Tinea: Head to Toe A dermatophyte tour of human skin. Tour de Tinea Head to Toe. Tips for Tinea Head to Toe. Psoriasis. Non-inflammatory Tinea Capitis
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1 Tinea: Head to Toe A dermatophyte tour of human skin Renee Howard, MD Assistant Clinical Professor of Dermatology, UCSF Tour de Tinea Head to Toe Tips for Tinea Head to Toe Capitis Faciei Corporis Pedis Unguim (onychomycosis) Diagnostic Therapeutic Non-inflammatory Tinea Capitis Psoriasis Seborrheic dermatitis: thick greasy scale frontal scalp & vertex Atopic dermatitis: fine scale all over; itchy Psoriasis: thick silverywhite scale sticks to hair Williams JV et al Pediatrics 2005;115:e1-6.
2 Psoriasis Tinea? No, Langerhans cell histiocytosis Inflammatory Tinea Capitis DDx Inflammatory Tinea Capitis Folliculitis: just pustules with no scale Discoid lupus: scarring skating rink alopecia with scale in hair follicle openings Alopecia areata: smooth pink-orange discrete patches with no scale
3 Tinea Capitis Rx Tinea Capitis Diagnostic Tip See the scale Do fungal culture! First line still Griseofulvin 20-25mg/kg micronized for 6-8 weeks with fatty meal. Second line agents for griseofulvin failure or intolerance are not FDA approved Lamisil 6 mg/kg/day Itraconazole 5 mg/kg/day Fluconazole 6 mg/kg/day Sethi A, Antaya R. Pediatr Infect Dis J 2006;25:643 Tinea Capitis Treatment Tip Must use systemic therapy; topical is adjunctive only If patient fails griseofulvin Check compliance Treat family members with antifungal shampoo; look for school contacts If inflammatory check history carefully for animal source (rabbits, guinea pigs, horses, puppies, kittens) Rash for a month; failed topical tolnaftate Can appear seborrheic dermatitis-like Gorani et al Pediatr Dermatol 2005;22:243. Look for tinea capitis or corporis Look for animal contact Tinea facei Dx Tip
4 Tinea facei? Tinea corporis? Neonatal lupus erythematosus Granuloma annulare Annular urticaria Tinea Corporis Diagnostic Tips All that is annular is not fungal If it scales, scrape it! If KOH negative, do fungal culture Remember pustular, vesicular and crusted plaques can also be tinea
5 Leismaniasis? Leishmaniasis? I think not 17 year old just back from summer trip to Costa Rica Itchy rash on feet came up the last few days there OMG I have leishmaniasis, says she in a panic Tinea Corporis Diagnostic Tip Scrape edge for KOH Do fungal culture if KOH negative or in an outbreak e.g. tinea gladiatorum Use moist cotton swab or toothbrush and rub scaliest area, usually border Swab media & send Tinea Corporis Treatment Tip Topicals: terbinafine, clotrimazole, miconazole, butenifine cream BID for 2 weeks Avoid combination topical steroid/antifungal creams Alston et al Pediatrics 2003;111:201 Nystatin for candida; not effective for dermatophyte If fails topical, use oral griseofulvin 15-20mg/kg for 3 weeks The many feet of tinea pedis Tinea Pedis Diagnostic Tip Do fungal culture if KOH negative or fails antifungal topical therapy If negative, consider inflammatory dermatoses such as psoriasis, atopic dermatitis, allergic contact dermatitis and juvenile plantar dermatosis.
6 Juvenile Plantar Dermatosis Tinea Pedis Therapeutic Tip Avoid potent topical steroid/antifungal combinations Greenberg et al Pediatr Dermatol 2002;19:78. If treating chronic inflammatory dermatosis such as psoriasis with topical steroids, monitor for fungal superinfection and add separate antifungal cream to regimen Address hyperhidrosis Onychomycosis: distal subungual Onychomycosis Diagnostic Tip Scrape under nail with 15 blade or curette KOH and fungal culture of scale Clip affected distal nail plate and send to pathology for special stains Onychomycosis Rx Tip Systemic terbinafine 6 mg/kg/day for 3 months Pulse itraconazole 5 mg/kg one week of every month for 3 months Fluconazole 3-6 mg/kb once weekly for 5 mos. Do baseline LFT s & repeat after 1 month. All off-label for children <18 years Sethi A, Antaya R. Pediatr Infect Dis J 2006;25:643 Onychomycosis in a 10 year old
7 Onychomycosis Rx Tip Tour de Tinea Topical therapy worth a try in young children because their nail plates are thinner Combine keratolytic with antifungal cream 40% urea cream and terbinafine cream Better topical treatments on the horizon Usually are treating parents
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