Unit 7. Viral infections: Viral infections: 1, Verruca vulgaris, Verruca plana 1, Verruca vulgaris, Verruca plana 2, Molluscum contagiosum 2, Molluscum

Unit 7.Unit 7.

• Viral infections: Viral infections: 1, Verruca vulgaris, Verruca plana1, Verruca vulgaris, Verruca plana 2, Molluscum contagiosum2, Molluscum contagiosum 3, Herpes simplex3, Herpes simplex

4, 4, Herpes zosterHerpes zoster -Etiology, Clinical features, Diagnosis & Treatment. Etiology, Clinical features, Diagnosis & Treatment. 1 hr1 hr

• Fungal infections:Fungal infections: 1, tinea capitis1, tinea capitis 2, tinea corporis2, tinea corporis 3, tinea of feet & hands3, tinea of feet & hands 4, onychomycosis4, onychomycosis 5, pityriasis versicolor 5, pityriasis versicolor - Etiology, Clinical features, Diagnosis and Treatment - Etiology, Clinical features, Diagnosis and Treatment 1 hr1 hr

Verruca vulgaris (Verruca vulgaris (common common warts)warts)

Verruca plana (Verruca plana (flat warts)flat warts)

Etiology:Etiology:Human PapillomavirusesHuman Papillomaviruses

HPV Types and Morphology and Site of Skin LesionsHPV Types and Morphology and Site of Skin Lesions

Lesion Location HPV GenotypeCommon wart Mostly hands 2, 4

Plantar wart Bottom of feet 1

Mosaic wart Hands and feet 2

Flat wart Arms, face, knees 3, 10, 28, 41

Butcher wart Hand 7

Extragenital Bowen disease

Upper and lower extremities, head

2, 3, 5, 16, 18, 20, 31, 33, 34, 54, 56, 58, 61, 62, 73

Macular plaques of epidermodysplasia verruciformis

Light-exposed areas

5, 8, 9, 12, 14, 15, 17, 19, 20, 21, 22, 23, 24, 25, 36, 47, 50

•occur on any skin surface occur on any skin surface --usually on hands and fingers--usually on hands and fingers•skin-colored-,skin-colored-, circumscribed-, rough-, circumscribed-, rough-, hyperkeratotic papulonodules with minimalhyperkeratotic papulonodules with minimal irregular irregular scalingscaling•asymptomatic, rare painfulasymptomatic, rare painful•AutoinoculationAutoinoculation

Clinical featuresClinical features verrucae vulgarisverrucae vulgaris

multiple small flat papules multiple small flat papules --most occur in groups --most occur in groups --less than 5 mm in diameter--less than 5 mm in diameter may induce pigmentationmay induce pigmentation mostmost on the face & handson the face & handsSpontaneously regression Spontaneously regression usually occursusually occurs

Clinical featuresClinical featuresFlat warts, or verrucae planaFlat warts, or verrucae plana

Diagnosis of wartsDiagnosis of wartsMost cutaneous warts can be Most cutaneous warts can be recognized clinicallyrecognized clinically

Histology Histology marked hyperkeratosismarked hyperkeratosis acanthosisacanthosis parakeratosisparakeratosis papillomatosispapillomatosis

Single Lesions Multiple LesionsPalms and soles Consider

•Verruca vulgaris•Callus, corn, clavus•Epidermal inclusion cyst•Milkers nodules (palms)•Orf (palms)

Consider•Arsenical keratoses•Verruca vulgaris•Palmoplantar keratoderma•Pyogenic granuloma•Psoriasis•Pits in basal cell nevus syndrome

Rule Out•Amelanotic acrolentiginous melanoma•Carcinoma cuniculatum

Rule Out•Secondary syphilis

Dorsum of hands and feet

Consider•Verruca vulgaris•Periungual warts•Actinic keratosisRule Out•Squamous cell carcinoma•Keratoacanthoma•Tuberculosis verrucosa cutis•Fish tank granuloma

Consider•Verruca vulgaris•Verrucae planae•Actinic keratosis•Acrokeratosis verruciformis•Stucco keratosis

Differential Diagnosis of Warty Lesions on Hands and Feet

Face Hand Trunk, Extremities•Perioral dermatitis•Adenoma sebaceum (mild)•Syringomas•Flat seborrheic keratosis•Actinic keratosis•Trichoepitheliomas

•Acrokeratosis verruciformis•Lichen planus•Stucco keratosis•Seborrheic keratosis

•Epidermodysplasia verruciformis•Pityriasis versicolor•Superficial actinic porokeratosis•Seborrheic

Differential Diagnosis of Plane Warts

Treatment of wartsTreatment of warts•Cryotherapy with liquid nitrogen Cryotherapy with liquid nitrogen (-196ºC)(-196ºC) √√•Laser Laser Carbon dioxide lasers Carbon dioxide lasers √√ pulse dye laser pulse dye laser

•Antimitotics Antimitotics Podofilox (Condylox, Podophyllotoxin)Podofilox (Condylox, Podophyllotoxin) Podophyllum resin (Pod-Ben-25, Podofin)Podophyllum resin (Pod-Ben-25, Podofin) podophyllotoxinpodophyllotoxin. . •Interferons Interferons Alfa-, beta-, & gamma- Alfa-, beta-, & gamma- •Immunostimulants Immunostimulants Imiquimod (Aldara) Imiquimod (Aldara) √√

•Antineoplastic agents Antineoplastic agents Fluorouracil (Efudex)Fluorouracil (Efudex)•Desiccants Desiccants Trichloroacetic acid 85% (Tri-ChlorTrichloroacetic acid 85% (Tri-Chlor))

Molluscum Contagiosum Molluscum Contagiosum pathogene：a large DNA poxvirus Molluscum contagiosum virus (MCV)

Clinical featureClinical featureasymptomatic; asymptomatic; some pruritus, tenderness, & pain. some pruritus, tenderness, & pain. self-limited self-limited but can persist for several years.but can persist for several years.

Physical:Physical:Papules—Papules—rounded or dome-shaped, pink, flesh-rounded or dome-shaped, pink, flesh-colored, waxy, smooth, umbilicated colored, waxy, smooth, umbilicated contain a caseous plugcontain a caseous plugmay be present in groups or widely may be present in groups or widely disseminated disseminated 2-5 mm (rarely up to 1 cm) in diameter2-5 mm (rarely up to 1 cm) in diameter

Molluscum ContagiosumMolluscum Contagiosum

Immunocompromised conditionsImmunocompromised conditions

Cytoplasmic viral inclusions become progressively larger Cytoplasmic viral inclusions become progressively larger toward the epidermal surface (hematoxylin and eosin, 200X)toward the epidermal surface (hematoxylin and eosin, 200X)

HistologyHistology Molluscum ContagiosumMolluscum Contagiosum

TreatmentTreatment• Topical applicationsTopical applications ：： Imiquimod cream 5% Imiquimod cream 5% √√

Trichloroacetic acid Trichloroacetic acid

CantharidinCantharidin

Tretinoin cream (0.1%) or gel (0.025%)Tretinoin cream (0.1%) or gel (0.025%)

• Cryotherapy with liquid nitrogenCryotherapy with liquid nitrogen

• expression & rupture of central core-expression & rupture of central core-- -

with tweezers, lasers, curettagewith tweezers, lasers, curettage

Molluscum ContagiosumMolluscum Contagiosum

Herpes SimplexHerpes Simplex

EtiologyEtiology：：Herpes simplex viruses (HSVs) Herpes simplex viruses (HSVs)

-- DNA viruses Herpes -- DNA viruses Herpes

labialis is caused by labialis is caused by HSV type 1HSV type 1

genital herpes is usually caused by genital herpes is usually caused by HSV type 2HSV type 2

•present as grouped vesicles on an erythematous basepresent as grouped vesicles on an erythematous base

•recurrent infectionrecurrent infection

Clinical featuresClinical featuresPrimary infection:Primary infection: a prodrome of fevera prodrome of fever sore throatsore throat lymphadenopathylymphadenopathy Painful vesicles on the lips, gingivaPainful vesicles on the lips, gingiva lesions ulcerate and heal within 2-3 weekslesions ulcerate and heal within 2-3 weeksRecurrences:Recurrences: Pain, burning, itching, or paresthesia precedes Pain, burning, itching, or paresthesia precedes recurrent vesicular lesions recurrent vesicular lesions ulcerate or form a crustulcerate or form a crust last approximately 1 weeklast approximately 1 week


Genital herpes:Genital herpes: HSV-2 is most common causeHSV-2 is most common cause

Primary infection:Primary infection: occurs within 2 days to 2 weeks after exposure to virus occurs within 2 days to 2 weeks after exposure to virus

Symptoms typically last 2-3 weeksSymptoms typically last 2-3 weeks. . Men–Men– painful, erythematous, vesicular lesions ulcerate on penispainful, erythematous, vesicular lesions ulcerate on penis

Women-Women- vesicular/ulcerated lesions on the cervix vesicular/ulcerated lesions on the cervix

painful vesicles on the external genitalia bilaterallypainful vesicles on the external genitalia bilaterally Associated symptoms-- Associated symptoms-- fever, malaise, edema, inguinal lymphadenopathy, dysuria, fever, malaise, edema, inguinal lymphadenopathy, dysuria, vaginal or penile dischargevaginal or penile discharge

Recurrences:Recurrences:


DiagnosisDiagnosis

Depend on clinical featuresDepend on clinical featuresLaboratory StudiesLaboratory Studies Tzanck smear:Tzanck smear: multinucleated giant cellsmultinucleated giant cells Serologic assays:Serologic assays: to detect antibodies against HSV-1 and HSV-2to detect antibodies against HSV-1 and HSV-2


Herpes simplex virus: positive Tzanck smear Herpes simplex virus: positive Tzanck smear

Histopathology of HSV infectionHistopathology of HSV infection

Classification Virus Isolated

Serology (Acute) Serology (Convalescent)

HSV-1 HSV-2 HSV-1 HSV-2

Primary HSV-1 HSV-1 – – + –

Primary HSV-2 HSV-2 – – – +

Primary HSV-1 plus previous HSV-2 infectiona HSV-1 – + + +

Primary HSV-2 plus previous HSV-1 infection

HSV-2 + – + +

Recurrent HSV-1 HSV-1 + – or + + – or +

Recurrent HSV-2 HSV-2 – or + + – or + +

Classification of Herpes Simplex Infections According to Viral Isolation and Paired Serologic Test Results

TreatmentTreatmentMost HSV infections are self-limited. Most HSV infections are self-limited. antiviral therapy—antiviral therapy— may shortens the course may shortens the course prevent dissemination and transmission. prevent dissemination and transmission. Intravenous, oral, and topical antiviral medications: Intravenous, oral, and topical antiviral medications: acyclovir, its prodrug valacyclovir, and famciclovir.acyclovir, its prodrug valacyclovir, and famciclovir.

Immunocompromised pateints with recurrent HSV Immunocompromised pateints with recurrent HSV infections--infections-- intravenous cidofovirintravenous cidofovir


Herpes ZosterHerpes Zoster (HZ) (HZ)shinglesshingles

EtiologyEtiologyvaricella-zoster virus (VZV)—varicella-zoster virus (VZV)— human herpes virus 3human herpes virus 3 a virus morphologically & antigenically identical to a virus morphologically & antigenically identical to the virus causing varicella (chickenpox). the virus causing varicella (chickenpox).

Clinical features of HZClinical features of HZ•Symptoms-Symptoms-prodromal sensory phenomena prodromal sensory phenomena along 1 or more skin dermatomes along 1 or more skin dermatomes lasting 1-10 days (averaging 48 h)lasting 1-10 days (averaging 48 h) noted as pain or paresthesiasnoted as pain or paresthesias prior to onset of cutaneous findingsprior to onset of cutaneous findingssevere pain-severe pain--"the band of roses from hell." -"the band of roses from hell."

Herpes ZosterHerpes Zoster

classic lesions--classic lesions-- grouped vesicles grouped vesicles --develops upon the --develops upon the erythematous baseerythematous base --initially clear--initially clear but eventually cloud, but eventually cloud, rupture, crust, & involuterupture, crust, & involute

clinical variations of HZ:clinical variations of HZ:

•Herpes zoster ophthalmicus (HZO)Herpes zoster ophthalmicus (HZO)•Zoster oticus Zoster oticus --also termed geniculate zoster--also termed geniculate zoster zoster auriszoster auris Ramsay-Hunt syndrome, Hunt syndromeRamsay-Hunt syndrome, Hunt syndrome:: •Glossopharyngeal and vagal zosterGlossopharyngeal and vagal zoster (herpes pharyngis, herpes laryngis):(herpes pharyngis, herpes laryngis):•Disseminated zoster:Disseminated zoster:•Recurrent zoster:Recurrent zoster:

Cutaneous Visceral Neurologic•Bacterial superinfection

•Pneumonitis •Postherpetic neuralgia

•Scarring •Hepatitis •Meningoencephalitis•Zoster gangrenosum

•Esophagitis •Transverse myelitis

•Cutaneous dissemination

•Gastritis •Peripheral nerve palsies

•Pericarditis •Motor •Cystitis •Autonomic •Arthritis •Cranial nerve palsies •Sensory loss •Deafness •Ocular complications

•Granulomatous angiitis (causing contralateral hemiparesis

Complications of Herpes ZosterComplications of Herpes Zoster

Most Likely•Zosteriform herpes simplex•Contact dermatitis•Insect bites•Burns

Consider•Papular urticaria•Erythema multiforme•Drug eruptions•Scabies

Dx, & DDx of Herpes ZosterDx, & DDx of Herpes Zoster

Always Rule OutBullous pemphigoidPemphigus vulgarisDermatitis herpetiformisEpidermolysis bullosa herpetifo

Herpes zoster, histopathology. A. Intraepidermal vesicle, acantholysis, reticular degeneration; underlying dermis shows edema and vasculitis. B. Multinucleated

giant cells with characteristic nuclear changes.

Herpes zoster, histopathology. A. Intraepidermal vesicle, acantholysis, reticular degeneration; underlying dermis shows edema and vasculitis. B. Multinucleated

giant cells with characteristic nuclear changes.

Treatment of HZTreatment of HZSystemic antiviral agents--Systemic antiviral agents-- Acyclovir Acyclovir its derivatives –its derivatives – valacyclovir, famciclovir, penciclovir, valacyclovir, famciclovir, penciclovir, & desciclovir& desciclovir

Systemic steroids:Systemic steroids: only in some sever casesonly in some sever cases

Varicella-zoster vaccine (ZostavaxVaricella-zoster vaccine (Zostavax ，， Merck)Merck)

Patient RegimenNormal

Age <50 years Symptomatic treatment alone, orFamciclovir 500 mg PO every 8 h for 7 days orValacyclovir 1 g PO every 8 h for 7 days orAcyclovir 800 mg PO 5 times a day for 7 daysa

Age 50 years, and patients of any age with cranial nerve involvement (e.g., ophthalmic zoster)

Famciclovir 500 mg PO every 8 h for 7 days orValacyclovir 1 g PO every 8 h for 7 days ofAcyclovir 800 –mg PO 5 times a day for 7 daysa

Immunocompromised

Mild compromise, including HIV-1 infection

Famciclovir 500 mg PO every 8 h for 7–10 days orValacyclovir 1 g PO every 8 h for 7–10 days orAcyclovir 800 mg PO 5 times a day for 7–10 daysa

Severe compromise Acyclovir 10 mg/kg IV every 8 h for 7–10 days

Acyclovir resistant (e.g., advanced AIDS)

Foscarnet 40 mg/kg IV every 8 h until healed

Treatment of HZTreatment of HZ

Fungal infections:Fungal infections: ==mycosesmycoses•Phyton–Phyton– from Latin/Greek word for plant from Latin/Greek word for plant•Dermato-phytes– Dermato-phytes– are a group ofare a group of keratinophilic fungi--keratinophilic fungi-- invade keratinized tissue (hair, nailsinvade keratinized tissue (hair, nails , , skin)skin)

•Dermato-phytosis– Dermato-phytosis– is a superficial dermatophytes infectionis a superficial dermatophytes infection common disorders worldwidecommon disorders worldwide Has a variety of clinical manifestationsHas a variety of clinical manifestations

Medical mycoses Medical mycoses

can be divided into four categories:can be divided into four categories: (1) cutaneous(1) cutaneous (2) subcutaneous(2) subcutaneous (3) systemic(3) systemic (4) opportunistic(4) opportunistic

Category Mycosis Causative Fungal AgentsSuperficial Pityriasis versicolor Malassezia species Tinea nigra Hortaea werneckii White piedra Trichosporon species Black piedra Piedraia hortae Cutaneous Dermatophytosis Microsporum species, Trichophyton species,

and Epidermophyton floccosum Candidiasis of skin,

mucosa, or nailsCandida albicans and other Candida species

Subcutaneous Sporotrichosis Sporothrix schenckii Chromoblastomycosis Phialophora verrucosa, Fonsecaea pedrosoi,

and others Mycetoma Pseudallescheria boydii, Madurella

mycetomatis, and others Phaeohyphomycosis Exophiala, Bipolaris, Exserohilum, and other

dematiaceous moldsEndemic (primary, systemic)

Coccidioidomycosis Coccidioides posadasii and Coccidioides immitis

Histoplasmosis Histoplasma capsulatum Blastomycosis Blastomyces dermatitidis Paracoccidioidomycosis Paracoccidioides brasiliensis

The Major Mycoses and Causative FungiThe Major Mycoses and Causative Fungi

Category Mycosis Causative Fungal Agents

Opportunistic Systemic candidiasis Candida albicans and many other Candida species

Cryptococcosis Cryptococcus neoformans and Cryptococcus gattii

Aspergillosis Aspergillus fumigatus and other Aspergillus species

Hyalohyphomycosis Species of Fusarium, Paecilomyces, Trichosporon, and other hyaline molds

Phaeohyphomycosis Cladophialophora bantiana; species of Alternaria, Cladosporium, Bipolaris, Exserohilum and numerous other dematiaceous molds

Mucormycosis (zygomycosis)

Species of Rhizopus, Lichtheimia, Cunninghamella, and other zygomycetes

Pneumocystis pneumonia Pneumocystis jiroveci

Penicilliosis Penicillium marneffei

The Major Mycoses and Causative FungiThe Major Mycoses and Causative Fungi

Type Anatomic Location Representative Disease Genus of Causative Organism(s)

Cutaneous Dead layer of skin Tinea versicolor Malassezia Epidermis, hair, nails Dermatophytosis (ringworm) Microsporum,

Trichophyton, Epidermophyton

SubcutaneousSubcutis Sporotrichosis Sporothrix Mycetoma Several generaSystemic Internal organs Coccidioidomycosis Coccidioides

Histoplasmosis Histoplasma Blastomycosis Blastomyces Paracoccidioidomycosis Paracoccidioides Opportunistic Internal organs Cryptococcosis Cryptococcus

Candidiasis Candida Aspergillosis Aspergillus Mucormycosis Mucor, Rhizopus

Features of Important Fungal DiseasesFeatures of Important Fungal Diseases

Laboratory Laboratory TestTest

MethodMethod FunctionFunction FindingsFindings

Potassium hydroxide preparation

Scales, subungual debris, or affected hair removed and placed on a glass slide. KOH 10% dropped on, covered with cover slip. The undersurface of the glass slide is heated.

KOH solution and gentle heating softens keratin and highlights the dermatophyte.

Long narrow septated and branching hyphae

Culture Sabouraud medium (4% peptone, 1% glucose, agar, water)

Facilitates growth of dermatophytes

Microscopic morphology of microconidia, culture features: surface topography and pigmentation

Modified Sabouraud medium (addition of chloramphenicol, cycloheximide, and gentamicin)

Facilitates growth of dermatophytes and inhibits growth of non-Candida albicans, Cryptococcus, etc

Dermatophyte test medium

Scales from the advancing border, subungual debris or affected hair embedded in the medium.

Medium contains the pH indicator phenol red.

Incubation at room temperature for 5–14 days results in change in color of medium.

Histolopathology special stains: PAS,GMS,ect.

Tissue may be obtained by skin or nail biopsy techniques

Stains fungal cell wall to detect fungal elements in tissue sections

Pink (PAS) or black (GMS) fungal elements noted in the stratum corneun.

Laboratory Test of fungal infactionLaboratory Test of fungal infaction

Microscopic examination of skin scrapings (scales) revealing septate, branching hyphae.

Three genera of dermatophytes. A: Trichophyton tonsurans is characterized by the production of elongated microcondia attached to a supporting hypha. B: Microsporum gypseum produces individual thin- and rough-walled macroconidia. C: Epidermophyton floccosum has club-shaped, thin- and smooth-walled macroconidia that typically arise in small clusters.

TineaTinea tinea --tinea -- is derived from the Latin word for worm or larvaeis derived from the Latin word for worm or larvae •tinea capitis (tinea capitis (scalp)scalp) •tinea corporis (tinea corporis (body surfaces)body surfaces) •tinea of hands and feettinea of hands and feet Tinea manuum and tinea pedisTinea manuum and tinea pedis•Onychomycosis Onychomycosis ( Tinea unguium ) - Nail( Tinea unguium ) - Nail •Pityriasis (Tinea) versicolor Pityriasis (Tinea) versicolor

Tinea cruris - Groin Tinea cruris - Groin Tinea barbae - Beard area and neck Tinea barbae - Beard area and neck Tinea faciale - Face Tinea faciale - Face Majocchi’s granuloma -hair follicle & dermisMajocchi’s granuloma -hair follicle & dermis

Risk factors for tinea infection:Risk factors for tinea infection:

•Moist conditions Moist conditions •Communal baths Communal baths •Immunocompromised states ----Immunocompromised states ----•Atopy Atopy •Genetic predisposition Genetic predisposition •Athletic activityAthletic activity ：： causes skin tears, abrasions, causes skin tears, abrasions, or trauma such as wrestling, judo, or socceror trauma such as wrestling, judo, or soccer

Skin DiseaseSkin Disease Location of Location of LesionsLesions

Clinical FeaturesClinical Features Fungi Most Frequently Fungi Most Frequently ResponsibleResponsible

Tinea corporis (ringworm)

Nonhairy, smooth skin

Circular patches with advancing red, vesiculated border and central scaling. Pruritic

Trichophyton rubrum, Epidermophyton floccosum

Tinea pedis (athlete's foot)

Interdigital spaces on feet of persons wearing shoes

Acute: itching, red vesicular. Chronic: itching, scaling, fissures

Trichophyton rubrum, Trichophyton mentagrophytes, Epidermophyton floccosum

Tinea cruris (jock itch)

Groin Erythematous scaling lesion in intertriginous area. Pruritic


Tinea capitis Scalp hair. Endothrix: fungus inside hair shaft. Ectothrix: fungus on surface of hair

Circular bald patches with short hair stubs or broken hair within hair follicles. Kerion rare. Microsporum-infected hairs fluoresce

Trichophyton mentagrophytes, Microsporum canis, Trichophyton tonsurans

Tinea barbae Beard hair Edematous, erythematous lesion Trichophyton mentagrophytes, Trichophyton rubrum, Trichophyton verrucosum

Tinea unguium (onychomycosis)

Nail Nails thickened or crumbling distally; discolored; lusterless. Usually associated with tinea pedis


Dermatophytid (id reaction)

Usually sides and flexor aspects of fingers. Palm. Any site on body

Pruritic vesicular to bullous lesions. Most commonly associated with tinea pedis

No fungi present in lesion. May become secondarily infected with bacteria

Histopathology of TineaHistopathology of Tinea

Histopathology of TineaHistopathology of Tinea

Disease Topical Treatment

Systemic Treatment

Tinea corporis/cruris

AllylaminesImidazolesTolnaftateButenafineCiclopirox

Adults:Terbinafine, 250 mg/day x 2–4 weeksItraconazole, 100 mg/day x 1 weekFluconazole, 150–300 mg/wk x 4–6 wksGriseofulvin, 500 mg/day x 2–4 wksChildren:Terbinafine, 3–6 mg/kg/day x 2 wksItraconazole, 5 mg/kg/day x 1 weekGriseofulvin, 10–20 mg/kg/day x 2–4 wks

Treatment of TineaTreatment of Tinea

Disease Topical Treatment Systemic TreatmentTinea pedis/manuum

AllylamineImidazolesCiclopiroxBenzylamineTolnaftateUndecenoic acid

Adults:Terbinafine, 250 mg/day x 2 weeksItraconazole, 200 mg twice daily x 1 weekFluconazole, 150 mg/week x 3–4 weeksChildren:Terbinafine, 3–6 mg/kg/day x 2 weeksItraconazole, 5 mg/kg/day x 2 weeks

OnychomycosisCiclopiroxAmorolfine

Adults:Terbinafine, 250 mg/day x 6–12 weeksItraconazole, 200 mg/day x 2–3 monthsFluconazole, 150–300 mg/week x 3–12 monthsChildren:Terbinafine, 3–6 mg/kg/day x 6–12 weeksItraconazole, 5 mg/kg/day x 2–3 monthsFluconazole, 6 mg/kg/week x 3–6 months

Treatment of TineaTreatment of Tinea

•EtiologyEtiology species of genera species of genera TrichophytonTrichophyton and and MicrosporumMicrosporum •three distinctly different formsthree distinctly different forms gray patchgray patch black dotblack dot favusfavus •3 types of Hair invasion3 types of Hair invasion Ectothrix species: Conidia form on the exterior of the hair shaft. Ectothrix species: Conidia form on the exterior of the hair shaft. Endothrix species: Conidia form within the hair shaft, Endothrix species: Conidia form within the hair shaft, each is filled with hyphae and spores. each is filled with hyphae and spores.

Favus species: Hyphae arrange within and around the hair shaftFavus species: Hyphae arrange within and around the hair shaft..

Kerion: Thick plaques and boggy skin Kerion: Thick plaques and boggy skin form often with bacterial infection superimposedform often with bacterial infection superimposed

Tinea capitisTinea capitis

Clinical features of Tinea capitis Clinical features of Tinea capitis

•begins as a small erythematous papule begins as a small erythematous papule around a hair shaft around a hair shaft

on the scalp, eyebrows, or eyelashes.on the scalp, eyebrows, or eyelashes. •numerous red papules-- numerous red papules-- with a typical ring formwith a typical ring form with paler and scalywith paler and scaly•hairs appear--hairs appear-- discolored, lusterless, and brittlediscolored, lusterless, and brittle•Pruritus usually minimalPruritus usually minimal•Alopecia (hair loss)--Alopecia (hair loss)-- with hairs breaking is commonwith hairs breaking is common•Inflammation may be mild or severeInflammation may be mild or severe

• Most LikelyMost LikelySeborrheic dermatitis, contact dermatitis, pustular or Seborrheic dermatitis, contact dermatitis, pustular or

plaque psoriasis, atopic dermatitis, bacterial plaque psoriasis, atopic dermatitis, bacterial pyodermas, folliculitis decalvans, lichen planopilaris, pyodermas, folliculitis decalvans, lichen planopilaris, and dissecting cellulitis of the scalpand dissecting cellulitis of the scalp

• ConsiderConsiderAlopecia areata, trichotillomania, pseudopeladeAlopecia areata, trichotillomania, pseudopeladeRule OutRule OutSubacute cutaneous lupus erythematosus, syphilisSubacute cutaneous lupus erythematosus, syphilis

Differential Diagnosis of Tinea CapitisDifferential Diagnosis of Tinea Capitis

Laboratory Studies for diagnosisLaboratory Studies for diagnosis

•Direct microscopic examination Direct microscopic examination plucked hairs are treated with plucked hairs are treated with KOHKOH -- -- Spores within or around the hair shaft can be detected.Spores within or around the hair shaft can be detected.

•Fungal culturesFungal cultures can be performed for identification of the species. can be performed for identification of the species.

•Wood light (UV light)Wood light (UV light) examination may be performed. examination may be performed.

•HistologyHistology is only needed for some cases is only needed for some cases

hyphae and spores around the hair shaft (hyphae and spores around the hair shaft (KOH)KOH)


Wood lamp examination of Wood lamp examination of a gray-patch area on the a gray-patch area on the scalpscalp

In In Microsporum canisMicrosporum canis infection, scalp hairs emit a infection, scalp hairs emit a diagnostic brilliant green diagnostic brilliant green fluorescence. fluorescence.


anan endoectothrix invasion of a hair endoectothrix invasion of a hair shaft by shaft by Microsporum audouinii.Microsporum audouinii. Intrapilary hyphae and spores around Intrapilary hyphae and spores around the hair shaft are seen (HE with the hair shaft are seen (HE with PAS).PAS).


Fungal hyphae and yeast cells of Fungal hyphae and yeast cells of Trichophyton Trichophyton rubrumrubrum seen on the stratum corneum of tinea seen on the stratum corneum of tinea capitis. PAS staincapitis. PAS stain

Treatment of Tinea capitisTreatment of Tinea capitis

antifungal medications--antifungal medications--itraconazole, terbinafine, ketoconazole, griseofulvin itraconazole, terbinafine, ketoconazole, griseofulvin and fluconazole, and fluconazole,

topical agentstopical agents Selenium sulfide shampooSelenium sulfide shampooantifungalantifungal creams, lotions, solutions, powders, sprayscreams, lotions, solutions, powders, sprays

tinea corporistinea corporisis a superficial dermatophyte infection on the glabrous skinis a superficial dermatophyte infection on the glabrous skin(ie, skin regions except the scalp, groin, palms, and soles)(ie, skin regions except the scalp, groin, palms, and soles)

EtiologyEtiology caused by a variety of dermatophytes, caused by a variety of dermatophytes, mainly mainly T tonsuransT tonsurans & also & also M canisM canis & & T rubrumT rubrum..

Clinical feature of Clinical feature of Tinea corporisTinea corporis

Lesion--Lesion--• begins as an erythematous, scaly plaque crust, vesicles begins as an erythematous, scaly plaque crust, vesicles • characterized by annular with raised edgescharacterized by annular with raised edges• on the exposed skin of trunk and extremitieson the exposed skin of trunk and extremities• may rapidly worsen and enlargemay rapidly worsen and enlarge

Tinea of feet and handsTinea of feet and hands

•Tinea pedis –Tinea pedis –is the term used for a dermatophyte infection of the soles of the is the term used for a dermatophyte infection of the soles of the feet and the interdigital spacesfeet and the interdigital spaces

•Tinea manuum– Tinea manuum– fungal infection of the palms and finger webs fungal infection of the palms and finger webs

Clinical features of Tinea pedisClinical features of Tinea pedis

4 possible clinical presentations:4 possible clinical presentations: Interdigital tinea pedis Interdigital tinea pedis Chronic hyperkeratotic tinea pedis Chronic hyperkeratotic tinea pedis Inflammatory/vesicular tinea pedis Inflammatory/vesicular tinea pedis Ulcerative tinea pedisUlcerative tinea pedis

Lesions--Lesions--•scaling, painful fissuring, maceration; scaling, painful fissuring, maceration; •erythema; erythema; •vesicles; pustules; and bullaevesicles; pustules; and bullae

Onychomycosis Onychomycosis (OM)(OM) Tinea unguimTinea unguim • a fungal infection that affects the a fungal infection that affects the toenails toenails or or fingernailsfingernails• may involve any component of the nail unitmay involve any component of the nail unit including the including the nail matrix, nail bed, or nail platenail matrix, nail bed, or nail plate

The main subtypes:The main subtypes: distal lateral subungual onychomycosis (DLSO)distal lateral subungual onychomycosis (DLSO) white superficial onychomycosis (WSO)white superficial onychomycosis (WSO) proximal subungual onychomycosis (PSO)proximal subungual onychomycosis (PSO) endonyx onychomycosis (EO)endonyx onychomycosis (EO) candidal onychomycosis candidal onychomycosis

*may have a combination of these subtypes*may have a combination of these subtypes*Total dystrophic onychomycosis *Total dystrophic onychomycosis refers to the most advanced form of any subtyperefers to the most advanced form of any subtype

Clinical features of OMClinical features of OM• usually asymptomaticusually asymptomaticfirst present for cosmetic reasons without any complaintsfirst present for cosmetic reasons without any complaints

•may interfere with standing, walking, and exercisingmay interfere with standing, walking, and exercising•may report paresthesia, pain, discomfort, and loss of dexterity may report paresthesia, pain, discomfort, and loss of dexterity •may report loss of self-esteem and lack of social interactionmay report loss of self-esteem and lack of social interaction•A careful history may reveal many environmental & A careful history may reveal many environmental & occupational risk factorsoccupational risk factors

Diagnosis of onychomycosisDiagnosis of onychomycosis

Direct microscopy Direct microscopy A 20% potassium hydroxide (KOH) A 20% potassium hydroxide (KOH)

CultureCulture identify the species of organism identify the species of organism

Histologic Findings Histologic Findings nail biopsy & PAS nail biopsy & PAS staining (periodic acid-Schiff stain)staining (periodic acid-Schiff stain)

most sensitive technique available to diagnosemost sensitive technique available to diagnose

TreatmentTreatmentTopical antifungalsTopical antifungals amorolfine (approved in other countries), amorolfine (approved in other countries), ciclopirox olamine 8% nail lacquer solution, ciclopirox olamine 8% nail lacquer solution, bifonazole/urea (available outside the United States)bifonazole/urea (available outside the United States)

Oral therapyOral therapy oral antifungal agents (itraconazole and terbinafine) oral antifungal agents (itraconazole and terbinafine) Derivatives of fluconazoleDerivatives of fluconazoleSurgical CareSurgical Care Surgical approaches: mechanical, chemical, or surgical nail Surgical approaches: mechanical, chemical, or surgical nail avulsionavulsion

combination of oral, topical, and surgical therapy combination of oral, topical, and surgical therapy can increase efficacy and reduce costcan increase efficacy and reduce cost

pityriasis versicolorpityriasis versicolorTinea versicolorTinea versicolor

• Clinical featuresClinical features a common, benign, superficial cutaneous fungal infectiona common, benign, superficial cutaneous fungal infection characterized by characterized by hypohypopigmented or pigmented or hyperhyperpigmented pigmented macules and patches on chest & back. macules and patches on chest & back. The color of lesion:The color of lesion: white to reddish brown or fawn coloredwhite to reddish brown or fawn colored fail to tan in the summerfail to tan in the summermay chronically recurmay chronically recur

• EtiologyEtiology the dimorphic, lipophilic organisms the dimorphic, lipophilic organisms in the genus in the genus Malassezia,Malassezia, formerly known as formerly known as PityrosporumPityrosporum. . • diagnosis diagnosis usually confirmed by potassium hydroxideusually confirmed by potassium hydroxide (KOH) (KOH)

white to reddish brown or fawn colored maculeswhite to reddish brown or fawn colored macules

pityriasis versicolorpityriasis versicolor

TreatmentTreatmenttopical agentstopical agentsselenium sulfide, sodium sulfacetamide, selenium sulfide, sodium sulfacetamide, ciclopiroxolamine, as well as azole and ciclopiroxolamine, as well as azole and allylamine antifungalsallylamine antifungals

Oral therapy Oral therapy Ketoconazole, fluconazole, and itraconazole Ketoconazole, fluconazole, and itraconazole does notdoes not prevent the high rate of recurrence prevent the high rate of recurrence--repeated intermittently throughout the year. --repeated intermittently throughout the year.

Thank you & QsThank you & QsThank you & QsThank you & Qs

Documents

Unit 7. Viral infections: Viral infections: 1, Verruca vulgaris, Verruca plana 1, Verruca vulgaris, Verruca plana 2, Molluscum contagiosum 2, Molluscum