Rosen & Barkin's 5-Minute Emergency Medicine Consult (716 page)

• Ciclopirox 8% nail lacquer: Apply to the affected nails daily, max. 48 wk; remove with alcohol every 7 days (peds: Same).
  
• Clotrimazole: Apply 1% cream to affected area BID for 4–6 wk (peds: Same).
  
• Fluconazole: Tinea unguium—150–300 mg/wk pulse therapy for 3–6 mo for fingernails, 6–12 mo for toenails; tinea corporis, cruris, and pedis: 150 mg PO weekly for 4–6 wk; tinea versicolor: 400 mg PO single dose (peds: 6 mg/kg/d for 3–6 wk for tinea capitis)
  
• Griseofulvin: Tinea capitis, corporis, cruris—500 mg PO QD for 4–6 wk (peds: 10–20 mg/kg up to 500 mg PO QD until the hair regrows, usually 6–8 wk)
  
• Itraconazole: Tinea capitis: Adults and peds: 3–5 mg/kg PO QD for 2–4 wk; tinea unguium: 200 mg PO QD for 3 mo; tinea versicolor: 400 mg PO QD for 3–7 days; contraindicated in CHF
  
• Ketoconazole: 2% topical cream QD for 4–6 wk; tinea capitis, corporis, cruris, pedis—200 mg PO QD for 4 wk (peds: 3.3–6.6 mg/kg PO QD for 4 wk); tinea versicolor—400 mg PO ×1 or 200 mg QD for 7 days (contraindicated with terfenadine and astemizole); soda increases absorption 65%
  
• Miconazole: Apply cream to affected area BID for 4–6 wk (peds: Same)
  
• Selenium sulfide: 2.5% shampoo to affected area for 10 min for 1–2 wk (peds: Same)
  
• Terbinafine: 1% topical cream BID
  for 4–6 wk for tinea pedis QD for tinea corporis and tinea cruris; tinea unguium—250 mg PO QD for 6 wk for fingernails, 12 wk for toenails (peds: <20 kg,
  67.5 mg/d; 20–40 kg, 125 mg/d; >40 kg, 250 mg/d at same interval as adult); tinea pedis: 250 mg PO per day for 2 wk; tinea capitis: 250 mg/d for 4 wk (dose by weight as for tinea unguium for 4 wk)
  
• Tolnaftate: Apply 1% cream/powder/solution to the affected area BID for 4–6 wk (peds: Same)
  

Topical preparations are preferred when possible

• Few studies addressing the use of antifungal medications during pregnancy in humans
  
• Some of the imidazoles have shown adverse effects in animals – class C (fluconazole, itraconazole, ketoconazole)
  
• Clotrimazole, miconazole, and terbinafine are class B drugs
  
• Weigh risk: Benefit as elective antifungal therapy generally not recommended.
  

• Tinea capitis: Terbinafine
  
• Tinea corporis, cruris, pedis: Topical terbinafine or imidazoles (ketoconazole, miconazole, and clotrimazole)
  
• Tinea versicolor: Selenium sulfide shampoo and topical ketoconazole
  

FOLLOW-UP

• Invasive disease in immunocompromised host
  
• Kerion with secondary bacterial infection
  

• Most patients may be managed as outpatients
  
• Children may return to school once appropriate treatment has been initiated
  

Patients started on oral antifungals should be referred for follow-up to monitor therapy and advised regarding symptoms of hepatitis

• Monitor for bacterial superinfection, cellulitis, generalized invasive infection:
  
  • Especially in immunocompromised (diabetics, HIV patients)
    

• Tinea capitis is the most common pediatric dermatophyte infection
  
• Itching is the main symptom in most forms of tinea, with associated hair loss in tinea capitis
  
• Cellulitis frequently complicates of tinea pedis
  
• Relapse of tinea pedis/cruris is common
  
  • Patients should wash or replace contaminated socks/towels/footwear
    

• González U, Seaton T, Bergus G, et al. Systemic antifungal therapy for tinea capitis in children.
  Cochrane Database Syst Rev
  . 2007;(4):CD004685.
  
• Kelly BP. Superficial fungal infections.
  Pediatr Rev.
  2012;33:e22–e37.
  
• Moriarty B, Hay R, Morris-Jones R. The diagnosis and management of tinea.
  BMJ
  . 2012;345:e4380.
  
• Rashid RM, Miller AC, Silverberg, MA. Tinea in Emergency Medicine. May 9, 2011.
  http://emedicine.medscape.com/article/787217-overview
  .
  
• Zhang AY, Camp WL, Elewski BE. Advances in topical and systemic antifungals.
  Dermatol Clin
  . 2007;25:165–183.
  

CODES

• 110.0 Dermatophytosis of scalp and beard
  
• 110.1 Dermatophytosis of nail
  
• 110.5 Dermatophytosis of the body
  

BASICS

• Prototypical volatile hydrocarbon
  
• Clear, colorless liquid with sweet odor
  

• Abused for its euphoric effect
  
• Occupational exposures
  
• Used as organic solvent found in:
  
  • Oil paints and stains
    
  • Paint thinners
    
  • Glues, inks, dyes, correction fluid
    
  • Coolants
    
  • Petroleum products
    
  • Aerosolized household products
    
  • Degreasers
    
• Production and use of gasoline is largest source of exposure
  

• Prevalent in adolescent age group:
  
  • Inexpensive “high” with readily available sources
    
  • Many psychosocial problems
    
• May develop chronic neurologic dysfunction
  
• Mechanism:
  
  • Rapidly absorbed by inhalation
    
  • Readily crosses blood–brain barrier, reaching high concentrations in brain
    
  • May sensitize myocardium to dysrhythmogenic effect of catecholamines
    
  • Inhibits myocardial voltage-gated sodium channels and inward rectifying potassium channels
    
  • Alveolar excretion and liver metabolism
    
• Methods of intoxication:
  
  • Sniffing: Simple inhalation of substance directly from container
    
  • Huffing: Vapors inhaled through cloth saturated with substance
    
  • Bagging: Vapors inhaled from bag containing substance
    
• Toxic range:
  
  • 100 ppm: Impairment of psychomotor and perceptual performance
    
  • 500–800 ppm: Headache, drowsiness, nausea, weakness, and confusion, potential lethal ranges
    
  • >800 ppm: Convulsions, ataxia, staggering gait
    
  • 10,000–30,000 ppm: Anesthesia within 1 min
    

DIAGNOSIS

• Acute:
  
  • Neurologic:
    
    • Depression
      
    • Euphoria
      
    • Ataxia
      
    • Dizziness
      
    • Seizures
      
  • Cardiac:
    
    • Fatal dysrhythmias
      
  • Pulmonary:
    
    • Chemical pneumonitis
      
    • Pulmonary edema
      
  • Electrolytes:
    
    • Hypokalemia
      
    • Hypocalcemia
      
    • Hyperchloremic metabolic acidosis, likely from hippuric acid metabolite
      
  • GI:
    
    • Abdominal pain
      
    • Nausea, vomiting
      
    • Hematemesis
      
  • Renal:
    
    • Distal renal tubular acidosis
      
    • Hematuria
      
    • Proteinuria
      
  • Musculoskeletal:
    
    • Diffuse weakness
      
• Chronic:
  
  • Neurologic:
    
    • Peripheral neuropathy (diffuse demyelination)
      
    • Leukoencephalopathy
      
    • Cerebral/cerebellar atrophy
      
    • Optic atrophy
      
    • Dementia
      
    • Cognitive/neurobehavioral abnormalities
      
  • Cardiac:
    
    • Dysrhythmias
      
    • Dilated cardiomyopathy
      
  • Renal:
    
    • Distal renal tubular acidosis
      
    • Renal failure
      
    • Fanconi syndrome
      
  • Musculoskeletal:
    
    • Rhabdomyolysis
      
  • Psychiatric:
    
    • Addiction/withdrawal
      

• Fetal solvent syndrome reported from mothers who chronically abused toluene while pregnant, resembles fetal alcohol syndrome
  
• Infant more likely premature, low birth weight, microcephaly, and developmental delay
  

• Detailed history of sniffing, huffing, bagging, or other abuse of paints/solvents
  
• Occupational exposures
  

• Presence of agent on lips, nose, or clothes (metallic paint has highest concentration)
  
• Perioral eczematous dermatitis from chronic huffing or bagging
  
• Odor of agents