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Podiarty Yr1 Tinea Pedis/Onychomycosis/ VP > Tines Pedis/Onychomycosis/VP > Flashcards

Tines Pedis/Onychomycosis/VP Flashcards

1
Q

Tinea Pedis

A

Dermatophyte infection of the skin

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2
Q

Aeitiology of Tinea Pedis
HOST factors

A

*Immunosuppression
-Chemotheraphy
-Immunosuppressive Drugs
-Steroids
-Organ Transplant
-Aquired Immunodeficiency Syndrome (AIDS)

*Poorly controlled Diabetes Mellitus

*Obesity/Age

*Profession - Occlusive footwear eg/ farming, industrial workers, wellies, steel toe cap boots

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3
Q

Aeitiology of Tinea Pedis
LOCAL factors

A

Moist conditions
Occlusive footwear
Poor foot hygiene
Hyperhidrosis
Shared footwear
Shared Towels
Public showering/barefoot walking
Trauma

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4
Q

Name 5 Dermatophytes

A

Microsporum

Epidermophyton Floccosum

Trichophyton
-Rubum
-Mentagrophytes
-Interdigitalis

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5
Q

Pathology Tinea Pedis

A

Dermatophyte infect stratum corneum

Inhabit keratin as branching hyape via enzyme secretion to breadown keratin

leads to increased proliferation which can result in scaling and epidermal thickening

unable to penetrate further in immunocompetent host

Inflammation seen is due to
-metabolic products of the fungus
-delayed hypersensitivity reaction

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6
Q

Clinical Sign & symptoms Tinea Pedis

A
  • discomfort
  • unilateral initially but spreads bilaterally easily
  • Tinea can be spread to/from another area of the body
  • Vesicles
  • Scaly patches
  • Dry powdery white lines
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7
Q

Presentaton 1
Tinea Pedis

Interdigital,

Organism,wherecommonly found and symptoms.

A
  • All organisms – T.rubrum,
    T. Mentagrophytes var.
    interdigitalis, E.
    Floccosum
  • Commonly starts between
    4th & 5th toes
  • Itching/burning/malodour
  • Fissures
  • Scaling
  • Erythema
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8
Q

Tinea pedis Interdigital - Simplex & Complex

Signs and symptoms

A

Dermatophytosis simplex
* Dry appearance
* Can be pruritic
* Epidermis may fissure

Dermatophytosis Complex
* Wet appearance
* Pruritic/ burning/malodour maybe present
*Peeling/maceration/ fissures
* Secondary bacterial infection
may be present

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9
Q

Presentation 2 Tinea Pedis

Moccasin
Dematopyte & presentation

A
  • T. Rubrum
  • Asymptomatic
  • Dry/powdery scaling
  • red appearance
  • Often has associated
    onychomycosis
  • Can be asymptomatic
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10
Q

Presentation 3
Tinea Pedis

Vesicular

A
  • T. metagrophytes var.
    intigitalis
  • Interdigital & plantar (medial
    longitudinal arch area) & dorsal
    foot
  • Inflamed appearance
  • Can burst brown/red exudate
  • Skin becomes scaly
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11
Q

Differential Diagnosis-

A

Palmoplantar
Pustulosis

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12
Q

Palmo Plantar Pustulosis

A
  • Chronic, recurrent
    inflammatory condition
  • Affects soles/palms
  • Topical corticosteroids
  • Referral to
    dermatologist
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13
Q

Differential Diagnoses 2

A

Pompholyx

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14
Q

Pompholyx

A
  • Eczema which affects the
    hands and feet, causing tiny
    blisters and irritation
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15
Q

Management of Tinea Pedis & Onychomycosis

2 key goals

A
  1. Target the
    fungus
  2. Prevent
    recurrence of
    fungus
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16
Q

Factors to consider for successful treatment

A

 Clinical presentation of infection
 Patient ability, medication history
 Non-concordance renders Rx
ineffective
 It requires patients to be
motivated/ concordant
 Clear, understandable and
comprehensive is advice essential to
prevent recurrence (occurs in up to
70% of patients)

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17
Q

Antifungal

A

Antifungals are used to prevent fungal growth
* Medicaments used are either fungistatic (inhibit growth) or fungicidal
(destroy fungi)

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18
Q

Topical treatment for Tinea Pedis

A

Topical treatments
* First line treatment
most common ones (Lamisil, Canesten, Daktarin)
- Active ingredients Terbinafine, Clotrimazole, Miconazole,
itraconazole

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19
Q

Topical medicaments for Tinea

A

Ointments/creams/ sprays/ powder
Lamisil
Miconazole
Clotrimazole

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20
Q

Ointment

A

Greasy / insoluable in water
Does not absorb easily into the skin (occlusive)
Good for dry scaling infection
Not on maceration
Useful on hyperkeratotic/ anyhydrotic fungal infection

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21
Q

Cream/ gel

A

Cream- emulsion of oil & water
Absorbs well into skin
can cause maceration , interdigital
Good overall coverage
Easy to apply

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22
Q

Spray

A

Dry powder in aerosal can
Good for interdigital
Good for patients who cannot reach to apply cream
Doesnt give best covereage

23
Q

Powder

A

Can clog/abrade in macerated areas
Hard to acheive equal distribution
Reduce friction

24
Q

Topical treatment for onychomycosis

A

Topical
treatments for
onychomycosis
* Topical treatments may only be
successful in superficial white /
early distal and lateral subungual
OM
* Nail lacquer or paint or solution
* Amorolfine (loceryl)
* Tioconazole (trosyl

25
Q

Oral treatment for onychomycosis

A

Terbinafine (Lamisil)
* 250 mg daily for 12 weeks
* More successful 70—80% cure
rates
* Hepatic function should be
monitored before/after treatment

Itraconazole (Sporonox)
* Active against a range of fungi
including yeasts and
dermatophytes
* 200 mg daily for 12 weeks
continuously or 400 mg daily for 1week per month (x2 of these
weekly course 21 days apart

26
Q

Patient Advice

A

Avoid wearing occlusive narrow footwear, such as, wellingtons, court shoes.

Wearing footwear made with a breathable material, such as leather, to keep the feet cool and dry.
Alternated every 2-3 days.

Maintain good foot hygiene by:
wearing cotton hosiery to aid with moisture wicking and ensure these are changed daily.
Avoid wearing nylon hosiery as this promotes more
moisture in the area.

After washing feet ensure you dry them thoroughly, particularly
between the toes.

Avoid sharing towels and wear protective footwear in communal areas to reduce risk
of transmission.

Wipe down and/or spray with a fungicidal treatment the inner liner of
your footwear.

Consider wearing insoles in footwear that are moisture wicking/anti-microbial
cloth to absorb moisture or reduce the likelihood of fungal growth.
Rotate with a second pair.

Continue to use the fungicidal (treatment) after visible signs/symptoms have
disappeared to ensure hyphae are not still present for at least 2-3 weeks.

Following treatment you should continue to maintain good foot hygiene. Applying
surgical spirit between the digits with a cotton bud could help to prevent build-up of
moisture/maceration between the digits.

27
Q

Lamisil
Active ingredient

A

Terbinafine 1%

once or 2x a day for 7 days

28
Q

Canestan - Active Ingredient

A

Clotrimazole 1%

2/3x daily 2 weeks

29
Q

Daktarin - active ingredient

A

Miconazole 2%

Skin - 2x a day - 7 days
nail- once or 2x a day - 10 days

30
Q

Sporonox - active ingredient

A

Oral
Itraconazole
(fungi, yeast, dermatphyte

200mg daily, 12 wks cotinuous
or
400mg daily for 1 wk per month

31
Q

Verruca Pedis

A

Benign neoplasm (abnormal mass of tissue) of the epidermis caused by viral infection (Human Pappiloma virus)

32
Q

Aeitiology of VP

A

Trauma to epidermis enables portal of entry for the HPV virus.

Transmission, skin to skin contact
communal changing areas/showers

HPV lays dormany in stratum basal layer and activates in stratum spinsum layer

33
Q

Pathology of VP

A

Pathology
* Virus metabolically inert
* Only replicated after infecting host cell
* Uses keratinocyte to transcribe / translate genetic information
* Leads to excessive production of keratinocytes within the
stratum spinosum

34
Q

Viral mitosis?

A

Viral Mitosis
* Replicates faster than normal
keratinocyte DNA
* Results in acanthosis of the
stratum spinosum
 Acanthosis = an abnormal
but benign thickening

35
Q

VP impact on dermis

A

Ridges elongate
* Increasing pressure on the
capillaries
* Leads to thrombosed/punctate
capillaries

36
Q

Clinical Observations of VP

A
  • Mosaic
  • Single plantar wart
  • HPV types 1, 2, 4, 60 or 63.
37
Q

VP Differential diagnoses

A
  • Heloma durum
  • Heloma vasculare
  • Foreign body
  • Trauma – puncture wound
  • Malignant meloma
38
Q

VP or HD?

A

Verruca pedis
Normally painless
Elicit pain on squeeze test
Skin striae pushed around lesion (knot in tree)
Punctate lesion
May not be on a weight bearing area

HD

Pain on direct pressure
Skin striae run up and stop at lesion
Normally no vessels visible
Weight bearing area
(intermittent compression,
torsion, friction)

39
Q

Vp treatment Aims /goals

A

To initiate the immune
system
Treatment Goals:
* Reduce size of VP/Resolve VP
* Reduce pain

40
Q

When considering treatments you should

A

Discuss various treatment options
with the patient including what is
involved
Take into account medical history
Vascular/neurological status
Patients commitments/lifestyle
Return times
Location of VP(s)

41
Q

VP treatment options

A

Treatment Options
Patient Education
* Discuss treatment options with patient- professional and OTC
products/ Advice re communal areas
Medicaments
* Caustics
* Keratolytics
* Cryotherapy
* Marigold

42
Q

Caustics/ keratolytics

A

Any substance which destroys organic tissue

43
Q

Keratolytics

A

Acts on keratinised issue, stratum corneum

breaks desmosome links, helps bind water, causing maceration of the tissues and further penetration of the. medicament

44
Q

name some keratolytics

A

Monochloracetic acid (both Kera & caustic)

Trichloracetic acid (stronger than mono)

Salicylic acid - neutraise with bicarb, zinc oxide, 4 x weekly treatments

45
Q

Keratolytic-
Salicylic Acdi

A

60% available in uni

vp’s- 40/60%
hd’s -20/40%

Salicylic acid
This is a paste which acts by interfering with the side salt linkages in the structure of
the keratin tissue. The tissues become saturated with tissue fluid so the cells die. It is
available as a white odourless preparation that is available in a range of strengths.
Commonly 50%-75% strengths are used.

46
Q

Application & advice fo Salicylic acid

A

Application
1. Use adhesive tape to delineate the site for treatment and adhere to the skin.
2. Semi-compressed felt padding – cut and shaped with apertures
corresponding to the site(s) of the lesion(s). Applied to the skin.
3. Using a wooden spatula, put the paste into the aperture.
4. Plug the aperture with gauze.
5. Cover entire surface of pad with fleecy web material and frame strap into
place.
The patient should be advised to leave the dressing in place for one week.
Aftercare/Advice
Should any adverse reaction ensue, advise the patient to remove the dressing and
wipe the surface to clear any remaining paste.
Mix a Bicarbonate of Soda paste (in water) and apply thickly to the area. This will
neutralise the acid. Leave in place for 5 minutes. Repeat as necessary. Apply a dry
dressing and re-present for treatment as soon as possible.
You are advised to revise the use of these preparations after 3 consecutive
applications.

47
Q

Caustics

A

Acts on non -keratinised cells

substance that are destructive to living tissue

withdraws o2 from tissues

48
Q

Name some caustics

A

Silver nitrate (HD & VP)

Pyrogallol

Marigold

49
Q

Application and advice of marigold

A

The patient should understand that they would be required to attend initially for 4
weekly appointments. They will be required to have a pad adhered to their foot after
each of the first 3 weekly treatments to contain the dressing. Self-treatment is then
undertaken for a further 8 weeks

  1. The patient should bring their tincture spray which was provided on their first
    visit. Apply this tincture spray to the verruca site.
  2. Adhesive tape masking plaster cut to size and to delineate the site for
    treatment. This is applied to the skin.
  3. Semi-compressed felt padding – cut and shaped with apertures
    corresponding to the site(s) of the lesion(s). Applied to the skin.
  4. Marigold paste (HTS 080 for corns and callus) (HTS 082 for verrucae) is filled
    into the apertures.
  5. The apertures are plugged with gauze.
  6. The whole surface is covered with a fleecy web cover and strapped into
    place.
  7. This is completed every visit for 3 visits. After each application the patient
    should be advised to get the padding wet to re-activate the marigold. If
    patient experiences any discomfort advise them to remove the padding and
    soak in warm, soapy water and contact the university.
  8. On the 4th visit you should show the patient how to apply their tincture spray
    which they will continue to do for 9 weeks. The patient should file the VP
    with an emery board and apply the tincture spray 3 times a day on week 1
    and then 2 times for the remaining weeks. The patient should have an appointment booked 10-12 weeks after their 4th appointment at the
    university for a review
50
Q

Appplication and advice of silver nitrate

A

Application
1. Use Vaseline TM or Yellow Soft Paraffin Wax ointment to delineate the
circumference of the verrucae.
2. Moisten not soak some gauze in a gallipot with normal tap water NOT
SALINE.
3. Gently dip the tip of the silver nitrate stick onto the moistened gauze to
activate the silver nitrate.
4. Apply silver nitrate stick directly to the site or verrucae and move over the
entirety using circular motions.
5. When the silver nitrate has dried, remove surrounding paraffin.
Aftercare:
Should any adverse reaction ensue, advise the patient to soak their foot in saline
solution or salt water for 10 minutes to neutralise the effect.
Review after treatment plan after 10 treatments

51
Q

Application & advice of Pyrogallol

A

Pyrogallol
This acts by reducing the oxygen in the tissue, so the cells die. 50% strength
ointment can be used. This is a deep, powerful reducing agent and is not self-
limiting.
The patient should understand that they would be required to attend for weekly
appointments. They will be required to have a pad adhered to their foot for a week
to contain the dressing. Patients cannot get this pad wet.
Application
1. Should pinpoint haemorrhage occur apply digital pressure to stop bleeding
and proceed. Do not proceed with salicylic acid application if Ferric Chloride
is used as a styptic. Apply a dry dressing and re-start the scheme at number
1 after 1 week.
2. Use adhesive tape to delineate the site for treatment and adhere to the skin.
3. Semi-compressed felt padding – cut and shaped with apertures
corresponding to the site(s) of the lesion(s). Applied to the skin.
4. Spatulate the caustic preparation into the aperture, creating a funnel of
caustic.
5. Plug the aperture with gauze.
6. Cover entire surface of pad with fleecy web material and frame strap into
place.
Leave in place for 1 week. Ask the patient to leave the dressing in-situ.
Aftercare/Advice
Should any adverse reaction ensue, advise the patient to remove the dressing and
wipe the surface to clear any remaining paste.
Mix a Bicarbonate of Soda paste (in water) and apply thickly to the area. This will
neutralise the acid. Leave in place for 5 minutes. Repeat as necessary. Apply a dry
dressing and re-present for treatment as soon as possible.
You are advised to revise the use of these preparations after 3 consecutive
applications.

52
Q

Cryotherapy

A

a thermal caustic which causes cell death and destructs lesion. To be used on a single lesion with an obvious centre

53
Q

Contraindications of cryotherapy

A

Contraindications:
 Patients with impaired sensation
 Impaired circulation. Tissue damage may result from
vasoconstriction, risk of delayed healing.
 Hypersensitivity to cold (i.e. raynauds)
 Children under 10 years of age are not usually prescribed
cryotherapy due to the developmental stage of their skin and
their immune responses.

54
Q

application adn advice for cryotherapy

A

Method 1:
1. Carefully assess the patient’s vascular and neurological
status.
2. Assess the level of the local fibro-fatty covering of the foot.
This must be sufficient to enable the patient to bear weight after treatment.
3. If necessary, apply a mask tape to delineate the verrucae.
This should not be a water based cream or preparation as this will retain the cold
and spread the effect into local good tissue.
4. Use the spray to direct a jet of Liquid Nitrogen at the centre of the lesion
from approximately 1 cm from the surface
5. Spray should be no more than 1 x 10 second application
Alternatively, on thin skin, it may be possible to alter the mode of
Application:
Method 2
1. Follow steps 1-3 above
2. Use the spray to direct a jet of Liquid Nitrogen on to a cotton bud applicator. Spray
should be approximately 20-second spray until the bud is frozen.
3. Apply this directly onto the skin for 1 x 10 second application.
4. Inspect the site when thawing is completed. A second application may be
required.
In both methods, the area of treatment should be inspected before a dry dressing is
applied.
7
Post Treatment
The patient is advised to return in 7 - 10 days for review. This is just to review the
site in case of any blistering etc. NOT for a second application
N.B:
* It is often the case that nothing obvious happens in this period.
* In other cases, slight blistering may occur.
* It is more usual for large blistering to be seen. This should be managed carefully
and sensitively.
* The blister should be de-roofed, drained and dressed with a dry dressing. See a
member of staff before proceeding
* The site should be inspected after another week (2 weeks after the original)
* No further applications of cryotherapy should be offered until the central mass of
elongated cells has reduced.

Podiarty Yr1 Tinea Pedis/Onychomycosis/ VP (1 decks)

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