511 - Self-Care: Fungal Skin Infections (WIP)

Most superficial fungal infections are caused by what type of fungi?

Dermatophyte fungi

What are clinical signs of infection?

soggy malodorous, thickened skin, acute vesicular rash, fine scaling of affected area w/ varying degrees of inflammation; clearer center surrounded by an inflammatory edge

What are the general areas that a Tinea infection can occur?

1. areas with excess moisture can accumulate (feet, groin, scalp, under nail and arms)

What can be an indication of increasing severity?

1. spreading of infection

2. pain becoming debilitating

What are complications that can come from Tinea infecton?

1. 2ndry bacterial infections

2. hair loss (t. capitis)

3. scaring of skin

How are tinea infections transmitted?

Caused by person-to-person contact with sharing contact with individuals infected with anthropohilic dermatophytes

Common name of Tinea pedis

Athletes’s foot

• dermatophytosis of the foot

Common name of Tinea Unguium

Ringworm of the nails

• onychomycosis

Common name of Tinea Corporis

Ringworm of the body

Common name of Tinea Cruris

Jock Itch

Tinea Capitis

Ringworm of scalp

Common presentation for each Tinea infection

Lesions (ring shaped with clear centers and red, scaly borders)

Risk factors of Tinea pedis

1. use of public pools or bathing facilities than in the general population

2. High-impact sports that cause chronic trauma to the feet

3. Wearing occlusive socks and shoes

Risk factors of Tinea corporis

1. daycare centers and in contact sports (children)

2. hot, humid climates

3. stress and being overweight

4. sweating or wearing wet clothing for long periods

Risk factors of Tinea Cruris

1. warm weather (but can occur any time of the year)

2. skin stays warm and moist for long periods (sweating and wet clothing in groin area)

3. men more than women (rare in children)

Risk factors of Tinea Capitis

1. direct chance with infected individual (children at greater risk)

Why do children have a higher risk of contracting/transmitting skin infections?

less attentive than adults to personal hygiene

Risk factors of general Tinea infections

Chronic health problems and meds that weaken or suppress immune system

Which Tinea infections are self-treatable?

1. T. Pedis (feet)

2. T. Corporis (general body)

3. T. Cruris (jock itch)

Which Tinea infections require referrals?

1. T. Unguium (nails)

2. T. Capitis (scalp)

What are pharmacological preventative measures that can be taken for Tinea infections?

1. Tolnaftate (Tinactin)

   1. the ONLY non-rx drugs for both prevention AND tx

2. Cliquinol/Undecylenic Acid (Cruex)

   1. approved for tx of T. Pedis and T. Cruris

   2. works by preventing fungal growth

3. Imidazoles:

   1. Clotrimazole (Lotrimin AF)

   2. Miconazole (Micaderm)

4. Squalene epoxidase inhibitor

   1. Butenafine (Lotrimin Ultra)

   2. Terbinafine (Lamisil)

5. Salts of Aluminum

What are non-pharmacological preventative measures that can be taken for Tinea infections?

Goal: prevent spreading of infection to other parts of body

1. use separate towel to dry affected area or dry affected area last

Goal: prevent spreading between people

1. do not share towels, clothing, or other personal articles w/ household members

2. launder contaminated towels/clothing in hot water + dry on hot dryer setting to prevent spreading infection

Goal: prevent infection to yourself

1. cleanse skin daily w/ soap + water, thoroughly pat dry to remove oils that promote growth of fungi

2. do not wear clothing/shoes that cause skin to stay wet

3. do not wear clothing/shoes that cause skin to stay wet (wool and certain synthetic fabrics prevent optimal air circulation)

4. allow shoes to dry thoroughly before wearing them again → dust shoes w/ med or non-med food powder to help keep them dry

5. place odor-controlling insoles in casual or athletic shoes → change every 3-4 months or more

Patient counseling for use of medication

1. Ask HCP for help in picking right antifungal and dosage

2. Term of care 2-4 weeks to cure (possibly 4-6 weeks)

3. Apply to clean, dry affected areas as directed (am/pm QID or BID) and massage into area

   1. Creams and Solutions easier to work into skin

4. Avoid getting product into eyes

5. Wash hands thoroughly w/ soap and water before AND after applying product

Patient Counseling points regarding reactions to drugs

1. Topical antifungals may cause itching, redness, and irritation

2. Tolnaftate (specifically) may sting slightly upon application

3. If apply to foot (where horny skin layer is thicker), apply keratolytic agent first to help w/ penetration

Patient Counseling points regarding oozing lesion

1. Apply aluminum acetate first

2. Soak area in aluminum acetate solution for 15-30 mins up to TID (q6 - 8 hrs) or apply to affected area in form of wet dressing

3. Aluminum acetate (Burow’s soln) available for immediate use or can be prepared (powders/tablets must be dissolved in water)

4. Use for NO MORE than 1 week, discontinue if inflammatory lesions appear/worsen

   1. Term of use is to avoid skin damage

Patient Counseling points regarding tx of wet/soggy athlete’s foot

1. Aluminum acetate as topical agent or foot soaks before antifungal

2. Soak feet BID until oder, wetness, and whiteness is gone

3. Soak QID to contrl sx

4. Deep fissures —> use more dilute soln

   1. 30% soln applied BID

5. Apply antifungal immediately after soaking and area has dried

Common side effects that patients expect when using topical antifungals?

1. Local skin irritation

2. Burning sensations

What parts of the body are exclusions to self-tx?

Nails, scalp, face, mucous membranes, genitalia

What characteristics of the infection are exclusions to self-tx?

1. unclear causation factor

2. worsening of condition

3. signs of possible 2ndary bacterial infection

4. excessive and continuous exudation

5. condition extensive, seriously inflamed, or debilitating

6. initial tx regimen unsuccessful or worsening despite tx

What do you tell a patient who has already tried tx-ing the infection?

Go to your PCP

What other chronic conditions make the patient excluded from self-care?

1. Diabetes

2. systemic infection

3. immune deficiency

What temporary conditions make the patient excluded from self-care?

1. Fever

2. Malaise

3. Both fever and malaise

4. Pregnancy

Sx of Tinea Corporis

• (other sx seen w/ tinea infections)

• spreads peripherally

• borders may contain vesicles or pustules

Sx of Tinea Pedis

• fissuring, scaling or maceration in interdigital spaces of toes; malodor; pruritus; stinging sensation on feet

• papules and scales w/ mild inflammation and diffuse hyperkeratotic dry scaling on soles on feet

Diagnosis of Tinea Infection

KOH tests

• detection of segmented hyphae in skin scrapings w/ a potassium hydroxide (KOH) prep

Fungal cultures

Based on location: how to differentiate between Bacterial infection, Tinea infection, and Contact dermatitis?

1. Bacterial infection:

   1. anywhere on the body

2. Tinea infection:

   1. areas of excess moisture can accumulate (feet, groin, scalp, under the arm)

3. Contact dermatitis:

   1. area with possible exposure to allergen/irritant (hands, face, ears, eyes, and anogenital area

Based on signs: how to differentiate between Bacterial infection, Tinea infection, and Contact dermatitis?

1. Bacterial:

   1. variety of lesions (macules to pustules to ulcers) w/ redness surrounding lesion; lesions often redder and warmer than surrounding unaffected skin

2. Tinea:

   1. soggy, malodorous, thickened skin; acute vesicular rash or fine scaling of affected area w/ varying degrees of inflammation

3. Contact Derm:

   1. variety of lesions: raised wheals (swollen surface of skin), fluid filled vesicles, or both

Based on sx: how to differentiate between Bacterial infection, Tinea infection, and Contact dermatitis?

1. Bacterial:

   1. itching and pain

2. Tinea:

   1. itching and SOME pain

3. Contact Derm:

   1. itching and SOME pain

Based on Quantity/severity: how to differentiate between Bacterial infection, Tinea infection, and Contact dermatitis?

1. Bacterial:

   1. localized to single region of body (can spread)

2. Tinea:

   1. localized to single region of body (can spread)

3. Contact Derm:

   1. affects all areas of exposed skin but does NOT spread

MOA of antifungals

inhibit synthesis of ergosterol (the main fungal sterol)

Concentrations of Topical Fungal Infection Agents

1. 1% Concentration

   1. Butenatine (Lotrimin Ultra)

   2. Clotrimazole (Lotrimin AF)

   3. Terbinafine (Lamisil)

   4. Tolnaftate (Tinactin)

2. 2% Concentration

   1. Miconazole (Micaderm)

3. Cliquinol/Undecylenic Acid (Cruex)

   1. 10 - 25%

4. Salts of Aluminum

   1. 20 - 30%

When would a referral be necessary during the course of self-tx with an antifungal?

1. If pt has been self-txing and saw no improvement after 1 week of consistent use

2. If pt experienced no relief, or worsening sx (itching, scaling, inflammation) in the first week of self-tx

3. If the infection has not cleared after 4 weeks of self-tx

Conditions to consider when choosing an Antifungal

1. Pt specified preference of frequency and duration of tx

2. cost

   1. Butenafine and terbinafine are expensive

3. DDIs

   1. miconazole and warfarin

4. Severity of ADRs w/ differing strengths of medications

   1. shorter tx duration = high conc of active → more side effects

5. Smell

   1. Clioquinol/Undecylenic Acid - odorous

6. Effectivness

   1. All antifungals have similar efficacy

   2. Clioquinol/Undecylenic Acid:

      1. approved for tinea pedis and cruris

      2. less effective on scalp or nails

   3. Creams and solutions are most effective

Freq and duration of tx w/ Clotrimazole and Miconazole

1. Tinea pedis and corporis:

   1. BID, 4 weeks

2. Tinea cruris

   1. BID, 2 weeks

Freq and Duration of tx w/ Butenafine

1. Tinea Pedis

   1. QD, 4 weeks

2. Tinea corporis and cruris

   1. QD, 2 weeks

Freq and Duration of Terbinafine

1. Tinea Pedis

   1. Btwn toes: BID, 1 week

   2. Bottom + sides: BID, 2 week

2. T. Corporis + Cruris:

   1. QD, 1 week

Freq and Duration of Tolnaftate

1. T. Pedis + T. corporis

   1. BID, 4-6 weeks

2. T. Cruris

   1. BID, 2 weeks

Salts of Aluminum

• no direct antifungal activity

  • astringent

  • antibacterial properties (>20%)

• indicated for relief of inflammatory conditions of skin

  • acute, inflammatory type and wet, soggy type of tinea infections

• T Pedis:

  • diluted in 10-40 parts of water (20-30% aluminum chloride soln)

    • Athlete’s foot: QID used until signs + sx (odor, wetness, whiteness) abate → QD cxl sx

  • whole foot immersed in water for 20 min Q6-8 or wrapped in wet dressing

Warnings w/ Salts of Aluminum

• Contraindication:

  • use on severely eroded or deeply fissured skin → risk of aluminum toxicity

    • salt diluted to lower conc (10% aluminum chloride) for initial tx

• should not be used more than 1 week

  • prolonged use of aluminum acetate → tissue necrosis

• if inflammatory lesions appear or worsen → diconc

Pregnant people should be tx-ed by….

PCP or OB/GYN

• can self-tx only if PCP/OB/GYN has given them recommendation of self-tx med

Which antifungal is a Category C for all trimesters for pregnant people?

Butenafine

Which antifungal(s) are a Category B

topical clotrimazole and miconazole

• use only in FIRST trimester BUT avoid due to increased risk of spontaneous abortions (SABs)

Risk for Breastfeeding women?

• inclusive for all non-rx topical antifungals