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    by: Yousry

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    1 : FUNGAL INFECTIONS m.Yousry abdel-mawla
    2 : FUNGAL INFECTIONS Fungal skin diseases are superficial and deep The superficial fungi affect the skin primarily The deep fungi affect internal organs and affect the skin secondarily to internal infection e.g madura foot, actinomycosis. The superficial fungi which cause human disease include: (a) dermatophytes, (b) yeast-like fungi.
    3 : Dermatophytes Fungi which are responsible for the so called "ringworm" infections. The vegetative phase of dermatophyte consists of septate hyphae which form a branching network (mycelium). The dermatophyte fungi responsible for skin disease in man include 3 genera Microsporum infect skin and hair Trichophyton infect skin, hair and nail Epidermophyton infect skin and nail Mode of infection (1) Direct contact with infected person or animal. (2) Indirect through cappings, beddings, towels or combs of the infected person.
    4 : Clinical forms of superficial fungus infections 1) Ringworm of the scalp (Tinea capitis). 2) Ringworm of the hairless skin (Tinea cicinata). 3) Ringworm of the beard area (Tinea barbae). 4) Ringworm of groin (Tinea cruris) and axillae (Tinea axillaris). 5) Ringworm of palms and soles (Tinea manum and Tinea pedis) 6) Ringworm of nails (onychomycosis).
    5 : Tinea capitis It ususally affects children. There are three clinical types: 1- Scaly type:Scaly well defined erythematous patches perforated by lusterless, brittle, broken off hairs. Most cases in Egypt are caused by T. violaceum and M. canis 2- Black dot type:Small bald patches where the infected hairs become thinned and break off at the surface of the skin and the dark stumps remaining in the hair follicles give the "black dot" appearance. This type is caused by T. violaceum 3- Kerion (Suppurative) type:It is caused by animal types of fungi mainly T. verrucosum and M. canis. The deep inflammatory reaction produces a raised boggy swelling on the scalp. The follicles ooze seropus but if the kerion is incised (a mistake!) no pus comes out. The suppuration is in the follicles themselves and causes the hairs to fall out. Small circumscribed areas of permanent baldness with depressed scars may be left (cicatricial alopecia).
    6 : Tinea Capitis
    7 : Tinea Capitis - Kerion
    8 : Tinea Capitis
    9 : Normal Hair
    10 : Tinea Capitis - Endothrix
    11 : Tinea Capitis - Exothrix KOH and ‘Quick Ink’ M. Canis
    12 : D.D of Kerion From abscess by Boggy surface, Lloss of hair, Absence of: pain, cystic fluctuation, local signs of inflammation and general constitutional symptoms.
    13 : Favus (Tinea favosa) Trichophyton schoenleini is the causative fungus of the disease. It affects adults and children. Clinically:a raised, concave, yellowish, saucer or cup-shaped sulphar crust called the scutulum on the scalp. Coalescence of the scutula gives rise to the honey comb appearance. The scalp has a distinctive mousy odour. In neglected cases the whole scalp may be involved. The disease destroys the hair follicles and results in extensive patchy hair loss with thin atrophic scars (cicatricial alopecia). The remaining short hair stumps coming out from the scalp give the picture of coconut hairs.
    14 : Woods Light – M. Canis
    16 : Onychomycosis
    17 : Onychomycosis with Onycholysis
    18 : White Onychomycosis
    19 : Diagnosis of Onychomycosis Try to identify fungi before oral therapy KOH of nail clipping May need some time to dissolve nail. Culture DTM - dermatophytes Sauborauds – Molds Nickerson – Yeast Nail clipping for histology and PAS staining if above is negative and clinical suspicion is high
    20 : Tinea corporis (Circinata) It is infection of the non hairy skin Caused by most species of Microspora and Trichophta. Seen in any age group. May be either asymptomatic or pruritic. lesions start as erythematous macules or papules that spread outward and develop into annular and arciform lesions with well defined scaling or papulovesicular, advancing active borders and healing centers. The disease is usually on the exposed surfaces of the body i.e the face, arms and shoulders but can be present on any site.
    23 : Tinea cruris &axillaris Heat, friction,obesity and maceration predispose to infection. It affects both the groin , inner thigh and or axilla starts as erythematous papules or papulovesicles which extend to form scaly patches with well defined raised borders. Lesions often extend into the gluteal folds and onto the buttocks Intense pruritus and discomfort are the main symptoms of the disease
    25 : Tinea barbae It is infection of the beard area and moustache It is confined to adult men. These are two forms. (a) Superficial type of infection looks like tinea corporis. (b) The deeper type: usually occurs at the angle of the jaw. It is characterized by pustular folliculitis and kerion formation.
    26 : Tinea Pedis(athlete's foot) Tinea pedis is caused usually by T. Interdigitale, T.rubrum and Epidermophyton floccosum Clinically it takes three forms (1) Mild to severe interdigital scaling and maceration with fissures is the most common form especially between the 4th and 5th toes. (2) Vesico-bullous type is an acute form and occurs mainly on the sides of the toes and the dorsum of feet. (3) The hyperkeratotic scaling type. Fine scaling usually extends up onto the sides of the feet and lower heel, where it exhibits a characteristic, clearly defined, fine polycyclic scaling border.
    27 : Taenia Manum Hyperkeratotic scaling form of with Exfoliating crescentic scales, Crcumscribed vesicular Red papular areas and Erythematous scaly sheets On the dorsum of hand. Accentuation of the flexural creases of hands is characteristic.
    28 : General Morphology Tinea Manuum
    29 : Two feet one hand
    30 : Tinea Pedis
    31 : General MorphologyTinea Pedis
    32 : Tinea Unguim (onychomycosis) Caused by different species of Tichophyton and Epidermophyton. Clinical changes of the nail include: 1-discolouration and opacity of nail plate 2-thickening and cracking of nail plate 3-subungual hyperkeratosis 4-onycholysis
    33 : Tinea incognito or steroid -modified tinea It is a fungus infection modified by wrongly applied topical or systemic corticosteroids. The inflammatory picture is almost totally supressed, the clinical picture is modified and immune response to the fungus is diminished. The history is characterisic: Initially; inflammation, scaling and itching are relieved and The patient is satisfied but once he stops steroids the case relapses rapidly with more aggressive picture. Repetition of steroids releives the condition again and so on.
    34 : Diagnosis of dermatophytes 1) Clinical picture. 2) Direct examination of skin scarpings, nail clippings or plucked hair. The specimens are placed on a microscopic slide in a few drops of 10% KoH, covered with a coverslip and gently warmed to dissolve the keratin then examined under microscope for detection of hyphae and spores. 3) Wood's light examination gives in T. schoenleini (pale green fluorescence) and Microsporum (green fluorescence). 4) Culture: On Sabouradu's agar medium. The resulting colonies are differentiated by their shape and colour.
    35 : Treatment of dermatophytes Local therapy for limited infections: 1-Imidazole derivatives which act on dermatophytes and yeasts. : clotrimazole 1% Miconazole 2% Ketoconazole 2% Econazole 1% Salconazole 2-Naftifine, terbinafine and Whitfield's ointment which act on dermatophytes only: Whitfields ointmemt: Salicylic acid 3 Benzoic acid 6 Lanoline 12 Vaseline 100 3- Magenta paint (Castellani paint) for inflammed T pedis.
    36 : Treatment of dermatophytes b) Systemic therapy for extensive infections and for Tinea capitis: 1- Griseofulvin is a fungistatic drug active against dermatophytes with dose 12.5 mg/kg (One tablet 125 mg for 10 kg body weight). 2- Allylamines: as Terbinafine: it is a fungicidal drug against dermatophytes with dose 250 mg/day for adults and 125 mg/day for children. 3- Itaconazole is active against dermatophytes and yeasts 200-400mg/day (for one week or more according to the type of infection. 4- Fluconazole is active mainly against yeast but has an effect on dermatophytes. It is taken as 150 mg capsule once per week. 5- Ketoconazole is a broad spectrum antifungal in a dose 200 mg daily for 10 days but it may be complicated by hepatitis.
    37 : Doses of drugs in each type of fungal infection Tinea capitis: 1) Griseofulvin: for 6-8 weeks. 2) Terbinafine for 4-6 weeks. Tinea Cruris, T. corporis and T. pedis: 1) Griseofulvin for 3 weeks. 2) Terbinafine for 2 weeks. 3) Itraconazole 200 mg /day for one week 4) Ketoconazole 200 mg/day for 10 days 5) Fluconazole 150 mg/week for 4 weeks
    38 : Onychomycosis therapy 1) Griseofulvin for 6 months for finger nails and 12 months for toe nails. 2) Itraconazole 200 mg bid for only one week every month ? for two months for finger nails and for 3 months in toe nails (pulse therapy). 3) Fluconazole 150 mg/week for 3 months for finger nails and 6 months for toe nails.
    39 : Diseases due to yeast 1- Pityriasis versicolor (tinea versicolor). 2- Candidiasis (moniliasis).
    40 : Pityriasis versicolor A chronic superficial fungal infection caused by Malassezia furfur and globosa yeasts Predisposing factors: Warm and humid climate, pregnancy, immunosuppression and genetic predisposition Lesions vary in colour from hyperpigmented pink to brown or hypopigmented round, coalescing macules and patches with fine scales They are found primarily on the trunk and neck Facial lesions(Forehead) are more common in children than in adults and in women than in men. Hypopigmented lesions are often noted by patients during summer months when they are accentuated by tanning of surrounding normal skin.
    43 :
    44 : Tinea Versicolor
    45 : Tinea Vesicolor – Woods Light Yellow White
    46 : Diagnosis of Pityriasis Vesicolor KOH preparation will reveal numerous short, straight and angular hyphae and clusters of thick-walled round and budding yeasts "spaghetti and meat balls". Wood's light :gold to orange fluorescence.
    47 : Therapy of Pityriasis Versicolor A_Topical: 1-Sodium thiosulphate 30% 2-Alcoholic Whitfield's lotion 3-Ketconazole shampoo 4-Sodium hyposulphite 30% 5-Selenium sulphate 2% 6-Topical azole derivatives: Miconazole, clotrimazole, ketoconazole, econazole, salconazole Bsystemic 1. Ketoconazole 200 mg/daily for 7-10 days 2. Itraconazole 200 mg/day ? 7 days 3. Fluconazole 150-300 mg /week for 2-4 weeks
    48 : Candidiasis (candidosis-moniliasis) The yeast like fungus Candida albicans can normally be found on mucous membranes, skin, in the gastrointestinal tract and in the vaginal vault. Under certain circumstances it can change from a commensal organism (yeast form) to a pathogen (mycelial form Predisposing factors: Candidosis is more common in very old, very young and very ill persons 1-Prolonged systemic administration of antibiotic or corticosteroids and contraceptives. 2- Humidity and maceration 3-Pregnancy, diabetes mellitus immunosuppression and debilitating diseases
    49 : Clinical manifestations Candidal intertriginous or flexural lesions (axillary, groin, perianal Erosio interdigitalis blastomycetica: maceration between middle and ring fingers Oral thrush and superficial glossitis Angular chelitis (perleche Onychia and paronychia Monilial proctitis, vulvo-vaginitis and balanitis Systemic candidosis: in very bad general conditions the organism may spread to many organs e.g heart, CNS, etc via blood stream
    50 : Candidal intertriginous or flexural lesions (axillary, groin, perianal In obese and or diabetic persons Well demarcated, with moist glazed red surface and peeling border and often surrounded by satellite erythematous papules or pustules. Irritation or pruritus is usual symptoms.
    51 : Oral thrush and superficial glossitis A white curd-like pseudomembrane formed of fibrin, desquamated epithelium, leukocytes and fungal mycelium Adhering to the buccal mucosa, tongue, gums and palate. If this is scraped off, the underlying mucosa is inflamed and friable.
    52 : Angular chelitis (perleche) Erythema, soreness and cracking at the angles of mouth.
    53 : Onychia and paronychia In housewives and people working in wet conditions The nails are affected Nail folds are red swollen and tender
    54 : Candidaisis of nail Paronychia
    55 : Candidiasis
    56 : Candidiasis
    57 : Difficult to be sure in Web spaces.
    58 : Therapy of Candidiasis A-Topical: Castellani's paint, gentian violet 1-2%, nystatin cream or powder and imidazole derivatives. B-Systemic: Polyene antifungals as Nystatin Fluconazole 150 mg once. Itraconazole 200mg twice daily for one day. Ketoconazole 200 -400 mg for one day.
    60 : THANK YOU

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