Lynn Jennings, M.D.
Fungal disease can present in many ways - irritable bowel syndrome and recurrent sinus infections, to name just two. This month, I would like to talk about one of the more common presentations of fungal infection, dermatitis, (inflammation of the skin). Specifically I would like to talk about psoriasis. Didn’t know that psoriasis could be caused by fungus? Let’s begin.
Before we begin I must give this disclaimer: This case study is for educational purposes only. I am using it to show you how a typical patient presents and the things I consider when I make a diagnosis. The patient’s name has been changed to protect her identity. I practice integrative/alternative medicine and my diagnoses and recommendations for treatment are often considered outside traditional practice. My goal is to educate and hopefully answer questions you may have. Most importantly, the information provided here should not be used as a substitute for an examination and/ or treatment by a licensed health care provider.
Presenting illness: Mrs. November is a 63-year-old white female who presented for evaluation and treatment of “possible fungal disease.” She states that her skin problems started about one year ago. Mrs. November was working in her garden with some potting soil and shortly thereafter developed a small, red, raised, circular lesion on one of her fingers. Since then the lesion has become a “rash” and has spread to both of her hands, palms, and feet. Mrs. November has seen a dermatologist who has told her she has psoriasis and that she needs to learn to live with this. None of the topical treatments she has been given, (steroids), has had any lasting effect. She has times when her dermatitis improves a bit, and times when it “flares up.” Mrs. November has never had a problem like this before.
Past medical history: Mrs. November has a history of hypertension, (high blood pressure), and hypercholesterolemia, (high cholesterol).
Medications: None
Supplements: Mrs. November is on multiple supplements and vitamins including fish oil, Coenzyme Q10, magnesium, L-carnitine, B-complex, probiotics, zinc piccolinate, psyllium, protease/bromelain, an arthritis formula supplement, and a skin detox supplement.
Allergies: No known drug or food allergies
Past surgical history: The only reported surgery is a laparotomy for an ectopic pregnancy many years ago.
Social history: Mrs. November is married, and lives in the country. She is retired. She does not smoke or drink alcohol. For exercise she walks and does a lot of yard work.
Diet: Initial Phase Diet for the past two weeks. She does not use any artificial sweeteners.
Review of systems: Mrs. November reports that she has had problems with recurrent sinus infections in the past but denies any history of frequent antibiotic use. She has problems with constipation. Mrs. November also reports that her joints ache and that this is worse in the morning. With regards to her presenting illness, she reports that her hands swell and that the joints in her hands ache. The skin on her hands cracks and scales. The remainder of her review of systems is unremarkable.
Physical exam: Blood pressure: 173/86 Pulse: 67 Height: 5’3” Weight:196 lbs
Hands: Examination of the hands revealed reddened, dry, scaly skin around the base of her fingernails with cracks in the skin radiating outward from the nail; raised, dry, scaly patches on the palms and dorsum of hand. Scales are silvery white. Mrs. November’s nails have horizontal grooving and depressions. Her hands and fingers are moderately edematous and it is painful to make a fist. Mrs. November’s toenails are thickened and yellow. Her feet also have similar lesions, although the areas around her toenails are not affected. The remainder of her physical exam is unremarkable.
Mrs. November has been diagnosed with psoriasis by her dermatologist. Her psoriasis is affecting her skin as well as her joints and nails. So it is time for a little crash course on psoriasis.
Psoriasis is a chronic, inflammatory, immunologically-mediated disorder that causes damage to tissues. It affects approximately 2-3% of the population of the United States and occurs with equal frequency in males and females. It can affect the skin most frequently on knees, palms, soles of the feet, elbows, and scalp. It can also affect the nails of the hands and feet. When it affects the joints, it is known as psoriatic arthritis. Psoriasis is classified into five different forms - plaque, guttate, pustular, erythrodermic, and inverse psoriasis. When the immune system is functioning normally, white blood cells will produce antibodies to foreign invaders such as bacteria, viruses, or fungi. In psoriasis, special white blood cells known as T-lymphocytes become overactive. T-lymphocytes normally produce chemicals that help to heal the skin. Normally, skin cells form, mature, and are sloughed off every 30 days or so. In psoriasis, the healing process goes wild. This process is greatly exaggerated with skin cells multiplying at a rapid rate and going through this cycle in 3-6 days. The result is inflammation and skin cells piling up on the surface.
Psoriasis generally lasts a lifetime with periods of remissions and flares. Flares can be caused by stress, change in the weather, injury to the skin, medications, (including blood pressure medication), and infections. Traditional medical treatment is limited to amelioration of the symptoms and includes topical creams and ointments, phototherapy, (involving ultraviolet light), and medications that modulate your immune system. Unfortunately once the medication is stopped, the psoriasis reoccurs.
Looking at Mrs. November's history, she states that her skin problems date back to her exposure to potting soil, (she wasn’t wearing gloves). What may surprise you is how many fungi you can find in soil, including potting soil. Soil is the natural habitat of pathogens such as Blastomyces dermatitidis, Coccidioides immitis, Cryptococcus neoformans, and Sporothrix schenckii. All of these fungi have been shown to cause disease in humans. Some of them cause serious, life-threatening diseases of the respiratory tract or central nervous system. What you may not know is that they can cause skin lesions, as well. For example, outbreaks of sporotrichosis caused by Sporothrix schenckii have been found in rose gardeners, and nursery and greenhouse workers.
The problem with fungal diseases of the skin is that they are notoriously slow to heal. It may surprise you to learn that this is something I didn’t really grasp. It wasn’t until I did some research for this article that it finally sank in. It is definitely going to change the way I deal with the skin manifestations of fungal disease. I expected that, after three months of a prescription antifungal, I should see some improvement. If they weren’t getting better then I must have chosen the wrong antifungal. Wrong! Fungus takes a long time to eliminate from your system and these lesions take a long time to heal. If you get a skin infection with one of these pathogens, you need to have patience - both the doctor and the patient - because you are going to be on antifungals for quite awhile.
Mrs. November was started on fluconazole for one month and nystatin for three months. She was also placed on probiotics. She was already following the Initial Phase Diet. I was concerned about her thyroid function because I have yet to see someone with fungal disease whose thyroid metabolism was normal. I asked her to take her temperature several times a day and to bring a record of them with her on her next visit. I also suggested that she soak her hands daily in water with some added baking soda. I also discussed with Mrs. November and her husband that her psoriasis might get worse before it would get better, secondary to a Herxheimer reaction.
Mrs. November returned for follow-up in six weeks. As expected, her psoriasis was worse. She tried soaking her hands in the baking soda solution, but as a result, the skin on her hands “dried out,” cracked, and bled. She began using an over-the-counter ointment, (non-steroidal), and this seemed to help. During the interval, she and her husband were on vacation and didn’t really follow the antifungal diet. Her body temperature during the day never ran higher than 97.3F. Since she had completed her fluconazole, I started her on itraconazole and continued her on the nystatin. I stopped the baking soda/water soaks and started her on compounded ointment containing aloe, vitamin E, and zinc. I also began her on thyroid replacement medication.
Mrs. November returned for follow-up in six weeks. She was on her third month of nystatin, and her second month of itraconazole. She reported that her hands seemed to be doing worse. Her hands were more swollen and she continued to have pain in the joints of her hands. The ointment “burned” her hands. The lesions on her feet seemed to be spreading. Mrs. November stated that she was trying to be faithful to the antifungal diet. Her friend gave her some triamcinolone cream, (steroid), and this seemed to help her hands. I kept her on the itraconazole and nystatin and let her continue the use the steroid cream to decrease the cracking and bleeding. I rationalized that I was still attacking the fungus with antifungals.
One month later, Mrs. November presented for follow-up. She reports that her psoriatic lesions are less painful but that they seem to be spreading. Overall she is pleased that she is not hurting as much. I continued her on the itraconazole and nystatin and added calcipotriene ointment, (vitamin D3 derivative), for topical use.
Fast forward to one month later. Mrs. November reported that she had still not seen any significant changes in psoriasis. However, the swelling in her hands was significantly decreased and her hands were no longer painful. She has completed three months of itraconazole and four months of nystatin. I decided to start her on ketoconazole. I also encouraged her to follow the antifungal diet and kept her on thyroid replacement. On a positive note, although her skin lesions continue, the arthritic component has improved drastically. Her hands are no longer swollen and painful in the joints.
Why did I spend so much time talking about her treatment? I wanted to show you how difficult it can be to treat fungal disease. Mrs. November is a good example because she demonstrates the typical problems encountered with treatment. It is hard to motivate someone to stay on the antifungal diet when they are not seeing results. Patients can lose confidence in their doctor and the doctor can lose confidence in him or herself. It would be great if there were guidelines for treating fungal disease, but there aren’t. We still can’t get traditional medicine to recognize that fungi can be the cause of many chronic diseases. So those of us “in the field” are learning as we go and are trying to do no harm.
For more information about the association between fungus and chronic disease I recommend: The Fungus Link Volumes 1-3 by Doug Kaufmann.
Blessings,
Lynn Jennings, MD
Champions Clinic