# Idiopathic Hypersomnia
– On presentation, patient w/ excessive daytime sleepiness (EDS) w/o clear cause despite adequate nocturnal sleep
– Comprehensive sleep hx w/ rule out of other sleep disorders (e.g., obstructive sleep apnea, narcolepsy)
– Key features: prolonged nocturnal sleep, difficulty waking up (sleep inertia), unrefreshing naps
– Potential complications: impaired cognitive function, depression, cardiovascular risk
– Differential diagnoses (Ddx): narcolepsy, sleep apnea, medication effects, mood disorders
– Polysomnography (PSG) and Multiple Sleep Latency Test (MSLT) findings critical for Dx
PLAN
– Confirm Dx w/ PSG & MSLT (sleep latency <8 min, <2 SOREMPs)
– Rule out other causes: TSH, CBC, CMP, vit B12, ferritin lvls
– Monitor for secondary effects: depression screening, cognitive function tests
– Rx options:
– Modafinil (Provigil) 100-400 mg QD in AM
– Armodafinil (Nuvigil) 150-250 mg QD in AM
– Methylphenidate 10-60 mg QD or BID
– Consider behavioral therapy: sleep hygiene, controlled napping
– Frequent re-evaluation of symptoms and medication side effects, Q4-6 months or PRN
– Watch for red flags in follow-up: increased EDS, sudden sleep attacks, cataplexy, hallucinations
– Consider impact on comorbidities: depression, cardiovascular risk management
– Note: caution w/ use of CNS depressants, alcohol
DERMATOPHYTES (TINEA)
1. INITIAL TX Tinea pedis, tinea corporis, tinea cruris —> topical antifungals
—> + corticosteroid IF especially inflammatory (low-dose, topical)
2. Refractory
– foot (tp): PO terbinafine, PO itraconazole, PO fluconazole >>> griseofulvin (long time to work)
– body (tc) or groin (jock itch; tc): PO terbinafine, PO itraconazole, PO fluconazole
What is the treatment for tinea capitis or onychomycosis? oral terbinafine
# Tinea Cruris (Jock Itch) (B35.6, L30.9, L29.0)
– Tinea cruris: Common fungal infection of groin region, often in athletes or individuals w/ excessive sweating
– Risk factors: Tight clothing, humid environments, immunocompromised status, diabetes, obesity
– Clinical presentation: Pruritic, erythematous, well-demarcated rash with central clearing, scaling edges, located in groin, inner thighs, buttocks
– Diagnostic criteria: KOH prep of skin scraping revealing hyphae, culture if needed, Wood’s lamp (coral red fluorescence)
– Differential diagnosis: Candidiasis, intertrigo, erythrasma, psoriasis, contact dermatitis
– Complications: Secondary bacterial infection, lichenification, spread to other body areas
PLAN
– Antifungal therapy:
– Topical agents (first-line):
– Clotrimazole 1% cream, apply BID for 2-4 weeks
– Miconazole 2% cream, apply BID for 2-4 weeks
– Terbinafine 1% cream, apply BID for 1-2 weeks
– Oral antifungals (for extensive or refractory cases):
– Terbinafine 250 mg PO QD for 2-4 weeks
– Fluconazole 150-300 mg PO weekly for 2-4 weeks
– Itraconazole 200 mg PO QD for 1 week
– Symptom management:
– Low-potency topical corticosteroids (e.g., hydrocortisone 1%) to reduce inflammation and itching (short-term use only)
– Preventive measures:
– Encourage loose-fitting, breathable clothing
– Advise to keep the area dry, use antifungal powders if needed
– Educate on avoiding sharing personal items like towels
– Monitor for signs of secondary infection or treatment failure
– Re-evaluation:
– If no improvement in 2 weeks or worsening, consider alternative diagnosis or oral antifungal therapy
– Consider dermatology referral for persistent or atypical cases