W#11 Pharma Peer replies

POST # 2 JOHN

For my posting we will explore Fungal Infections specifically Tinea. Tinea is a group of fungal infections caused by dermatophytes that invade and multiply within keratinized tissue including skin, hair, and nails. It is a very common skin infection and is called "ringworm" because it can appear as circular and ring-like lesions on the skin. People on antibiotics are susceptible as well as those who are immunocompromised are especially at risk for developing fungal infections. This includes people with HIV/AIDS, Diabetes, taking steroids or on chemotherapy. They infections are classified into three groups:  • Trichophyton which infect skin, hair, and nails • Epidermophyton which infect skin and nails • Microsporum which also infect skin and nails (Hubert & VanMeter, 2018). They are also classified based on body location of affected site. • Tinea Pedis (athlete's foot): infection of the feet • Tinea Unguium: infection of the fingernails, toenails, and the nail bed • Tinea Corporis: infection of the arms, legs, and trunk • Tinea Cruris (jock itch): infection of the groin area • Tinea Manuum: infection of the hands and palm area • Tinea Capitis: infection of the scalp and hair • Tinea Faciei: infection of the face • Tinea Barbae: infestation of facial hair (Hubert & VanMeter, 2018). Antifungals are the first line of treatment. These include topical creams, powders and oral medications. They are prescribed based on the type and locations of the infection. Topicals are used for superficial infections while orals are used for more extensive infections and those effecting the hair and nails.   Topical medications are divided into 4 groups: Allylamine/Benzylamine, Imidazole, Polyene and. They are poorly absorbed by intact skin in the human body and generally not metabolized or excreted by the body. Treatment lengths vary by location Other (Woo & Robinson, 2016).  • Allylamine/Benzylamine include: Terbinafine and nafitine inhibit squalene epoxidase causing a buildup of squalene in the cell organism which leads to death. Butenafine is a Benzylamine inhibits squalene creating a deficit in cell membranes which inhibit growth. • Imidazole antifungals alter the fungal cell membrane by inhibiting ergosterol synthesizes allowing the cell contents to leak out. These drugs are effective for a wide variety of infections. Clotrimazole is active against a wide variety of dermatophytes and Candida organisms.   • Polyenes include Nystatin. Are indicated for Candida (yeast) species nystatin binds to the sterols in the cell membrane of both fungus and human cells making it more permeable allowing cell contents to leak out.  They are not indicated for Dermatophyte infections. • Other - Includes Tolnaftate which stunts mycelial growth.  (Woo & Robinson, 2016)

Systemic Antifungals or oral Medications include Griseofulvin., terbinafine and itraconazole. They are used for more severe infections or one involving hair or nails which topicals do not penetrate enough to be therapeutic. (Ilkit & Durdu. 2015). Patients may need a baseline CBC, liver and renal panels prior to treatment. Griseofulvin is contradicted for pregnant women and men seeking to father a child within the next 6 months (Woo & Robinson, 2016). Terbinafine can be used in patient 4 years or older to treat Tinea Capitis. Treatment Options With the exception of Tinea Unguium and Tinea Capitis most infections can usually be treated with over the counter topical agents. Patients should wear loose fitting designed to wick moisture away from the body. Areas prone to infection should be dried completely before being covered with clothes. Patients should not walk barefoot or share clothes during times of infection (Ilkit & Durdu. 2015). Topical agents are well tolerated by all age groups with no restrictions reported by Woo & Robinson is out text book (Woo & Robinson, 2016, page 674-675). Clotrimazole may interact with spermicides leading to contraceptive failure. As an aside Corticosteroids may interfere with Econazole and C. Albicans (Woo & Robinson, 2016). 

Sorry my well formatted table in word did not translate well. 

Selected Antifungals and treatment modalities
Category	Infection	Treatment length
Imidazoles
Clotrimazole (1%) Cream, lotion	T. corporis/cruris/pedis	BID 4-6 weeks
Econazole (1%) Cream	T. corporis/cruris/pedis	Daily BID 4-6 weeks
Miconazole (1%) Cream, lotion	T. corporis/cruris/pedis	BID 4-6 weeks
Oxiconazole (2%) Cream, lotion	T. corporis/cruris/pedis	Daily BID 4 weeks
Sertaconazole (2%) Cream	T. corporis/cruris/pedis	BID 4 weeks
Luliconazole (1%) Cream, lotion	T. corporis/cruris/pedis	DAILY 2 weeks
Eberconazole (1%) Cream	T. corporis/cruris/pedis	DAILY 2-4 weeks
Triazoles
Efinaconazole (10%) Solution	T. pedis	DAILY Up to 52 weeks in coexisting tinea unguium
Allylamines
Terbinafine Cream, powder	T. corporis	BID 2 weeks
	T. cruris	BID 2 weeks
	T. pedis	BID 4 weeks
	T. manum BD 4 weeks	BID 4 weeks
Naftifine 1% Cream	T. corporis/cruris/pedis	DAILYBID Use 2 weeks beyond resolution of symptoms
Butenafine 1% Cream	T. corporis/cruris/pedis	DAILYBID 2-4 weeks
Others
Amolorfine 0.25% Cream	T. corporis	BID 4 weeks
Amphotericin B (1 mg) 0.1% gel	T. corporis	BID 2 week

References

Hubert, R., & VanMeter, K. C. (2018). Gould's Pathophysiology for the Health Professionals (6th ed.). St. Louis, MO: Elsevier. Ilkit, M., & Durdu, M. (2015). Tinea pedis: the etiology and global epidemiology of a common fungal infection. Critical Reviews In Microbiology, 41(3), 374–388 Sahoo, A. K., & Mahajan, R. (2016). Management of tinea corporis, tinea cruris, and tinea pedis: A comprehensive review. Indian Dermatology Online Journal, 7(2), 77–86.  https://doi.org/10.4103/2229-5178.178099 Woo, T. M., & Robinson, M. V. (2020). Pharmacotherapeutics for advanced practice nurse prescribers (5th ed.). Philadelphia, PA