The Fungus Amongus

Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 1.5- Approximate time required: 90 min.

Educational Goal: 

To familiarize the In Home Care Giver with the concepts of fungal infections.

Educational Objectives:

1. Enumerate the prevalence of fungal infections and explain the reasons why it is so high.

2. Describe the signs and symptoms of fungal infections.

3. Explain how to prevent and treatment fungal outbreaks

4. Explain why relapse rates are so high and what to do about it.

5. How to overcome patient non-compliance issues.

Procedure:            

1. Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records. 

 

Disclaimer

  The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

 

 

The Fungus Amongus

 

 Who Has the Fungus Amongus?

     There are a lot of nasty things that like to chew on us (besides tax collectors and ex-spouses, that is). Among the most prevalent is a group of fungi known as dermatophytes. You might know them better by their common names, athlete’s foot, jock itch, ring worn, and nail fungus.

     At any given time, more than 30 percent of the population can have fungi growing on them somewhere.  Athlete’s foot alone will infect more than 70 percent of all adults at least once in their lifetime.  In populations that have poor hygiene or compromised immune systems, the infection rate soars.  Since a majority of foster care clients comes from these groups, caregivers should be aware of and know how to deal with “The Fungus Amongus.” 

Why Is Fungus So Prevalent?

     Fungus is a group of organisms that is related to yeasts and molds.  They were here long before man came along and will be here long after we’re gone.  Fungi need only two things to survive - a carbon-based food source and water.  They can spread in two ways. They grow like plants, extending themselves along root like filaments called hyphae and they produce spores that are microscopic and can travel in the air.  Since they have been here a long, long time it’s safe to say that fungus and fungal spores can be found pretty much everywhere in our environment.

      Fungi come in a wide variety. The fungus that likes to grow on us is called Dermatophytes. As fungi, dermatophytes can survive just about anywhere, but they seem to thrive in warm, damp environments.  They don’t even need a human host to survive.  This makes fungal infections very contagious. All it takes is for the skin to come in contact with a source of a fungus and that person can become infected. Once infected, that person is now a fungal source and they can spread it to any other surface they come in contact with where the conditions are right for growth. Unfortunately for most humans, hot sweaty feet are ideal conditions for fungus to grow, especially between the two smallest toes.  

      It is now easy for you to understand that the highest risk areas for the spread of dermatophytes are warm, damp communal areas like gym showers, bathrooms, and pools - plenty of moist surfaces and lots of skin to come in contact with contaminated areas. And the highest prevalence for athlete’s food is found in young to middle-age men.

 

 

You Can Be Fungus-Free

     Regardless of the source or the prevalence, healthcare providers can identify and eliminate fungus from their homes.  It can be done in two phases. First, the home: Professional cleaners say that you usually don’t have a fungus problem, you actually have a moisture problem. First, if you can control how much moisture there, is you can control how much fungus there is.  Second, the infected person: antifungal medications and moisture control usually do the trick.  Being fungus free is mostly about timely action and knowing what to do.

     Luckily, fungal infections are not life threatening. For most, they just result in a chronic itch and stinging pain when the skin cracks. Complications can arise when secondary infections take advantage of the weakened skin area. Due to this and its contagious nature, care providers must learn to screen for and treat fungal infections quickly and effectively. If you know what you’re doing, fungus is easily identified and eradicated. Of course, the first place to start is with yourself and your home then move on to your current residents. After your home is fungus free, all you have to do is carefully screen new move-ins. Your home can be free from fungal infections

 

Signs and Symptoms

 

     To get rid of the fungus amongus, caregivers must know what to look for and where to find it. First, let’s all get on the same page.

Medical Language

     In medical terms, skin fungi are dermatophytes. The three main infectious types are trichophyton, epidermophyton, and microsporum. Dermatophytic infections of the skin can manifest themselves anywhere on the body. Infections are named by the beginning term “tinea” and the ending term dependent on the area of involvement. Thus tinea capitis affects the scalp, tinea barbae- the face, tinea unguum- the nails, tinea manuum- the hands, tinea cruris- the groin area (jock itch), and tinea pedis is the feet (athlete’s foot). But outside of understanding medical literature and other health professionals, who cares what the Latin name is? What really matters is what it looks like. What is the physical appearance of a fungal infection?  To know what you’re looking for, you have to understand what is going on in the affected area.  

 

Anatomy

 

     The skin is the largest organ of your body and is composed of multiple layers of tissue. The two main groups are the dermis and epidermis.   The epidermis is the skin’s outermost layer. It is made up of skin cells that provide protection for the inner skin layers.  Basal cells at the bottom of the epidermis reproduce and move the new skin cells outward thus replacing the outermost cells that wear off. 

     When an infection occurs, dermatophytes invade and start to grow under the top most layers of the epidermis skin cells. The basal cells respond by overproducing cells trying to slough off the infection.  As the excess cells reach the skin’s surface, they cause the first visible appearance of a fungal infection. (Understanding this will become important in treatment. More about that later.) If the infection gets bad enough, the body’s immune system senses the infection and tries to contain and stop it by inflammation, sensitivity, and other immune responses. That sensitivity is most often felt as an itching sensation alerting us to the presence of an active infection.

 

The Different Varieties

     Now that we have covered the basics and are all on the same page, let us review what some of the most common fungal infections look like. Starting from the top:

 

Tinea Capitis  (cradle cap)

     Not all flaky dandruff is from a dry scalp.  If you encounter a bad case of dandruff that just won’t go away with dandruff treatment, talk to the doctor about the possibility of fungus. More pronounced infections can appear as round bald patches with tiny black dots that are actually hair shafts that have broken off.  Patches can appear scaly and can also be red or swollen with puss-filled sores.   The scalp is usually itchy.

 

Dermatophytosis (ringworm)

     Ringworm, of course, is not a worm at all but it does look like there is one under the skin.  Infections are itchy and have red, raised, scaly patches that may blister and ooze. The patches have sharply-defined edges. Red patches are often redder around the outside with normal skin tone in the center. This may look like a ring. And just in case you are wondering, you can catch ringworm from handling infected pets.

 

Tinea Curuis (jock itch)

     Jock itch (or any folds of the body like under the breast, anus, or fat folds) is basically ring worm.  The signs are itching in the fold of the skin, red, raised, scaly patches that may blister and ooze. The patches usually are redder on the outside with sharply defined edges, abnormally light or dark skin and patches can have a bad smell.

 

Tinea Pedis (athlete’s foot)

     The classic signs of athlete’s foot are itchy flaky or peeling skin, most often accompanied by bad odor.   There are three main types of athlete’s foot. The most common is interdigital tinea pedis or fungus in between the toes. In this type of infection, the skin within the toe web will appear as inflamed, scaly, and with soggy white tissue.  Splitting of the skin, called fissures, may be present between or under the toes.   Hypereratotic or moccasin-type infection is a more prolonged infection that covers the soles and lower sides of the foot (where a moccasin would cover). The skin appears darker, scaly, flaky, reddened, and slightly thicker. The least common form is called acute vesicular tinea pedis, where fluid-filled cysts or blisters (vesicles) form, pop, and create open sores. The inflammation is usually quite itchy.

Tinea unguium or Onychomycosis (nail fungus)

     Dermatophytes can get under and even in the nails of the hand and foot.  Typically, the nail thickens and a white, yellow, or brown discoloration occurs. Occasionally, pitting and small fissures are present. Sometimes the nails get so thick that it interferes with walking and shoe apparel.  Toe nail fungus is a long-term problem. It is very difficult to treat. It can also act as a repository for the dermatophytes that can continually re-infect the surrounding skin.  A podiatrist (foot doctor) is another option for treatment and is better equipped to handle thickened nails.

Look-Alike Conditions.

     There are other conditions that can mimic fungal infections. Maladies like eczema, seborrhea, and localized allergic reactions have been mistakenly identified as fungal outbreaks. Fortunately, you as a caregiver don’t have to tell them apart. You are just screening for the possibility of infection and the doctor will do the diagnosis.  The guiding principle is “when in doubt send them out,” to the doctor, that is. 

Complications

     Life is never as simple as black and white. The same is true with fungal infections. Complications can arise that may need attention.  The most common complication  is odor. As the fungus spreads, the skin is compromised, leaving an opening for bacteria to grow. Signs of a bacterial infection are swelling, red streaks, and pain. The body can fight off these infections by itself, but those with weakened immune systems may need antibiotic help. These secondary infections can produce very unpleasant odors. Controlling the bacteria is the key to controlling the odor. For those with compromised immune systems like diabetics, uncontrolled fungal infections can be the first step toward amputations.

     Two less common but nevertheless serious complications are the ID reaction and asthmatic attacks.  The ID reaction or dermatophytid is in basic terms a localized allergic reaction to the fungus. It is typically seen as a generalized, diffuse rash. It might look very nasty but the condition will go away by itself when the infection is cured. There have been some reports of increased asthma attacks when fungal infections are present. It would be wise to keep a rescue inhaler handy when treating fungus. 

 

Treatments

 

Now let’s talk about how to get rid of the Fungus Amongus

Prevention

     Prevention is always the best cure. Fungus needs a wet environment to thrive and direct contact to the skin to spread. If you can control these two conditions, you can pretty much keep you home fungal infection free.  Good hygiene techniques are your best bet at prevention.

Bathrooms

     Bathrooms and showers are always damp and can be hard to maintain a surface free of fungus.  Molds also grow in the same conditions as fungus, so if you see mold, there is a good chance that fungus is there also. Here are a few cleaning tips:

  • Increase ventilation by running a fan or opening a window.
  • Wipe down bath tubs and showers and keep plumbing in good repair. 
  • Porous or absorbent material may have to be thrown away if they become moldy.
  • Don’t paint or caulk over moldy corners.
  • Choose cleaning products that say they are disinfectant cleaners. Cleaning an area by itself will not kill all the fungus, and disinfecting an area without cleaning also leaves behind hiding places for the fungus to grow back.  You can use separate products but choosing a disinfectant cleaner is more efficient use of your time. It is important to leave the disinfectant on the surface for about 10 minutes so that it can penetrate the surface and kill the fungus.
  • While treating a fungal infection, clean surfaces more often.

Laundry

     Towels, wash rags, socks, and clothing can be a source for the spread of the fungus amongus.  Bleach kills fungus, also the “Hot” settings on you laundry machines kills as well. Keep you dryer vents clear and your dryer will run hotter. 

Shoes

     It’s hard to wash shoes, but let’s face it, they need it from time to time.  Bacteria can really make them stink.  What good is it to treat the infection if you continually put the same infected shoes on.  A few cleaning tip for shoes (and slippers).

  • You can purchase special disinfecting shoe insert machines. One idea is to let the business buy the machine and rent it to those with a problem. It could pay for itself or even be a source of income.
  • Treat shoes with antifungal powders.
  • Pour rubbing alcohol onto shoes and let stand for five minutes. This will kill the bacteria, too.   (It could also ruin shoes- be careful.)
  • If you’re desperate or the above is impractical, place the shoes into an airtight plastic bag and put them in the freezer overnight. That will kill the fungus amongus and eliminate odor-causing bacteria.
  • If you have sweaty feet, you may have to buy ventilated shoes.

Feet

     Keep feet dry. Dry in between the toes after bathing. Don’t share towels. It might also be a good idea to have a separate towels for infected areas to keep the infection from spreading to different parts of the body. Change socks often.  Flip flops or shower shoes are also be a good idea, especially in communal areas that are not under your control.

 

Cures

 

Non-Pharmacological Treatment

     Even with your best effort sometimes an infection will slip past your prevention efforts, or you have a new client move in with an active infection.  It is good to note that (depending on the severity of the case and hygiene efforts of the patient) about 30-40 percent of infections can resolve themselves. There is a lot of anecdotal evidence that changing the pH [p(H)] can kill off fungus. So, home remedies like soaking your feet in vinegar, baking soda, boric acid, or bleach might or might not help. You can try these on yourself but you cannot use them on your resident without a doctor’s permission. 

Pharmacological Treatment

     Most infections respond well to topical antifungal agents. For severe or topical treatment failure, oral medications may be needed.  In addition, depriving the infection of moisture through the use of a dry powder or zinc oxide-based diaper rash cream may be a good add-on treatment. For scalp infection, there are antifungal shampoos.

     In cases where there is significant pain and rash, the doctor might use a topical steroid in addition to an antifungal or in a combination steroid/antifungal product.  You should know as a caregiver that applying topical treatments to fissures and open sores are going to sting. 

     One note of interest, fungi are complicated structure that are not easily mutated. Therefore you don’t see much medication-resistant strains developing. 

 

 

More Medical Terminology

     In considering treatments, it is important to understand the difference between the terms fungistatic and fungicidal.  Fungistatic means to halt the progression or growth of the organism. Fungicidal means to kill it off. You can probably guess that a fungistatic agent take longer to eradicate the outbreak. 

Topical (on top of the skin)

     Topical agents are the first-line therapy for most doctors. They are safe, easy-to-use, and inexpensive. In clinical trials, fungicidal agents are the most effective while undecyline acid is the least effective.

 

Table 1. Nonprescription Antifungal Products

Agent

Brand Names

Formulations

Dosing

Minimum
Effective
Duration

Comments

Azole

   clotrimazole 1%

Desenex®

Lotrimin® AF

cream, lotion,

powder,

solution,

spray solution

BID

4

fungistatic

   ketoconazole 2%

EXTINA®

Nizoral®

Cream

 

1% Shampoo*

BID

6

fungistatic

   miconazole 2%

Desenex®,

Lotrimin® AF,

Micatin®,

Micozole,

Monistat®

cream, lotion,

gel, powder ,

spray

powder,

spray

solution

BID

4

fungistatic

   tolnaftate 1%

Lamisil AF

Defense,

Tinactin®

cream,

powder,

spray powder,

spray solution,

solution

BID

4

fungistatic

   undecylenic acid

 

5% to 25%

BID

4

fungistatic

   5% to 25%

Desenex®

cream,

powder,

powder spray,

liquid

 

 

 

Allylamines

   terbinafine

   1%

Lamisil AT®

cream,

spray solution,

gel

QD

1

fungicidal

Benzylamines

   butenafine

   1%

Lotrimin®

Ultra

cream

BID for
1 week,
then QD
for 4
weeks

5

fungicidal

 

* Shampoo is dosed differently, see container for proper use.

 

 

Table 2. Prescription Products for the Treatment of Tinea Pedis

Agent

Brand Names

Formulation

Dosing

Minimum
Effective
Duration

Comments

Azoles

   econazole 1%

Spectazole®

cream

QD

4

fungistatic

   oxiconazole 1%

Oxistat®

cream,
lotion

QD or BID

4

fungistatic

   sertaconazole 2%

ERTACZO®

cream

BID

4

fungistatic

   sulconazole 1%

Exelderm®

solution

BID

4

fungistatic

   itraconazole 200 mga

SPORANOX®

capsules,

oral

solution,

injection

QD-BID

1-4b

fungistatic

   fluconazole

   50 to100 mg

DIFLUCAN®

Tablets,
injection for
intravenous
infusion
only, oral
suspension

QD

4-6b

fungistatic

Allylamines

   naftifine 1%

NAFTIN®

cream,

gel

QDBID

4

fungistatic

   terbinafine 250 mga

LAMISIL®

tablets

QD po

2b

fungistatic
the most
effective
oral agent

Others

   ciclopirox 0.77%

Loprox®

Cream, gel,

lotion,

shampoo

BID

4

fungistatic

 

aNot FDA-approved for the treatment of Tinea pedis.

Source of tables 1 and 2: Gina J. Ryan PharmD, BCPS, CDE, Fostering Patient Adherence in the Management of Tinea Pedis

Oral Medications

     There are times when topical therapy is not enough. The doctor may choose to use or add on an antifungal oral medication. Itraconazole, terbinafine, and fluconazole come as oral tablets.

Tea Tree Oil

     There are many antifungal products that contain tea tree oil. Despite some reports, tea tree oil does not kill fungus. It is believed to help by instantly reliving the itch. Without the constant scratching, wounds heal faster by themselves.

 

Preventing Recurrence

 

     There is a high relapse rate for fungal infections.   As many as 70 to 80 percent of cases relapse. In my opinion, the two major reasons for this are poor hygiene and incomplete eradication of the existing fungal infection. Let me explain further.

 

     Remember that fungus invades under the skin.  The body tries to slough it off by over producing skin cells. That is the visual signs of infection. Most uninformed patients will treat the infection until all visible signs are gone. Unfortunately for those patients, there is still a full-blown infection going on that they can’t see.  So, in essence, they never really cure themselves in the first place and the infection comes roaring back.

 

 The key to preventing recurrence is proper education and regular inspections.

 Teach proper hygiene techniques to your staff, family, and clients.

Reinforce and reward good efforts.

Tell patients about how they might still be infected and to continue therapy long after all visible signs of the fungus amongus are gone.

The rule of thumb is fungistatic meds require two-four additional weeks and fungicidal treatments require one week after all visible signs are gone. 

Regular inspection of the home and patient is just good patient care.

                                           

     If despite your best efforts the infections keep coming back, then most likely the patient is getting re-infected from an outside source. Check for pets or neighborhood animals with balding spots (possibly an active fungal infection). Look for moldy spots in their environment. If you can’t identify or illuminate the source, you may have to use antifungal powders on a continual basis as a preventative measure. Getting a PRN order from the doctor would do the trick.

 

Noncompliance Issue

     One more piece of patient information for you. If there is an open fissure or wound, antifungal treatments will sting - sometimes a lot. Warn your patients beforehand and inform them that the sting will go away as the body heals. If noncompliance because of pain becomes an issue, you might ask the doctor for a topical steroid cream or tea tree oil.  

 

Conclusion

 

     The fungus amongus may be common in the general population, but it doesn’t have to be prevalent in your home. With proper hygiene and patient care technique, you can completely eliminate it from your home. In the end, it will be one less thing for you to worry about.

Good luck in your efforts.

 

 

References:

1. What is a Dermatologist?, Consumers' Research Council of America.

http://www.consumersresearchcncl.org/Healthcare/Dermatologists/derma_chapter1.html

2. Gina J. Ryan PharmD, BCPS, CDE. Michael Cantrell, DPM. Fostering Patient Adherence in the Management of Tinea Pedis, Apr 10. 2010. Power-pakCE. 

http://www.powerpak.com/course/preamble/106739

3. Athlete’s Foot. Health Spot.

http://www.ihealthspot.com/Home/PatientEducation/FamilyPractice/tabid/10431/ctl/View/mid/17218/Default.aspx?ContentPubID=940

4. Athlete’s Foot. Wikipedia The Free Encyclopedia.

http://en.wikipedia.org/wiki/Athlete's_foot

5. Guha Krishnaswamy, James H. Quillen. Dermatology for the practicing allergist: Tinea pedis and its complications.  Mar.29,2004. Clinical and Molecular Allergy.

http://www.clinicalmolecularallergy.com/content/2/1/5

6. Jock Itch. PubMed Health, U.S. National Library of Medicine.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001879/

7. Onychomycosis. Wikipedia The Free Encyclopedia.

http://en.wikipedia.org/wiki/Onychomycosis

8. Tinea Capitis. PubMed Health, U.S. National Library of Medicine.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001881/

9. Ringworm. PubMed Health, U.S. National Library of Medicine.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002411/

10. Athlete’s Foot (Tinea Pedis). Our Health Network.Com

http://www.ourhealthnetwork.com/conditions/FootandAnkle/AthletesFoot.asp

11. Epidermis. Wikipedia The Free Encyclopedia.                           

http://en.wikipedia.org/wiki/Epidermis_(skin)

12. A Brief Guide to Mold, Moisture, and Your Home. U.S. Environmental Agency.

http://www.epa.gov/mold/cleanupguidelines.html

13. How to Disinfect Used Shoes. WikiHow.com.

http://www.wikihow.com/Disinfect-Used-Shoes

14. Tisha Tolar. How to Disinfect Showers for Athlete's Foot. eHOW.com.

http://www.ehow.com/how_5681103_disinfect-showers-athlete_s-foot.html

15.  Mary Marlowe Leverette. How to Prevent Spread of Athlete's Foot in Laundry. About.com

http://laundry.about.com/od/laundrybasics/a/athletesfootlaundry.htm

16.  Ivan Bristow, Manfred Mak. Fungal foot infection: the hidden enemy?  Wounds uk, 2009, Vol 5, No 4

http://www.woundsinternational.com/pdf/content_9316.pdf

 

 The Fungus Amongus

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