Fungal Infections: Superficial Superficial fungal infections affect the outer layers of the skin, nails or scalp. These type of infections are generally mild in healthy people, but may become severe in people who are very sick or with lowered immunity. The three main groups of fungi that cause these infections are dermatophytes, yeasts and moulds. Most fungal infections are treated empirically (ie, diagnosis is assumed based on history and symptoms). A definite diagnosis requires skin scrapings and/or nail clippings to be sent for mycology culture and is usually not done unless there has been no response to typical therapy. Dermatophyte infections Dermatophytes feed off keratin and are the main group of fungi to cause infection of the skin, hair and nails. There are more than 40 different species of this fungi and they can live for up to a year off the body in shed human skin scales. They are common in areas with high temperature and humidity, and may be transmitted either by direct body contact, via towels or clothing, or through wet surfaces (eg, swimming pool or bathroom floors). Dermatophyte infections are commonly seen on the scalp (tinea capitis), feet (tinea pedis), groin (tinea cruris), nails (tinea unguium) and other body surfaces (tinea corporis). Topical antifungals are effective for treating most dermatophyte infections. Tinea capitis (ringworm of the scalp) Symptoms of tinea capitis include scaling and loss of hair on the scalp. More common in children, it is usually due to contact with an infected kitten or, rarely, an older dog or cat. It is usually treated with an oral antifungal agent. Tinea pedis (athlete’s foot) Dermatophytes are the most common cause of athlete’s foot (see Foot Care). Tinea cruris (jock itch) Dermatophyte infections of the groin are more common in men than women. Symptoms typically include an intensely itchy, reddish/brown rash with a scaly raised border that spreads down the inner thighs from the groin or scrotum. Infection often originates from the feet (tinea pedis) or nails (tinea unguium) and is transferred by scratching or when the person dries themselves with a towel. Treatment is with antifungal creams or powders. Tinea unguium Dermatophytes are a common cause of fungal nail infections (also called tinea unguium or onychomycosis), although infection can also be caused by yeasts or moulds. Fungal nail infections are more common as people age and often spread from dermatophyte infections of the feet, or less commonly, the hands. Infection most commonly involves the great toenail or little toenail (see Fungal Nail Infections [Onychomycosis] for more extensive information). Tinea corporis (ringworm) Tinea corporis infections usually occur on the trunk or limbs. It is often called ringworm as infection causes a circular, red and itchy rash that looks like a worm under the skin. Edges of the rash are usually raised with an area of clear skin in the middle. Infection can originate from the feet (tinea pedis) or nails (tinea unguium) or from cats, dogs or cattle. Treatment is with antifungal creams. Yeast infections Candida and Malassezia are two common types of yeast. Candida infections Candida are white-coloured yeasts which are normal inhabitants of the TREATMENT OPTIONS Category Examples Comments Topical antifungals Topical nail preparations [GENERAL SALE] eg, zinc undecenoate (Mycota) [PHARMACY ONLY MEDICINE] eg, bifonazole (Canesten Bifonazole), clotrimazole (Canesten range), ketoconazole (Daktagold, Nizoral), miconazole (Resolve Tinea, Daktarin), terbinafine (Dermafex Cream, Lamisil Cream*, Lamisil Dermgel*, Lamisil range, SolvEasy Tinea Cream) See Fungal Nail Infections (Onychomycosis): Treatment options Terbinafine is fungicidal and can resolve superficial skin infections with once-daily applications. Most other antifungals are fungistatic and also effective, although more frequent application and longer treatment courses (continuing for one to two weeks after the infection has cleared) are required. Each product should be used according to the manufacturer’s instructions. Creams are easy to apply. They are good if the skin is moist, because they are water soluble. Lotions are suitable for hairy areas. Spray powders can give even cover on difficult to reach places (eg, under breasts or groin). Non-spray powders may clump, but may be useful for putting in clothing (eg, bras) to help reduce reinfection. Tinctures may sting if the skin is broken or irritated. Antifungal creams containing hydrocortisone (ie, Canesten Plus, Resolve Plus) also calm inflammation. Natural products Acetic acid, tea-tree oil, garlic Various natural topical products have been used in the treatment of athlete’s foot and related fungal infections. Products with an asterisk have a detailed listing in the Fungal Infections: Superficial section of OTC Products, starting on page 238. PharmacyToday.co.nz A part of your everyday. New Zealand’s premier pharmacy website keeping you up to date between issues. www.pharmacytoday.co.nz Page 74 HEALTHCARE HANDBOOK 2017-2018 Common Disorders
CONTINUING OTC EDUCATION human digestive tract. Most of the time, they cause no symptoms or disease; however, occasionally, a proliferation of the yeast may be triggered by certain environmental factors (eg, humid weather, plastic overpants in babies) or when a person’s natural immunity is lowered. Candida infections (also called candidiasis) can affect the mucosa (ie, the lining of the mouth, anus and genitals), nail folds, skin, and rarely the whole body. Oral candidiasis (also called oral thrush) usually presents as creamy-white soft elevated patches on the tongue or palate that can be removed to reveal inflamed mucosa underneath. It is an unusual infection in healthy adults but commonly occurs in babies, people prescribed inhaled corticosteroids or those who are immunosuppressed (see Oral Health). Vaginal candidiasis (also called vaginal thrush or a vaginal yeast infection) is common in women (see Vaginal Thrush). Candida is a common cause of chronic paronychia (inflammation of the nail fold). It causes the nail fold to become swollen and lifted off the nail plate. It may be red and tender and sometimes a little pus can be expressed. The nail plate becomes distorted and ridged as it grows. Treatment may take months and oral antifungal agents may be necessary if topical antifungal creams are not successful (see Fungal Nail Infections [Onychomycosis] for more extensive information). Candida infections can also cause or exacerbate nappy rash (see Nappy Rash). More severe systemic infections are not covered by this handbook. Malassezia infections Malassezia are a normal inhabitant of the skin that are associated with several conditions such as dandruff (see Dandruff), seborrhoeic dermatitis (see Dermatitis/Eczema), and pityriasis versicolor. In pityriasis versicolor, the Malassezia yeast causes pink, coppery brown or pale patches to form on the skin, typically on the trunk, neck or shoulders. It may be mildly itchy and more noticeable in dark-skinned people. This infection is more common in hot, humid climates or in those who sweat heavily, so may recur each summer. Selenium sulfide (found in some anti-dandruff shampoos) or a topical antifungal product is usually effective if applied overnight for at least two weeks. Oral antifungal agents prescribed by a doctor may be needed for extensive pityriasis versicolor or when topical treatments have failed. Partaking in vigorous exercise an hour after taking the medicine may help sweat the antifungal agents onto the skin surface, increasing effectiveness. Refer to PHARMACIST The following questions aim to identify customers who would benefit from further input from a pharmacist. Your initial assessment or a caregiver's history may have already provided some answers. Decide if any further questions still need to be asked and refer any “yes” answers or elderly people to a pharmacist. • Does the person have any other health conditions (eg, immunosuppression, diabetes, is pregnant or breastfeeding)? • Is the infection in a nail or is the mouth, scalp or beard involved? • Is there any oozing, blisters, crusting, swelling, or a foul odour? • Is this a recurring infection or is the infected area extensive? • Is the infection vaginal? • Is the itching severe with broken, chapped skin? • Has previous treatment been unsuccessful? • Does the person have any other symptoms (eg, flu-like symptoms, increased thirst or urination)? • Does the person have any allergies to topical medicines? Initial assessment Decide if you can appropriately and respectfully discuss or visualise the customer's skin condition in the pharmacy. If not, involve a pharmacist. Refer other customers with "yes" answers to the Refer to Pharmacist questions to a pharmacist; also refer if you are unsure what the condition is, or do not know the appropriate treatment product. Mould infections Moulds can be picked up through soil contact and can occasionally infect the skin or nails. Mould infections of the feet can appear similar to tinea pedis and in the nails may be indistinguishable from other types of fungal nail infection, although mould infections commonly cause inflamed nail beds, unlike dermatophyte infections. Mould infections are often difficult to treat and should be suspected if antifungal treatment has been ineffective. Refer to the pharmacist. Page 75
According to Stéphane Rossini, incoming Chairman of the Agency Council, the culture of collaboration will remain a factor in ensuring that Switzerland is successful in retaining a high-quality medicines control system: “A globalised economy and the international consumption of therapeutic products entail synergies and collaboration.”
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