Fungal infections

Dermatology Nursing, April, 2008 by Marcia J. Hill

* Fungal infections include dermatophytes, tinea versicolor, and candidiasis.

* Dermatophytes are known as tineas and are superficial infections of the skin, and are responsible for the vast majority of skin, hair, and nail infections.

* They invade the skin and survive on dead keratin (stralama corneum).

* They cannot survive on mucosal surfaces which are devoid of keratin.

* Some patients may have genetic predisposition to dermatophyte infections.

* Lesions vary in presentation and may resemble other dermatoses leading to misdiagnosis.

* Classifications include genera, anthropophilic, geophilic, and zoophilic.

* Classifications are by body region: tinea corporis (nonhairy parts of body, face, neck, and extremities); tinea cruris (groin, inner thighs); tinea capitis (scalp); tinea pedis (feet); and tinea unguium (toenails, fingernails).

* Characterized by an annular lesion with active border of infection and central clearing.

* Vesicles are present in severe inflammation.

* Treatments include anti-infectives and topical agents.

* Tinea versicolor (pityriasis versicolor, tinea flava) is a superficial, chronic fungal infection seen on the upper think, arms, or neck.

* It is caused by Pityrosporum orbiculare (Malassezia furfur).

* Some factors contributing to fungal proliferation are heat/humidity, Cushing's disease, pregnancy, malnutrition, oral contraceptives, and immunosuppression.

* It is characterized by lesions and distribution.

* Postpubertal and mature individuals are more susceptible.

* Pruritus may be present.

* Some clinical manifestations are multiple, small, circular macules of varying color; lesions enlarge radially.

* Lesions may be slightly scaly, papular, nummular, and confluent; red to fawn-colored macules, patches, or follicular papules.

* Diagnostic tests include KOH, Wood's lamp, and, rarely, fungal culture.

* Topical treatments include selenium sulfide shampoo, sodium thiosulfate, miconazole, ketoconazole, sulfur-salicylic shampoo, zinc pyrithione shampoo, and keratolytic soaps.

* Systemic treatment includes ketoconazole.

* Nursing considerations are shown in Table 1.

* Candidiasis (moniliasis, thrush) is a skin, mucous membrane, and internal infection caused by proliferation of normal flora in the mouth, vaginal tract, and gut.

* Candida albicans, a yeast-like fungus, is the most common cause of superficial and systemic fungal infections.

* Some factors predisposing to proliferation of organisms are pregnancy, oral contraceptives, antibiotic therapy, diabetes, immunocompromised states, and topical steroids.

* Outer layers of epithelium of mucous membranes and stratum corneum of skin are affected.

* Candidiasis of moist areas includes vulvovaginitis and oral candidiasis.

* Intertrigo occurs in large skin folds; heat and moisture provide environment for proliferation of organisms.

* Clinical presentations include pustules and erythematous, moist, glistening plaques extending beyond the limits of opposing skin folds; painful fissuring can occur.

* Initial signs of candidiasis infections are pruritus and discharge.

* Satellite lesions may develop.

* Diagnostic tests include KOH, Wood's lamp, and fungal culture.

* Treatment for vulvovaginitis involves miconazole, clotrimazole, terconazole, or butoconazole vaginal cream; oral azoles; nystatin vaginal tabs; and gentian

* Oral candidiasis therapy includes nystatin oral suspension, clotrimazole troche, gentian violet, and oral azoles.

* Treatment for intertrigo consists of maintaining dryness, Burow's compresses, antifungal creams, absorbent powders, and oral azoles.

* Nursing considerations are shown in Table 1.

Marcia J. Hill, MSN, RN, is Dermatology Regional Clinical Coordinator, Genentech, Inc., Columbus, TX, and Editor, Dermatology Nursing.

Table 1.
Nursing Considerations for Patients with Cutaneous Infections

Nursing Diagnoses         Outcomes           Interventions

Impaired skin integrity   Skin integrity     Assess lesions, remove
related to inflammatory   has been           crusts or necrotic
process.                  improved or        material before applying
                          maintained.        medication; elevate and
                                             immobilize affected
                                             extremity as indicated
                                             (cellulitis/erysipelas).

High risk for impaired    Skin integrity     Instruct patient and
skin integrity related    is preserved.      significant others
to exudates.                                 regarding good handwashing
                                             technique; contain and
                                             eliminate exudates with
                                             appropriate dressings.

High risk for infection   No evidence        Instruct patient and
related to inadequate     of infection       significant other
primary or secondary      spread.            regarding importance
defenses.                                    of using good handwashing
                                             technique and appropriate
                                             disposal of dressings to
                                             avoid spread of infection;
                                             observe for signs of
                                             spreading infection;
                                             maintain good nutritional
                                             status.

Body image disturbance    Patient exhibits   Assess patient's percep-
related to presence of    improved/          tion of body image; allow
lesions.                  positive body      verbalization; give
                          image.             positive feedback.

Pain related to           Pain is            Assess level of discom-
infection.                relieved; need     fort; intervene appro-
                          for analgesics     priately to relieve any
                          is decreased.      discomfort (medications,
                                             elevation and immobili-
                                             zation, compresses).

Impaired mobility         Mobility is        Assess restriction in
related to pain and       increased.         mobility and cause;
edema.                                       elevate to help relieve
                                             edema.