ANTIFUNGAL THERAPYANTIFUNGAL THERAPY

Tinea Infection TreatmentTinea Infection Treatment

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SUDIPTO HALDARSUDIPTO HALDAR

Cause Of Fungal InfectionCause Of Fungal Infection

Superficial Fungal Infections may be caused by different Superficial Fungal Infections may be caused by different types of Fungi, liketypes of Fungi, like - - DermatophytesDermatophytes MoldsMolds YeastsYeastsThe most common fungal infections are caused by the The most common fungal infections are caused by the Dermatophytes, which are the most abundant in their Dermatophytes, which are the most abundant in their distributiondistributionSuch infections are commonly termed as Such infections are commonly termed as TINEATINEA Infections Infections

Tinea Infection:Tinea Infection:

The common The common TINEATINEA Infections are : Infections are :Tinea corporisTinea corporisTinea crurisTinea crurisTinea pedisTinea pedisTinea capitisTinea capitisTinea versicolorTinea versicolorTinea unguium Tinea unguium (Onychomycosis caused by dermatophytes)(Onychomycosis caused by dermatophytes)

Common Superficial infections caused by oher species Common Superficial infections caused by oher species includeincludeOnychomycosis Onychomycosis (caused by Candida)(caused by Candida)

Cutaneous candidiasisCutaneous candidiasis

Tinea CorporisTinea Corporis Cause:Cause: Tinea corporis is a common skin disorder among children. Tinea corporis is a common skin disorder among children.

However, it may occur in people of all ages. It is caused by mold-like However, it may occur in people of all ages. It is caused by mold-like fungi called dermatophytes. fungi called dermatophytes.

Fungi thrive in warm, moist areas. The following raise your risk for a Fungi thrive in warm, moist areas. The following raise your risk for a fungal infection:fungal infection:

Long-term wetness of the skin (such as from sweating)Long-term wetness of the skin (such as from sweating) Minor skin and nail injuriesMinor skin and nail injuries Poor hygienePoor hygiene Tinea corporis can spread easily to other people. You can catch the Tinea corporis can spread easily to other people. You can catch the

condition if you come into direct contact with an area of ringworm on condition if you come into direct contact with an area of ringworm on someone's body, or if you touch contaminated items such as:someone's body, or if you touch contaminated items such as:

ClothingClothing CombsCombs Pool surfacesPool surfaces Shower floors and wallsShower floors and walls The fungi can also be spread by pets (cats are common carriers). The fungi can also be spread by pets (cats are common carriers).

SymptomsSymptoms

Symptoms may include Symptoms may include itching.. The rash begins as a small area of red, raised spots and The rash begins as a small area of red, raised spots and

pimples. The rash slowly becomes ring-shaped, with a red-pimples. The rash slowly becomes ring-shaped, with a red-colored, raised border and a clearer center. The border may colored, raised border and a clearer center. The border may look scaly.look scaly.

The rash may occur on the arms, legs, face, or other exposed The rash may occur on the arms, legs, face, or other exposed body areas.body areas.

Tinea CorporisTinea Corporis

Signs and testsSigns and tests The health care provider can often diagnose tinea corporis by The health care provider can often diagnose tinea corporis by

how the skin looks.how the skin looks. In some cases, the following tests may be done:In some cases, the following tests may be done: Looking at a skin scraping of the rash under the microscope Looking at a skin scraping of the rash under the microscope

using a KOH (using a KOH (potassium hydroxide) test) test Skin lesion biopsy

Tinea CorporisTinea Corporis

TreatmentTreatment TOPICAL THERAPY:TOPICAL THERAPY: Topical therapy should be applied to the

lesion and at least 2 cm beyond this area once or twice a day for at least 2 weeks, depending on which agent is used. Topical azoles and allylamines show high rates of clinical efficacy. These agents inhibit the synthesis of ergosterol, a major fungal cell membrane sterol.

SYSTEMIC THERAPY:SYSTEMIC THERAPY: Systemic therapy may be indicated for Systemic therapy may be indicated for tinea corporis that includes extensive skin infection, immunosuppression, tinea corporis that includes extensive skin infection, immunosuppression, resistance to topical antifungal therapy. Use of oral agents requires resistance to topical antifungal therapy. Use of oral agents requires attention to potential drug interactions and monitoring for adverse effects. attention to potential drug interactions and monitoring for adverse effects.

Tinea CrurisTinea Cruris

Tinea cruris, a pruritic superficial fungal infection of the groin Tinea cruris, a pruritic superficial fungal infection of the groin and adjacent skin, is the second most common clinical and adjacent skin, is the second most common clinical presentation for dermatophytosis. Tinea cruris is a common presentation for dermatophytosis. Tinea cruris is a common and important clinical problem that may, at times, be a and important clinical problem that may, at times, be a diagnostic and therapeutic challenge. diagnostic and therapeutic challenge.

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

The most common etiologic agents for tinea cruris The most common etiologic agents for tinea cruris include include Trichophyton rubrum Trichophyton rubrum and and Epidermophyton floccosumEpidermophyton floccosum; ; less commonly less commonly Trichophyton mentagrophytesTrichophyton mentagrophytes and  and Trichophyton verrucosumTrichophyton verrucosum are involved.  are involved.

Tinea cruris is a contagious infection transmitted by fomites, Tinea cruris is a contagious infection transmitted by fomites, such as contaminated towels or hotel bedroom sheets, or by such as contaminated towels or hotel bedroom sheets, or by autoinoculation from a reservoir on the hands or feet (tinea autoinoculation from a reservoir on the hands or feet (tinea manuum, tinea pedis, tinea unguium). manuum, tinea pedis, tinea unguium).

The etiologic agents in tinea cruris produce keratinases, which The etiologic agents in tinea cruris produce keratinases, which allow invasion of the cornified cell layer of the epidermis. The allow invasion of the cornified cell layer of the epidermis. The host immune response may prevent deeper invasion. Risk host immune response may prevent deeper invasion. Risk factors for initial tinea cruris infection or reinfection include factors for initial tinea cruris infection or reinfection include wearing tight-fitting or wet clothing or undergarments. wearing tight-fitting or wet clothing or undergarments.

Tinea Cruris TreatmentTinea Cruris Treatment

Clinical cure of an uncomplicated tinea cruris infection usually can be Clinical cure of an uncomplicated tinea cruris infection usually can be achieved using topical antifungal agents of the imidazole or allylamine family. achieved using topical antifungal agents of the imidazole or allylamine family. Consider patients unable to use topical treatments consistently or with Consider patients unable to use topical treatments consistently or with extensive or recalcitrant infection as candidates for systemic administration of extensive or recalcitrant infection as candidates for systemic administration of antifungal therapy, which has been proven safe in immunocompetent persons.antifungal therapy, which has been proven safe in immunocompetent persons.

Prevention of tinea cruris reinfection is an essential component of disease Prevention of tinea cruris reinfection is an essential component of disease management. Patients with tinea cruris often have concurrent dermatophyte management. Patients with tinea cruris often have concurrent dermatophyte infections of the feet and hands.infections of the feet and hands.

Treat all active areas of tinea cruris infection simultaneously to prevent Treat all active areas of tinea cruris infection simultaneously to prevent reinfection of the groin from other body sites.reinfection of the groin from other body sites.

Advise patients with tinea pedis to put on their socks before their undershorts Advise patients with tinea pedis to put on their socks before their undershorts to reduce the possibility of direct contamination.to reduce the possibility of direct contamination.

Advise patients with tinea cruris to dry the crural folds completely after Advise patients with tinea cruris to dry the crural folds completely after bathing and to use separate towels for drying the groin and other parts of the bathing and to use separate towels for drying the groin and other parts of the body.body.

Tinea PedisTinea Pedis

Tinea pedis is the term used for a dermatophyte infection of the soles of Tinea pedis is the term used for a dermatophyte infection of the soles of the feet and the interdigital spaces. Tinea pedis is most commonly caused the feet and the interdigital spaces. Tinea pedis is most commonly caused bybyTrichophyton rubrum,Trichophyton rubrum, a dermatophyte initially endemic only to a small  a dermatophyte initially endemic only to a small region of Southeast Asia and in parts of Africa and Australia. Interestingly, region of Southeast Asia and in parts of Africa and Australia. Interestingly, tinea pedis was not noted in these areas then, possibly because these tinea pedis was not noted in these areas then, possibly because these populations did not wear occlusive footwear. The colonization of the populations did not wear occlusive footwear. The colonization of the T T rubrumrubrum –endemic regions by European nations helped to spread the fungus  –endemic regions by European nations helped to spread the fungus throughout Europe. Wars with accompanying mass movements of troops throughout Europe. Wars with accompanying mass movements of troops and refugees, the general increase in available means of travel, and the rise and refugees, the general increase in available means of travel, and the rise in the use of occlusive footwear have all combined to make in the use of occlusive footwear have all combined to make T rubrumT rubrum the  the world's most prevalent dermatophyte world's most prevalent dermatophyte

Tinea PedisTinea Pedis

Causes:Causes: Athlete's foot occurs when a certain fungus grows on your skin in your Athlete's foot occurs when a certain fungus grows on your skin in your

feet. In addition to the toes, it may also occur on the heels, palms, and feet. In addition to the toes, it may also occur on the heels, palms, and between the fingers.between the fingers.

Athlete's foot is the most common type of Athlete's foot is the most common type of tinea fungal infections. The  fungal infections. The fungus thrives in warm, moist areas. Your risk for getting athlete's foot fungus thrives in warm, moist areas. Your risk for getting athlete's foot increases if you:increases if you:

Wear closed shoes, especially if they are plastic-linedWear closed shoes, especially if they are plastic-lined Keep your feet wet for prolonged periods of timeKeep your feet wet for prolonged periods of time Sweat a lotSweat a lot Develop a minor skin or nail injuryDevelop a minor skin or nail injury Athlete's foot is contagious, and can be passed through direct contact, or Athlete's foot is contagious, and can be passed through direct contact, or

contact with items such as shoes, stockings, and shower or pool surfaces.contact with items such as shoes, stockings, and shower or pool surfaces.

SymptomsSymptoms

The most common symptom is cracked, flaking, peeling skin The most common symptom is cracked, flaking, peeling skin between the toes or side of the foot. Other symptoms can between the toes or side of the foot. Other symptoms can include:include:

Red and itchy skinRed and itchy skin Burning or stinging painBurning or stinging pain Blisters that ooze or get crustyBlisters that ooze or get crusty If the fungus spreads to your nails, they can become If the fungus spreads to your nails, they can become

discolored, thick, and even crumble.discolored, thick, and even crumble. Athlete's foot may occur at the same time as other fungal skin Athlete's foot may occur at the same time as other fungal skin

infections such as ringworm or infections such as ringworm or jock itch..

Tinea Pedis TreatmentTinea Pedis Treatment

Tinea pedis can be treated with topical or oral antifungals or a combination of both. Topical agents are used for 1-6 weeks, depending on manufacturers' recommendations. A patient with chronic hyperkeratotic (moccasin) tinea pedis should be instructed to apply medication to the bottoms and sides of his or her feet. For interdigital tinea pedis, even though symptoms may not be present, a patient should apply the topical agent to the interdigital areas and to the soles because of the likelihood of plantar-surface infection.

Tinea VersicolorTinea Versicolor

A fungal infection of the skin caused by A fungal infection of the skin caused by Malassezia furfurMalassezia furfur and  and characterized by finely desquamating, pale tan patches on the characterized by finely desquamating, pale tan patches on the upper trunk and upper arms that may itch and do not tan. In upper trunk and upper arms that may itch and do not tan. In dark-skinned people the lesions may be depigmented. The dark-skinned people the lesions may be depigmented. The fungus fluoresces under Wood's light and may be easily fungus fluoresces under Wood's light and may be easily identified in scrapings viewed under a microscope. Topical identified in scrapings viewed under a microscope. Topical and oral antifungal agents may be used, as well as repeated and oral antifungal agents may be used, as well as repeated applications of selenium sulfide. The pale patches may persist applications of selenium sulfide. The pale patches may persist for up to 1 year after successful treatment, and recurrence is for up to 1 year after successful treatment, and recurrence is common. common.

Tinea VersicolorTinea Versicolor

Signs & Symptoms:Signs & Symptoms: Acidic bleach from the growing yeast Acidic bleach from the growing yeast causes areas of skin to be a different color than the skin around causes areas of skin to be a different color than the skin around them. These can be individual spots or patches. Specific signs them. These can be individual spots or patches. Specific signs and symptoms of the infection include:and symptoms of the infection include:

Patches that may be white, pink, red, or brown and can be Patches that may be white, pink, red, or brown and can be lighter or darker than the skin around them.lighter or darker than the skin around them.

Spots that do not tan the way the rest of your skin does.Spots that do not tan the way the rest of your skin does. Spots that may occur anywhere on your body but are most Spots that may occur anywhere on your body but are most

commonly seen on your neck, chest, back, and arms.commonly seen on your neck, chest, back, and arms. The spots may disappear during cool weather and get worse The spots may disappear during cool weather and get worse

during warm and humid weather. They may be dry and scaly during warm and humid weather. They may be dry and scaly and may itch or hurt, although this is not common.and may itch or hurt, although this is not common.

Treatment Of Tinea VersicolorTreatment Of Tinea Versicolor

Treatment of tinea versicolor can consist of creams, lotions, or Treatment of tinea versicolor can consist of creams, lotions, or shampoos that are put on the skin. It can also include shampoos that are put on the skin. It can also include medication given as pills. The type of treatment will depend  given as pills. The type of treatment will depend on the size, location, and thickness of the infected area.on the size, location, and thickness of the infected area.

Treatment options include:Treatment options include:

Topical anti-fungals:Topical anti-fungals:These products are applied directly to These products are applied directly to your skin and may be in the form of lotions, shampoos, your skin and may be in the form of lotions, shampoos, creams, or soaps. They keep the growth of the yeast under creams, or soaps. They keep the growth of the yeast under control. Over-the-counter anti-fungal topical products control. Over-the-counter anti-fungal topical products containing ingredients such as containing ingredients such as selenium sulfide,  sulfide, miconazole, , clotrimazole, and terbinafine are available. But sometimes , and terbinafine are available. But sometimes prescription medications may be needed.prescription medications may be needed.

Treatment Of Tinea VersicolorTreatment Of Tinea Versicolor

Anti-fungal pills: Anti-fungal pills: These may be used to treat more serious or These may be used to treat more serious or recurrent cases of tinea versicolor. Or in some cases they may recurrent cases of tinea versicolor. Or in some cases they may be used because they can provide a simpler and quicker be used because they can provide a simpler and quicker resolution of the infection. These medicines are given by resolution of the infection. These medicines are given by prescription and can have side effects. So it's important to be prescription and can have side effects. So it's important to be monitored by your doctor while using anti-fungal pills.monitored by your doctor while using anti-fungal pills.

Treatment usually eliminates the fungal infection. However, the Treatment usually eliminates the fungal infection. However, the discoloration of the skin may take up to several months to discoloration of the skin may take up to several months to resolve.resolve.

Onychomycosis

Onychomycosis is a Onychomycosis is a fungal  infection of the toenails or  of the toenails or fingernails. fingernails.

Cause: Onychomycosis causes fingernails or toenails to Cause: Onychomycosis causes fingernails or toenails to thicken, discolor, disfigure, and split. At first, onychomycosis thicken, discolor, disfigure, and split. At first, onychomycosis appears to be only a cosmetic concern. Without treatment, appears to be only a cosmetic concern. Without treatment, however, the toenails can become so thick that they press however, the toenails can become so thick that they press against the inside of the shoes, causing pressure, irritation, against the inside of the shoes, causing pressure, irritation, and and pain. . Fingernail infection may cause psychological, social,  infection may cause psychological, social, or employment-related problems. or employment-related problems.

Onychomycosis Symptoms & SignsOnychomycosis Symptoms & Signs

Onychomycosis usually does not cause any symptoms unless Onychomycosis usually does not cause any symptoms unless the nail becomes so thick it causes pain when wearing shoes. the nail becomes so thick it causes pain when wearing shoes. People with onychomycosis usually go to the doctor for People with onychomycosis usually go to the doctor for cosmetic reasons, not because of physical pain or problems cosmetic reasons, not because of physical pain or problems related to onychomycosis.related to onychomycosis.

As the nail thickens, onychomycosis may interfere with As the nail thickens, onychomycosis may interfere with standing, walking, and exercising.standing, walking, and exercising.

Paresthesia (a  (a sensation of pricking, tingling, or creeping on  of pricking, tingling, or creeping on the skin having noobjective cause and usually associated the skin having noobjective cause and usually associated with injury or irritation of a nerve), pain, discomfort, and loss with injury or irritation of a nerve), pain, discomfort, and loss of agility (dexterity) may occur. Loss of self-esteem, of agility (dexterity) may occur. Loss of self-esteem, embarrassment, and social problems can also develop.embarrassment, and social problems can also develop.

Severe cases of Severe cases of CandidaCandida infections can disfigure the fingertips  infections can disfigure the fingertips and nails.and nails.

Treatment on OnychomycosisTreatment on Onychomycosis

In the past, medicines used to treat onychomycosis (OM) were In the past, medicines used to treat onychomycosis (OM) were not very effective. OM is difficult to treat because nails grow not very effective. OM is difficult to treat because nails grow slowly and receive very little blood supply. However, recent slowly and receive very little blood supply. However, recent advances in treatment options, including oral (taken by mouth) advances in treatment options, including oral (taken by mouth) and topical (applied on the skin or nail surface) medications, and topical (applied on the skin or nail surface) medications, have been made. Newer oral medicines have revolutionized have been made. Newer oral medicines have revolutionized treatment of onychomycosis. However, the rate of treatment of onychomycosis. However, the rate of recurrence is high, even with newer medicines. Treatment is recurrence is high, even with newer medicines. Treatment is expensive, has certain risks, and recurrence is possible. expensive, has certain risks, and recurrence is possible.

Dosage & Administration Of Terbinafine to Dosage & Administration Of Terbinafine to Eradicate TineaEradicate Tinea

The Oral dose of Terbinafine is a constant 250 mg O.D. in adultsThe Oral dose of Terbinafine is a constant 250 mg O.D. in adults The duration can vary considerably, depending on the condition (severity, The duration can vary considerably, depending on the condition (severity,

area of distribution and duration of the disease)area of distribution and duration of the disease) ADULT DOSAGEADULT DOSAGE Tinea Corporis :Tinea Corporis : Topical applicationTopical application once or twice daily, for 1 to 2 wks; once or twice daily, for 1 to 2 wks;

OrallyOrally 250 mg O.D. for up to 4 weeks 250 mg O.D. for up to 4 weeks

Tinea Cruris :Tinea Cruris : Topical applicationTopical application once or twice daily for 1 to 2 weeks; once or twice daily for 1 to 2 weeks; Orally Orally 250 mg O.D. for 2 to 4 weeks250 mg O.D. for 2 to 4 weeks

Tinea Pedis :Tinea Pedis : Topical applicationTopical application once or twice daily for 1 week; once or twice daily for 1 week; Orally Orally 250 mg O.D. for up to 6 weeks250 mg O.D. for up to 6 weeks

Tinea Capitis :Tinea Capitis : Orally Orally 250 mg O.D. for 4 weeks (rarely found in adults)250 mg O.D. for 4 weeks (rarely found in adults) Tinea Versicolor :Tinea Versicolor : Topical application once or twice daily for 1 to 2 Topical application once or twice daily for 1 to 2

weeks, suitable oral antimycotic drug may be co-prescribed, like weeks, suitable oral antimycotic drug may be co-prescribed, like Terbinafine itself, or Fluconazole.Terbinafine itself, or Fluconazole.

Dosage & Administration Of TerbinafineDosage & Administration Of Terbinafine PAEDIATRIC DOSAGEPAEDIATRIC DOSAGE Terbinafine can be safely used in children over 1 year of age, for Tinea infections, Terbinafine can be safely used in children over 1 year of age, for Tinea infections,

Onychomycosis, and especially Onychomycosis, and especially Tinea Capitis,Tinea Capitis, in the following per kg body wt. in the following per kg body wt. dosedose::

10 - 20 kg10 - 20 kg -- 62.5 mg O.D.62.5 mg O.D. 20 - 40 kg20 - 40 kg -- 125 mg O.D.125 mg O.D. >40 kg>40 kg -- 250 mg O.D.250 mg O.D.

The indication-wise dosage in children is as follows :The indication-wise dosage in children is as follows : Tinea CapitisTinea Capitis -- 2 weeks to 4 weeks2 weeks to 4 weeks Tinea CrurisTinea Cruris -- 2 to 4 weeks2 to 4 weeks Tinea Corporis Tinea Corporis -- 4 weeks4 weeks Onychomycosis Onychomycosis -- Up to 6 weeks, in case of fingernail, or Up to 6 weeks, in case of fingernail, or

longerlonger Up to 12 weeks, in case of toenail, or Up to 12 weeks, in case of toenail, or

longerlonger

Adjuvant therapy with Ketoconazole in Tinea Adjuvant therapy with Ketoconazole in Tinea InfectionInfection

2% Ketoconazole w/w offers freedom from and protects against 2% Ketoconazole w/w offers freedom from and protects against Tinea Versicolor, and also effective as an adjuvant therapy Tinea Versicolor, and also effective as an adjuvant therapy along with topical and oral antifungal drugs to treat tinea and along with topical and oral antifungal drugs to treat tinea and candida skin infections.  candida skin infections.