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55 Cards in this Set

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Characteristics of a fungal skin infection?
- mildly to moderately itchy (not as much as eczema)
- dry and scaley
- annular (ring shaped), with a definite edge and centrally clearing
- thrive in warm, moist areas such as groin and toes; also on arms and hands and scalp (UK)
- tinea versicolor: mostly at centre of chest, spreading outwards, uncommon up to neck, elbows, hip, rare above and below this.
When do you refer skin tinea?
1. When it's hard to differentiate between tinea and eczema
2. When it hasn't responded to treatment, or if it wont respond: nails, scalp, soles of feet (can try terbinafine) and hands
3. When it is in large areas, or in two areas and compliance with a topical treatment likely to be poor
Treatment of Tinea Versicolor (Aka Pityriasis versicolor) with Malassezia furfur?
1. Econozole 1%
2. Ketoconazole 2% shampoo (Nizoral) 10min 10/7
3. Miconazole 2% shampoo (Hair science antidandruff) 10min 10/7
4. Selenium sulfide 2.5% 7-10/7

If unsuccessful (after time for repigmentation), give ketoconazole 200mg 10/7 or itraconazole 200mg 5/7
When do you need to use terbinafine more than d-bd for 7/7?
7/7: toes, T.versicolor
2-4/7: mocassion/planar soles of feet
1-2/52: body, groin
2/52: candidasis (hence 2 week groin treatment a good idea)
Treatment of tinea topically?
1. terbinafine
2. bifonazole (d) until several days after resolves
3. ketoconazole d-bd
3. miconazole bd
3. econazole bd-tds
3. clotrimazole bd-tds until 14/7 after resolves
Azole antifungals?
- MOA
- pregnancy?
- are ketoconazole and bifonazole better?
- how long after gone do you use it?
1. impair ergosterol biosysnthesis; fungistatic (terbinafine fungicidal for tinea)
2. SAFE IN BREASTFEEDING; Clotrimazole, econazole and miconazole are preferred in pregnancy because of greater experience cf ketoconazole and bifonazole
3. ketoconazole and bifonazole do not offer significant advantages despite d application
4. until 2/52 after gone awat (AMH 2008)
Bifonazole products
Canesten Once Daily Bifonazole, Mycospor 1% creams
Clotrimazole products
1. Canesten, Clotreme, Clozole, Clonea, Topizol 1% creams
2. Canesten 1%.20mL liquid
3. Hydrozole (1% clotrimazole, 1% hydrocortizone)
Econazole products
Pevaryl 1%
- foaming solution
- cream

Dermazole cream
Ketoconazole products
2% cream (DaktaGOLD, Nizoral)
1% shampoo (Nisoral)
2% shampoo (Nizoral, Sebizole)
Miconazole products
2% cream (Daktarin, Resolve Jock Itch, Resolve Tinea)
2% liquid (Daktarin Tincture, Resolve Solution)
2% lotion (Daktarin)
2% spray (Daktarin, Eulactol)
2% powder (Daktarin, Resolve)
2% shampoo (Hair Science Anti Dandruff)

Resolve Balm (with bufexamac 5%)
Resolve Plus (0.5/1)
Daktozin (miconazole 0.25% with zinc oxide 15%)
Tolnafate products
- useful?
Can be irritating, less effective than azoles or terbinafine

1% cream (Tinaderm, Mycil healthy feet, Tineafax)
1% liquid.10mL (Tinaderm) - ineffective on nail beds but may be useful adjunct to systemic agents
1% ointment (ringworm ointment)
0.07% spray & powder spray(Tinaderm)
1% powder (Tinaderm, Mycil Healthy feet, Tineafax)
Other treatment advice for tinea?
Keep dry and cool:
- dry between toes, and use a drying agent if required (such as Condy's crystals, Burrow's solution)
- use breathable socks and shoes
Hygeine measures:
- use a seperate towel
- wear thongs in public places
- disinfect shower
- change socks daily and wash or discard old shoes
- evaluate family members for infection
cutaneous candidiasis
- which areas?
- before treatment do what?
- topical treatment?
Tends to occur: in axillae, groin, armpits, skin folds especially in the obese

Look for immunosuppression, diabetes, systemic ABX or steroids, occlusion, mechanical irritation

Azoles and the treament of choice
Nystatin also effective but not against tinea (need sure diagnosis)
Terbinafine is fungistatic not fungicidal so no benefit and more costly
Systemic treatment of cutaneous candidiasis?
When widespread, unresponsive or immunocompromised

1. Fluconazole is choice
2. Itraconazole is good but less well studied
3. Ketoconazole is not preferred because of its serious side effects
Nystatin - products for dermatological use? Dose regimen?
Mycostatin cream 100,000 units/g
Apply liberally bd-tds until 2 weeks after symptoms have gone
Symptom improvement in 1-3 days
Tinea mannum
- differential diagnosis?
Usually atypical tinea appearance & misdiagnosed as eczema or psoriasis.
It usually occurs because of presence of tinea pedia, and is transferred to the hand by scratching.
It there is no foot involvement or if it involves both hands, then dermatitis is more likely.
How do you distinguish tinea from psoriasis?
Psoriasis is NOT itchy and are more scaley, without central clearing.
There is also usually a family history.
Tinea incognito - note the papules - how does this come about?
Often after use of steroid creams due to misdiagnosis as dermatitis. Steroids reduce inflammation but allows tinea to proliferate, causing return of infection worse than before on withdrawal of cream.
Chronic paronchyia - what is it and what causes it?
This is infection of the nail fold around the nail plate. Painless, due to trauma to the nail plate, usually manicures.
Candida
Treatment
1. Educate patient to avoid trauma, wear gloves (cotton), keep nails out of the water
2. Use a solution: Miconazole or clotrimazole solutions
3. can also apply WSP to waterproof, when required.
Nappy rash - treatment
1. Breathable, disposable nappies, such as huggies, which are the most absorbent & allow nappy free periods
2. Avoid cleaning with irritants, e.g. baby wipes: use olice oil or diluted bath oil
3. Apply antifungal
4. Apply a barrier cream - it is considered adequate if it is still present at next nappy change. (Sudocream, RCH nappy goo)
Onychomycosis - what's that?
Do what before treatment?
Treatment?
Infection of the nail. Can be Candida or Tinea (which would be Tinea unguium)

Look for diabetes and immunosuppression. Confirm by microscopy and culture.

Systemic treatment is more effective.
1. Terbinafine (Lamisil) 250mg d for 6/51 (hand) or 12/52 (foot)
2. Itraconazole (Sporanox) 200mg bd for 7/7 every month for 3-4/12
3. Fluconazole 150-300mg weekly for 12-52/52
4. Griseofulvin only works for ~30% after 1 year

Amorolfine (Loceryl) only for superficial or distal nail infections. Apply 1-2 times weekly for 6-12/12

Totally dystrophic nail takes 9/12 to grow out: scratch the border to ensure efficacious treatment.
How do you use Loceryl nail laquer?
Thoroughly file down and clean nail using cleaning pad provided.
Apply laquer to entire nail.
Before repeating, file and clean off remaining lacquer.
Do not use cosmetic lacquers, artificial nails or occlussive dressing.
Use seperate nail file for affected and unaffected nails.
How do you use Lamisil Once liquid 1% 4g? When can you use it?
Clean and dry both feet.
Apply a thin layer to each foot, including toes, soles, and sides - leave to dry for 1-2 minutes
Do not wash the area for 24hrs after applying.

Use for tinea pedis of toes - appears as effective as 7/7 treatment. Not recommended for plantar/mocassin type tinea pedis.
Seborrhoeic dermatitis?
- infective agent?
- symptoms
- complications
- Malassezia fufur aka Pityosporum ovale (as for Pityriasis versicolor)
- Tends to be centred around areas of high sebum because it is unable to synthesis these neccessary lipids for itself
- mild, red, itchy, scaly rash around central part of face, scalp, eyebrows, eyelids, nose folds, and midchest.
- can cause blepharitis and otitis externa
Seborrhoeic dermatitis
- differential diagnoses?
1. atopic dermatitis: usually on same area in infants (face, scalp, trunk) but usually also a family history of dermatitis/asthma/hayfever
2. Psoriasis - no eyelid or eyebrow involvement
3. Pityriasis versicolor on the trunk with scale - no itch, face is spared
Seborrhoeic dermatitis
- treatment
- a topical imidazole or shampoo.
- often topical steroids are also required!!!
Cradle cap
- treatment
1. apply olive oil to the scalp and leave overnight, shampoo in the morning, and remove scales with a towel or toothbrush or soft brush
2. Keratolytic: Egozite Cradle Cap Lotion (oil based with salicylic acid), on alternate days until controlled, then twice weekly to control.
3. refer to GP.
Tinea
- pregnancy?
- BF?
- Children?
- drug interactions?
Safe to use terbinafine (B1) and azoles!!
Bf - safe
Children - use in <12 y/o is not recommended by manufacturer but AMH has no such leanings.
No DIs
Griseofulvin
- product
- MOA
- indication
- Grisovin: 125mg.100, 500mg.28 tablets
- Prevents DNA replication
- Tina corporis, tinea capitis, tinea unguium, tinea pedis, tinea crurus where topical treatment has failed or is inappropriate
Grisovin
- CIs (2)
- Pregnancy & BF
CI: SLE and Severe hepatic disease
Pregnancy B3: avoid use. Women should use additional contraception for 1 month after stopping (due to increased metabolism of COC). Men should avoid fathering a child for 6/12 after use as may affect sperm (but not reports of this happening)
- BF: avoid use
Grisolvin - drug interactions
1. COCs - may reduce efficacy for 1 month after use
2. Warfarin - may reduce INR
Grisolvin - adverse effects
Common: diarrhoea, nausea
Infrequent: Photosensitivity, hives, rash, blurred vision, dizziness, taste disturbance
Rare: TEN, precipitation of SLE, leucopenia
Grisovin - dose including children
Tinea of feet & nails: 1 g d
Tinea of hair, skin, groin: 500mg d
Child: 10-20mg/kg d

Up to 12/12 for toenails
4-6/12 for skin and hair
Grisovin - administration advice & counselling points
1. Take with food or milk to increase absorption
2. L16
3. VERY OCCASSIONALLY can increase effects of alcohol (flushing, increased heart rate)
4. L8
5. Affects COC for 4 weeks
6. Men may avoid having kids for 6/12
Grisovin
- how does it rate for tinea capitis and unguium?
- what's its spectrum of activity?
- monitoring?
- choice for capitis, second to itraconazole and terbinafine for unguium
- just dermatophytes not candidiasis so accurate diagnosis is important
- CBC
Lamisil tablets - products
- PBS listing
- MOA
- Indications
- Contraindication (1)
- Caution
- Preg/BF
- 250mg.42 tab (Lamisil, Tamsil, Zabel, Terbihexal)
- PBS-A for proximal or extesive nail involvement that has failed topical treatment
- Inhibits ergosterol synthesis
- Nail and skin fungal infections
- CI in severe liver disease
- Cautions with psoriasis (may worsen, while grisovin worsens SLE)
- Preg B1 but safe, "appears safe" for breastfeeding
Tamsil
- drug interactions
1. CYP2D6 inhibitor, and its effects may last several months after stopping treatment --> increasing effects of amitriptyline, imipramine, nortriptylnie
Zabel
- administration dose
- adverse effects
- counselling
250mg d for 6/52 (fingernails), 2-4/52 (skin), 12/52 (toenails)

Common: n/v/d/abdo pain, elevation of LFTs, muscle pain
Rare: heparitis, SHS, TENs, blood dyscrasia, worsening psoriasis

Nails: need to grow out before they look healthy again
All: report signs of liver problems (tired, anorexic, pale feces, dark urine) or blood dyscrasias (mouth ulcers, sore throat, bruising, fever)
Nystatin - tablets and oral products
500,000 unit.50 TABS or CAPS (Nilstat Oral)

100,000 units.28 (Mycostatin Pastilles)
100,000 units/mL (Mycostatin, N-Stat, Nilstat Oral drops)
Nystatin
- moa
- pregnancy/BF
- A/Es
- dose
- binds to ergosterol, altering membrane permiability
- safe: no cautions of CI or DIs
- n/v/d if >5million units d
- thrush: 1mL qid (up to 5ml qid), after meals of drinking, swish around, continue until 2 days after symptoms gone *same dose in all age groups!
- intestinal: 1-2 tab tds-qid or in a child 1-5mL qid
-
Miconazole oral - products
- preg, BF
- THERE ARE NO CI/CAUTIONS
- DIs
- A.Es
- dose
- counselling
- Cat A - safe
- DIs: monitor INR; otherwise the DIs occuring with ketoconazole may VERY RARELY occur with miconazole topical
- A/es: mild GI upset
- If >1year: 0.5 tsp qid for 7-14 days
- if <1yr: 0.25 tsp wid for 7-14 days
- take after food and drink and use for ONE WEEK after symptoms are gone (vs 2 days for nilstat)
- apply to front of mouth if <6/12 or those who can't swallow
- if caused by dentures, apply gel to dentrures after cleaning and leave overnight
Azole antifungals
- MOA
- Spectrum
- Fungistatic, impairing synthesis of ergosterol. Then the host defense system kills the cell. Ketoconazole also inhibits synthesis of hydrocortisone and testosterone, which may be significant at >400mg d
- Works against Candida, cryptococcus, malassezia furfur, dermatophytes. Itraconazole, Voriconazole and posaconazole effective against many moulds too.
Azole antifungals: of the 5 systemic azoles, what are their dose forms and brands?
1. Fluconazole: 50mg.28, 100mg.28, 150mg.1, 200mg.28 capsules; oral liquid; injection (Diflucan, Dizole, Ozole, Canesoral)
2. Ketoconazole (Nizoral): 200mg.10/30 tabs & as a shampoo and cream
3. Itraconazole (Sporanox): 100mg.15/28/60 caps, oral liquid
4. Posaconazole: oral liquid
5. Voriconazole (Vfend): 50mg.56, 200mg.50 tabs, oral liquid, injection

They're all in oral liqids except for Nizoral
Azole antifungals - systemic
A/Es
Common:
- n/v/d
- elevated LFTs
- dizziness (less common with Nizoral)
Rare: blood dyscrasias, hepatitis, anaphylaxis
Azoles in
- breast feeding
- pregnancy
- BF: excreted into breast milk. Nizoral and Daktarin are safe. Diflucan "appears safe"
- Preg: Diflucan is Cat D although a single 150mg dose "appears safe". Miconazole is safe. The others should be avoided, Cat B3.
Dizole, Fluzole, Ozole dose in
- oral or oesophageal thrush
- vaginal thrush prevention
- skin
- nails
- systemic
- meningitis
oral/oesophageal thrush: 50-200mg d
Prevention of V. thrush: 2-3 doses of 150mg 3 days apart, then 100-150mg weekly for up to 6/12
- Skin: 50mg d or 150mg weekly for 2-6/52
- Nails: 150-300mg weekly for 3-12 months
- Systemic: 200-400mg d
- Cyptococcal meningitis: 800mg stat, then 400mg d
Sporanox
- cf BA of tablets and liquid
- capsule doses for
(a) tinea corporis/manus
(b) nails
(c) pityriasis versicolor
(d) recurrent thrugh vag.
- oral liquid in fasting state has 60% GREATER BA than a capsule with a meal (so approx halve the dose)
- body: 100mg d for 14/7 or 200mg d for 7/7; hand and feet: 100mg d for 28/7 or 200mg bd for 7/7
(b) 200mg bd for 7/7, monthly, for 2/12 hands, or 3/12 toenails (Alternatively, 200mg d for 3/12)
(c) 200mg d for 1 week
(d) 200mg bd for 1 day.
Sporanox administration advice?
Take caps with food [need acidic stomach] (but not rice) and liquid on an empty stomach (At least 1 hour before food)

Seperate caps by 2 hours from ANTACIDS
Nizoral doses
- place in therapy of superficial infections?
- skin & nail infections
- vaginal thrush
- do not use unless there is no alternative
- 200mg-400mg d for 1-2 months (up to 6-12/12 for nails)
- 200mg bd for 5/7
Nizoral counselling
1. take with food to improve absorption
2. Do not take antacids within 2 hours - needs acid to be absorbed
3. report signs of liver disease
Ketoconazole Drug Interactions
1. with griseofulvin
2. we've done antacids
3. we'll do CYP3a4 next slide
1. increased risk of hepatic toxicity: wait 1 month after griseofulvin to start Nizoral
Oral Azole DIs
(a) general management of CYP3A4 interactions? (Ketoconazole also CYP2C19, Fluconazole also CYP2C9)
(b) when do we worry about DIs with single dose fluconazole or oral miconazole?
(c) with amphotericin?
(d) specials with fluconazole?
(e) specials with itraconaole?
Inhibit CYP3A4 and other enzymes. Affects most hepatically metabolised drugs.
(a) generally, temporarily withhold or reduce dose & monitor.
(b) warfarin; cisapride (combination is CI)
(c) possibly antagonistic
(d) prolongs QT interval
(e) antacids/PPIs/H2A, negative inotropic effects: caution with CCBs
** It is recommended that Sporanox & Nizoral be taken with Coke if PPIs or H2As are used.
Dandruff - no this is not the same as seborrhoeic dermatitis.
- signs and symptoms
- differential diagnoses
- itchy! unlike psoriasis and serborrhoea
- serborrhoea: ears, eyebrows, eyelashes also affected.. red skin on scalp
- contact dermatitis: scaling, new products
- tinea capitis: broken hairs, itch
Treatment of dandruff?
1. Selsun - 5mins twice a week, weekly for prevention
2. Zinc pyrethione (Head and Shoulders) - 5mins twice a week, weekly for prevention
3. Nizoral 1-2% - better tolerated than Selsun; twice a week for treatment and weekly for prevention, leave on for 5 mins.
4. Coal tar - has no evidence