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Duncanville Dermatology
Clinic
Dermatology Residency
KCOM Dermatology
Department
Topics Covered
KOH
Culture
Woods light
Questions
1. What is a Woods light useful for ?
2. If I think it might be a fungus but it is KOH negative,
what can be done to prove it ?
3. How do you know the endpoint of therapy when
treating tinea capitis ?
4. How do you know the endpoint of therapy when
treating tinea versicolor ?
5. If a patient has thick ugly nails, what is the chance
that it is classic onychomycosis ?
Diagnostic Tests
KOH Preparations
Skin
Diagnostic Tests
KOH Preparations
Nails
Hair
Be Persistent !
Tinea Versicolor
Trichophyton
Tonsurans
Tinea Versicolor
Mosaic Fungus
Lipid droplets in
interepithelial
spaces and cell
membrane
overlap simulate
fungal hyphae.
Diagnostic Tests
Fungal Cultures
DTM
Nickersons
Media
Yeast
Black growth is (+)
Sabourauds
Molds
Media
Diagnostic Tests
Fungal Culture
Sample Collection
Scrape
Tinea Capitis
Diagnostic Tests
Woods
Light
Tinea Capitis
Blue
Other Areas:
Useful
PAS
Tinea Corporis
Tinea Faciales
Tinea Cruris
Tinea Manuum
Tinea Vesicolor
Candidiasis
Tinea Capitis
Tinea Capitis
Children most common cases.
Most Common Organisms:
T. Tonsurans - acounts for 90% in U.S.
M. Canis - seen in children with infected animals.
Adults not infected.
Tinea Capitis
Presentations of Tinea Capitis
1. Non-inflammatory black dot type
2. Seborrheic type
3. Pustular
4. Inflammatory (Kerion)
Tinea Capitis
Black
Dot Type
Large
Tinea Capitis
Tinea Capitis
Seborrheic type
Common
resembles dandruff
Close exam for broken hairs, black dots
Adenopathy
Frequently negative KOH (70%)
Culture often necessary for DX
Tinea Capitis
Kerion
Inflamed,
Tinea Capitis
Pustular
Discrete pustules and crusted areas
No significant hair loss or scale
Often KOH negative
Frequently treated as bacterial at first
Morphology
Woods
Lamp
Blue green.
Hair
of lesion
Shaft Exam
Endo/Exothrix
Culture
Normal Hair
General Morphology
Tinea Pedis
Tinea Pedis
General Morphology
Tinea Manuum
Tinea Pedis
Groups: M > F. Young and middle aged.
Patient is susceptible to reoccurrence
Onychomycosis and tinea pedis associated.
Differential:
Eczema, contact dermatitis
Psoriasis.
Erythrasma and Candida (esp in web spaces.)
Pitted keratolysis
General Morphology
Onychomycosis
Onychomycosis
4 Types:
1.
2.
Distal Subungal
White superficial
3.
Proximal Subungal
4.
Candidaonychomycosis
Onychomycosis
White Onychomycosis
Candidaisis of nail
Paronychia
Onychomycosis
Differential Diagnosis: (50% of thick nails not classic fungus.)
Psoriasis
Psoriasis
Lichen Planus
Pseudomonas of nail
Molds
Onychogryphosis
Diagnosis of Onychomycosis
Try to identify fungi before oral therapy
1. KOH of nail clipping
2. Culture
DTM - dermatophytes
Sauborauds Molds
Nickerson Yeast
Treatment of Onychomycosis.
Debridement of infected area helps penetration / comfort.
Mechanical
Topical Treatment:
Agents
Treatment of Onychomycosis
Oral therapy
Effective. Relapse rate 15-20 % in one year.
Lamisil 250mg. 6 weeks/12 weeks.
Baseline labs and one month.
CBC (neutropenia), Liver function.
Treatment of Onychomycosis
Notes on Therapy
Other Azoles require longer therapy.
Nails will not appear clear at end of
therapy
Measurements and digital photography
verify effectiveness.
General Morphology
Tinea Corporis
Papulosquamous
Erythematous
Annular
Scaling
Crusting
Ringworm
General Morphology
Tinea Faciales
General Morphology
Tinea Cruris
General Morphology
Tinea Versicolor
Red
Hypo pigmented
Hyperpigmented
Asymptomatic.
Tinea Versicolor
More
apparent
in the
summer.
Tinea
Vesicolor
Hyperpigmented
Variety
Looks Like: intertrigo,
erythrasma .
Vitiligo
White
without
scale.
Pityriasis Alba
Frequently on face,
KOH neg. Few
lesions.
May have fine white
scale.
Pityriasis Rosea
Papules or
plaques with
Collarette of
scale, KOH (-),
Woods light
neg. HX.
Guttate Psoriasis
Tinea Versicolor
Diagnosis:
Scrape lightly fine white scale
KOH Positive for short hyphae and spores
(Spaghetti and meatballs)
Woods Light pale yellow white fluoresce.
Culture rarely done.
Tinea Versicolor
Tinea Versicolor-Treatment
Topicals for limited involvement.
Selenium Sulfide Shampoos: lather 10
minutes wash off x 7 days.
Ketoconazole 2% shampoo: 5 minutes 1-3
days.
Imidazoles topicals to body qd-bid for 2-4
wks.
Terbinafine spray.
Tinea Versicolor-Treatment
Oral for extensive
Itraconazole, fluconazole,
ketoconazole.
Dosing varies: single dose to 5-10 days of
therapy.
Likes gastric ph for absorption.
Avoid bathing with 12 hours of ingestion.
Tinea Versicolor-Treatment
Notes
Hypopigmentation resolves slowly
No scale when scraped indicates cure.
Sunlight helps restore pigment
Prophylaxis before summer in some patients.
Selenium shampoos
Q month orals
Candidiasis
Candida Albicans
Normal Flora
Occurs in moist areas especially where skin touches.
Presentation: primary lesion is a red pustule.
Most Common: pustules dissect horizontally through the
stratum corneum leaving a red, glistening denuded
surface with long continuous border with satellite lesions.
May also present as an eruption of multiple pustules
which become erythematous papules between skin folds.
Candidiasis
Immunosuppression of any type (disease,
steroids), D.M., Antibiotics or receptive
environments predispose.
Diagnosis: History of predisposing factors
and/or classic appearance of lesions at typical
locations.
Red and glistening in intertriginous area esp in
predisposed individual think candida.
Candidiasis
Candidiasis
Candidiasis
Differential:
1. Erythrasma likes skin creases
2. Eczema may look like pustular candida
3. Bacterial folliculitis as above
4. Psoriasis gluteal cleft
5. Tinea same locations
Candidiasis
KOH for pseudohyphae and spores
May be impossible to tell visually from tinea.
Woods Light
Culture. Nickersons (+)
Remember yeast part of normal flora.
Candidiasis
Treatment of Candidiasis
Topical azoles.
Diaper rash
Angular chelitis.
THE END