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  /Title (fungal-infections.pdf)
  /Creator (Cheatography)
  /Author (happyfeet2020)
  /Subject (Fungal Infections Cheat Sheet)
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        \hspace*{-6pt}\includegraphics[width=5.8cm]{/web/www.cheatography.com/public/images/cheatography_logo.pdf}}
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    \vspace{-2pt}\large{\bf{\textcolor{DarkBackground}{\textrm{Fungal Infections Cheat Sheet}}}} \\
    \normalsize{by \textcolor{DarkBackground}{happyfeet2020} via \textcolor{DarkBackground}{\uline{cheatography.com/144934/cs/31344/}}}
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  \mymulticolumn{2}{p{5.377cm}}{\bf\textcolor{white}{Cheatographer}}  \\
  \vspace{-2pt}happyfeet2020 \\
  \uline{cheatography.com/happyfeet2020} \\
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  \mymulticolumn{1}{p{5.377cm}}{\bf\textcolor{white}{Cheat Sheet}}  \\
   \vspace{-2pt}Published 11th April, 2022.\\
   Updated 29th March, 2022.\\
   Page {\thepage} of \pageref{LastPage}.
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  Measure your website readability!\\
  www.readability-score.com
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\begin{tabularx}{5.377cm}{x{2.09034 cm} x{2.88666 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Tinea Pedis}}  \tn
% Row 0
\SetRowColor{LightBackground}
{\bf{1. Acute Vesicular }} & T.mentagrophytes and sometimes E.floccosum \tn 
% Row Count 2 (+ 2)
% Row 1
\SetRowColor{white}
 & Small vesicles, vesiculopustules and/or blisters typically seen near instep. \tn 
% Row Count 6 (+ 4)
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\SetRowColor{LightBackground}
 & {\emph{Treatment}}: Topical anti-fungal \tn 
% Row Count 8 (+ 2)
% Row 3
\SetRowColor{white}
{\bf{2. Chronic Papulosquamous}} & T.ruburm, sometimes T.mentagrophytes \tn 
% Row Count 10 (+ 2)
% Row 4
\SetRowColor{LightBackground}
 & Often assoc. with hereditary palmoplantar keratoderma \tn 
% Row Count 13 (+ 3)
% Row 5
\SetRowColor{white}
 & Thick, boggy yellow to brown hyperkeratosis with peripheral scaling and/or fissures. \tn 
% Row Count 17 (+ 4)
% Row 6
\SetRowColor{LightBackground}
 & Usually bilateral. Characterized by a moccasin-like distribution. Hands may be infected as well. most common pattern is for both feet and one hand to be involved. When both hands and feet are infected, T.mentagrophytes is the organism \tn 
% Row Count 28 (+ 11)
% Row 7
\SetRowColor{white}
 & {\emph{Treatment}}: Debridement, topical anti-fungal and urea based emollient. May need oral \tn 
% Row Count 32 (+ 4)
\end{tabularx}
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\begin{tabularx}{5.377cm}{x{2.09034 cm} x{2.88666 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Tinea Pedis (cont)}}  \tn
% Row 8
\SetRowColor{LightBackground}
{\bf{3. Chronic Interdigital}} & T.mentagrophytes and sometimes T.rubrum and E.floccosum \tn 
% Row Count 3 (+ 3)
% Row 9
\SetRowColor{white}
 & Fissuring, scaling, and maceration in the toes spaces. \tn 
% Row Count 6 (+ 3)
% Row 10
\SetRowColor{LightBackground}
 & Hyperhidrosis is typically the cause \tn 
% Row Count 8 (+ 2)
% Row 11
\SetRowColor{white}
 & {\emph{Treatment}}: Wash and DRY in between toes. Can use cotton balls to place in between toes to absorb moisture. Can use Drysol products for feet and shoes. Can use alcohol spray to dry out area. If wear boots, use boot dryer to prevent moisture. Use sprays not cream. If use cream, needs to be completely rubbed in.  Clean shoes and change socks every day. \tn 
% Row Count 24 (+ 16)
% Row 12
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{\bf{4. Acute Ulcerative}} & T.mentagrophytes and can be complicated by grm- bacteria \tn 
% Row Count 27 (+ 3)
% Row 13
\SetRowColor{white}
 & Presents with maceration, weeping, and ulceration of the sole with assoc. white hyperkeratosis and odour \tn 
% Row Count 32 (+ 5)
\end{tabularx}
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\begin{tabularx}{5.377cm}{x{2.09034 cm} x{2.88666 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Tinea Pedis (cont)}}  \tn
% Row 14
\SetRowColor{LightBackground}
 & Need to rule our secondary infection by bacterial cultures and gram stains. \tn 
% Row Count 4 (+ 4)
% Row 15
\SetRowColor{white}
 & {\emph{Treatment}}: Oral antibiotics and topical anti-fungal \tn 
% Row Count 7 (+ 3)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{Most commonly caused by T. rubrum, T.mentagrophytes. E.floccosum}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
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\begin{tabularx}{5.377cm}{x{1.94103 cm} x{3.03597 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Diagnosis of Mycological Conditions}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{Clinical Presentation} \tn 
% Row Count 1 (+ 1)
% Row 1
\SetRowColor{white}
KOH microscopic evaluation & Nail or skin clipped and placed in 10\% KOH solution. Observe under microscope for septa and branching hyphae \tn 
% Row Count 6 (+ 5)
% Row 2
\SetRowColor{LightBackground}
Fungal Cultures & Sabouraud's dextrose agar most common fungal mediym \tn 
% Row Count 9 (+ 3)
% Row 3
\SetRowColor{white}
Biopsy & Only used when concerned about malignancy. Can be examined with periodic acid schiff \tn 
% Row Count 13 (+ 4)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{Dermatophytes are group of fungi capable of colonizing keratinized tissues such as the stratum corneum, nails and hair. They use keratin as a source of nutrients. \newline Three Genera of Dermatophytes: 1) Microsporum 2) Trichophyton 3) Epidermophyton}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
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\begin{tabularx}{5.377cm}{x{1.89126 cm} x{3.08574 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Deep Fungal Infections}}  \tn
% Row 0
\SetRowColor{LightBackground}
{\bf{Majocchi's Granuloma}} & caused by T.rubrum \tn 
% Row Count 2 (+ 2)
% Row 1
\SetRowColor{white}
 & Starts as a fungal folliculitis and spreads into the dermis where it forms an inflammatory nodule \tn 
% Row Count 7 (+ 5)
% Row 2
\SetRowColor{LightBackground}
 & clinically, there is a erythematous plaque with indistinct borders and no central clearing \tn 
% Row Count 11 (+ 4)
% Row 3
\SetRowColor{white}
 & Oral therapy is necessary \tn 
% Row Count 13 (+ 2)
% Row 4
\SetRowColor{LightBackground}
{\bf{Sporotrichosis}} & Secondary to sporothrix schenckii \tn 
% Row Count 15 (+ 2)
% Row 5
\SetRowColor{white}
 & introduced into the dermis traumatically from thorns or splinters with the conidia \tn 
% Row Count 19 (+ 4)
% Row 6
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 & Happens in gardeners \tn 
% Row Count 20 (+ 1)
% Row 7
\SetRowColor{white}
 & Starts as a papule that becomes a painless ulcer with a ragged undermined red border. May follow lymphatics so wont respond to a topical. \tn 
% Row Count 26 (+ 6)
% Row 8
\SetRowColor{LightBackground}
 & Tx: potassium iodide PO, Amphotericine B IV, PO itraconazole or terbinafine \tn 
% Row Count 30 (+ 4)
\end{tabularx}
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\vfill
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\begin{tabularx}{5.377cm}{x{1.89126 cm} x{3.08574 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Deep Fungal Infections (cont)}}  \tn
% Row 9
\SetRowColor{LightBackground}
{\bf{Chromoblastomycosis}} & Caused by species pf phialophora, fonsecaea and cladosporium \tn 
% Row Count 3 (+ 3)
% Row 10
\SetRowColor{white}
 & Nodule develops and ulcerates followed by scales, crust and scarring and keloid formation \tn 
% Row Count 7 (+ 4)
% Row 11
\SetRowColor{LightBackground}
 & Tx: local heat, same as for sporotrichosis. Need to consult with infectious disease specialist \tn 
% Row Count 11 (+ 4)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
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\begin{tabularx}{5.377cm}{x{1.64241 cm} x{3.33459 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Polyenes- Inhibitors of Fungal Membrane Stability}}  \tn
% Row 0
\SetRowColor{LightBackground}
{\bf{MOA of Nystatin:}} & Binds to ergosterol and produced channels/pores that alter fungal membrane permeability -\textgreater{} leakage of cell contents -\textgreater{} cell death \tn 
% Row Count 5 (+ 5)
% Row 1
\SetRowColor{white}
Nystatin Cream & mitte: 15g or 30g tube or 450g jar, sig: apply to affected areas of skin on feet twice a day for four weeks \tn 
% Row Count 10 (+ 5)
% Row 2
\SetRowColor{LightBackground}
 & uses: candida infections (and to lesser extent dermatophyte infections) of the skin and mucosa \tn 
% Row Count 14 (+ 4)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
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\begin{tabularx}{5.377cm}{x{1.89126 cm} x{3.08574 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Echinocandins- Inhibitors of Fungal Wall Synthesis}}  \tn
% Row 0
\SetRowColor{LightBackground}
{\bf{MOA}} & Target fungal cell wall synthesis by inhibiting synthesis of B-(1,3)-D glucans (a key component in the fungal cell wall). Disruption of cell wall integrity -\textgreater{} osmotic stress -\textgreater{} lysis of fungal cell -\textgreater{} fungal cell death \tn 
% Row Count 10 (+ 10)
% Row 1
\SetRowColor{white}
{\bf{Ciclopirox}} (Topical) & 1\% cream, mitte: 45g tube sig: applied twice a day to affected areas of skin for 4 weeks. Good for dermatophyte and candida infections of the skin \tn 
% Row Count 17 (+ 7)
% Row 2
\SetRowColor{LightBackground}
 & 1\% lotion (loprox) mitte: 60ml bottle sig: applied twice a day to affected areas of skin for 4 weeks \tn 
% Row Count 22 (+ 5)
% Row 3
\SetRowColor{white}
 & Nail Lacquer 8\% (Penlac) mitte: 6.6ml bottle with brush applicator sig: apply once a day to all affected nails for 6-9 months. Remove build up with alcohol or nail polish remover every 7-10 days. Loprox and penlac are good for skin and nails \tn 
% Row Count 33 (+ 11)
\end{tabularx}
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\vfill
\columnbreak
\begin{tabularx}{5.377cm}{x{1.89126 cm} x{3.08574 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Echinocandins- Inhibitors of Fungal Wall Synthesis (cont)}}  \tn
% Row 4
\SetRowColor{LightBackground}
 & {\emph{MOA}}: Chelates metal ions in fungal membrane which increase fungal cell membrane permeability (inhibits membrane transfer system by interrupting na/K/ATPase) -\textgreater{} fungal cell death \tn 
% Row Count 8 (+ 8)
% Row 5
\SetRowColor{white}
 & Effective against some bacteria \tn 
% Row Count 10 (+ 2)
% Row 6
\SetRowColor{LightBackground}
 & exerts anti inflammatory activity by inhibiting 5-lipoxygenase and COX enzymes \tn 
% Row Count 14 (+ 4)
% Row 7
\SetRowColor{white}
{\bf{Tolnaftate}} & topical: OTC powder (tinactin), gel and cream. unknown MO. Good for tinea versicolour and mild dermatophytes infections of skin \tn 
% Row Count 20 (+ 6)
% Row 8
\SetRowColor{LightBackground}
{\bf{Undecycline Acid}} & topical: OTC power (desenex), cream, spray (tolcylen) Unknown MOA. Used as preventative or adjunct. Uses: candida and mild dermatophyte infections of skin \tn 
% Row Count 27 (+ 7)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{Routine debridement will help decrease fungal load and help with drug penetration !!}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
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\begin{tabularx}{5.377cm}{x{2.53827 cm} x{2.43873 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Tinea Ungium/ Onychmycosis}}  \tn
% Row 0
\SetRowColor{LightBackground}
Caused by: & E.floccosum, T.rubrum, T.mentagrophytes \tn 
% Row Count 3 (+ 3)
% Row 1
\SetRowColor{white}
Toe nail infections may seem chronic and resistant to therapy due to: & 1. Footgear occlusion \tn 
% Row Count 7 (+ 4)
% Row 2
\SetRowColor{LightBackground}
 & 2. Nail trauma \tn 
% Row Count 8 (+ 1)
% Row 3
\SetRowColor{white}
 & 3. Decreased circulation \tn 
% Row Count 10 (+ 2)
% Row 4
\SetRowColor{LightBackground}
 & 4. Endogenous re-infection \tn 
% Row Count 12 (+ 2)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
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\begin{tabularx}{5.377cm}{x{1.59264 cm} x{3.38436 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Other Fungal Infections}}  \tn
% Row 0
\SetRowColor{LightBackground}
{\bf{Candidiasis}} & candida albicans is a yeast fungus \tn 
% Row Count 2 (+ 2)
% Row 1
\SetRowColor{white}
 & {\emph{Clinical manifestations}}: Intertrigo, OM, tinea pedis, folliculitis, paronychia \tn 
% Row Count 5 (+ 3)
% Row 2
\SetRowColor{LightBackground}
Candidal Paronychia & Treatment for 4-6 weeks w/ topical imidazoles, nystatin, ciclopirox or terbinafine \tn 
% Row Count 9 (+ 4)
% Row 3
\SetRowColor{white}
Tinea Versicolour & Caused by Malassezia furfur (yeast) \tn 
% Row Count 11 (+ 2)
% Row 4
\SetRowColor{LightBackground}
 & characterized by hypopigmented and/or hyperpigmented macules w/ a fine scale localized to the trunk and thighs \tn 
% Row Count 16 (+ 5)
% Row 5
\SetRowColor{white}
 & Usually found in lipic rich areas and releases an acid that impacts melanin \tn 
% Row Count 19 (+ 3)
% Row 6
\SetRowColor{LightBackground}
 & Tx: topical azole cream/shampoo, terbinafine gel, selenium sulfide,cicloppirox \tn 
% Row Count 22 (+ 3)
% Row 7
\SetRowColor{white}
 & Oral Tx: fluconazole, itraconazole. Oral terbinafine is not effective \tn 
% Row Count 25 (+ 3)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
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\begin{tabularx}{5.377cm}{x{2.18988 cm} x{2.78712 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{PREVENTION}}  \tn
% Row 0
\SetRowColor{LightBackground}
1. Keep skin intact (protected) & 2. Prevent excessive moisture- don't let skin get excessively wet, change socks and wet shoes. Dry thoroughly after shower \tn 
% Row Count 6 (+ 6)
% Row 1
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{3. Avoid contamination- wear shower shoes. Put socks on first, disinfect shoes and bathtub} \tn 
% Row Count 8 (+ 2)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
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\begin{tabularx}{5.377cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{5.377cm}}{\bf\textcolor{white}{Inhibitors of the Ergosterol Synthesis Pathway}}  \tn
\SetRowColor{LightBackground}
\mymulticolumn{1}{p{5.377cm}}{\vspace{1px}\centerline{\includegraphics[width=5.1cm]{/web/www.cheatography.com/public/uploads/happyfeet2020_1648516941_Ergosterol-synthesis-pathway-showing-sites-of-inhibition-of-different-antifungal-agents.png}}} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
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\begin{tabularx}{5.377cm}{x{2.14011 cm} x{2.83689 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Allylamines}}  \tn
% Row 0
\SetRowColor{LightBackground}
{\bf{MOA:}} & Inhibit squalene epoxidase and prevents formation of lanosterol from squalene. lanosterol is needed for production of ergosterol which is needed for normal structure and function of plasma membrane. Accumulation of squalene which is a toxic metabolite will occur, making these drugs fungicidal \tn 
% Row Count 14 (+ 14)
% Row 1
\SetRowColor{white}
{\emph{Oral Terbinafine}} & Hepatic CYP metabolism, renal excretion (inactive). Highly lipid soluble so penetrates through nails. However, benefits do not outweigh risk for tx of OM. \tn 
% Row Count 21 (+ 7)
% Row 2
\SetRowColor{LightBackground}
 & Pulse dosing is effective as it is less overall drug so better on liver and less costly \tn 
% Row Count 25 (+ 4)
% Row 3
\SetRowColor{white}
{\bf{Topical Terbinafine}}: & 1\% cream or gel or 1\% spray, mitte: 15g or 30g, tube or 30ml for spray sig: apply to affected areas of skin on feet once or twice a day \tn 
% Row Count 32 (+ 7)
\end{tabularx}
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\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Allylamines (cont)}}  \tn
% Row 4
\SetRowColor{LightBackground}
 & Uses: tinea pedis (dematophytes), tinea corporis, tinea cruris \tn 
% Row Count 3 (+ 3)
% Row 5
\SetRowColor{white}
{\bf{Oral Terbinafine}}: & Daily dosing: 250mg tablets mitte: 84 tablets sig: one tablet po daily for 12 weeks (LFT and CBC baseline lab tests with repeat at 4-6 weeks) \tn 
% Row Count 10 (+ 7)
% Row 6
\SetRowColor{LightBackground}
 & Pulse dosing: 250mg tablets, mitter: 42 tablets sig: two tables po daily for 1 week followed by 3 weeks off for three months then mitte 7 tablets sig: one tablet po daily for 7-21 days \tn 
% Row Count 19 (+ 9)
% Row 7
\SetRowColor{white}
 & Uses: OM, tinea \seqsplit{pedis(dermatophytes)/capitis/cruris/corporis}, and systemic fungal and candida infections \tn 
% Row Count 24 (+ 5)
% Row 8
\SetRowColor{LightBackground}
 & Contraindicated in pts with liver disease or renal impairment \tn 
% Row Count 27 (+ 3)
% Row 9
\SetRowColor{white}
 & side effects: Hepatotoxicity, neutropenia, GI upset, skin reactions, taste/smell disturbances, renal and liver function impairment \tn 
% Row Count 33 (+ 6)
\end{tabularx}
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\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Allylamines (cont)}}  \tn
% Row 10
\SetRowColor{LightBackground}
{\bf{Allylamine Hepatotoxicity:}} & increase in serum transaminase levels, symptomatic liver injury occurs rarely, majority of cases resolve within 3-6mos of stopping meds \tn 
% Row Count 7 (+ 7)
% Row 11
\SetRowColor{white}
{\bf{Allylamine Interactions}} & warfarin and other CYP metabolism drugs, cimetidine, azole antifungals, TCAs, SSRI, beta blockers, opioids, MAO inhibitors, anti-arrythmics (ie digoxin), \tn 
% Row Count 14 (+ 7)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
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\begin{tabularx}{5.377cm}{x{2.43873 cm} x{2.53827 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Types of Onychomycosis}}  \tn
% Row 0
\SetRowColor{LightBackground}
{\bf{1. Distal Subungal Onychomycosis}} & Most common OM and most common organism is T.rubrum \tn 
% Row Count 3 (+ 3)
% Row 1
\SetRowColor{white}
 & Fungal penetrates distal hyponychium or lateral nail fold region \tn 
% Row Count 7 (+ 4)
% Row 2
\SetRowColor{LightBackground}
 & Starts with subungual debris, yellowing and onycholysis \tn 
% Row Count 10 (+ 3)
% Row 3
\SetRowColor{white}
 & After many years, keratinization of the distal nail bed occurs with loss of the nail grooves. Proximal nail plate then appears as a thick mound w/ neglected care, a ram's horn deformity develops \tn 
% Row Count 20 (+ 10)
% Row 4
\SetRowColor{LightBackground}
 & non dermatophytes such as aspergillus niger can also cause OM (ddx is pseudomonas infection) \tn 
% Row Count 25 (+ 5)
% Row 5
\SetRowColor{white}
{\bf{2. Proximal Subungual Onychomycosis}} & Occurs secondary to fungi entering the proximal nail fold and then the matrix and nail plate. \tn 
% Row Count 30 (+ 5)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{5.377cm}{x{2.43873 cm} x{2.53827 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Types of Onychomycosis (cont)}}  \tn
% Row 6
\SetRowColor{LightBackground}
 & infection involves the nail plate but the nail surface is intact \tn 
% Row Count 4 (+ 4)
% Row 7
\SetRowColor{white}
 & Debris develops under nail plate then onycholysis. Nail appears white and fluid may accumulate under nail \tn 
% Row Count 10 (+ 6)
% Row 8
\SetRowColor{LightBackground}
{\bf{3. White Superficial Onychomyocosis}} & Due to T.mentagrophytes \tn 
% Row Count 13 (+ 3)
% Row 9
\SetRowColor{white}
 & Fungi infect the superficial nail plate. Nails are dry, soft, powdery white \tn 
% Row Count 17 (+ 4)
% Row 10
\SetRowColor{LightBackground}
 & Topical may work early on as it is on the nail plate \tn 
% Row Count 20 (+ 3)
% Row 11
\SetRowColor{white}
{\bf{4. Candidal Onychomycosis}} & Caused by candida albicans \tn 
% Row Count 22 (+ 2)
% Row 12
\SetRowColor{LightBackground}
 & Nails are thick, white-yellow or yellow-brown \tn 
% Row Count 25 (+ 3)
% Row 13
\SetRowColor{white}
 & entire nail plate is involved often with paronychia, inflammation and toe tip vesiculation \tn 
% Row Count 30 (+ 5)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{5.377cm}{x{2.43873 cm} x{2.53827 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Types of Onychomycosis (cont)}}  \tn
% Row 14
\SetRowColor{LightBackground}
{\bf{Complications}} & Permanent nal matrix or nail bed changes, subungual ulceration, secondary bacterial infection, possibly gangrene \tn 
% Row Count 6 (+ 6)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{5.377cm}{x{2.33919 cm} x{2.63781 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Azoles}}  \tn
% Row 0
\SetRowColor{LightBackground}
{\bf{MOA}}: & Inhibit 14a-sterol demethylase and prevent formation of ergosterol by preventing lanosterol conversion to ergosterol. Fungistatic \tn 
% Row Count 7 (+ 7)
% Row 1
\SetRowColor{white}
{\bf{Clotrimazole}} (Topical) & 1\% cream mitte: 15g or 30g tubes or 500g tub sig: apply to affected areas on feet twice a day for four weeks. \tn 
% Row Count 13 (+ 6)
% Row 2
\SetRowColor{LightBackground}
 & Uses: superficial fungal and candida infections of stratum corneum and squamous mucosa (not good for hair and nails) \tn 
% Row Count 19 (+ 6)
% Row 3
\SetRowColor{white}
{\bf{Miconazole}}(Topical) & 2\% cream or 2\% spray  mitte: 30g tube or 85g cans for spray  sig: apple to affected areas twice a day for four weeks \tn 
% Row Count 25 (+ 6)
% Row 4
\SetRowColor{LightBackground}
 & uses: same as clotrimazole \tn 
% Row Count 27 (+ 2)
% Row 5
\SetRowColor{white}
{\bf{Ketoconazole}}(Topical) & 2\% cream mitte: 30g tube sig: apply to affected areas once-twice a day for 4 weeks. \tn 
% Row Count 31 (+ 4)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{5.377cm}{x{2.33919 cm} x{2.63781 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Azoles (cont)}}  \tn
% Row 6
\SetRowColor{LightBackground}
 & uses: same as above \tn 
% Row Count 1 (+ 1)
% Row 7
\SetRowColor{white}
{\bf{Efinaconazole (Jublia)}} (Topical) & 10\% cream, applied daily to nails with no need to remove excess product \tn 
% Row Count 5 (+ 4)
% Row 8
\SetRowColor{LightBackground}
 & uses: DLSO, AE: dermatitis and vesicles on application sites \tn 
% Row Count 8 (+ 3)
% Row 9
\SetRowColor{white}
 & Gold standard for topical tx of OM \tn 
% Row Count 10 (+ 2)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{-Azoles inhibit hepatic P450 enzymes therefore drug to drug interactions are an important consideration whenever they are used. \newline -Topical azoles are better for candida infections and are less expensive whereas allylamines are better against common dermatophytes but are more expensive}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}


% That's all folks
\end{multicols*}

\end{document}