CPD Zone Update PREMIUM CPD CONTENT FOR £1 PER WEEK Buy UPDATEPLUS for £52+VAT chemistanddruggist.co.uk/update Visit chemistanddruggist.co.uk/update-plus for full details This module covers: September ● Types of fungi Infections month» UPDATE ● How athlete’s foot is contracted and treatment options ● Influenza September 6 Module 1719 ● Presenting symptoms and treatment for ● Antibiotic resistance September 13 fungal nail infections ● Causes of and self-care advice for fungal ● Fungal infections September 20 skin and groin infections ● Common parasites September 27* ● Preventing the spread of fungal scalp infections and oral and topical treatments *Online-only for Update and Update Plus subscribers Fungal skin infections Steve Titmarsh Fungal infection of the body can produce a wide range of diseases. Yeast infection, involving Candida species, for example, causes problems such as oral candidiasis, angular chelitis, skin fold infections (intertrigo) and nappy rash. Dermatophyte infections of the skin cause problems such as athlete’s foot and fungal nail infections. Systemic fungal infection tends to be more serious, resulting in conditions such as aspergillosis, cryptococcal meningitis and pneumocystis.1,2 This article focuses on fungal skin infections of the feet, scalp, nails, body and groin. The infecting organism is usually a dermatophyte or ringworm (tinea). There are three genera of dermatophyte: Trichophyton, Microsporum and Epidermophyton. Humans act as hosts in the case of anthropophilic dermatophytes – for example, Trichophyton rubrum – while animals host zoophilic dermatophytes such as Microsporum canis, which typically affects household pets. Both types of fungi depend on their hosts and can survive only by passing from one host to another. Other dermatophytes, known as geophilic, are found in soil – for example, Microsporum fulvum. While anthropophilic organisms provoke minimal immune response in human skin, zoophilic or geophilic dermatophytes can provoke a more pronounced inflammatory reaction.3 Athlete’s foot Fungal foot infection affects between 15 and 25 per cent of the population at any one time. It is common among adolescents, but rarely seen before puberty.4 Athlete’s foot (or tinea pedis) is frequently contracted under warm, moist conditions when bare feet come into contact with skin scales from infected individuals such as in public swimming pools, communal showers and changing rooms. Athlete’s foot has several forms: interdigital, moccasin and vesiculobullous. The interdigital Swimming pools are a common breeding ground for athlete’s foot infections for those of all ages 24 CHEMIST+DRUGGIST 20.09.2014 CPD Zone Update Topical treatment for fungal nail infections is more effective than oral therapy Interdigital athlete’s foot (tinea pedis) Fungal nail infection (onychomycosis) form is most common and is usually caused can involve all or part of the nail. Toenails by Trichophyton rubrum, which also causes the are affected more often than fingernails. The moccasin form of the condition. It appears as infection develops slowly – the nail thickens and white, cracked or macerated areas between changes colour, and can become white, black, toes and affected skin may also be red, scaly, yellow or green;7 the nail plate distorts; and the flaky and dry.5 When the infection spreads to nail bed and surrounding tissue may thicken.8 the sole and sides of the foot this is known as Fungal nail infection tends to affect older the moccasin form, and presents with a diffuse people, while children are rarely affected. scaling pattern. Prevalence among people aged over 60 years The third and least common type is known old is thought to be as high as 30 per cent.8 as vesiculobullous and is often caused by Mild infection may not need treatment with Trichophyton mentagrophytes.4 It appears mostly medicines because self-care methods – such as on the soles of the feet as inflammatory not wearing shoes that make feet hot, keeping eruptions.4 The infection may rarely spread to nails short, dry and clean and using one nail the hands if they are not thoroughly washed clipper for the infected nails and another for after touching infected skin. So-called tinea the normal ones – may be sufficient.9 manuum usually affects the palm of one hand, After confirming which organism is which can become dry, red and itchy.5 causing the infection by analysis of nail Treatment of mild infection is usually with clippings, oral antifungals (terbinafine a topical antifungal such as clotrimazole, or itraconazole) or antifungal nail paint miconazole, econazole, ketoconazole (not containing amorolfine may be recommended. licensed for children), terbinafine (not licensed Oral therapy has been shown to be more for children), tolnaftate or undecanoic acid. effective than topical treatment.8 They are usually applied to the affected area, Children with fungal nail infection should including a margin of several centimetres of be referred for specialist treatment, as should True or normal skin, once or twice daily for up to six those who do not respond to primary care weeks. Treatment should continue for one or treatment or who are immunocompromised. two weeks after the visible rash has cleared.6 People whose nails are damaged by footwear or Any associated fungal nail infection (see below) who have deformed nails that damage adjacent should be treated at the same time to prevent toes should see a podiatrist.10 re-infection. People with athlete’s foot should:4,5 false? ● regularly wash feet and dry thoroughly, Fungal skin and groin infection especially between the toes Fungal skin or groin infections are more Find the answer online ● not scratch affected areas common among men than women and can ● avoid going barefoot in public places be caught by contact with an infected person when you subscribe to ● keep feet cool and dry or animal (common examples include dogs, C+D’s premium CPD ● wear cotton socks cats, guinea pigs and cattle) or with items ● regularly change and wash socks contaminated with the fungus (for example, package UPDATEPLUS ● regularly wash towels and bedding clothes, bed linen or towels). Sometimes contact ● alternate their footwear, particularly running with soil can result in infection, but this is rare. shoes and trainers, so that dry shoes can be Fungal infection of the body – also known as Don’t get left behind, worn at all times. ringworm or tinea corporis – is often caused by Patients whose diagnosis is uncertain, Trichophyton rubrum, which can also cause groin keep UP to DATE with do not respond to topical antifungals, have infection (tinea cruris), as well as Trichophyton extensive or severe infection, or who are mentagrophytes and Epidermophyton floccosum.12 UPDATEPLUS. immunocompromised should be referred The infection is mainly seen in adolescent and to a dermatologist.4 young men. Women who are overweight or Details overleaf wear tight clothes may also be affected. Fungal nail infection Patients with tinea corporis typically have People with athlete’s foot may also suffer with one or more red or pink, flat or slightly raised fungal nail infection (onychomycosis), which patches of skin that grow larger into ring- Update plus-side ad-right1 sept 20.indd 1 15/09/2014 12:21 CPD Zone Update Fungal ringworm infection (tinea corporis) Fungal scalp infection (tinea capitis) shaped lesions with red, scaly borders and a severe inflammatory reaction, with symptoms ● the infection is recurrent clear centre.10 including erythema, pustules and crusting. ● the person is immunocompromised. Infection of the groin is most frequently To help the prevent re-infection or seen, affecting skin folds of the inner thighs transmission of infection to others, individuals References around the groin area. Lesions are commonly should be advised to throw away, where 1. Centres for Disease Control and Prevention. red to red-brown, flat or slightly raised plaques possible, items such as hats, combs, pillows, Fungal diseases. www.cdc.gov/fungal/diseases/ with active borders (pustules or vesicles). They blankets and scissors, which can transmit index.html often itch, and in some cases there is uniform fungal spores. 2. Medicines Complete www. scale without central clearing.10 Alternatively, where possible, clean items medicinescomplete.com Treatment for mild, non-extensive infection with bleach. Towels should be washed regularly 3. DermNet NZ. Mycology of dermatophyte includes topical clotrimazole, econazole or and not shared with other people. If children infections. www.dermnetnz.org/fungal/ miconazole. A mild topical corticosteroid show signs of scaling or hair loss they should be mycology.html such as hydrocortisone 1 per cent can be referred to their doctor.11 4. NICE Clinical Knowledge Summaries. Fungal recommended for people who have particularly Ideally, a positive microscopy or positive skin infection – foot. cks.nice.org.uk/fungal- inflamed skin, but should not be used for more culture of skin scrapings should be obtained skin-infection-foot. than one week.10 before starting treatment. 5. NHS Choices. Athlete’s foot. www.nhs.uk/ As with other fungal infections, personal Oral treatment is preferred for adults. Conditions/Athletes-foot/Pages/Symptoms.aspx hygiene and cleanliness are important in Griseofulvin is recommended for Microsporum 6. DermNet NZ. Topical antifungal medications. managing the condition and restricting or infections. Treatment should be given for four www.dermnetnz.org/treatments/topical- preventing its spread. Advise people to:10 to eight weeks (eight to 12 weeks in resistant antifungal.html ● wash clothes and bed linen frequently to cases) and continued for at least two weeks 7. NHS Choices. Fungal nail infection. www.nhs. eradicate the fungus after all signs of infection have gone. uk/Conditions/Fungal-nail-infection/Pages/ ● wash affected skin every day and dry The drug should be taken after a high- Symptoms.aspx thoroughly afterwards, particularly in fat meal for increased absorption and to 8. NICE Clinical Knowledge Summaries. Fungal the skin folds minimise the risk of gastrointestinal side nail infection. cks.nice.org.uk/fungal-nail- ● not share towels and wash them frequently effects.