SUPERFICIAL

FUNGAL
INFECTIONS

Eylem Emel Arıkan

 Learning goal: TT, K

TT: Tanı koyabilmeli, tedavi edebilmeli. Should diagnose and

treat.

K: Korunma yöntemlerini uygulayabilmeli. Must be able to

perform protective methods to prevent the disease.
SUPERFICIAL FUNGAL
INFECTIONS

Dermatophytes Dermatophytoses
Malessia furfur Tinea versicolor
Candidia Candidiasis
Dermatophytoses (Tinea Infections)

Tinea capitis Scalp

Tinea corporis Body
Tinea barbae ve facialis Face and beard
Tinea inguinalis (cruris) Groins
Tinea pedis Feet
Tinea manum Hands
Tinea unguinum Nails
(onychomycosis)
Tinea inkognito Inkognito
Dermatophytoses (Tinea Infections)

• The names of dermatophyte infections ;

‘tinea’ + the Latin name for the involved body site;
tinea pedis : foot
tinea cruris :groin...

• Trichophyton, Microsporum, and Epidermophyton – that invade only

keratinized tissue (stratum corneum, hair and nails).

• Dx: KOH ± fungal culture of skin /hairs/nails

Tinea pedis

• T. rubrum or T. mentagrophytes

1 Interdigital: Erythema, scaling, and

maceration in the web spaces, especially
the two lateral web spaces, which have
the most occlusion;
Tinea pedis

2 Moccasin: Diffuse scaling and

erythema that extends onto the lateral
aspect of the feet

3 Inflammatory (vesicular): Vesicles

and bullae, especially on the medial
aspect of the plantar surface.
Tinea cruris

• T. rubrum
• Favors the upper inner thighs and can extend to the lower abdomen and
buttocks
Tinea Corporis

• T. Rubrum, M. canis

• Peripheral enlargement and central clearing

• DDx: Allergic contact dermatitis, atopic

dermatitis, annular erythemas, psoriasis,
seborrheic dermatitis, pityriasis
rosea,subacute lupus erythematosus,
cutaneous T cell lymphoma.
Tinea manuum

• Often due to same dermatophyte as

associated tinea pedis

• Can be unilateral ;‘one hand, two feet

syndrome’ = Celal Muhtar Disease

• Tinea unguium of the involved hand is a

clinical clue
Tinea faciei

• Misdiagnosis is common

• Application of topical CS is a
typical history, often leading to
tinea incognito
Tinea barbae

• Trichophyton mentagrophytes and

Trichophyton verrucosum

• Invasion of hair shafts and intense

inflammation with follicular pustules and
abscess formation
 Tinea capitis

• Ectothrix infection: Occurs outside hair shaft.

Caused by Microsporum spp.

• Endothrix infection: Occurs within hair shaft

without cuticle destruction.
Caused by Trichophyton spp.
Tinea capitis
Tinea capitis

• “Black dot” tinea capitis: Variant of

endothrix resembling seborrheic
dermatitis.

• Kerion: Variant of endothrix with

boggy inflammatory plaques.

• Favus:Variant of endothrix with

arthroconidia and air spaces within
hair shaft
Topical Medications
∙ Twice daily for 2–4 weeks
o • Allylamines (e.g. terbinafine 1% cream, naftifine 1% gel)
o • Imidazoles (e.g. econazole 1% cream, sulconazole 1% solution)
o • Hydroxypyridinones (e.g. ciclopirox 0.77% cream or gel)
Oral Medications
Fluconazole Griseofulvin Itraconazole Terbinafine
Tinea corporis and pedis 150–200 mg/week × 2–6 500–1000 mg/day (microsize) 200–400 mg/day × 1 week 250 mg/day × 1–2 weeks
(moccasin type)/tinea weeks or 375–750 mg/day
manuum ( adults ) (ultra-microsize) × 2–4 weeks
Tinea corporis and pedis 6 mg/kg/week × 2–6 weeks 15–20 mg/kg/day (microsize 3–5 mg/kg/day (maximum Daily dosing as for tinea
(moccasin type)/tinea suspension) × 2–4 weeks 400 mg) × 1 week capitis (see below) × 1–2
manuum ( children ) weeks
Tinea unguium ( adults ) Toenail ± fingernail involvement
150–200 mg/week × 9 1–2 g/day (microsize) or 200 mg/day × 12 weeks or 250 mg/day × 12 weeks
months 750 mg/day (ultra-microsize) 200 mg BID × 1 week per
until nails are normal month for 3–4 consecutive
months
Fingernail involvement only
150–200 mg/week × 6 1–2 g/day (microsize) or 200 mg/day × 6 weeks or 250 mg/day × 6 weeks
months 750 mg/day (ultra-microsize) 200 mg BID × 1 week per
until nails are normal month for 2 consecutive
months
Tinea capitis ( adults ) 6 mg/kg/day × 3–6 weeks 10–15 mg/kg/day 5 mg/kg/day (maximum 250 mg/day × 3–4 weeks
(ultra-microsize; usually 400 mg) × 4–8 weeks
maximum 750 mg/day) × 6–8
weeks
Tinea capitis ( children ) 6 mg/kg/day × 3–6 weeks 20–25 mg/kg/day (microsize 5 mg/kg/day (maximum Granules
suspension) × 6–8 weeks 400 mg) × 4–8 weeks 125 mg (<25 kg), 187.5 mg
(25–35 kg), or 250 mg
(>35 kg) × 3–4 weeks
Tinea unguium

• Onychomycosis is a more general term that

includes nail infections due to
dermatophytes, Candida spp., and
saprophytes
• Trichophyton rubrum and Trichophyton
mentagrophytes
- Distal subungal onychomycosis
- White superifcial onychomycosis
- Proximal subungal onychomycosis
- Dystrophic onychomycosis
Tinea incognito

Caused by the use of

topical corticosteroids

Spreads fast

Vesiculopustular lesions
Tinea (Pityriasis) Versicolor

• Malassezia spp. are part of normal flora

• Malassezia infections are not contagious;

overgrowth of resident cutaneous flora

• Transformation of M. furfur from the yeast

form to the hyphal form

• Multiple, brown, tan or pink, oval to round

macules, patches, or thin plaques
Tinea (Pityriasis) Versicolor

• Most commonly develops on the upper

trunk and shoulders

• Often first noticed in the summer

• Predisposing Factors:
- Sweating
- Warm season or climates
- Hyperhidrosis; aerobic exercise
Tinea (Pityriasis) Versicolor

• Fine scaling is best appreciated by gently

abrading lesions

• Ddx:
Hypopigmented Macules: Vitiligo,
pityriasis alba, postinflammatory
hypopigmentation
Scaling Lesions: Tinea corporis,
seborrheic dermatitis, cutaneous T cell
lymphoma

Initial therapy (often combination)
Maintenance therapy
(tinea versicolor commonly recurs)
∙ Topical
∙ • Application of antifungal shampoo for 10
minutes, weekly to twice weekly for 2–4
weeks
∙ • Selenium sulfide shampoo
∙ • Ketoconazole shampoo,
∙ • Imidazoles, e.g. ketoconazole 2% cream
daily to BID × 2 weeks
∙ Oral
∙ • Fluconazole 200–400 mg PO once weekly ×
2–3 doses
∙ Examples of topical regimens
∙ • Treat previously affected sites with topical
imidazole daily for 2 weeks prior to
anticipated sun exposure (temperate
climates)
∙ • Apply antifungal shampoo (see above) 1–2
times every month (tropical climates)
CANDIDIASIS
(MONILIASIS)
CANDIDIASIS
(MONILIASIS)

Eylem Emel Arıkan

Mucosal Candida Infections

• Risk factors:

- Diabetes mellitus
- Treatment with broad-spectrum antibiotics
- Use of inhaled CS and dentures (oral candidiasis)
- Immunosuppression; common in otherwise healthy neonates and infants
- HIV infection
- Hyposalivation
Mucosal Candida Infections

• Most commonly due to Candida

albicans or C. Tropicalis

• Healthy individuals: Oropharynx and

genitalia

• Host defense defects: In the esophagus

and tracheo- bronchial tree

• Thrush with “cottage cheese”-like exudate

on the buccal mucosa.
Mucosal Candida Infections

• Angular Cheilitis: Intertrigo at the

angles of lips

• Erythema; slight erosion

• Usually associated with oropharyngeal

Candida colonization
Cutaneous Candida Infections

erosive, erythematous
patch
+
satellite pustules
+
intertriginous zone
Candidiasis Treatment

∙ Immunocompetent patient
∙ • Clotrimazole 10 mg troche five times Daily
∙ • Nystatin 100 000 units/ml suspension: 4–6 ml swish and
Mucosal swallow four times daily (adults); 1 ml in each cheek four
(continue treatment for 7–14 days after clinical times daily (infants)
resolution) ∙ Immunocompromised patient OR failure to respond to
topical Rx
∙ • Oral fluconazole 200 mg PO on day 1, then 100–200 mg
PO daily
∙ If mild, topical treatment
∙ • Imidazoles (e.g. ketoconazole 2% cream twice daily for 2
weeks or until resolved)
∙ If moderate to severe OR fails to respond to topical
∙ Rx
∙ • Fluconazole 50–100 mg daily for 14 days OR
∙ • Fluconazole 150 mg PO weekly for 2–4 weeks
Cutaneous
∙ Chronic mucocutaneous candidiasis
∙ • Fluconazole 400–800 mg PO daily for 4–6 months
∙ • May require lifelong suppressive treatment with
fluconazole 200 mg PO daily