E.Tinea versicolor responds to topical therapies, such as
terbinafine, econazole, ketoconazole, and selenium sulfide
lotion or shampoo (Exsel, Head & Shoulders, Selsun).
Recurrences may be less frequent if a short course of oral
itraconazole (Sporanox) is instituted.
VIII.Cutaneous Candidiasis
A.Cutaneous candidiasis is caused by C albicans. Other
candidiasis infections include angular cheilitis (perlèche),
erosio interdigitalis blastomycetica, candidal intertrigo,
balanitis, vaginitis, and paronychia. Involvement of the
skinfolds is most common, but any area of the skin with
increased moisture is susceptible.
B.Wearing of occlusive clothing, obesity or disorders
affecting the immune system (eg, diabetes, AIDS) may
increase susceptibility to candidal infection.
C.Candidal skin infection often presents with erythema,
cracking, or maceration. When maceration develops in the
web spaces of the fingers, the skin can become soft and
white. Candidal skin infection is characterized by irregular
(serrated) edges, tissue erythema, and satellite lesions.
D.In patients with normal immunity, candidiasis is most
often treated with topical therapy. Commonly used topical
agents include nystatin (Mycostatin), ketoconazole,
miconazole, and clotrimazole. Therapy with oral
fluconazole (Diflucan) is highly effective.
References: See page 255.
Paronychia, Herpetic Whitlow, and
Ingrown Toenails
I.Paronychia
A.Paronychia is an inflammation involving the lateral and
posterior fingernail folds. Predisposing factors include
overzealous manicuring, nail biting, diabetes mellitus, and
frequent immersion in water. Paronychia also is associated
with antiretroviral therapy for HIV infection.
B.Paronychia may be either acute or chronic. Acute
paronychia is caused by staphylococcus aureus, and it is
characterized by the onset of pain and erythema of the
posterior or lateral nail folds, with development of a
superficial abscess. Chronic paronychia represents an
eczematous condition.
C.Treatment
1.Acute paronychia. Therapy of acute paronychia
includes local care (warm compresses or soaks for 20
minutes, three times per day) and antibiotic therapy. An
antistaphylococcal agent such as dicloxacillin (250 mg
TID) or cephalexin (Keflex) [500 mg BID to TID]) for
seven to ten days is the preferred therapy. An alternative
is erythromycin 333 mg TID or azithromycin (Zithromax
[500 mg on day one, followed by 250 mg per day for four
days]). incision and drainage is necessary if an abscess
is present.
2.Chronic paronychia. Patients should be advised to
keep their hands as dry as possible and to use gloves
for all wet work. Patients should avoid irritant or allergen
exposure. Chronic paronychia is an eczematous
process, and Candida infection is a secondary phenom-
enon. Thus, the treatment should be a topical
corticosteroid, such as triamcinolone 0.1% ointment.
Comparison of Acute and Chronic Paronychia
Features Acute Chronic
Clinical Red, hot, tender Swollen, tender, red
appear- nail folds, with or (not as red as
ance without abscess acute), boggy nail
fold; fluctuance rare
People at People who bite People repeatedly
high risk nails, suck fingers, exposed to water or
experience nail irritants (e.g., bar-
trauma (manicures) tenders, housekeep-
ers, dishwashers)
Pathogens Staphylococcal Candida albicans (95
aureus, strepto- percent), atypical
cocci, Pseudomo- mycobacteria,
nas, anaerobes gram-negative rods
Treatment Warm soaks, oral Avoidance of water
antibiotics and irritating sub-
(clindamycin stances; use of topi-
[Cleocin] or cal steroids and
amoxicillinnclavulan antifungal agents;
ate potassium surgery
[Augmentin]); spon-
taneous drainage, if
possible; surgical
incision and drain-
age
II.Herpetic Whitlow
A.Herpetic whitlow (herpes simplex virus infection of the
finger) occurs as a complication of primary oral or genital
herpes infection via a break in the skin. It also occurs in
medical personnel who have contact with oral secretions.
Herpetic whitlow is characterized by erythema, swelling,
pain, and vesicular or pustular lesions.
B.The diagnosis of herpetic whitlow is suspected by an
exposure history as well as the presence of vesicles.
Tzanck smear reveals multinucleated giant cells.
C.Treatment consists of oral acyclovir (Zovirax [400 mg
TID]) for ten days A topical antibiotic cream, such as
bacitracin, may help to prevent secondary bacterial
infection.
III.Ingrown Toenail
A.Ingrown toenails occur when the lateral nail plate pierces
the lateral nail fold. The great toenail is most commonly
affected. Signs and symptoms include pain, edema,
exudate, and granulation tissue. Predisposing factors
include poorly fitting shoes, excessive trimming of the
lateral nail plate (pincer nail deformity), and trauma.
B.Treatment
1.The lateral nail plate should be allowed to grow well
beyond the lateral nail fold before trimming horizontally.
Patients should wear well-fitting shoes.
2.Mild-to-moderate lesion
a.Mild-to-moderate lesions are characterized by
minimal to moderate pain, little erythema, and no
discharge.
b.Place a cotton wedging or dental floss underneath
the lateral nail plate to separate the nail plate from the
lateral nail fold, thereby relieving pressure.
c.Soak the affected foot in warm water for 20 minutes,
three times per day.
3.Moderate-to-severe lesion
a.Moderate-to-severe lesions are characterized by
substantial erythema and pustular discharge. Treat-
ment consists of the following:
Anesthetize the area with lidocaine 1% without
epinephrine.
Using nail-splitting scissors or a hemostat, insert
the instrument under the nail plate and remove the
involved nail wedge with nail clippers or scissors.
Remove any granulation tissue with a curette
and/or silver nitrate sticks.
Dilute hydrogen peroxide 1:1 with tap water and
cleanse the site 2 or 3 times a day, followed by
application of either bacitracin or mupirocin
ointment. [ Pobierz całość w formacie PDF ]