Practical Knowledge for the Massage Therapist: Systemic Fungal Diseases

There are countless strains of fungus that can lead to infection. Candida is the most common variety, accounting for 80% of all hospital-acquired systemic infections, the frequency of which increased fivefold in the 1980’s alone. It is the most common fungal disease among immunocompromised patients and the fourth most prevalent organism found in the bloodstream. The infection may be associated with prolonged hospitalization and excess mortality specifically attributable to Candidiasis (Beers 1999, 1220). Other varieties of mycoses do exist, including ringworm, jock itch, athlete’s foot and tinea versicolor, but occur less frequently with relatively benign impacts. 

Candidiasis is a fungal disease similar to yeast that affects the integumentary system. The most notable symptoms of Candidiasis are red, scaly patches of skin, often with secretions. The rash or skin lesions may be sore, itchy, odorous or resolve in permanent scarring of the tissues. Yeasts tend to disseminate to other organs so it is not uncommon to identify the issue in the vaginal area, nail beds, mouth and the gastrointestinal tract (Premkumar, 77). The scalp often harbors the organism (Beers 1999, 806). Hosts with weak immune systems may experience acute, rapidly progressive symptoms impacting vital organ systems (Beers 1999, 1209).

Fungi are members of the normal flora in the body; however, events that promote multiplication of the fungus can cause an overgrowth resulting in symptomatic infection. Mycoses are opportunists that thrive in compromised hosts. Clients with suppressed immunity, particularly those being treated for cancer or AIDS, are more susceptible to infection because the body’s natural defense systems are weakened. Therapists should be cautious when working with these clients, bearing in mind that systemic mycoses can be fatal for these patients (Beers 2006, 987). Clients taking antibiotics, immunosuppressants, or those patients receiving radiation therapy are at increased risk.

Opportunities for Candidiasis infection include breaks or burns of the skin and various impediments of the ciliary transport system. Infection may also enter the body through the gastrointestinal tract via contaminated food and water (Premkumar, 362). IV lines and gastrointestinal ports are effective points of entry. It is frequently associated with UTIs, trauma and surgery (Beers 1999, 1220).  The massage therapist should be most concerned about transmission of the illness between individuals in close contact with one another (Premkumar, 77), or by way of infected towels, utensils and bedding (Premkumar, 362). 

Therapists should be attentive to the signs of fungal infection in vulnerable and high-risk populations. Poor hygiene and infrequent diaper changes in children and elderly adults can provide a fertile environment for fungal growth (Beers 2006, 987). A study among children indicated that an overwhelming number of those children were allergic to certain fungal spores and adults likely have similar hypersensitivities to fungi (Stametes). High-density housing situations and shared bathroom facilities are often associated with infection by way of fecal contaminants. There is an increased risk of infection with use of catheters and symptoms may present as cystitis, resulting in urinary frequency, urgency, dysuria and suprapubic pain (Beers 1999, 1891). Animals are frequently carriers of fungal spores so farmers who work in close proximity to birds, bats and soil products are often exposed (Premkumar, 141).

Skin scrapings are available to diagnose tinea and candidiasis (Beers 2006, 935); however, the fungus is a normal member of the body’s fauna and will be present in a healthy patient (Beers 2006, 988). Lab tests designed to screen for fungal infection are likely to produce a positive result, so the usefulness of the test is limited and usually unhelpful. Blood cultures for fungal diseases are frequently negative (Beers 1999, 1891) and may not be sensitive or specific enough to detect the infection (Beers 1999, 1210). Invasive, progressive infection is typically diagnosed when a positive culture is accompanied by a characteristic lesion, in which case, systemic antifungal therapy is needed to treat the disease. Fever, with yeast detected in the urine, is an indication of renal candidiasis (Beers 1999, 1891) and should be considered serious, progressive and potentially fatal (Beers 1999, 2021).

Fungal infection can be treated with topical antifungal products. For some patients, the condition can be chronic, carrying on for months or years without diagnosis (Beers 1999, 1210). Stubborn infections may require prolonged, aggressive oral antifungal therapy lasting 6-12 months or more. Secondary bacterial infections can arise alongside the fungal issue so the patient may be addressing the problem on multiple fronts (Beers 1999, 1891). It may be prudent for the patient to regularly boil or replace hair brushes, combs, and styling products that come into contact with infected areas of the skin.

The incubation period for the condition can be as long as 14 days, during which time the fungus is communicable, so the infection can be very difficult to control (Werner, 30). For this reason, it is recommended that anyone who has close, regular contact with the diagnosed patient be treated for the condition as if they too are infected (Werner, 33). Medication should be prescribed pending lab results and to qualifying, asymptomatic patients (Beers 1999, 1891).

Some strains of fungus have developed a resistance to antifungal medications (Beers 1999, 1212). Strain identification and proper diagnoses are essential in order to treat the condition effectively (Beers, 1999, 1226). Improper medication, inaccurate dosing, or incomplete treatment can result in a more virulent disease. The severity of the systemic disease must be weighed against the potential risks associated with the medication administered. Likewise, interactions the medication may have with other drugs consumed by the patient should be considered and the patient should be advised of products which may alter the efficacy of the medication prescribed (Beers 1999, 1212-1213).

Massage is generally contraindicated local to the infection, but massage of the infected area through the sheet is appropriate (Werner, 33). The therapist should ask questions about the communicability of the patient’s condition sufficient to determine whether massage is appropriate and document the presence of any symptoms (OBMT). Given that the condition is spread with contact, the therapist should avoid moving the infection from one area of the body to another. Steer clear of broken skin or acute lesions and request permission from the client to work on or around infected areas (Dixon). Touching the affected areas may elicit pain or itching. 

Patients may be asymptomatic, without any visible indication of infection; therefore, it is important to employ thorough and consistent sanitation practices. Massage tables, bolsters, head rests and other similar products should be sanitized after use by each patient. If long periods of time pass between patients, or if those products are handled by others between patients, sanitation practices should be reemployed before use with the next patient.

While soap and water solutions are typical in clinical settings, bleach products may be more effective at eliminating fungal spores. A household bleach solution containing 1/3 cups bleach per gallon of room-temperature water is recommended. This solution can be applied to massage products after the initial soap cleaner is used to remove debris from the surface. Allow the bleach solution to sit on the surface of the product for at least one minute before wiping. Apply enough bleach solution that the product appears visibly wet during this time. Always wash your hands after disinfecting, and prepare a new bleach solution daily. The effectiveness of the bleach solution will decline beyond 24 hours (https://www.cdc.gov).

Laundering linens with bleach and hot water is also advisable, followed by a hot dry cycle (Premkumar, 365). Temperatures should exceed those beyond which fungal spores can survive. Storage of both clean and dirty linens should be addressed by the clinic in a manner that prevents contamination. 

Sanitation records are occasionally requested by relevant health authorities (ORS 687.123), and licensing Boards impose guidelines with respect to sanitation (ORS 687.059), so contemporaneous logs should be kept documenting the clinic’s disinfection practices (Premkumar, 365). This should include application to doorknobs, flooring and other surfaces in addition those supplies regularly used to conduct massages. Refer to your State’s governing Board for specific policies regarding proper care and cleaning of equipment and linen.

References:

Beers, Mark H. et al. “The Merck Manual of Diagnosis and Therapy,” Seventeenth Edition, ISBN 0911910-10-7, Merck Research Laboratories, 1999, Whitehouse Station, NJ.

Beers, Mark H. et al. “The Merck Manual,” Eighteenth Edition, ISBN 0911910-18-2, Merck Research Laboratories, 2006, Whitehouse Station, NJ.

Centers for Disease Control and Prevention. “Cleaning and Disinfecting with Bleach.” CDC, October 31, 2022. https://www.cdc.gov/hygiene/cleaning/disinfecting-bleach.html.

Dixon, Marian W. The Science of Skin: Contagious Skin Conditions. May 2023. https://drive.google.com/file/d/1nc6LHR1dfyQWMcWWLawmraqycmKc4jJh/view. Powerpoint presentation.

Oregon Board of Massage Therapists. “Communicable Disease Guidelines.” State of Oregon, June 12, 1998. https://oregon.gov/obmt/Documents/Communicable%20Disease%20Guidelines.pdf.

State of Oregon. Oregon Revised Statutes, Volume 17, Title 52, Chapter 687. Massage Therapists; Direct Entry Midwives. May 2023. https://oregon.public.law/statutes/ors_chapter_687.

Premkumar, Kalyani. “Pathology A to Z: A Handbook for Massage Therapists,” Second Edition, ISBN 0-9680730-5-0, VanPub Books, 1999, Calgary, Canada.

Stametes, Paul. “On Psilocybin Mushrooms and the Mycology of Consciousness,” CIIS Public Programs, May 4, 2022, British Columbia, Canada.

Werner, Ruth. “A Massage Therapist’s Guide to Pathology: Critical Thinking and Practical Application,” Sixth Edition, ISBN 978-1-14963-1082-8, Wolters Kluwer, 2016, Philadelphia, PA.