Skin fungal infection

Fungal diseases are classified into 4
groups:
According To Pathogenicity:
1• Superficial mycoses
2• Mucocutaneous mycoses
3• Subcutaneous mycoses
4• Deep mycoses/SYSTEMIC MYCOSIS

Who is at risk?
• Anyone with a weakened immune system may
be more likely to contract a fungal infection, as
well as anyone who is taking antibiotics.
• Cancer treatment and diabetes may also make a
person more prone to fungal infections.

Transmission
- Most commonly from another person less
by direct skin-to-skin contact
- From animals such as dogs or cats
- Least commonly from soil (Environmental).

Diagnosis ?
1) Clinical Diagnosis (Skin lesion )
2) Laboratory Examinations :
 Direct Microscopy :Sampling
 Wood Lamp : Darken room and illuminate
affected site with Wood lamp
 Fungal Cultures : Specimens collected
From scaling skin lesions, hair, nails.

Management
1) Prevention : Apply powder containing
imidazoles to areas prone to fungal
infection after bathing.
2) Topical antifungal
3) Systemic antifungal agents

Superficial fungal infections
Superficial fungal infections of the skin are
one of the most common dermatologic
conditions seen in clinical practice.

fungal infections
Superficial fungal infections are caused by numerous
fungi that are capable of superficially invading
the following:
1.Skin
2.Mucosal sites
3.These fungi are commensural organisms that frequently
colonize normal epithelium.
4.Infections can extend more deeply in the
immunocompromised host.

1▪ Skin
• Epidermis
• Hair/hair follicles
• Nail apparatus
2▪ Mucosal sites
• Oropharynx
• Anogenitalia

3▪ These fungi are commensural organisms that
frequently colonize normal epithelium.
•Dermatophytes: infect keratinized epithelium,
hair follicles, and nail apparatus
•Candida Albacans: Yeast infection
• Malassezia species: Require a humid
microenvironment and lipids for growth.

Dermatophytoses Of Epidermis
1) Tinea Pedis
2) Tinea corporis
3) Tinea cruris
4) Tinea manuum
5) Tinea Facialis
6) Tinea Incognito

Dermatophytoses of Hair
1) Tinea Capitis
2) Tinea Barbae
3) Dermatophytic Folliculitis
4) Majocchi Granuloma

Tinea Pedis
• Dermatophytic infection of the feet
• Clinical findings: erythema, scaling,
maceration, and/or bulla formation

EpidemiologyEpidemiology
• Age of Onset :
Late childhood or young adult life. Most
common, 20–50 years.
• Sex : Males > females.
• Predisposing Factors : Hot, humid
weather; occlusive footwear; excessive
sweating.

• Transmission :
Walking barefoot on contaminated floors.
Arthrospores can survive in human scales
for 12 months.

Clinical Manifestation
• Duration : Months to years or lifetime .
• Skin Symptoms :
Usually Asymptomatic
Pruritus
Pain with bacterial superinfection.

Skin Lesions
4 Types :
1. Interdigital Type
Two patterns:
• Dry scaling
• Maceration, peeling, fissuring of toe
webs. Hyperhidrosis common.
• Most common site: between fourth and
fifth toes. Infection may spread to
adjacent areas of feet.

Tinea pedis: interdigital dry type

Tinea pedis: interdigital macerated type

2. Moccasin Type :
• Well-demarcated erythema with minute
papules on margin, fine white scaling, and
hyperkeratosis(confined to heels, soles,
lateral borders of feet).

3. Inflammatory/Bullous Type :
•Vesicles or bullae filled with clear fluid .
•Pus usually indicates superinfection with S.
aureus infection or GAS.

4. Ulcerative Type :
Extension of interdigital tinea pedis onto
dorsal and plantar foot.

Diagnosis ?
• Direct Microscopy :In bullous type, examine
scraping from the inner aspect of bulla roof for detection of
hyphae.
 Wood Lamp
 Fungal Cultures : for fungal and bacteria

Management
• Tinea pedis can be treated with topical or oral
antifungals or a combination of both.
topical agents are used for 1-6 weeks.
 Antifungal agent :
Topical antifungal :
• Miconazole (Micatin)
• Ketoconazole (Nizoral)
• Econazole (Spectazole)
• Oxiconizole (Oxistat)
Systemic antifungal :
•Fluconazole :150-, 200-mg tablets;
oral suspension (10 or 40 mg/mL)
•Ketoconazole : 200-mg tablets

Secondary prophylaxis:
Important in preventing recurrence T.pedis. Daily washing
of feet while bathing with benzoyl peroxide bar is effective
and inexpensive. Antifungal powders, alcohol gels.

Subacute or chronic dermatophytosis of
the groin, pubic regions, and thighs.
 “Always” associated with tinea pedis, the
source of the infection.
 Synonym : “Jock itch.”
Tinea Cruris

Epidemiology And Etiology
• Age of Onset :
Adult.
• Sex :
Males > females.
• Etiology :
Trichophyton rubrum, T.mentagrophytes .

Predisposing Factors:
1)Warm, humid environment.
2) tight clothing worn by men.
3) obesity
4)Chronic topical glucocorticoid application.

• Duration: Months to years. Often, history
of long-standing tinea pedis and prior
history of tinea cruris.
• Skin Symptoms: Often none. In some
persons pruritus .

Skin Lesions
• Large, scaling, well-demarcated dull red
/brown plaques
• Papules, pustules may be present at margins .

Distribution
• Groins and thighs; may extend to
buttocks. Scrotum and penis are rarely
involved.

Management
Antifungal AgentsAntifungal Agents
Topical :
Systemic : If recurrent, if dermatophytic
folliculitis is present, or if it has failed to
respond to adequate topical therapy. See
“Management,”(before )

Management
• Prevention:
After eradication of tinea cruris, tinea pedis, and
tinea unguium, reinfection can be minimized by
wearing shower shoes when using a public or
home (if family members are infected) bathing
facility; using antifungal powders; benzoyl
peroxide wash; alcohol gels.

Dermatophytosis of the glabrous facial
skin
 Well-circumscribed erythematous patch
 More commonly misdiagnosed than any
other dermatophytosis.
Synonym : ((Tinea faciei))
Tinea Facialis

• Age of Onset:
More common in children.
• Etiology:
T. tonsurans associated with tinea
capitis in black children and their parents.
T.mentagrophytes, T. rubrum most
commonly; also M. audouinii, M. canis.

Predisposing Factors :
1. Animal exposure
2. chronic topical application of
glucocorticoids.

Skin Symptoms:
•Most commonly asymptomatic.
•At times, pruritus and photosensitivity.

Skin Lesions
1. Well-circumscribed macule to plaque of variable
size; elevated border and central regression

2. Scaling is often minimal but can be
pronounced.
3. Pink to red.
4. In black patients,
hyperpigmentation.
5. Any area of face but
usually not symmetric.

Management
Antifungal Agents
See before

• Epidermal dermatophytosis, often associated with
dermatophytic folliculitis.
• Occurs after the topical application of a
glucocorticoid preparation to a site colonized or
infected with dermatophyte.
• Occurs when an inflammatory dermatophytosis is
mistaken for psoriasis or an eczematous
dermatitis .
Tinea Incognito

• Lesions are usually aymptomatic but may
be very pruritic or even painful.
• Involved sites often have exaggerated
features of epidermal dermatophytoses,
being a deep red or violaceous with
follicular papules or pustules.
• Epidermal atrophy caused by chronic
glucocorticoid application may be present.
• Systemic antifungal therapy may be
indicated due to deep involvement of the
hair apparatus.

 Differential Diagnosis of Tinea Incognito
- Dermatitis
- Other forms of Tinea

Trichomycosis
1) Tinea Capitis
2) Tinea Barbae
3) Dermatophytic Folliculitis
4) Majocchi Granuloma

• Dermatophytes are capable of invading
hair follicles and hair shafts, causing
dermatophytic trichomycosis .
• Two types of hair involvement are
seen:
Dermatophytic folliculitis

Tinea Capitis
• Dermatophytic trichomycosis of the scalp.
• Synonyms : Ringworm of the scalp

• Age of Onset:
school-age children. Most common at 6–
10 years of age; less common after age
16. In adults it occurs most commonly in a
rural setting.
• Race:
Much more common in blacks than in
whites.

• Etiology:
90% of cases of tinea capitis caused by
T. tonsurans
most cases were caused by: M. audouinii .
Less commonly :
M. gypseum, T.mentagrophytes, T. rubrum.

Transmission
• Person-to-person, animal to-person, via
fomites.
• Spores are present on asymptomatic
carriers, animals, or inanimate objects.
• Risk Factors: For favus : debilitation,
malnutrition, chronic disease .

Duration : Weeks to months
Skin Symptoms:
 Inflammatory tinea capitis:
•Pain, tenderness
•± Alopecia
• Noninflammatory infection:
•Scaling
•Scalp pruritus
•Diffuse or circumscribed alopecia
•Occipital or posterior auricular adenopathy

Skin Lesions
1. Small-Spored Ectothrix Tinea Capitis :
’’Gray patch” tinea capitis

2. Endothrix Tinea Capitis:
“Black dot” tinea capitis :
Broken-off hairs near surface give
appearance of “dots” (swollen hair shafts) in
dark-haired patients. Dots occur as affected
hair breaks at surface of scalp. Tends to be
diffuse and poorly circumscribed.

Tinea capitis: ”black dot” variant

Kerion :
• Inflammatory mass in which remaining
hairs are loose.
• Characterized by boggy, purulent,
inflamed nodules and plaques
• Usually extremely painful; drains pus from
multiple openings, like honeycomb.

Kerion An extremely painful, boggy, purulent inflammatory
nodule on the scalp of this 4-year-old child.

Tinea capitis: favus Extensive hair loss with atrophy,
scarring, and so-called scutula, i.e., yellowish adherent
crusts present on the scalp; remaining hairs pierce the
scutula. Trichophyton schoenleinii was isolated on culture.

Diagnosis ?
• Direct Microscopy :Specimens should include hair
roots and skin scales.
 Fungal Cultures : for fungal and bacteria
With brush-culture technique .

Management
1. Prevention : Ketoconazole or selenium
sulfide shampoo may be helpful in eradicating
the asymptomatic carrier state.
2. Topical antifungal : Topical agents are
ineffective in management of tinea capitis.
Duration of treatment should be extended until
symptoms have resolved and fungal cultures
negative.

3. Oral antifungal agents :Griseofulvin is
considered the drug of choice in the United States.
Short term terbinafine, itraconazole, and
fluconazole have been shown to be comparable in
efficacy and safety to griseofulvin .
4. Adjunctive therapy : -Prednisone
-Systemic antibiotics
5. Surgery: Drain pus from kerion lesions.

Tinea Versicolor
Pityriasis Versicolor (PV)
•Chronic asymptomatic scaling
epidermomycosis
• Associated with the superficial overgrowth
of the hyphal form of Malassezia furfur

Clinical findings:
▪ Well-demarcated scaling patches
▪ Variable pigmentation: hypo- and
hyperpigmented; pink Most commonly
on the trunk.

• Age :
Young adults
• Etiology :
M. furfur (previously known as
Pityrosporumovale, P. orbiculare )

Predisposing Factors
1)Warm season or climates; tropical climate
2)Hyperhidrosis; aerobic exercise
3)Oily skin
4)Glucocorticoid treatment
5)Immunodeficiency
6)Application of lipids such as cocoa butter
7)predisposes young children to PV

Duration : Months to years .
Skin Symptoms:
Usually none.
Occasionally, mild pruritus.
Individuals with PV usually present because
of cosmetic concerns about the
dyspigmentation.

Skin Lesions
• Macules, sharply marginated round or oval in
shape, varying in size.
DDx ?

Pityriasis versicolor:
Hyperpigmented
A 23-year-old obese black female
with discoloration of the neck for 1
year. Sharply marginated brown
scaling macules on the left side of the
neck.
The velvety texture and
hyperpigmentation
of the skin of the neck is
acanthosis nigricans associated with
obesity.

Pityriasis versicolor:
Hyperpigmented
A 36-year-old male with
pigmented patches on trunk and arms for
several years. Multiple pink, well
demarcated scaling macules becoming
confluent on the upper and lateral trunk,
neck and arm.

Laboratory Examinations
• Direct Microscopic Examination of
Scales Prepared with KOH :
Filamentous hyphae and globose yeast
forms,termed spaghetti and meatballs ,
• Wood Lamp: Blue-green fluorescence of
scales.

Management
1. Topical antifungal :
- Selenium sulfide (2.5%) lotion or
shampoo
- Ketoconazole shampoo
2. Systemic therapy:
- Ketoconazole 400 mg
- Fluconazole 400 mg stat
- Itraconazole 400 mg stat
3. Secondary prophylaxis :Ketoconazole
or selenium sulfide shampoo

Tinea Unguium/Onychomycosis
• is a fungal infection of the nail. This condition
may affect toenails or fingernails, but toenail
infections are particularly common.

• Age :
Children or adults.
• Etiology :
• Between 95 and 97% caused by T. rubrum and T.
mentagrophytes. Much less common: Epidermophyton
floccosum, T. violaceum, T. schoenleinii, T. verrucosum
(usually infects only fingernails).
• Sex :
Somewhat more common in men.

Geographic Distribution
• Worldwide. Etiologic agent varies in
different geographic areas. More common
in urban than in rural areas (associated
with wearing occlusive footwear).

Transmission
transmitted from one individual to another,
by fomite or direct contact,
commonly among family members.
Some spore forms (arthroconidia) remain
viable and infective in the environment for
up to 5 years.

Risk Factors
 Diabetes mellitus.
Treatment with immunosuppressive drugs.
HIV/AIDS
 For toenail onychomycosis, most
important factor is wearing of occlusive
footwear .

• Approximately 80% of onychomycosis occurs on
the feet, especially on the big toes .
 3 Types :
1 . DLSO: (distal and lateral subungual type)
White patch is noted on the distal or lateral
undersurface of the nail and nail bed, usually
with sharply demarcated borders. In time,
whitish color can become discolored to a brown
or black hue.

Onychomycosis of toenails: distal and lateral
subungual type (DLSO)

Onychomycosis of toenails: distal and lateral subungual
type (DLSO)

2. SWO : (superficial white Onychomycosis)
A white chalky plaque is seen on the
proximal nail plate, which may become
eroded with loss of the nail plate

3. PSO : (proximal subungual onychomycosis )
A white spot appears from beneath
proximal nail fold. In time, white
discoloration fills lunula, eventually moving
distally to involve much of undersurface of
the nail.

Laboratory Examinations
• All clinical diagnoses of onychomycosis should
be confirmed by laboratory testing .
• Nail Samples:
For :
DLSO: distal portion of involved nail bed;
SWO: involved nail surface;
PSO: punch biopsy through nail plate to involved nail bed.

• Direct Microscopy :
Direct microscopic examination of nail samples is
used to confirm the clinical diagnosis.
• Fungal Culture
• Histology of Nail Clipping :
Indicated if clinical findings suggest onychomycosis
after negative KOH wet mounts. PAS stain is
used to detect fungal elements in the nail. Most
reliable technique for diagnosing
onychomycosis .

Management of Tinea Unguium
1. Debridement :
is the medical removal of dead, damaged, or infected
tissue to improve the healing potential of the remaining
healthy tissue.

2. Topical agents :
Available as lotions and lacquer. Usually not
effective except for SWO.
Ciclopirox (Penlac) nail lacquer: monthly
professional nail debridement
recommended.

3. Systemic agents :
such as itraconazole appear effective in the
treatment of onychomycosis
Itraconazole:
200 mg/d for 6 weeks (fingernails),
12 weeks (toenails) (continuous therapy).

Indications for Systemic Therapy
 Fingernail involvement,
 limitation of function,
 pain (thickened great toenails with pressure on
nail bed, ingrowing toe nails).
 physical disability.
 potential for secondary bacterial infection.
 difficulty in trimming nails .

• SOURCE: From FITZPATRICK’S COLOR ATLAS
AND SYNOPSIS OF CLINICAL DERMATOLOGY
SIXTH EDITION

Skin fungal infection

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