Superficial Fungal Infectinos

Question 1

What are the 4 Superficial Fungal Infections?

Answer 1

● Athlete’s foot (tinea pedis)
● “Jock itch” (tinea cruris)
● Ringworm (tinea corporis)
● Onychomycosis (tinea unguium

Question 2

● Athlete’s foot (tinea ____)
● “Jock itch” (tinea _____)
● Ringworm (tinea ______)
● Onychomycosis (tinea ______)

Answer 2

● Athlete’s foot (tinea pedis)
● “Jock itch” (tinea cruris) [crude]
● Ringworm (tinea corporis) [corporate RING]
● Onychomycosis (tinea unguium) [ungulate- nail]

Question 3

Waht are dermatophytes?

Answer 3

a pathogenic fungus that grows on skin, mucous membranes, hair, nails, feathers, and other body surfaces, causing ringworm and related diseases.

Question 4

How are fungal infection sspread?

Answer 4

Transmission: Direct contact from infected people, fomites, the environment (soil) or
animals

Question 5

Waht are 3 predisposing host factors?

Answer 5

Predisposing host factors:
● Moisture (occlusive clothing/shoes, warm humid climates)
● Genetic susceptibility
● Impaired immunity (e.g., diabetes, HIV, chemotherapy)

Question 6

Waht organisms is athletes foot caused by?3

Answer 6

• most commonly fungus/dermatophytes
• but yeast can be involved
• and gram neg bacteria in ulcerative forms.

Question 7

What are predisopsong host facctors for athletes foot?

• local factors?

Answer 7

Host factors: immunosuppression, poorly controlled diabetes mellitus, obesity,
hyperhidrosis

Local factors: trauma, occluded skin, poor hygiene, moist conditions, contaminated
surface

Question 8

how athletes food spread?

Answer 8

DIRECTLY via contact with infected person. or INDIRECTLY via contaminated surfaces (swimming pool, changeroom floor).

Question 9

What is hte most COMMON VARIANT OF ATHLETES FOOD u must know?

• describe presentation.
• usualy foudn btwn which toes?
• _______ ALL OTHER PRESENTATIONS of ahtletes foot.

Answer 9

chronic interdigital infection.
- itching, burning btwn the toes.
- skin appears red scaly and dry that progresses to white fisuses, scaling.
- is stinky.

• btwn 4-5th toes.
• REFER ALL OTHER PRESENTATIONS of ahtletes foot.

Question 10

otehr variants of athletes foot?

• what are some red flags questions to ask ?

Answer 10

• mocassin typ e–> toenails infected.
• vesicular -> small vesicls appear near instep and plantar surface.
• ulcerative: weeping and inflamted.

Question 11

__% will acquire Athlete’s foot infection at some point in their lifetime

● athletes foot more common i nwhich gender>

● Prevalence increases with ____

● ____ have 30% prevalence rate

Answer 11

70% will acquire Athlete’s foot infection at some point in their lifetime
● Males are 4 times more likely than females to acquire infection
● Prevalence increases with age
● Marathon runners have 30% prevalence rate

Question 12

What are some non-pharm tips for ATHLETES FOOT?

● Avoid ______________ in public spaces.
● Manage ______.
● allow shoes to ______.
● avoid ________ shoes
● ______shoes
● Personal ___
● __ and -___ feet thoroughly
● ______ socks daily (choose breathable sock materials, avoid nylon)
● do not share what?

Answer 12

● Avoid going barefoot in public spaces ) -
sandals!
● Manage hyperhidrosis (antiperspirant or absorbent powders - talcum/aluminum
chloride);
● allow shoes to dry thoroughly
● avoid tight-fitting shoes
● Breathable shoes - leather/canvas allow feet to breathe
● Personal hygiene
● wash feet and dry feet thoroughly
● change socks daily (choose breathable sock materials, avoid nylon)
● launder items used by infected person often and DONT SHARE TOWELS. –> Don’t dry off infected part of body then dry other parts of body- can re-inoculate.

Question 13

Waht is first line therapy for ahtletes foot?
- second line?

Answer 13

1st: topical antigunal.

2nd: systemic antigungal. Terbinafine po - is for more complex presentation (moccasin or vesicular) and are usually referred anyway.

Question 14

What is the prescription product for athletes foot? (3)

• duration of trx for lamisil?
• what are the other trx for athletes foot?
• duration trx?

Answer 14

• Lamisil (Terbinafine cream, spray):
  duration: 1-2 wks if mild; 4 wks if needed.
  –> requires APA.
• imidazoles.
• duration: all 4 wks.
• Miscellan
• Hydroxypyridones….. see slide

Rx: terbinafine cram, ketoconazole and ciclopirox cream. others otc.

Question 15

Waht is the most effective drug for athletes foot? con?

Answer 15

TERBINAFINE! CON: REQUIRES APA.

terbinafine>miconazole/clotrimazole>tolnaftate

Question 16

is tea treee oild effective for Athletes foot?

Answer 16

no!

Question 17

Educate on how to apply a topical antifungal for athletes foot.

• apply hwere?
• how muhc?
• how often and for how long?
• what about sprays?

Answer 17

● Apply to clean dry area
● Affected area including 2-3 cm beyond the border
● Most products (e.g., creams, lotions etc) apply/massage into area twice
daily for at least 4 weeks (AND CONTINUE USING ~1 week after the
infection has cleared to prevent recurrence).

● Sprays: apply to skin only.
- powders – apply to dry footwear and skin (check directions)

Question 18

What do you monitor for Athletes foot?

Efficacy:
- most imp tip?
- refer if no improvement after how many wks trx?

Safety:
- common AEs of topical products?
- should they d/c if dvlp rash?

Answer 18

Efficacy:
● Finish recommended course of treatment to prevent reoccurrence, even though symptoms
may resolve before treatment is complete.

● Refer if worsens or no improvement after 2 weeks of treatment or not completely resolved after 6 weeks of treatment

Safety:
Topical products: Local skin irritation or hypersensitivity (burning, erythema, pruritus, rash,
stinging).
–> yes. Rash suggests possible allergy to product - discontinue use and consult HCP

Question 19

are topical steroids recommended in athletes foot?

Answer 19

NO! do not recommend. Could use in mild cases, but incr cost, more side effects, and can sometimes lead to more growth, so not often used. But just be aware you may see this. When see this, ask whether they really need the steroid.

Question 20

can athletes foot cause jock itch?

Answer 20

yes!Can be transmitted from underwear sliding up from foot. Be careful when dressing from self-inoculating

Question 21

Describe the lcoation of jock itch.

• is penis and scrotum involved?

Answer 21

Involves groin - medial and upper parts of the thigh and pubic
area, Occasionally anal cleft
● Unlike candida – penis and scrotum usually spared
● May also involve buttocks

Question 22

Describe presentation of jock itch.

• symmetry?
• appearance?

Answer 22

● Often Bilateral/symmetrical due to inner thigh contact’’

● Round, well-defined bordered lesions (red-brown) with a raised
erythematous margin (ring like)

● Patches may be less erythematous and more hyperpigmented on
darker skin compared to lighter skin

● Dry scaling is frequent

● Can be asymptomatic or pruritic

● May become macerated and infected,
although rare

Question 23

Waht are some differntial dx of jock ithc?

Answer 23

Candidiasis (very red with poorly defined borders), seborrheic dermatitis
(usually also involves scalp, face etc), psoriasis (symmetrical erythematous
plaques) or bacterial infections

Question 24

what are some non pharm recommendations for jock itch?

• avoid what kind of clothes?
• how should they dry off?
• launder?
• are dyring powders recommended?

Answer 24

Avoid tight fitting clothes to reduce moisture at the affected area.

Wear clothes made out of breathable fibers (cotton).

Dry all areas completely (use separate towel to dry groin area).

Laundering of contaminated clothing separately.

Drying powders?? NO! can actually incr fungal growth.

Question 25

What is first line trx for jock itch? duration?

• what is the duration of trx for the other options (i..e ketoconazole, clotrimazole, miconazoke, and ciclopirox)?

Answer 25

• Topical Terbinafine once a day x 1 wk (lamasil) - Rx
• all others are BID for 2-4 wks.

Question 26

When would you consider systemic therapy for jock ithc?

Answer 26

only if topical fails.

Question 27

How does ringworm present?

• location?

Answer 27

● Begins as flat, circular scaly spots with central clear
portion
● Raised vesicular red border
○ Can have pustules within the active border
○ May appear more erythematous on lighter skin tones and hyper pigmented on darker skin tones
● Advances outwards
● Occurs on upper body, extremities
○ May occur on the face (3-4%)

● Usually asymptomatic***, occasionally pruritic

Location: hairless skin of trunk or limbs (excludes, hands, feet and groin) –> mainly arms,legs and tummy.

Question 28

What is the trx for ringworm? how different than jock ithc?

• duration topical terbinafine?

Answer 28

Similar to jock itch –> except trx for 4 wks instead of 1 wk.

• exception: Topical terbinafine only requires 1 wk.

Question 29

incr prevalence of onchomycosis inw hich pops (30?

Answer 29

elderly, diabetic, imunocompromised.

Question 30

Waht is onchomycosis?

Answer 30

Onychomycosis is a fungal infection of the fingernails or toenails that causes discoloration, thickening, and separation from the nail bed.

Question 31

(1/3 of nail fungus cases associated with _______.

Answer 31

(1/3 of cases associated with tinea pedis)

Question 32

what are the 3 hallmark signs of onchomycosis?

-what is required for dx?

Answer 32

Hallmarks:
thickenign, discoloration and separation.

• a doc doing a nail clippping.

Question 33

• what is the most common type of Onchomyocosis?

Answer 33

• Distal lateral subunual onchomucssi (DLSO) –> MOST COMMON FOMR.
• superficial white oncho SWO
• proxial subungal oncho (PSO) - least common.

Question 34

What are red flags for referal for Onchomycosis?

• dx?
• how many nails affected? how much involvement of nail?
• suspected ___ induced.
• immunosuppressed?
• poorly controlled what med condition?
• below what age?
• what issue with nail presetnation?

Answer 34

● If patient has not been previously diagnosed.
● >3 nails affected or Involvement of > 50% of nail – oral therapy recommended.
● Suspected drug or disease induced.
● Patient immunosuppressed.
● Poorly controlled diabetes or patients with peripheral vascular disease.
● <18 yo
● Nail presentation: Trauma to nail, pitting, lifting –> may need removal.

Question 35

What are some non pharm recommendsaitons to prevent reuccrence of onchomychosis?

• wear what around house instead?
• keep nails how?
• avoid sharing what?
• what can they apply to dry skin?
• control what ?
• mark what?

Answer 35

Wear footwear and socks that minimize humidity –> wear sandals around house instead of socks.

Keep nails clean and cut short

Avoid sharing nail clippers or footwear

Apply emollients on cracked skin to reduce further entry points for fungus

Control chronic health conditions (diabetes mellitus or peripheral vascular
disease)

Mark margin of fungal growth on nail to monitor efficacy of treatment

Question 36

Which route of antifungal is preferred in onchomychosis?

Answer 36

PO therapy FIRSTLINE over topical.

** BIG diff from all the other fungal infections***

Question 37

Waht is the number 1 choice trx for onchomychosis?
- drug , dose , duraiton for fingernail vs toenail?

• what are the AE to monitor for
• what labs to monitoros?
• inhibits which cyp?

Answer 37

PO Terbinafine (Lamisil) 250 mg daily (6-12 wks for fingernails; 12-24 wks for toenails (double)).

AE: GI upset, headache, rash, loss smell/taste, hearing disturbance, hepatotoxicity**. Serious - AST/ALT
hepatotoxicity, **SJS/toxic epidermal necrosis, neutropenia

> Labs - at baseline LFTs and at 4-6 weeks

• inhibits 2D6 –ddis much less than with azoles tho.

Question 38

Waht is teh biggest limiation to the other onchoomychosis therapy, itrsaconazole PO?

Answer 38

has many DDIs!! strong 3A4 inhibitor!!

Question 39

What is the TOPICAL trx for onchomychosis?

• when would you consider this over PO?

Answer 39

Efinaconazole solution (Jublia).

indicaiton: option for those with ci to PO therapy?

Question 40

Waht are the directions for Jublia?

• HOW MANY APPlications do you need for big toe?
• do you need to scrub off hte med after?
• need to debride nail?
• common AEs?
• what is teh mycological and clincial cur rates?

Answer 40

Apply 1 application to the dry toenail, preferably at bedtime for up to 48 weeks (BASICALLY A YEAR) . (Big
toenail 2 applications (see next slide). Afterwards, ensure to use the brush to spread
around the entire toenail (cuticle, folds of nail and sides/underside of toenail and on the
end of toenail and surrounding skin). Allow to dry for 30 seconds
- big toe = 2 applicaitons*** know.

● No need to remove the medication weekly due to lack of medication build up.
● No need to debride or remove diseased nail
● Monitor for application site vesicles and dermatitis (redness, itching, burning, stinging insurrounding areas)

Mycological cure = 54%, clinical cure = 17%

Cure rate: very good!! 54%. Clinical cure: 17% will have FULL clinical cure. Others my need to switch to PO therapy.

Question 41

What is Monitoring and Follow up for onchomyhsois?

• how long does it take to work?
• when will growth of diseased nail stop?
• when should nail appear back to normal ppaearnace?
• when to follow up?
• how can pt monitior progression of nail outgrowth?
• When would you refer to gp? no benefit after how many wks?
• advise pt to report sign of what?
• monitor what labs if syst therapy?

Answer 41

• advicse to Expect slow response to topical treatment. Growth of diseased area of nail should stop in 12 weeks for toenails; nail should appear normal in 12 to 18 months.

○ Follow-up with patient in 12 weeks.

○ Have patient measure distance of disease-free nail outgrowth monthly (normal
growth rate is 1.5–2 mm/month) to ensure that nail remains disease-free.

○ Refer patient to primary care provider if new lesions appear, or if no benefit to
diseased nail(s) at 12 week follow-up.

● Advise patient to watch for and report any signs of secondary infections e.g. cellulitis
(swelling, warmth, pain, draining around nails).

● Monitor Safety: side effects from therapy, check for irritation caused by topical
agents,Baseline liver function tests for systemic therapy