CUTANEOUS MYCOSES
September 2016
Perspective
You have been called for
a long awaited interview.
You dress smartly and
comb your hair.
Unbeknown to you this is
what you take to the
interview
Superficial mycoses
These are superficial cosmetic fungal infections of
the skin or hair shaft
No living tissue is invaded and there is no cellular
response from the host
Essentially no pathological changes are elicited
Patients are often unaware of their condition
Superficial mycoses
Disease
Causative organisms
Incidence
Pityriasis versicolor
Seborrhoeic
dermatitis
including Dandruff
and
Follicular pityriasis
Malassezia spp.
(a lipophilic yeast)
Common
Tinea nigra
White piedra
Trichosporon spp.
Common
Black piedra
Piedraia hortae
Rare
Malassezia infections
Malassezia species are basidiomycetous yeasts and form
part of the normal skin flora of humans and animals.
Malassezia species may cause various skin
manifestations
Fungaemia due to lipid-dependent Malassezia species
usually occurs in patients with central line catheters
receiving lipid replacement therapy, especially in infants
Primary isolation and culture of Malassezia species is
challenging
Clinical manifestations
(Pityriasis versicolor)
A chronic, superficial fungal disease of the skin characterised by well-demarcated white, pink,
fawn, or brownish lesions, often coalescing, and covered with thin furfuraceous scales
Pityriasis folliculitis:
Characterised by follicular
papules and pustules
localised to the back,
chest and upper arms,
sometimes the neck, and
more seldom the face.
These are itchy and often
appear after sun
exposure.
Laboratory diagnosis:
1. Clinical material: Skin scrapings from patients with
superficial lesions, blood and indwelling catheter tips from
patients with suspected fungaemia.
2. Direct Microscopy: Skin scrapings taken from
patients with Pityriasis versicolor stain rapidly when
mounted in 10% KOH, glycerol and Parker ink solution and
show characteristic clusters of thick-walled round, budding
yeast-like cells and short angular hyphal forms
Management:
The most appropriate antifungal treatment for
pityriasis versicolor is to use a topical imidazole in
a solution or lathering preparation.
Ketoconazole shampoo has proven to be very
effective.
Alternative treatments include zinc pyrithione
shampoo or selenium sulfide lotion applied daily
for 10-14 days or the use of propylene glycol 50%
in water twice daily for 14 days.
White piedra
White piedra is a superficial cosmetic fungal
infection of the hair shaft caused by Trichosporon.
Infected hairs develop soft greyish-white nodules
along the shaft.
Essentially no pathological changes are elicited.
White piedra is found worldwide, but is most
common in tropical or subtropical regions.
Laboratory diagnosis:
Management:
Shaving the hairs is the simplest method of
treatment. Topical application of an imidazole
agent may be used to prevent reinfection.
Cutaneous Mycoses
These are superficial fungal infections of the skin,
hair or nails.
No living tissue is invaded, however a variety of
pathological changes occur in the host because of
the presence of the infectious agent and its
metabolic products.
Dermatophytosis
Dermatophytosis (tinea or ringworm) of the scalp,
glabrous skin, and nails is caused by a closely
related group of fungi known as dermatophytes
which have the ability to utilise keratin as a
nutrient source, i.e. they have a unique enzymatic
capacity [keratinase].
The disease process in dermatophytosis is unique
for two reasons:
o Firstly, no living tissue is invaded; the
keratinised stratum corneum is simply
colonised.
o However, the presence of the fungus and its
Clinical manifestations:
The common anthropophilic species are primarily
parasitic on man
They are unable to colonise other animals and
they have no other environmental sources.
On the other hand, geophilic species normally
inhabit the soil where they are believed to
decompose keratinaceous debris.
Natural habitat
Incidence
Epidermophyton floccosum
Humans
Common
Trichophyton rubrum
Humans
Very Common
Trichophyton interdigitale
Humans
Very Common
Trichophyton tonsurans
Humans
Common
Trichophyton violaceum
Humans
Less Common
Trichophyton concentricum
Humans
Rare*
Trichophyton schoenleinii
Humans
Rare*
Trichophyton soudanense
Humans
Rare*
Microsporum audouinii
Humans
Less Common*
Microsporum ferrugineum
Humans
Less Common*
Trichophyton mentagrophytes
Mice, rodents
Common
Trichophyton equinum
Horses
Rare
Trichophyton eriotrephon
Hedgehogs
Rare*
Trichophyton verrucosum
Cattle
Rare
Microsporum canis
Cats
Common
Nannizzia gypsea
Soil
Common
Nannizzia nana
Soil/Pigs
Rare
Lophophyton cookei
Soil
Rare
ANTROPOPHILIC
Trichophyton rubrum...
GEOPHILIC
Microsporum gypseum...
ZOOPHILIC
Tinea pedis
Infections by anthropophilic dermatophytes are
usually caused by the shedding of skin scales
containing viable infectious hyphal elements
[arthroconidia] of the fungus.
Desquamated skin scales may remain infectious in
the environment for months or years.
Substrates like carpet and matting that hold skin
scales make excellent vectors.
Thus, transmission of dermatophytes like
Trichophyton rubrum, T. interdigitale and
Epidermophyton floccosum is usually via the feet.
"Moccasin-type" tinea
pedis caused by E.
floccosum (left) and
vesicular type tinea
pedis caused by T.
interdigitale (right).
Tinea cruris
Tinea cruris refers to dermatophytosis of the proximal
medial thighs, preum and buttocks.
It occurs more commonly in males and is usually due to
spread of the fungus from the feet.
Thus the usual causative
agents are T. rubrum,
T. interdigitale and
E. floccosum.
Tinea unguium
(dermatophyte
onychomycosis)
Trichophyton rubrum and T.
interdigitale are the
dominant dermatophyte
species involved
Only 50% of dystrophic nails
have a fungal aetiology,
Essential to establish a
correct laboratory diagnosis
by either microscopy and/or
culture, before treating a
patient with a systemic
antifungal agent.
Tinea
Tinea corporis refers to
corporis
dermatophytosis of the
glabrous skin and may
be caused by
anthrophophilic species
such as T. rubrum (left)
usually by spread from
another body site or by
geophilic and zoophilic
species such as M.
gypseum and M. canis
(right) following contact
with either
contaminated soil or an
Tinea capitis
Tinea capitis refers to
dermatophytosis of the
scalp. Three types of in vivo
hair invasion are
recognised:
1. Ectothrix invasion is
characterised by the
development of
arthroconidia on the
outside of the hair shaft.
infected hairs usually
fluoresce a bright
greenish yellow colour
under Wood's ultraviolet
light. Common agents
include Microsporum
canis, Nannizzia.gypsea,
richophyton. equinum
3. Favus usually caused by Trichophyton schoenleinii, produces favuslike crusts or scutula and corresponding hair loss.
Laboratory diagnosis
Clinical Material
Skin Scrapings, nail scrapings and epilated hairs.
Laboratory needs enough specimen to perform both
microscopy and culture.
Any ointments or other local applications present should
first be removed with an alcowipe.
Using a blunt scalpel, tweezers, or a bone curette, firmly
scrape the lesion, particularly at the advancing border.
Direct Microscopy
Skin Scrapings, nail
scrapings and epilated
hairs should be examined
using 10% KOH and Parker
ink or calcofluor white
mounts.
Direct
Microscopy
KOH mount of infected
hairs showing "small
spored" ectothrix
invasion by M. canis
(left) and "large
spored" ectothrix
invasion by M.
gypseum (right).
Direct
Microscopy
KOH mount of an
infected hair
showing an
endothrix invasion
caused by T.
tonsurans.
Culture
Management
Treatment of dermatophytosis is often dependant on the
clinical setting.
uncomplicated single cutaneous lesions can be adequately
treated with a topical antifungal agent,
topical treatment of scalp and nail infections is often
ineffective and systemic therapy is usually needed to cure
these conditions.
Chronic or widespread dermatophyte infections, acute
inflammatory tinea and "Moccasin" or dry type T. rubrum
infection involving the sole and dorsum of the foot usually
also require systemic therapy.
Infection
Recommended
Tinea
Terbinafine 250 mg/day
unguium
6 weeks for finger nails,
[Onychomycos
12 weeks for toe nails.
is]
Tinea capitis
Griseofulvin 500mg/day
[not less than 10 mg/kg/day]
until cure [6-8 weeks].
Tinea cruris
Tinea pedis
Alternative
Itraconazole 200 mg/day/3-5 months or 400 mg/day for one
week per month for 3-4 consecutive months.
Fluconazole 150-300 mg/ wk until cure [6-12 months].
Griseofulvin 500-1000 mg/day until cure [12-18 months].
Terbinafine 250 mg/day/4 wks.
Itraconazole 100 mg/day/4wks.
Fluconazole 100 mg/day/4 wks
Terbinafine 250 mg/day for 2-4 weeks.
Itraconazole 100 mg/day for 15 days or 200 mg/day for 1week.
Fluconazole 150-300 mg/week for 4 weeks.
Griseofulvin 500mg/day
until cure [4-6 weeks].
Chronic and/or
widespread
Terbinafine 250 mg/day
nonfor 4-6 weeks.
responsive
tinea.