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446- ID and transplant > Superficial Fungal Infections > Flashcards

Superficial Fungal Infections Flashcards

1
Q

dermatophytosis is a

A

superficial mycotic infection of the skin

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2
Q

tinea is the latin word for

A

fungus

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3
Q

dermatophytes are

A

a group of filamentous fungi that require keratin for growth- survive on dead keratin

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4
Q

most superficial fungal infections are caused by which 3 genera of dermatophytes

A

(trichophyton, Epidermophyton, microspore)

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5
Q

how are superficial fungal infections generally transmitted

A

direct contact, fomites, environment (soil), animals

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6
Q

what are some predisposing host factors that may increase the chance of a superficial fungal infection

A

moisture (occlusive clothing/ shoes, warm humid climates), genetic susceptibility, impaired immunity (ex- diabetes, HIV, chemo)

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7
Q

tinea pedis is most commonly caused by ___________ and _________

A

dermatopytes
gram - bacteria that are ulcerative

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8
Q

which of the following is false about athletes foot
1. females are more likely to get it than males
2. prevalence increases with age
3. 70% will acquire it in their lifetime
4. marathon runners have a 30% prev rate
5. all of the above are true

A

1- males 4x more likely

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9
Q

what are the 4 variations of athlete’s foot

A

chronic interdigital infection
mocassin type infection
vesicular
ulcerative

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10
Q

what is the most common variant of athlete’s foot

A

chronic interdigital infection

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11
Q

describe the sx of chronic interdigital infxn

A

often between 4th and 5th toe
scaling, fissuring, whitened, thickened
burning, itching, malodorous

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12
Q

describe the sx of moccasin type infection

A

typically both feet
mild inflammation + diffuse scaling
toenails may be affected

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13
Q

describe the sx of vesicular type tinea pedis

A

Small vesicles near instep + mid anterior plantar surface
Typically with skin scaling

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14
Q

describe the sx of ulcerative type tinea pedis

A

Weeping and inflamed
Often malodorous due to secondary bacterial infxn

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15
Q

in tinea pedis fungus invades the __________, there is __________ initially or the patient may be ____________

A

outermost layer of the skin
drying and scaling initially
pt may be asymptomatic

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16
Q

what promotes fungal growth

A

moisture + increase temp by hot sweaty feet

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17
Q

list 2 differential dx for tinea pedis

A

Contact dermatitis, eczema, psoriasis, or bacterial infxns

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18
Q

list 2 nonpharm measures for tinea pedis

A

Mainly focused on prevention of recurrence + avoiding transmission
Avoid standing barefoot in public spaces, manage hyperhidrosis (antiperspirants or absorbent powders - talc/ aluminum Cl), allow shoes to dry thoroughly, avoid tight fitting shoes, breathable shoes- leather/ canvas allow feet to breathe
Personal hygiene: wash feet and dry thoroughly, change socks daily (avoid nylon materials), launder items used by infected person often + don’t share towels

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19
Q

what are the 4 classes of pharm tx for tinea pedis

A

allylamines
imidazoles
misc
hydroxypyridone

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20
Q

list the drug that is an allylamide that treats tinea pedis

A

terbinafine

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21
Q

what 3 topical imidazoles may be used to tx tinea pedis

A

miconazole, clotrimazole, ketoconazole

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22
Q

what 2 topical hydroxypyridones may be used to tx tinea pedis

A

ciclopirox
undecylenic acid

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23
Q

what is the 1 drug that is topical in misc for tx of tinea pedis

A

tolnaftate

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24
Q

how should terbinafine topical be used?

A

app 1-2x/d F4wks, 1-2wks if mild

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25
Q

rank the following topical TP tx from most to least pref: clotrimazole, tolnaftate, terbinafine, miconazole

A

terbinafine > clotrimazole/ miconazole > tolnaftate

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26
Q

what class of topical agents is pref in TP

A

allylamines

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27
Q

T or F: tea tree oil is effective for TP tx

A

F- but no harms

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28
Q

T or F: recurrence of TP is common

A

T- tx failure in 30% cases often d/t poor adherence- need to assess cause

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29
Q

product selection in TP should be based on

A

individual preference

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30
Q

what is a major downside of topical ointments for TP

A

remain on skin longer = can occlude + cause maceration = slowed skin healing

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31
Q

how should you apply topical TP products

A

Apply to clean dry area
Affected area including 2-3cm beyond border
Most products (Ex- creams, lotions, etc) = apply/ massage into area BID F4wks (should be used for ~1wk after infxn cleared to prevent recurrent infxn)
Sprays/ powders - apply to dry footwear and skin (check directions)

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32
Q

you should refer for TP if there is no improvement in _____________ or sx are not completely resolved by __________

A

no improvement after 2wks
not completely resolved after 6wks of tx

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33
Q

systemic tx for TP should be considered in pts with

A

immunocomp, DM, tx failure, mocassin type presentaion

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34
Q

prior to using systemic tx for TP, a _________________ should be done

A

microscopy/ culture growth (to confirm presence of dermatophyte)

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35
Q

what allylamide may be used for systemic tx of TP

A

terbinafine

36
Q

what azoles may be used for systemic tx of TP

A

itraconazole
fluconazole

37
Q

T or F: topical antifungal/ CS combinations may be more efficacious than single entity antifungal agents for TP

A

F- rec to aviod due to reduced eff + incr cost + SEs

38
Q

jock itch involves the ___________ area and occasionally the _________

A

groin, medial and upper pts of thight, pubic area, occasionally anal cleft

(may also include buttocks)

39
Q

T or F: tinea cruris often spares the penis and scrotum

A

T

40
Q

3 principle dermatophytes for jock itch

A

T. rubrum (most common), T. mentagrophytes, E. floccosum

41
Q

how is tinea cruris transmitted

A

Contagious- transmitted by contaminated towels, hotel bed sheets, or autoinoculation from reservoir on hands or feet (caution- pts with tinea pedis- can spread from infected feet to groin when putting on underwear)

42
Q

list 2 RFs for tinea cruris

A

Moist conditions including tight fitting/ wet clothing/ undergarments
Humid climates
Genetic predisposition
Immunocompromised (DM, HIV, chemo)
Males- esp in summer months

43
Q

tinea cruris is often _____________ due to inner thigh contact. it leaves __, __________ lesions with ___________ margin

A

bilateral/ symmetrical
round, well defined bordered lesions with raised erythematous margin

44
Q

which of the following applies to tinea cruris
1. dry scaling is common
2. may be asymptomatic
3. can become macerated + infected
4. all of the above

A

4

45
Q

list 2 differential dx for tinea cruris

A

Candidiasis (v red with poorly defined borders),
seborrheic dermatitis (usually also involves scalp, face, etc)
psoriasis (symmetrical erythematous plaques)
bacterial infections

46
Q

list 2 nonpharm tx for tinea cruris

A

Avoid tight fitting clothes to reduce moisture at affected area
Wear clothes made out of breathable fibers (cotton)
Dry all areas completely (use separate towel to dry groin area)
Laundering of contaminated clothing separately
Drying powders- no evidence + concern that cornstarch could encourage fungal growth by acting as food source for yeast (may help reduce moisture + rubbing)

47
Q

T or F: you should recommend a drying powder for tinea cruris to keep the area less moist

A

F- no evidence + concern that cornstarch could encourage fungal growth by acting as food source for yeast (may help reduce moisture + rubbing)

48
Q

what are the 3 imidazole, 1 hydroxypyridone, and 1 allylamine topical tx for tinea cruris

A

clotrimazole, miconazole, ketoconazole
ciclopirox olamine
terbinafine

49
Q

what are the 3 systemic tx for TCruris

A

oral terbinafine, fluconazole, itraconazole

50
Q

what 2 drying powders are there for TC

A

Tolnaftate 1% cr/spray (Tinactin)- BID F2-4wks
Undecylenic acid (Fungicure) BID F2wks

51
Q

tinea corporis infects the _____________, less commonly can affect the ______

A

hairless skin of trunk and arms (excludes face, hands, feet, groin)
less commonly face

52
Q

what are teh 3 possible organisms for TCorporis

A

T. rubrum (most common), M. canis, T. mentagrophytes

53
Q

describe TCorprois presntation

A

starts as flat, circular, scaly spots with central clear portion
raised vesicular red border - may have pustules within active border
occurs on upper body and extremities
usually asymptomatic, occasionally pruritic

54
Q

how is TCorporis transmitted

A

Direct skin to skin contact (ex- wrestlers), animal contact, fomite, environment

55
Q

RFs for TCorporis

A

Humid climates, impaired immune states, occlusive clothing, genetic predisposition

56
Q

how is TCorporis tx

A

Similar to Tinea cruris
Usually used for longer tx period (~4wks)- exception = topical terbinafine F1wk

57
Q

the prev of tinea unguium increases in

A

elderly, DM, immunocomp

58
Q

what organisms may cause tinea unguium

A

T. rubrum (50-70%), T. mentagrophytes (5-17%), E. floccosum, many other dermatophytes
Rarely caused by candida or molds (ex- aspergillosis)

59
Q

how is tinea Unguium transmitted

A

1/3 causes associ wtih TP

60
Q

describe the presentation of tinea unguium

A

Usually toenails but can affect fingernails
Nail plate may separate from nail bed (onycholysis)
Subungual area thickens (subungual hyperkeratosis)
Nail plate turns yellowish/ brown or white
Needs physician to diagnose via nail clipping: culture, direct microscopy (KOH exam), biopsy
Hallmark sx: thickening, discoloration, separation

61
Q

what are the 3 hallmark sx of tinea unguium

A

thickening, discoloration, separation

62
Q

what are the 3 types of tinea unguium

A

Distal lateral subungual onychomycosis (DLSO) - most common type
Superficial white onychomycosis (SWO)- 10%
Proximal subungual onychomysosis (PSO)- least common - may be a sx of immunocomp = refer

63
Q

list 2 times when you should refer the pt for tinea unguium

A

Pt has not been previously dx
>3 nails affected or involvement of >50% nail- PO tx rec
Suspected drug or disease induced
Pt immunosuppressed
Poorly controlled diabetes or pts with peripheral vascular disease
<18yrs
Nail presentation: trauma to nail, pitting, lifting

64
Q

what is preferred in tx of tinea unguium? topical, oral, or surgical tx?

A

oral- 1st line esp for more extensive nail involvement
surgery = last resort + not always successful
topical = less eff than systemic tx due to poor penetration, recurrence after stopping, poor adherence

65
Q

what are 5 pharm tx for tinea unguium

A

topical efinaconazole
topical propylene glycol, urea, lactic acid
oral terbinafine
itraconazole
fluconazole

66
Q

efinaconazole MOA

A

blocks production of ergosterol (important pt of fungal membrane) = loss of fxn, death, reduction in infxn

67
Q

efinaconazole is mostly used for __________ TU cases

A

mild-mod

68
Q

what are the directions on using topical efinazonazole

A

Apply 1 application to the dry toenail, preferably at bedtime for up to 48 weeks. (Big toenail 2 applications (see next slide). Afterwards, ensure to use the brush to spread around the entire toenail (cuticle, folds of nail and sides/underside of toenail and on the end of toenail and surrounding skin). Allow to dry for 30 seconds
No need to remove the medication weekly due to lack of medication build up
No need to debride or remove diseased nail
Monitor for application site vesicles and dermatitis (redness, itching, burning, stinging in surrounding areas)

69
Q

T or F: jublia is only for toenails

A

T- not indicated for fingernail onychomycosis

70
Q

tropical propylene glycol, urea, lactic acid is used in _________ cases of TU and has ______ systemic absorption

A

mild
minimal

71
Q

what are the directions for emtrix use

A

applied daily to infected nail + under free edge, cover nail with thin layer + allow to dry for few min
Used up to 24wks

72
Q

which can be used on fingernails- jublia or emtrix

A

emtrix

73
Q

AEs of emtrix include

A

transient irritation of skin next to affected nail, whitening of nail, nail may become loose and detach

74
Q

what is the drug of choice in TU

A

oral terbinafine (lamasil)

75
Q

why is oral terbinafine the drug of choice in TU

A

best efficacy, tol, lower risk of DDI comp other PO options

76
Q

oral terbinafine remains in nails ____ mths after stopping

A

8mths

77
Q

what labs must be monitored with use of oral terbinafine

A

baseline LFTs + wks 4-6

78
Q

oral terbinafine inhibits _________

A

CYP2A6

79
Q

itraconazole is detectable in nails within _______ of tx

A

1-2wks

80
Q

intraconazole is a strong ______ inhibitor

A

CYp3A4

81
Q

what are the 2 types of itraconazole dosing for TU

A

pulse dosing: 200mg BID F1wk/mth, repeat 2-3 cycles
continuous dosing: 200mg daily F6-8wks 9fingernails), 12wks (toenails)

82
Q

what type of itraconazole dosing is most commonly prescribed

A

continuous

83
Q

what labs must be ordered for itraconazole

A

liver enzymes qmth

84
Q

what is a 3rd line tx for PO tx of TU + useful in peds or DDI

A

fluconazole

85
Q

describe the efficacy of the following for tinea infections
- bitter orange
- garlic
- tea tree oil
- vick’s vaporub

A

Bitter orange- T. corporis, T. cruris, T. pedis- insuff reliable evidence
Garlic - T. pedis - possibly effective (garlic gel cont 0.6% ajoene) but insuff reliable evidence
Tea tree oil: possibly ineffective
Vick’s vaporub- T. unguium- no proven benefit

86
Q

growth of diseased area of nail should stop in _______ for toenails, nails should appear normal in _____

A

12wks
12-18mths

87
Q

when should u FU with tinea pts

A

12wks

446- ID and transplant (18 decks)

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