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Fungal (Skin + Nail) Infections - Coggle Diagram
Fungal (Skin + Nail) Infections
Tinea pedis
(Athlete's foot)
Foot infection due to a dermatophyte fungus; infection is usually acquired by direct contact with the causative organism, for example using a shared towel, or by walking barefoot in a public change room.
Particularly prevalent in hot, tropical, urban enviro
Who gets it?
More commonly affects males and adolescents/young adults
Esp.
sports
players as they may wear occlusive footwear, sweat heavily, fail to dry their feet carefully after showering, be exposed to fungal spores on surfaces of communal areas
Risk Factors
Occlusive footwear (e.g. heavy industrial boots)
Excessive sweating (hyperhidrosis)
Underlying immunodeficiency or diabetes mellitus
Systemic corticosteroids or immune suppressive medications
Poor peripheral circulation or lymphoedema.
Clinical Features
Tinea pedis
tends to be asymmetrical, and may be unilateral; usually presents in one of three ways:
Itchy erosions and/or scales between the toes, esp. between 4th and 5th toes
Scale covering the sole and sides of the feet (hyperkeratotic/moccasin type, usually caused by T. rubrum)
Small to medium-sized blisters, usually affecting the inner aspect of the foot (vesiculobullous type).
Athlete's foot
Moist, peeling skin between the toes
White, yellow, or greenish discolouration
Sometimes, thickened skin
Painful fissures
Unpleasant smell
Onychomycosis
Mild infections affecting <50% of one or two nails may respond to topical antifungal medications, but cure usually requires an oral antifungal medication for several months
Nail infection due to dermatophytes, yeasts or moulds; may affect one or more toenails and fingernails and most often involves the great toenail or the little toenail.
Increasingly common with increased age
Clinical Features -
can present in one or several different patterns:
Lateral onychomycosis — a white or yellow opaque streak appears at one side of the nail
Subungual hyperkeratosis — scaling occurs under the nail
Distal onycholysis— the end of the nail lifts, free edge often crumbles
Superficial white onychomycosis — flaky white patches and pits appear on the top of the nail plate
Proximal onychomycosis — yellow spots appear in the half-moon (lunula)
Onychoma or dermatophytoma — a thick localised area of infection in the nail plate
Destruction of the nail
Pharmacological Treatments
(Antifungals)
Amorolfine
Pharmacy only; 5% Application (Nail Lacquer)
Dose:
apply to infected nails 1–2 times weekly after filing and cleansing; allow to dry (approx. 3 mins); treat finger nails for 6 months, toe nails for 9–12 months (review at intervals of 3 months)
Topical antimycotic - fungistatic or fungicidal effect based on alteration of the fungal cell membrane targeted primarily on sterol biosynthesis
Adverse effects:
local irritation and hypersensitivity reactions - discontinue use if severe
Monitoring:
treatment should be continued without interruption until the infected nails are completely cured and re-grown.
Educations points:
avoid nail varnish or artificial nails during treatment; don't use nail files for infected nails on healthy nails
Ciclopirox
Pharmacy only, Prescription; 8% Application (Nail Lacquer)
Dose:
apply to the infected nails every second day for 1 month, then twice weekly for second month, and once weekly thereafter for up to 6 months
Before first application and once weekly remove as much of the affected nail as possible; once weekly cleanse all lacquer from nail
Stops growth of the fungus
Adverse effects:
local irritation and hypersensitivity reactions
Monitoring:
Use for up to 48 weeks of using it every other day and having your doctor remove the loose, infected nail as often as monthly is usually how long it takes to get a clear or almost clear nail (which means that 10% or less of your nail is still affected). You may need as long as 6 months of treatment before you first notice your nail(s) getting better
Education points:
if skin irritation occurs and persists, discontinue treatment; don't cover the affected area with a bandage after applying; don't use nail polish or other nail cosmetic products on the treated nails
Miconazole
Pharmacy only; 2% Cream, Lotion, Powder (+ Dusting powder), Solution, Spray, Tincture
Dose
Skin
infection: apply twice daily continuing for 10 days after lesions have healed
Nail
infection: apply 1–2 times daily
Possesses an antifungal activity against the common dermatophytes and yeasts as well as an antibacterial activity against certain gram-positive bacilli and cocci. Its activity is based on the inhibition of the ergosterol biosynthesis in fungi and the change in the composition of the lipid components in the membrane, resulting in fungal cell necrosis.
Adverse effects:
local irritation and hypersensitivity reactions
Itraconazole
Prescription; 100mg Capsule; 10mg/mL Oral Liquid
Dose:
Tinea corporis and tinea cruris (if other treatment ineffective or extensive disease) = either 100 mg once daily for 15 days or 200 mg once daily for 7 days
Onychomycosis = either 200 mg once daily for 3 months or course (‘pulse treatment’) of 200 mg twice daily for 7 days, subsequent courses repeated after 21-day treatment-free interval; fingernails 2 courses, toenails 3 courses
Adverse effects:
nausea, diarrhoea, dyspepsia, abdominal pain, vomiting, dysgeusia, cough, headache, dizziness rash, pyrexia
Itraconazole and its main metabolite are fungistatic, which works by stopping the growth of the fungus
Avoid concomitant use of CYP3A4 substrates, calcium supplements, indigestion medicines such as antacids and omeprazole, grapefruit, grapefruit juice or sour/Seville oranges
Monitoring:
monitor liver function if treatment continues for longer than one month, if receiving other hepatotoxic drugs, if history of hepatotoxicity with other drugs, in hepatic impairment, or if signs or symptoms of hepatitis develop
Education points:
ensure highly effective contraception during treatment and until the next menstrual period following end of treatment; capsules - absorption is improved when taken with a full meal or an acidic beverage such as cola or fruit juice, swallow whole; suspension - absorption is improved when taken on an empty stomach, swish solution around the mouth before swallowing, don't rinse mouth after swallowing solution
More effective treatment for
onychomycosis
due to
candida
infection
Terbinafine
Topical
General sale, Pharmacy only; 1% (hydrochloride) Cream, Gel, Solution, Spray
Dose:
apply thinly 1–2x daily for up to 1 week in tinea pedis, 1–2 weeks in tinea corporis and tinea cruris, 2 weeks in cutaneous candidiasis and pityriasis versicolor; review after 2 weeks
Fungal skin infections
Adverse effects:
local irritation and hypersensitivity reactions
Systemic
Dermatophyte infections of the nails; candida and tinea infections (including tinea pedis, cruris, corporis) where oral therapy appropriate (due to site, severity or extent)
Prescription; 25mg/mL Oral Liquid; 250mg Tablet
Dose:
250 mg daily usually for 2–6 weeks in tinea pedis, 2–4 weeks in tinea cruris and cutaneous candida, 4 weeks in tinea corporis, 6 weeks–3 months in nail infections (occasionally longer in toenail infections)
Adverse effects:
taste disturbance, nausea, diarrhoea, dyspepsia, headache, arthralgia, myalgia, rash, urticaria
Monitoring:
Monitor hepatic function (discontinue if abnormalities in liver function tests) and complete blood count after 4–6 weeks; mouth ulcers, fever, sore throat, stomach pain, yellowing of eyes or skin, skin rash = tell doctor or pharmacist immediately
Education points:
take regularly as directed with food and a glass of water and keep taking it until the course is finished
Not recommended for those with
liver disease
Allylamine medicine used to treat fungal infections, esp. effective against dermatophytes (tinea infections); inhibits a fungal enzyme, squalene epoxidase, and stops the cells making ergosterol, the main component of the cell wall.
First line treatment and more effective for dermatophyte infections
Non-Pharmacological
Lasers which emit IR radiation (
onchomycosis
)
kill fungi by the production of heat within the infected tissue
Photodynamic therapy (
onchomycosis
)
Application of 5-aminolevulinic acid or methyl aminolevulinate followed by exposure to red light
Drying feet and toes meticulously after bathing
Using desiccating foot powder once or twice daily
Avoid wearing occlusive footwear for long periods
Thoroughly drying shoes and boots
Cleaning the shower and bathroom floors using a product containing bleach and treating shoes with antifungal powder
Use of barrier protection (sandals) in communal facilities (
tinea pedis
)