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Chapter 20

II. E

(6) Ultraviolet radiation (UV) has long been recognized as a safe and effective treatment
for managing psoriasis. Varying types of phototherapy are available to patients. All
phototherapy treatment regimens should be initiated and managed by a physician or
dermatologist.

III. FUNGAL INFECTIONS

A. Overview
1. Fungal skin infections, also known as tineas or ringworm (due to its characteristic circular
appearance), are some of the most commonly encountered dermatologic conditions. It is estimated that up to 20% of the American population may be infected with a tinea infection at any
given time.
2. Several factors may predispose people to becoming infected with a tinea. Fungi grow best in
warm, moist environments. Tight clothing or shoes that are worn on a repeated basis may facilitate fungal growth. Sharing public showers or pools can also promote the spread of tinea infections. Patients with diseases or conditions that suppress the bodys natural immune response
(such as diabetes, poor personal hygiene, malnutrition, or a compromised epithelium) are at
greater risk of contracting tinea infections.
3. Nonprescription therapies usually work quite well in resolving many types of tinea infections
completely.
B. Pathophysiology
1. Tinea infections are typically superficial. The fungi that cause tineas thrive on dead skin cells
within the stratum corneum. Skin, hair, and nails may all be affected by a tinea infection.
2. The three most prevalent fungi in the United States that cause tinea infections are Trichophyton,
Microsporum, and Epidermophyton.
3. Fungi may be transmitted to an unaffected individual either through direct contact with an infected person or animal or through contact with a fomite.
C. Clinical presentation. Tineas are categorized by the area of the body they affect.
1. Tinea capitis is also known as ringworm of the scalp. Tinea capitis occurs more frequently in children than adults. This may be due in part to a lack of social inhibition in sharing items like brushes
and combs. Epidermal gland secretions also increase at puberty and have a fungicidal effect.
2. Tinea corporis, or ringworm of the body, is not limited to a specific area of the body. Rather,
tinea corporis may take on several clinical appearances and can affect any area of the body. Often,
patients with tinea corporis are infected with one or more additional tineas.
3. Tinea cruris is more commonly referred to as jock itch. The intertriginous areas of the groin
make it an ideal environment for fungal infections. For anatomical reasons, males are more likely
to suffer from tinea cruris than females.
4. Tinea nigra is perhaps the least common of the tineas. It is mainly seen in people who live in humid coastal areas and may be transmitted through sand. Tinea nigra is primarily found on fingers
and feet.
5. Tinea pedis, or athletes foot, is by far the most common tinea infection. Sports players and
people who share pools or showers are at the greatest risk for contracting tinea pedis. Once
present, athletes foot is exacerbated in patients who continue to wear shoes and socks, fostering a
warm and moist environment for the fungus to survive.
6. Tinea unguium, or onychomycosis, is a fungal infection of the nails. Toenails are more frequently affected by tinea unguium than fingernails. Onychomycosis can ultimately lead to loss of
the affected nail if not treated appropriately.
7. Tinea versicolor is a chronic fungal infection of the skin. Tinea versicolor is caused by Pityrosporum (see II.B.2) and primarily affects people living in hot, humid climates.
D. Treatment
1. Nonpharmacological measures
a. To maintain proper hygiene and to minimize the likelihood of contracting a tinea or spreading a tinea to another person, patients should wash their body daily with soap and water.
b. Any contaminated towels and clothing must be washed in hot water.
c. Patients with tinea infections should be counseled to avoid sharing towels.
d. Allow shoes and clothing to dry completely before wearing them.

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e. As much as possible, noninfected patients should avoid direct contact with and avoid using
the same showers as people who have fungal infections.
f. If a shower must be shared, patients should be counseled to wear shower shoes/sandals while
in the shower.
2. Pharmacological therapies
a. Nonprescription topical medications
(1) Only three types of tinea infections respond to self-treatment with nonprescription therapies: tinea corporis, tinea cruris, and tinea pedis. All other tinea infections should be
referred to a physician for evaluation and treatment.
(2) Each of the antifungals listed in the following text is applied topically for 1 to 4 weeks.
These agents are generally well-tolerated, and systemic side effects are rare.
(a) Butenafine (Lotrimin Ultra) is available as a 1% cream. Butenafine should only be
used in patients 12 and older.
(b) Clotrimazole (Desenex AF Cream, Lotrimin AF Lotion) is also sold as a 1% cream,
lotion, or solution. Some patients will experience mild burning and stinging with use
of clotrimazole.
(c) Miconazole (Cruex Antifungal Spray Powder, Micatin Jock Itch Cream) is a 2%
powder, cream, or lotion and is closely related chemically to clotrimazole.
(d) Terbinafine (Lamisil AT) is available as a 1% cream, gel, or spray. Like butenafine,
terbinafine should only be recommended in patients age 12 and older.
(e) Tolnaftate (Tinactin) is a 1% cream, gel, or powder that has served as the OTC standard of care for fungal infections for decades (prior to many of these other products
being introduced). Tolnaftate is the only active ingredient that carries FDA approval
for both the treatment and prevention of athletes foot, when used on a daily basis.
(f) Undecylenic acid (Cruex Cream, Fungicure Liquid) is marketed in concentrations
of 10% to 25% and comes in multiple forms, including a cream, solution, powder,
and spray. Products containing undecylenic acid and its salts carry an unpleasant
odor, which may be unacceptable to some patients.
b. Prescription treatment options. Patients who do not respond to self-treatment with any of
the OTC therapies described previously within 1 week should be referred to their primary
care provider for evaluation. If the condition shows improvement within the first week, patients are free to continue with self-treatment.
(1) Topical antifungals are available for use in patients who do not experience resolution
of their tinea infection with OTC therapies or who have a tinea infection that cannot be
self-treated.
(a) Ciclopirox (Loprox) is available as a cream, gel, or lacquer for the treatment of tinea
corporis, cruris, pedis, versicolor, and unguium.
(b) Econazole (Spectazole) 1% cream is indicated for the treatment of tinea corporis,
cruris, pedis, and versicolor.
(2) More severe fungal infections require treatment with systemic therapies.
(a) The azole antifungals [fluconazole (Diflucan), itraconazole (Sporanox), ketoconazole (Nizoral), posaconazole (Noxafil), and voriconazole (Vfend)] are generally
well-tolerated. The azoles may cause varying degrees of hepatotoxicity, and the class
is notorious for its wide spectrum of drugdrug interactions.
(b) Griseofulvin (Grifulvin V) is available as both an oral tablet and suspension. Because
griseofulvin increases photosensitivity, patients taking this agent should avoid prolonged exposure to the sun.
(c) In addition to its status as an OTC topical agent, terbinafine (Lamisil) is also available
as a prescription oral antifungal. It is considered the first-line agent for onychomycosis.

IV. ACNE
A. Overview
1. Definition. Acne vulgaris is a disorder of the pilosebaceous units, mainly of the face, chest, and back.
The lesions usually start as open or closed comedones and evolve into inflammatory papules and pustules that either resolve as macules or become secondary pyoderma, which results in various sequelae.

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