FELLOWSHIP IN FAMILY MEDICINE

ST. JOHN’S MEDICAL COLLEGE, BANGALORE 560 034

TOPIC: FUNGAL INFECTION

Case 1: Mr Vijay

Mr Vijay is 18-year-old and comes to you with this lesion since few weeks in the forearm. Initially it
started as small papule and later it assumed this appearance and its itchy. No other complains and
no similar complaint in the past.

1. What is the differential diagnosis? How do

you differentiate between them?
2. What do you think is the diagnosis? List
the points suggestive?
3. How will you treat this patient?

ANSWERS TO QUESTIONS
1. What is the differential diagnosis? How do you differentiate between them?
The common differential diagnosis is
Diagnosis Local examination
Tinea corporis annular, erythematous, scaly,
pruritic patches or plaques
with central clearing with
well-defined, scaly, often
reddish margins; commonly,
margins may show papulo-
vesicles

Diagnosis:

Potassium hydroxide
preparation may detect
segmented hyphae

1|Page
 FELLOWSHIP IN FAMILY MEDICINE

ST. JOHN’S MEDICAL COLLEGE, BANGALORE 560 034

Annular May have family history of
psoriasis psoriasis

annular, well-demarcated,
erythematous plaques with
adherent, silvery-white scales
and central clearing. The
elbows, knees, scalp,
intergluteal region, lower
back, are classically involved.
(Nail changes may be there in
both) arthritis may occur
Atopic Personal or family history of
dermatitis atopy (like allergic rhinitis,
conjunctivitis or/ & asthma);;
lesions depending upon the
duration such as acute, sub
acute or chronic morphology
varies &

may be lichenified. Areas

depending upon the age
patient may favour the
flexural aspect.

Chronic & chronically

relapsing
Nummular Recurrent, older age group,
eczema more confluent scale; less
likely to have central clearing

Pruritic lesions with poorly

demarked borders

Commonly involves
extremities

2|Page
 FELLOWSHIP IN FAMILY MEDICINE

ST. JOHN’S MEDICAL COLLEGE, BANGALORE 560 034

2. What do you think is the diagnosis? List the points suggestive? How will you confirm the
diagnosis? (Any tinea infection)
The most probable diagnosis is Tinea corporis

Points suggestive are

1. itchy lesion
2. Lesion with central clearing, erythematous well-defined borders
3. No other system involvement
4. history of similar patches may be present in the family members

Investigation for tinea infection:

Potassium hydroxide scraping: KOH -Detect segmental hyphae
This is a simple, inexpensive, quick and sensitive test. Samples to be taken depend on the site of
infection.
• T. capitis – Easily Pluckeble dry lustreless hair/ broken hairs, scale
• T. cruris – Papules, vesicle, Scales & or crusts from the edge T. corporis - Scales from the
edge
• T.unguium - Clippings of discoloured nail plate, subungual debris
Cultures need to be done when the KOH mount is negative or when it is necessary to identify the
species. Growth may take upto 4 weeks.

3. How will you treat this patient? What are the general measures you advice for any
fungal infection to prevent reinfection?

For localised lesion topical therapy should be sufficient

For more extensive lesions and nonresponsive to topical therapy systemic therapy is considered

Treatment regimen is sent as supplemental material a IJDVL recommendation on antifungal

treatment
General measures for any fungal infection

1. Correct predisposing factors where suspected - diabetes or immunocompromised state

2. Keep the affected skin clean and dry. Wash daily. Take care to dry between the toes and
in the skin folds, Use your own towel.
3. Because fungi thrive in moist warm environments, patients should be encouraged to wear
loose-fitting garments made of cotton or synthetic materials designed to wick moisture
away from the surface. Socks should have similar properties
4. Areas likely to become infected should be dried completely before being covered with
clothes. Patients should also be advised to avoid walking barefoot and sharing garments.
5. Wear open-toed sandals when possible. Avoid long periods in occlusive footwear such as
gum boots or tramping boots.
6. In the case of zoophilic fungal infections, infected animals should be identified and
treated.

3|Page
 FELLOWSHIP IN FAMILY MEDICINE

ST. JOHN’S MEDICAL COLLEGE, BANGALORE 560 034

4. Mr X comes back to you after few months with more extensive lesion shown in the
picture. How will you treat him

• In such cases review the diagnosis

• If earlier not done get KOH smear examination
• If positive and confirmatory – review the treatment history
• Look for the nail involvement – if affected treatment duration and drug regimen should
follow Onychomycosis regimen which will take care of Tinea elsewhere
• Since the lesion is extensive treat with oral antifungal along with the topical application

For treatment guidelines - Treatment regimen is sent as supplemental material a IJDVL

recommendation on antifungal treatment
Rule out immunocompromised state -RBS and other tests based on history

4|Page
 FELLOWSHIP IN FAMILY MEDICINE

ST. JOHN’S MEDICAL COLLEGE, BANGALORE 560 034

Case 2: Mr Prakash

A 40-year-old Mr Prakash comes to you with the complaints of Skin lesion in the upper thigh since
few weeks and its very itchy.

1.What is the differential diagnosis? How

would you differentiate each of them?

2. What do you think is the diagnosis? List the

points suggestive of your diagnosis?

3.How will you treat him?

ANSWERS TO QUESTIONS
1.What is the differential diagnosis? How would you differentiate each of them?
The differential is
• Tinea cruris
• Candidal intertrigo
• Erythrasma
• Seborrheic Dermatitis

Tinea Cruris

usually occurs in male adolescents and

young men; usually spares scrotum and
penis

5|Page
 FELLOWSHIP IN FAMILY MEDICINE

ST. JOHN’S MEDICAL COLLEGE, BANGALORE 560 034

Candida Intertrigo

Itching or burning or both can be

present, Folds are prominently involved,
instead of scales maceration more
prominent, Involves scrotum; satellite
pustular lesions; uniformly red without
central clearing

Erythrasma

Asymptomatic, uniformly Red-brown

patches; no active border; coral red
fluorescence with a Wood lamp
examination

2. What do you think is the diagnosis? List the points suggestive of your diagnosis?
The most probable diagnosis is Tinea cruris
1. Well defined lesion with erythematous borders with central clearing
2. Scrotum not involved

3. How will you treat him? What are the indications for oral antifungal drugs?

• Topical antifungal creams such as Terbinafine, Clotrimazole, Econazole, Ketoconazole, and

• Miconazole is frequently prescribed. Of note, Nystatin is not effective for tinea cruris.
• Daily application of talcum, antifungal, or other powders to keep the area dry will help
• prevent recurrences.
• Hot baths and tight-fitting clothing should be avoided. Males may do better wearing
• boxers rather than briefs and women should wear cotton underwear and avoid tightfitting
pants.

Indications for oral antifungal treatment-

1. Lesion is extensive
2. Nail Involvement
3. Immunocompromised
4. Failed topical therapy

6|Page
 FELLOWSHIP IN FAMILY MEDICINE

ST. JOHN’S MEDICAL COLLEGE, BANGALORE 560 034

5. Write treatment for Intertrigo, candidal intertrigo and erythrasma?

Intertrigo- It is inflammation of intertriginous or opposing areas

It can be infective: like erythrasma, candida tinea etc
or non infective: like flexural Psoriasis, seborrheic dermatitis, contact dermatitis
Treatment depends upon the cause

Candida intertrigo
• Addressing predisposing factors is the most important step in treatment.
• Topical antifungal creams such as Nystatin, Clotrimazole, and Ketoconazole are frequently
prescribed.
• Antifungal powders that help to dry the moist skin areas can be used for prevention.
• Severe infections or those not responding to topical treatment may require an oral
antifungal agent such as Fluconazole.
• Oral fluconazole (used for resistant cases)-100-200mg for 1 week
Erythrasma
Topical: Fucidic Acid, erythromycin, clindamycin,
Oral: erythromycin
Topical therapy till the lesion disappears

7|Page
 FELLOWSHIP IN FAMILY MEDICINE

ST. JOHN’S MEDICAL COLLEGE, BANGALORE 560 034

Case 3: Mr Shankar

Mr Shankar is a 50-year-old comes to your clinic with itchy lesions in the toes for 3 weeks.

1.What is the differential diagnosis? How do

you differentiate between them?

2.What do you think is the diagnosis? List

the points suggestive?

3.How will you treat this patient?

ANSWERS TO QUESTIONS
1.What is the differential diagnosis? How do you differentiate between them?

Candidal Intertrigo

Erythematous and macerated plaques

with peripheral scaling. There are often
associated superficial satellite papules or
pustules

• Tinea pedis -rare in prepubertal

children; erythema, scale, fissures,
maceration; itching between toes
extending to sole, borders, and
occasionally dorsum of foot
• may be accompanied by tinea
manuum [“one-hand, two-feet”
involvement] or onychomycosis)
• (Picture more suggestive of ulcerated
candidiasis)

8|Page
 FELLOWSHIP IN FAMILY MEDICINE

ST. JOHN’S MEDICAL COLLEGE, BANGALORE 560 034

Foot eczema

• May have atopic history

• Morphology depends upon the
duration and type of the eczema
• For example, pompholyx presents
with deep seated vesicles
• (this picture more suggestive of
dry moccasin Tinea)

Contact dermatitis of foot

Distribution may match footwear as in

this case, if toe ring related CD favour the
contact site

2.What do you think is the diagnosis? List the points suggestive?

Most probable diagnosis is Tinea pedis. Points suggestive are

• Erythematous, scaly lesions extending to the dorsum of foot, asymmetrical

• Involvement of interdigital web space
• Itchy lesion

3.How will you treat this patient?

follow the supplementary material

9|Page
 FELLOWSHIP IN FAMILY MEDICINE

ST. JOHN’S MEDICAL COLLEGE, BANGALORE 560 034

Case 4: Master Anand

Master Anand is a 7-year-old boy who presents with painful lesion on the scalp for 2 months with
loss of hair.

1.What is the differential diagnosis? How do

you differentiate between them?

2.What do you think is the diagnosis? List the

points suggestive?

3.How will you treat this patient?

ANSWERS TO QUESTIONS
1.What is the differential diagnosis? How do you differentiate between them?

Tinea Capitis

Seen in children, one or more patches of

alopecia, scale with erythema, pustules,
tenderness, pruritus, with cervical and
suboccipital lymphadenopathy; dry lustreless
hair, usually no complete hair loss

Alopecia areata

Discrete patches of hair loss with no

epidermal changes (i.e., no scale); total loss
of hair or fine

miniature hair growth; exclamation point

hairs; no crusting; no inflammation; possible
nail pitting

10 | P a g e
 FELLOWSHIP IN FAMILY MEDICINE

ST. JOHN’S MEDICAL COLLEGE, BANGALORE 560 034

Psoriasis

Gray or silver scale; nail pitting; may family

history of psoriasis2

involvement of other sites, no alopecia seen

Seborrheic dermatitis

Alopecia uncommon; lymphadenopathy

uncommon; yellow greasy scales; other
typical area distribution involving nasolabial
folds, , eyebrows, postauricular folds, chest

(This picture is of psoriasis not seborrheic

dermatitis)

2.What do you think is the diagnosis? List the points suggestive?

The most probable diagnosis is Tinea Capitis
Points suggestive are
• Alopecia with scale in children
• Boggy mass-kerion is seen
• Postulation & crusting with pain

3.How will you treat this patient?

Diagnosis should be confirmed before treatment with KOH smear or culture
• Treatment is oral antifungal. Topical therapy may not be effective.
• Along with oral antifungal Selenium sulfide or ketoconazole shampoo twice a week (apply
for 5 minutes and then wash) can be prescribed as adjuvant therapy

Oral Antifungal treatment

• Griseofulvin-15-20mg per kg bodyweight for 6 weeks
• Terbinafine-125-250 once a day for 6 weeks
• Fluconazole-6mg per kg body weight for 6 weeks

11 | P a g e
 FELLOWSHIP IN FAMILY MEDICINE

ST. JOHN’S MEDICAL COLLEGE, BANGALORE 560 034

Short cases

ANSWERS TO QUESTIONS

1.What is the diagnosis and list the points

suggestive?

2. How will you treat?

Pityriasis versicolor
Points:
• hypo or hyperpigmented, scaly perifollicular macules which coalesce.
• Sites of predilection are upper trunk, neck, face and upper arms

Topical antifungals - One of the following can be used

• Selenium sulphide applied for 10mts before rinsing, daily for 7-14days,
• Antifungal creams or lotions i.e., azoles (clotrimazole, miconazole, ketoconazole) applied
twice daily for 2 wks.
• Application of 2% ketaconazole shampoo to skin, allowed to dry and left on overnight for 3
consecutive days.
• Ciclopirox shampoo is also effective when left on for 10-15 minutes before rinsing for 2 wks.
• Systemic antifungals - Fluconazole 400mg single dose or itraconazole 200mg daily for 7 days.

1.What is the diagnosis and list the points

suggestive?

2. How will you treat?

Most probable diagnosis is Oral candidiasis

Points suggestive: white adherent plaques which are difficult to remove. On removal an
erythematous base is revealed. The lesions are usually seen on tongue, palate, buccal mucosa and
gingiva.
12 | P a g e
 FELLOWSHIP IN FAMILY MEDICINE

ST. JOHN’S MEDICAL COLLEGE, BANGALORE 560 034

Lotions and oral suspensions of imidazoles- clotromazole (Oral candid paint) 5 times a day for one
week.
In moderate to severe disease can be treated with Fluconazole 100mg to 200mg for 1 to 2 weeks.
Recurrent oral candidiasis-treated with Itraconazole

1.Whta are the differential diagnosis for this?

2.What is the diagnosis and list the points

suggestive?

3.How will you treat?

1.What is the diagnosis and list the points suggestive?

Differential diagnosis is
• low-grade trauma
• Psoriasis
• lichen planus
Appearance can be indistinguishable from onychomycosis; may have other manifestations of
alternate diagnosis

2.What is the diagnosis and list the points suggestive?

Onychomycosis
Points suggestive:
discolored [white, yellow, brown], thickened nail with subungual keratinous debris and possible
nail detachment

3.How will you treat?

Diagnosis should be confirmed before treatment with KOH smear or culture since it’s a long term
treatment
follow the treatment guidelines

13 | P a g e
 FELLOWSHIP IN FAMILY MEDICINE

ST. JOHN’S MEDICAL COLLEGE, BANGALORE 560 034

Antifungal Topical therapy and oral drugs (Commonly used)

Drug Forms Trade names Cost

Azoles

Fungitop and zole

Miconazole Cream 2-5% 20-40Rs
ointment 2%

Candid cream

Clotrimazole Lotion and cream 1% Candid lotion 90-150 Rs

Canesten lotion

Allylamine

Cream 1%and
Terbinafine Terbicip, Sebifin , Tyza 100-150Rs
ointment, powder, gel

Selinium sulphide Shampoo Selseb, Dandrex 250 Rs

Systemic antifungal

AZOLE

50mg, 100mg, 150mg

Flucan, Wycon,
Fluconazole (Widely available as 10Rs per tablet
Fungicide
150mg)

Itraconazole 100mg Itrazole, Itrazane 100-250Rs

Allylamine

Terbinafine oral TRFY, Terbicip 100-250 Rs

• Powders and sprays may be used to prevent reinfection.

• Use lotions in intertriginous or hairy areas and on oozing lesions.

• Use creams on non-oozing and moderately scaling lesions.

• Use ointments on hyperkeratotic lesions

14 | P a g e
 FELLOWSHIP IN FAMILY MEDICINE

ST. JOHN’S MEDICAL COLLEGE, BANGALORE 560 034

Take home message.

1. Tinea infections are caused by dermatophytes and are classified by the involved site.
2. The most common infections in prepubertal children tinea capitis, whereas adolescents and
adults are more likely to develop tinea cruris, tinea pedis, and tinea unguium
(onychomycosis).
3. The clinical diagnosis can be unreliable because tinea infections have many mimics, which can
manifest identical lesions. For example, tinea corporis can be confused with eczema, tinea
capitis can be confused with alopecia areata, and onychomycosis can be confused with
dystrophic toenails from repeated low-level trauma or psoriasis.
4. Physicians should confirm suspected onychomycosis and tinea capitis with a potassium
hydroxide preparation or culture.
5. Tinea corporis, tinea cruris, generally respond to inexpensive topical agents such as
terbinafine cream or butenafine cream, but oral antifungal agents may be indicated for
extensive disease, failed topical treatment, immunocompromised patients, or severe
moccasin-type tinea pedis.
6. Oral terbinafine is first-line therapy for tinea capitis and onychomycosis because of its
tolerability, high cure rate, and low cost.
7. Kerion should be treated with griseofulvin unless Trichophyton has been documented as the
pathogen. Failure to treat kerion promptly can lead to scarring and permanent hair loss.

Practice changers

• Skin lesions are very common presentation in general practice. General practitioners should
be well versed in identifying and differentiating the lesions. Use right medication and avoid
unnecessary steroids. If not confident about the diagnosis, refer the patient to
dermatologist.

• Avoid both topical and systemic steroids when the diagnosis is not confirmatory.

• Completely avoid steroids for confirmed cases of fungal infection.

• Avoid tripple and quadraple cream combinations as it will not only promote resistance but
also confuse and modify clinical picture resulting further delayed diagnosis and proper
treatment.

15 | P a g e
 FELLOWSHIP IN FAMILY MEDICINE

ST. JOHN’S MEDICAL COLLEGE, BANGALORE 560 034

16 | P a g e