Fungal Skin Infections Aditya K. Gupta, MD, PhD, FRCP(C), FAAD,*† Melissa A. MacLeod, MSc,† Kelly A. Foley, PhD,† Gita Gupta, MD,‡ Sheila Fallon Friedlander, MDx *Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada †Mediprobe Research, Inc, London, Ontario, Canada ‡Wayne State University, Detroit, MI xDermatology and Pediatrics, Pediatric Dermatology Training Program, University of California at San Diego School of Medicine, Rady Children’s Hospital, San Diego, CA Education Gap Most pediatricians appear to be familiar with candidal diaper dermatitis, but there is a lack of knowledge about other, less common fungal infections in children. Objectives After completing this article, readers should be able to: 1. Recognize the clinical presentations of different fungal infections in children. 2. Know the differential diagnosis of various fungal skin infections. 3. Know what diagnostic tests can be used to confirm infection. 4. Be aware of available treatment options and how to manage the infections appropriately. AUTHOR DISCLOSURE Dr A. Gupta has disclosed that he is on the Speakers’ Bureaus of Valeant, Janssen, Novartis, and Bayer; he is a consultant for Anacor, Sandoz, and Moberg INTRODUCTION Pharma; and he is a clinical trials investigator for Valeant Canada, Nuvolase, Bristol Meyers Candidal diaper dermatitis is the most common fungal infection of childhood. Squibb, Eli Lilly, Merck, Novartis, Janssen, and This yeast infection almost always secondarily invades diaper-area skin that has Allergan. Ms MacLeod and Dr Foley have disclosed that they are employees of been damaged by an irritant contact dermatitis from maceration, urine, and/or Mediprobe Research, Inc, which conducts stool. Children in the preschool-age group who no longer wear diapers are clinical trials under the supervision of Dr. A. more likely to develop tinea infections, particularly tinea capitis. Tinea refers to Gupta. Drs G. Gupta and Fallon Friedlander have disclosed no financial relationships dermatophyte infections in the epidermis and areas high in keratin, such as the relevant to this article. This commentary does hair and nails. In prepubertal children, tinea capitis and tinea corporis are most contain a discussion of an unapproved/ common; in adolescence, tinea pedis (TP), tinea cruris, and tinea unguium investigative use of a commercial product/ (onychomycosis) are more common. (1) Yeast infections other than candidal device. diaper dermatitis, including pityriasis versicolor (PV) (formerly known as tinea ABBREVIATIONS versicolor) and mucocutaneous candidiasis (MC), may also occur. Chronic MC CMC Chronic mucocutaneous candidiasis (CMC) is a rare, usually inherited disorder. PVis a common infection in adolescents HIV Human immunodeficiency virus and adults that usually affects the sebum-prone areas (face, chest, back). Fungal id Dermatophytid KOH Potassium hydroxide infections can be a substantial source of morbidity in the pediatric population, MC Mucocutaneous candidiasis accounting for about 15% of pediatric outpatient visits in the United States. (2) PCR Polymerase chain reaction This article reviews the epidemiology and clinical presentations of tinea in- PV Pityriasis versicolor fections (capitis, corporis, pedis, cruris, unguium), PV, and MC in children. The TP Tinea pedis 8 Pediatrics in Review Downloaded from http://pedsinreview.aappublications.org/ by guest on February 27, 2017 differential diagnosis and methods for confirming diagnosis audouinii was the major source of tinea capitis in North based on clinical presentation are discussed. Recommended America. (6) Subsequently, epidemiology shifted and cur- treatment options for each typeofinfectionarespecified rently about 95% of tinea capitis in North America is caused (Table 1). Of note, many recommendations are off-label, as the by Trichophyton species (predominantly T tonsurans). Micro- safety of many agents has not been established for children. sporum species, (7) usually transmitted by pets, causes the remainder of the cases. However, in central and southern Europe as well as in developing countries, M canis is the TINEA CAPITIS most common causal species. (7) It is important for clini- Epidemiology cians to be aware of the predominant pathogen in their Tinea capitis, a communicable fungal infection of the scalp communities because this has implications for optimal and hair shaft, is the most common fungal infection in treatment choice. children. (3) The prevalence ranges from less than 1% in western Europe to as much as 50% in Ethiopia where the Clinical Presentation infection is endemic. (4) In North America, the prevalence is Tinea capitis may be difficult to diagnose because clinical estimated to range from 3% to 8% in children. It is unclear signs may be subtle and can vary substantially from child to whether it is increasing, but immigrant populations, par- child. Symptoms may include scaling, alopecia, broken hair ticularly those from Africa, are at higher risk. (5) Tinea shafts at the scalp, erythema, pustules, and/or large boggy capitis most often affects children between ages 3 and 9 scalp masses. Patients may complain of pruritus or tender- years, those of African heritage, those of low socioeconomic ness, and occipital and posterior cervical adenopathy are often status, and those residing in urban settings and/or crowded present (Fig 1). A nonspecific, eczematous, pruritic eruption living conditions. (1)(4) Prior to the 1950s, Microsporum may be noted on the trunk and extremities either before or TABLE 1. Summary of Treatment Recommendations for Tinea Infections in Children* INFECTION FIRST-LINE TREATMENT ALTERNATIVES TERTIARY OPTIONS Tinea capitis Oral antifungals: terbinafine, griseofulvin Adjunctive agents: selenium sulfide Itraconazole, fluconazole (Microsporum canis) shampoo, ketoconazole shampoo Tinea corporis/ Topical antifungals: butenafine, ciclopirox, Oral antifungals (resistant or severe Tinea cruris clotrimazole, miconazole, terbinafine, infection): terbinafine, griseofulvin, tolnaftate itraconazole, fluconazole Tinea pedis Topical antifungals: butenafine, clotrimazole, Topical antifungals: ciclopirox Urea cream miconazole, terbinafine Oral antifungals (resistant or recurrent infection): terbinafine, itraconazole, fluconazole Pityriasis versicolor Zinc pyrithione, selenium sulfide, or Oral antifungals (resistant, recurring, serious ketoconazole shampoos infection): itraconazole, fluconazole Other topical antifungals: clotrimazole, ketoconazole, miconazole, terbinafine Tinea unguium Topical antifungals: ciclopirox, efinaconazole, Oral antifungals (severe infection): Itraconazole, fluconazole (onychomycosis) tavaborole terbinafine MC – Oropharyngeal Mild: Clotrimazole troches, miconazole, Fluconazole-resistant infections: Amphotericin B candidiasis nystatin suspension itraconazole, posaconazole suspension Moderate-severe: fluconazole MC – Esophageal Fluconazole Intravenous fluconazole, echinocandin Amphotericin B candidiasis/CMC (anidulafungin, caspofungin, micafungin) Fluconazole-resistant infections: itraconazole, voriconazole, amphotericin B, or an echinocandin *Some agents may be used off-label usage in children or be approved for particular ages. See Table 3 for details. CMC¼chronic mucocutaneous candidiasis, MC¼mucocutaneous candidiasis. Vol. 38 No. 1 JANUARY 2017 9 Downloaded from http://pedsinreview.aappublications.org/ by guest on February 27, 2017 during treatment; this is known as an autoeczematization or Diagnostic Tests dermatophytid (id) eruption. Tinea capitis typically presents Clinical diagnosis should be confirmed via either potassium as 1 of 6 clinical patterns: gray type, black dot, diffuse scale, hydroxide (KOH) microscopy or culture. Culture is prefer- pustular type, favus, and kerion. Gray type is characterized able because speciation is provided, allowing determination by circular patches of alopecia and marked scaling with or of the most appropriate treatment option. Polymerase chain without erythema. (4)(8) Black dot presents with patches of reaction (PCR) evaluation of dermatophyte infections has alopecia and is dotted with broken hair stubs (“black dots”). become much more cost effective and “kits” are now avail- Diffuse scale is characterized by widespread scaling and is able, which is likely to lead to wider availability of this dandruff-like, with or without erythema. Pustular type pre- exceedingly rapid and sensitive test in the next few years. sents as alopecia with scattered pustules, scaling, and lymph- At this time, PCR appears more sensitive for nail and skin adenopathy. Favus has distinctive yellow cup-shaped crusting infections than for hair samples. (12) Wood’s light exami- around the hair called scutula, along with patchy alopecia nation causes Microsporum species to fluoresce, but most and generalized scale; this variant is extremely rare and not infections in North America are caused by Ttonsurans,which usually seen in the United States. Kerion is a boggy tumor does not fluoresce. (13) Pathogens that do fluoresce include with pustules, lymphadenopathy, erythema, and tenderness. Microsporum species and Trichophyton schoenleinii. (7) Under (4)(8) It is the most severe inflammatory response and can microscopic analysis, an infected hair can present with be caused by either Ttonsuransor Mcanis. (9) When chil- mycelium (mass of fungal hyphae) on the external surface dren present without distinguishing characteristics of tinea of the hair shaft (ectothrix) or with mycelium within the hair capitis such as black