Treatment of Superficial Fungal

InfectionsAmy Theos, MD

Associate Professor of Dermatology

University of Alabama

Disclosures

I have no relevant conflicts of interest

Off-label treatments will be discussed

Key Points

Tinea capitis requires treatment with an oral antifungal

Kerion is a treatment emergency

Id reactions often mistaken for drug allergy

Tinea versicolor is uncommon in childhood

Topical steroid combinations have no role for the treatment of tinea corporis

Overview

Tinea capitis

Tinea corporis

“Tinea” versicolor

Tinea Capitis

Many different clinical presentations Discrete patches of alopecia

with scale

Most common in school age children

Prevalence: 11% Birmingham

Most common in African Americans / Hispanics

Tinea Capitis - Etiology

Most common organism in U.S.

Trichophyton tonsurans (90%): spread from person or fomites, endothrix, negative fluorescence

Microsporum canis (10%): spread from animals; ectothrix; positive fluorescence

Most common organism worldwide

M. canis

Tinea Capitis

Varied clinical presentations “Black dot” Seborrheic dermatitis-like Pustules Kerion Asymptomatic carrier state

High index of suspicion in any child with scalp symptoms

Perform fungal culture when in doubt

Tinea Capitis

Tinea Capitis

Tinea Capitis

Tinea Capitis

Tinea Capitis

Tinea Capitis

Diagnosis of Tinea Capitis

Clinical diagnosis

KOH of broken hairs

Fungal culture

Tinea Capitis

Non-threatening techniques for specimen collection

Q-tip method

Saline moistened gauze pad

Sterile toothbrush

Obtain broken hairs

Treatment of Tinea Capitis

Oral agents required

Topical antifungals as adjunct

Treat infected family members

Disinfect or discard fomites

Treat pets if M. canis

Treatment of Tinea Capitis

Therapy must penetrate the hair follicle to be effective

Griseofulvin has been the “gold standard”

Alternatives:

Terbinafine

Fluconazole

Itraconazole

Griseofulvin

Dose and duration has increased over the past 40 years 1974: 10 mg/kg/day for 4 weeks

1994: 10 – 20 mg/kg/day for 4 weeks

1997: 10 – 20 mg/kg/day for 4 – 6 weeks

Current: 20 - 25 mg/kg/day for 6 – 8 weeks (up to 16 weeks may be necessary)

FDA approved > 2 years of age

Ultramicrosize formulation 10 – 15 mg/kg/day

Griseofulvin in Tinea Capitis

Advantages

Relatively safe

Available in liquid formulation

Disadvantages

Drug resistance

Poor compliance

Fungistatic

Patients Who Require An Alternative to Griseofulvin

Intolerant of griseofulvin

GI upset, taste, headaches

Adverse reaction

Rash, hives

Phototoxic

Pregnancy category X

Non-responsive to griseofulvin

Terbinafine for Tinea Capitis

Terbinafine

FDA approved 2007 for treatment of tinea capitis ≥ 4 years

125 mg or 187.5 mg granule packets or 250 mg tablets

< 25 kg: 125 mg/day

25 – 35 kg: 187.5 mg/day

> 35 kg: 250 mg/day

6 weeks

Terbinafine for Tinea Capitis

Terbinafine for Tinea Capitis

Terbinafine was superior to griseofulvin for the treatment of tinea capitis due to T. tonsurans, but not M. canis

No significant AE or abnormal liver transaminasesoccurred during study period

Safe and effective alternative to griseofulvin

Can be more cost effective than griseofulvin if use generic

Non-FDA Approved Alternatives

Fluconazole

RCT for tinea capitis (880 children)

As effective as griseofulvin for M. canis and T. tonsurans

No significant differences between 3 week and 6 week treatment courses

6 mg/kg/day for 3 - 6 weeks

Available as liquid formulation

Approved in neonates/infants for fungal infections

Non-FDA Approved Alternatives

Itraconzole Usage based on small pilot studies / anecdotes

Effective for M. canis and T. tonsurans

5 mg/kg for 4 – 6 weeks

Higher risk of hepatotoxicity

More drug interactions

Ketoconazole – do NOT use FDA removed dermatophyte infection as an approved

indication

Adjunctive Treatments

Antifungal shampoo decrease risk of transmission

Treat symptomatic family members

Antifungal shampoo for family members

Disinfect or discard fomites

Special Circumstances

Kerion

Host inflammatory response

Painful, boggy, nodules with yellow crusting / pustules, lymphadenopathy

Treatment emergency

High risk of scarring

Kerion

Griseofulvin is treatment of choice

Usually no need for topical or oral antibiotics

Prednisone can decrease pain, but doesn’t speed resolution or lessen risk of scarring

1 mg/kg/d x 5 days, then 0.5 mg/kg/d x 5 days

Adjunctive ketoconazole shampoo

Fungal cultures often negative

Dermatophyt”id” Reaction

Hypersensitivity reaction

Often appears soon after antifungal started

Monomorphic papules/vesicles start at hairline, spread down face, ears, and chest

Pruritic

Treatment: continue griseofulvin, topical or oral steroid to rash, oral antihistamines

Id Reaction

Infant With Tinea Capitis

No FDA approved treatments for tinea capitis < 2 years old

Fungal culture mandatory

Identify source of infection

Infant With Tinea Capitis

Treatment

Topical therapy may be adequate (ketoconazole 2% shampoo, topical azole gel or foam for better penetration)

Griseofulvin 15 mg/kg/d for 6 weeks

Fluconazole 6mg/kg/d for 3-6 weeks (FDA approval for use in neonates with non-dermatophyte fungal infections)

Tinea Versicolor

Misnomer – NOT a dermatophyte

Malasezzia spp. a lipid-dependent yeast

More common in tropical climates

Most common in adolescents and young adults

Not contagious

Component of normal skin flora

Tinea Versicolor

Tinea Versicolor

Tinea Versicolor

Topical treatment Ketoconazole 2% cream QD x 2 weeks

Ketoconazole 2% shampoo QD x 3 days

Selenium sulfide 2.5% lotion or shampoo x 10 minutes x 7 days

Terbinafine cream

Oral treatment (severe or resistant to topical) Itraconazole 400 mg x 1 dose

Fluconazole 300 mg once a week x 2 – 4 weeks

Griseofulvin and oral terbinafine not effective

Tinea Versicolor

Recurrent disease

Ketoconazole 2% shampoo or selenium sulfide 2.5% monthly

Counsel patients that pigmentary changes can persist for many months

Tinea Versicolor

Tinea Corporis

Dermatophyte infection of body

Annular red patch with peripheral scaly border

T. rubrum most common

Tinea Corporis

Topical antifungals usually sufficient

Over the counter or Rx

Azoles (i.e. miconazole), terbinafine, naftifine, ciclopirox

Nystatin NOT effective

Oral antifungals if fail topical, widespread, immune-compromised for 1-4 weeks

Tinea Corporis

Topical steroids can worsen and prolong tineainfections

Combination topical antifungal and corticosteroid creams should be avoided

Topical steroids can cause skin atrophy

Mask erythema and scale making diagnosis difficult (tinea incognito)

Can result in folliculitis (Majocchi granuloma)

Tinea Incognito

Tinea Incognito

Conclusions

Tinea capitis requires oral antifungal treatment

Griseofulvin and terbinafine appropriate first-line treatment

Fluconazole and itraconazole second-line treatment

Kerion is a treatment emergency and griseofulvin is the treatment of choice

Id reactions can mimic drug rash

Tinea versicolor is uncommon before adolescence

Avoid topical steroid preparations for tinea corporis

Thanks for your attention!

Amy.theos@childrensal.org