FUNGAL INFECTIONS OF THE SKIN

 

Patient diagnosed with fungal disease, requiring PO antifungal medication, should have baseline LFTs and if using terbinafine a CBC.

 

  1. TINEA
     
    1. 1. Corporis (ringworm) - round shape with central clearing and demarginated scaly edges. Local application of antifungals bid x 1-2 wk. Oral antifungal given if the previous are not helpful.
       
    2. 2. Pedis (athlete's foot) - present on soles and interdigital area of foot. May appears as blister or scale, wet or dry.  Treated with wet aluminum acetate (Burrow's solution) when maceration is present and topical antifungals (e.g. clotrimazole 1% cream) bid.  If lesion is chronic, oral antifungals in addition to topicals may be used (Itraconazole, Terbinafine).
       
    3. 3. Cruris (jock itch) - erythema and scaling of the well demarginated edges. Wood's lamp test is (-)ve . Treatment of  T. Cruris is a topical antifungal bid for 2 weeks.  Examine the feet!!! If pt has T pedis or T ungium, they will continue to infect the groin unless the feet are treated.
       
    4. Tinea Cruris must be differentiated from Erythrasma. This is a brownish-red confluent lesion that occurs mainly in obese patients and has predilection to groin, axilla, under the  breast. Lesion is due to bacteria (Corynebacterium) and Wood's lamp test is (+)ve, i.e. reveals  coral-red fluorescence. Treatment is with Erythromycin 250 mg qid x 14 days.
       
    5. Unguium - on fingernails or toenails. White to yellow discoloration. Treatment has variable efficacy and requires close follow up for the 3 – 4 month duration. Fingernails generally respond better than toenails.  Topical therapy cannot treat nail fungus.
       
    6. Capitis - can present as skin atrophy, alopecia or scaling lesion. Almost exclusively seen in children.  Wood's lamp is (-) in most cases in the US where T capitis is caused by T. tonsurans but may be (+) if organism is M canis.  KOH is (+)ve. Treatment c/o oral antifungal (Griseofulvin 15 to 20 mg/kg/day for 6 –8 weeks) and Selenium shampoo.
       
    7. arbae - presents as pustules to the shaving area and may be confused with  folliculitis. Topical antifungals are not effective. Oral antifungals are used.
       
  2. PITYRIASIS
     
    1. Versicolor (Tinea Versicolor) -brownish color with scaly edges easily i.d. on Wood's lamp and KOH (hyphae and spores).  Treat with topical antifungals bid for two weeks or selenium sulfide 2.5% lotion for 10 min/qd for 1wk.  If recurrent or very extensive may give oral antifungal.  Patients should be instructed to wash body with a selenium sulfide shampoo q wk for prevention of recurrences.
       
    2. Rosea - this is not a fungal infection. Viral etiology is probable. Pt has "herald patch" on the back that precedes the exanthema by 1 to 2 weeks.  Rash consists of oval macules with an erythematous border with fine scale that are present within natural skin lines (Christmas tree distribution). Treatment is symptomatic. Antihistamines and topical steroids help alleviate pruritus.   Eruption is self-limited and resolves in about 6 weeks.

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