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U N I T 1 3
Integumentary Function
Treatment of more severe cases usually requires oral
antifungal therapy, such as terbenafine, administered
for several months.
8
All of the oral agents require
careful monitoring for side effects. A nail lacquer con-
taining the antifungal agent ciclopirox is available for
use in the topical management of mild to moderate
infections of the fingernails and toenails caused by
T. rubrum
. A new nail may require 3 to 12 months
to grow. Thus, people being treated with antifungal
agents need to be reminded that the resolution of the
infection requires 4 to 6 months for fingernails and
longer for toenails.
Dermatophytid Reaction.
A secondary skin eruption
may occur in persons allergic to the fungus respon-
sible for the dermatophytosis. This dermatophytid or
allergic reaction may occur during an acute episode of
a fungal infection. The most common reaction occurs
on the hands in response to tinea pedis. The lesions
are vesicles with erythema extending over the palms
and fingers, sometimes extending to other areas (Fig.
46-5). Less commonly, papules or vesicles erupt on the
trunk or extremities. These eruptions may resemble
tinea corporis. Lesions may become excoriated and
infected with bacteria. Treatment is directed at the
primary site of infection. The intradermal reaction
resolves in most cases without intervention if the pri-
mary site is cleared.
Candidal Infections.
Candidiasis (moniliasis) is a fun-
gal infection caused by
C. albicans
. This yeastlike fun-
gus is a normal inhabitant of the gastrointestinal tract,
mouth, and vagina (see Chapter 41). The skin prob-
lems result from the release of irritating toxins on the
skin surface.
C. albicans
is almost always found only
on the surface of the skin; it rarely penetrates deeper.
Some persons are predisposed to candidal infections by
conditions such as diabetes mellitus, antibiotic therapy,
pregnancy, oral contraceptive use, poor nutrition, and
immunosuppressive diseases.
9
Oral candidiasis may be
the first sign of infection with human immunodeficiency
virus (HIV).
Candida albicans
thrives on warm, moist, intertrigi-
nous areas (i.e., between folds or adjacent surfaces) of
the body. The rash is red with well-defined borders.
Patches erode the epidermis, and there is scaling. Mild
to severe itching and burning often accompany the
infection. Severe forms of infection may involve pus-
tules or vesiculopustules as well as maculopapular
satellite lesions found outside the clearly demarcated
borders of the candidal infection. Satellite lesions often
are diagnostic of diaper rash complicated by
Candida
.
The appearance of candidal infections varies according
to the site (see Chapter 41 for a discussion of vaginal
candidiasis).
Diagnosis usually is based on microscopic examina-
tion of skin or mucous membrane scrapings placed in a
KOH solution. Treatment measures vary according to
the location. Preventive measures such as wearing rub-
ber gloves are encouraged for persons with infections of
the hands. Intertriginous areas often are separated with
clean cotton cloth and allowed to air dry as a means of
decreasing the macerating effects of heat and moisture.
Topical and oral antifungal agents, such as clotrima-
zole, econazole, ketoconazole, and miconazole, are
used in treatment depending on the site and extent of
involvement.
Bacterial Infections
Bacteria are considered normal flora of the skin. Most
bacteria are not pathogenic, but when pathogenic bac-
teria invade the skin, superficial or systemic infections
may develop. Bacterial skin infections are commonly
classified as primary or secondary. Primary infections are
superficial skin infections such as impetigo. Secondary
infections consist of deeper cutaneous infections, such
as infected ulcers. Diagnosis usually is based on cultures
taken from the infected site. Treatment methods include
antibiotic therapy and measures to promote comfort
and prevent the spread of infection.
Impetigo.
Impetigo is a common, superficial bacterial
infection caused by staphylococci, group A
β
-hemolytic
streptococci, or both.
10
It is common among infants
and young children, although older children and
adults occasionally contract the disease. Impetigo
initially appears as a small vesicle or pustule or as a
large bulla on the face or elsewhere on the body. As
the primary lesion ruptures, it leaves a denuded area
that discharges a honey-colored serous liquid that dries
as a honey-colored crust with a “stuck-on” appearance
(Fig. 46-6). New vesicles erupt within hours. Pruritus
often accompanies the lesions, and skin excoriations
that result from scratching multiply the infection sites.
Although a very low risk, a possible complication of
untreated streptococcal impetigo is poststreptococcal
glomerulonephritis (see Chapter 25). Topical mupirocin
FIGURE 46-5.
Dermatophytid or id reaction on the fingers due
to a tinea infection. An id immunologic reaction, also known
as autoeczematization, is an itchy, vesicular rash produced
in response to an intense inflammatory process that can be
located in another region of the body. (From the Centers for
Disease Control and Prevention Public Health Image Library.
No. 4805.)
