Proceeding S.Z.P.G.M.I vol: 100-2) !!)!)G, pp. I- l l. Fungal Infections in Children My coses Aysha Maqbool, Asim Maqbool, Sajid Maqb-ool Depa1tment of Paediatrics, Shaikh Zayed Hospital, Lahore. • SUMMARY Superficialfungal infections in childhood are a frequent presentation in the paediatricoat patient clinic. Three groups of fungi are generally pathogenic in man. In the dernw.tophytes, children suffer mostly from scalp infections i.e. tinea capitis, which if not treated can lea.ti to permanent alopecia. In the second group, tinea versicolor is a spreading infection of the trunk resulting in macules of various shapes and sizes. Candidiasis in the third group constitutes by far the largest group of infections in children from the neonatal age to adolescence. The spectrum varies from the rare chronic mucocutaneous candidiasis to diaper candidiasis, one of the most common fungal infections in toddlers. This article, deals with the superficial infections in children, their epidemiology, clinical features, diagnostic tests and treatment modalities, with specialreference to drug regimens and laboratory tests in Pakistan. INTRODUCTION epidermophyton and microsporum are the 3 genera of dermatophytes that infect man. Tinea versicolor is acteria and viruses constitute a large majority caused by Malassezia fmfur and candidiasis by B of pathogenic organisms that invade the human C.albicans. Subcutaneous mycotic infection m tissue. Fungi constitute a smaller group that are less children is caused by C. albicans presenting as common, however, no less pathogenic and invasive chronic mucocutaneous candidiasis. Systemic than bacteria. mycoses include histoplasmosis, aspergillosis, Fungi constitute a large group of euka1yotic blastomycosis and mucormycosis amongst others. organisms which depend for their nutrients on Various fungal dermatological presentations previously elaborated organic materials on which will be discussed in this article with an emphasis on they live as saprophytes or parasites. They show updated therapy. considerable diversity in size and morphology. Only some 180 of the very large familyof fungi are capable A) SUPERFICIAL MYCOSES of causing disease in man. The disease caused by fungi can be divided into 3 main groups; I. DERMATOPHYTOSES A) Superficial mycoses affecting the keratinous This group of fungal infection commonly tissues of the skin, hair, and nail. reffered to as ring worm or Tinea infection includes B) Subcutaneous mycoses which involve the skin, cutaneous infection caused by 3 genera of fungi, 10 subcutaneous tissue and bone. Trichophyton, Epidermophyton and Microsporum • C) Systemic mycoses usually initiating in the lung These fungi may be a1thropophilic (person to person and sometimes becoming widely disseminated. contact e.g. T. Tonsuram) zoophilic (animal contact e.g. M Canis) or geophilic (soil contact e.g. M. In children, fungi from all 3 groups are gypseum). pathogenic. In superficial fungi, Dermatophytic infection, Tinea versicolor and candida infections are 1. Tinea Capitis 3 major pathogenic groups. Trichophyton, Tinea capitis is the most common cutaneous 1 Fungal Infections in Children 92 Differential Diagnosis: Non inflammatory inflammation . Intra lesional steroids can be tinea capitis may be confused principally with injected in lesions < 3 cm in diameter. For sebborhoeic dermatitis, alopecia areata, larger areas of scalp involvements, prednisolone trichotillomania, and traction alopecia. 1-2mg/kg/day for 3 weeks may be required. Inflammatory tinea ca pi tis may be misdiagnosed as impetigo, follicultitis or 2. Tinea Corporis: dissecting cellulitis. Superficial tinea infection of the' non-hairy skin �I is termed tin ea corporis. M. canis and T. Treatment: Systemic therapy with rubrum are the dermatophytes most commonly 92 griseofulvin 12-20mg/kg for 6 weeks to 3 responsible for tinea corporis . months is the treatment of choice66• For Although the infection may involve people of all children unable to swallow tablets, griseofulvin ages, the disorder is seen most commonly in suspension may be recommended or the children, or in those with systemic diseases grisactin capsules can be pulled apart and the such as diabetes, leukemia, or other debilitating powder dispensed in milk or other suitable illnesses. William J Barson 6 repo1ted one such vehicles··. case where a patient with Systemic Lupus Selenium sulphide lotion used as shampoo Erythematosis or immuno suppressive therapy appears to be sporocidal and when prescribed in developed tinea corporis with M. Cannis. conjunction with griseofulvin, this results in Contact with domestic animals, pa1ticularly earlier negative cultures from lesions of tinea young kittens and puppies is a common cause of capitis:17• Because griseofulvin kills the hyphae affliction in young children. of the dermatophytes, but not the spores, it has been postulated that the addition of twice Clinical Features: Clinically tinea corporis weekly shampoo with selenuim sulphide may usually occurs as pruritic annular plaques, with lessen the chances of spreading infectious advancing scaling borders and evidence of spores to other suseptible individuals. central clearing. Lesions may occur any where Recently in a clinical pilot study on the efficacy on the body. Occasionally in the and safety of oral Terbinafine, the first oral immunosuppressed patient, the lesions may be allylamine, it was shown that terbinafine is wide spread, forming confluent plaques. effective and safe in the treatment of dry non­ The presenting picture of tinea' that results 12 inflammatory Tinea capitis: • This is repo1ted to from the application of a topical steriod be due to its superior penetration into the preparation to an underlying tinea corporis is 40 epidermis and the high concentration of the called tinea incognito . This alters the host drug in sebum and hair due to its lipophilicity88• immunologic response to the fungus resulting Haroon and colleagues:11 have shown similar in large multicentric ring lesions with an active successful therapeutic results with terbinafine peripherally advancing border. in treating children with tinea capitis. Diagnosis is confirmed by Potassium Hydroxide Several recent studies by Robe1t and examination of skin scrapings from the border colleagues87 and Gan V.M et al.22 have of the lesions. Culture may be required if compared the efficacy of griseofulvin with Potassium H_ydroxide examination is negative. ketoconazo1e in the treatment of tinea capitis in Differential Diagnosis: Any from of dermatitis pa1ticularly nummular eczema, may be paediatric patients. In each of these studies confused with tinea corporis as may herald ketoconazole was found to be effective and safe; patch of pityriasis rosea and some form of although it was not found to be more efficacious psoriasis. than griseofulvin therapy. Treatment: Topical therapy is the treatment Griseofulvin is recognised as relatively safe and of choice for dermatophytic infection limited to effective in children provided that it is given to the skin in children. Clotrimazole, Miconazole individuals without contraindications or haloprogin and tolnaftate are still all efficacious sensitivity to the drug and provided that it is 7 against most dermatophytic species. They are given in proper dosage8 ·��- Kerion is best applied as a cream or solution daily twice to the treated with glucoco1ticoids to reduce 3 Maqbool et al. 7 entire lesion and an area of approximately 1 cm In a review published by Ko1tig' , high cure outside the lesion for 2-3 weeks or until clearing rates have been shown in a preliminary study occurs. with oral terbinafine for 12 months which 53 24 E.N Macasaet from Manila also showed in a cleared toe nail tinea in 15 of 17 patients ·"-\ preliminary study topical 1 % solution of griseofulvin to be effectiveagainst tinea corporis 4. Tinea Pedis: with no adverse effects suffered by any of the 53 The occurance of tinea pedis in childhood is patients. often regarded as an infrequent disease in the 66 Recent American studies show terbinafine, an paediatric and dermatologic literature . A 4 5 allylamine, as efficacious and well tolerated as recent study by Kearse and Miller · did griseofulvin for oral therapy of tinea however document Tinea Pedis to be more 3,89 . corporisi common than previously rep01ted. A dermatophyte was isolated in nearly 50% of the 3. Tinea Ungum: children evaluated for foot dermatitis. Onychomycosis caused by infection with a Michelle' 1 reports a case of bullous tinea pedis dermatophyte is rare before puberty though in a 2 year old child, fmther reinforcing 1H occasional cases have been repo1ted in infants . upcoming paediatric tinea pedis. As recent as This has been attributed to faster linear nail 1992 Anne and Bernard�' in their study again growth with subsequent elimination of the showed tinea pedis not to be a rare occurence. 8 fungus• • Recent literature suggests functional abnormality of the stratum corneum as one of Clincal Features: This condition presents as the local factors of the host affecting thickening and yellowing of the distal nail plate trichophyton infection, since trichophyton 1s x 1 which may progress to involve the entire nail parasitic only in the stratum corneum • 96 plate • One or several nails may be involved, toe nails more frequently than finger nails. Clinical Features: The most common form of The gold standard of diagnosing onychomycosis tinea pedis is inte1triginous dermatitis is Potassium Hydroxide examination and 19 characterized by peeling, maceration