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Fungal Infections – an Overview REVIEW Fungal infections – An overview Natalie Schellack, BCur, BPharm, PhD(Pharmacy); Jade du Toit, BPharm; Tumelo Mokoena, BPharm; Elmien Bronkhorst, BPharm, MSc(Med) School of Pharmacy, Faculty of Health Sciences, Sefako Makgatho Health Sciences University Correspondence to: Prof Natalie Schellack, [email protected] Abstract Fungi normally originate from the environment that surrounds us, and appear to be harmless until inhaled or ingestion of spores occurs. A pathogenic fungus may lead to infection. People who are at risk of acquiring fungal infection are those living with human immunodeficiency virus (HIV), cancer, receiving immunosuppressant therapy, neonates and those of advanced age. The management of superficial fungal infections is mainly topical, with agents including terbinafine, miconazole and ketoconazole. Oral treatment includes griseofulvin and fluconazole. Invasive fungal infections are difficult to treat, and are managed with agents including the azoles, echinocandins and amphotericin B. This paper provides a general overview of the management of fungus infections. © Medpharm S Afr Pharm J 2019;86(1):33-40 Introduction more advanced biochemical or molecular testing.4 Fungi normally originate from the environment that surrounds Superficial fungal infections us, and appear to be harmless until inhaled or ingestion of spores Either yeasts or fungi can cause dermatomycosis, or superficial occurs. Infection with fungi is also more likely when the body’s fungal infections.7 Fungi that infect the hair, skin, nails and mucosa immune system becomes weakened. A pathogenic fungus may lead to infection. The number of fungus species ranges in the can cause a superficial fungal infection. Dermatophytes are found millions and only a few species seem to be harmful to humans; the naturally in soil, human skin and keratin-containing structures, 3 ones found mostly on the mucous membrane and the skin have which provide them with a source of nutrition. been noted to cause fatal infections.1 Table I. The classification of superficial fungal infections according People who are at risk of acquiring fungal infection are those to the site of infection8 living with human immunodeficiency virus (HIV), cancer, receiving Classification Common names immunosuppressant therapy, neonates and those of advanced Scalp Tinea capitis Ringworm of the head age.2 In crowded living conditions and low income communities Beard Tinea barbae – the prevalence of fungal infections is much higher.3 Face Tinea facie Ringworm of the face Skin (body) Tinea corporis Ringworm Fungi are divided into yeasts and moulds, and some can be a Tinea versicolor – combination of both, which are called dimorphic. Some fungi Hands Tinea manuum – 4 are also seen as atypical. Moulds are filamentous fungi that are Nails Tinea unguium – multicellular in structure. They grow best in warm and damp Groin Tinea cruris Jock itch conditions. They can reproduce and survive in extreme conditions Feet Tinea pedis Athletes foot by producing spores.5 Yeasts are unicellular and mainly reproduce asexually by budding.6 Dimorphic fungi appear to be in a mould form between 25 °C to 30 °C, however, at body temperature (37 °C) Overview and management of superficial they appear as a yeast or yeast-like structure.5 fungal infections Identification of the genus is made by examining the colony under An overview of different fungi causing superficial fungal infections a microscope, whereas the identification of the species requires and the management thereof is set out in Table II. S Afr Pharm J 33 2019 Vol 86 No 1 Table II. Overview and management of superficial fungal infections REVIEW Aetiology Transmission Causative agents Diagnosis Signs and symptions Management Tinea capitis • Affects children between 3–9 years. • Direct contact • Trichophyton tonsurans • Signs and • Itching • Griseofulvin, terbinafine, fluconazole, • Adults are usually asymptomatic • Sharing of combs, • Microsporum canis symptoms • Scaly patches with no itraconazole.3,11 Decreases viable carriers. hairbrushes, and hats. • Microscopy hair spores on patients and asymptomatic • Prevalent in crowded and poverty- • Cats and dogs • Cultures9,10 • Black dots on area of hair carriers. stricken areas. loss • All patients and household contacts • Cervical and suboccipital should be treated with ketoconazole, lymphadenopathy selenium sulphide, and povidone iodine.3,11 Tinea barbae • Affects mostly males on the beard/ • Farm and domestic • Trichophyton verrucosum • Appearance • One or more flat circular • Terbenafine, itraconazole. moustache and neck areas. animals can spread it to • Trichophyton • Microscopy erythematous patch with • Topical creams are ineffective.11,12 humans mentagrophytes • Culture raised borders • Scaly and itchy • Sometimes causes hair loss Tinea • Also referred to as onychomycosis • Trichophyton rubrum • Microscopy • Thickened • Local treatment: amorolfine 5% nail S Afr Pharm J Pharm S Afr unguium (fungal infection that affects the nail • Trichophyton • Cultures • Brittle lacquer. unit). mentagrophytes • Periodic acid– • Discoloured nails • Topical creams are ineffective in • It affects children, adolescents and Schiff (PAS) stain nail infections due to inadequate adults. penetration in the nail. • Infection of toenails is more prevalent • Oral: terbinafine (first-line), than fingernails. itraconazole and fluconazole.9,11 34 • Onychomycosis takes about 3–6 months to treat. 2019 Vol 86 No1 Vol 2019 Tinea pedis • Commonly seen in young adolescent • Trichophyton rubrum • Clinical • Occurs within interdigital • Topical: miconazole, clotrimazole and males. (common) examination spaces and soles of the terbinafine. • Affects males more than females. • Trichophyton • Microscopic feet • Oral: terbinafine, griseofulvin, or • Fungal growth is promoted by moisture mentagrophytes examination • Maceration, soggy or dry itraconazole.11 and warmth. • Epidermophyton • Cultures10,13 • Scaly and itching of the • Risk of acquiring infection from locker floccosum affected area, associated room floors, swimming pools athletic with burning shoes and sports equipment. • Malodour Tinea cruris • Commonly affects men more than • Occurs in warm and • Trichophyton rubrum • Clinical • Well-demarcated • Topical: miconazole, terbinafine or women. moist climates, is • Trichophyton presentation borders, itching clotrimazole and clotrimazole 1% and • Involves the groin area, portion of the prevalent in athletes, mentagrophytes • Erythema hydrocortisone 1% 30 g (if there is upper thigh, usually doesn’t affect the overweight people, • Epidermophyton • Scaling of patches10 inflammation). scrotum but can spread to the buttocks. excessive sweating floccosum (Kaushik et al, 2015) • Oral: terbinafine, griseofulvin, or itraconazole.11 Tinea corporis • Occurs at any age, and involves the face • Person-to-person • Trichophyton tonsurans • Patient history • Starts with one or more • Topical: miconazole, terbinafine and (occasionally), shoulders, trunk, legs contact (common) • Physical circular plaques with a clotrimazole. and arms. • Trichophyton rubrum examination raised border • Oral: terbinafine, fluconazole and • Microsporum canis • Microscopy9,10 • Itchy itraconazole.11 • Epidermophyton • Erythematous scaly floccosum spots; plague size • Ranges from 1–5 cm Table II. Overview and management of superficial fungal infections (Cont.) REVIEW Aetiology Transmission Causative agents Diagnosis Signs and symptions Management Tinea cruris • Commonly affects men more than • Occurs in warm and • Trichophyton rubrum • Clinical • Well-demarcated • Topical: miconazole, terbinafine or women. moist climates, is • Trichophyton presentation borders, itching clotrimazole and clotrimazole 1% and • Involves the groin area, portion of the prevalent in athletes, mentagrophytes • Erythema hydrocortisone 1% 30 g (if there is upper thigh, usually doesn’t affect the overweight people, • Epidermophyton • Scaling of patches10 inflammation). scrotum but can spread to the buttocks. excessive sweating floccosum (Kaushik et al, 2015) • Oral: terbinafine, griseofulvin, or itraconazole.11 Tinea • Affects the palmar and interdigital areas • Direct contact with • Trichophyton rubrum • See tinea pedis • Dry, scaly, sometimes • See tinea pedis. manuum of the hand/s, and can appear at the infected person, animal (common) itchy diffuse same time as tinea pedis. or soil • Trichophyton hyperkeratosis • It is commonly referred to as the ‘one mentagrophytes hand two feet syndrome’. • Epidermophyton floccosum S Afr Pharm J Pharm S Afr Table III. Overview and management of invasive fungal infections Infection Aetiology Causative agents Signs and symptions Diagnosis Management Yeasts: 36 Invasive • Candida species are • Candida albicans • Asymptomatic • Culture from sterile • Fluconazole is first-line treatment of invasive candidiasis infections for those who candidiasis part of the normal • Candida krusei • Fever, chills and site such as spinal fluid are not critically ill, and have not had previous exposure to azoles.15 5 2019 Vol 86 No1 Vol 2019 flora, thus any breach • Candidia glabrata reduced oxygenation or bone marrow • C. krusei displays intrinsic resistance towards fluconazole. in the superficial 17 • Candidia parapsilosis • Symptoms of sepsis • Cultures taken from • Voriconazole is choice of drug for fluconazole-resistant species such as C. krusei. surface can lead to respiratory, digestive 15 • Candida tropicalis may be present Itraconazole is second-line treatment for invasive
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