APRIL 2016 PROFESSIONAL DEVELOPMENT AND PRACTICE SUPPORT FOR THE SELF CARE PROGRAM. Fungal skin care. Vol.17 NUMBER 3 PRINT POST APPROVED

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1 PROFESSIONAL DEVELOPMENT AND PRACTICE SUPPORT FOR THE SELF CARE PROGRAM APRIL 2016 Fungal skin care Vol.17 NUMBER 3 PRINT POST APPROVED

2 John Bell says Contents APRIL 2016 Vol.17 NUMBER 3 Production coordinator Rhyan Stanley Contributor Sarah Gray Peer review Peter Andrews Layout Hiba Attar This publication is supplied to subscribers of the Self Care program. For information on the program, contact PSA at the address below. Advertising policy: inpharmation will carry only messages that are likely to be of interest to members and which do not reflect unfavourably, directly or by implication, on the pharmacy profession or the professional practice of pharmacy. Messages that do not comply with this policy will be refused. Views expressed by authors of articles in inpharmation are their own and not necessarily those of PSA, nor PSA editorial staff, and must not be quoted as such. The information contained in this material is derived from a critical analysis of a wide range of authoritative evidence. Any treatment decisions based on this information should be made in the context of the clinical circumstances of each patient. PSA4926 ISSN: Photographs in non-news articles in inpharmation are for illustrative purposes only and the models appearing in these photographs should not be presumed to endorse any product mentioned in the article or suffer from any condition mentioned in the article. PHARMACEUTICAL SOCIETY OF AUSTRALIA LTD. ABN PO Box 42, Deakin West ACT 2600 P: or E: selfcare@psa.org.au PHARMACIST CPD 4 Facts Behind the Fact Card: Fungal skin care PHARMACY ASSISTANT S EDUCATION 12 Counter Connection: Fungal skin care REGULARS 16 Noticeboard Self Care Fact Cards Fungal skin conditions (also known as mycoses) are a common dermatological condition that can be caused by a variety of microorganisms. See page 4, Facts Behind the Fact Card: Fungal skin care Keep your Fact Cards up-to-date. Re-order any title at any time at efactcards Self Care Fact Cards are now available online. To gain access contact selfcare@psa.org.au Counter Connection certificates You can now print a certificate upon successful completion of Counter Connection modules and include in your training records for QCPP. Available at: Display units Self Care display units can be ordered at: Product category is Self Care display options. Sponsorship For sponsorship and advertising enquiries contact: Joey Calandra Director, Strategic Partnerships & Engagement P: E: joey.calandra@psa.org.au Pharmaceutical Society of Australia Ltd., 2016 This magazine contains material that has been provided by the Pharmaceutical Society of Australia (PSA), and may contain material provided by the Commonwealth and third parties. Copyright in material provided by the Commonwealth or third parties belong to them. PSA owns the copyright in the magazine as a whole and all material in the magazine that has been developed by PSA. In relation to PSA owned material, no part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968 (Cth), or the written permission of PSA. Requests and inquiries regarding permission to use PSA material should be addressed to: Pharmaceutical Society of Australia, PO Box 42, Deakin West ACT Where you would like to use material that has been provided by the Commonwealth or third parties, contact them directly. 2 inpharmation April 2016 I Pharmaceutical Society of Australia Ltd.

3 Health column Fungal skin conditions By Sarah Gray Fungal skin conditions are a common phenomenon in primary care and it is essential that both pharmacists and pharmacy assistants are well-informed about these conditions. Broadly, there are two major forms of fungal skin conditions tinea and thrush. The most common fungal skin conditions in primary care are tinea (i.e. athlete s foot, ringworm, jock itch, and nail infections), oral thrush, vaginal thrush, and nappy rash. As the signs and symptoms for each type of fungal skin condition can be similar, it is integral that pharmacy staff can differentiate between common presentations, and provide appropriate advice on a case-by-case basis. It is also important that both the pharmacy assistant and pharmacist are aware of when to refer patients for further medical advice (such as those with diabetes, immunosuppression, treatment resistance, or recurrent infection). There are a variety of topical antifungal agents available over-the-counter for the treatment of fungal skin conditions. These products are available in a range of formulations such as gels, creams, powders, and sprays. Topical antifungal agents should always be used in an appropriate manner to improve the chances of symptom resolution and to prevent the risk of symptom recurrence. Patients should always be advised on the recommended treatment duration and expectations of when signs and symptoms should resolve. As fungal skin conditions can be easily spread, it is also essential that pharmacy staff share key prevention tips with patients. Advice regarding best treatment options and hygiene measures (such as how to best cleanse and dry the area, what type of clothing to choose and how to reduce cross-contamination) can play a vital role in the overall management of these conditions. Advice of this nature can prove to be invaluable for patients who experience recurrent infections (such as athlete s foot). The pharmacist and pharmacy assistant are best-placed to provide both treatment and preventive advice to patients. LEADING PHARMACY INNOVATION PSA16 The event that redefined Australian professional pharmacy conferences returns in 2016! Bringing back the best of 2015 plus new and enhanced features for an even better delegate experience. Do not miss the vast array of practical, income generating workshops; clinical and therapeutic updates; career pathways, as well as thought provoking plenary and panel sessions. Register online now for early bird discounts at #PSA16SYD SYDNEY JULY 2016 FOUR POINTS BY SHERATON DARLING HARBOUR, SYDNEY inpharmation April 2016 I Pharmaceutical Society of Australia Ltd. 3

4 John Bell Facts saysbehind the Fact Card Fungal skin care Pharmacist CPD Module number 270 Fungal skin care By Sarah Gray This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed. Fungal skin conditions (also known as mycoses) are a common dermatological condition that can be caused by a variety of microorganisms. 1 Learning objectives 2 After reading this article, pharmacists should be able to: Discuss the causes of common dermatophyte and yeast related skin infections Describe factors which may increase the risk of common dermatophyte and yeast related skin infections Recommend appropriate therapy and provide key counselling points for common dermatophyte and yeast related skin infections Recommend strategies to reduce the risk of developing common dermatophyte and yeast related skin infections Advise customers where they can obtain further information. Competencies addressed: 1.3, 4.2, 6.1, 6.2, 6.3, 7.1. It is thought that the incidence of superficial fungal skin infections is on the rise, most likely related to the increasing popularity of gyms and community swimming pools (where infections are often spread), and the rising number of immunocompromised patients. 2 Therefore, on a regular basis, patients will likely present to the pharmacy with the signs and symptoms of a fungal skin condition on various areas of the body. Given this, it is important that the pharmacist is able to differentiate between the most common types of infection, and provide appropriate recommendations. Broadly, there are two major types of superficial fungal skin conditions dermatophyte (i.e. tinea) and yeast based (i.e. candida) infections. 1 These infections typically affect the outer layers of skin, nails, hair and mucous membranes, and mostly produce mild clinical manifestations. 1,2 Patients with these conditions not only require an understanding of best treatment options, but also need an awareness of measures to implement to prevent spread, as these conditions are extremely contagious, easily spreading from person to-person through shared floors (i.e. bathrooms or change rooms) or objects (i.e. towels). 3 Importantly, pharmacists should also be able be aware of when to refer patients to a medical practitioner for review (see Practice point 1). Dermatophyte infections Dermatophytes are the most common cause of fungal skin infections. 2 They are defined as moulds that live on the skin s stratum corneum, hair or nails, and require keratin for survival. 4 Infections caused by dermatophytes are rarely invasive and cause varying clinical symptoms dependent upon the organism and location of the infection. 4 There are three dermatophytes which cause tinea infections Trichophyton, Micropsorum and Epidermophyton. 5 It is important to note that certain patient groups may be at a higher risk of dermatophyte fungal skin conditions (see Practice point 2). Tinea Tinea can be a challenging condition to both diagnose and treat in the primary care setting. 5 The condition is classified based on the location of the infection (see Table 1). 6 The most common forms of tinea in the primary health arena are tinea pedis, tinea corporis and tinea cruris. 5 Tinea pedis, or athletes foot is the most common dermatophyte infection. 5 4 inpharmation April 2016 I Pharmaceutical Society of Australia Ltd.

5 Fungal skin care Pharmacist CPD Module number 270 Facts Behind the Fact Card Tinea infections are usually diagnosed based on clinical signs, history and clinical examination. 6 In some cases, a potassium hydroxide preparation can be used to confirm a dermatophyte infection under microscopic investigation. 5,6 In persistent cases that are not responding to standard treatment alone or are extremely widespread, skin biopsies may be also be required. 6,14 Treatment of tinea As dermatophyte infections are typically confined to the superficial layers of the skin, treatment with topical antifungal agents is often the most effective option. 5,14 In cases where the tinea treatment is required to penetrate the hair or nails (i.e. tinea barbae, tinea capitis and tinea unguium) a systemic agent may be required. 5 In addition, with superficial forms of tinea, in cases where a large surface area is affected, systemic agents may be the preferred treatment option. 5 However, when using systemic agents confirmation of a tinea infection via microscopy and skin culture is essential before commencing therapy. 14 There are a variety of topical antifungal agents that can be used in the treatment of tinea. Topical antifungals are available in a wide range of formats such as gels, lotions, powders, solutions and sprays. 18 Antifungal agents which are effective against dermatophyte infections (i.e. tinea) can be separated into azoles, and allylamines (see Table 2). 14,18 According to the Australian Therapeutic Guidelines, terbinafine (an allylamine) is the first line treatment for tinea infections. 14 Terbinafine has a number of benefits, including a more rapid action (provides relief within days), which allows for a shorter course of treatment. 18 Table 1 Broad classifications and clinical signs of common forms of tinea 5-17 Tinea classification/common name and fungal cause Tinea capitis/ringworm of the scalp Tinea corporis/ringworm (Includes tinea faciei of the face) Tinea cruris/jock itch Affected site Hair follicles of the scalp and surrounding area Mainly affects pre adolescent children Body (except scalp, beard, feet or hands) Groin Mainly affects adult men Clinical presentation Highly variable: smooth areas of skin with hair loss, dry scaling, inflammation, erythema, Three types exist: Gray patch: fine scaling, patchy and circular alopecia, dull grey colour Black spot: itching and fine scaling, scaly patches of alopecia with broken hairs at the border and crusting Favus: yellow crusts, matted hair Pink/red, round, scaly, itchy patches (central clearing and defined border) Single or multiple lesions (1 to 5 cm in size, but groups of lesions can join to form larger areas) Appears on upper thigh and inguinal folds (mostly in adolescent/young adult males) penis is usually unaffected Rash with scaly and raised red border Tinea manuum Hand Most likely in people Can affect one or both hands Inflammatory rash, raised border and clearing centre who are in contact with Peeling, dryness, mild itching and burning of the animal (i.e. cattle, dogs) palm or soil fungus Blistering rash on palm or at edges of fingers Appear in crops Contain clear, sticky fluid Tinea pedis/athletes foot Foot More common in adults than children Affects the skin between the toes (can sometimes spread to the sole, side and dorsum of the foot) Redness and maceration between toes Scaling and peeling (in chronic cases) Tinea unguium/onchomycosis Nail Can affect one or more toenails (big toe and little toe most commonly affected) Thickened, brittle and discoloured toenails Note 80% of cases of onchomycosis are caused by dermatophytes Practice Point 1 When to refer 21,36,41 Patients should be referred to their medical practitioner for review in the following cases: infection which starts to weep or becomes malodorous ringworm of the scalp, as it may require oral antifungals condition does not resolve with recommended treatment patients with diabetes, poor circulation or immunosuppression first time presentation of oral or vulvovaginal candidiasis or recurrent cases of these conditions (i.e. recurs within two months of treatment or greater than three infections annually) in cases of vulvovaginal candidiasis unusual vaginal bleeding, pregnancy (or suspected pregnancy), possibility of a sexually transmitted infection large areas of the trunk involved (may require systemic treatment). inpharmation April 2016 I Pharmaceutical Society of Australia Ltd. 5

6 John Bell Facts saysbehind the Fact Card Fungal skin care Pharmacist CPD Module number 270 Practice Point 2 Patients at increased risk of fungal 11,16,21,26,28, 31,33,42 44 skin conditions General factors: Immunocompromised patients are more likely to suffer from opportunistic infections (e.g. patients with human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS), chemotherapy patients, patients taking systemic corticosteroids). Patients with diabetes skin infections are more common in this patient group. This is associated with metabolic changes, chronic neurological complications and an impaired immune response. Specific forms of tinea are more common in the following cases: Tinea manuum manual labour, sweating profusely or already suffering from hand dermatitis. Tinea pedis exposure to communal change rooms, bathrooms or swimming pools, wearing occlusive footwear, sweating excessively. Specific yeast based infections are more common in the following cases: Oral candidiasis dry mouth, dentures, smoking, nutritional deficiency (i.e. iron or vitamin B deficiency), use of inhaled corticosteroids. Angular cheilitis dry, chapped lips, dentures, poor nutrition (i.e. coeliac disease, iron or riboflavin deficiency), oral retinoid medication. Vulvovaginal candidiasis pregnancy, taking broad-spectrum antibiotics, patients with diabetes and iron deficiency anaemia. Intertrigo frequently wet hands (i.e. gardeners), obese individuals. Paronychia finger sucking (i.e. infants), following manicures or pedicures, artificial nail application, oral retinoid therapy, already suffering from hand dermatitis. Combined steroid and antifungal agents In Australia, there are two combinations of combined antifungal and corticosteroid creams available over-the-counter: Clotrimazole 1% and hydrocortisone 1% Miconazole 2% and hydrocortisone 0.5/1% The combination of an antifungal agent with an anti-inflammatory ingredient (i.e. hydrocortisone) allows for the treatment of associated inflammatory symptoms that may be present. 6 The hydrocortisone provides rapid relief from symptoms while the antifungal agent more slowly eradicates the fungal infection. 6 There is some evidence to show that this combination therapy is more efficacious than use of either ingredient alone, with some suggestion that the steroid increases the activity of the antifungal agent. 6 Tips on applying topical antifungals Generally, treatment with topical antifungals is required for approximately two weeks; however, some cases of tinea pedis may require 4 weeks of therapy. 6,20 It is also advised that treatment is continued for 1 2 weeks after clinical signs resolve, dependent upon the agent. 6,18,20 Newer antifungal agents such as terbinafine have been shown to require shorter courses of treatment, also being associated with fewer infection relapses (due to fungicidal activity). 6 Topical antifungal agents should be applied to the affected area, as well as the healthy skin 2 cm beyond the border. 6,20 After applying topical antifungals, the hands should be washed well to avoid further spread of infection. 21 Table 2 Topical antifungal agents for tinea 5,14,18,19 Onchomycosis is treated with a nail lacquer, which is usually applied once or twice weekly. 20 Before application, the affected nail bed should be roughened with an emery board. 20 Unlike other forms of tinea, the treatment course for onchomycosis is usually 6 12 months as this is the length of time required for fingernails or toenails to regrow. 18,20 Self-care measures and prevention of tinea There are several self-care (non pharmacological) measures that can be employed in the treatment of tinea. Fungi generally thrive in moist environments, therefore patients should be encouraged to choose loose-fitting clothing, preferably made from cotton or wool (which will help to remove moisture from the skin surface). 6,22 Cotton socks are also preferable. 6,22 If possible, patients should attempt to wear open-toe footwear to reduce occlusion. 21 Areas of skin that are prone to tinea infection (i.e. between the toes) should be well dried before the application of socks or clothing. 6 When walking in public areas (i.e. change rooms, pools) it is best to wear footwear to reduce the risk of cross contamination. 6,22 Antifungal powders can be applied to the feet or in the shoes to help reduce the risk of tinea pedis. 1,22 Lastly, patients with tinea should avoid sharing towels, hats or hair brushes. 20 A separate, clean towel should be used to dry the affected areas. 21 Agent Indications Mechanism of action Directions for use Terbinafine (Lamisil, SolvEasy Tinea, Tamsil) Tinea Allylamine fungicidal agent against dermatophytes (inhibits fungal synthesis) Apply once or twice daily Bifonazole (Mycospor) Clotrimazole (Canesten, Clonea) Tinea Azole antifungals fungistatic activity (inhibit fungal growth) Econazle (Pevaryl) Miconazole (Daktarin, Resolve) Tolnaftate Tinea Narrow spectrum antifungal agent (Tinaderm, Mycil, Tineafax) Exact mechanism of action not well understood inhibits fungal growth of dermatophytes Amorolfine Onchomycosis Fungistatic and fungicidal activity (Loceryl) (interferes with fungal cell membrane function) Apply one to three times daily Apply twice daily (Note tolfantate may cause skin irritation) Apply once or twice a week 6 inpharmation April 2016 I Pharmaceutical Society of Australia Ltd.

7 Fungal skin care Pharmacist CPD Module number 270 Facts Behind the Fact Card Yeast based infections The most common yeast based skin infections are caused by candida or malassezia organisms. 5 It is important to note that certain patient groups may be at a higher risk of yeast based fungal skin conditions (see Practice point 2). Candida Skin infections caused by the candida species (a group of yeasts) are a common phenomenon. 23,24 Candida albicans is the cause of around 70 80% of candida Table 3 Clinical features of common candidal infections 15,24-35 infections, typically affecting areas such as the groin, axillae, gluteal folds, umbilicus, digital web spaces, oral cavity, vagina and beneath the breasts. 18,25 A candida infection can also occur in the nail plate and the surrounding skin, which is commonly referred to as onchomycosis or paronychia. 25 The candida yeasts normally reside on the skin and mucous membranes, until certain conditions (i.e. dampness, heat, immunosuppression) allows for a clinical infection due to yeast overgrowth (see Practice point 2). 25 The most common candidal skin infections include oral candidiasis, angular cheilitis, Infection Signs and symptoms Other features of note Oral candidiasis White patches on the gums, tongue and/or Also known as oral thrush inside of the mouth (leave a raw area when Common infection of the oral cavity (usually peeled away) due to Candida albicans) Smooth, red, shiny patches on the tongue Can be acute or chronic Occurs when an increased number of yeast cells invade the oral mucosa Angular cheilitis Vulvovaginal candidiasis Balantis Intetrigo Paronychia Candidal onchomycosis Painful cracks at the corner of the mouth, with associated blisters, redness, crust and bleeding Burning, itch and soreness of vagina and vulva White, curd-like, abnormal vaginal discharge (resembles cottage cheese) Red rash on the vulva (which can also spread to the other pubic areas) Discomfort and sometimes dysuria Inflammation of the head of the penis Pink, red rash (can be smooth, scaly, spotty or patchy) Itch, discomfort and discharge Mild erythema (red plaques) Burning sensation Sometimes malodorous or macerated (moist, white, peeling skin) Cracked and sore skin Associated blisters or pustules Acute cases develops rapidly, over a few hours Painful, red and swollen Multiple vesicles present Nail plate may lift up Usually clears within a few days Chronic cases more gradual process (often spreads to several nails) Can persist for months Swelling of proximal nail folds Cuticle can detach from nail plate Usually affects several or all digits Digits can take a drumstick like appearance Symptoms persist for a few days or can become chronic Also known as vaginal thrush Usually caused by Candida albicans) Can be uncomplicated (sporadic episodes) or complicated (recurrent) Complicated cases can lead to urethritis or phimosis (foreskin adheres to inflamed skin and is not able to retract) Also known as skin fold infections (caused by skin on skin friction) Most prevalent in obese individuals Can occur between the toes (typically associated with tinea pedis), web spaces of the hands, under the breasts, in the groin or between the buttocks Commonly presents as nappy dermatitis/rash Also known as nail fold infections or whitlow (defined as inflamed skin around a fingernail or toenail) Can be acute or chronic Usually chronic in nature Note can be caused by dermatophytes (see table 1), yeasts or moulds Only 20% of cases of onchomycosis are caused by yeasts (i.e. Candida) Practice Point 3 Self-care measures for nappy rash infection 14,37,38 Various measures can be implemented in the prevention and management of nappy rash: Choose disposable nappies, which are highly absorbent. If cloth nappies must be used, change them every 2 hours and do not apply plastic over pants/nappy liners. Cloth nappies should be washed on a high temperature (over 60 C), to destroy any biological enzymes and detergents. When wiping the area attempt a front to back motion. It is best to leave nappies off for as long as possible to avoid contact with irritants (i.e. ammonia). Avoid soap use a soap substitute. Avoid bubble bath, talcum powder or perfumed products. Practice good hygiene such as hand washing and cleansing the nappy area at change times. Clean the nappy area with a soap substitute and damp cloth (do not use nappy wipes). Regularly apply a thin layer of a barrier preparation after every nappy change (such as zinc and castor oil cream, zinc oxide cream or 10% liquid paraffin in zinc paste. Related Fact Cards Tinea Thrush Nappy rash inpharmation April 2016 I Pharmaceutical Society of Australia Ltd. 7

8 John Bell Facts saysbehind the Fact Card Fungal skin care Pharmacist CPD Module number 270 vulvovaginal candidiasis, balantis, intertrigo (including nappy dermatitis/rash), paronychia and onchomycosis (see Table 3). 24 The diagnosis of candida infections is based on the presentation of signs and symptoms, along with microscopy and skin swab cultures in some cases, as appropriate (bearing in mind that candida usually live in the oral cavity) Treatment of Candida The mainstay of therapy for candida infections is topical azole antifungal agents (see Table 4). 23,25 Drying agents (i.e. Burow solution) may also be useful for some patients. 25 Additionally, as candida infection is more likely in high risk individuals (see Practice point 2), it is essential to manage any predisposing factors to avoid infection relapse (i.e. possible investigation for diabetes, cease oral antibiotics if relevant). 14,18 Azole antifungals are the treatment of choice due to their fungistatic activity, resulting in high efficacy against candidal infections. 18 In most cases of a candidal infection, hydrocortisone 1% (applied twice daily) can be added to therapy to treat the associated inflammation if required. 14 Candidal nail infections require specific therapy (see Table 4), with paronychia sometimes requiring antibiotic therapy with flucloxacllin. 18 When using topical azoles or nystatin for the treatment of candida infections, therapy should be continued for 2 weeks after symptoms resolve. 18 In cases of angular cheilitis, the regular use of a lip emollient may also assist with symptoms. 28 Self-care measures for the prevention of candidal infections The practice of good hygiene is essential in the overall management of candidal infections. 18 Patients should keep the skin as dry and clean as possible. 18 Patients who suffer from intertrigo should wear light and absorbent clothing, avoiding fabrics (i.e. cotton) which contain nylon and other synthetic fibres. 32 In cases of oral candidiasis, good oral hygiene such as cleaning the teeth, buccal cavity, gums, tongue and dentures may assist with the prevention of relapse. 27 In cases where a patient uses a preventative corticosteroid inhaler, ensure they are rinsing the mouth well after use (see Practice point 2). 36 Patients with angular cheilitis should consider if a nutritional deficiency has contributed to symptom presentation; iron and riboflavin deficiency have been associated with this condition. 28 Malassezia Table 4 Topical antifungal agents for yeast infections 14,18 The most common skin condition caused by the malassezia yeast is called pityriasis versicolor (also known as tinea versicolor). 39 Like candida, malassezia is a normal part of the skin s microbiota, and in some patients the yeast can grow more actively (the reason for this is not well understood). 40 This infection most commonly affects the face, neck, upper arms and trunk (i.e. chest and back), and causes the presentation of hypo or hyper-pigmented, round, flaky, well demarcated patches. 14,39,40 Patches may coalesce to form large and irregular areas Agent Indications Notes Terbinafine Cutaneous candidiasis Pityriasis versicolor (gel format) Has fungistatic action against candida species A more expensive option Bifonazole (Mycospor) Cutaneous candidiasis Treatment of choice Clotrimazole (Canesten, Clonea) Econazle (Pevaryl) Miconazole (Daktarin, Resolve) Pityriasis versicolor (note foaming liquid format for econazole) Nystatin Cutaneous candidiasis Is effective in treating candida species Note if infection is not clearly diagnosed, azole antifungals are preferred as they are also effective against dermpatophyte infections Amorolfine Onychomycosis Systemic treatment is usually required (more effective) Amorolfine is typically useful for superficial infections or where there is distal end nail involvement only of infection. 37 Patches can appear to be copper/brown or pink in colour, and generally are asymptomatic (in some cases they may be associated mild itch). 40 Pityriasis versicolor tends to occur more commonly in humid climates (due to heavy sweating) and in young children or adults. 14,40 Pityriasis versicolor can be diagnosed via examination under a wood lamp, where affected areas produce a yellow-green fluorescene. 39,40 A skin biopsy may also be useful in the diagnosis of this condition. 39,40 Management of pityriasis versicolor As most cases of this condition are asymptomatic, treatment is usually for cosmetic reasons. 14 Mild cases of pityriasis versicolor can usually be treated with topical antifungal agents (see Table 4). Azole antifungals are effective in the treatment of this condition, with treatment course options as either: 14 econazole 1% solution (Pevaryl) applied topically to wet skin, left overnight, for 3 nights ketoconazole 2% shampoo (Nizoral) used topically once daily (on the scalp for 3 5 minutes before washing off) for 5 days miconazole 2% shampoo (Hair Science Anti-dandruff) used topically once daily (on the scalp for 10 minutes before washing off) for 10 days. Alternatively, selenium sulfide 2.5% shampoo (Selsun) can be applied to the affected area/s once a day (to wet skin) for 7 10 days and kept on for 10 minutes or overnight before being washed off the skin. 14 Treatment of pityriasis versicolor typically takes around 2 weeks, but can vary on a case-by-case basis. 40 In recurrent cases of pityriasis versicolor, topical antifungal therapy should be repeated, and in some cases, systemic antifungal agents may be prescribed. 40 Some patients may experience persistent white marks on the skin after the yeast has been eradicated from the skin antifungal therapy will not be able to reduce the appearance of white marks inpharmation April 2016 I Pharmaceutical Society of Australia Ltd.

9 Fungal skin care Pharmacist CPD Module number 270 Facts Behind the Fact Card Case study Patricia (49 years) presents to your pharmacy today with a request for advice on the management of her skin condition. Last week, Patricia s doctor informed her that she had a case of athlete s foot, which she assumes is related to her regular running and exercise patterns. This is the third time Patricia has experienced athlete s foot in the past two years, and she is starting to get a little fed up with this recurrent issue. You discover that Patricia has used a topical antifungal agent (clotrimazole) for this condition in the past, and she thinks this seemed to work well. Patricia also presents today to get her regular prescriptions filled for metformin 500 mg, rampiril 5 mg and a salbutamol puffer. What advice can you share with Patricia regarding the management of her athlete s foot? You advise Patricia that athlete s foot (tinea pedis) is a common fungal skin condition in adults. As Patricia runs regularly, she would wear occlusive footwear, and her feet would be commonly exposed to a moist environment (which would likely encourage the overgrowth of dermatophytes). You inform Patricia about the best treatment options for her condition. She should apply terbinafine cream once or twice daily to the affected area and over a 2 cm border beyond the visible infection. After applying the cream she should wash her hands well to prevent the spread of infection. Patricia should apply the cream for around 2 weeks, or until symptoms resolve, and then continue to apply the cream for a further week to improve the chances of complete symptom resolution (and avoid subsequent recurrences). Terbinafine cream is an effective antifungal agent, and usually there is limited recurrence of tinea after appropriate treatment with this agent. You also advise Patricia on self-care measures that can prevent further spread or recurrence of her condition: choose socks that are made from cotton (to allow moisture to dry from the skin s surface) when possible, wear open-toe footwear dry the skin well (especially between the toes) after showering, and before the application of socks If using communal areas (i.e. change rooms) wear shoes Try to use some antifungal powders in the running shoes to help reduce the risk of further infections Avoid sharing towels and clothing, and dry the feet with a separate, clean towel. You also advise Patricia that patients with diabetes can be more prone to fungal skin infections. As her condition has become recurrent, she should consider visiting her doctor for a consultation. Finally, you give Patricia a Tinea PSA Self Care Fact Card for further information regarding the management of her condition. Box 1. A focus on nappy rash Nappy rash can be caused by a variety of factors, such as urine and faeces (due to ammonia and faecal enzymes in soiled nappies), teething, moisture, friction and fungal skin infections. 37,38 Warm and damp conditions in the nappy (over extended periods of time) can result in the growth of fungus (such as candida) which can cause irritation of the baby s skin. 37 Nappy rash which is associated with candida usually has a defined red area around the perianal skin with associated papules and pustules. 38 The recommended treatment for mild, irritant nappy rash includes the use of hydrocortisone 1% (twice daily) and a topical antifungal (nystatin 100,000 units/g twice daily or miconazole plus zinc oxide mg/g at every nappy change where hydrocortisone is not applied). 14 The use of a stronger topical corticosteroid may be warranted for more severe cases of this condition. 14 As part of the overall management of nappy rash, self-care measures should be implemented (see Practice point 3). inpharmation April 2016 I Pharmaceutical Society of Australia Ltd. 9

10 John Bell Facts saysbehind the Fact Card Fungal skin care Pharmacist CPD Module number 270 References 1. DermNetNZ (introduction to fungal infections). At: Garber G. An overview of fungal infections. Drugs. 2001;61(Suppl 1): mydr (fungal skin infections). At: pharmacy-care/fungal-skin-infections 4. Merck Manual (overview of dermatophytoses). At: dermatologic-disorders/fungal-skin-infections/overview-ofdermatophytoses 5. Ely J, Rosenfeld S, Stone M. Diagnosis and management of tinea infections. Am Fam Physic. 2014;90(1): Weinstein A, Berman B. Topical treatment of common superficial tinea infections. Am Fam Physic. 2002;65(10): DermNetNZ (tinea). At: tinea.html 8. DermNetNZ (tinea capitis). At: fungal/tinea-capitis.html 9. Fuller L, Barton C, Mustapa M. British Association of Dermatologists guidelines for the management of tinea capitis BJD. 2014;171: Merck Manuals (tinea corporis). At: com/professional/dermatologic-disorders/fungal-skininfections/tinea-corporis 11. DermNetNZ (tinea manuum). At: fungal/tinea-manuum.html 12. DermNet NZ (tinea cruris). At: fungal/tinea-cruris.html 13. DermNetNZ (fungal nail infections (onchomycosis)). At: Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 4. Melbourne: Therapeutic Guidelines Ltd; Shirwaikar A, Shirwaikar T, Lobo R, et al. Treatment of onchomycosis: an update. Indian J Pharm Sci. 2008;70(6): DermNetNZ (tinea pedis). At: fungal/tinea-pedis.html 17. Field L, Adams B. Tinea pedis in athletes. Int J Dermatol. 2008;47: Rossi S, ed. Australian medicines handbook. Adelaide: Australian Medicines Handbook; At: online/view.php?=index.html 19. Product information. emims. St Leonards: CMP Medica Australia. Pty Ltd; DermNetNZ (topical antifungal medications). At: dermnetnz.org/treatments/topical-antifungal.html 21. Pharmaceutical Society of Australia. Tinea Self Care Fact Card. Canberra: PSA; DermNetNZ (treatment of fungal infections). At: dermnetnz.org/treatments/fungal-treatment.html 23. Rex J, Walsh T, Sobel J, et al. Pratcice guidelines for the treatment of candidiasis. CID. 2000;30: DermNetNZ (candida). At: fungal/candida.html 25. Merck Manual (candida (mucocutaneous)). At: msdmanuals.com/professional/dermatologic-disorders/ fungal-skin-infections/candidiasis-(mucocutaneous) 26. DermNetNZ (oral candidiasis). At: org/fungal/oral-candidiasis.html 27. Akpan A, Morgan R. Oral candidiasis. Postgrad Med. 2002;78: DermNetNZ (angular chelitis). At: org/site-age-specific/angular-cheilitis.html 29. Dovnik A, Golle A, Novak D, et al. Treatment of vulvovaginal candidiasis: a review of the literature. Acta Dermatovenerol APA. 2015;24: DermNetNZ (balantis). At: DermNetNZ (candidiasis of skin folds). At: dermnetnz.org/fungal/candida-intertrigo.html 32. Janniger C, Schwartz R, Szepietowski, et al. Intetrigo and common secondary skin infections. Am Fam Physic. 2005;72(5): DermNetNZ (paronychia). At: fungal/paronychia.html 34. DermNetNZ (fungal nail infections (onchomycosis)). At: Medscape (onchomycosis). At: com/article/ overview 36. Pharmaceutical Society of Australia. Thrush Self Care Fact Card. Canberra: PSA; Morris H. Getting to the bottom of nappy rash. Community Pract. 2012;85(11): Woolley S. The rough with the smooth: managing nappy rash. Community Pract. 2015;88(5): Gupta A, Lyons D. Pityriasis veriscolor: an update on pharmacological treatment options. Expert Opin Pharmacother. 2014;15(2): DermNetNZ(pityriasis versicolour). At: dermnetnz.org/fungal/pityriasis-versicolor.html 41. Rutter P, Newby D. Community Pharmacy Australia and New Zealand Edition. 3rd edition. London: Elsevier; p. 42. Centers for Disease Control (who gets fungal infections). At: Foss N, Polon D, Takada M. Skin lesions in diabetic patients. Rev Saude Publica. 2005;39(4): DermNetNZ (vulvovaginal candidiasis). At: dermnetnz.org/fungal/vaginal-candidiasis.html 10 inpharmation April 2016 I Pharmaceutical Society of Australia Ltd.

11 Fungal skin care Pharmacist CPD Module number 270 Facts Behind the Fact Card Assessment questions for the pharmacist Fungal skin care Personal ID number: Full name:... Pharmacy:... Address:... Suburb:... State:...Postcode:... Circle one correct answer from each of the following questions Before undertaking this assessment, you need to have read the Facts Behind the Fact Card article and the associated Fact Cards. This CPD activity has been accredited as a Group 2 activity. Two CPD credits (Group 2) will be awarded to pharmacists with four out of five questions correct. PSA is accredited by the Australian Pharmacy Council to accredit providers of CPD activities for pharmacists that may be used as supporting evidence of continuing competence. Please submit your assessment by 31 May 2016 Submit answers Submit online at Fax: Mail: Self Care Answers Pharmaceutical Society of Australia PO Box 42 DEAKIN WEST ACT 2600 Accreditation number: CS This activity has been accredited for 2 Group 2 CPD credits suitable for inclusion in an individual pharmacist s CPD plan. Please retain a copy for your own purposes. Photocopy if you require extra copies. 1. Peter comes to the pharmacy today, with an irritating rash on his scalp. He thinks he is suffering from tinea, as he has had this on his scalp in the past. Which ONE of the following is NOT a symptom of tinea capitis? a) Malodorous liquid oozing from the affected area. b) Smooth areas of skin with hair loss. c) Itching and fine scaling. d) Patchy and circular lesions. 2. Which of the following topical antifungal agents is NOT effective against both dermatophyte and yeast based fungal skin infections? a) Clotrimazole. b) Terbinafine. c) Miconazole. d) Nystatin. 3. With regards to oral candidiasis, which ONE of the following is CORRECT? a) It is caused by micropsorum fungal pathogens. b) The condition occurs when an elevated number of yeast cells invade the oral mucosa. c) It is a common condition in patients taking oral retinoids. d) Improved oral hygiene will not assist in the management of this condition. 4. Bianca is experiencing inflammation and cracks in the corner of her mouth which are red and bleeding. Which fungal skin infection is she most likely suffering from? a) Pityriasis versicolor. b) Intertrigo. c) Angular cheilitis. d) Balanitis. 5. When applying topical antifungal agents, which ONE of the following is INCORRECT? a) They should never be applied at the same time as a corticosteroid. b) It is best to apply the product on the affected area, and for 2 cm beyond the infected margins. c) The usual treatment course ranges from 2 4 weeks. d) Products should generally be continued for 1 2 weeks after symptoms cease. inpharmation April 2016 I Pharmaceutical Society of Australia Ltd. 11

12 CHILD HEALTH SKIN CARE John Bell says Counter Connection Fungal skin care Pharmacy assistant s education Module number 270 Fungal skin care By Sarah Gray This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed. Fungal skin conditions are a common problem, which affect a large number of customers. Nappy rash occurs when a baby s skin becomes irritated and inflamed. It is caused by urine, faeces or other irritating substances that come into contact with skin in the nappy area. Changing nappies often and taking good care of baby s skin can help prevent nappy rash. A pharmacist can give advice about nappy rash. Causes Babies who have very sensitive skin or suffer from a skin condition A baby s skin can be irritated by: (e.g. eczema/dermatitis, psoriasis) are faeces (bowel motions/stools/poo) more likely to get nappy rash. especially loose faeces caused by some foods, medicines, infections or teething urine (wee) especially when the nappy is left on too long or is covered by plastic pants. Plastic pants make nappy rash more likely by keeping the baby s skin warm, wet and airless irritating chemicals nappy rinses, detergents, soaps, bleach, water and fabric softeners left on cloth nappies can be irritating. Cloth nappies need to be rinsed well with clean water. Some nappy change creams and lotions, and some skin wipes can also irritate the skin friction nappies with a rough surface (e.g. cloth nappies) can damage sensitive skin. Nappy rash Tinea (Ringworm) Tinea is a common skin infection caused by a fungus. It usually affects warm, moist areas of skin and often occurs between the toes and around the groin. It can also affect other body areas, including the scalp and nails. Most cases of tinea can be treated with medicines available from a pharmacist. Tinea is sometimes called ringworm, Groin tinea (jock itch) but it is not caused by a worm and the scaly, red rash on the inner thighs. skin rash is not always ring-shaped. It may also occur on the buttocks. Tinea spreads from person to person It does not usually occur on the through skin-to-skin contact, or genitals or anal area. The rash often indirectly through contaminated towels, clothes, shoes, bedding, mats has red, scaly edges and may have and floors. People can also catch tinea a pale centre. Groin tinea can be from animals (e.g. cats, dogs, guinea very itchy. pigs) with tinea. small blisters may form in the rash area. Signs and symptoms Foot tinea (athlete s foot) Foot tinea most often occurs between the toes. Tinea between the toes: looks moist, with peeling and cracks may be white or red is often itchy; may burn or sting may have an unpleasant smell. Tinea can also cause itching, scaling, peeling and cracking on other parts of the foot. Small blisters may form in the affected area. Customers will often present to the pharmacy with a fungal skin rash, and it is important that the pharmacy assistant is aware of how to best manage these conditions. There are two main types of fungal skin conditions tinea and thrush (or candidal) infections. These infections usually cause mild signs and symptoms, but they are very contagious so can spread to other areas of the body, or to other people quite easily. Table 1. Types of tinea Type of tinea (common name) Ringworm Jock itch Athlete s foot Onychomycosis (nail infection) What it looks like Tinea Tinea is a common condition that can occur as many different types (see Table 1). The most common types of tinea seen in community pharmacy practice are athlete s foot, ringworm, jock itch, and nappy rash. Tinea is best treated with a topical antifungal product, which are available as gels, lotions, powders, solutions, and sprays. There are several different topical antifungal products available at the pharmacy (see Table 2). Terbinafine seems to be the most effective product, as it works more quickly than other agents and can be used for a shorter period of time. Can occur on the scalp, body or face Smooth patches of skin with hair loss Redness and itch Depending on the type of ringworm there can also be other signs such as scales or yellow crusts Occurs in the groin and upper thigh Red rash which is scaly and has a raised edge Affects the skin between the toes Redness and soggy-looking skin which can be scaly and peeling Occurs on the fingernails or toenails Nails look thick, brittle and discoloured 12 inpharmation April 2016 I Pharmaceutical Society of Australia Ltd.

13 Fungal skin care Pharmacy assistant s education Module number 270 Counter Connection Treatment with topical antifungals is usually required for 2 weeks, but in more severe cases, customers may need to use the product for up to 4 weeks. Once the tinea rash has been treated (and the skin looks normal) the customer should continue to use the product for 1 2 weeks. As terbinafine is a very effective agent, this may not always need to be used for additional time. When applying the product, the affected area should be well covered, and the product should also be applied to an area of 2 cm beyond the edge of the rash. After applying the product, the customer should wash their hands well, as this will reduce the risk of spreading the infection to other areas of the body, or to other people. When advising customers on the best way to apply amorolfine nail lacquer, for a fungal nail infection, they should be informed they need to roughen the nail with an emery board before use. Then they need to apply the lacquer once or twice a week for 6 12 months, as this is how long it takes for the fingernails or toenails to regrow. Self-care for tinea There are several ways that customers can try to reduce the risk of fungal skin infections and their spread. As fungal skin infections are more likely to occur in a moist/wet environment (such as sweaty socks or running gear) it is best to choose loose-fitting clothing that is made from cotton or wool, as this allows this skin to breathe and dry properly. When possible, it is best to wear open-toed footwear, which will allow the feet and toes to breathe naturally. Some areas of the body are more likely to be affected by tinea, such as in between the toes (athlete s foot), and these areas should be well-dried before putting on clothes or socks. It is best that customers use a clean, separate towel when Table 2. Topical antifungals for tinea Name Terbinafine (Lamisil, SolvEasy Tinea, Tamsil) Bifonazole (Mycospor) Clotrimazole (Canesten, Clonea) Econazle (Pevaryl) Miconazole (Daktarin, Resolve) Tolnaftate (Tinaderm, Mycil, Tineafax) Amorolfine (Loceryl) drying affected areas, and they should avoid sharing towels with others. Thrush Thrush is caused by yeast, known as Candida species. However, in some cases (such as excess dampness, heat, and patients who are unwell), this yeast can overgrow on the skin s surface, and this can lead to a thrush infection. Thrush is most common in the mouth (oral thrush) and vagina (vaginal thrush). Oral thrush affects the gums, tongue and inside of the mouth. Customers with oral thrush will usually have white patches in the mouth, and smooth, red patches on the tongue. If the white patches are scratched away, the area will be very raw and red. Oral thrush is most common in patients who have a nutritional deficiency (i.e. iron or vitamin B deficiency) and those using inhaled corticosteroids for asthma prevention. Vaginal thrush appears as a red rash inside the vagina, which can be associated with discomfort and pain while urinating. There is usually a white, curd-like discharge from the vagina which looks like cottage cheese. Vaginal thrush occurs most commonly in patients who are pregnant, patients with diabetes, patients who wear dentures, or patients who are taking antibiotics. Thrush is best treated with a topical antifungal medicine (i.e. clotrimazole). Oral thrush is best treated with an oral gel or liquid formulation antifungal product, as these can be applied directly inside the mouth. Vaginal thrush can be treated with a pessary or cream product, which should be applied to the vagina at night. The pharmacist can also recommend an oral capsule for the treatment of vaginal thrush (please refer to the pharmacist as these are Pharmacist Only medicines). How to use Apply once or twice daily Apply one to three times daily Apply twice daily (Note: tolnaftate may cause skin irritation) Apply once or twice a week to nails Box 1. Self-care advice for nappy rash Parents or caregivers can be provided with some important information about how to manage nappy rash: Choose disposable nappies these are highly absorbent. (If cloth nappies must be used, it is best to change them every 2 hours and do not apply plastic over pants/nappy liners.) Cloth nappies should also be washed on a high temperature (over 60 C), to destroy any bugs and detergents used in the washing process. Wipe from front-to-back. Leave nappies off for as long as possible to allow the area to breathe. Avoid soap use a soap substitute. Avoid bubble bath, talcum powder or perfumed products. Cleanse the nappy area at change times with a soap substitute and damp cloth (do not use nappy wipes). Regularly apply a thin layer of a barrier cream or ointment after every nappy change. Self-care for thrush With oral thrush, customers should be advised to brush and floss the teeth well, ideally twice a day. Dentures should be soaked well and cleaned overnight. If customers are using an inhaled corticosteroid medicine, they should rinse the mouth well after use (refer to the pharmacist for more consumer medicine information). Women experiencing vaginal thrush should wear loose clothing and undergarments which are made of cotton or wool (natural fibres) which are airy. They should avoid using condoms or diaphragms while they are treating thrush, and for 3 days after finishing treatment. Nappy rash There are several causes of nappy rash, ranging from moisture and friction, to a fungal skin infection. Warm, damp conditions in the nappy can promote the overgrowth of yeast (such as Candida) and lead to irritation of the skin. Common signs of nappy rash include redness, swelling, white spots and yellow crusting of the skin. inpharmation April 2016 I Pharmaceutical Society of Australia Ltd. 13