superficial fungal infections - dr mcquaid

tinea infections are common cutaneous infections, caused by _________

dermatophytes

what is vulvovaginal candidiasis?

inflammation of vulvovaginal area

NOT an STI

what is considered uncomplicated vulvovaginal candidiasis?

< 3 episodes per year

non-pregnant

immunocompetent individual

mild-moderate symptoms

what is considered a complicated vulvovaginal candidiasis infection?

severe infection

pregnant or immunocompromised individual

uncontrolled diabetes mellitus

what is considered a recurrent vulvovaginal candidiasis infection?

3 or more test-confirmed infections within a year

who does vulvovaginal candidiasis occur most often in?

females 20-40 years of age

post-menopausal females on HRT

how does vulvovaginal candidiasis present?

itching, burning, soreness, redness, irritation, edema

pain with intercourse or urination

discharge: white, thick, clumpy (zero to minimal associated odor)

list RX treatment options for uncomplicated VVC

fluconazole: PO x 1 dose

nystatin: PV

terconazole: PV

list OTC treatment options for uncomplicated VVC

all are admin PV

clotrimazole

miconazole

tioconazole

boric acid

when should boric acid be used for uncomplicated VVC?

pts have allergy to azoles

T/F boric acid taken orally can result in death

TRUE

-given as a suppository PV

what route should be used for treating uncomplicated VVC?

topical or systemic

-no difference in efficacy

-consider pt preference

list treatment options for complicated VVC if the patient is pregnant

most are 7 days, nystatin is 7-14 days

clotrimazole: PV

miconazole: PV

nystatin: PV

what agents should be AVOIDED in pregnancy?

fluconazole

terconazole

boric acid

for complicated VVC in non-pregnant individuals we should use _______ of oral or topical agents

a. shorter courses

b. longer courses

b.

in complicated VVC, non-pregnant pts, ________ can be used in adjunct to antifungals when vulvar inflammation is severe

topical steroids

-lotrisone (betamethasone and clotrimazole)

-nystatin and triamcinolone

list treatment options for complicated VVC for non-pregnant pts

topical duration: 7-14 days

fluconazole: PO

clotrimazole: PV

miconazole: PV

terconazole: PV

a patient had 2 test-confirmed VVC infections within 1 year

are prophylactic doses of fluconazole indicated?

NO

recurrent: 3 or more test-confirmed VVC infections within 1 year

prophylaxis: fluconazole at start and end of abx course

list tx options for recurrent VVC

fluconazole monotherapy

fluconazole + oteseconazole combo therapy

what is the recommended duration of therapy for topical antifungals when treating complicated VVC?

7-14 days

what are the non-albicans candida species (NAC) that are often resistant to azole therapy?

c. glabrata (most common)

c. krusei

VVC case:

if c. glabrata is confirmed in a non-pregnant pt, what is preferred treatment?

alternatives?

preferred: vaginal boric acid

alternatives: flucytosine, amphotericin B

what antifungal for VVC has many drug-interactions?

fluconazole

when should topical azoles be administered?

what do you need to avoid for duration of tx?

admin: bedtime

avoid: tampons, douches, spermicides, vaginal intercourse

a patient that had VVC came into the pharmacy. She said her symptoms had improved and she didn’t feel like using the suppositories anymore, so she was going to stop even though she had a few days of treatment left. What should you tell her?

BAD GORL

complete full course of therapy, even if symptoms improve

what is oropharyngeal candidiasis (OPC) aka “thrush” and esophageal candidias caused by?

candida albicans

who might candida albicans become pathogenic in?

a. immunocompetent

b. immunocompromised

c. both

c.

how is oropharyngeal/esophageal candidiasis characterized?

white plaques

cotton-mouth

loss of taste

burning sensation (tongue)

pain with eating/swallowing

when does testing need to be performed to diagnose oropharyngeal/esophageal candidiasis?

pt does NOT possess obvious risk factors for thrush

exam findings are NOT clearly identifiable as thrush

what route of administration is preferred for oropharyngeal candidiasis treatment (does NOT extend to esophagus)?

topical

what is the preferred treatment option for esophageal candidiasis (extensive disease) and/or severely immunocompromised pts?

systemic fluconazole

increased dose and duration

list tx options for oropharyngeal candidiasis

clotrimazole troches

miconazole buccal tabs

nystatin suspension

fluconazole tablet

what are some counseling points when using troches for oropharyngeal/esophageal candidiasis?

allow to dissolve (~30 minutes)

do not chew or swallow whole

not preferred with dry mouth

what are some counseling points when using buccal tablets for oropharyngeal/esophageal candidiasis?

apply with clean hands after meals/brushing teeth

do not chew or swallow whole

preferred over troches in pts with dry mouth

what is preferred in pts with dry mouth from oropharyngeal/esophageal candidiasis?

a. troches

b. buccal tablets

c. both

b.

what are some counseling points when using oral suspension for oropharyngeal/esophageal candidiasis?

shake well before use

swish and retain in mouth for as long as possible (several minutes) before swallowing

what are some counseling points for oropharyngeal/esophageal candidiasis in general?

remove dentures while applying medication

rinse mouth after using inhalers

complete full course of therapy, even if symptoms improve

superficial cutaneous fungal infections are also known as ________ and may appear on areas of skin, hair, follicles, or nails

mycoses

________ is NOT effective for tinea (dermatophyte) infections

topical nystatin

_________ is NOT preferred for the treatment of superficial curaneous fungal infections (mycoses)

oral ketoconazole

what is mycoses of the toes, foot/feet, AKA “athlete’s foot”, called?

a. tinea pedis

b. tinea manuum

c. tinea corporis

d. tinea cruris

a.

what is mycoses of the hand(s) and skin of the fingers called?

a. tinea pedis

b. tinea manuum

c. tinea corporis

d. tinea cruris

b.

what is mycoses of the trunk of body (can include extremities) and the face, AKA “ringworm”, called?

a. tinea pedis

b. tinea manuum

c. tinea corporis

d. tinea cruris

c.

what is mycoses of the proximal thighs and/or buttocks, AKA “jock itch”, called?

a. tinea pedis

b. tinea manuum

c. tinea corporis

d. tinea cruris

d.

when is topical therapy preferred for tinea corporis?

localized disease

what has outbreaks that are common among athletes who have direct skin-to-skin contact?

tinea corporis

aka “ringworm”

is tinea cruris more common in men or women?

men

aka “jock itch”

list OTC/Rx topical products for tx of tinea infection

topical is preferred

butenafine (lotrimin)

ciclopirox (ciclodan)

tolnaftate (tinactin)

terbinafine (lamisil)

list oral RX products that are used for tx of tinea infections

fluconazole

itraconazole

terbinafine

list counseling points for topical formulations for tinea treatment

external use only

cream or gel should be gently massaged into clean skin

adverse effects: irritation or allergic contact dermatitis at site

which of the following must be administered with a full meal?

a. fluconazole

b. itraconazole

c. terbinafine

b.

what is mycoses of the scalp and hair follicles called?

a. tinea capitis

b. tinea barbae

a.

what is mycoses of facial hair follicles called?

tinea barbae

what is the preferred treatment for tinea capitis?

what can be used as adjunctive therapy?

preferred: oral antifungals (terbinafine, griseofulvin)

adjunct: antifungal shampoo

tinea barbae most commonly occurs in ___________

adolescent and adult males

________ therapy is necessary for treatment of tinea barbae

oral antifungals

-fluconazole

-itraconazole

-terbinafine

onychomycosis: mycoses affecting the nails is also known as ______

tinea unguium

______ therapy is preferred for onychomycosis due to higher complete cure rates and shorter courses of therapy

a. topical

b. oral

b.

topical therapy for onychomycosis is preferable for what patients?

CIs to PO therapy

drug interactions

patient preference

list topical RX/OTC tx options for onychomycosis

which one is RX only?

efinaconazole (jublia): RX only

tavaborole

ciclopirox

list oral tx options for onychomycosis

which is preferred?

considered gold standard of therapy

terbinafine: preferred

itraconazole

what are counseling points for topical tx of onychomycosis?

apply to clean, dry nail (wait ≥ 10 mins after showering)

apply evenly over entire nail plate and to surrounding skin and nail bed under nail plate if possible

bedtime admin is preferred

apply daily over previous coat for 7 days

wash hands after applicatioon

trim nails

adverse effects: irritation or allergic contact dermatitis or nail discoloration