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Pediatric Fungal Infections

W. Steven Pray, PhD, DPh
Bernhardt Professor, Nonprescription Products and Devices
College of Pharmacy
Southwestern Oklahoma State University

Weatherford, Oklahoma

Gabriel E. Pray, PharmD
Walmart Pharmacy

Edmond, Oklahoma



5/16/2014


US Pharm
. 2014;39(5):8-11.

Parents of infants and young children are justifiably concerned about any medical condition they notice in their child. Some of these conditions, such as common fungal infections, are minor and may be self-treated, while others should be referred to a physician. Pharmacists should be prepared to provide appropriate counseling to parents in these situations.

Tinea Corporis

Tinea corporis is also known as tinea circinata or “ringworm” of the body.1 It is one of a group of fungal infections, closely related to tinea pedis (athlete’s foot) and tinea cruris (jock itch).2 The dermatophytic fungi responsible for these infections include Epidermophyton floccosum and Microsporum canis. These and the other fungal pathogens all proliferate in conditions of high temperature and high humidity, making them more common in regions of the globe with warmer climates, such as tropical and subtropical areas.2

Whereas tinea pedis and tinea cruris are more common in postpubertal patients, tinea corporis is more common in those who are prepubertal. Person-to-person contact can spread the infection.3 Common sites for contracting ringworm include day care centers and any location where children gather to engage in activities involving skin contact, such as summer camps. Contact with contaminated fomites is also responsible for transmission.3

Tinea corporis is also caused by a set of pathogens that are common on animal skin; thus, another way it is contracted is through petting and playing with a dog or cat. Kittens and puppies are especially likely to pass the infection.4 Other animal vectors identified by the CDC are cows, goats, pigs, and horses.

Given these modes of dissemination, the epidemiologic preference for children is logical. Younger children are more likely to engage in activities that transfer fungi, such as play involving skin-to-skin contact and petting strange kittens or puppies that roam their neighborhood.

Other factors also increase risk of infection. Patients who already have tinea pedis or tinea cruris are more likely to develop tinea corporis, as the fungi spread to any area where conditions are favorable for growth. Wearing tight clothing and having excess body weight are also contributory.2

The locations involved with tinea corporis are the face, trunk, and extremities.2 The condition excludes the feet, scalp, groin, and hands, as tinea infections in these locations are given other designations (e.g., tinea pedis, capitis, cruris, and manuum). The fungi penetrate the skin at an initial entry point and begin to live on the upper layer of dead skin scales (stratum corneum).5 Patients may initially notice a flat, scaly area. The fungi grow outward in a roughly circular manner from the initially infected area. The leading edge of growth is inflamed, reddened, and raised slightly above the surrounding skin. As the growth line expands outward, the skin in the central portion of the lesion may begin to appear more normal.2 The result is often a ring of red, inflamed skin sharply differentiated from the uninfected skin, often with a more healthy-looking center. This characteristic presentation reflects the old notion that there is a worm beneath the skin, circling in on itself.6 What appears as a worm is in reality the active growth margin. Infected patients often complain that the rash is pruritic.

Treatment: Several non-prescription products can be recommended for treatment of tinea corporis. Patients should be advised to apply these to external skin as directed after cleaning the area with a mild soap; to keep them away from the eyes; and to supervise children who require them. First-generation antifungals are applied twice daily for 4 weeks to effect a cure of tinea corporis, and they should not be used in anyone aged <2 years. Ingredients in this class include undecylenic acid (e.g., Fungi Cure Liquid), tolnaftate (e.g., Tinactin), miconazole (e.g., Micatin Cream), and clotrimazole (e.g., Lotrimin AF).2

Second-generation antifungals are characterized by shorter times to cure for tinea corporis and also by more restrictive age cutoffs. Terbinafine (e.g., Lamisil AT) cures tinea cruris if used once daily for 1 week. Butenafine (e.g., Lotrimin Ultra Cream) cures tinea corporis if used once daily for 2 weeks. They should not be used for tinea corporis in those aged <12 years.2

Pharmacists should avoid products that claim to be safe and effective for tinea corporis but are lacking in evidence. One is Blue Star Ointment, which contains a mix of ingredients (i.e., salicylic acid, methyl salicylate, menthol, camphor, benzoic acid, lanolin, aloe vera), none of which is FDA-approved as safe and effective for curing tinea corporis.7


Oropharyngeal Candidiasis (Thrush)

Oral candidiasis, often called thrush, is a common pediatric fungal infection with an attack rate of 5% to 7% in infants aged >1 month.8 It is not common in healthy adults, although risk factors include HIV/AIDS, chemotherapy, diabetes, dentures, and therapy with inhaled corticosteroids or broad-spectrum antibiotics.8,9

Candida is a normal resident of the mucous membranes.10 Any condition that would cause the intraoral microbiologic environment to become imbalanced may lead to candidal overgrowth. An inciting factor in pediatric patients is administration of broad-spectrum antibiotics. Antibiotic-induced death of intraoral bacterial species allows the opportunistic Candida to overgrow.11

Manifestations of oropharyngeal candidiasis include creamy or velvety white, slightly elevated patches or plaques on the oral mucosa (e.g., inner cheek, gingiva, palate, tonsils) and tongue. They may look like cottage cheese and adhere to the area to which they are attached; scraping them away may reveal a bleeding raw area of tissue.11 The lesions are often painful, and if left untreated, infected areas increase in number and size. The child may have difficulty swallowing, and there may be cracking at the corners of the mouth.12

Diagnosis and Treatment: Oropharyngeal candidiasis should be diagnosed by the physician through direct visual examination of the affected areas, microscopic examination of a collected sample, or culture.13 If oral candidiasis is confirmed, the physician may choose to wait, as thrush in infants often resolves on its own within 2 weeks.11 However, if the time of involvement exceeds 2 weeks, treatment is essential to prevent serious sequelae.14 Physicians may prescribe nystatin suspension for any age or clotrimazole troches in children old enough to use them properly.14

Since pharmacists are prohibited by their state practice acts from diagnosing medical conditions,15 it is most appropriate to refer patients with suspected thrush to a physician for a firm diagnosis and prescription when needed. When a thrush infection is confirmed in infants, pharmacists can recommend that parents sterilize or discard all pacifiers.11 Furthermore, if the baby is bottle-fed, parents should be advised to discard all nipples and purchase new ones.

Diaper Rash

Diaper rash is an irritant derma-titis that affects infants, most commonly those aged between 4 and 15 months.16 Loose stools are the primary cause of diaper rash, and babies who are breastfed experience more frequent bowel movements and softer stools than those fed cow’s milk, which may increase the risk of diaper rash.17 On the other hand, many parents notice diaper rash more frequently when their baby begins to ingest solid food.16

Several factors coalesce to damage infant skin and cause diaper dermatitis. First is that the diaper is an occlusive dressing, allowing the skin beneath to break down more readily in certain circumstances.2 Also, when urine is in sustained contact with skin, it allows ammonia within the urine to raise the skin pH. If stool is also present in the diaper, the higher pH reactivates skin-destructive enzymes in the fecal material.

The simplest and safest method to treat diaper rash is liberal application of petrolatum. Powders have a potential risk of causing deadly inhalation pneumonia in babies if a cloud of powder surrounds the baby’s nose and mouth.2 A general rule is to refer the baby to a pediatrician if the skin is broken, and especially if the child has acnelike lesions, blebs, ulcerations, large bumps, or pustules.16 Parents should also seek professional care if the rash worsens or does not improve in 2 to 3 days, if it spreads to the abdomen, back, arms, or face, or if the baby develops a fever.16

Fungal Infection: Diaper rash may become infected with Candida.16 Candida, like superficial tineas, prefers warm, moist locations on the body. The area beneath a diaper has all of the elements preferred by Candida—warmth from body heat and moisture from urine. While uncomplicated diaper rash is erythematous and inflamed, when Candida invades the skin, the color changes to a beefy or bright red, and the child cries violently after urinating, as urine causes a great deal of discomfort. Parents may also notice smaller red lesions (referred to as satellite lesions) that eventually grow to merge with the larger central lesions.

No antifungal nonprescription product is known to be safe and effective for unsupervised use in diaper dermatitis infected with Candida.2 First- and second-generation topical antifungals are only indicated for superficial tineas. Vaginal antifungals are only indicated for Candida in the vagina.

If the pharmacist suspects the presence of diaper dermatitis infected with Candida, a referral for a physician diagnosis is mandatory. The physician can then prescribe a specific antifungal to cure the condition.

PATIENT INFORMATION


What Is Ringworm?

Ringworm (tinea corporis) is a fungal skin infection that can affect just about anyone of any age, although it is more common in children.

What Are Some of the Common Causes?

To get ringworm, you must first come into contact with the fungi that cause it. You may contract the infection by touching a person, animal, or object with the organism on it. Pets, shower and pool surfaces, and combs are all common sites that carry these fungi. The fungi that cause ringworm are able to thrive on warm, wet parts of the skin. This includes areas prone to sweating (under the arms or beneath the breasts) and areas not bathed often. Fungi that have reached the skin can penetrate damaged skin to begin an actual infection. Once they have become inoculated into the broken skin areas, they spread quickly.

What Are the Symptoms?

The original infection looks like red spots, but as it progresses it resembles its namesake and begins to look like a red circle, or “ring,” with a less inflamed center. The only other major symptom commonly observed is itching.

How Do I Know If It Is Ringworm?

A healthcare provider usually can tell you whether it is ringworm by a simple observation of the skin. Occasionally a skin scraping, which is sent to a laboratory, may be done, but this is uncommon.

How Do I Treat It?

Try to keep the skin dry, as the fungi enjoy moist environments, and consult your pharmacist for an antifungal product. Generally, OTC creams will take care of the infection (e.g., Lamisil, Lotrimin, Micatin, Tinactin), but sometimes oral medication is necessary. Follow all the directions on any product before, during, and after use. If treatment is successful, most infections are eradicated within 4 weeks.

How Do I Stop It From Spreading to Others?

Because showers and pool areas are so likely to harbor the fungi, many infections are contracted in these areas. Wearing foot coverings in community showers or pools will help prevent transmission. Wash your towels with soap, dry them well, and use a new towel each time to ensure that towels are not consistently wet.

If you have fungal infections in other areas, such as athlete’s foot, make sure not to dry the body with towels that have already touched the feet. If your child has ringworm, he or she can return to school after you have begun treatment. Pets should be treated if they are also infected. Steer clear of stray animals to help avoid transmission.

When Should I Contact My Healthcare Provider?

Ringworm does not usually go away on its own. If you have any questions upon presentation with these symptoms or during treatment, or you do not believe self-treatment is working, you should contact your healthcare provider.

Remember, if you have questions, Consult Your Pharmacist.

REFERENCES

1. Definition of dermatophytes (ringworm). CDC. www.cdc.gov/fungal/diseases/dermatophytes/definition.html. Accessed March 28, 2014.
2. Pray WS. Nonprescription Product Therapeutics. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2006.
3. Ringworm. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/001439.htm. Accessed March 28, 2014.
4. Ringworm and animals. CDC. www.cdc.gov/healthypets/diseases/ringworm.htm. Accessed March 28, 2014. 
5. Tinea corporis. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/000877.htm. Accessed March 28, 2014.
6. Tinea infections. MedlinePlus. www.nlm.nih.gov/medlineplus/tineainfections.html. Accessed March 28, 2014.
7. Blue Star Ointment. CVS/pharmacy. www.cvs.com/shop/product-detail/Blue-Star-Ointment?skuId=630681. Accessed March 28, 2014.
8. Oral candidiasis statistics. CDC. www.cdc.gov/fungal/diseases/candidiasis/thrush/statistics.html. Accessed March 28, 2014.
9. Oropharyngeal/esophageal candidiasis (“thrush”). CDC. www.cdc.gov/fungal/diseases/Candidiasis/thrush/. Accessed March 28, 2014.
10. Definition of oral candidiasis. CDC. www.cdc.gov/fungal/diseases/candidiasis/thrush/definition.html. Accessed March 28, 2014.
11. Thrush. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/000626.htm. Accessed March 28, 2014.
12. Symptoms of oral candidiasis. CDC. www.cdc.gov/fungal/diseases/candidiasis/thrush/symptoms.html. Accessed March 28, 2014.
13. Diagnosis and testing of oral candidiasis. CDC. www.cdc.gov/fungal/diseases/candidiasis/thrush/diagnosis.html. Accessed March 28, 2014.
14. Treatment & outcomes of oral candidiasis. CDC. www.cdc.gov/fungal/diseases/candidiasis/thrush/treatment.html. Accessed March 28, 2014.
15. Talking to the pharmacist. KidsHealth. http://kidshealth.org/parent/general/body/pharmacist.html. Accessed April 14, 2014.
16. Diaper rash. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/000964.htm. Accessed March 28, 2014.
17. Weaver LT, Ewing G, Taylor LC. The bowel habits of milk-fed infants. J Pediatr Gastroenterol Nutr. 1988;7:568-571.
18. Newman J. Using gentian violet. Pregnancy & childbirth. About.com. http://pregnancy.about.com/cs/breastfeedinginfo/a/aanho6.htm. Accessed April 14, 2014.

To comment on this article, contact rdavidson@uspharmacist.com.

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