Fungal Infections Eugene Sanik, D.O. 3rd Year Dermatology 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 Mycology • Fungi first appeared 1.5 billion years ago • Among earliest organisms domesticated by humans • Serious problem only since 20th century • 1.5 million fungal species known • Less than 100 are pathogenic to humans • Except for dermatophytes, not contagious 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) 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 • Tinea nigra • Black piedra • White piedra Pityriasis Versicolor Treatment of Pityriasis Versicolor • Topical ketoconazole very effective against Malassezia • Oral fluconazole and itraconazole as effective with lower recurrence • Oral ketoconazole not recommended (FDA warning) • Oral terbinafine not effective Tinea Nigra Hortaea werneckii (melanin-producing yeast) Black Piedra and White Piedra Piedra Hortae Trichosporon 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 • Candidiasis of skin, mucous membranes, and nails • Do not invade subcutaneous tissue Dermatophytosis • Microsporum, Trichophyton, and Epidermophyton • Most common causes: • Tinea capitis – T. tonsurans • Tinea faciei – T. rubrum • Tinea corporis – T. rubrum • Tinea pedis – T. rubrum • Bullous tinea pedis – T. mentagrophytes • White superficial onychomycosis – T. mentagrophytes • Distal & proximal subungual onychomycosis – T. rubrum • betamethasone did not compromise the antifungal 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 Griseofulvin. • 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 folliculitis • Tinea capitis • Tinea barbae • Majocchi’s granuloma • Require treatment with oral antifungals • 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 dermatophyte 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 molds • Superficial white onychomycosis • Distal lateral subungual onychomycosis • Proximal subungual onychomycosis Onychomycosis Treatment Mycologic Cure Rate (negative KOH and culture) Topical Ciclopirox (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 immunosuppression • 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 Blastomycosis Cryptococcosis Phaeohyphomycosis Histoplasmosis Aspergillosis Chromomycosis Coccidioidomycosis Fusariosis Mycetoma (Madura foot) Paracoccidioidomycosis Mucormycosis Lobomycosis Penicilliosis Rhinosporidiosis Zygomycosis Sporotrichosis • DDX: Atypical mycobacterium, Nocardia, Leishmania, Tularemia Chromomycosis • Fonsecaea pedrosoi (most common cause) Madura Foot (Mycetoma) Lobomycosis • Lacazia loboi • “keloidal blastomycosis” • Dolphins Histoplasmosis Blastomycosis Coccidiomycosis Paracoccidiomycosis Opportunistic Systemic • Disseminate in immunocompromised patients - Organ transplant, post-chemotherapy, HIV • Candida species most common Mucormycosis References 1. 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