ACHA



DRAFT Tinea Infections in Young Adults DRAFTTinea = dermatophycosis (“infested by a dermatophyte”)Tinea pedis70% of the population is infected at some point in their liferisk: heat, alkaline pH, moisturefour forms: interdigital, inflammatory (vesicular), chronic hyperkeratotic (moccasin), and ulcerativeautoinnoculation of other sites is commonTinea corporistinea of the face (excluding the beard area in men), trunk, and limbslesions varying in size, degree of inflammation, and depth of involvementclassically lesions start off as flat, scaly spots that then develop a raised border that extends out at varying rates in all directions; the advancing, scaly border may have red, raised papules or vesicles while the central area becomes brown or hypopigmented and less scaly as the active border progresses outwardperson-to-person contact is the main culprit of transmission; common in competitive wrestlingfungal infection of the beard area (tinea barbae) should be considered when inflammation is found in this region; bacterial folliculitis and inflammation secondary to ingrown hairs are commonTinea crurislesions are usually unilateral and start in the crural fold; half-moon–shaped plaque forms as well-defined scaling, and, occasionally, a vesicular border advances out of the crural fold onto the thigh; the skin within the border will turn red-brown, is less scaly, and can develop red papulesinfection can travel to the buttocks and gluteal cleft areadifferential diagnoses includes intertrigo and erythrasmaTinea capitasoccurs most frequently in prepubertal children between 3 and 7 years of age common modes of transmission include infected persons, fallen hairs, animals, fomites (clothing, bedding, hairbrushes, combs, hats), and furnitureseborrheic dermatitis and psoriasis can often be confused with tineaTinea unguium (onychomycosis)dermatophytes account for approximately 90% of toenail infections, whereas yeasts account for the majority of infections affecting the fingernails four types of onychomycosis: distal subungual onychomycosis, white superficial onychomycosis, proximal subungual onychomycosis, and candida onychomycosisPityriasis versicolor (formerly tinea versicolor)superficial fungal infection of the skin caused by Malassezia yeastsrare before puberty and in the elderly populationetiology is multifactorial and genetic susceptibility seems to play a role; other recognized risk factors are malnutrition, oral contraceptives, immune suppression, hyperhidrosis and use of oil or greasy skincare products as well as topical corticosteroidsprimarily localized to the chest, back and upper armscharacterized by flaky round or oval macular elements; lesions are light pink, hypopigmented (a common finding in dark skin individuals) or hyperpigmentedmild itching may accompany the visible changesMalassezia folliculitisinflammatory condition caused by infection with Malassezia of the sebaceous glandsoily skin or occlusion of the skin and hair follicles with skin care products or cosmetics can predispose; warm sweaty skin is also a risk factor, and deterioration after sun exposure is often observed; common among immunosuppressed patients, diabetics, as well as in patients receiving broad-spectrum antibioticson the back, chest, upper arms, neck and rarely the face a rash of uniform 2–3 mm large erythematous papules or pustules is seen; may be confused with acne but comedones are absent and itching is commonTinea incognito = topical steroid-modified tinea infectionDermatophytid reaction = acute, generalized dermatosis that develops from a remote localized immunological insultManifests as generalized pruritic, disseminated, papulovesicular eruption developing after a localized fungal infectionEradication of the primary fungal infection is the fundamental treatment for id reactionsTreatment regimens (for discussion purposes only; accuracy and completeness is not guaranteed)TineaTopicalOral (adult dosing)pedisclotrimazole 1%, C/L, BID 4-6 wkseconazole 1%, C, OD?BID 4-6 wksmiconazole 1%, C/L, BID 4-6 wksoxiconazole 2%, C/L, OD?BD 4 wkssertaconazole 2%, C, BID 4 wksluliconazole 1%, C/L, OD 2 wksterbinafine, C/P, BID 4 wksbutenafine 1%, C, OD?BID 2-4 wksothersterbinafine 250 mg, OD, 1-2 wksitraconazole 100-200 mg, OD, 2-4 wksfluconazole 150 mg/week, 4 wksotherscorporisSame as pedis, except terbinafine is 2 wksterbinafine 250 mg, OD, 2-3 wksitraconazole 200 mg, OD, 1-2 wksfluconazole 150-300 mg/wk, 3-4 wksotherscrurissame as for corporissame as for corporiscapitasN/Agriseofulvin 6–12 wks!terbinafine 250 mg OD for 4–6 wkitraconazole 2-4 mg/kg/day for 4-6 wksunguiumciclopirox 8% solution, daily for 48 wksFingernailsitraconazole 200 mg/day for 8 consecutive wksitraconazole 200 mg BID for 1 wk per month for 2–3 monthsterbinafine 250 mg/day for 6 wksfluconazole 150–200 mg/wk for 6 months Toenailsitraconazole 200 mg/day for 12 consecutive wksitraconazole 200 mg BID for 1 wk per month for 3–4 monthsterbinafine 250 mg/day for 12 wksfluconazole 150–200 mg/wk for 9–12 monthsCaution when prescribing oral antifungals in the presence of renal impairment, hepatic impairment, and pregnancy.C = cream, L = lotion, P = powder, OD = once daily, BID = twice dailyNo guidelines exist for chronic dermatophytosis.Treatment regimens (for discussion purposes only; accuracy and completeness is not guaranteed)ConditionTopicalOral (adult dosing)Pityriasis versicolorketoconazole 2% shampoo, OD for 5 days; prophylactic treatment OD up to 3 days in the beginning of the summer seasonketoconazole 2%, C, OD-BID for 2 weeksciclopirox olamine 1.5% shampoo, 2 times weekly for 2 weeksmiconazole 1%, C BID for 2 weeksclotrimazole 1%, C, BID for 2 weeksterbinafine, C/gel, BID for 1 weekselenium sulphide 2.5% shampoo, OD for 3 days followed by the same procedure one week later, maintenance therapy once every 3rd monthzinc pyrithione 1% shampoo 2–3 times weeklyothersfluconazole 300 mg weekly for 2–3 weeksfluconazole 400 mg onceitraconazole 200 mg OD for 1 week or 100 mg OD for 2 weeks, then 200 mg BID once a monthitraconazole 400 mg onceothersMalassezia folliculitisketoconazole 2% shampoo, twice weekly for 2–4 weeksmiconazole 1%, C, BID for 4 weeksselenium sulphide 2.5% shampoo, OD for 3 days; maintenance once a weekitraconazole 200 mg daily up to 3 weeksfluconazole 100–200 mg OD for 1–4 weeksfluconazole 300 mg once weekly for 1–2 monthsNote: Resistance to various antifungals exists among Malassezia species. Regimen might have to be altered if there is inadequate clinical response.Caution when prescribing oral antifungals in the presence of renal impairment, hepatic impairment, and pregnancy.C = cream, L = lotion, P = powder, OD = once daily, BID = twice dailyOTC selenium sulfide shampoos are 1%; OTC ketoconazole shampoos are 1%ReferencesHald M et al: Evidence-based Danish guidelines for the treatment of Malassezia relatedskin diseases. Acta Derm Venereol 2015; 95:12–19Hay RJ: Tinea capitis: current status. Mycopathologia 2017;182:87–93Ilkit M et al: Cutaneous id reactions: A comprehensive review of clinical manifestations, epidemiology, etiology, and management. Crit Rev Microbio 2012;38(3):191-202Ilkit M and Durdu M: (2015) Tinea pedis: The etiology and globalepidemiology of a common fungal infection. Crit Rev Microbiol 2015;41(3):374-388Kaushik N et al: Prim Care Clin Office Pract 2015;42:501–516Rubenstein RM and Malerich SA: Malassezia (Pityrosporum) folliculitis. J Clin Aesthet Dermatol 2014;7(3):37–41Sahoo AK, Mahajan R: Management of tinea corporis, tinea cruris, and tinea pedis: a comprehensive review. Indian Dermatol Online J 2016;7:77-86Van Zuuren EJ et al: Evidence-based topical treatments for tinea cruris and tineacorporis: a summary of a Cochrane systematic review. Br J Dermatol 2015;172:616–641Vinelli et al: Superficial fungal diseases of the hair, skin, and nails. In: Clinical Infectious Diseases 2ed, D Schlossberg (ed), 2015White TC et al: Fungi on the skin: dermatophytes and Malassezia. Cold Spring Harb Perspect Med 2014;4:a019802 ................
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