Lee: Superficial Fungal Infections

Lee: Superficial Fungal Infections Tuesday, October 29, 2024 11:45 PM Superficial Mycoses (fungal infection) • Most common infections in the world and 2nd most common vaginal infections in North America • Mucocutaneous candidiases ○ Vulvovaginal candidiasis ○ Oropharyngeal candidiasis ○ Esophageal candidiasis • Common dermatophyte infections ○ Tinea pedis - foot ○ Tinea corporis - skin ○ Tinea manuum - hand ○ Tinea cruris - groin ○ Tinea unguium - nails ○ Tinea capitis – scalp Candida • Yeast found in normal microbiome • Most common: C. albicans • Oropharyngeal Candidiasis (OPC) or thrush ○ Common: C. albicans ○ Local risk factors ▪ Steroid/Antibiotic use ▪ Dentures ▪ Xerostomia (dry mouth, reduced saliva, Sjogren’s Syndrome) ▪ Smoking ▪ Disruption of oral mucosa ○ S/sx ▪ Dysphagia (difficulty swallowing) ▪ Odynophagia (painful swallowing) ○ Lab test ▪ Cultures to help identify organisms but do not distinguish between infection and colonization ○ Treatment ▪ Goal: Eliminate clinical S/S, treat initial episode of OPC to avoid progression to esophageal candidiasis ▪ Standard treatment: Topical Agents ▪ Healthy patients with no underlying immunodeficiency • Nystatin • Clotrimazole ▪ Consider systemic therapy if: ▪ OPC patients refractory to topical treatment ▪ Cannot tolerate topical agents ▪ Moderate to severe diseases ▪ High risk for disseminated systemic/invasive candidiasis (e.g., HIV) Mild Moderate to Severe Fluconazole-refractory Recurrent • 1st line • Fluconazole 100-200 mg tab PO QD x 7-14 days • 1st line • Fluconazole • Clotrimazole troches/lozenge • Itraconazole oral solution ○ Topical + vaginal forms (Mycelex, etc.) • Posaconazole oral suspension ○ Prophylaxis: 10 mg 3 x /day ○ Without food ○ Treatment: 10 mg 5x/day x 14 days ○ Better BA ○ Allow troche to dissolve slowly over 15-30 minutes • Alternative ○ Side Effects: increase LFTs, nausea, dysgeusia • Voriconazole ○ Monitoring: LFT • AmB deoxycholate oral suspension ▪ • Miconazole mucoadhesive buccal • Alternative • Nystatin (Bio-Statin) oral suspension ○ Suspension, tablet ○ Topical forms (Nyamyc, Nustop) ○ Dosing: Oral Candidiasis ▪ Suspension: 400,000-600,000 units 4 times/day; swish in the mouth and retain for as long as possible (several minutes) before swallowing ○ Side Effects: N/V/D, stomach pain, minimal GI absorption, low systemic risk • Esophageal Candidiasis ○ 2nd most common site of GI candidiasis ○ 2nd most common AIDS-defining disease after Pneumocystis jiroveci pneumonia ○ Systemic risk factors ▪ Drugs (Cytotoxic chemotherapy, Corticosteroids, and immunosuppressant) ▪ Neonates/Elderly ▪ HIV/AIDS ▪ Diabetes ▪ Malignancies ▪ Nutritional deficiencies (e.g., iron, folate, and vitamins B1, B2, B6, B12, and C) ○ S/sx ▪ Dysphagia, odynophagia, and retrosternal chest pain, epigastric pain ○ Lab Tests ▪ Upper GI endoscopy (Gold Standard) ▪ Cultures confirm diagnosis • C. albicans • Drug – resistant Candida species ○ Treatment Initial Non-tolerated Oral Therapy • 1st line • 1st line • Oral fluconazole • IV fluconazole • Echinocandin IV ▪ • Alternative • AmB dexoycholate Fluconazole-refractory Recurrent • 1st line • Chronic suppressive therapy w/ fluconazole • Itraconazole oral solution • Voriconazole IV/PO • Alternative • Echinocandin IV • AmB deoxycholate • Posaconazole oral suspension or ER tablet (off-label) • Vulvovaginal Candidiasis (VVC) ○ Classified by either frequency or severity ▪ Sporadic ▪ Recurrent: 4 episodes within a 12 – month period ▪ Uncomplicated: sporadic infections that are susceptible antifungal therapy regardless of the duration of treatment ▪ Complicated: recurrent or severe disease, non–Candida albicans candidiasis, and host factors including diabetes mellitus, immunosuppression, and pregnancy ○ Common pathogen: C. albicans ○ Risk Factors ▪ Sexual Activity (not STI) ▪ Not recommend treatment of asymptomatic partners ▪ Contraceptive agents • Diaphragms • Sponges • intrauterine device ▪ Oral contraceptive at higher dose only ▪ Antibiotic use ▪ Diabetes Mellitus ▪ Diet (excess refined carbohydrates) ▪ Douching (rinsing the vagina with a liquid solution) ▪ Tight – fitting clothing ○ Treatment ▪ Goals of therapy • Complete resolution of symptoms • Asymptomatic candida colonization: does NOT require therapy ▪ Positive outcomes • Symptoms of VVC are resolved within 24 to 48 hours • No adverse medication events • Self-assessment of symptom relief is appropriate for most cases ▪ Avoidance/Improvement of predisposing factors • Avoid harsh soaps and perfumes that can cause or worsen vulvar irritation. • Douching is not recommended • Cool baths can soothe the skin • Avoid constrictive clothing/prolonged hot tub use • Daily ingestion of 240 mL yogurt containing Lactobacillus acidophilus? Controversial Uncomplicated • 1st line • Topical antifungal agents ▪ Complicated Recurrence • Severe acute • 10-14 days of induction therapy w/ topical agent or oral fluconazole, followed by oral • Fluconazole 150 mg q72h for total fluconazole 150 mg QWeek x 6 months 2-3 doses • If pregnant: topical antifungal agents Azole-Resistance (C. glabrata) • 1st line • Boric Acid intravaginal • Alternative • Nystatin intravaginal suppositories • Flucytosine 17% cream (+/3% AmB cream) x 14 days • • Alternative • Fluconazole 150 mg PO x 1 dose Additional Candida Recommendations ○ Usually if first vulvovaginal yeast infection refer to PCP ○ Do not treat asymptotic Candida in the urine unless ▪ neutropenic ▪ low birth weight infant ▪ patients that will undergo urological manipulation ○ Do not treat Candida growth in respiratory tract Tinea Infections Infection Treatment Tinea corporis – skin ("ringworm") • Non-prescription antifungal creams, lotions, or powders applied to the skin for 2-4 weeks • Clotrimazole (Lotrimin, Mycelex) • Miconazole • Terbinafine (Lamisil) ○ Tablet, topical (Rx, OTC) ○ MOA: Inhibit squalene epoxidase, a key enzyme in fungi sterol biosynthesis, resulting in a deficiency of ergosterol and buildup of squalene within the cell wall, leading to cell death ○ Dosing: 250 mg/day in 1-2 divided doses without regards to meals ○ C/I: Chronic or active liver disease ○ Warnings: Hepatotoxicity (less than azoles), taste/smell disturbance (including loss of taste or smell that can be permanent), depression neutropenia, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, serious skin reactions ○ Side effects: HA, increase LFT, skin rashes, abdominal pain, pruritus, diarrhea, dyspepsia, taste disturbance ○ Monitoring: CBC, LFTs • Ketoconazole (Xolegel) Tinea capitis – scalp • Rx antifungals 1-2 months • Terbinafine (Lamisil) 250 mg/day PO x 4-8 weeks • Adjunctive antifungal shampoo (e.g. ketoconazole, selenium sulfide, or povidone-iodine) Tinea pedis – foot ("Athlete's Foot) • Mild infection • Topical therapy for 2-4 weeks • Severe infection or Refractory disease • Terbinafine: 250 mg PO daily X 2 weeks • Itraconazole: 200 mg PO twice daily X 1 week • Fluconazole • Griseofulvin • Oral therapy recommended when involvement of the nail ○ Tinea manuum – hands • Treatment similar to tinea pedis • Mild infection • Treatment with topical therapy 2-4 weeks • Severe infections or involvement of nails • Oral antifungal therapy • Application of emollients that contain lactic acid can be useful Tinea cruris – groin (Jock Itch) • Treatment with topical therapy • Continue 1-2 weeks after symptom resolution • Severe infection: oral therapy required • Relief of pruritis and burning • Short – term ( 2 or 3 days) topical steroids (2.5% hydrocortisone) Tinea unguium – nails (onychomycosis) • Risk factors: ○ Increasing age, family history and genetic factors ○ Immunodeficiency ○ Diabetes Mellitus ○ Psoriasis ○ Peripheral Vascular Disease ○ Smoking ○ prevalence of tinea pedis ○ frequent nail trauma ○ sporting activities (swimming) • Treatment expensive and only confirmed with diagnosis • Prolonged duration (3-4 months for fingernail infections & 4-6 months for toenail infections) • Oral Therapy • 1st-line: Terbinafine (Lamisil) → 250 mg PO daily • Alt: Itraconazole (Sporanox) → 200 mg PO daily • Topical Therapy • Infection is superficial • Involves partial area of nail plate not exceeding 50% • Limited to 3-4 nails • Early stages when infection is still confined • Don’t use systemic therapy • Ciclopirox 8% solution(Penlac®): Apply once daily to affected nails and to the underside of the nail • Efinaconazole 10% Topical Solution (Jublia®): Apply topically to affected toenails once daily for 48 weeks (an year) • Duration • Toenail: 12 weeks (4-6 months) • Fingernail: 8 weeks (2-3 months)