Superficial Fungal Infections Flashcards
Mucocutaneous Candidiasis
- Vulvovaginal candidiasis (VVC)
- Oropharyngeal candidiasis (OPC)
- Esophageal candidiasis (EPC)
VVC
- Normal vaginal environments protect against infections
- Up to 75% of women believed to experience 1 episode of symptomatic VVC in lifetime
VVC Pathogens
- Candida albicans (most common, 80-90%)
- C. glabrata (second most common)
VVC Risk Factors
- Contraceptives
- Sexual Activity
- Antibiotic use
- SGLT2-i
- Host characteristics
VVC Risk + Contraceptives
- Diaphragms with spermicide
- Contraceptive sponge
- Intrauterine device
- Vaginal ring
VVC Risk + Sexual Activity
- Not considered STI
- Risk increases with increased sexual activity
- Oral-genital contact may increase risk
VVC Risk + Host Characteristics
- Pregnancy
- Diabetes
- Immunosuppression
VVC Presentation
- Intense vulvar itching
- Soreness, irritation, erythema, edema
- Curdy “cheese”-like discharge
- Burning with urination
- Painful sexual intercourse
Diagnosing VVC
- Positive clinical presentation
- Wet preparation OR culture
VVC Classifications
- Mild: mild/mod. sxs, =<3 episodes/year, immunocompetent, non-pregnant
- Complicated: patients with at risk host characteristics
- Recurrent: >=4 episodes within 12 months
- Antifungal-resistant: positive yeast cultures but fail to respond to antifungal therapy with adherence
Treating Uncomplicated VVC
- Azole antifungals
- No significant difference in clinical outcomes between topical azoles
- Choose based on cost, therapy length, formulation, convenience
Topical VVC Treatment Counseling
- Use applicator given by manufacturer
- Insertion should be as far as possible without discomfort
- Don’t use tampons
- Lying down, night-time administration, and use of pads may decrease mess
- Treatment can decrease efficacy of latex condoms/diaphragms
- Don’t use for 72 hours
Immunocompromised VVC Treatment
-Oral fluconazole 150 mg Q72h for 2 doses
OR
-Topical azole antifungal therapy for 10-14 days
Pregnancy VVC Treatment
- Topical clotrimazole or miconazole for at least 7 days
- Avoid oral agents
Recurrent VVC Treatment
Induction
-Fluconazole 150 mg q72h x 3 doses (or daily x10 days)
OR
-Topical azole antifungal x 10-14 days
BOTH followed by maintenance
Maintenance
-Fluconazole 150 mg qweek x 6mo
VVC Non-pharm Recommendations
- Avoid harsh soaps/perfumes in vaginal area
- Genital area should be kept clean/dry
- Avoid constrictive clothing
- Douching NOT recommended
- Cool baths to soothe skin
- Benefits of lactobacillus is unclear
OPC
- Aka Thrush
- Involves buccal mucosa, tongue, and gums
- Presentation: creamy white, plaque-like lesions that are easily scraped off
- Sxs: erythema, burning tongue, metallic taste
EPC
- Same presentation as OPC but in esophagus
- May cause retrosternal burning pain/discomfort or dysphagia
OPC/EPC Pathogens
- Candida albicans (most common, 70-80%)
- C. glabrata
- C. tropicalis
OPC/EPC Risk Factors
- Steroids (inhaled)
- Antibiotic use
- Radiation therapy
- Dentures
- Xerostomia
- Smoking
- Disruption of oral mucosa
- Age (extremes)
- Immunocompromised
- Diabetes
- Nutritional deficiencies
OPC/EPC + HIV
- Common
- Increased risk when CD4<200 cells/uL
- ART reduces likelihood of infection
- No measures available to reduce exposure
- Primary prophylaxis not recommended
OPC Initial Mild Treatment
- Clotrimazole 10 mg troches
- Miconazole 50mg mucoadhesive buccal tablets
- Nystatin 100,000 u/mL suspension
Duration: 7-14 days
OPC Mod-Severe Treatment
-Fluconazole 100mg or 200 mg orally, daily
Duration: 7-14 days
Non-pregnant + HIV Patient
Preferred drug = fluconazole
Fluconazole-Refractory OPC Treatment
- Itraconazole 10 mg/mL solution
- Posaconazole 40 mg/mL suspension
- Voriconazole 200 mg tablets
Duration 14-28 days
OPC Counseling
- Use topical antifungals after meals to increase contact time
- Troches should dissolve slowly in mouth
- Suspension should be swished at least 1 minute in mouth, gargled and swallowed
- Remove dentures while medication is applied
- Disinfect dentures every night
- Avoid troches in xerostomia patients
- Maintain good oral hygiene
- Stop smoking
- Avoid alcohol
EPC Treatment
-Fluconazole 200-400 mg
Duration: 14-21 days
Fluconazole-Refractory EPC Treatment
- Itraconazole 10 mg/mL solution
- Posaconazole 40 mg/mL suspension
- Voriconazole 200 mg tablets
Duration: 14-21 days
EPC Treatment + No Orals
- IV fluconazole 400 mg
- IV micafungin 150 mg
- IV caspofungin 70 mg
- IV anidulafungin 200 mg
Mycotic Infections of Skin/Hair/Nails
- Affects 20-25% of global population
- Usually pathogens are dermatophytes
- Pathogens: trichophyton, epidermophyton, microsporum
Dermatophyte Infection Risk Factors
- Moist environments, exposure to water
- Skin breakdown
- Skin folds
- Sharing of personal belongings
- Close living quarters
Dermatophyte Infection Diagnosis
- Patient history/exam
- Microscopic examination
- Culture used less frequently
Tinea Pedis
- “Athlete’s Foot”
- Most common dermatophytosis
- Treatment duration for 2-4 weeks using topicals
Tinea Pedis Presentation
- Fissuring, scaling, skin breakdown between toes
- Plantar surface form chronic scales on heels/side of feet
- Vesiculobulous form: vesicles, pustules, and occasionally bullae on soles of feet
Tinea Pedis Non-Pharm
- Disinfect footwear
- Avoid walking barefoot in public places
- Wear absorbent socks
- Use non-occlusive shoes
- Decrease hyperhidrosis
Tinea Cruris
- Often occurs concurrently with tinea pedis
- High humidity/warm temperatures along with wet/tight clothing
- Presents: red scales with raised borders, itching, burning
- Treat with topicals for 1-2 weeks after symptom resolution
- Non-pharm: keep area dry, examine feet
Tinea Corporis
- “Ringworm”
- Infection of skin on trunk, extremities, or face
- Lesions may be singular or multiple
- Round, scaly lesions with central clearing
- Pruritis and pustules are variable
- Treatment: topical therapy
Dermatophyte Treatment
- Typically lasts 2-4 weeks
- Topicals are first line
- Fluconazole orally is an alternative
Tinea Unguium or Onychomycosis
- Infection of nail apparatus
- Affects ~8% of population
Nail Infection Risk Factors
- Increased age (>40)
- Immunodeficient
- Diabetes
- Peripheral vascular disease
- Smoking
- Tinea pedis
- Nail trauma
- Certain sports (swimming)
Onychomycosis Treatment
First line: Terbinafine 250 mg orally
- Other oral options: Fluconazole or Itraconazole
- Topical options: Ciclopirox nail lacquer, efinaconazole, tavaborole
- Not treating is also an option
