Clinical Practice Guideline Superficial Fungal Infection
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1 Clinical Practice Guideline Superficial Fungal Infection ก ก ก กก ก ก ก ก กก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก * ก Superficial fungal infection ก 1. ก (Pityriasis versicolor, Tinea versicolor) 2. ก ก (Dermatophytosis) 3. (Onychomycosis) 4. (Candidiasis) ก (Pityriasis versicolor, Tinea versicolor) Pityriasis versicolor ก ก กก Malassezia furfur ก ก * / ก 1
2 ก 1. ก ก Wood s light (golden-yellow fluorescence) 2. ก ก % ก ก scotch tape ก methylene blue ก short, fragmented hyphae round to oval budding yeast cells 2.2 ก ก ก ก 1. ก ก (Standard treatment) ก กก ก ก ก ก ก กก ก ก. ก ก 15 ก 2-4 ก - 2.5% selenium sulfide shampoo - 1-2% zinc pyrithione shampoo - 2% ketoconazole shampoo. 20% sodium thiosulfate 40-50% propylene glycol 2 ก 2-4 ก methelene blue/koh with ink ก ก negative 1. ก 2. ก ก ก ก ก ก กก / 2
3 2. ก ก ก (Alternative treatment) 2.1 ก imidazole ก ก ก ก 2.2 ก ก ก ก ketoconazole 200 ก ก. ( ) - ก - กกก ก ก ก ก กก ก ก กก ก ก ก ก ก ก ก 1. ก selenium sulfide, ketoconazole ก 2. ก ketoconazole 400 ก ก. ก 3 ก ก (Dermatophytosis) Dermatophytosis ก Dermatophyte ก (keratin) ก (stratum corneum) ก 1. ก ก ก ก ก ก ก 1.1 ก ก ก Tinea capitis ( ก ก ) 1.2 ก ก ก (Tinea faciei) (Tinea corporis) (Tinea cruris) (Tinea manuum) (Tinea pedis) 1.3 ก ก ก Tinea unguium ก ก (Tinea capitis) ก ก ก 1. Grey-patch ringworm กก ก ก ก ก ก Wood s lamp 2. Kerion ก ก ก ก ก ก ก ก ก ก ก ก 3
4 ก ก ก ก ก ก ก ก 1. (Annular lesion Ringworm) ก ก ก ก กก กกก ก 2. (Papulosquamous lesion) ก ก ก ก ก (Tinea unguium) ( ) 2. ก ก 2.1 ก ก 10% ก ก branching, septate hyphae hyphae ก ก arthroconidia microconidia, arthroconidia hyphae 2.2 ก ก ก ก ก ก 1. ก ก (Standard treatment) Keratolytic ก benzoic acid compound (Whitfield s ointment) - Undecylinic acid (Desenex) - Tolnaftate - Imidazole ก clotrimazole, econazole, ketoconazole, miconazole, sertaconazole - Allylamine ก ก ก 2-4 ก ก ก griseofulvin (micronized) ก ( ) ก - ก ก - ก ก ก ก - ก 2. ก ก ก (Alternative treatment) griseofulvin, ก griseofulvin, ก ก ก ก ก - Ketoconazole - Itraconazole - Terbinafine 4
5 T.corporis T.manuum, T.pedis T.capitis Griseofulvin (micronized) ก Itraconazole Terbinafine gm/day 4 wk. 200 mg bid 7 day 250 mg/day 1-2 wk gm/day 6-8 wk. 200 mg bid mg/day 2-4 wk. ก ก mg/kg/day 8-12 wk 5 mg/kg/day 4-8 wk. <20 kg 62.5 mg/day kg 125 mg/day >40 kg 250mg /day 4 wk., ก KOH/Culture ก ก KOH/Culture กก ก 1. Oral griseofulvin mg/kg/d selenium sulfide ketoconazole shampoo กก ก negative KOH, Culture 2 negative - - 5
6 3. ก ก (Supportive treatment) 3.1 ก % aluminium chloride ก ก ก 3.3 undecylinic acid tolnaftate powder 3.4 ก ก ก 3.5 T. capitis selenium sulfide ketoconazole shampoo spore (Onychomycosis) Onychomycosis ก 50 ก ก ก กก 2 ก 1. ก กก ก ก tinea unguium 2. ก ก ก ก ก ก 1. ก ก 1.1 (onycholysis) 1.2 ก ก ก ก 2.1 ก 10-20% ก 2.2 ก ก ก ก 1. ก ก (Standard treatment) Griseofulvin (micronized) ก / 4-6 ก ก ก 3 กก 2. ก ก ก (Alternative treatment) 2.1 Itraconazole 200 ก. 2 ก 7 2 (pulse therapy) 2.2 Terbinafine 200 ก Adjunctive treatment ก ก (40 % urea) ก ก ก 1. ก ก (Standard treatment) 1.1 Griseofulvin (micronized) ก / 8-12 ก ก ก 3 กก 1.2 Itraconazole 200 ก. 2 ก (pulse therapy) 1.3 Terbinafine 200 ก. 12 6
7 2. Adjunctive treatment ก ก (40 % urea) ก ก ก ก ก ก ก ก ก ก ก psoriasis, lichen planus KOH preparation ก ก ก KOH กก ก negative KOH preparation KOH negative ก ก dermatophyte กก ก ก dermatophyte กก ก ก กก ก ก 7
8 (Candidiasis) Candidiasis ก ก ก candida ก ก Candida albicans ก (normal flora) ก ก - Non-immunologic factors ก กก ก (normal bacterial flora) ก ก Cushing syndrome ก ก - Immunologic factors ก ก ก ก ก ก 1. ก ก ก 1.1 ก 3 - ก ก ก - ก ก - ก ก - ก glans penis, prepuce ก 1.3 กก ก ก ก ก ก ก (satellite lesion) ก 1.4 ก ก ก ก ก ก ก 2. ก ก % ก budding yeast pseudohyphae 2.2 ก, CBC,, HIV antibody 2.3 ก ก ก ก 1. ก ก (Standard treatment) 1.1 ก - Nystatin oral suspension (4-6 IU) ก ก ก clotrimazole (1 ก.) 5 2 8
9 - Imidazole cream nystatin ก imidazole 1.2 ก ก ก - Ketoconazole 200 ก./ KOH preparation 2. ก ก ก (Alternative treatment) - Itraconazone ก./ Fluconazole ก./ 7 3. ก ก (Supportive treatment) 3.1 ก 3.2 ก sexual partner negative 1. ก ก 2. ก 4 ก 1. Griseofulvin 2. Polyene: ก Nystatin 3. Azole compounds: ก Ketoconazole, Itraconazole, Fluconazole 4. Allylamine : Terbinafine Griseofulvin - ก ก ก nucleic acid ก metaphase fungistatic ก ก ก ก - ก ก micronized form ก ก ก - ก porphyria 9
10 - cyclosporin ก anticoagulant barbiturate ก griseofulvin Polyene ก fungistatic ก ergosterol ก cell membrane Nystatin ก Candida ก ก ก กก Azole compound ก fungistatic cytochrome p-450 demethylase ก ergosterol ก cell membrane ก ก 1. Ketoconazole - ก ก ก ก ก ก ก - idiosyncratic hepatotoxicity ก fulminant hepatitis ก cytochrome p-450 enzymes adrenal gland, ก ก ก ก, gynecomastia dose-related placenta ก teratogenicity Drug interaction: - ก ketoconazole ก antacid, H 2 blocker, anticholinergic, antispasmodic agent - ketoconazole ก cyclosporin, chlordiazepoxide, insulin, warfarin sulfonylureas - ketoconazole ก ก metabolized ก rifampicin, phenytoin isoniazid - ketoconazole ก ก - ก ก terfenadine astemizole cisapride ก cardiac arrythmia - ก lovastatin, simvastatin ก rhabdomyolysis - ก alpazolam, midazolam, triazolam ก prolong sedation ก 2. Itraconazole - ก ก ก ketoconazole - Drug interaction ketoconazole ก ก ก ก cytochrome P-450 ก 10
11 3. Fluconazole - hydrophilic tissue fluid ก CSF ก 50-90% - ก unchanged form - ก - Drug interaction ketoconazole ก ก (>400mg/d) Allylamine - ก ก squalene epoxidase ก squalene fungicidal - ก ก ก ก lipophilic กก ก ก - ก ก ก ก ก ก ก References 1. Albright SD, Hitch JM. Rapid treatment of tinea versicolor with a selenium sulfide shampoo. Arch Dermatol 1965; 93: Elwski BE, Hay RJ. Update on the management of onychomycosis : Highlights on the third annual international summit on cutaneous antifungal therapy. Clin Infect Dis 1996; 23: Faergemann J, Fredricksson T. An open trial of the effect of a zinc pyrithione shampoo in tinea versicolor. Cutis 1980; 25: Faergemann J, Fredriksson T. Propylene glycol in the treatment of tinea versicolor. Acta Derm Venereol (Stockh) 1980; 60: Gupta AK, Sauder DN. Antifungal agents : An overview. Part 1. J Am Acad Dermatol 1994; 30: Gupta AK, Sauder DN. Antifungal agents : An overview. Part 2. J Am Acad Dermatol 1994; 30: Hay RJ, Midgeley G. Short course ketoconazole therapy in pityriasis versicolor. Clin Exp Dermatol 1984; 9: Hay RJ. The management of superficial candidiasis. J Am Acad Dermatol 1999; 40: S Hay RJ. Yeast infections. Dermatologic Clinics 1996; 14: Higgins EM, Fuller LC, Smith CH. Guideline for the management of tinea capitis. BJD 2000; 143: Katz HI. Oral antifungal adverse drug interactions. In: Cutaneous fungal infection. 2 nd ed. Blackwell Science 1998; Martin AG, Kobayashi GS. Superficial fungal infection: Dermatophytosis, tinea ungium, piedra.in: Freeberg IM, Eisen AZ, eds. Fitzpatrick s Dermatology in General Medicine. 5 th ed. New York, McGraw-Hill 1999; Martin AG, Kobayashi GS. Yeast infections: candidiasis, pityriasis (tinea) versicolor. In: Freeberg IM, Eisen AZ, eds. Fitzpatrick s Dermatology in General Medicine. 5 th ed. New York, McGraw-Hill 1999; Rausch LJ, Jacobs PH. Tinea versicolor: treatment and prophylaxis with monthly administration of ketoconazole. Cutis1984; 34: Rippon JW. Dermatophytosis and dermatomycosis. In: Rippon JW, ed. Medical Mycology, 3 rd ed. Philadelphia, WB Saunders 1988: Savin RC, HorwItz SN. Double-blind comparison of 2% ketoconazole cream and placebo in the treatment of tinea versicolor. J Am Acad Dermatol 1986; 15: Vander Schroeff JG, et al. A randomized treatment duration-finding study of terbinafine in onychomycosis. Br J Dermatol 1992; 126: Zaias N. Pityriasis versicolor with ketoconazole. J Am Acad Dermatol1989; 20:
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