adult cutaneous fungal infections

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Adult Cutaneous Fungal Infections

Medical Student Core Curriculum in Dermatology

Last updated May 23, 2011

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Module Instructions

The following module contains a number of blue, underlined terms which are hyperlinked to the dermatology glossary, an illustrated interactive guide to clinical dermatology and dermatopathology.

We encourage the learner to read all the hyperlinked information.

http://missinglink.ucsf.edu/lm/DermatologyGlossary/index.html

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Goals and Objectives

The purpose of this module is to help medical students develop a clinical approach to the evaluation and initial management of patients presenting with cutaneous fungal infections.

By completing this module, the learner will be able to:• Identify and describe the morphologies of superficial fungal infections• Describe the correct procedure for performing a KOH examination

and interpreting the results• Recognize the use and limitations of KOH examination and fungal

cultures to diagnose fungal infections• Recommend an initial treatment plan for an adult with tinea pedis,

tinea versicolor, candidal intertrigo, and seborrheic dermatitis

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Superficial Fungal Infections: The Basics

Dermatophytoses are estimated to affect 20-25% of people worldwide, making them one of the most common infections.

Superficial cutaneous fungal infections are limited to the epidermis, as opposed to systemic fungal infections (e.g. endemic mycoses and opportunistic infections).

Three groups of cutaneous fungi cause superficial infections: dermatophytes, Malassezia spp., and Candida spp.

Dermatophytes (which include Trichophyton spp., Microsporum spp., and Epidermophyton spp.) infect keratinized tissues: the stratum corneum (outermost epidermal layer), the nail or the hair.

The term tinea is used for dermatophytoses and is modified according to the anatomic site of infection, e.g. tinea pedis

http://missinglink.ucsf.edu/lm/DermatologyGlossary/epidermis.html

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Case OneMr. Eugene Brown

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Case One: History HPI: Eugene Brown is a 62-year-old healthy man who

presents to his primary care physician with a one-year history of itching and burning of his feet.

PMH: no chronic illnesses or prior hospitalizations Medications: none Allergies: no known allergies Family history: noncontributory Social history: lives with wife, works as a banker Health-related behaviors: reports no alcohol, tobacco or

drug use ROS: increased nocturia, otherwise negative

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Case One: Skin Exam

How would you describe these exam findings?

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Case One: Skin Exam

Erythema and scaling are present on the plantar surface and between the toes

Case One, Question 1

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Which of the following is Mr. Brown’s most likely diagnosis?

a. Atopic dermatitisb. Candidal intertrigoc. Onychomycosisd. Psoriasise. Tinea pedis

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Answer: e Which of the following is Mr. Brown’s most likely

diagnosis?a. Atopic dermatitis (Characterized by red patches and plaques ±

scale. Lichenification may also result)b. Candida intertrigo (Erythematous, eroded areas with satellite

papules. Less likely location)c. Onychomycosis (Fungal infection of the nail)d. Psoriasis (The interdigital and plantar surfaces of the toes are

unusual locations for psoriasis. Would expect a well-demarcated plaque with a thick silvery scale)

e. Tinea Pedis

http://missinglink.ucsf.edu/lm/DermatologyGlossary/atopic_dermatitis.html

http://missinglink.ucsf.edu/lm/DermatologyGlossary/onychomycosis.html

http://missinglink.ucsf.edu/lm/DermatologyGlossary/psoriasis.html

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Tinea Pedis: The Basics Tinea pedis (“athlete’s foot”) is the most common fungal

infection seen in developed countries, and is most commonly caused by the fungus Trichophyton rubrum

Shoes provide an ideal environment for fungus to grow due to moisture

Public showers, gyms, and swimming pools are common sources of infection

It is difficult to permanently cure and may often recur There are three clinical patterns of infection: interdigital,

moccasin, and vesiculobullous type

Most common, presents with scaling and redness between the toes and may have associated maceration.

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Tinea Pedis: Interdigital Type

http://missinglink.ucsf.edu/lm/DermatologyGlossary/maceration.html

Also known as chronic hyperkeratotic type.

Sharply marginated scale, distributed along lateral borders of feet, heels, and soles.

At times, vesicles and erythema are present at the margins.

Often associated with onychomycosis (nail fungal infection).

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Tinea Pedis: Moccasin Type

http://missinglink.ucsf.edu/lm/DermatologyGlossary/hyperkeratosis.html

Moccasin type may present as “one hand, two feet” syndrome.

Affected hand shows unilateral fine scaling, particularly in the creases (see below), and nails are often involved.

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Tinea Pedis: Moccasin Type

Grouped, 2-3 mm vesicles or bullae are seen, often on the arch or instep. They may be itchy or painful.

Vesiculobullous type tinea pedis represents a delayed hypersensitivity immune response to a dermatophyte.

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Tinea Pedis: Vesiculobullous Type

Back to Case OneEugene Brown

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Which of the following is the most appropriate next step in diagnosis?

a. Begin empiric treatment with antifungals.b. KOH examc. Skin biopsyd. Wood’s light

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Answer: b Which of the following is the most appropriate next

step in diagnosis? a. Begin empiric treatment with antifungals (First need a

diagnosis. There are many scaly eruptions that can occur on the foot)

b. KOH exam c. Skin biopsy (This is too invasive when a simpler test is

available)d. Wood’s light (Organisms will not fluoresce on wood’s

light)

http://missinglink.ucsf.edu/lm/DermatologyGlossary/woods_light_examination.html

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Case One: KOH Exam

What are the diagnostic features in this KOH exam?

Magnification 40x

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Case One: KOH Exam

What are the diagnostic features in this KOH exam?

Parallel walls throughout the entire length

Septated and branching hyphae

Magnification 40x

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KOH Exam: Basic Facts

KOH microscopy is the easiest and most cost effective method used to diagnose fungal infections of the hair, skin, and nail.

Proper technique requires training.• Sensitivity is dependent on the operator’s

experience. KOH dissolves keratinocytes to allow easy viewing

of hyphae. Heat is used to accelerate this reaction.

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The KOH Exam Procedure

1. Clean and moisten skin with alcohol swab

2. Collect scale with #15 scalpel blade

3. Put scale on center of glass slide

4. Add drop of KOH and coverslip; heat slide gently with flame to adequately dissolve keratin

5. Microscopy: scan at 10X to locate hyphae; then study in detail at 40X if needed

Click here to watch the videoMake sure to turn on your computer volume

(video length 8min 41sec)

http://www.aad.org/education/medical-student-core-curriculum/dermatology-skills-videos/koh-preparations

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Which of the following are possible pitfalls of KOH prep?

a. False negative KOH due to prior partial treatment with antifungals

b. Misidentification of clothing fibers or lint as hyphae

c. Possibility of mistaking lipid or cell membranes for hyphae

d. All of the above are limitations

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Answer: d Which of the following are possible pitfalls of KOH prep?

a. False negative KOH due to prior partial treatment with antifungals

b. Misidentification of clothing fibers or lint as hyphae (clothing fibers or lint are tapered, while hyphae have parallel walls throughout)

c. Possibility of mistaking lipid or cell membranes for hyphae (hyphae have parallel walls throughout and tend to be longer)

d. All of the above are limitations

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Treatment of Tinea Pedis: Hygiene For all types of tinea pedis, hygiene and

topical antifungals are effective first-line therapies

Hygiene:• Dry the area after bathing• Change socks daily and alternate shoes worn• Consider wearing open shoes such as sandals• Use foot powder (available over the counter) to

keep feet dry

Topical Antifungals

There are several classes of topical antifungal medications

Some classes are fungistatic (stop fungi from growing), others are fungicidal (they kill fungi)

Not all conditions are treatable with topical antifungals (specifically, hair infections and nail infections do not respond to topical treatment and require systemic treatment)

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Treatment of Tinea Pedis: Topical Topical antifungals: apply until tinea shows resolution,

then continue treatment for a minimum of two weeks• Imidazoles: Fungistatic

Examples: clotrimazole, miconazole, sulconazole, oxiconazole, ketoconazole (least activity against dermatophytes)

• Allylamines: Fungicidal Examples: terbinafine, butenafine, naftifine

• Ciclopirox: Fungicidal and fungistaticExample: Ciclopirox olamine

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Treatment of Tinea Pedis By Type Interdigital:

• Topical imidazoles, ciclopirox olamine, and allylamines Plantar Moccasin/Chronic Hyperkeratotic:

• Topical allylamines and imidazoles• Keratolytics are also useful: e.g. salicylic acid, benzoic acid

(Whitfield’s ointment)*, urea, and lactic acid Vesiculobullous:

• Compresses in conjunction with antifungal agents • May require an oral agent such as terbinafine or itraconazole

* Whitfield’s ointment is a combination of salicylic and benzoic acid. In US can be bought through online pharmacies or compounded.

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Which of the following are common complications of tinea pedis? You may choose more than one answer.

a. Deep vein thrombosisb. Furunculosis of the lower legc. Lower leg cellulitisd. Peripheral neuropathye. Tinea corporis

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Answer: c & e Which of the following are common complications of

tinea pedis?a. Deep vein thrombosisb. Furunculosis of the lower legc. Lower leg cellulitis (the most common risk factor for

lower leg cellulitis in immunocompetent non-diabetics is tinea pedis, which creates a portal of entry for bacteria)

d. Peripheral neuropathye. Tinea corporis (from autoinoculation)

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Onychomycosis

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Another complication of tinea pedis is onychomycosis, a chronic fungal infection of the nailbed that tends to spread to other nails.

Responds very poorly to topical antifungals

First line treatments are oral terbinafine or itraconazole

Onychomycosis

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Identification of fungus in the affected nail (at minimum a positive KOH prep or nail biopsy) is necessary before treatment, for several reasons:• May mimic other conditions (e.g. psoriasis, lichen

planus) • Treatment is expensive, of long duration, and with

potential side effects• Oral antifungals also have drug-drug interactions

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Case TwoMr. Daniel Green

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Case Two: History

HPI: Daniel Green is a healthy 18-year-old who presents with a lesion on his right leg that has been present for 2 weeks. The lesion is itchy and is growing in size.

PMH: no major illnesses or hospitalizations Medications: none Allergies: none Family history: noncontributory Social history: Lives with his parents and sister. The family

adopted a puppy 3 months ago. No history of recent travel. Health-related behaviors: no tobacco, alcohol or drug use.

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Case Two: Skin Exam


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Case Two: Skin Exam

This is a sharply marginated, erythematous annular lesion with central clearing and raised papulovesicular border with scaling.

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Case Two, Question 1

Which of the following is the most appropriate next step in diagnosis?

a. Biopsyb. KOH examc. Wood’s light examd. All of the above

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Answer: b Which of the following is the most appropriate

next step in diagnosis? a. Biopsyb. KOH examc. Wood’s light examd. All of the above

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Which of the following is the most likely diagnosis?

a. Atopic dermatitisb. Psoriasisc. Seborrheic dermatitisd. Tinea corporise. Tinea cruris

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Answer: d Which of the following is the most likely diagnosis?

a. Atopic dermatitis (Poorly defined erythematous patches without central clearing)

b. Psoriasis (Well-demarcated erythematous plaques with silvery scale)

c. Seborrheic dermatitis (Inflammatory reaction to yeast typically affecting face, chest, and/or scalp, often with scaling)

d. Tinea corporis e. Tinea cruris (Dermatophyte infection in the groin)



http://missinglink.ucsf.edu/lm/DermatologyGlossary/seborrheic_dermatitis.html

http://missinglink.ucsf.edu/lm/DermatologyGlossary/tinea.html

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Tinea Corporis Tinea corporis, “ringworm”, refers to dermatophytosis

of the skin, usually affecting the trunk and limbs• Affects all age groups• Most prominent symptom is itching• Asymmetric distribution• The margin of the lesion is the most active; central

area tends to heal• Scrapings should be taken from the red scaly margin

for KOH exam• A variant of this is tinea cruris or “jock itch”, which has

a similar presentation but appears in the groin

Tinea Corporis

Annular lesion with central clearing is typical of tinea corporis

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Why Perform A Fungal Culture?

Cultures identify the specific species of fungi causing the infection

As opposed to tinea pedis, tinea corporis is caused by different fungal species with different environmental sources • Animals (cats/dogs), tinea capitis, tinea pedis

Using a fungal culture to identify the species will help identify the source and guide treatment

Even if the KOH prep is negative, a culture may be positive

Tinea Corporis: Treatment Begin with topical treatment Topical antifungals are applied until tinea shows resolution,

then continue treatment for a minimum of two weeks• Imidazoles (fungistatic)• Allylamines (fungicidal)• Ciclopirox (fungicidal and fungistatic)

Oral antifungals are indicated in the following situations:• If there is a poor response to topical agents• If an animal is the source of infection• If eruptions involve a large surface area

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Case ThreeMs. Anna Jones

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Case Three: History

HPI: Ms. Jones is a 27-year-old woman who presents with mild itchiness of her back which began mid summer. She is also concerned about areas on her back that do not tan.

PMH: asthma Medications: occasional multivitamin Allergies: no known drug allergies Social history: spends her summer months in Florida. Is an

avid runner. Health-related behaviors: occasional glass of wine 1-2 times

per month, no tobacco or drug use ROS: negative

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Case Three: Skin Exam


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Case Three: Skin Exam

Well-demarcated, pink and tan, macules and patches, across the back.

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Case Three, Question 1


a. Pityriasis alba b. Seborrheic dermatitisc. Tinea corporisd. Tinea versicolore. Vitiligo

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Answer: d Which of the following is the most likely diagnosis?

a. Pityriasis alba (noninfectious, asymptomatic poorly-defined areas of hypopigmentation; self-limited)

b. Seborrheic dermatitis (abnormal immune response to normal skin yeast causing scaling and crusting)

c. Tinea corporis (fungal skin infection, presents as erythematous annular lesions with central clearing)

d. Tinea versicolore. Vitiligo (autoimmune loss/dysfunction of melanocytes

causing areas of complete depigmentation)

http://missinglink.ucsf.edu/lm/DermatologyGlossary/pityriasis_alba.html


http://missinglink.ucsf.edu/lm/DermatologyGlossary/tinea_corporis.html

http://missinglink.ucsf.edu/lm/DermatologyGlossary/vitiligo.html

Diagnosis: Tinea Versicolor

Tinea versicolor (aka Pityriasis versicolor) is not a dermatophytosis

It is an infection caused by species of Malassezia, a lipophilic yeast that is a normal resident in the keratin of the skin and hair follicles of individuals at puberty and beyond

Tends to recur annually in the summer months

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Tinea Versicolor

Characterized by well-demarcated, tan, salmon, or hypopigmented patches, occurring most commonly on the trunk (facial involvement is rare)

Macules will grow, coalesce and various shapes and sizes are attained in an asymmetric distribution

Visible scale is not often present, but when rubbed with a finger or scalpel blade, scale is readily seen • This is a diagnostic feature of tinea versicolor• Evoked scale will disappear after treatment

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A Closer Look at Tinea Versicolor

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Which of the following is the most appropriate next step in management?

a. Fungal cultureb. KOH examc. Skin biopsyd. Wood’s light exam

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next step in management?a. Fungal culture (Malassezia spp. are easily identified

by a KOH exam but are not easily cultured)b. KOH exam c. Skin biopsyd. Wood’s light exam

Microscopy

The KOH exam shows short hyphae and small round spores. Characteristic “spaghetti and meatball” pattern.

Spores (yeast forms)

ShortHyphae

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Microscopy with dye added to the specimen

Characteristic “spaghetti and meatball” pattern corresponding to hyphae and spores.

Magnification 40x

Tinea Versicolor: Morphology

It’s called “versicolor” because it can be light, dark, or pink to tan.• In untanned Caucasians, the lesions may be salmon-colored

or brown.

• In tanned Caucasians, the lesions may appear pale in comparison to the surrounding skin.

• In darker skinned individuals, lesions may appear hyper- or hypopigmented.

Let’s look at some examples of the various colors of tinea versicolor.

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Tinea Versicolor: lighter

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Tinea Versicolor: darker

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Tinea Versicolor: pink or tan

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Which of the following treatments would you recommend for Ms. Jones?

a. Antifungal shampoob. Ketoconazole creamc. Nystatin creamd. Oral terbinafine

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Answer: a Which of the following treatments would you

recommend for Ms. Jones?a. Antifungal shampoob. Ketoconazole cream (effective for limited

areas, but not widespread infections)c. Nystatin cream (not effective)d. Oral terbinafine (in contrast to topical

terbinafine, oral terbinafine is not effective)

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What is true about treatment of tinea versicolor?a. Normal pigmentation should return within a

week of treatmentb. Oral azoles should be used in most casesc. When using shampoos as body wash, leave

on for ten minutes before rinsing

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Answer: c What is true about treatment of tinea versicolor?

a. Normal pigmentation should return within a week of treatment (usually takes weeks to months to return to normal)

b. Oral azoles should be used in most cases (mild cases can be treated with topicals)

c. When using shampoos as body wash, leave on for ten minutes before rinsing

Tinea Versicolor: Topical Treatment

Shampoos: selenium sulfide 2% shampoo, ketoconazole shampoo, pyrithione zinc shampoo • Apply daily to affected areas, lather, and rinse • Spreads easily to cover larger areas

Azole creams: ketoconazole, econazole, miconazole, clotrimazole • Apply daily or bid for 2 weeks • Can be effective for limited areas, but infections tend to be

widespread, so local topical treatment associated with high relapse rate

• More expensive than shampoos 66

Tinea Versicolor: Oral treatment

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Oral medication should be used when a large area is involved.

Oral medications of choice include: • Ketoconazole• Fluconazole• Itraconazole

Ketoconazole can be given as a one-time dose. • Take on an empty stomach, exercise until perspiring

(medication is delivered via sweat), and avoid shower six hours after taking medication.

Tinea Versicolor: Maintenance Therapy

Many patients relapse If the patient has had more than one previous

episode then recommend maintenance therapy Maintenance therapy: topicals are used 1-2x/week

• Ketoconazole shampoo• Selenium sulfide (2.5%) lotion or shampoo• Salicylic acid/sulfur bar• Pyrithione zinc (bar or shampoo)

Refer patients who fail maintenance therapy to dermatology

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Case FourMs. Betty Raskin

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Case Four: History

HPI: Ms. Raskin is a 62-year-old woman who presents with a red itchy rash beneath her breasts

PMH: Type 2 diabetes (last hemoglobin A1c 9.2%), obesity

Medications: Metformin, which she says she often does not remember to take

Family history: noncontributory Social history: lives in Texas part-time Health-related behaviors: no tobacco, alcohol or drug use ROS: negative

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Case Four, Question 1

a. Well-demarcated red plaques with overlying thick silvery scale

b. Grouped vesicles on an erythematous base

c. Sharply defined red plaques involving the skin folds with surrounding satellite papules

d. Inflammatory nodules

Which of the following best describe these characteristic exam findings?

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a. Well-demarcated red plaques with overlying thick silvery scale

b. Grouped vesicles on an erythematous base

c. Sharply defined red plaques involving the skin folds with surrounding satellite papules

d. Inflammatory nodules

Answer: c Which of the following best describe these characteristic

exam findings?

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a. Atopic dermatitisb. Candidal intertrigoc. Psoriasisd. Seborrheic dermatitise. Tinea cruris

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Case Four, Question 2Answer: b Which of the following is the most likely diagnosis?

a. Atopic dermatitis (chronic eruption of pruritic, erythematous, oozing papules and plaques, usually with secondary lichenification and excoriation)

b. Candidal intertrigoc. Psoriasis (characterized by well-demarcated, erythematous

papules and plaques with overlying silvery scale) d. Seborrheic dermatitis (typical skin findings range from fine white

scale to erythematous patches and plaques with greasy, yellowish scale)

e. Tinea cruris (dermatophytosis of the groin, genitalia, pubic area, perineal, and perianal skin, usually appears as multiple erythematous papulovesicles with a well-marginated, raised border)




http://missinglink.ucsf.edu/lm/DermatologyGlossary/tinea.html

Candidal Intertrigo: Basic Facts

Candidal intertrigo = candidiasis of large skin folds May arise in the following areas:

• Groin or armpits• Between the buttocks• Under large pendulous breasts• Under overhanging abdominal folds

KOH exam reveals pseudohyphae Burns more than itches

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Which of the following factors predispose to candidal intertrigo?

a. Diabetes mellitusb. Hot, humid weatherc. Limited mobilityd. Obesitye. All of the above

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Answer: e Which of the following factors predispose to

candidal intertrigo?a. Diabetes mellitusb. Hot, humid weatherc. Limited mobilityd. Obesitye. All of the above

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Which of the following is the most appropriate next step in management?

a. Barrier creams or ointments (e.g. petroleum jelly, zinc oxide paste, etc.)

b. Nystatin ointmentc. Oral antifungal agentd. Oral glucocorticoid

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next step in management?a. Barrier creams or ointments (useful as

adjunct/preventive therapy, but does not eradicate candida)

b. Nystatin ointment (useful for candida, ointment base prevents maceration in moist areas)

c. Oral antifungal agent (usually can be treated with topical agent)

d. Oral glucocorticoid (may worsen the infection) 79

Candidal Intertrigo: Management

Topical antifungal agents• Polyenes and Imidazoles: nystatin, miconazole,

clotrimazole, or econazole • Allylamines are not used to treat candida

Prevention• Keep intertriginous areas dry, clean, and cool• Encourage weight loss for obese patients• Washing with benzoyl peroxide bar may reduce

Candida colonization80

Candidal Intertrigo: Management

Topical anti-inflammatory• Low strength glucocorticoid preparations

rapidly improves the itching and burning, but should be stopped after one week

Systemic antifungal agents (used for infections resistant to topical treatment)• Oral fluconazole, itraconazole, or ketoconazole

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Take Home Points Cutaneous fungal infections are extremely common. There are three clinical patterns of tinea pedis infection:

interdigital, moccasin, and vesiculobullous type. If it scales, scrape it! KOH examination is the easiest and

most cost effective method used to diagnose fungal infections of the hair, skin, and nails.

Fungal culture is important because it may be positive when KOH prep is negative, and is the only easily available method to definitively identify the organism.

Culture is especially helpful in tinea corporis when the source of infection is not obvious (as opposed to tinea pedis).

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Take Home Points Tinea versicolor is characterized by well-demarcated, tan,

salmon, or hypopigmented patches, occurring most commonly on the trunk.

Topical treatment is usually appropriate as a first-line agent for tinea pedis, tinea corporis, and candidal intertrigo, however oral medications are called for when involvement is extensive, when tinea corporis is thought to have been transmitted by an animal, and in fungal infections of the nails.

Fungal infections have high rates of recurrence after treatment, but maintaining a dry, clean skin environment is helpful for prevention.

Monitoring for recurrence and maintenance treatments may be helpful in patients with recurrent infection.

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Acknowledgements This module was developed by the American Academy

of Dermatology Medical Student Core Curriculum Workgroup from 2008-2012.

Primary authors: Iris Ahronowitz, MD; Ronda Farah, MD; Sarah D. Cipriano, MD, MPH; Raza Aly, PhD, MPH; Timothy G. Berger, MD, FAAD.

Peer reviewers: Heather Woodworth Wickless, MD, MPH; Daniel S. Loo, MD, FAAD.

Revisions and editing: Sarah D. Cipriano, MD, MPH; John Trinidad. Last revised July, 2011.

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References Aly R and Maibach H. 1999. Atlas of Infections of the Skin.

Churchill Livingstone. Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The

Web-Based Illustrated Clinical Dermatology Glossary. MedEdPORTAL; 2007. Available from: www.mededportal.org/publication/462.

De Kock CA, Sampers GH, Knottnerus JA. Diagnosis and management of cases of suspected dermatomycosis in The Netherlands: influence of general practice based potassium hydroxide testing. Br J Gen Pract. 1995 Jul;45(396):349-51.

Erbagci Z. Topical therapy for dermatophytoses: should corticosteroids be included? Am J Clin Dermatol. 2004;5(6):375-84.

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References Gupta AK, Kogan N, Batra R. Pityriasis versicolor: a review of

pharmacological treatment options. Expert Opin Pharmacother. 2005 Feb;6(2):165-78.

Havlickova B, Czaika VA, Friedrich M. Epidemiological trends in skin mycoses worldwide. Mycoses. 2008 Sep;51 Suppl 4:2-15.

Huang DB, Ostrosky-Zeichner L, Wu JJ, Pang KR, Tyring SK. Therapy of common superficial fungal infections. Dermatol Ther. 2004;17(6):517-22.

Weinberg JM, Koestenblatt EK, Tutrone WD, Tishler HR, Najarian L. Comparison of diagnostic methods in the evaluation of onychomycosis. J Am Acad Dermatol. 2003 Aug;49(2):193-7.

Welsh O, Vera-Cabrera L, Welsh E. Onychomycosis. Clin Dermatol. 2010 Mar 4;28(2):151-9.

adult cutaneous fungal infections

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