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Superficial Fungal Infections in Children
Teri Turner, MD, MPH, MED Associate Professor of
PediatricsBaylor College of
Medicine/Texas Children’s Hospital
Objectives
• Identify superficial fungal infections (SFIs)
• Discuss the management of common SFIs
• Compare and contrast SFIs with other non-fungal disease look-alikes
• Describe methods to differentiate SFIs from other disease processes
2
Case #1
• You are seeing a 6 year old child for an itchy flaky scalp. Mom thinks he has dandruff. You believe he has tinea capitis. • Do you need to do further testing to confirm?
• Should you treat his asymptomatic 8 year old brother?
• Should you do a culture on the family dog?
• When can he go back to school?
• How long should he be treated and are lab tests needed?
3
Why is this important?
• Superficial skin infections can be mistaken for other common diseases
• An accurate diagnosis is essential to the appropriate management strategy
• Patient understanding is the key to treatment adherence
4
Case #2• 4 week old infant
• Progressive hair loss x 2 weeks
5
What is your differential diagnosis and what would you do?
6
Tinea Capitis
• 95% of cases – Trichophyton tonsurans
• Most cases occur between 3-7 yrs. of age
• More common with crowded living conditions, low SES, urban settings and AA
• Indirect contact with fallen hair and cells
• Some call it a “modern day epidemic”
Abdel-Rahman SM, et al. Pediatrics 2010 7
Case #2: Tinea Capitis
• Rare in infants less than 1
• Most often normal infants but think about immunodeficiency
• Look for source of infection in household contacts
• Treat with oral fluconazole
Gilaberte Y, et al. Br J Dermatol 2004Romano C, et al. Pediatr Dermatol 2001 8
Presentations
• Non-inflammatory “black dot”
• Seborrheic (diffuse scale)
• “Gray patch”
• Pustular
• Kerion (inflammatory)
• Favus
©2007 by American Academy of Pediatrics
Shy R Pediatrics in Review 2007;28:164-174
9
When scalp scaling is noted in a child, the fungus is guilty until proven innocent
©2007 by American Academy of Pediatrics
Shy R Pediatrics in Review 2007;28:164-174
10
Differential Diagnosis
• Alopecia areata
• Impetigo
• Pediculosis
• Psoriasis
• Seborrhea dermatitis
• Traction alopecia
• Trichotillomania
www.dermatlas.org11
Alopecia Areata
• Sharply demarcated, round nearly bald patches of hair loss
• Occ. will have hairs that look like exclamation points (mostly at periphery)
• Treatment is individualized
www.dermatlas.org 12
Tinea vs. Alopecia
www.dermatlas.orgShy R Pediatrics in Review 2007;28:164-174
©2007 by American Academy of Pediatrics13
Tinea Capitis should be in the differential of any child who presents with alopecia
www.espd.info14
Frequency of Signs and Symptoms
www.health-7.com
15
Case #3
www.dermatlas.org
9 year old girl, URI, hair thinning, no scale, no pruritus, shotty cervical lymphadenopathy
Mother is worried about ringworm of the scalp
16
Case #3: Traction Alopecia
• Hairstyles that constantly pull
• Also associated with chemical relaxers and tight rollers
• Usually no scale and no pruritis
• Typically on the frontal and temporal areas
• “Fringe” sign – fringe of proximal hair
• Treatment – loosen the hair style
www.dermatlas.org17
Case # 4
www.dermatologynursing.net
7 year old cousin, thinning hair, slight pruritus, no adenopathy, visible flakes
18
Case # 4: Tinea Capitis
www.dermatologynursing.net
7 year old cousin, thinning hair, slight pruritus, no adenopathy, visible flakes
19
To confirm with microscopy or culture
• When in doubt, confirm with KOH or culture
• Woods lamp not helpful
• Provide counseling • No sharing of hair brushes, combs, hats, etc.
• Wash bedding in hot water
• No sports with scalp-to-scalp contact
• Should you screen other family members?
• Should you screen the family pet?
White JW, et al. J Eur Acad Dermatol Venereal 2007 20
Management of Tinea Capitis
• Griseofulvin – 6-12 weeks (no baseline labs)• May need up to 16 weeks of treatment
• If treating > 8 wks (CBC, ALT, AST, BUN, Cr)
• Higher doses recommended (20-25 mg/kg/d microsizeand 10-15 mg/kg/d for ultramicrosize)
• Terbinafine – once daily for 2-4 weeks• Liver transaminases prior to therapy
• Oral granules sprinkled on food
• $14/day (compared to $4.50) – generic now available
• Dosing based on weight
Lipozencic J, et al. Br J Dermatology 2002Tey HL, et al. J Am Acad Dermatology 2011
21
Case #5 Topical or Oral Treatment?
www.ethnomed.org
22
Case #5 Oral Treatment
www.ethnomed.org23
Adjunctive Topical Treatment
• Ketoconazole 2% shampoo
• Selenium sulfide 1% shampoo
• Povidone-iodine 2.5% shampoo
• Ciclopirox 1% shampoo
• Use sporicidal shampoo 3X weekly for 2-4 weeks
• Decreases viable spores – treat everyone
Pomeranz AJ, et al. Arch Pediatr Adolesc Med 1999.White JW et al. J Eur Acad Dermatol Venereal 2007 24
Case #6: Fungal cx negative: Antibiotics or Antifungals?
Proudfoot L. NEJM March 22, 2012 25
Case #6: Kerion: Treat with Antifungals (+/- glucocorticoid)
Proudfoot L. NEJM March 22, 2012 26
Case # 7
• 3 year old female
• Treated for 2 wks. with oral griseofulvin
• Recently developed this scaling erythematous rash
• 1-3 mm papules
• Diagnosis & management?
www.dermatlas.org 27
Case # 7: Dermatophytid (Id) Reaction
• Secondary dermatitic eruptions
• Pruritic, papulovesicular eruption
• Often distal from the original infection
• Continue antifungals
• Topical corticosteroids and antipruritic agents
www.dermatlas.org 28
Case #1 Revisited
• You are seeing a 6 year old child for an itchy flaky scalp. Mom thinks he has dandruff. You believe he has tinea capitis. • Do you need to do further testing to confirm?
• Should you treat his asymptomatic 8 year old brother?
• Should you do a culture on the family dog?
• When can he go back to school?
• How long should he be treated and are lab tests needed?
29
Case #8
www.dermatlas.org 30
Case #8
• What is your differential diagnosis?
• What laboratory tests (if any) do you want to do?
• What is your management plan?
• How would you counsel this family?
31
Differential Diagnosis
• Drug eruption
• Erythema multiforme
• Granuloma annulare
• Nummular eczematous dermatitis
• Pityriasis rosea
• Psoriasis
• Secondary syphilis
• Tinea (pityriasis) versicolor
• Tinea corporis
32
Case #8: Granuloma Annulare
• Subacute onset
• No epidermal changes (nonscaly, nonpruritic)
• Usually on dorsum of hands and feet
• Slowly enlarges with “central clearing”
• Etiology unknown
• Observation
www.dermatlas.org
33
Tinea vs. Granuloma
www.dermatlas.netwww.fromyourdoctor.com 34
Case #9
• 10 yr. old female
• pruritic lesion on arm x 6 mos.
www.health-pictures.com 35
Case #9: Nummular eczema
• Coin shaped
• Scaly patch
• No central clearing
• Itchy
• “Atopic”
• Xerosis
www.health-pictures.com
36
Tinea vs. Eczema
www.dermatlas.net www.health-pictures.com37
Case #10 What is your diagnosis?
www.dermatlas.org
38
Case #10: Tinea incognito
• Tinea corporis that has been inappropriately treated with steroids
• Original infection slowly extends
• Pruritic
• KOH prep
www.dermatlas.org 39
Case #11 Is This Tinea?
anagen.ucdavis.edu 40
Case #11 Pityriasis Rosea
anagen.ucdavis.edu
www.aafp.org
www.advancedskinwisdom.com
41
Case #12 Is This Tinea?
www.dermatlas.org42
Case #12 Majocchi granuloma
• Deep folliculitis due to a cutaneous dermatophyte infection
• Women who frequently shave their legs
• Use of potent topical steroids under occlusion
www.dermatlas.org
43
Case #13 Crusted papules and confluent vesicles. Is this Tinea?
www.dermatlas.org44
Case #13 Tinea Corporis
www.dermatlas.org45
Tinea Corporis
• T. rubrum
• Skin scraping from active border of lesion
• Multiple lesions look like a flower petal
www.dermatlas.org www.hardinmd.lib.uiowa.edu46
Tinea Corporis• Topical antifungals
• Do not use nystatin
• Extensive disease (or immunocompromised) treat orally
• Tinea faceii may require a longer course of treatment
www.dermatlas.orgwww.hardinmd.lib.uiowa.edu
47
Tinea Corporis Revisited
• What is your differential diagnosis?
• What laboratory tests (if any) do you want to do?
• What is your management plan?
• How would you counsel families?
48
Tinea Corporis Gladiatorum
• Fluconazole 200 mg weekly x 3 weeks – negative cultures by the third week of therapy (preferred)
• Topical antifungals also effective but need longer therapy
• Restrict sports participation 10-15 days
www.medscape.comwww.isport.com
Kohl TD, et al. PediatrInfect Dis J. 2000.Kohl TD, et al. Clin J Sport Med 1999.Beller M, et al. J Am Acad Dermatol 1994.
49
Case #14 Which one is Tinea?
www.dermatlas.org
A B
C
50
Case #14 Which one is Tinea?
www.dermatlas.org
A B
C
Tinea cruris Erythrasma
Candidiasis
51
Tinea Cruris
• Usually occurs in adolescent males
• Usually is bilateral
• Spares the scrotum and penis
• Look for tinea elsewhere
• Topical antifungals of the imidazole or allylamine family
52
Case #15 What is the diagnosis and treatment?
www.hardinmd.lib.uiowa.edu53
Case #15 Moccasin Type Tinea Pedis
www.hardinmd.lib.uiowa.edu54
Case #16 Is this Tinea?
www.onlinedermclinic.com55
Case #16 Psoriasis
www.onlinedermclinic.com56
Case #17 Tinea, Candida or Dyshidrosis?
www.phil.cdc.gov57
Case #17 Tinea Pedis
www.phil.cdc.gov58
Case #18 Is it Tinea?
www.dermatlas.org59
Case #18 Juvenile Plantar Dermatosis
www.dermatlas.org60
Case #19 Which is Pityriasis Versicolor?
www.medicinenet.com
www.graphicshunt.com
61
Case #19 Which is Pityriasis Versicolor?
www.medicinenet.com
62
www.dermatlas.org www.dermatlas.org
health-7.com
63
Case #20 Is this Pityriasis Versicolor?
missinglink.ucsf.edu64
Case #20 Vitiligo
missinglink.ucsf.edu65
Case #21 Is this tinea in an 8 year old girl?
www.dermatlas.org 66
Case #21 Proximal subungual onychomycosis
www.dermatlas.org 67
Case #22 Tinea?
www.podiatry-arena.com68
Case #22 Candidiasis due to thumb sucking
www.podiatry-arena.com69
Case #23 Out, out *$#% spot. What is the cause of these nail changes?
www.webmdboots.com70
Case #23 Excessive Hand Washing due to Obsessive Compulsive Disorder
www.webmdboots.com71
New Recommendations -Ketoconazole
• Oral ketoconazole should not be used as first line therapy for any fungal infection.
• Ketoconazole should not be used for dermatophyte or candida infections.
• Risks of oral ketoconazole include: potentially fatal liver toxicity, adrenal insufficiency and serious drug interactions (QT prolongation).
• Topical ketoconazole may still be an appropriate choice for certain fungal infections.
72
Summary
• SFIs are very common
• Many things can look like SFIs
• KOH prep, fungal cultures, and a Wood lamp can help with differentiation.
• Treatment for tinea capitis requires systemic therapy as does tinea unguium.
• Tinea pedis, manuum, and cruris are rare in prepubescent children
73
References
• Kelly BP. Superficial Fungal Infections. Pediatrics in Review. 2012;33(4): e22-e37.
• Shy R. Tinea Corporis and Tinea Capitis Pediatrics in Review May 2007; 28:164-174.
• Weinstein A and Berman B. Topical Treatment of Common Superficial Tinea Infections. Am Fam Physician. 2002 May 15;65(10):2095-2103.
• Andrews MD and Burns M. Common Tinea Infections in Children. Am Fam Physician. 2008 May 15;77(10):1415-1420.
• Hainer BL. Dermatophyte Infections. Am Fam Physician.2003 Jan 1;67(1):101-109.
• Tully AS et al. Evaluation of Nail Abnormalities. Am Fam Physician April 15 2012 Vol. 85 No. 8
74
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