Fungal

Eugene Sanik, D.O. 3rd Year Resident Disclosures

• No financial relationships to disclose Learning Objectives

• Understand the causes of fungal infections • Illustrate and recognize their clinical presentations • Review latest evidence-based treatment guidelines Introduction to

• Fungi first appeared 1.5 billion years ago • Among earliest organisms domesticated by humans • Serious problem only since 20th century • 1.5 million fungal known • Less than 100 are pathogenic to humans • Except for , not contagious Classification of Fungal Diseases

• Superficial - Do not have ability to invade skin, , or nails

• Cutaneous - Dermatophytes

• Deep - Localized subcutaneous (implantation or dermal spread) - Dimorphic systemic (hematogenous spread) - Opportunistic (immunocompromised patients) Classification of Fungal Diseases

• Superficial - Do not have ability to invade skin, hair, or nails

• Cutaneous - Dermatophytes

• Deep - Localized subcutaneous (implantation or dermal spread) - Dimorphic systemic (hematogenous spread) - Opportunistic (immunocompromised patients) Superficial Fungal Infections

• Pityriasis versicolor • • Black • Pityriasis Versicolor

Treatment of Pityriasis Versicolor

• Topical very effective against • Oral fluconazole and as effective with lower recurrence • Oral ketoconazole not recommended (FDA warning) • Oral terbinafine not effective Tinea Nigra

Hortaea werneckii (melanin-producing ) Black Piedra and White Piedra

Piedra Hortae beigelii Differential Diagnosis of Piedras

Trichomycosis axillaris Head Lice Corynebacterium Pediculus humanus capitis Classification of Fungal Diseases

• Superficial - Do not have ability to invade skin, hair, or nails

• Cutaneous - Dermatophytes

• Deep - Localized subcutaneous (implantation or dermal spread) - Dimorphic systemic (hematogenous spread) - Opportunistic (immunocompromised patients) Cutaneous Mycoses

• Dermatophytoses of skin, hair, and nails • of skin, mucous membranes, and nails • Do not invade subcutaneous tissue

• Microsporum, , and Epidermophyton

• Most common causes: • – T. tonsurans • – T. rubrum • – T. rubrum • Tinea pedis – T. rubrum • Bullous tinea pedis – T. mentagrophytes • White superficial – T. mentagrophytes • Distal & proximal subungual onychomycosis – T. rubrum

• betamethasone did not compromise the effects of clotrimazole

• clinical endpoints consistently favored the combination drug, which relieved symptoms more rapidly • Once daily application is as effective as twice daily, with better compliance • Azoles, benzylamines, and allylamines show no difference in clinical effectiveness • Azole-corticosteroid combination achieved higher clinical cure rates than azole monotherapy • Duration inadequately addressed • When given for 2 weeks, Terbinafine has statistically significantly better cure rates than Itrazonazole, Fluconazole, Ketoconazole, and . • Itraconazole for 4 weeks as effective as 2 weeks of Terbinafine Tinea Treatment: Summary

TOPICAL • Any topical antifungal, once daily for 2-4 weeks - optional: add moderate potency topical steroid

ORAL • Terbinafine 250mg once daily for 2 weeks Fungal

• Tinea capitis • • Majocchi’s

• Require treatment with oral

• Fungi thought to have evolved to survive harsh winters and resist temperatures < 50°C, but authors conjecture: - Fungi may be secondarily destroyed as tissue necrosis occurs - Rapid cooling forms intracellular ice crystals and disrupts the cell membrane - rewarming damages the cell membrane again and stimulates the immune system

Dermatophytid (“id”) reaction

• Hypersensitivity reaction to antigens • Classic presentation is vesicular eruption on the sides of fingers with inflammatory tinea pedis • Examine the feet in all cases of suspected hand eczema! • Eruptions can also be urticarial and panniculitic Onychomycosis (Tinea Unguium)

• T. rubrum (most common), yeast, nondermatophyte • Superficial white onychomycosis • Distal lateral subungual onychomycosis • Proximal subungual onychomycosis

Onychomycosis Treatment

Mycologic Cure Rate (negative KOH and culture) Topical (Penlac) 29% Topical Tavaborole (Kerydin) 35% Topical Efinaconazole (Jublia) 55%

Oral Fluconazole (Diflucan) 48% Oral Itraconazole (Sporanox) 54% Oral Terbinafine (Lamisil) 77% Candidiasis

• C. albicans inhabits skin, GU, and GI tract • Opportunistic pathogen • Frequently infects intertriginous areas • Predisposing factors include hygiene, diabetes, antibiotic use, and • Clinical spectrum can range from short-lived superficial to overwhelming systemic infections

Candidiasis Treatment

TOPICAL • Any topical antifungal for cutaneous candidiasis • Rinse-and-spit with fluoconazole solution is superior to nystatin and amphotericin B for thrush

ORAL • Fluconazole 50-100mg/day (95%+ success rate) Classification of Fungal Diseases

• Superficial - Do not have ability to invade skin, hair, or nails

• Cutaneous - Dermatophytes

• Deep - Localized subcutaneous (implantation or dermal spread) - Dimorphic systemic (hematogenous spread) - Opportunistic (immunocompromised patients) Deep Fungal Infections

Subcutaneous Systemic Opportunistic

Sporotrichosis Phaeohyphomycosis Chromomycosis Mycetoma (Madura foot) Penicilliosis

• DDX: Atypical mycobacterium, Nocardia, Leishmania, Tularemia Chromomycosis

• (most common cause) Madura Foot (Mycetoma) Lobomycosis

• loboi • “keloidal blastomycosis” • Dolphins Histoplasmosis Blastomycosis

Coccidiomycosis Paracoccidiomycosis Opportunistic Systemic

• Disseminate in immunocompromised patients - Organ transplant, post-chemotherapy, HIV • Candida species most common Mucormycosis

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