LYMPHEDEMA FUNGAL INFECTIONS
This page has been updated, please see:
Fungal Infections Associated with Lymphedema
http://www.lymphedemapeople.com/wiki/doku.php?id=fungal_infections_associated_with_lymphedema
Lymphedema Skin Fungus
Our Home Page: Lymphedema People
http://www.lymphedemapeople.com/
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Related Terms: Tinea, Athlete's Feet, Candida, Jock Itch, Yeast Infections, Oral thrush, Cryptococcosis, Sporotrichosis, Pityriasis Versicolor, Histoplasmosis, Blastomycosis, Tinea Pedis, Tinea Cruris, Tinea Corporis, Tinea Unguiuum, Tinea Barbae, Tinea Manuum, Tinea Capitis
Types of Fungal Infections
For those of us with lymphedema, proper skin care is essential to our health and well being. The skin must be cared for correctly and every effort must be made to avoid fungus and fungal infections. If after all we do, we acquire one, it must be treated promptly. These fungal infections can be catastrophic.
Definition of a fungus: Member of a class of primitive vegetable organisms. These plants lack cholorphyll, are generally parasitic and reproduce by spores.
Fungus causing infections can be classified in two distinct groupings. Fungus infections from a mold-like fungi include athlete's feet, jock itch, ringwowrm and tinea capitis.
Fungus infections from a yeast-like fungi include diaper rash, oral thrush, cutaneous candida and some genital rashes.
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Fungal Infections
http://www.merck.com/mrkshared/mmanual_home2/sec17/ch197/ch197a.jsp
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Skin Fungus Infections
http://quickcare.org/skin/fungus.html
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Types of
Fungal infections
Types list: The list of types of Fungal infections mentioned in various
sources
includes:
Candida
Vaginal Candidiasis
Oral thrush
Athlete's foot
Tinea
Yeast infections
Ringworm - not a worm but a fungus.
Cryptococcosis
Sporotrichosis
Pityriasis Versicolor
Types discussion: Mycoses can affect your skin, nails, body hair,
internal
organs such as the lungs, and body systems such as the nervous system.
Aspergillus fumigatus, for example, can cause aspergillosis, a fungal
infection
in the respiratory system.
Some fungi have made our lives easier. Penicillin and other
antibiotics, which
kill harmful bacteria in our bodies, are made from fungi. Other fungi,
like
certain yeasts, also can be beneficial. For example, when a warm liquid
like
water and a food source are added to certain yeasts, the fungus
ferments. The
process of fermentation is essential for making healthy foods like some
breads
and cheeses.1
Acknowledgment and Thanks
Wrong Diagnosis.com
http://www.wrongdiagnosis.com/f/fungal_infections/subtypes.htm
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How Do I
Know if I Have a Fungal Infection?
There are many skin problems that can look like a fungal infection so
the best
way to know for sure is to ask your doctor. However, there are some
signs you
can look for with the different types of fungal infections:
Athlete's foot
has symptoms that include dry, cracked, and itchy
skin between
the toes. Some people also have red, scaly blisters on the bottoms and
sides of
their feet. There may also be a watery discharge from the blisters.
Jock itch
appears as
a rash with elevated edges. It too is itchy and often feels
like it is burning. It's pretty common, especially if you play sports
where you
sweat and wear athletic equipment.
Ringworm
of the
head begins as a small pimple that becomes larger. The hair in
the infected area can become brittle and break off, leaving scaly
patches of
baldness. But don't sweat it - it will grow back! If you have ringworm
on your
arms, legs, or chest, you may see small, red spots that grow into large
rings.
Candida, the yeast-like fungus, causes the skin around the
infected area to
itch. The skin may also be red and swollen.
Farewell to Fungus!
Getting rid of a fungal infection is not all that difficult. Your
doctor may
decide to scrape a small amount of the irritated skin or clip off a
piece of
hair or nail and look at it under a microscope. Once your doctor knows
what kind
of infection you have, there are special antifungal creams and shampoos
that can
help to get rid of it. Sometimes the doctor will prescribe a medicine
to take by
mouth for many weeks. Make sure you take the medicine for as long as
the doctor
tells you.
Maybe fungal infections can't be avoided altogether, but there are some
ways you
can help yourself ward them off.
Walk away from athlete's foot by following these simple steps:
Wash your feet everyday.
Dry your feet completely, especially between your toes.
Wear sandals or shower shoes when walking around in locker rooms,
public pools,
and public showers.
Wear clean socks and if they get wet or damp, be sure to change them as
soon as
you can. Use a powder (talcum or antifungal) on your feet to help
reduce
perspiration.
You may love to play sports and not be able to avoid jock itch, but you
can help
to keep it away when you:
Wear clean, cotton underwear and loose-fitting pants.
Keep your groin area clean and dry.
Yeast infections can be avoided, too, if you:
Don't hang out in wet swimsuits; change as soon as possible.
Wear clean, cotton underpants.
The truth is there may always be a "fungus among us," but we can make
it a lot tougher for them to invade and grow!
Reviewed by: Patrice Hyde, MD
Date reviewed: November 2000
Acknowledgment and Thanks
Kids Health.org
http://kidshealth.org/kid/health_problems/skin/fungus.html
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What are
the different types of fungal infection?
When it comes to human body, the term fungus refers to a type of germ
that lives
on all of us. This germ harmless most of the time, can cause problems
occasionally. This is called a fungal infection. Persistent fungal
infections
may be indicators of an imbalance in the body's microflora (the small,
usually
bacterial, inhabitants of gut,skin surfaces and mucous membranes).
What are the different types of fungal infection?
Tinea
is a type
of fungal infection of the hair, skin, or nails. When it's on
the skin, tinea usually begins as a small red area the size of a pea.
As it
grows, it spreads out in a circle or ring. Tinea is often called
"ringworm" because it may look like tiny worms are under the skin (but
of course, they're not!). Because the fungi that cause tinea (ringworm)
live on
different parts of the body, they are named for the part of the body
they
infect. Scalp ringworm is found on the head, and body ringworm affects
arms,
legs, or the chest.
Athlete's foot
is another
type of fungal infection that usually appears between
the toes but can also affect the bottom or sides of the feet.
Jock itch
is a
fungal infection of the groin and upper thighs. (This usually
occurs only in boys and men.)
Candida
is a
yeast-like fungus. This fungus most often affects
the skin around the nails or the soft, moist areas around body
openings. Diaper
rash in babies is a form of candidal infection, as is thrush, the white
patches
most often found in the mouths of kids and babies. Older girls and
women may
develop another form of candidal infection in the area in and around
the vagina.
This is called a yeast infection
http://channels.apollolife.com/show.asp?NewAid=9710
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Fungal Infections
Posted 10/24/2003
Carol A. Kauffman, MD
Abstract and Introduction
http://www.medscape.com/viewarticle/462308?WebLogicSession=QAGuVIzfpIjnhdTo6iZkwtN8LmwmmqA1u72P9ZKUL1qdyM6tEcIP|6405954668970367243/184161394/6/7001/7001/7002/7002/7001/-1
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Fungal
Infection: Do you have it?
Fungal Infection is an infection caused by a fungus, affecting not only
people
but also animals and plants.
"Fungus irritates the nose
and causes allergies."
www.doctorfungus.org
Fungal infections in human include: Aspergillosis, Blastomycosis,
Candidiasis,
Coccidioidomycosis, Cryptococcosis, Histoplasmosis,
Paracoccidiomycosis,
Sporotrichosis, Zygomycosis, Chromoblastomycosis, Eye Infections,
Lobomycosis,
Mycetoma, Otomycosis, Phaeohyphomycosis, Rhinosporidiosis, and Nail,
Hair, and
Skin disease (such as: Onychomycosis (Tinea unguium), Piedra,
Pityriasis
versicolor, Tinea barbae, Tinea capitis, Tinea corporis, Tinea cruris,
Tinea
favosa, Tinea nigra, and Tinea pedis).
http://www.fungus-fungi-fungal.com/
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Fungal
infections
diseases caused by organisms of the kingdom Fungi, which includes
various genera
that may cause disorders with musculoskeletal manifestations (Table 1).
These
pathogical conditions are discussed in more detail under their specific
names.
Fungal infections, Table 1. Various types of fungal infections.
Disease Organism
Actinomycosis Actinomyces species
Nocardiosis Nocardia species
Cryptococcosis (torulosis) Cryptococcus neoformans
North American blastomycosis Blastomyces dermatitidis
South American blastomycosis (paracoccidioidomycosis) Blastomyces
brasiliensis
Coccidioidomycosis Coccidioides immitis
Histoplasmosis Histoplasma capsulatum
Sporotrichosis Sporothrix schenkii
Candidiasis Candida albicans
Mucormycosis Mucor species
Aspergillosis Aspergillus species
Maduromycosis (mycetoma) Madurella,Nocardia, Streptomyces species
http://www.amershamhealth.com/medcyclopaedia/Volume%20III%201/FUNGAL%20INFECTIONS.asp
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Fungal
Infections
One of the main reasons people find tinea infections don't clear up is
because
they don't use their medicines long enough.
"Most tinea infections need treatment for one to two weeks or sometimes
more, but they should also be treated for a minimum of one week after
the
infection has cleared," recommend Self Care pharmacists.
Many people know they are suffering from a yeast infection, jock itch
or
athletes foot, but never really realized that these are all different
types of
fungal infections. Most fungal infections are commonly called tinea.
You can get
tinea infections on your body (for example ringworm, jock itch), or on
your
feet, nails or scalp.
Another tinea infection, called pityriasis versicolor, affects the skin
on the
trunk of the body, especially the back. It can also spread to the neck,
arms or
stomach. When people tan in summer the affected parts remain as whitish
patches
on their body and they may often wonder what this is.
There are also other fungal infections like oral thrush (in the mouth)
or nappy
rash.
Although fungal infections can occur at any time during the year, they
tend to
occur most frequently during the warm summer months.
Fungal infections are caused by organisms called fungi and the heat of
the
warmer weather gives the fungi ideal conditions to grow. Fungal
infections tend
to develop where two skin surfaces come together such as between toes,
the
buttocks and under the breasts in women. These areas tend to be moister
because
they sweat a lot or they are not dried well enough after a shower or
bath.
A very common fungal infection is athletes foot, also called tinea
pedis. You
don't have to be an athlete to get athletes foot. Athletes foot occurs
most
frequently in warm conditions, when the feet sweat a lot and don't get
a lot of
air circulation.
Athletes foot can be caught by sharing public showers or walking
barefoot in
these places. The infection usually starts around the fourth and fifth
toes
where the skin can become soft and whitish in colour and start to
flake. The
infection is often very itchy.
All fungal infections can be treated with medicines from your pharmacy.
Treatments are available as creams, lotions, solutions, oral liquids
for mouth
thrush, powders or sprays. Your Self Care pharmacist can suggest the
best
treatment for your needs.
"However you must use your anti-fungal medicines until the infections
has
cleared," advise Self Care pharmacists. "To prevent the infection from
coming back you should also use it for at least another week or so
after it
clears."
Nail and scalp fungal infections need stronger medicines, which your
doctor can
prescribe and you may need to use the medicines for a much longer time.
For more information on different fungal infections and their
treatment, talk to
your local Self Care pharmacist and get your free copy of the Fungal
Infections
fact card.
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Fungus
Infections
Resource site for common fungal infections, causes, treatment,
prevention and
links
http://journals.aol.com/patoco2/FungusInfections
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Athlete's
Foot
American Podiatric Medical Association
http://www.apma.org/topics/athfoot.htm
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National
Candida Society
http://www.candida-society.org.uk/
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Intravascular
Catheters and Management of Candidemia
http://www.doctorfungus.org/mycoses/human/Candida/CandidemiaAndCatheters.htm
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Human
Mycoses
http://www.doctorfungus.org/mycoses/human/human_index.htm
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Tinea
Infections: Athlete's Foot, Jock Itch and Ringworm
http://familydoctor.org/316.xml
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Fungus Infections: Preventing Recurrence
Doctors have excellent treatments for skin fungus infections
that occur on
the feet, nails, groin, hands and other locations. Unfortunately, there
is a
strong tendency for fungal infections to recur in many people even
after
effective clearing with medication. This is because we all have our
strengths
and weaknesses. Some people are prone to allergies. Others get lots of
colds.
Others get stomach ulcers. And some people are prone to recurrent skin
fungus
infections.
The tendency for fungus to recur in many adults, especially on the feet
and
toenails, is a genetic condition. Their skin cannot recognize the
fungus as
foreign and get rid of it. After having a fungus there for a while the
body's
immune system learns to live with the fungus and no longer tries to get
rid of
it.
Children only rarely get fungal infections of the feet, especially
before the
age of five. Their bodies still react vigorously to the fungus. For
some reason,
they are more likely to get it on the scalp than adults are.
Fungus is all around us, on floors, in dirt, and on other people. It is
hard to
avoid forever. It likes warmth and moisture, making certain parts of
the skin
more vulnerable. A fungus is a superficial skin problem, not an
internal one. It
does not spread by going inside the body. Cortisone creams, tried by
many
patients, help fungus grow! The rash may get less red and itchy at
first, but
spreads out and recurs, itchier than ever, when the cortisone is
stopped.
A fungus sheds "spores", like tiny seeds, which wait for the right
moment to grow into new fungus. The most common place for these spores
to
collect is in shoes. Therefore, after effective treatment, a fungus may
recur
quickly where spores are present. Fungus doesn't care what color the
socks are.
White socks offer no advantage. Absorbent cotton or wool socks are best.
http://www.aocd.org/skin/dermatologic_diseases/fungus_preventing.html
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Treating Onychomycosis
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Onychomycosis (tinea unguium) is a fungal infection of the nail bed, matrix or plate. Toenails are affected more often than fingernails.1,2 Onychomycosis accounts for one third of integumentary fungal infections and one half of all nail disease.1 Tinea unguium occurs primarily in adults, most commonly after 60 years of age. The incidence of this infection is probably much higher than the reported 2 to 14 percent.1 Occlusive footwear, locker room exposure and the dissemination of different strains of fungus worldwide have contributed to the increased incidence of onychomycosis.3
 FIGURE 1. Distal and lateral subungual onychomycosis. |
 FIGURE 2. Fissure formation (arrow) in distal subungual onychomycosis. |
Tinea unguium is more than a cosmetic problem, although persons with this infection are often embarrassed about their nail disfigurement. Because it can sometimes limit mobility, onychomycosis may indirectly decrease peripheral circulation, thereby worsening conditions such as venous stasis and diabetic foot ulcers.4 Fungal infections of the nails can also be spread to other areas of the body and, perhaps, to other persons.
Dermatophytes, yeasts and nondermatophytic molds can infect the nails.1 The clinical significance of molds is uncertain, because they may be colonizing organisms that are not truly pathogenic.3,5
Classification of Onychomycosis
Distal Subungual Onychomycosis
The most common form of tinea unguium is distal subungual
onychomycosis, which
can also be distal and lateral (Figures 1 and 2). Distal
subungual
onychomycosis may develop in the toenails, fingernails or both. Some
degree of
tinea pedis is almost always present. The infection is usually caused
by Trichophyton
rubrum, which invades the nail bed and the underside of the
nail plate,
beginning at the hyponychium and then migrating proximally through the
underlying nail matrix2,3 (Figure
3).
Susceptibility to distal superficial onychomycosis may occur in an
autosomal
dominant pattern within families.1
White Superficial Onychomycosis
White superficial onychomycosis accounts for only 10 percent of
onychomycosis
cases.3
The toenails are usually affected (Figure
4). White superficial onychomycosis is caused by certain
fungi that directly
invade the superficial layers of the nail plate and form
well-delineated opaque
"white islands" on the plate. As the disease progresses, these patches
coalesce to involve the entire nail plate. The nail becomes rough, soft
and
crumbly. The most common causative agent is Trichophyton
mentagrophytes.1-3
 FIGURE 3. Anatomy of the toenail, showing the right large toe. |
Proximal Subungual Onychomycosis
Proximal subungual onychomycosis is the least common form of tinea
unguium in
healthy persons (Figure 5). It occurs when the
infecting organism,
usually T. rubrum, invades the nail unit through
the proximal nail fold,
penetrates the newly formed nail plate and then migrates distally.
Fingernails
and toenails are equally affected.1
This form
of onychomycosis usually occurs in immunocompromised persons and is
considered a
clinical marker of human immunodeficiency virus infection.1
Proximal subungual onychomycosis can also arise secondary to local
trauma.1-3
Candidal Onychomycosis
Patients with chronic mucocutaneous candidiasis may develop candidal
infection
of the nails. Candida species may invade nails previously damaged by
infection
or trauma.1,3
Candidal paronychia more
commonly affects the hands and usually occurs in persons who frequently
immerse
their hands in water.5
Total Dystrophic Onychomycosis
Total dystrophic onychomycosis may be the end result of any of the four
main
forms of onychomycosis. This condition is characterized by total
destruction of
the nail plate.3
Diagnosis
Because fungi are responsible for only about one half of nail dystrophies, the diagnosis of onychomycosis may need to be confirmed by potassium hydroxide (KOH) preparation, culture or histology. Psoriasis, lichen planus, contact dermatitis, trauma, nail bed tumor and yellow nail syndrome may be mistakenly diagnosed as onychomycosis.1,2 A fungal etiology is unlikely if all fingernail or toenails are dystrophic.3
 FIGURE 4. White superficial onychomycosis (arrow). |
 FIGURE 5. Proximal subungual onychomycosis (arrow). |
Obtaining a Specimen
The technique used to collect specimens depends on the site of the
infection.1,3
In distal subungual onychomycosis, the concentration of fungus is greatest in the nail bed. Therefore, the nail should be clipped short, and a small curette or number-15 scalpel blade should be used to obtain a specimen from the nail bed as close to the cuticle as possible. A specimen should also be taken from the underside of the nail plate.
In white superficial onychomycosis, a number-15 blade or curette can be used to scrape the nail surface or the white area, and remove infected debris.
In proximal superficial onychomycosis, the healthy nail plate should be gently pared away with a number-15 scalpel blade. A sharp curette can be used to remove material from the infected proximal nail bed as close to the lunula as possible.
In candidal onychomycosis, infected material should be collected from the proximal and lateral nail edges.
Treatment
Historically, the treatment of onychomycosis has been challenging. Orally administered griseofulvin (Grisactin, Gris-Peg) has been available for many years, but its use is limited by a narrow spectrum, the necessity for long courses of treatment and high relapse rates. The oral form of ketoconazole (Nizoral) is much more effective but carries a risk of hepatotoxicity.6
Onychomycosis has long been treated with topical antifungal preparations. However, these agents are inconvenient to use, and results are often disappointing. Treatment using nail avulsion in combination with topical therapy has been somewhat more successful, but this approach can be time-consuming, temporarily disabling and painful.
The U.S. Food and Drug Administration (FDA) has labeled ciclopirox (Penlac) nail lacquer for the treatment of mild to moderate onychomycosis caused by T. rubrum without involvement of the lunula. Although safe and relatively inexpensive, ciclopirox therapy is seldom effective.7
In recent years, treatment outcomes in patients with onychomycosis have improved substantially, primarily because of the introduction of more effective oral antifungal medications.8 Current evidence supports the use of these newer agents as part of individualized treatment plans that consider patient profiles, nail characteristics, infecting organism(s), potential drug toxicities and interactions, and adjuvant treatments.9
Triazole and allylamine antifungal drugs have largely replaced griseofulvin and ketoconazole as first-line medications in the treatment of onychomycosis. These agents offer shorter treatment courses, higher cure rates and fewer relapses.10 Of the newer drugs, terbinafine (Lamisil) and itraconazole (Sporanox) are the most widely used, with fluconazole (Diflucan) rapidly gaining acceptance. These medications share characteristics that enhance their effectiveness: prompt penetration of the nail and nail bed,3,11 persistence in the nail for months after discontinuation of therapy12,13 and generally good safety profiles. Published studies measuring "mycologic cure" (negative KOH preparation or negative cultures) and "clinical cure" (normal nail morphology) have demonstrated the effectiveness of all three medications.
Terbinafine
Terbinafine is an allylamine antifungal agent that is active against
dermatophytes, which are responsible for the majority of onychomycosis
cases.
This agent is notably less effective against nondermatophytes,
including Candida
species and molds.
Adverse effects, including headache, rash and gastrointestinal upset, are reported more often with terbinafine than with placebo. Yet these side effects are uncommon and resolve with discontinuation of the drug.14 Because of its hepatic metabolism, terbinafine has several important drug interactions (Table 1).15-17
Rare but serious complications, such as cholestatic hepatitis, blood dyscrasias and Stevens-Johnson syndrome, have been reported in patients treated with terbinafine. Consequently, liver enzyme levels and a complete blood count (including a platelet count) should be obtained before terbinafine is initiated and repeated every four to six weeks during treatment.18 Terbinafine should be discontinued if the aspartate aminotransferase or alanine aminotransferase level becomes elevated to two or more times normal.
The FDA-labeled dosage of terbinafine is 250 mg per day given continuously for 12 weeks to treat toenail infections and for six weeks to treat fingernail infections. Studies have shown that the regimen for toenails results in a mycologic cure rate of 71 to 82 percent and a clinical cure rate of 60 to 70 percent.19,20 Shorter courses and pulse dosing of terbinafine have shown promise in small studies, but data are not yet sufficient to support the use of these regimens.21
Itraconazole
Itraconazole is a newer triazole medication with a broad antifungal
spectrum
that includes dermatophytes, many nondermatophytic molds and Candida
species.
Headache, rash and gastrointestinal upset occur in about 7 percent of
treated
patients, but hepatic toxicity is rare.22
Because itraconazole is metabolized by the hepatic cytochrome P450 system, significant drug interactions can occur (Table 1).15-17 Notably, concurrent use with quinidines and pimozide (Orap) is contraindicated because of the risk of ventricular arrhythmias. Itraconazole is also contraindicated for concomitant use with 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, such as atorvastatin (Lipitor), because of the increased risk of rhabdomyolysis. In addition, itraconazole should not be taken with some benzodiazepines, such as midazolam (Versed) and triazolam (Halcion), because of exaggerated sedation and potential airway compromise.15
Increased gastric pH decreases the absorption of itraconazole. Therefore, the effectiveness of this antifungal agent can be decreased by histamine H2 blockers such as ranitidine (Zantac) and famotidine (Pepcid), and by proton pump inhibitors such as omeprazole (Prilosec) and lansoprazole (Prevacid). For this reason, itraconazole should be taken with food.
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The FDA-labeled dosage of itraconazole is 200 mg once daily taken continuously for 12 weeks to treat toenail infections and for six weeks to treat fingernail infections. The FDA has labeled pulse therapy only for the treatment of fingernail infections. Pulse treatment consists of 200 mg taken twice daily for one week per month, with the treatment repeated for two to three months (i.e., two to three "pulses").7,8,22,23 This dosage, given in three to four pulses, has also been shown to be effective in the treatment of toenail infections.7,8,22,23 Published studies have demonstrated similar success rates for continuous and pulse therapies, with mycologic cure rates ranging from 45 to 70 percent and clinical cure rates ranging from 35 to 80 percent.22,24,25
Liver enzyme monitoring is recommended before continuous therapy is initiated and every four to six weeks during treatment. No monitoring recommendation is given for pulse therapy.26
Fluconazole
Like itraconazole, fluconazole is active against common dermatophytes,
Candida
species and some nondermatophytic molds. Adverse effects, including
nausea,
headache, pruritus and liver enzyme abnormalities, are reported in
approximately
5 percent of treated patients.26
These side
effects remit after the discontinuation of fluconazole. The absorption
of this
drug is not pH sensitive and is not affected by acid suppression or
food intake.
However, fluconazole has important drug interactions15
(Table
1).15-17
Fluconazole is not currently labeled by the FDA for the treatment of onychomycosis, but early efficacy data are promising.13,27,28 Attention has focused on once-weekly dosing (450 mg), taking advantage of the drug's pharmacokinetics to reduce treatment costs, decrease rates of adverse effects and potentially improve compliance.
In one placebo-controlled study involving patients with fingernail onychomycosis,29 fluconazole in a dosage of 450 mg taken once weekly for three months was associated with a 90 percent clinical cure rate and nearly total mycologic eradication. Lower dosages were slightly less effective. No differences in complication rates were observed between the treatment and placebo groups. Published outcomes data27,28 on the use of fluconazole in toenail fungal infections demonstrated "clinical improvement" (i.e., less than 25 percent of the nail still affected) rates of 72 to 89 percent, compared with 3 percent for placebo.27 Treatment duration in these studies varied from four to nine months, with a small but measurable advantage shown for longer courses.27-29
Treatment guidelines for the newer antifungal medications are provided in Table 2.
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Comparative Clinical Trials
Much of the published data on the treatment of onychomycosis are of limited clinical use. Many studies have been small and observational, and they have lacked randomization and control subjects. Recently, however, the results of a handful of larger randomized, controlled trials have been published. These studies provide more convincing guidance in choosing appropriate therapy.
In a 1998 study30 of 378 patients with dermatophytic onychomycosis, continuous terbinafine therapy was shown to be more effective than continuous itraconazole therapy in patients with toenail onychomycosis. Intention-to-treat analysis showed nearly 85 percent negative cultures in the treatment group compared with 55 percent in the placebo group, and 65 percent clinical improvement in the terbinafine group compared with 37 percent in the itraconazole group.
Other studies comparing terbinafine and itraconazole had similar findings.31,32 A recent prospective, double-blind, randomized, controlled trial33 compared the use of continuous terbinafine therapy and pulsed itraconazole therapy in 496 patients with toenail fungal infection. This well-designed study showed that terbinafine provided superior clinical and mycologic outcomes up to 15 months after treatment. To date, fluconazole has not been included in published direct-comparison trials.
Most patients in the published studies were infected with dermatophytes, against which terbinafine is most effective. Outcomes data for the treatment of nondermatophytic and candidal onychomycosis are limited, but broader spectrum triazole medications may be more effective against these pathogens.
Cost
Onychomycosis is expensive to treat. Costs include medications, procedures, laboratory tests and health care providers' time, as well as expenses associated with the management of adverse drug effects and treatment failures.
One pharmacoeconomic study34 compared the cost-effectiveness of continuously dosed terbinafine and itraconazole in the treatment of toenail onychomycosis.34 The investigators concluded that continuous terbinafine therapy is less expensive, at a little over one half the price of continuous itraconazole treatment. It should be noted, however, that itraconazole pulse therapy is less expensive than continuous treatment (lower overall drug cost and no need for blood monitoring). Furthermore, the pharmacoeconomic study used national reference pricing and wholesale drug costs. Local laboratory standards, retail pharmacy costs and increasingly common payor formulary considerations may significantly alter individual costs.
Adjuvant Treatments
In addition to oral medications, some patients benefit from other treatments. Surgical or chemical nail avulsion may be useful in patients with severe onycholysis, extensive nail thickening or longitudinal streaks or "spikes" in the nail. These nail changes can be caused by a granulated nidus of infection (dermatophytoma), which responds poorly to standard courses of medical therapy.35,36
Longer courses of antifungal therapy may be useful in patients whose nails grow slowly, who have diminished blood supply to the nail bed as a result of conditions such as peripheral vascular occlusion or diabetes mellitus, or who have total or nearly total nail plate involvement.9
Topical antifungal creams or powders may also be beneficial, especially in patients with concomitant tinea pedis.
To improve treatment outcomes and prevent recurrence, patients should be counseled about proper foot hygiene (Table 3). Patients should be encouraged to wear breathable footwear and 100 percent cotton socks when possible. They should be advised to keep their feet dry throughout the day. Similar infection patterns observed in households and patrons of communal bathing facilities suggest a role for foot protection in high-risk areas.21
Treatment Failure and Relapse
Rates of treatment failure can be extracted from published trials, but data on relapse are less readily available. Post-treatment follow-up is long, drop-out rates in many studies are significant or unreported, and most studies have not allowed crossover of treatment regimens. Furthermore, especially in outcomes of clinical improvement (as opposed to cure or fully normal nail appearance), evaluation criteria have not been standardized and often include subjective assessments that are difficult to quantify. Published studies have not specifically addressed the management of treatment failures or relapse.
Despite these difficulties, several measures may be helpful in managing unsuccessful treatment or relapse. The first step is to confirm mycology. If the initial diagnosis was based on a KOH preparation alone, culture of properly collected specimens is mandatory. Culture reports often identify multiple organisms, including possibly nonpathogenic molds, and treatment should be directed at the organism(s) most likely to be causative. A microbiology or infectious disease consultation may be valuable in interpreting the culture report.
Of note, there has been some concern about evolving drug resistance among fungal pathogens, particularly with the widespread use of systemic fluconazole therapy to treat oropharyngeal and recurrent vaginal candidiasis.5 However, the impact of antifungal resistance on the treatment of onychomycosis is not yet clear.
Careful clinical review may identify patient or nail characteristics that are impeding treatment. These factors can be addressed with appropriate medication changes or adjuvant measures. Because of superior efficacy, continuous antifungal therapy may be considered in patients who fail or relapse after pulse therapy.
Onychomycosis in Children
Onychomycosis in children is rare, with an estimated prevalence of 0.2 percent.38 Most often, onychomycosis develops in children with immunosuppression (e.g., acquired immunodeficiency syndrome, chemotherapy, congenital immunodeficiency syndromes), a strong familial history of onychomycosis or extensive cutaneous mycosis (tinea capitis or pedis).
Although griseofulvin remains the mainstay of onychomycosis treatment in children, the efficacy of this drug is variable, and relapse is common. Newly available medications may improve the traditionally mediocre treatment outcomes in this age group.
The FDA has not yet labeled terbinafine for use in children. However, some studies have shown terbinafine to be safe and quite effective in the treatment of tinea capitis, and it is licensed for this purpose in several countries.39 In more limited trials, itraconazole has also been shown to be safe and efficacious in the treatment of tinea capitis.21 If the safety and effectiveness of terbinafine and itraconazole are established over the longer courses needed to treat nail infections, they may become potent first-line therapies for onychomycosis in children.
The authors thank Barbara Apgar, M.D., M.S., and Stephen A. Swisher, M.D., University of Michigan Medical School, Ann Arbor, for their guidance and support.
Figures 1, 2, 4 and 5 were supplied by James E. Rasmussen, M.D., professor of dermatology and pediatrics, University of Michigan Medical School, Ann Arbor.
Members of various medical faculties develop articles for "Practical Therapeutics." This article is one in a series coordinated by the Department of Family Medicine at the University of Michigan Medical School, Ann Arbor. Guest editor of the series is Barbara S. Apgar, M.D., M.S., who is also an associate editor of AFP.
This is a corrected version of the article that appeared in print.
The Authors
PHILLIP RODGERS, M.D.,
is clinical instructor in the Department of Family Medicine at the
University of
Michigan Medical School, Ann Arbor. Dr. Rodgers graduated from the
Medical
College of Ohio, Toledo, and completed a family practice residency at
the
University of Michigan Medical School.
MARY BASSLER, M.D.,
is clinical instructor in the Department of Family Medicine at the
University of
Michigan Medical School. Dr. Bassler graduated from Saint Louis
University
School of Medicine, St. Louis, and completed a family practice
residency at
Santa Monica (Calif.) Hospital.
Address correspondence to Phillip Rodgers, M.D., Briarwood Family Practice, University of Michigan Health System, 1801 Briarwood Circle, Ann Arbor, MI 48108 (e-mail: prodgers@umich.edu). Reprints are not available from the authors.
http://www.aafp.org/afp/20010215/663.html
--------------------------------------------------------------
What are
fungal infections of the nails?
Fungal infections of the nails are common. The fungus grows in the nail
bed,
where the nail meets the skin. The fungus grows slowly and does not
spread to
internal organs. The main concern is the nail discoloration (usually
yellow) and
change in nail texture and growth. Nails can become crumbly, break
easily, and
grow irregularly. But because other nail conditions can mimic fungal
infection,
most doctors will confirm the diagnosis by sending a nail clipping for
laboratory evaluation -- especially if treatment is being considered.
Fungal infections are not commonly contagious or spread easily between
people.
The fungus grows in people whose bodies "allow" the fungus to become
established without mounting an immune response to suppress the fungus.
We know
of no ways to boost your immune system to make fungal infections less
likely.
You may be able to prevent fungus infections by:
Keeping your feet dry, avoiding constant moisture
Avoid non porous, closed shoes made of synthetic materials
Wearing absorbent socks
Wearing water proof sandals when in public showers
What can be done about fungal nail infection?
Because the fungus grows slowly, it is hard to eliminate. The anti
fungal
medications that eliminate the fungus are strong, must be taken by
mouth, and
must be taken conscientiously for months in order to be effective. Each
drug has
potential side effects on other body organs (especially the liver,
skin, or bone
marrow). To monitor for side effects, periodic blood testing must be
obtained,
usually monthly, during the time you take the medication. Any symptoms
suggesting organ damage should be reported immediately to your
physician, such
as: unusual fatigue, severe loss of appetite, nausea, yellow eyes, dark
urine,
pale stool, skin rashes, bleeding, enlarged lymph glands, or signs of
infection.
Unfortunately, anti fungal creams applied directly to the nail cannot
penetrate
the nail bed to kill the fungus at its source, so they are not usually
effective.
How effective are the medications at curing the fungus?
The anti fungal medications usually suppress the nail infection when
taken as
directed. Unfortunately, they cannot guarantee permanent cure. At least
1 in 5
patients (20%) and probably more will have a recurrence of the original
nail
infection at some time, and re-treatment with medication would be
necessary.
Should I take medication to treat my fungal nail infection?
Doctors usually recommend treating fungal nail infections only when
such
infections cause secondary problems, like pain, recurring ingrown
toenails, or
secondary bacterial infections of the nails or skin. If the nail
infection
causes no symptoms, then doctors often will discourage treatment
because of the
potential side effects, the need to monitor the blood throughout
therapy, and
the high recurrence rate. Patients with liver or heart disease
generally should
not take these medications.
Some insurance companies require documentation of secondary problems
beyond the
mere presence of the fungal infection before they will cover the costs
of the
anti fungal medications.
April 2002
Acknowledgment and Thanks
Palo Alto Medical Foundation
http://www.pamf.org/patients/nailfungus.html
---------------------------------------------------------------
Ringworm
Ringworm is a contagious fungus infection that can affect the scalp,
the body,
the feet (athlete's foot), or the nails.
People can get Ringworm from: 1) direct skin-to-skin contact with an
infected
person or pet, 2) indirect contact with an object or surface that an
infected
person or pet has touched, or 3) rarely, by contact with soil.
Ringworm can be treated with fungus-killing medicine.
To prevent Ringworm, 1) make sure all infected persons and pets get
appropriate
treatment, 2) avoid contact with infected persons and pets, 3) do not
share
personal items, and 4) keep common-use areas clean.
What is Ringworm?
Ringworm is a contagious fungus infection that can affect the scalp,
the body
(particularly the groin), the feet, and the nails. Despite its name, it
has
nothing to do with worms. The name comes from the characteristic red
ring that
can appear on an infected person's skin. Ringworm is also called Tinea.
What is the infectious agent that causes Ringworm?
Ringworm is caused by several different fungus organisms that all
belong to a
group called "Dermatophytes." Different Dermatophytes affect different
parts of the body and cause the various types of Ringworm:
Ringworm of the scalp
Ringworm of the body
Ringworm of the foot (athlete's foot)
Ringworm of the nails
Where is Ringworm found?
Ringworm is widespread around the world and in the United States. The
fungus
that causes scalp Ringworm lives in humans and animals. The fungus that
causes
Ringworm of the body lives in humans, animals, and soil. The fungi that
cause
Ringworm of the foot and Ringworm of the nails live only in humans.
How do people get Ringworm?
Ringworm is spread by either direct or indirect contact. People can get
Ringworm
by direct skin-to-skin contact with an infected person or pet. People
can also
get Ringworm indirectly by contact with objects or surfaces that an
infected
person or pet has touched, such as hats, combs, brushes, bed linens,
stuffed
animals, telephones, gym mats, and shower stalls. In rare cases
Ringworm can be
spread by contact with soil.
What are the signs and symptoms of Ringworm?
Ringworm of the scalp usually begins as a small pimple that becomes
larger,
leaving scaly patches of temporary baldness. Infected hairs become
brittle and
break off easily. Yellowish crusty areas sometimes develop.
Ringworm of the body shows up as a flat, round patch anywhere on the
skin except
for the scalp and feet. The groin is a common area of infection (groin
Ringworm). As the rash gradually expands, its center clears to produce
a ring.
More than one patch might appear, and the patches can overlap. The area
is
sometimes itchy.
Ringworm of the foot is also called athlete's foot. It appears as a
scaling or
cracking of the skin, especially between the toes.
Ringworm of the nails causes the affected nails to become thicker,
discolored,
and brittle, or to become chalky and disintegrate.
How soon after exposure do symptoms appear?
Scalp Ringworm usually appears 10 to 14 days after contact, and
Ringworm of the
skin 4 to 10 days after contact. The time between exposure and symptoms
is not known for the other types of Ringworm.
How is Ringworm diagnosed?
A health-care provider can diagnose Ringworm by examining the site of
infection
with special tests.
Who is at risk for Ringworm?
Anyone can get Ringworm. Scalp Ringworm often strikes young children;
outbreaks
have been recognized in schools, day-care centers, and infant
nurseries. School
athletes are at risk for scalp Ringworm, Ringworm of the body, and foot
Ringworm; there have been outbreaks among high school wrestling teams.
Children
with young pets are at increased risk for Ringworm of the body.
What is the treatment for Ringworm?
Ringworm can be treated with fungus-killing medicine. The medicine can
be in
taken in tablet or liquid form by mouth or as a cream applied directly
to the
affected area.
What complications can result from Ringworm?
Lack of or inadequate treatment can result in an infection that will
not clear
up.
Is Ringworm an emerging infection?
Although Ringworm is not tracked by health authorities, infections
appear to be
increasing steadily, especially among pre-school and school-age
children. Early
recognition and treatment are needed to slow the spread of infection
and to
prevent re-infection.
How can Ringworm be prevented?
Ringworm is difficult to prevent. The fungus is very common, and it is
contagious even before symptoms appear.
Steps to prevent infection include the following:
Educate the public, especially parents, about the risk of Ringworm from
infected
persons and pets.
Keep common-use areas clean, especially in schools, day-care centers,
gyms, and
locker rooms. Disinfect sleeping mats and gym mats after each use.
Do not share clothing, towels, hair brushes, or other personal items.
Infected persons should follow these steps to keep the infection from
spreading:
Complete treatment as instructed, even after symptoms disappear.
Do not share towels, hats, clothing, or other personal items with
others.
Minimize close contact with others until treated.
Make sure the person or animal that was the source of infection gets
treated.
This fact sheet is for information only and is not meant to be used for
self-diagnosis or as a substitute for consultation with a health-care
provider.
If you have any questions about the disease described above or think
that you
might have a fungus infection, consult a health-care provider.
http://www.astdhpphe.org/infect/ringworm.html
-----------------------------------------------------------------
Oral Thrush
What is oral thrush?
Oral thrush in an adult.
Oral thrush is an infection of yeast fungus, Candida albicans, in the
mucous
membranes of the mouth. Strictly speaking, thrush is only a temporary
candida
infection in the oral cavity of babies. However, we have for this
purpose
expanded the term to include candida infections occurring in the mouth
and
throat of adults, also known as candidosis or moniliasis.
How do you get oral thrush?
Candida is present in the oral cavity of almost half of the population.
Everyone
who wears dentures will have candida, without necessarily suffering any
ill
effects.
Candida does not become a problem until there is a change in the
chemistry of
the oral cavity that favours candida over the other micro-organisms
that are
present.
These changes can occur as a side effect of taking antibiotics or drug
treatment
such as chemotherapy. These changes can also be caused by certain
conditions
such as diabetes, drug abuse, malnutrition, and as a consequence of
immune
deficiencies relating to old age or infection, such as AIDS.
Furthermore, people whose dentures don't fit well can sustain breaks in
the
mucous membranes in their mouth, which can act as a gateway for
candida. People
who suffer from this problem often have moist, pale pink spots on their
lips,
known as angular cheilitis, which is an indication of a candida
infection.
What are the symptoms of oral thrush?
White, cream coloured, or yellow spots in the mouth. The spots are
slightly
raised. There is normally no pain in the area underneath the spots. If
you
scrape off these spots, they leave small wounds that bleed slightly. In
adults,
thrush can cause an uncomfortable burning sensation in the mouth and
throat.
Who is at special risk?
Newborn babies.
Denture users.
Adults with diabetes or other metabolic disturbance.
People undergoing antibiotic or chemotherapy treatment.
Drug users.
People with poor nutrition.
People with an immune deficiency.
How does the doctor diagnose oral thrush?
In babies, thrush is usually diagnosed on the basis of the clinical
picture.
Occasionally, in order to make a diagnosis, the doctor will scrape the
baby's
tongue and send the sample for analysis.
In adults, many other diseases and illnesses, including very early
stages of
cancer, can have similar symptoms. Therefore it is important to consult
your
doctor and get a thorough check-up.
In cases where thrush occurs as the result of disease or illness in
other organs
or systems, like AIDS, sudden and very intense thrush can be a sign of
a general
aggravation of the main illness. This makes it all the more important
to pay
attention to this and similar changes, so you can get help in time.
How is oral thrush treated?
Firstly, the condition that caused the thrush must be brought under
control.
This might involve investing in new and better fitting dentures, or
adjusting
diabetes treatment. For AIDS patients, it is not always possible to
correct the
immune deficiency, and a course of oral treatment using antifungal
drugs has to
be used.
Once the condition that caused the oral thrush has been treated, the
thrush
itself can be cured. Treatment is with antifungal medicines such as
nystatin,
amphotericin or miconazole in the form of pastilles that are sucked or
oral
suspensions that are held in the mouth before swallowing. These allow
the
antifungal agent to act locally in the mouth.
In certain complicated cases, or if the infection spreads, systemic
treatment
will be necessary in the form of antifungal tablets, or perhaps in the
form of
injections.
Coping with the symptoms of oral thrush
Thrush can make the mouth so sensitive that it is impossible to perform
regular
oral hygiene. Use a very soft toothbrush. It can often help to rinse
the mouth
with a diluted solution of 3 per cent hydrogen peroxide.
Outlook
If whatever caused the thrush can be brought under control, the
infection is
likely to go away after a few days of treatment with a fungicide.
Based on a text by Dr Flemming Andersen and Ulla Søderberg, specialist
Last updated 01.02.2002
Ackowledgment and Thanks
Net Doctor.co.uk
-----------------------------------------------------------------
Cryptococcal meningitis is a very serious fungal infection. It is caused by a fungus found mainly in dirt and bird droppings. Meningitis means swelling of the meninges. The meninges cover the brain and spinal cord.
Symptoms can be hard to recognize as being caused by cryptococcal infection. Watch for fever, vomiting, headache, nausea, fatigue, loss of appetite, and a general feeling of not being well. Other symptoms are a stiff neck and, infrequently, seizures. Pneumonia can be an early sign of infection. Tell your doctor about symptoms right away.
A common treatment for this condition is amphotericin B, which must be given by intravenous injection. A new treatment that can be given by pill, in some cases, or by intravenous injection is Flucanozole, or Diflucan. Most people prefer this treatment because it causes few side effects.
Histoplasmosis can be a life-threatening fungal infection and commonly occurs in the Southwestern U.S. In the past, histoplasmosis was treatable only with intravenous amphotericin. Itraconazole is used today, although it may not be effective for treating histoplasmosis involving the central nervous system and brain, since it does not penetrate well into the cerebrospinal fluid, which is the fluid that surrounds the spinal cord and brain.
Blastomycosis is a fungal infection involving the lungs and occasionally spreading to the skin. The fungus is of unknown natural source. Most reported cases are from the southeastern states and the Mississippi River valley, and occur in men ages 20 to 40. When infection occurs in the lungs, a dry hacking or productive cough, chest pain, fever, chills, drenching sweats, and shortness of breath are initial symptoms. If untreated, the disease slowly causes death. Amphotericin B is highly effective. Improvement begins within a week, with rapid disappearance of organisms.
http://www.aegis.com/factshts/network/simple/fungal.html
================================================
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Advocates for Lymphedema
Dedicated to be an advocacy group for lymphedema patients. Working towards education, legal reform, changing insurance practices, promoting research, reaching for a cure.
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Lymphedema People / Advocates for Lymphedema
=======================================================
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For Information about Lymphedema Complications
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=======================================================
Lymphedema People
Support Groups
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Children
with Lymphedema
The time has come for families, parents, caregivers to have a support
group of
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Lipedema
Lipodema Lipoedema
No matter how you spell it, this is another very little understood and
totally
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Come join, be a part of the family!
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If you are a man with
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Support group for parents, patients, children who suffer from all forms
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Lymphatic
Disorders Support Group @ Yahoo Groups
While we have a number of support groups for lymphedema... there is
nothing out
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comprehensive information sites on all lymphatic disorders, I thought
perhaps,
it is time that one be offered.
DISCRIPTION
Information and support for rare and unusual disorders affecting the
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system. Includes lymphangiomas, lymphatic malformations,
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Reviewed Nov. 29, 2011
