Adult Cutaneous Fungal Infections 2: Yeasts. Basic Dermatology Curriculum
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1 Adult Cutaneous Fungal Infections 2: Yeasts Basic Dermatology Curriculum Last updated November 27,
2 Module Instructions The following module contains a number of blue, underlined terms which are hyperlinked to the dermatology glossary, an illustrated interactive guide to clinical dermatology and dermatopathology. We encourage the learner to read all the hyperlinked information. 2
3 Goals and Objectives The purpose of this module is to help medical students develop a clinical approach to the evaluation and initial management of patients presenting with cutaneous fungal infections. By completing this module, the learner will be able to: Identify and describe the morphologies of superficial fungal infections Describe the correct procedure for performing a KOH examination and interpreting the results Recommend an initial treatment plan for an adult with tinea versicolor, candidal intertrigo, and seborrheic dermatitis 3
4 Case Four Ms. Anna Jones 4
5 Case Four: History HPI: Ms. Jones is a 27-year-old woman who presents with mild itchiness of her back which began mid summer. She is also concerned about areas on her back that are darker than the surrounding skin. PMH: asthma Medications: occasional multivitamin Allergies: no known drug allergies Social history: spends her summer months in Florida and is an avid runner. 5
6 Case Four : Skin Exam How would you describe these exam findings? 6
7 Case Four : Skin Exam Well-demarcated, hyperpigmented macules and patches, across the back. 7
8 Case Four, Question 1 Which of the following is the most likely diagnosis? a. Pityriasis alba b. Seborrheic dermatitis c. Tinea corporis d. Tinea versicolor e. Vitiligo 8
9 Case Four, Question 1 Answer: d Which of the following is the most likely diagnosis? a. Pityriasis alba (noninfectious, asymptomatic poorlydefined areas of hypopigmentation; self-limited) b. Seborrheic dermatitis (abnormal immune response to normal skin yeast causing scaling and crusting) c. Tinea corporis (fungal skin infection, presents as erythematous annular lesions with central clearing) d. Tinea versicolor e. Vitiligo (autoimmune loss/dysfunction of melanocytes causing areas of complete depigmentation) 9
10 Diagnosis: Tinea Versicolor Tinea versicolor (aka Pityriasis versicolor) is not caused by a dermatophyte It is a colonization caused by species of Malassezia, a lipophilic yeast that is a normal resident in the keratin of the skin and hair follicles of individuals at puberty and beyond Tends to recur annually in the summer months 10
11 Tinea Versicolor Characterized by well-demarcated, tan, salmon, or hypopigmented or hyperpigmented patches, occurring most commonly on the trunk and arms Macules will grow, coalesce and various shapes and sizes are attained in an asymmetric distribution Visible scale is not often present, but when rubbed with a finger or scalpel blade, scale is readily seen This is a diagnostic feature of tinea versicolor Evoked scale will disappear after treatment 11
12 A Closer Look at Tinea Versicolor 12
13 Tinea Versicolor: Morphology It s called versicolor because it can be light, dark, or pink to tan. In untanned Caucasians, the lesions may be salmoncolored or brown. In tanned Caucasians, the lesions may appear pale in comparison to the surrounding skin. In darker skinned individuals, lesions may appear hyperor hypopigmented. Let s look at some examples of the various colors of tinea versicolor. 13
14 Examples of Tinea Versicolor Light spots Dark spots Pink or tan spots 14
15 Case Four, Question 2 Which of the following is the most appropriate next step in management? a. Fungal culture b. KOH exam c. Skin biopsy d. Wood s light exam 15
16 Case Four, Question 2 Answer: b Which of the following is the most appropriate next step in management? a. Fungal culture (Malassezia spp. are easily identified by a KOH exam but are not easily cultured) b. KOH exam c. Skin biopsy (too invasive; KOH is better) d. Wood s light exam (mild fluorescence may be present but not as sensitive as KOH exam) 16
17 Microscopy Spores (yeast forms) Short Hyphae The KOH exam shows short hyphae and small round spores. Characteristic spaghetti and meatball pattern. 17
18 Microscopy with dye added to the specimen Magnification 40x Characteristic spaghetti and meatball pattern corresponding to hyphae and spores. 18
19 Case Four, Question 3 Which of the following treatments would you recommend for Ms. Jones? a. Antifungal shampoo b. Hydroquinone cream c. Nystatin cream d. Oral terbinafine 19
20 Answer: a Case Four, Question 3 Which of the following treatments would you recommend for Ms. Jones? a. Antifungal shampoo b. Hydroquinone cream (this bleaching cream is not an appropriate treatment) c. Nystatin cream (not effective) d. Oral terbinafine (in contrast to tinea corporis, this is not very effective in tinea versicolor) 20
21 Topical Treatment is First-line 1. Shampoos: selenium sulfide 2% shampoo, ketoconazole shampoo, zinc pyrithione shampoo Apply daily to affected areas, wait 10 minutes, then rinse Repeat daily for 1-4 weeks As effective as oral therapy 2. Imidazole creams: ketoconazole, clotrimazole Apply daily or bid for 1-4 weeks Very effective for limited areas Usually more expensive than shampoos due to surface area 21
22 Tinea Versicolor: Oral treatment Oral medication may be used when topical therapy fails, if the benefits outweigh the risks or the patient has a strong preference for oral therapy Oral medications of choice include: Fluconazole 300 mg / week for 2-4 weeks Itraconazole 200 mg / day for 7 days or 100 mg / day for 14 days Warn about dangers: hepatotoxicity, drug interactions, GI side effects, congestive heart failure, etc. Monitor liver function if giving more than 7 days 22
23 Tinea Versicolor: Maintenance Therapy Many patients relapse If the patient has had more than one previous episode, recommend maintenance therapy Maintenance therapy: topicals are used 1-2x/week Ketoconazole shampoo, Selenium sulfide (2.5%) lotion or shampoo, Zinc pyrithione (bar or shampoo) Leave on for 10 minutes before rinsing off Refer concerned patients who fail maintenance therapy 23
24 Case Five Ms. Betty Raskin 24
25 Case Five: History HPI: Ms. Raskin is a 62-year-old woman who presents with a red itchy rash beneath her breasts PMH: Type 2 diabetes (last hemoglobin A1c 9.2%), obesity Medications: Metformin, which she says she often does not remember to take Family history: noncontributory Social history: lives in Texas part-time 25
26 Case Five, Question 1 Which of the following best describe these characteristic exam findings? a. Well-demarcated red plaques with overlying thick silvery scale b. Grouped vesicles on an erythematous base c. Sharply defined red plaques involving the skin folds with surrounding satellite macules d. Inflammatory nodules 26
27 Case Five, Question 1 Answer: c Which of the following best describe these characteristic exam findings? a. Well-demarcated red plaques with overlying thick silvery scale b. Grouped vesicles on an erythematous base c. Sharply defined red plaques involving the skin folds with surrounding satellite macules d. Inflammatory nodules 27
28 Case Five, Question 2 Which of the following is the most likely diagnosis? a. Atopic dermatitis b. Candidal intertrigo c. Psoriasis d. Seborrheic dermatitis e. Tinea cruris 28
29 Case Five, Question 2 Answer: b Which of the following is the most likely diagnosis? a. Atopic dermatitis (chronic eruption of pruritic, erythematous, oozing papules and plaques, usually with secondary lichenification and excoriation) b. Candidal intertrigo c. Psoriasis (characterized by well-demarcated, erythematous papules and plaques with overlying silvery scale) d. Seborrheic dermatitis (typical skin findings range from fine white scale to erythematous patches and plaques with greasy scale) e. Tinea cruris (dermatophytosis of the groin, genitalia, pubic area, perineal, and perianal skin, usually appears as multiple erythematous papulovesicles with a well-marginated, raised border) 29
30 Intertrigo: Basic Facts Intertrigo = inflammation of large skin folds Inframammary fold, gluteal cleft, inguinal creases, and folds under pannus (abdomen) Up to 10% of intertrigo is complicated by Candida yeast colonization Classic symptom: burns more than itches Classic sign: satellite macules, papules, or pustules around the erythema in the fold KOH exam may reveal pseudohyphae, but fungal culture may be more sensitive than KOH for Candida 30
31 Candidal intertrigo Classic satellite papules seen in Candida intertrigo Consider doing a fungal culture if diagnosis uncertain 31
32 Case Five, Question 4 Which of the following is the most appropriate next step in management? a. Clotrimazole cream b. Oral prednisone c. Oral terbinafine d. Wear tighter, supportive clothing made of synthetic fabrics 32
33 Case Five, Question 4 Answer: a Which of the following is the most appropriate next step in management? a. Clotrimazole cream (better activity against Candida than nystatin) b. Oral prednisone (may worsen the infection) c. Oral terbinafine (not effective for Candida) d. Wear tighter, supportive clothing made of synthetic fabrics (it s the opposite: loose cotton clothing is best) 33
34 Prevention Intertrigo Management Keep intertriginous areas dry, clean, and cool Dry areas after bathing with hair dryer on cool setting; repeat twice daily Encourage weight loss for obese patients Wear loose clothing made of cotton 34
35 Candidal Intertrigo Management Topical antifungal agents Imidazoles: miconazole, clotrimazole, econazole More effective than nystatin, but cream formulations may burn. Warn patients to expect this. Also treat dermatophytes in case you re not sure Polyene: nystatin Only works for Candida, not dermatophytes Has advantage of powder and ointment formulations Allylamines (terbinafine, naftifene) are not effective for Candida yeast 35
36 Candidal Intertrigo: Management Topical anti-inflammatory Low strength corticosteroid preparations rapidly improves the itching and burning Desonide ointment or 1% hydrocortisone ointment twice daily for 1-2 weeks Ointments burn less than creams when applying Longer use can cause steroid atrophy, so avoid Alternatively may use tacrolimus ointment 0.1%, which does not cause atrophy 36
37 Case Six John Wong 37
38 Case Six: History HPI: Mr. Wong is a 59 year-old man with several years of redness and scaling on his forehead, eyebrows, and central face. It improves slightly with moisturizers and does not itch. It does not worsen with heat, exercise, or alcohol. PMH: none Allergies: none Medications: allopurinol Family History: non-contributory Social History: accountant 38
39 Case Six : Skin Exam 39
40 Case Six, Question 1 How would you describe the rash on Mr. Wong s face? a. Erythematous patches with overlying scale b. Lichenified plaques with silvery scale c. Papules and pustules d. Vesicles and crust 40
41 Answer: a Case Six, Question 1 How would you describe the rash on Mr. Wong s face? a. Erythematous patches with overlying scale b. Lichenified plaques with silvery scale c. Papules and pustules d. Vesicles and crust 41
42 Case Six, Question 2 What is the most likely diagnosis? a. Actinic keratoses b. Allergic contact dermatitis c. Atopic dermatitis d. Rosacea e. Seborrheic dermatitis 42
43 Answer: e Case Six, Question 2 What is the most likely diagnosis? a. Actinic keratoses (scaly is greasy, not keratotic) b. Allergic contact dermatitis (he does not itch) c. Atopic dermatitis (very itchy; no history of this) d. Rosacea (no history of typical triggers; usually telangiectasias or papules, not scaling) e. Seborrheic dermatitis 43
44 Seborrheic dermatitis Seborrheic dermatitis is a very common inflammatory reaction to the Malassezia (Pityrosporum ovale) yeast that thrives on seborrheic (oil-producing) skin Inflammatory reaction to normal flora This is a chronic condition than can be controlled but not cured Presents as erythematous scaling patches on the scalp, hairline, eyebrows, eyelids, central face and nasolabial folds, external auditory canals, or central chest Seborrheic dermatitis is often worse in patients with HIV 44
45 Here are some examples of seborrheic dermatitis 45
46 Seborrheic dermatitis 46
47 Seborrheic dermatitis Often hypopigmented in darker skin types 47
48 Seborrheic dermatitis Favors central chest May be erythematous, hypopigmented If partially treated, may be just a few papules 48
49 Case Six, Question 3 Which of the following would be an appropriate treatment for Mr. Wong? a. Clobetasol proprionate cream b. Desonide cream (mild steroid, low potency) c. Erythromycin ointment d. Nystatin cream e. 5-fluorouracil cream 49
50 Answer: b Case Six, Question 3 Which of the following would be an appropriate treatment for Mr. Wong? a. Clobetasol proprionate cream (too potent) b. Desonide cream (mild steroid, low potency) c. Erythromycin ointment (this is not bacterial) d. Nystatin cream (for Candida yeast species, not Malassezia species) e. 5-fluorouracil cream (for actinic keratoses) 50
51 Seborrheic dermatitis treatment Topical ketoconazole twice daily Reduces yeast counts; choose vehicle based on patient Low-potency topical steroid (e.g. desonide) are safe to use for flares on the face Use twice daily for 1-2 weeks for flares Antidandruff shampoo for scalp, chest Ketoconazole, selenium sulfide, zinc pyrithione shampoos Lather, leave on 10 minutes, rinse; repeat 3-5x/week Refer patients who fail these therapies 51
52 Summary: Adult Fungal Treatment Tinea pedis Tinea corporis Tinea cruris Tinea versicolor 1 st line 2 nd line Clotrimazole Miconazole cream Selenium sulfide, zinc pyrithione shampoos Terbinafine Naftifene Butenafine cream or gel Oral fluconazole or itraconazole Candida Seborrheic dermatitis Clotrimazole Miconazole cream or Nystatin powder, ointment Ketoconazole cream Desonide or 1% hydrocortisone ointment Desonide or 1% hydrocortisone for flares 52
53 Take Home Points Tinea versicolor is characterized by well-demarcated, tan, salmon, or hypopigmented patches, occurring most commonly on the trunk. KOH confirms the diagnosis. Candida intertrigo classically has satellite macules and papules or pustules around patches of erythema Topical treatment is usually appropriate as a first-line agent for tinea versicolor, candidal intertrigo, and seborrheic dermatitis Tinea versicolor and seborrheic dermatitis are chronic conditions requiring maintenance therapy Monitoring for recurrence and maintenance treatments may be helpful in patients with recurrent infection 53
54 Acknowledgements This module was developed by the American Academy of Dermatology Medical Student Core Curriculum Workgroup from Primary authors: Iris Ahronowitz, MD; Ronda Farah, MD; Sarah D. Cipriano, MD, MPH; Raza Aly, PhD, MPH; Timothy G. Berger, MD, FAAD. Peer reviewers: Heather Woodworth Wickless, MD, MPH, FAAD; Daniel S. Loo, MD, FAAD. Revisions and editing: Sarah D. Cipriano, MD, MPH; John Trinidad. Last revised by Patrick E. McCleskey, MD, FAAD, October
55 References Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web-Based Illustrated Clinical Dermatology Glossary. MedEdPORTAL; Available from: Hu SW, Bigby M. Pityriasis versicolor: a systematic review of interventions. Arch Dermatol 2010;146(10): Janniger CK, Schwartz RA, Szepiotowski JC, Reich A. Intertrigo and common secondary skin infections. Am Fam Physician 2005;72: Mistiaen P, Poot E, Hickox S, Jochems C, Wagner C. Preventing and treating intertrigo in the large skin folds of adults. Dermatol Nursing 2004;16(1): Naldi L, Rebora A. Seborrheic dermatitis. N Eng J Med 2009;360:
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