? pH of the skin, mucosal surfaces and body fluids
? Epidermal turnover
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? Normal flora (bacterial; fungal)
Predisposing factors
? Climate: Tropical, profuse sweating
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? Manual labor population? Lower socioeconomic status
? Friction with clothes, synthetic innerwear
? Malnourishment
? Immunosuppressed patients: HIV infection/AIDS,
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congenital immunodeficiencies, patients oncorticosteroids, immunosuppressive drugs
(posttransplant), diabetes mel itus
Fungal infections: Classification
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v Superficial cutaneous:
Surface infections e.g., Pityriasis versicolor,
Dermatophytosis, Candidiasis, Tinea nigra, Piedra
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v Subcutaneous:
Mycetoma, Chromoblastomycosis, Sporotrichosis,
Phaeohyphomycosis
v Systemic: (opportunistic infection)
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Histoplasmosis, Candidiasis, ZygomycosisPityriasis versicolor
Etiologic agent: Malassezia furfur (formerly:
Pityrosporum)
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Clinical features:? Common among youth
? Genetic predisposition, familial occurrence
? Multiple, discrete, discoloured, macules, may be
fawn, brown, grey colored or hypopigmented
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? Pinhead sized to large sheets of discolouration?Seborrheic areas, upper half of body: trunk, arms,
neck, abdomen
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P.versicolor : Investigations? Wood's Lamp (365 nm) examination: Yel ow
fluorescence
? KOH preparation:
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"Spaghetti and meatbal " appearance
Coarse mycelium, fragmented to short filaments 2-5
micron wide, together with spherical, thick-wal ed
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yeasts 2-8 micron in diameter, arranged in grape likefashion.
Treatment P. versicolor
Topical:
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? Ketoconazole, Clotrimazole, Miconazole,Terbinafine, Selenium sulfide
Oral:
? Fluconazole 400 mg single dose
? Ketoconazole 200mg OD x 14days
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? Oral griseofulvin & oral terbinafine: NOT effective.? Hypopigmentation wil take weeks to fade
? Scaling wil disappear soon
Treatment P. versicolor
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?P. versicolor recurs if predisposing factors not taken
care of
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?Minimizing sweat, frequent washes and control ofimmunosuppression causes long remission
? Treatment: Oral Itraconazole, Ketaconazole,
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Fluconazole or topical Ketoconazole shampoo.Tinea nigra palmaris
Etiology: Hortaea werneckii (formerly: Exophiala
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wernecki )
Clinical features: Asymptomatic superficial infection
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of palms; deeply pigmented, brown or black macular,non-scaly patches, resembling a silver nitrate stain.
? Treatment: Topical antifungals (e.g.,
ketoconazole)
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Black piedra
?Etiology: Piedraia hortae
?Distribution: South America and in South-East Asia
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?Clinical features: Hard, dark, multiple superficialnodules; firmly adherent black, gritty, hard nodules
on hairs of scalp, beard, moustache or pubic area,
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hair may fracture easily.
?Treatment:
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Shaving or cutting the hair.Terbinafine
White piedra
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Etiology: Trichosporon beigeliClinical features:
Soft, white, grey or brown superficial nodules on
hairs of the beard, moustache , pubic areas.
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Hair shaft weakened and breaks.Treatment: Shaving or cutting the hair. Responses to
topical antifungals, azoles and al yamines have been
reported but are unpredictable.
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Dermatophytosis
Mycology:
?Three genera:
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Microsporum, Trichophyton, Epidermophyton
?They can be zoophilic, anthropophilic or geophilic.
?Thrive on dead, keratinized tissue - within the stratum
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corneum of the epidermis, within and around the fully
keratinized hair shaft, and in the nail plate and
keratinized nail bed.
Dermatophytes are keratinophillic
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?The topmost layer (stratum corneum) is a sheet of non
-nucleated cel s (corneocytes) containing protein ?
keratin ? stuck together forming a tough barrier
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? This barrier, when dry al ows fungi to stay on the
surface but stops them from piercing it
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? However, when moist, it becomes porous and sucks inthe fungi like a sponge.
Dermatophytosis (Ringworm)
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vTerminology:
?Head: Tinea capitis
?Face: Tinea faciei
?Beard: Tinea barbae
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?Trunk/body: Tinea corporis?Groin/gluteal folds: Tinea cruris
?Palms: Tinea manuum
?Soles: Tinea pedis
?Nail: Tinea unguium
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Tinea capitisInvasion of hair shaft by a dermatophyte fungus.
Clinical features:
?Common in children with poor nutrition and hygiene.
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Rare after puberty because sebum is fungistatic.
?Wide spectrum of lesions - a few dull-grey, broken-off
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hairs, a little scaling to a severe, painful, inflammatorymass covering the scalp.
?Partial hair loss is common in al types; cicatricial
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(scarring ) alopecia can occurTinea capitis
Endothrix and Ectothrix
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Term used to indicate infection of hair shaft, sporeslying inside or outside hair shaft.
4 varieties:
?Gray patch
?Black dot
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?Favus?Kerion (similar to a `boil')
Non inflammatory Tinea capitis:
Black dot/ Grey patch
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? Breakage of hair gives rise to `black dots'
?Patchy alopecia, often circular, numerous broken-off
hairs, dull grey
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? Inflammation is minimal
?Wood's lamp examination: green fluorescence
(occasional non-fluorescent cases)
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Tinea capitis: Kerion
Inflammatory variety
Painful, inflammatory boggy swel ing with purulent
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discharge.Hairs may be matted, easily pluckable
Lymphadenopathy
Co-infection with bacteria is common
May heal with scarring alopecia
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Tinea capitis: FavusInflammatory variety
Yel owish, cup-shaped crusts (scutula) develop around
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a hair with the hair projecting central y. Adjacentcrusts enlarge to become confluent mass of yel ow
crusting.
Hair may be matted
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Extensive patchy hair loss with cicatricial alopeciaTinea faciei
Erythematous scaly patches on the face
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Annular or circinate lesions and indurationItching, burning and exacerbation after sun exposure
Seen often in immunocompromised adults
Tinea barbae
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Ringworm of the beard and moustache areasInvasion of coarse hairs
Disease of the adult male
Highly inflammatory, pustular fol iculitis
Hairs of the beard or moustache are surrounded by
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inflammatory papulopustules, usual y with oozing or
crusting, easily pluckable
Persist several months
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Tinea corporis
Lesions of the trunk and limbs, excluding ringworm of
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the specialized sites such as the scalp, feet and groinsetc.
The fungus enters the stratum corneum and spreads
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centrifugal y. Central clearing results once the fungiare eliminated.
A second wave of centrifugal spread from the original
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site may occur with the formation of concentricerythematous inflammatory rings.
Tinea corporis
Classical lesion:
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Annular patch or plaque with erythematouspapulovesicles and scaling at the periphery with
central clearing resembling the effects of ring worm.
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Polycyclic appearance in advanced infection due toincomplete fusion of multiple lesions
Sites: waist, under breasts, abdomen, thighs etc.
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Tinea cruris
Itching
Erythematous plaques, curved with wel demarcated
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margins extending from the groin down the thighs.
Scaling is variable, and occasional y may mask the
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inflammatory changes.Vesiculation is rare
Tinea mannum
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Two varieties:Non inflammatory: Dry, scaly, mildly itchy
Inflammatory: Vesicular, itchy
Tinea pedis
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Wearing of shoes and the resultant maceration
Adult males commonest, children rarely
Peeling, maceration and fissuring affecting the lateral
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toe clefts, and sometimes spreading to involve theundersurface of the toes.
Two varieties:
Dry, scaly, mildly itchy, extensively involved ('moccasin foot
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`)
Vesicular, itchy, with inflammatory reactions affecting
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al parts of the feetTinea pedis : Prevention
Keeping toes dry
Not walking barefoot on the floors of communal
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changing rooms
Avoiding swimming baths.
Avoid closed shoes
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Avoid nylon socksUse of antifungal powders
Tinea Unguium
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Dirty, dull, dry, pitted, ridged, split, discoloured,thick, uneven, nails with subungual hyperkeratosis
Different types described depending on the site of nail
involvement and its depth.
Distal and lateral onychomycoses
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Proximal subungual onychomycosesWhite superficial onychomycoses
Total dystrophic onychomycoses
Treatment: Ringworm
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Topical: Ketoconazole, Clotrimazole, Miconazole,
Butenafine, Terbinafine.
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Vehicle: Lotions, creams, powders, gels are available.Treatment: Tinea
Oral: Griseofulvin 250 mg BD
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Fluconazole 150 mg weeklyKetoconazole 200 mg OD
Terbinafine 250 mg OD
Itraconazole 200 mg OD
Duration: T. capitis - 6 weeks
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T. faciei - 4 weeksT. cruris - 4 weeks
T. corporis - 4-6 weeks
T. manuum/pedis - 6-8 weeks
Shorter duration required for terbinafine & itraconazole
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Treatment: Tinea unguiumThe same line of Treatment for 3 months (fingernail)
to 6 months (toenails)
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8% Ciclopirox olamine lotions for local application
Amorolfine nail lacquer painted weekly
Pulse Therapy
Terbinafine: 250mg given 1BD x 1week / per month
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Itraconazole: 200mg given 1BD x 1week/month3 pulses for fingernails, 4 pulses for toenails.
Treatment Principles
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Patient should be explained clearly about thepredisposing factors
Need for personal hygiene, proper clothing should be
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emphasized
Selection of topical medication:
Do not use ointments on areas of friction or on greasy
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areas
Do not rub creams/ointments in groin folds
Choose steroid combinations only if itch is a major
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complaint. Do not use antifungal creams in
combination with potent steroids
Treatment Principles
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Dermatophytosis wil take 3-4 weeks to resolve and
patient should be told about the need for complete
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treatment. Treat 1 week beyond apparent cure.Need for hygiene, proper clothing.
Onychomycosis requires 3-6 months of treatment.
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Treat 4 weeks beyond apparent cure.
Temporary relief should not be mistaken for cure
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CandidiasisCausative organism:
Candida albicans, Candida tropicalis, Candida
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pseudotropicalisSites of affection:
Mucous membrane
Skin
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NailsCandidiasis : Mucosal
Oral thrush:
Creamy, curd-like, white pseudomembrane, on
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erythematous base
Sites:
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Immunocompetent patient: cheeks, gums or thepalate.
Immunocompromised patients: affection of tongue
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with extension to pharynx or oesophagus; ulcerative
lesions may occur.
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Angular cheilitis (angular stomatitis / perleche):Soreness at the angles of the mouth
Candidiasis : Mucosal
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Vulvovaginitis (vulvovaginal thrush): Itching and
soreness with a thick, creamy white discharge
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Balanoposthitis:Tiny papules on the glans penis after intercourse,
evolve as white pustules or vesicles and rupture.
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Radial fissures on glans penis in diabetics.Vulvovaginitis in conjugal partner
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Candidiasis - FlexuralIntertrigo: (Flexural candidiasis):
Erythema and maceration in the folds; axil a, groins and
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webspaces.Napkin rash:
Pustules, with an irregular border and satel ite lesions
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Candidiasis: NailChronic Paronychia:
Swel ing of the nail fold with pain and discharge of
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pus.Chronic, recurrent.
Superadded bacterial infection
Onychomycosis:
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Destruction of nail plate.Treatment of candidiasis
Treat predisposing factors like poor hygiene,
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diabetes, AIDS, conjugal infectionTopical:
Clotrimazole, Miconazole, Ketoconazole, Ciclopirox
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olamineOral:
Ketoconazole 200mg, Itraconazole 100-200mg and
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Fluconazole 150mg