Superficial Fungal Skin Infections

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These are fungal infections that affect the outer layers of the skin, the nails and hair. When florid, it may be associated with immunosuppression such as in diabetes and retroviral infection and corticosteroid abuse.

Cause

  • Dermatophytes (tinea) i.e. microsporum, epidermophyton, trichophyton
  • Yeasts i.e. candida, malassezia

Symptoms

  • Itchy scaly ring shaped rash on the skin
  • Scaly bald patches of the scalp
  • Distorted, discoloured finger or toe nails
  • Itchy and sore skin folds
  • Scaly patches of skin with altered pigmentation

Signs

  • Round scaly patches with thickened edges and clear centre on the skin 
  • Scaly bald patches of the scalp
  • Distorted discoloured nails
  • Altered pigmentation of skin (hypopigmented or brownish appearance) 
  • Pustular rash in the flexures

Investigations

  • Skin scrapings for microscopy and culture (mycology)
  • Nail and/or hair clippings for microscopy and culture
  • FBS and HIV status (if infection is florid and/or oral candidiasis present)  

TreatmentTreatment/Management Objectives

  • To eradicate infection
  • To prevent transmission
  • To identify and treat any predisposing conditions

Non-pharmacological treatment

  • Good personal hygiene
  • Use of loose clothing
  • Open footwear

Pharmacological treatment 

 See sections below

Referral Criteria

  • Refer to a dermatologist if patient fails to respond to treatment.

Dermatophyte infection of scalp (tinea capitis)

Evidence Rating: [C]

1st Line Treatment

  • Griseofulvin, oral, 

Adults

500 mg daily (double in severe infection) for 4 weeks

Children

1 month-12 years; 10 mg/kg (max. 500 mg) once daily or in two divided doses for 4 weeks

12-18 years; 500 mg once daily or in two divided doses (may be doubled in severe infections) for 4 weeks

2nd Line Treatment

  • Terbinafine, oral,

Adults

Not recommended 

Children over 1 year; 

Body weight > 40 kg; 250 mg once daily for 4 weeks 

Body weight 20-40 kg; 125 mg once daily for 4 weeks

Body weight 10-20 kg; 62.5 mg once daily for 4 weeks

Dermatophyte infection of body (tinea corporis), perineum (tinea cruris), hands (tinea manuum) and feet (tinea pedis)     

Evidence Rating: [C]

1st Line Treatment

  • Benzoic Acid compound ointment (Whitfield’s ointment), topical, 

Adults and Children: Apply twice daily to patches up to one or two weeks after the last visible rash has cleared

Or

  • Clotrimazole 1%, topical, 

Adults and Children: Apply twice daily to patches up to one or two weeks after last visible rash has cleared

Or 

  • Miconazole 2%, topical, 

Adults and Children: Apply twice daily to patches up to one or two weeks after last visible rash has cleared

Or

  • Ciclopirox olamine 1%, topical, 

Adults and Children: Apply twice daily to patches up to one or two weeks after last visible rash has cleared

2nd Line Treatment

  • Griseofulvin, oral, 

Adults

500 mg daily (double in severe infection) for 4 weeks

Children

12-18 years; 500 mg once daily or in two divided doses (may be doubled in severe infections) for 4 weeks

1 month-12 years; 10 mg/kg (max. 500 mg) once daily or in two divided doses for 4 weeks

Or

  • Itraconazole, oral,

Adults

200 mg once daily or 12 hourly for 7 days

Children

12 years-18 years; 200 mg daily for 7 days 

1 month-12 years; 3-5 mg/kg (max. 100 mg) once daily for 15 days or 30 days (for tinea pedis and manuum)

Or

  • Terbinafine, oral,

Adults

250 mg daily for 2-6 weeks  

Children over 1 year; 

Bodyweight > 40 kg; 250 mg once daily for 4 weeks, (6 weeks-3 months in nail infections - see below) 

Body weight 20-40 kg; 125 mg once daily for 4 weeks

Body weight 10-20 kg; 62.5 mg once daily for 4 weeks

Dermatophyte infection of nails (onychomycosis)

Evidence Rating: [C]

1st Line Treatment

  • Itraconazole, oral,

Adults

200 mg 12-24 hourly for 7 days, repeated courses after 21 days interval (max. of 2 courses for finger nails and 3 courses for toe nails)

Children

12 years-18 years; 200 mg 12 hourly for 7 days, repeated courses after 21 days interval  (finger nails 2 courses, toe nails 3 courses)

1 year-12 years; 5 mg/kg (max 200 mg) daily for 7 days, repeated courses after 21 days interval (finger nails 2 courses and toe  nails 3 courses)

Or

  • Terbinafine, oral,

Adults

200 mg daily for 6 weeks-3 months

Children over 1 year; 

Bodyweight over 40 kg; 250 mg once daily for 6 weeks – 3 months

Body weight 20-40 kg; 125 mg once daily for 6 weeks – 3 months

Body weight 10-20 kg; 62.5 mg once daily for 6 weeks – 3 months

2nd Line Treatment

  • Griseofulvin, oral, 

Adults

500 mg daily (double in severe infection) for 4 weeks

Children

12-18 years; 500 mg once daily or in two divided doses  (may be doubled in severe infections) for 4 weeks

1 month-12 years; 10 mg/kg (max. 500 mg) once daily or in two divided doses for 4 weeks

For  Candida intertrigo

Evidence Rating: [C]

  • Benzoic Acid compound ointment (Whitfield’s ointment), topical: Apply twice daily to patches up to one or two weeks after the last visible rash has cleared. 

Or

  • Clotrimazole 1%, topical, 

Apply twice daily to patches up to one or two weeks after last visible rash has cleared

Or 

  • Miconazole 2%, topical, 

Apply twice daily to patches up to one or two weeks after last visible rash has cleared

Or

  • Ciclopirox olamine 1%, topical, 

Apply twice daily to patches up to one or two weeks after last visible rash has cleared. 

For Oral candidiasis and Pityriasis versicolor

Please refer to section on oral candidiasis and pityriasis versicolor