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9/2/2017 Fungal Skin Infections

Fungal Skin Infections

Penny F. Miller, BSc(Pharm), MA(Ed) Date of Revision: April 2016

Introduction

Superficial fungal infections are very common skin diseases affecting the majority of people at some point in their lifetime. Numerous fungi are capable of invading the , hair, nails and mucosa. Three genera of (Trichophyton, Epidermophyton and Microsporum) and yeastlike fungi, Candida or Malassezia furfur, are responsible for most infections.1,2 This chapter is divided into 3 sections: Infections, Yeast Infections: Pityriasis Versicolor (), and Yeast Infections: Cutaneous . Table 1 provides information on the characteristics and differential diagnosis of fungal skin infections.

1,3,4,5 Table 1: Characteristics and Differential Diagnosis of Fungal Skin Infections Condition Distribution Lesions Differential Diagnosis

Infections caused by dermatophytes (see Dermatophyte Infections)a

Tinea Beard Reddened areas (bacterial or candidal): small Barbae with perifollicular pustules around hair follicles. and Perioral dermatitis: papules and pustules pustules or surrounding the mouth and chin. Often swollen, inflamed includes a history of topical steroid use. See mass with pus and . hair loss. Acne vulgaris: pustules and blackheads affecting other areas of the face as well. See Acne. Acne : pustules and dilated or broken blood vessels with facial flushing involving cheeks. See Acne. : itchy vesicles and papules that become scaly, thickened and itchy when chronic. See Atopic, Contact, and .

Tinea Scalp May be quite Seborrheic dermatitis: yellow, greasy scales; Capitis varied from an often involves the hairline and face. See irregular-shaped Dandruff and Seborrheic Dermatitis. scaly patch with : honey-coloured crusts. See broken hairs or a Bacterial Skin Infections: Impetigo, Furuncles very inflamed soft, and Carbuncles. swollen mass called a kerion : symmetric distribution of silvery with hair loss. scales on reddened base. See Psoriasis. : small nonscaly patches of sudden hair loss. See Hair Care and Hair Growth.

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Condition Distribution Lesions Differential Diagnosis

Tinea Exposed Typically annular Psoriasis: thick and silvery scales often in a Corporis areas, (round), symmetrical arrangement. See Psoriasis. namely, erythematous Seborrheic dermatitis: yellow, greasy scales trunk, limbs patch; scaly with a affecting face, scalp and central chest. See and face vesicular border Dandruff and Seborrheic Dermatitis. and central clearing. Nummular eczema: smaller lesions usually affecting arms, legs and neck. Contact dermatitis: acute onset of itchy vesicles. See Atopic, Contact, and Stasis Dermatitis. Lyme disease: an initial erythematous circular lesion ( migrans) with a central clearing at the site of the tick bite. It lacks scales. See Bites and Stings. : acute onset of small scaled lesions in a Christmas tree distribution on the trunk. A single salmon-coloured patch that can be mistaken for appears on the trunk 2 weeks preceding this .

Tinea Symmetrical, Annular, Yeast Infections: Cutaneous Candidiasis: Cruris involving the erythematous Very red with poorly defined borders and has upper inner patch, with scales satellite lesions (vesicles, papules) outside thigh and and central the borders of the rash. The scrotum or penis groin clearing. The may be involved. The penis borders are well Erythrasma: Overgrowth of normal skin and scrotum defined. bacterium, Corynebacterium minutissimum; are usually presents as bilateral, irregular-shaped, brown spared plaques with scales found in intertriginous (skin fold) areas. Psoriasis: Symmetrical erythematous patches. See Psoriasis. Seborrheic dermatitis: Usually also involves the scalp, face and central chest. See Dandruff and Seborrheic Dermatitis.

Tinea Palmar Usually dry, mild Allergic or contact dermatitis: Acute onset and Manuum surface of the diffuse scales on very pruritic. See Atopic, Contact, and Stasis hand more an erythematous Dermatitis. often than base. usually involves other skin the back of areas. See Atopic, Contact, and Stasis the hand Dermatitis. Only one Psoriasis: Silvery scale. Involved nails are hand may be pitted. See Psoriasis. involved if it occurs in conjunction with tinea pedis

Infections caused by yeast (see Yeast Infections: Pityriasis Versicolor (Tinea Versicolor) and Yeast Infections: Cutaneous Candidiasis)

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Condition Distribution Lesions Differential Diagnosis

Yeast Back, chest, Multiple white-pink : Nonscaly, chalk-white lesions. Infections: upper arms to brown macules Seborrheic dermatitis: Yellow, greasy scales Pityriasis with an overlying involving the chest as well as the scalp. See Versicolor fine scale. Dandruff and Seborrheic Dermatitis. (Tinea Versicolor) Tinea Corporis: Well-defined borders.

Yeast Moist areas, A “beefy red” Tinea Corporis or : Well-defined Infections: skin folds, edematous area borders, no satellite lesions and the scrotum Cutaneous particularly with irregular is not involved. Candidiasis the groin edges and many Contact dermatitis: Will not have satellite small papules lesions. See Atopic, Contact, and Stasis (satellite lesions) Dermatitis. outside of the borders. Psoriasis: Symmetrical with well-defined borders and no satellite lesions. See Psoriasis.

a Tinea pedis is discussed in Athlete's Foot.

Dermatophyte Infections

Pathophysiology

The dermatophytes (an umbrella term that includes the genera Microsporum, Trichophyton and Epidermophyton) survive on dead keratin and do not invade living tissue. They affect the top layer of the epidermis, hair, nails and skin. Mucosal tissues are spared as they lack a keratin layer. Infections are transmitted through direct contact with infected persons or fomites, or occasionally infected soil or animals. Many predisposing factors can contribute to dermatophyte infections including conditions that increase moisture such as occlusive clothing or shoes and warm humid climates. Impaired immunity states (e.g., diabetes, HIV infection, chemotherapy) or genetic predisposition can also increase susceptibility to dermatophyte infection. Dermatophyte infections are commonly called ringworm or tinea which means fungus. Classification of tinea infections is based on their anatomic location rather than the fungal species.1,2 See Athlete's Foot for an in-depth discussion of tinea pedis.

Tinea Corporis

The classic presentation affects the smooth and bare (glabrous) areas of the trunk or limbs (excluding the face, hands, feet and groin) and begins as a flat, circular, scaly spot with a clearing central portion and a raised vesicular red border that advances circumferentially outward.1,2 (See photo, Tinea Corporis). Outbreaks of tinea corporis can occur in athletes who have skin-to-skin contact, such as wrestlers, where it is called tinea corporis gladiatorum.6,7

Photo 1: Tinea Corporis

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iStockphoto

Tinea Cruris

Tinea cruris or “jock ” involves the groin area (medial and upper parts of the thigh and the pubic area). Occasionally the anal cleft is affected. Unlike yeast infections, the scrotum and penis are spared. The infection occurs most often in men during the summer months. Often a reservoir for the infection is found on the feet.6 The lesions are usually bilateral, scaly with red-brown centres and a clearly defined, raised border. Pruritus is common.1,2,6

Tinea Manuum

An infrequent infection, tinea manuum may present as the classic pattern of limited erythema and scaling of the dorsal surface of the hands. Another form affecting the palmar hand surfaces produces diffuse dryness and hyperkeratosis of only one palm and is associated with tinea pedis, referred to as “two feet– one hand syndrome”.1,2

Tinea Capitis

Tinea capitis is a dermatophyte infection involving the scalp hair follicles and adjacent skin. Children are primarily affected. The most common form, “black dot tinea capitis”, often appears as an annular patch of itchy, scaling skin and hair loss. Hairs may eventually break off flush with the scalp surface, and debris in the follicle formerly occupied by hair appears as black dots.6

A less common type of tinea capitis contracted from cats and dogs, called “gray patch tinea capitis”, causes hairs in the affected area to turn gray as a result of loss of the hair sheath. The hairs break 1 or 2 millimetres above the scalp and the remaining hair stubs have a frosted appearance. The initial erythematous, scaling patch eventually subsides.

Tinea scalp infections may result in a hypersensitivity response where some patients develop a boggy inflammatory mass called a kerion that can result in scarring and permanent hair loss.

Tinea of the scalp is common in low socioeconomic and crowded environments, and the causative dermatophyte species vary among different countries. It is contagious via direct contact with infected persons, animals or contaminated clothing (e.g., hats, combs). Affected shedded hairs can harbour viable organisms for more than 1 year.1,2

Tinea Barbae

https://www.myrxtx.ca/print/new/documents/MA_CHAPTER/en/psc1168 4/16 9/2/2017 Fungal Skin Infections Coarse hair of the beard area and occasionally the mustache area in adult men may become infected with tinea. Typically this is a disease spread by animals to farm workers. The lesions are usually unilateral and may appear as typical scaly patches, follicular pustules or erythematous kerions.1,8

Tinea pedis/athlete's foot is discussed in Athlete's Foot.

Goals of Therapy

Eradicate causative organism Resolve the lesion and symptoms Prevent spread of the infection Prevent secondary complications

Patient Assessment

Assess patient's signs, symptoms and history including:

location and distribution of lesions aggravating factors, affect on activities and quality of life treatments attempted.

Characteristics and differential diagnosis of fungal skin infections can be found in Table 1. Topical antifungal treatment is effective for tinea corporis, tinea cruris and tinea pedis.4

Further assessment and/or treatment is required in those patients who are:5

experiencing an infection with unclear etiology immunocompromised (e.g., high dose or prolonged immunosuppressant drug therapy, advanced or uncontrolled diabetes, acquired immunodeficiency syndrome) experiencing tinea capitis, tinea barbae or tinea unguium (tinea of the nails) for systemic therapy since topical agents do not penetrate the hair follicles or nails well responding poorly or are intolerant to topical therapy experiencing an extensive, disabling, multifocal or inflammatory disease.

Topical therapy can be attempted for tinea manuum but because of the thickness of palmar skin and frequent association with infected fingernails, systemic therapy is often necessary.

Nonpharmacologic Therapy

Skin should be kept clean and dry to discourage fungal proliferation. Using an electric hairdryer on the cool setting will aid in drying the skin; avoid excessive rubbing with towels. Loose-fitting cotton clothing that allows adequate ventilation is encouraged. Nonmedicated powders can be used to absorb excess perspiration but cornstarch should be avoided since it may provide nourishment for fungi, thereby delaying resolution. Clothing and linens of the infected person should be laundered separately from those of other family members.3,4

Pharmacologic Therapy

Topical pharmacologic options available for the treatment of dermatophyte skin infections include: clotrimazole, ketoconazole, miconazole, terbinafine, tolnaftate and undecylenic acid.9 Topical antifungal treatment is effective for tinea corporis, tinea cruris and tinea pedis.10,11 The azoles (clotrimazole, ketoconazole, miconazole) are generally more effective than tolnaftate.12,13 A systematic review provided low-quality evidence that the topical azoles, terbinafine and ciclopirox achieve comparable clinical and https://www.myrxtx.ca/print/new/documents/MA_CHAPTER/en/psc1168 5/16 9/2/2017 Fungal Skin Infections mycological cure rates (all have an NNT of 2), but treatment duration is shorter with terbinafine.14 Terbinafine treatment for 1 week has produced similar cure rates to those reported for azole treatment for 4 weeks.15,16

Nystatin is ineffective in the treatment of dermatophytosis.9 Undecylenic acid is effective but there are insufficient data to compare its efficacy with that of other topical antifungals.13,17

Because they are rubbed into the skin, creams and lotions are considered to be more effective than sprays or powders, which are often used adjunctively. Lotions and powders are preferred in intertriginous areas where creams may be more occlusive and could lead to maceration. Liberal use of antifungal powder (e.g., tolnaftate) may help to absorb skin perspiration and prevent rubbing.

Optimal dosage regimens and durations of treatment for various fungal infections have not been determined due to lack of quality evidence, except in the case of terbinafine treatment of tinea corporis and tinea cruris which is recommended to be applied once daily for 1 week.14 Treatment with other antifungals is usually for a minimum of 2 weeks or until 1 week after the skin clears. Tinea cruris may respond in 2 weeks while tinea corporis typically requires 4 weeks of treatment.

Patients with widespread disease or persistent recurrence or who are immunocompromised may require treatment with systemic antifungals (e.g., oral terbinafine, itraconazole, fluconazole).

Before the advent of effective antifungal agents, keratolytics such as Whitfield's ointment (salicylic acid 3% and benzoic acid 6%) were used to produce desquamation of the fungus-containing epidermis. There is insufficient evidence to determine whether Whitfield's ointment is effective.14 The preparation can be irritating and if used over a large surface area, can lead to salicylate toxicity.18 Safer and more effective antifungal agents are preferred.

Topical corticosteroids may suppress the signs of the fungal infection by altering the appearance of the lesions, which are then called “tinea incognito”. Corticosteroids may also decrease the local immunologic reaction in persistent or recurrent infections or accelerate fungal growth resulting in the invasion of deeper tissues.19 However, in severe inflammatory cases, a low-potency topical corticosteroid may be used in combination with the topical antifungal for a short period until itch and irritation are relieved, after which the antifungal is continued alone for the remainder of the treatment period.14 The combination of corticosteroid and antifungal agent should be avoided in occluded areas and on the face.20

More information regarding topical therapy for fungal skin infections can be found in Table 3.

Monitoring of Therapy

Table 2 provides a monitoring plan for patients with fungal skin infections.

. . . . . Yeast Infections: Pityriasis Versicolor (Tinea Versicolor)

Pathophysiology

Pityriasis versicolor is an infection of the stratum corneum of the skin where sebaceous glands are present, especially the upper trunk. Since the term tinea refers to diseases caused by dermatophytes, the preferred term for this infection which is caused by yeast (and not dermatophytes) is is pityriasis (meaning scaling). Malassezia species (formerly called Pityrosporum orbiculare or Pityrosporum ovale) normally colonize the skin but cause an opportunistic infection in association with hereditary factors, immunodeficiency, malnutrition, oily skin, hyperhidrosis or use of corticosteroids or oral contraceptives.24 It affects about 3% of the general population and occurs most commonly in postpubertal adults and in warm, humid climates.25,26 The term versicolor denotes a variety of colours or changing colours.

The most common presentation is multiple white to reddish-brown macules that may coalesce to form large patches of various colours ranging from white to tan. A fine scale is apparent when scratched. The lesions https://www.myrxtx.ca/print/new/documents/MA_CHAPTER/en/psc1168 6/16 9/2/2017 Fungal Skin Infections tend to be darker than the surrounding skin in fair-skinned patients and lighter in dark-skinned patients. This is primarily a cosmetic problem where the lesions do not tan along with the surrounding normal skin. Recurrence rates are as high as 60–80%.27 (See photo, Pityriasis Versicolor). It is not considered contagious and is not due to poor hygiene.25

Photo 2: Pityriasis Versicolor

Science Photo Library

Goals of Therapy

Reduce or eliminate yeast elements Reduce or eliminate skin lesions and symptoms Prevent recurrences of infection

Patient Assessment

Characteristics and differential diagnosis of pityriasis versicolor can be found in Table 1. Patients with pityriasis versicolor usually have only cosmetic manifestations; pruritus is unusual. Self-care measures are appropriate for those with pityriasis versicolor. If the etiology of the infection is unclear, patients require further assessment to confirm diagnosis.26,28

Nonpharmacologic Therapy

Because yeasts thrive in moist environments, controlling excess heat and humidity may be helpful. Avoid application of oil to the skin, as Malassezia species can overgrow in such an environment.

Pharmacologic Therapy

More information regarding topical therapy for fungal skin infections can be found in Table 3.

Pityriasis versicolor can be successfully treated with a number of topical antifungal agents. Those used most commonly include: topical azoles (clotrimazole, ketoconazole, miconazole) and selenium sulfide 2.5% suspension.

Ketoconazole is the most extensively studied treatment approach. In one meta-analysis, topical ketoconazole was associated with a mycological eradication rate of 65% compared with 45% for https://www.myrxtx.ca/print/new/documents/MA_CHAPTER/en/psc1168 7/16 9/2/2017 Fungal Skin Infections terbinafine.29 Another study found ketoconazole 2% shampoo produced clinical cure rates of about 70%.30 Other azoles such as clotrimazole and miconazole, as well as the hydroxypyridone ciclopirox olamine, appear to have equivalent efficacy.29,31,32,33

Selenium sulfide suspension has traditionally been used and remains effective.34,35 It appears to be as efficacious as topical azoles and is more cost effective when the condition is widespread.25

Topical terbinafine has been used but has inferior evidence of efficacy.31,32,33

Other topical agents such as sulfur 2%, salicylic acid, zinc pyrithione 1% or 2% shampoo, benzoyl peroxide or extemporaneously compounded propylene glycol 50% have demonstrated limited efficacy in older trials.18,25,36,37,38

Oral therapy for patients with extensive infection or those who are intolerant of or unable to use topical therapy includes fluconazole (400 mg single dose or 300 mg weekly for 2 weeks) or itraconazole (200 mg daily for 5–7 days).25,26,32,39 Oral terbinafine is ineffective.31 Oral ketoconazole is not recommended due to the risk of hepatotoxicity.40

Preventive Therapy

Pityriasis versicolor has a high rate of recurrence; prophylactic treatment with topical or oral therapy on an intermittent basis is often necessary. Preventive treatment with once- to twice-monthly applications of selenium sulfide suspension can reduce the recurrence rate to less than 15%. Soaps or shampoos containing zinc pyrithione, salicylic acid or sulfur can also be used.9 Itraconazole 200 mg taken once monthly has also been used successfully.41

Monitoring of Therapy

A monitoring plan for patients with fungal skin infections is provided in Table 2. Resolution of scaling with pityriasis versicolor occurs promptly but the pigmentary changes may take weeks to months to resolve.

. . . . . Yeast Infections: Cutaneous Candidiasis

Pathophysiology

Candida yeasts are part of the normal flora of the oropharynx, intestinal tract and vagina. Infections arise when skin pH is increased, competing bacteria are removed by antibiotic treatments, glucose content in sweat increases (as in diabetes) and/or the surrounding environment is warm and moist.42,49 With impaired host defenses, infections may not only affect skin, nails or mucous membranes but may also rarely lead to systemic infections. Risk factors for cutaneous candidiasis include diabetes mellitus, malignancy, obesity, tropical environment, neutropenia, HIV infection, psoriasis, contact dermatitis and use of corticosteroids, antibiotics, cytotoxic or immunosuppressant agents.26,42,43 See photo, Candidiasis (Intertrigo).

Photo 3: Candidiasis (Intertrigo)

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Custom Medical Stock Photo/Science Photo Library The most common form of Candida albicans infection is intertrigo. Any skin fold area such as the gluteal fold, axillae (armpits), interdigital spaces, area under breasts or abdominal folds can be affected. These occluded areas create moist, warm environments ideal for C. albicans to flourish.26 Intertrigo is often colonized with bacteria which can lead to a secondary bacterial infection. This may result in , especially in patients with diabetes. In addition, the macerated skin can break down to cause fissures and ulcers, particularly in the deep folds of obese persons, leading to and disability.44,45

Candidal occurs in individuals who have their hands in water excessively. This condition consists of painful, reddened and swollen folds. Chronic infection can lead to transverse depressions of the nail plate and brownish discoloration and eventual separation of the nail plate from the nail bed (onycholysis).31,46 See Fungal Nail Infections ().

Goals of Therapy

Eradicate or reduce the yeast elements Eliminate or reduce lesions and symptoms Prevent spread of infection Prevent recurrences

Patient Assessment

A description and differential diagnosis of cutaneous candidiasis is provided in Table 1. The lesions are red, macerated patches with irregular scalloped borders. Papules and pustules called satellite lesions form outside of the borders. Symptoms of pruritus and soreness are common.9

Patients with widespread, systemic or persistent, recurrent infection or those who are immunocompromised require further assessment and/or treatment by an appropriate healthcare practitioner.

Nonpharmacologic Therapy

Hygiene measures such as daily bathing and avoidance of tight-fitting clothing aid in skin dryness, making a less desirable environment for yeasts. Useful measures for keeping the area dry include using cool water compresses (1 minute on, 1 minute off) for 15–20 minutes 3 times daily. The affected area should be air dried afterwards. Applying nonmedicated powders several times daily helps to reduce the moisture in skin folds and may help prevent the infection.47 Although 1 study did not find enhanced yeast growth,48 it is recommended that the use of cornstarch be avoided as this may promote the growth of Candida.6

https://www.myrPxthx.caar/pmrinat/nceow/ldoogcuimce Tntsh/MeAr_aCpHyAPTER/en/psc1168 9/16 9/2/2017 Fungal Skin Infections Pharmacologic Therapy

Many topical antifungal agents are effective for the treatment of cutaneous candidiasis including: azole antifungals (e.g., clotrimazole, ketoconazole, miconazole) nystatin, ciclopirox olamine and terbinafine (see Table 3). Tolnaftate and undecylenic acid are ineffective.

If there is pronounced inflammation, low- to mid-potency topical corticosteroids may be used sparingly once or twice daily for short periods (1–2 weeks) in conjunction with an antifungal.42,49 Stronger topical corticosteroids should be avoided as the occlusive effect of skin folds can increase absorption of the corticosteroid and accelerate skin atrophy and striae.46

Monotherapy with drying antifungal powders (e.g., miconazole spray) is less effective than monotherapy with antifungal creams or ointments due to comparatively decreased skin penetration.49

In widespread cutaneous disease and immunocompromised patients, oral azole antifungals (e.g., fluconazole, itraconazole) may be indicated. Oral terbinafine may not be as effective as oral azole antifungals.50

More information regarding topical therapy for fungal skin infections can be found in Table 3.

Monitoring of Therapy

Substantial improvement should be evident within 1 week of topical treatment. If topical corticosteroids are used (with antifungals) to control an inflammatory intertrigo, patients should be monitored closely for the development of a hidden bacterial infection or striae.45

Persistent candidal infection may be a sign of immunosuppression and these patients should undergo further investigation. Table 2 suggests a monitoring plan for patients with fungal infections.

. . . . . Natural Health Products

A number of herbal therapies have been used for a variety of fungal skin infections, including: goldenseal, purple coneflower (Echinacea), slippery elm bark. St. John's wort and (Melaluca). There is insufficient evidence to recommend the use of any of these herbs.51,52 One study of tea tree oil in tinea pedis showed some benefit.53

Monitoring of Therapy

Table 2: Monitoring of Therapy for Fungal Skin Infections Symptoms Monitoring Desired Actions Outcome

Lesions specific for Patient: Daily for lesions Clearing of all If no improvement or each fungal infection decreasing in size and lesions within 4 wk spreading of lesions by no more new lesions 1 wk, patient requries developing further assessment Healthcare Practitioner: and/or treatment. Next visit

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Symptoms Monitoring Desired Actions Outcome

Pain, swelling, Patient: Daily for any No development Patient requires further redness or drainage evidence of new onset of of these assessment and/or these symptoms symptoms treatment if these Healthcare Practitioner: symptoms develop, as Next visit they may indicate a bacterial superinfection.

Recurrent lesions Patient: Watch for No new lesions Patient requires further recurrence of any new assessment to rule out lesions for weeks or any underlying months following initial predisposing infection conditions. Emphasize preventive measures.

Inflammation being Patient: Daily Resolution of If no improvement or treated with inflamed areas lesion is worsening by corticosteroids 1 wk, patient requires further assessment and/or treatment. Emphasize correct use of cool compresses.

Allergy Patient: Daily while on No Stop therapy. Patient therapy requires further assessment and/or treatment.

Irritation caused by Patient: Daily while on Little to no Stop therapy if no topical agents therapy irritation that improvement in Healthcare Practitioner: subsides with irritation secondary to After 1 wk or next continued use the topical agent after pharmacy visit several doses.

Drug Table

Table 3: Topical Antifungal Agents21,22 cream, spray

Drug/C ostb Dosage Adverse Comments Effects

Drug Class: Allylyamines

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Drug/C ostb Dosage Adverse Comments Effects

terbinafine Tinea corporis/cruris: Once daily × Irritation, Effective for treatment of 1% cream, 1 wk burning, infections caused by spray Pityriasis versicolor: Once daily– erythema, dermatophytes or Lamisil BID × 1–2 wk contact yeasts. dermatitis In dermatophyte $$ Cutaneous candidiasis: Once infections: less frequent daily–BID × 2 wk application and shorter duration of treatment than other topical antifungals.

Drug Class: Azoles

clotrimazole Tinea corporis: BID × 4 wk Irritation, Effective in treatment of 1% cream Tinea cruris: BID × 2–4 wk erythema, infections caused by Canesten itching, dermatophytes or Topical, Pityriasis versicolor: BID × 2 wk stinging. yeasts. generics Cutaneous candidiasis: BID × 2–3 Rare: wk hypersensitivity $ reactions.

ketoconazole Tinea corporis: Once daily × 3–4 Itching, Effective for treatment of 2% cream, wk burning, infections caused by shampoo Tinea cruris: Once daily × 2–4 wk stinging, skin dermatophytes or Ketoderm, Pityriasis versicolor: Shampoo sensitivity, yeasts. Nizoral (used as a lotion): itching, contact Various regimens have Scrub into affected area then rinse dermatitis. been studied and found $ off after 5 min to be effective. Single dose or once daily × 3 days Regimens with longer Cream: Once daily × 2–3 wk durations of treatment may lead to longer time Cutaneous candidiasis: Once daily before recurrence.23 × 2–3 wk

miconazole Tinea corporis: BID × 4 wk Irritation, Effective for treatment of 2% cream Tinea cruris: BID × 2–4 wk erythema, infections caused by Micatin itching, dermatophytes or Derm, Pityriasis versicolor: BID × 2 wk stinging. yeasts. Monistat Cutaneous candidiasis: BID × 2–3 Rare: Derm, wk hypersensitivity generics reactions.

$

Drug Class: Hydroxypyridone

ciclopirox Tinea corporis/cruris: Cream or Itching, Effective for treatment of olamine 1% lotion: BID × 4 wk burning, infections caused by cream, Pityriasis versicolor: Cream or stinging, skin dermatophytes or lotion, lotion: BID × 2 wk sensitivity, yeasts. shampoo contact Loprox, Shampoo: Twice weekly × 2 wk dermatitis. Stieprox

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Drug/C ostb Dosage Adverse Comments Effects

Drug Class: Polyenes

nystatin 100 Cutaneous candidiasis: BID–TID × Rarely Ineffective in treatment 000 units/g 2–3 wk irritation. of dermatophytoses. cream, ointment generics

$

Drug Class: Thiocarbamates

tolnaftate 1% Tinea corporis or cruris: BID × 2–4 Local skin Ineffective in treatment Tinactin wk irritation. of cutaneous candidiasis. $

Drug Class: Other antifungal agents

selenium Pityriasis versicolor: Apply to Skin irritation. sulfide 2.5% affected areas and lather with a suspension small amount of water. Allow Selsun product to remain on skin for 10 min, then rinse the body $ thoroughly. Use once daily × 1–2 wk Prevention: Once to twice monthly

undecylenic Tinea corporis: BID × 4 wk Itching, Ineffective in treatment acid 1% gel, Tinea cruris: BID × 2 wk burning, of cutaneous liquid stinging. candidiasis. Fungicure

$

a Application instructions (unless otherwise stated): skin should be clean and dry. Apply in a thin layer to the affected area and 2–3 cm beyond its border, and rub in lightly. b Cost of smallest available pack size; includes drug cost only. Legend: $ <$10 $$ $10–20

Suggested Readings

Gupta AK, Einarson TR, Summerbell RC et al. An overview of topical antifungal therapy in dermatomycoses. A North American perspective. Drugs 1998;55:645-74.

Hainer BL. Dermatophyte infections. Am Fam Physician 2003;67:101-8.

Janniger CK, Schwartz RA, Szepietowski JC et al. Intertrigo and common secondary skin infections. Am Fam Physician 2005;72:833-8.

UpToDate. Goldstein AO, Goldstein BG. Dermatophyte (tinea) infections. Available from: www.uptodate.com. Subscription required. https://www.myrxtx.ca/print/new/documents/MA_CHAPTER/en/psc1168 13/16 9/2/2017 Fungal Skin Infections References

1. Verma S, Heffernan MP. Superficial fungal infection: dermatophytosis, onychomycosis, tinea nigra, piedra. In: Fitzpatrick TB, Wolff K et al., eds. Fitzpatrick's dermatology in general medicine. 7th ed. New York: McGraw-Hill; 2008. 2. Habif TP. Superficial fungal infections. In: Habif TP. Clinical dermatology: a color guide to diagnosis and therapy. 4th ed. New York: Mosby; 2004. 3. Hooper BJ, Goldman MP. Primary dermatologic care. St. Louis: Mosby; 1999. 4. Goldstein BG, Goldstein AO. Practical dermatology. 2nd ed. St. Louis: Mosby; 1997. p. 71-7. 5. Lookingbill DP, Marks JG. Principles of dermatology. 3rd ed. Philadelphia: Saunders; 2000. 6. UpToDate. Goldstein AO, Goldstein BG. Dermatophyte (tinea) infections. Available from: www.uptodate.com. Accessed July 2015. Subscription required. 7. Pleacher MD, Dexter WW. Cutaneous fungal and viral infections in athletes. Clin Sports Med 2007;26:397-411. 8. Hainer BL. Dermatophyte infections. Am Fam Physician 2003;67:101-8. 9. Kyle AA, Dahl MV. Topical therapy for fungal infections. Am J Clin Dermatol 2004:5:443-51. 10. Drake LA, Dinehart SM, Farmer ER et al. Guidelines of care for superficial mycotic infections of the skin: tinea corporis, tinea cruris, , tinea manuum, and tinea pedis. Guidelines/Outcomes Committee. American Academy of Dermatology. J Am Acad Dermatol 1996;34:282-6. 11. Gilbert DN, Chambers HF, Eliopoulos GM et al. Sanford guide to antimicrobial therapy. 45th ed. Hyde Park: Antimicrobial Therapy; 2015. 12. Crawford F, Hollis S. Topical treatments for fungal infections of the skin and nails of the foot. Cochrane Database Syst Rev 2007;(3):CD001434. 13. Hart R, Bell-Syer SE, Crawford F et al. Systematic review of topical treatments for fungal infections of the skin and nails of the feet. BMJ 1999;319:79-82. 14. El-Gohary M, van Zuuren EJ, Fedorowicz Z et al. Topical antifungal treatments for tinea cruris and tinea corporis. Cochrane Database Syst Rev 2014;8:CD009992. 15. Budimulja U, Bramono K, Urip KS et al. Once daily treatment with terbinafine 1% cream (Lamisil) for one week is effective in the treatment of tinea corporis and cruris. A placebo-controlled study. Mycoses 2001;44:300-6. 16. Schopf R, Hettler O, Brautigam M et al. Efficacy and tolerability of terbinafine 1% topical solution used for 1 week compared with 4 weeks clotrimazole 1% topical solution in the treatment of interdigital tinea pedis: a randomized, double-blind, multi-centre, 8-week clinical trial. Mycoses 1999;42:415-20. 17. Crawford F, Hart R, Bell-Syer S et al. Topical treatments for fungal infections of the skin and nails of the foot. Cochrane Database Syst Rev 2000;(2):CD001434. 18. Gupta AK, Einarson TR, Summerbell RC et al. An overview of topical antifungal therapy in dermatomycoses. A North American perspective. Drugs 1998;55:645-74. 19. Alston SJ, Cohen BA, Braun M. Persistent and recurrent tinea corporis in children treated with combination antifungal/corticosteroid agents. Pediatrics 2003;111:201-3. 20. Erbagci Z. Topical therapy for dermatophytoses: should corticosteroids be included? Am J Clin Dermatol 2004;5:375-84. 21. Gupta AK, Sauder DN, Shear NH. Antifungal agents: an overview. Part I. J Am Acad Dermatol 1994;30:677-98. 22. Gupta AK, Sauder DN, Shear NH. Antifungal agents: an overview. Part II. J Am Acad Dermatol 1994;30:911-33. 23. Gupta AK, Foley KA. Antifungal treatment for pityriasis versicolor. J Fungi 2015;1:13-29. 24. Gupta AK, Cooper EA, Ryder JE et al. Optimal management of fungal infections of the skin, hair, and nails. Am J Clin Dermatol 2004;5:225-37. 25. Schwartz RA. Superficial fungal infections. Lancet 2004;364:1173-82. 26. Janik MP, Heffernan MP. Yeast infections: candidiasis and tinea (pityriasis) versicolor. In: Fitzpatrick TB, Wolff K et al., eds. Fitzpatrick's dermatology in general medicine. 7th ed. New York: McGraw- Hill; 2008. 27. Faergemann J. The role of Malassezia yeasts in skin disease. Mikol Lek 2004;11:129-33. https://www.myrxtx.ca/print/new/documents/MA_CHAPTER/en/psc1168 14/16 9/2/2017 Fungal Skin Infections 28. eMedicine from WebMD. Burkhart CG, Gottwald L. Tinea versicolor. Available from: emedicine.medscape.com. Updated July 21, 2014. Accessed July 2015. Registration required. 29. Hu SW, Bigby M. Pityriasis versicolor: a systematic review of interventions. Arch Dermatol 2010;146 1132-40. 30. Lange DS, Richards HM, Guarnieri J et al. Ketoconazole 2% shampoo in the treatment of tinea versicolor: a multicenter, randomized, double-blind, placebo-controlled trial. J Am Acad Dermatol 1998;39:944-50. 31. Savin R. Diagnosis and treatment of tinea versicolor. J Fam Pract 1996;43:127-32. 32. Hald, M, Arendrup MC, Svejgaard EL et al. Evidence-based Danish guidelines for the treatment of Malassezia related skin diseases. Acta Derm Venereol 2015;95:12-9. 33. Drake LA, Dinehart SM, Farmer ER et al. Guidelines of care for superficial mycotic infections of the skin: Pityriasis (tinea) versicolor. Guidelines/Outcomes Committee. American Academy of Dermatology. J Am Acad Dermatol 1996;34:287-9. 34. Hull CA, Johnson SM. A double-blind comparative study of sodium sulfacetamide lotion 10% versus selenium sulfide lotion 2.5% in the treatment of pityriasis (tinea) versicolor. Cutis 2004;73:425-9. 35. Hersle K. Selenium sulphide treatment of tinea versicolor. Acta Derm Venereol 1971;51:476-8. 36. Gupta AK, Batra R, Bluhm R et al.. Pityriasis versicolor. Dermatol Clin 2003;21:413-29. 37. Fredriksson T, Faergemann J. Double-blind comparison of a zinc pyrithione shampoo and its shampoo base in the treatment of tinea versicolor. Cutis 1983;31:436-7. 38. Gupta A, Bluhm R, Summerbell R. Pityriasis versicolor. J Eur Acad Dermatol Venereol 2002;16:19- 33. 39. Gupta AK, Lane D, Paquet M. Systematic review of systemic treatments for tinea versicolor and evidence-based dosing regimen recommendations. J Cutan Med Surg 2014;18:79-90. 40. U.S. Food and Drug Administration. FDA Drug Safety Communication. FDA limits usage of Nizoral (ketoconazole) oral tablets due to potentially fatal liver and risk of drug interactions and adrenal gland problems. Available from: www.fda.gov/Drugs/DrugSafety/ucm362415.htm. Accessed: February 8, 2016. 41. Faergemann J, Gupta AK, Al Mofadi A et al. Efficacy of itraconazole in the prophylactic treatment of pityriasis (tinea) versicolor. Arch Dermatol 2002;138:69-73. 42. Guidelines of care for superficial mycotic infections of the skin: mucocutaneous candidiasis. Guidelines/Outcomes Committee. American Academy of Dermatology. J Am Acad Dermatol 1996;34:110-5. 43. Ramos-E-Silva M, Lima CM, Schechtman RC et al. Superficial mycoses in immunodepressed patients (AIDS). Clin Dermatol 2010;28:217-25. 44. Vanhooteghem O, Szepetiuk G, Paurobally D et al. Chronic interdigital dermatophytic infection: a common lesion associated with potentially severe consequences. Diabetes Res Clin Pract 2011;91:23-5. 45. eMedicine from Web MD. Selden ST. Intertrigo. Updated September 3, 2014. Available from : emedicine.medscape.com. Accessed July 2015. Registration required. 46. eMedicine from Web MD. Scheinfeld NS. Cutaneous candidiasis. Updated January 12, 2015. Available from : emedicine.medscape.com. Accessed July 2015. Registration required. 47. Hay RJ. The management of superficial candidiasis. J Am Acad Dermatol 1999;40:S35-42. 48. Leyden JJ. Corn starch, Candida albicans, and diaper rash. Pediatr Dermatol 1984;1:322-5. 49. UpToDate. Parker ER. Candidal intertrigo. Available from: www.uptodate.com. Accessed July 2015. Subscription required. 50. McClellan KJ, Wiseman LR, Markham A. Terbinafine. An update of its use in superficial mycoses. Drugs 1999;58:179-202. 51. Gardiner R, Kemper KJ. Herbs in pediatric and adolescent medicine. Pediatr Rev 2000;21:44-57. 52. Natural Medicines Comprehensive Database. Available from: www.naturaldatabase.com. Accessed July 2015. Subscription required. 53. Satchell AC, Saurajen A, Bell C et al. Treatment of interdigital tinea pedis with 25% and 50% tea tree oil solution: a randomized, placebo-controlled, blinded study. Australas J Dermatol 2002;43:175-8.

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