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SUPERFICIAL
FUNGAL
INFECTIONS
Dr R V RANADE
PROF & HOD
DYP Medical College
KOLHAPUR
Fungal Infection
 Most common type of infection
 20 – 25 % worlds population
Predisposing FactorsPredisposing Factors
 Tropical climate
 Manual labour population
 Low socioeconomic status
 Profuse sweating
 Friction with clothes, synthetic innerwear
 Malnourishment
 Immunosuppressed patients
HIV, Congenital Immunodeficiencies, patients on corticosteroids,
immunosuppressive drugs, Diabetes
Superficial
Cutaneous Fungal Infection
Deep
Fungal Infection
3 Genera : Microsporum
Trichophyton
Epidermophyton
Superficial Infections:
I. T . Capitis
II. T . Barbae
III. T . Faciei
IV. T . Corporis
V. T . Manuum
VI. T . Pedis
VII. T. Cruris
VIII. Onychomycosis
I Tinea Capitis ( Scalp Ringworm )
 Invasion of a hair shaft by a dermatophyte fungus
 Mainly in children; rare after puberty because
sebum is fungistatic
 Boys > Girls
 Wide spectrum of lesions: few dull grey broken off
hairs, with little scaling to severe, painful
inflammatory mass
 Partial hair loss is common in all type
4 Varieties
 Gray Patch (Ectothrix )
 Black Dot ( Endothrix )
 Favus
 Kerion
I Tinea Capitis - Grey Patch ( Ectothrix )
 Non inflammatory type
 Etiology: Microsporum spp
 Patches of partial hair loss- often circular in
shape
 Hairs – dull and grey – easily pluckable
Tinea Capitis - Grey Patch ( Ectothrix )
I Tinea Capitis - Black Dot ( Endothrix )
 Endothrix organisms
 Hair shaft is brittle
 Broken off hairs – black dot
 Inflammation is minimal
 Wood’s Lamp examination: green fluorescence
Tinea Capitis - Black Dot ( Endothrix )
I Tinea Capitis - Kerion
 Inflammatory type
 Painful, boggy swelling
with purulent discharge
 Vesicles and pustules
 Thick crusting with
matting of hair
 Lymphadenopathy
 Secondary bacterial
infection
 Heals with scarring
I Tinea Capitis - Favus
 Inflammatory type
 Begins early in life
 Yellow, cup shaped
crust – scutulum
Concavity faces
upwards
 Mousy odor
 Hair may be matted
 Extensive patchy
hairloss with cicatricial
alopecia
II Tinea Barbae – T.Sycosis, Barber’s Itch
 Ringworm of beard & moustache area
 Disease of adult males
 Invasion of coarse hairs
 Inflammatory papulopustules, seropurulent
discharge
 Hairs- easily epilated
 Simulate bacterial folliculitis
 Diagnosis- confirmed by KOH mount
Tinea Barbae
III Tinea Faciei
 Dermatophyte infection on
non bearded area of face
 Burning, itching &
photosensitivity
 Erythematous scaly patches
 Extends peripherally- raised
border
 Central area-
hypopigmented or brown
 Seen often in
immunocompromised
patients
IV Tinea Corporis
 Dermatophyte infections of skin other than
those involving the scalp, beard, face, hands,
feet and groin
 The fungus enters the stratum corneum and
spreads centrifugally
Tinea Corporis
Typical lesion- annular /
polycyclic
Borders – erythematous,
vesicular or scaly
Centre – clear,
hyperpigmentation
Concentric rings may be
seen
Sites: Waist, under breasts,
abdomen, thighs, etc.
Differential Diagnosis of T. Corporis
 Psoriasis
 Lichen Simplex Chronicus
 Pityriaisis Rosea
 Candidiasis
 Nummular eczema
 Tertiary Syphilis
 Annular lesions of Leprosy
V Tinea Manuum
 Ringworm of palmar skin
 Commonly occurs in adults, in males
 2 main clinical types:
(1) Non inflammatory squamous form
 Most common clinical presentation
 Hyperkeratosis of palms and fingers
 Accentuation of flexural creases
 Association – hyperhidrosis
(2) Inflammatory vesicular / dyshidrotic / eczematous form:
 Uncommon in temperate climates
 Vesicles occur-mainly on palms
 Itchy
 Heal spontaneously
VI Tinea Pedis ( Athlete’s Foot )
 Dermatophyte infection of the feet
 Most common fungal infection worldwide
 30-70 % of population in developed countries
 Wearing of shoes and resultant maceration
 Adult males commonest
VI Tinea Pedis ( Athlete’s Foot )
4 clinically accepted variants:
(1) The chronic intertriginous type
commonest type
fissuring, scaling or maceration
lateral 3rd
& 4th
toe webs
(2) Chronic papulosquamous type
inflammation
patchy ‘mocassin like’ scaling over soles
(3)Vesicular or vesiculobullous type
small vesicles/ vesiculopustules- seen at instep
and mid anterior plantar surface
Associated with scaling
(4) Acute ulcerative variant
Maceration, weeping and ulceration of the soles
often complicated by secondary infections
VI Tinea Pedis-Prevention
 Keeping toes dry
 Not walking barefoot on the floors of communal changing rooms
 Avoiding swimming baths.
 Avoid closed shoes
 Avoid nylon socks
 Use of antifungal powders
VII Tinea Cruris ( Dhobi’s itch, Jock itch )
 Dermatophytic infection of the
groins
 Itching
 Sharply demarcated,
erythematous advancing
annular skin rash
 Extends from groins to the
thighs
 Scaling is variable, and
occasionally may mask the
inflammatory changes.
 Vesiculation is rare
VIII Onychomycosis
 Infection of nail caused by fungus
 Common infection
 20 % of all nail diseases
 Incidence is increasing
 Dirty, dull, dry, pitted, ridged, split, discoloured,
thick, uneven, nails with subungual hyperkeratosis
Onychomycosis
 4 Clinical types
( 1 ) Distal and lateral sunungual Onychomycosis
( 2 ) Proximal Subungual Onychomycosis
( 3 ) White Superficial Onychomycosis
( 4 ) Total Dystrophic Onychomycosis
Distal and lateral sunungual Onychomycosis
 Most common type
 90 % of all fungal nail
infection
 Etiology: T.rubrum
 Toe nails > finger nails
 Infection starts in distal
nailbed or lateral nailfold,
then moves proximally
White Superficial Onychomycosis
 2nd
most common
 Well circumscribed
powdery white patches
o nail plate- easily
scraped way
 Surface of nail- rough &
friable
Proximal Subungual Onychomycosis
 Least common variant
 Etiology: T.rubrum
 1st
clinical sign is a
whitish-brownish area
on proximal part of nail
 Early indicator of HIV
infection
Treatment of Dermatophyte Infections-Treatment of Dermatophyte Infections-
Topical
 Bifonazole, Oxiconazole, Clotrimazole, Miconazole,
Butenafine, Terbinafine.
 Vehicle: Lotions, creams, powders, gels are available.
Treatment of Dermatophyte Infections-Treatment of Dermatophyte Infections-
Systemic
 Griseofulvin 250 mg BD
 Fluconazole 150 mg weekly
 Terbinafine 250 mg OD
 Itraconazole 200 mg OD
Duration
 T.capitis - 6 weeks
 T.faciei - 4 weeks
 T.cruris - 2-4 weeks
 T.corporis - 4-6 weeks
 T.manuum/pedis - 6-8 weeks
Treatment of OnychomycosisTreatment of Onychomycosis
 The same line of Treatment for
3 months (fingernail)
6 months (toenails)
 8% Ciclopirox olamine lotions for local application
 Amorolfine lacquer painted weekly
 Pulse Therapy
Terbinafine: 250mg given 1BD 1week / per month
Itraconazole: 200mg given 1BD 1week/month
3 pulses for fingernails
4 pulses for toenails.
Treatment PrinciplesTreatment Principles
 Dermatophytosis will take 3-4 weeks to resolve and patient
should be told about the need for complete treatment.
Treat 1 week beyond apparent cure.
 Need for hygiene, proper clothing.
 Onychomycosis requires 3-6 months of treatment. Treat 4
weeks beyond apparent cure.
 Temporary relief should not be mistaken for cure
CandidiasisCandidiasis
 Causative organism:
Candida albicans
Candida tropicalis
Candida pseudotropicalis
 Sites of affection:
Mucous membrane
Skin
Nails
Candidiasis : MucosalCandidiasis : Mucosal
 Oral thrush:
Creamy, curd-like, white
pseudomembrane, on
erythematous base
 Sites:
Immunocompetent patient: cheeks,
gums or the palate.
Immunocompromised patients:
affection of tongue with
extension to pharynx or oesophagus
 Angular cheilitis (angular stomatitis /
perleche)
Soreness at the angles of the mouth
Candidiasis : MucosalCandidiasis : Mucosal
 Vulvovaginitis (vulvovaginal thrush)
Itching and soreness with a thick, creamy white discharge
 Balanoposthitis:
Tiny papules on the glans penis after intercourse, evolve as
white pustules or vesicles and rupture.
Radial fissures on glans penis in diabetics.
Vulvovaginitis in conjugal partner
Candidiasis - FlexuralCandidiasis - Flexural
 Intertrigo (Flexural
candidiasis):
Erythema and maceration in
the folds, axilla, groins and
webspaces.
 Napkin rash:
Pustules, with an irregular
border and satellite lesions
Candidiasis: NailCandidiasis: Nail
 Chronic Paronychia:
Swelling of the nail fold with
pain and discharge of pus.
Chronic, recurrent.
Superadded bacterial infection
 Onychomycosis:
Destruction of nail plate.
Treatment of candidiasisTreatment of candidiasis
 Treat predisposing factors like poor hygiene, diabetes,
AIDS, conjugal infection
 Topical
Clotrimazole
Miconazole
Ciclopirox olamine
 Oral:
Itraconazole 100-200mg
Fluconazole 150mg
Pityriasis versicolorPityriasis versicolor
 Etiologic agent: Malassezia furfur
 Common among youth
 Genetic predisposition, familial
occurrence
 Multiple, discrete, discoloured,
macules.
 Fawn, brown, grey or hypopigmented
 Pinhead sized to large sheets of
discolouration
 Seborrheic areas, upper half of body:
trunk, arms, neck, abdomen.
P.versicolor - InvestigationsP.versicolor - Investigations
 Wood’s Lamp examination:
Yellow fluorescence
 KOH preparation:
Spaghetti and meatball appearance
Coarse mycelium, fragmented to short filaments 2-5
micron wide and up to 2-5 micron long, together with
spherical, thick-walled yeasts 2-8 micron in diameter,
arranged in grape like fashion.
Treatment P. versicolor - TopicalTreatment P. versicolor - Topical
Topical
Clotrimazole
Miconazole
Bifonazole, Oxiconazole, Butenafine,Terbinafine,
Selenium sulfide, Sodium thiosulphate
Oral
 Fluconazole 400mg single dose
 Griseofulvin is NOT effective.
 Hypopigmentation will take weeks to fade
 Scaling will disappear soon
THANK YOU

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Superficial fungal infections

  • 1. SUPERFICIAL FUNGAL INFECTIONS Dr R V RANADE PROF & HOD DYP Medical College KOLHAPUR
  • 2. Fungal Infection  Most common type of infection  20 – 25 % worlds population
  • 3. Predisposing FactorsPredisposing Factors  Tropical climate  Manual labour population  Low socioeconomic status  Profuse sweating  Friction with clothes, synthetic innerwear  Malnourishment  Immunosuppressed patients HIV, Congenital Immunodeficiencies, patients on corticosteroids, immunosuppressive drugs, Diabetes
  • 5. Fungal Infection 3 Genera : Microsporum Trichophyton Epidermophyton
  • 6. Superficial Infections: I. T . Capitis II. T . Barbae III. T . Faciei IV. T . Corporis V. T . Manuum VI. T . Pedis VII. T. Cruris VIII. Onychomycosis
  • 7. I Tinea Capitis ( Scalp Ringworm )  Invasion of a hair shaft by a dermatophyte fungus  Mainly in children; rare after puberty because sebum is fungistatic  Boys > Girls  Wide spectrum of lesions: few dull grey broken off hairs, with little scaling to severe, painful inflammatory mass  Partial hair loss is common in all type
  • 8. 4 Varieties  Gray Patch (Ectothrix )  Black Dot ( Endothrix )  Favus  Kerion
  • 9. I Tinea Capitis - Grey Patch ( Ectothrix )  Non inflammatory type  Etiology: Microsporum spp  Patches of partial hair loss- often circular in shape  Hairs – dull and grey – easily pluckable
  • 10. Tinea Capitis - Grey Patch ( Ectothrix )
  • 11. I Tinea Capitis - Black Dot ( Endothrix )  Endothrix organisms  Hair shaft is brittle  Broken off hairs – black dot  Inflammation is minimal  Wood’s Lamp examination: green fluorescence
  • 12. Tinea Capitis - Black Dot ( Endothrix )
  • 13. I Tinea Capitis - Kerion  Inflammatory type  Painful, boggy swelling with purulent discharge  Vesicles and pustules  Thick crusting with matting of hair  Lymphadenopathy  Secondary bacterial infection  Heals with scarring
  • 14. I Tinea Capitis - Favus  Inflammatory type  Begins early in life  Yellow, cup shaped crust – scutulum Concavity faces upwards  Mousy odor  Hair may be matted  Extensive patchy hairloss with cicatricial alopecia
  • 15. II Tinea Barbae – T.Sycosis, Barber’s Itch  Ringworm of beard & moustache area  Disease of adult males  Invasion of coarse hairs  Inflammatory papulopustules, seropurulent discharge  Hairs- easily epilated  Simulate bacterial folliculitis  Diagnosis- confirmed by KOH mount
  • 17. III Tinea Faciei  Dermatophyte infection on non bearded area of face  Burning, itching & photosensitivity  Erythematous scaly patches  Extends peripherally- raised border  Central area- hypopigmented or brown  Seen often in immunocompromised patients
  • 18. IV Tinea Corporis  Dermatophyte infections of skin other than those involving the scalp, beard, face, hands, feet and groin  The fungus enters the stratum corneum and spreads centrifugally
  • 19. Tinea Corporis Typical lesion- annular / polycyclic Borders – erythematous, vesicular or scaly Centre – clear, hyperpigmentation Concentric rings may be seen Sites: Waist, under breasts, abdomen, thighs, etc.
  • 20. Differential Diagnosis of T. Corporis  Psoriasis  Lichen Simplex Chronicus  Pityriaisis Rosea  Candidiasis  Nummular eczema  Tertiary Syphilis  Annular lesions of Leprosy
  • 21. V Tinea Manuum  Ringworm of palmar skin  Commonly occurs in adults, in males  2 main clinical types: (1) Non inflammatory squamous form  Most common clinical presentation  Hyperkeratosis of palms and fingers  Accentuation of flexural creases  Association – hyperhidrosis (2) Inflammatory vesicular / dyshidrotic / eczematous form:  Uncommon in temperate climates  Vesicles occur-mainly on palms  Itchy  Heal spontaneously
  • 22. VI Tinea Pedis ( Athlete’s Foot )  Dermatophyte infection of the feet  Most common fungal infection worldwide  30-70 % of population in developed countries  Wearing of shoes and resultant maceration  Adult males commonest
  • 23. VI Tinea Pedis ( Athlete’s Foot ) 4 clinically accepted variants: (1) The chronic intertriginous type commonest type fissuring, scaling or maceration lateral 3rd & 4th toe webs (2) Chronic papulosquamous type inflammation patchy ‘mocassin like’ scaling over soles (3)Vesicular or vesiculobullous type small vesicles/ vesiculopustules- seen at instep and mid anterior plantar surface Associated with scaling (4) Acute ulcerative variant Maceration, weeping and ulceration of the soles often complicated by secondary infections
  • 24. VI Tinea Pedis-Prevention  Keeping toes dry  Not walking barefoot on the floors of communal changing rooms  Avoiding swimming baths.  Avoid closed shoes  Avoid nylon socks  Use of antifungal powders
  • 25. VII Tinea Cruris ( Dhobi’s itch, Jock itch )  Dermatophytic infection of the groins  Itching  Sharply demarcated, erythematous advancing annular skin rash  Extends from groins to the thighs  Scaling is variable, and occasionally may mask the inflammatory changes.  Vesiculation is rare
  • 26. VIII Onychomycosis  Infection of nail caused by fungus  Common infection  20 % of all nail diseases  Incidence is increasing  Dirty, dull, dry, pitted, ridged, split, discoloured, thick, uneven, nails with subungual hyperkeratosis
  • 27. Onychomycosis  4 Clinical types ( 1 ) Distal and lateral sunungual Onychomycosis ( 2 ) Proximal Subungual Onychomycosis ( 3 ) White Superficial Onychomycosis ( 4 ) Total Dystrophic Onychomycosis
  • 28. Distal and lateral sunungual Onychomycosis  Most common type  90 % of all fungal nail infection  Etiology: T.rubrum  Toe nails > finger nails  Infection starts in distal nailbed or lateral nailfold, then moves proximally
  • 29. White Superficial Onychomycosis  2nd most common  Well circumscribed powdery white patches o nail plate- easily scraped way  Surface of nail- rough & friable
  • 30. Proximal Subungual Onychomycosis  Least common variant  Etiology: T.rubrum  1st clinical sign is a whitish-brownish area on proximal part of nail  Early indicator of HIV infection
  • 31. Treatment of Dermatophyte Infections-Treatment of Dermatophyte Infections- Topical  Bifonazole, Oxiconazole, Clotrimazole, Miconazole, Butenafine, Terbinafine.  Vehicle: Lotions, creams, powders, gels are available.
  • 32. Treatment of Dermatophyte Infections-Treatment of Dermatophyte Infections- Systemic  Griseofulvin 250 mg BD  Fluconazole 150 mg weekly  Terbinafine 250 mg OD  Itraconazole 200 mg OD Duration  T.capitis - 6 weeks  T.faciei - 4 weeks  T.cruris - 2-4 weeks  T.corporis - 4-6 weeks  T.manuum/pedis - 6-8 weeks
  • 33. Treatment of OnychomycosisTreatment of Onychomycosis  The same line of Treatment for 3 months (fingernail) 6 months (toenails)  8% Ciclopirox olamine lotions for local application  Amorolfine lacquer painted weekly  Pulse Therapy Terbinafine: 250mg given 1BD 1week / per month Itraconazole: 200mg given 1BD 1week/month 3 pulses for fingernails 4 pulses for toenails.
  • 34. Treatment PrinciplesTreatment Principles  Dermatophytosis will take 3-4 weeks to resolve and patient should be told about the need for complete treatment. Treat 1 week beyond apparent cure.  Need for hygiene, proper clothing.  Onychomycosis requires 3-6 months of treatment. Treat 4 weeks beyond apparent cure.  Temporary relief should not be mistaken for cure
  • 35. CandidiasisCandidiasis  Causative organism: Candida albicans Candida tropicalis Candida pseudotropicalis  Sites of affection: Mucous membrane Skin Nails
  • 36. Candidiasis : MucosalCandidiasis : Mucosal  Oral thrush: Creamy, curd-like, white pseudomembrane, on erythematous base  Sites: Immunocompetent patient: cheeks, gums or the palate. Immunocompromised patients: affection of tongue with extension to pharynx or oesophagus  Angular cheilitis (angular stomatitis / perleche) Soreness at the angles of the mouth
  • 37. Candidiasis : MucosalCandidiasis : Mucosal  Vulvovaginitis (vulvovaginal thrush) Itching and soreness with a thick, creamy white discharge  Balanoposthitis: Tiny papules on the glans penis after intercourse, evolve as white pustules or vesicles and rupture. Radial fissures on glans penis in diabetics. Vulvovaginitis in conjugal partner
  • 38. Candidiasis - FlexuralCandidiasis - Flexural  Intertrigo (Flexural candidiasis): Erythema and maceration in the folds, axilla, groins and webspaces.  Napkin rash: Pustules, with an irregular border and satellite lesions
  • 39. Candidiasis: NailCandidiasis: Nail  Chronic Paronychia: Swelling of the nail fold with pain and discharge of pus. Chronic, recurrent. Superadded bacterial infection  Onychomycosis: Destruction of nail plate.
  • 40. Treatment of candidiasisTreatment of candidiasis  Treat predisposing factors like poor hygiene, diabetes, AIDS, conjugal infection  Topical Clotrimazole Miconazole Ciclopirox olamine  Oral: Itraconazole 100-200mg Fluconazole 150mg
  • 41. Pityriasis versicolorPityriasis versicolor  Etiologic agent: Malassezia furfur  Common among youth  Genetic predisposition, familial occurrence  Multiple, discrete, discoloured, macules.  Fawn, brown, grey or hypopigmented  Pinhead sized to large sheets of discolouration  Seborrheic areas, upper half of body: trunk, arms, neck, abdomen.
  • 42. P.versicolor - InvestigationsP.versicolor - Investigations  Wood’s Lamp examination: Yellow fluorescence  KOH preparation: Spaghetti and meatball appearance Coarse mycelium, fragmented to short filaments 2-5 micron wide and up to 2-5 micron long, together with spherical, thick-walled yeasts 2-8 micron in diameter, arranged in grape like fashion.
  • 43. Treatment P. versicolor - TopicalTreatment P. versicolor - Topical Topical Clotrimazole Miconazole Bifonazole, Oxiconazole, Butenafine,Terbinafine, Selenium sulfide, Sodium thiosulphate Oral  Fluconazole 400mg single dose  Griseofulvin is NOT effective.  Hypopigmentation will take weeks to fade  Scaling will disappear soon