Clinical Presentation-Skin Disorders

Tinea capitis, or “ringworm” of the scalp, presents as one or more sharply marginated plaques of partial alopecia. Inflammation and scale are present, but often these two changes are quite minimal. The recognition of broken hairs (stubble and black dots at the follicular orifices) is the best clue to correct diagnosis. Nearly all cases occur in children, but the diagnosis should be considered in any adult presenting with evidence of localized alopecia . Kerion formation is a complication that occurs in about 10% of cases. This represents a sensitization phenomenon whereby the fungi induce a remarkably brisk inflammatory reaction with resulting pustulation, crusting, and edema formation. Wood’s lamp examination does not reveal fluorescence in the most common forms of tinea capitis or in kerion formation. Unfortunately, KOH preparations are difficult for the inexperienced to interpret. For this reason, any suspected diagnosis requires the plucking of infected hairs for fungal culture. Course and PrognosisTinea capitis and zoophilic tinea corporis usually resolve spontaneously after 6 to 12 months of activity. Tinea pedis, tinea cruris, and anthropophilic tinea corporis continue indefinitely. There are, however, periods of relative quiescence and exacerbation. All of these fungal diseases respond well to treatment, but with the exception of tinea capitis and zoophilic tinea corporis infections, recurrence following treatment is rather likely. PathogenesisTinea pedis, tinea cruris, and anthropophilic tinea corporis are most commonly caused by Trichophyton rulnum. Trichophyton interdigitate and Epidermophhyton floccoswn infections are also seen. Generally, one cannot predict the causative organism on the basis of clinical appearance. Zoophilic tinea corporis can be caused by Microsporum canis, Trichophyton mentagrophytes, and Trichophyton verrucosum. Tinea capitis is caused by Trichophyton tonsurans in 90% of cases. The likelihood of inoculation with any of these fungi is enhanced if cuts and scratches are present on the skin. Clinical evidence of infection following inoculation is enhanced by the presence of warmth and moisture, such as occurs in the groin and under footwear. Depression of cell-mediated immune responsiveness, as in atopic patients, is a major predisposing factor for the development of T. rubrum infection. TherapyTinea cruris and those cases of tinea pedis that involve only the web spaces can be treated with any of the topical antifungal agents. Other forms of tinea pedis usually require the use of griseofulvin. Mild cases of tinea corporis also respond well to topical agents. Extensive disease and those cases with a component of follicular involvement are best treated with griseofulvin. Tinea capitis requires the use of griseofulvin. Orally administered ketoconazole therapy is rarely appropriate for either tinea corporis or capitis. Kerion on nation, if present, can be treated with intralesional steroid injections or with a short burst of systemically administered steroids.

Tinea capitis, or “ringworm” of the scalp, presents as one or more sharply marginated plaques of partial alopecia. Inflammation and scale are present, but often these two changes are quite minimal. The recognition of broken hairs (stubble and black dots at the follicular orifices) is the best clue to correct diagnosis. Nearly all cases occur in children, but the diagnosis should be considered in any adult presenting with evidence of localized alopecia . Kerion formation is a complication that occurs in about 10% of cases. This represents a sensitization phenomenon whereby the fungi induce a remarkably brisk inflammatory reaction with resulting pustulation, crusting, and edema formation. Wood’s lamp examination does not reveal fluorescence in the most common forms of tinea capitis or in kerion formation. Unfortunately, KOH preparations are difficult for the inexperienced to interpret. For this reason, any suspected diagnosis requires the plucking of infected hairs for fungal culture.
Course and Prognosis

Tinea capitis and zoophilic tinea corporis usually resolve spontaneously after 6 to 12 months of activity. Tinea pedis, tinea cruris, and anthropophilic tinea corporis continue indefinitely. There are, however, periods of relative quiescence and exacerbation. All of these fungal diseases respond well to treatment, but with the exception of tinea capitis and zoophilic tinea corporis infections, recurrence following treatment is rather likely.
Pathogenesis

Tinea pedis, tinea cruris, and anthropophilic tinea corporis are most commonly caused by Trichophyton rulnum. Trichophyton interdigitate and Epidermophhyton floccoswn infections are also seen. Generally, one cannot predict the causative organism on the basis of clinical appearance. Zoophilic tinea corporis can be caused by Microsporum canis, Trichophyton mentagrophytes, and Trichophyton verrucosum. Tinea capitis is caused by Trichophyton tonsurans in 90% of cases.

The likelihood of inoculation with any of these fungi is enhanced if cuts and scratches are present on the skin. Clinical evidence of infection following inoculation is enhanced by the presence of warmth and moisture, such as occurs in the groin and under footwear. Depression of cell-mediated immune responsiveness, as in atopic patients, is a major predisposing factor for the development of T. rubrum infection.
Therapy

Tinea cruris and those cases of tinea pedis that involve only the web spaces can be treated with any of the topical antifungal agents. Other forms of tinea pedis usually require the use of griseofulvin. Mild cases of tinea corporis also respond well to topical agents. Extensive disease and those cases with a component of follicular involvement are best treated with griseofulvin. Tinea capitis requires the use of griseofulvin. Orally administered ketoconazole therapy is rarely appropriate for either tinea corporis or capitis. Kerion on nation, if present, can be treated with intralesional steroid injections or with a short burst of systemically administered steroids.

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You have tried everything on your nail fungus: OTC antifungal ointments and creams, Penlac, Vicks Vaporub, Listerine, tea tree oil, vinegar. You have used them individually and in combinations as recommended by friends, all to no avail. You have other recourse but to try oral medication.

Nail fungus is scientifically known as onychomycosis. It is caused by a type of fungus known as dermatophyte which invades the nails through a break in the skin. The fungus feeds on keratin, the main component of the hard shell or the nail plate.

Nail Fungal infection is often tough to treat because the nail plate inadvertently harbors and protects the infecting agent. For this reason, it is sometimes recommended to treat the disease from within using oral prescription medication. As with most prescription drugs, doctors order lab tests on the diseased nail either through fungal culture, KOH preparation or nail biopsy in order to determine the type of infection. From there, the doctors will determine the appropriate course of treatment.

1. Sporanox (Itraconazole)

Sporanox is a capsule administered to patients suffering from different fungal infections including onychomychosis of the toenails and fingernails. It is usually taken by patients for at least 3 months although the effect may be seen in as much as 9 months up to a whole year.

The Food and Drug Administration (FDA) issued a pubic advisory on the potential danger of Sporanox to overall health. It has been found to have contraindications on people with congestive heart failure or CHF as well as with liver malfunction. Thus, physicians order several laboratory tests and conduct research on a person’s medical history prior to prescribing the drug.

2. Lamisil (Terbinafine)

Lamisil is the most doctor prescribed medication for nail fungal infection. It is in tablet form and Lamisil has about the same success rate as that of Sporanox although costs relatively less. It is usually taken for 6 weeks by patients with fingernail infections or for 3 months for patients with toenail infections.

The FDA issued an advisory on the potential danger of Lamisil tablets on liver health. Thus, prior to issuing prescriptions and 6 weeks into the course of treatment, administering physicians require their patients to take liver functions tests to ensure safety.

There is also a topical variety of Lamisil which can be used in conjunction with the oral treatment for faster result. Lamisil topical treatment is excluded from the FDA’s advisory concerning Lamisil’s adverse effect on liver health.

3. Diflucan (Fluconazole)

Diflucan is an antifungal drug primarily prescribed for treatment of infections due to candida such as vaginal, esophageal and oropharyngeal, as well as for cryptococcal meningitis. The FDA has not yet approved its use for nail fungus treatment although a study shows that it performed significantly more effective compared to placebo treatment of the disease. It is administered in mild to moderate infections for a duration of 3 to 6 months, and in moderate to severe infections for a duration of 6 to 9 months.

Diflucan is also potentially harmful to liver health. Thus patients are advised by their doctors to take a liver functions test prior to taking the medication. There have also been reported rare cases of anaphylaxis and skin rashes in patients who have taken the drug.