred in HIV pts
treatment for moderate to severe oropharyngeal candidiasis
fluconazole tablet 100-200 mg daily 7-14 days
itraconazole 10 mg/ml solution x up to 28 days
general duration of therapy 7-14 days
refactory treatment for severe oropharyngeal candidiasis
IV enchinocandins
IV amphotericin B
not highly rec
for treatment of esophageal candidiasis and what is always required
systemic treatment
fluconazole 200-400 mg daily
alternative
-IV fluconazole,
-IV echinocandins (c,m,a) ,
-IV ambB
general treatment 14-21 days
esophageal candidiasis treatment for fluconazole refectory disease
itraconazole 10/mg/ml solution 200 mg daily
21-28 days
topical preparations decrease the efficacy of
latex condoms
itraconazole can cause or worsen
heart failure
itraconazole is a potent
CYP3A4 inhibitor
what is preferred in pregnant patients with esophageal candidiasis
amphotericin B
what should be used if xerostomia exists
suspension or buccal mucoadhesive
monitoring parameters for oropharyngeal candidiasis/esphogeal candidasis
avoid drinking/ smoking
dentures must be brushed (chlorhexidine gluconate)
monitor liver enzymes with extended azoles use
daily monitoring with amphotericin B due to nephrotoxicity
mycotic infections ( ringworms) are caused by what dermatophytes
trichophyton
epidermophyton
microsporum
some species of candida involved
risk factors for mycotic infections
prolong sweating
poor hygiene
skin folds
sedentary lifestyle
bed bound
HIV, DM, immunocommpromised
steroid use
what type of mycotic infections must be treated with prescription product?
tinea capitis
tinea barber
tinea unguium -onychomycosis
what type of mycotic infections can be treat with OTC products?
tinea pedis- athletes foot - most common
tinea manuum- hands
tinea cruris- jock itch in males
tinea vericolor/pityriasis
non-pharmacological therapy for mycotic infections
improve hygiene
breathable clothing and non occlusive shoes
keep area dry
avoid contact with infected persons
wash contaminated clothing in hot water and hot dryer setting
spinkle or spray medicated or non medicated powders in shoes
what are some important exclusion factors for fungal infections?
Causative factor unclear
signs of secondary bacterial infection, excessive and continuous exudation, condition extensive, uncontrolled diabetes,
involves genitalia, face, mucous membranes (“sensitive areas”), nails, or scalp,
fever, malaise, unsuccessful initial treatment or worsening of condition
what is the most efficient and effective formula for mycotic infections?
cream/solutions
clotrimazole and miconazole MOA
inhibit the product of sterols found on the fungi cell walls
inhibit peroxidative abd oxidative enzyme activity
Tinea pedis/corpis: BIDx 4 weeks
Tinea cruris: BID x 2 weeks
Terbinafine MOA and duration
inhibit squalene expoxidase reeded in the fungi sterol biosynthesis, leading to accumulation of squalene within the cells and ultimately cell death
Tinea pedis: BID x 1-4 weeks
Tinea cruris: QD x 1 week
Tinea corporis: QD x 1 week
Butenafine MOA and duration
Inhibits squalene epoxidase enzyme needed in fungi sterol biosynthesis, leading to accumulation of squalene within the cells and ultimately cell death
Tinea pedis: BID x 1 week OR QD x 4 weeks
Tinea cruris: QD x 2 weeks
Tinea corporis: QD x 2 weeks
MOA of tolnaftate and duration
Unknown, but proposed to distort the hyphae and stunt mycelial fungi growth
Can be used to treat tinea pedis, corporis, and cruris
BID x 2-4 weeks, up to 6 weeks in severe cases
what OTC medication can be usedfpr prophylaxis and treatment
tolnaftate
MOA and duration for aluminum salts
No antifungal activity
Used solely for astringent properties to relieve inflammation
CI: Contraindicated with severe erosion or deeply fissured skin
Tissue necrosis with extended use
Child poisoning if ingested
Aluminum acetate for tinea pedis
Diluted with 10-40 parts water, 20 minutes TID until symptom reduction (acutely, no more than 1 week)
Aluminum chloride for tinea pedis:
BID until symptom reduction, then QD to prevent re-infection (acutely, no more than 1 week)
what is the treatment for tinea capitis
terbinafine 250 mg/ day x 4-8 weeks
shampoo in conjunction with oral therapy or treatment of asymptomatic carriers
treatment for tinea barbae
removal of the facial hair is recommended
terbinafine 250 mg/ day x 4-8 weeks
what is tinea versicolor caused by and what is the treatment
malassezia genus yeast
Ketoconazole 2% shampoo twice weekly x 4 weeks (topical is usually enough)
rare oral therapy:
fluconazole
itraconazole
is the cure rate for tinea unguium high or low
low
what is tinea unguium caused by
Caused by dermatophytes most frequently
-Trichophyton rubrum
-Trichophyton mentagrophytes
Can be caused by non-dermatophytic
-molds and C. albicans
risk factors for tinea unguium
Age >40
Family history
Immunodeficiency
Diabetes/neuropathy
Psoriasis*
Peripheral vascular disease
Smoking
Prevalence of tinea pedis
Sports like swimming
nail lacquer - cicloporox 8% solution
Topical tinea unguium therapy
- cure rate: 32-65% as low at 8%
- duration 1 yr
-will not penetrate the if nail plate is intact
-no systemic side effects or interactions
Tavaborolee (kerydin) 5% solution
Topical tinea unguium therapy
Rate of cure ~15-18%, with better cure rate in mild to moderate cases
Apply to clean dry nails, cover the nail completely as well as the skin under the nail. Wipe away any excess and allow to dry completely. Apply once daily for 48 weeks.
AE: local irritation, redness, excoriation, dermatitis
efinaconazole (julia) 10% solution
Topical tinea unguium therapy
Rate of cure ~17%, with better cure rate in mild to moderate cases
wait 10 min after bathing or showering, apply 1 drop (2 drops if it is the big toe) and spread over the entire nail and the hyponychium with the applicator, let dry completely. Apply once daily for 48 weeks
avoid pedicures, nail polish, or other cosmetic nail products
Product is flammable – no smoking while applying
AE: Application site dermatitis, pain
what is the most effective for systemic tinea unguium therapy
First line: Terbinafine
Alternatives:
Itraconazole capsule/tablet,
fluconazole (less preferred)
Fluconazole:150 to 450 mg once weekly x 3-6 months (fingernails) or 6-12 months (toenails)
Terbinafine and itraconazole are ________ agents that penetrate the nail and are slowly eliminated so drug concentrations persist after end of treatment
lipophilic
terbiunafin SE and monitoring
-GI, rash, urticarial, itching, headache; *SJS (although rare)
-Absolute lymphocyte counts (CBC); LFTs
itraconazole SE and monitoring
LFTs, especially in pts receiving daily therapy
what are preferred during pregnancy in
Topical azoles and terbinafine
what is the preferred treatment for tinea unguium, tinea capitis, and tinea barbae
Terbinafine
what is the most efficacious topical product for tinea unguium although it is costly and has a low cure rate?
Efinaconazole
