Fungal Disease

Dermatophyte (Tinea)

  • Common label for three types of fungus (Microsporum, Epidermophyton, Trichophyton)
  • Presentation
    • Red annular scaly pruritic patch or plaque with central clearing and active border
    • Consider confirmation with KOH preparation or culture if appearance atypical or prior to oral treatment
  • Subtypes
    • Tinea corporis (ringworm)
    • Tinea capitis (scalp)
    • Tinea cruris (jock itch)
    • Tinea pedis (athlete's foot)
    • Tinea unguium (onychomycosis)
    • Tinea manuum (commonly “one-hand, two-feet” involvement)
    • Tinea barbae
    • Tinea incognito (altered appearance of dermatophyte infection caused by topical steroids)
  • Topical antifungals (azoles, allylamines, ciclopirox, butenafine, tolnaftate)
    • Ketoconazole (Ketoderm) 2% cream once daily
    • Terbinafine (Lamisil)1% cream daily-BID
    • Ciclopirox (Loprox) 1% cream BID

Note: Nystatin not effective for dermatophyte infections (only treats candida)

  • Consider oral antifungals (eg. Fluconazole 150-200mg PO weekly, Terbinafine 250mg PO daily, Itraconazole, Griseofulvin) if
    • Tinea capitis, onychomycosis, severe pedis (eg. mocassin-type)
    • Multiple regions or extensive
    • Refractory to topical

Yeast (Malassezia)

Pityriasis versicolor (formerly Tinea versicolor)

  • Hypo or hyper-pigmented macules on trunk and upper extremities
  • Responds well to topical treatment (antifungal, selenium sulfide, zinc pyrithione) but commonly recurs (can consider prophylaxis)

Seborrheic dermatitis

  • Greasy scaly ill-defined plaques in areas rich in sebaceous glands (scalp, face, upper trunk, intertriginous areas)
  • Treatment
    • Antifungal shampoos (selenium sulfide 2.5%, ketoconazole 2%, or ciclopirox 1%)
      • Alternative shampoos (coal tar, sulfur, zinc)
      • Use daily until remission (usually 2-4 weeks), then weekly to prevent relapse
    • Consider keratolytics if thick scales (salicylic acid, lactic acid, urea, propylene glycol)
    • Consider topical corticosteroid for pruritus or inflammation

Yeast (Candida)

Oropharyngeal candidiasis (thrush)

  • Treatment
    • Nystatin 500,000 units PO QID


  • Combination of both infectious (fungal, bacterial) and inflammatory
  • Treatment
    • Dry environment to minimize maceration/re-infection
    • Consider topical antifungals, topical antibiotics, avoid steroids (risk of skin atrophy)
      • eg. Ciclopirox 1% cream BID, Terbinafine 1% cream or spray solution daily , Ketoconazole 2% cream daily

Deep Fungal Infections

Majocchi's granuloma

  • Deep folliculitis presents as scaly plaque with pustules and nodules
  • Treat with oral antifungal 4-6w


  • Presents as boggy pus-filled lump surrounded by alopecia
  • Fungal abscess often misdiagnosed as bacterial infection
  • Treat with oral antifungal 6-8w minimum

Nail Fungal Infections


  • DDx
    • Psoriasis (nail pitting, oil drop sign)
    • Bacterial infection - Pseudomonas aeruginosa (black/green nail)
    • Dermatitis/Eczema
    • Lichen Planus
    • Viral warts
    • Onycholysis
    • Onychogyphosis (elderly nail thickening and scaling)
    • Trauma
  • Treatment not mandatory
    • Consider treatment if repeated cellulitis, risk factors for cellulitis (diabetes, immunosuppression), nail pain, discomfort
    • Prior to treatment obtain samples of the subungual debris and nail clippings
      • Fungal culture
      • KOH preparation or PAS stain (if positive can begin treatment)
    • Terbinafine 250mg PO daily (x6w for fingers, x 12w for toes) or topical if drug interactions or patient's preference
      • ALT at baseline and repeat q4-6w
  • Prevention (of recurrence)
    • Treat tinea pedis
    • Wear cotton socks, frequent changes
    • Keep feet dry
    • Protect feet in shared areas
    • Improve health conditions (diabetes, smoking)