Superficial Fungal Infections in Children

Teri Turner, MD, MPH, MED Associate Professor of

PediatricsBaylor College of

Medicine/Texas Children’s Hospital

Objectives

• Identify superficial fungal infections (SFIs)

• Discuss the management of common SFIs

• Compare and contrast SFIs with other non-fungal disease look-alikes

• Describe methods to differentiate SFIs from other disease processes

2

Case #1

• You are seeing a 6 year old child for an itchy flaky scalp. Mom thinks he has dandruff. You believe he has tinea capitis. • Do you need to do further testing to confirm?

• Should you treat his asymptomatic 8 year old brother?

• Should you do a culture on the family dog?

• When can he go back to school?

• How long should he be treated and are lab tests needed?

3

Why is this important?

• Superficial skin infections can be mistaken for other common diseases

• An accurate diagnosis is essential to the appropriate management strategy

• Patient understanding is the key to treatment adherence

4

Case #2• 4 week old infant

• Progressive hair loss x 2 weeks

5

What is your differential diagnosis and what would you do?

6

Tinea Capitis

• 95% of cases – Trichophyton tonsurans

• Most cases occur between 3-7 yrs. of age

• More common with crowded living conditions, low SES, urban settings and AA

• Indirect contact with fallen hair and cells

• Some call it a “modern day epidemic”

Abdel-Rahman SM, et al. Pediatrics 2010 7

Case #2: Tinea Capitis

• Rare in infants less than 1

• Most often normal infants but think about immunodeficiency

• Look for source of infection in household contacts

• Treat with oral fluconazole

Gilaberte Y, et al. Br J Dermatol 2004Romano C, et al. Pediatr Dermatol 2001 8

Presentations

• Non-inflammatory “black dot”

• Seborrheic (diffuse scale)

• “Gray patch”

• Pustular

• Kerion (inflammatory)

• Favus

©2007 by American Academy of Pediatrics

Shy R Pediatrics in Review 2007;28:164-174

9

When scalp scaling is noted in a child, the fungus is guilty until proven innocent

©2007 by American Academy of Pediatrics

Shy R Pediatrics in Review 2007;28:164-174

10

Differential Diagnosis

• Alopecia areata

• Impetigo

• Pediculosis

• Psoriasis

• Seborrhea dermatitis

• Traction alopecia

• Trichotillomania

www.dermatlas.org11

Alopecia Areata

• Sharply demarcated, round nearly bald patches of hair loss

• Occ. will have hairs that look like exclamation points (mostly at periphery)

• Treatment is individualized

www.dermatlas.org 12

Tinea vs. Alopecia

www.dermatlas.orgShy R Pediatrics in Review 2007;28:164-174

©2007 by American Academy of Pediatrics13

Tinea Capitis should be in the differential of any child who presents with alopecia

www.espd.info14

Frequency of Signs and Symptoms

www.health-7.com

15

Case #3

www.dermatlas.org

9 year old girl, URI, hair thinning, no scale, no pruritus, shotty cervical lymphadenopathy

Mother is worried about ringworm of the scalp

16

Case #3: Traction Alopecia

• Hairstyles that constantly pull

• Also associated with chemical relaxers and tight rollers

• Usually no scale and no pruritis

• Typically on the frontal and temporal areas

• “Fringe” sign – fringe of proximal hair

• Treatment – loosen the hair style

www.dermatlas.org17

Case # 4

www.dermatologynursing.net

7 year old cousin, thinning hair, slight pruritus, no adenopathy, visible flakes

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Case # 4: Tinea Capitis

www.dermatologynursing.net

7 year old cousin, thinning hair, slight pruritus, no adenopathy, visible flakes

19

To confirm with microscopy or culture

• When in doubt, confirm with KOH or culture

• Woods lamp not helpful

• Provide counseling • No sharing of hair brushes, combs, hats, etc.

• Wash bedding in hot water

• No sports with scalp-to-scalp contact

• Should you screen other family members?

• Should you screen the family pet?

White JW, et al. J Eur Acad Dermatol Venereal 2007 20

Management of Tinea Capitis

• Griseofulvin – 6-12 weeks (no baseline labs)• May need up to 16 weeks of treatment

• If treating > 8 wks (CBC, ALT, AST, BUN, Cr)

• Higher doses recommended (20-25 mg/kg/d microsizeand 10-15 mg/kg/d for ultramicrosize)

• Terbinafine – once daily for 2-4 weeks• Liver transaminases prior to therapy

• Oral granules sprinkled on food

• $14/day (compared to $4.50) – generic now available

• Dosing based on weight

Lipozencic J, et al. Br J Dermatology 2002Tey HL, et al. J Am Acad Dermatology 2011

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Case #5 Topical or Oral Treatment?

www.ethnomed.org

22

Case #5 Oral Treatment

www.ethnomed.org23

Adjunctive Topical Treatment

• Ketoconazole 2% shampoo

• Selenium sulfide 1% shampoo

• Povidone-iodine 2.5% shampoo

• Ciclopirox 1% shampoo

• Use sporicidal shampoo 3X weekly for 2-4 weeks

• Decreases viable spores – treat everyone

Pomeranz AJ, et al. Arch Pediatr Adolesc Med 1999.White JW et al. J Eur Acad Dermatol Venereal 2007 24

Case #6: Fungal cx negative: Antibiotics or Antifungals?

Proudfoot L. NEJM March 22, 2012 25

Case #6: Kerion: Treat with Antifungals (+/- glucocorticoid)

Proudfoot L. NEJM March 22, 2012 26

Case # 7

• 3 year old female

• Treated for 2 wks. with oral griseofulvin

• Recently developed this scaling erythematous rash

• 1-3 mm papules

• Diagnosis & management?

www.dermatlas.org 27

Case # 7: Dermatophytid (Id) Reaction

• Secondary dermatitic eruptions

• Pruritic, papulovesicular eruption

• Often distal from the original infection

• Continue antifungals

• Topical corticosteroids and antipruritic agents

www.dermatlas.org 28

Case #1 Revisited

• You are seeing a 6 year old child for an itchy flaky scalp. Mom thinks he has dandruff. You believe he has tinea capitis. • Do you need to do further testing to confirm?

• Should you treat his asymptomatic 8 year old brother?

• Should you do a culture on the family dog?

• When can he go back to school?

• How long should he be treated and are lab tests needed?

29

Case #8

www.dermatlas.org 30

Case #8

• What is your differential diagnosis?

• What laboratory tests (if any) do you want to do?

• What is your management plan?

• How would you counsel this family?

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Differential Diagnosis

• Drug eruption

• Erythema multiforme

• Granuloma annulare

• Nummular eczematous dermatitis

• Pityriasis rosea

• Psoriasis

• Secondary syphilis

• Tinea (pityriasis) versicolor

• Tinea corporis

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Case #8: Granuloma Annulare

• Subacute onset

• No epidermal changes (nonscaly, nonpruritic)

• Usually on dorsum of hands and feet

• Slowly enlarges with “central clearing”

• Etiology unknown

• Observation

www.dermatlas.org

33

Tinea vs. Granuloma

www.dermatlas.netwww.fromyourdoctor.com 34

Case #9

• 10 yr. old female

• pruritic lesion on arm x 6 mos.

www.health-pictures.com 35

Case #9: Nummular eczema

• Coin shaped

• Scaly patch

• No central clearing

• Itchy

• “Atopic”

• Xerosis

www.health-pictures.com

36

Tinea vs. Eczema

www.dermatlas.net www.health-pictures.com37

Case #10 What is your diagnosis?

www.dermatlas.org

38

Case #10: Tinea incognito

• Tinea corporis that has been inappropriately treated with steroids

• Original infection slowly extends

• Pruritic

• KOH prep

www.dermatlas.org 39

Case #11 Is This Tinea?

anagen.ucdavis.edu 40

Case #11 Pityriasis Rosea

anagen.ucdavis.edu

www.aafp.org

www.advancedskinwisdom.com

41

Case #12 Is This Tinea?

www.dermatlas.org42

Case #12 Majocchi granuloma

• Deep folliculitis due to a cutaneous dermatophyte infection

• Women who frequently shave their legs

• Use of potent topical steroids under occlusion

www.dermatlas.org

43

Case #13 Crusted papules and confluent vesicles. Is this Tinea?

www.dermatlas.org44

Case #13 Tinea Corporis

www.dermatlas.org45

Tinea Corporis

• T. rubrum

• Skin scraping from active border of lesion

• Multiple lesions look like a flower petal

www.dermatlas.org www.hardinmd.lib.uiowa.edu46

Tinea Corporis• Topical antifungals

• Do not use nystatin

• Extensive disease (or immunocompromised) treat orally

• Tinea faceii may require a longer course of treatment

www.dermatlas.orgwww.hardinmd.lib.uiowa.edu

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Tinea Corporis Revisited

• What is your differential diagnosis?

• What laboratory tests (if any) do you want to do?

• What is your management plan?

• How would you counsel families?

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Tinea Corporis Gladiatorum

• Fluconazole 200 mg weekly x 3 weeks – negative cultures by the third week of therapy (preferred)

• Topical antifungals also effective but need longer therapy

• Restrict sports participation 10-15 days

www.medscape.comwww.isport.com

Kohl TD, et al. PediatrInfect Dis J. 2000.Kohl TD, et al. Clin J Sport Med 1999.Beller M, et al. J Am Acad Dermatol 1994.

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Case #14 Which one is Tinea?

www.dermatlas.org

A B

C

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Case #14 Which one is Tinea?

www.dermatlas.org

A B

C

Tinea cruris Erythrasma

Candidiasis

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Tinea Cruris

• Usually occurs in adolescent males

• Usually is bilateral

• Spares the scrotum and penis

• Look for tinea elsewhere

• Topical antifungals of the imidazole or allylamine family

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Case #15 What is the diagnosis and treatment?

www.hardinmd.lib.uiowa.edu53

Case #15 Moccasin Type Tinea Pedis

www.hardinmd.lib.uiowa.edu54

Case #16 Is this Tinea?

www.onlinedermclinic.com55

Case #16 Psoriasis

www.onlinedermclinic.com56

Case #17 Tinea, Candida or Dyshidrosis?

www.phil.cdc.gov57

Case #17 Tinea Pedis

www.phil.cdc.gov58

Case #18 Is it Tinea?

www.dermatlas.org59

Case #18 Juvenile Plantar Dermatosis

www.dermatlas.org60

Case #19 Which is Pityriasis Versicolor?

www.medicinenet.com

www.graphicshunt.com

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Case #19 Which is Pityriasis Versicolor?

www.medicinenet.com

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www.dermatlas.org www.dermatlas.org

health-7.com

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Case #20 Is this Pityriasis Versicolor?

missinglink.ucsf.edu64

Case #20 Vitiligo

missinglink.ucsf.edu65

Case #21 Is this tinea in an 8 year old girl?

www.dermatlas.org 66

Case #21 Proximal subungual onychomycosis

www.dermatlas.org 67

Case #22 Tinea?

www.podiatry-arena.com68

Case #22 Candidiasis due to thumb sucking

www.podiatry-arena.com69

Case #23 Out, out *$#% spot. What is the cause of these nail changes?

www.webmdboots.com70

Case #23 Excessive Hand Washing due to Obsessive Compulsive Disorder

www.webmdboots.com71

New Recommendations -Ketoconazole

• Oral ketoconazole should not be used as first line therapy for any fungal infection.

• Ketoconazole should not be used for dermatophyte or candida infections.

• Risks of oral ketoconazole include: potentially fatal liver toxicity, adrenal insufficiency and serious drug interactions (QT prolongation).

• Topical ketoconazole may still be an appropriate choice for certain fungal infections.

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Summary

• SFIs are very common

• Many things can look like SFIs

• KOH prep, fungal cultures, and a Wood lamp can help with differentiation.

• Treatment for tinea capitis requires systemic therapy as does tinea unguium.

• Tinea pedis, manuum, and cruris are rare in prepubescent children

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References

• Kelly BP. Superficial Fungal Infections. Pediatrics in Review. 2012;33(4): e22-e37.

• Shy R. Tinea Corporis and Tinea Capitis Pediatrics in Review May 2007; 28:164-174.

• Weinstein A and Berman B. Topical Treatment of Common Superficial Tinea Infections. Am Fam Physician. 2002 May 15;65(10):2095-2103.

• Andrews MD and Burns M. Common Tinea Infections in Children. Am Fam Physician. 2008 May 15;77(10):1415-1420.

• Hainer BL. Dermatophyte Infections. Am Fam Physician.2003 Jan 1;67(1):101-109.

• Tully AS et al. Evaluation of Nail Abnormalities. Am Fam Physician April 15 2012 Vol. 85 No. 8

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