DERMATOPHYTOSIS

Chiara Noli, DVM, Dip ECVD

Servizi Dermatologici Veterinari, Peveragno (CN), Italy
www.dermatologiaveterinaria.it – www.servizidermavet.it

Dermatophytes attack the keratin structures of the epidermis and, being an important zoonosis
should be recognized and vigorously treated, even if appearing as a mild clinical entity.
There are more than 38 species of dermatophytes know to be pathogenic to man and animals. The
three genera Microsporum, Trichophyton and Epidermophyton are capable of invading the keratin
of the stratum corneum, hair and nails of domestic animals, even if the affected animal is not their
natural host.

Etiopathogenis
About 98% of feline dermatophytosis cases are caused by Microsporum canis. This fungus is well
adapted to this species and the cat represents the natural reservoir of M. canis. Dermatophytes are
not members of the normal feline skin flora and isolation of the fungus represents either a clinical
case or an asymptomatic carrier. The incidence of this disease varies geographically and dependent
on the coat length. Cats who wander or live in contact with other animals are predisposed.
Trichophyton infections are relatively rare. Rodents can be asymptomatic carriers of T.
mentagrophytes or infection can be transmitted from soil or infected horses and cattle.
Canine dermatophytosis is less common and is often associated with immunosuppression (e.g.
transport stress or parasitism in puppies) or an infected cat in the environment. M. canis is also the
major canine pathogen but cases of soil based infection of T. mentagrophytes occur, mainly in rural
areas, on parts of the body in contact with the ground. There is a breed predisposition: Yorkshire
terriers have a predisposition for M. Canis while Jack Russell terriers have a higher incidence of
Trichophyton infection.
Transmission is by spores or fragments of skin and hair, either directly or through fomites such as
bedding and combs. Spores are extremely resistant and may survive up to 18 months in the
environment. To cause infection, the spores must penetrate the epidermis or enter the interior of the
hair follicle. Contact does not always result in infection because spore penetration is prevented by
grooming behavior of the host (especially cats), normal epidermal shedding and inhibition by the
resident skin microflora.
Dermatophytes derive their nutrition from the breakdown of keratin by fungal keratinase and hair in
anagen phase provides a good medium for fungal growth. The host immune response is vital to the
elimination of dermatophyte infection. Antibodies of the IgG and IgM classes are produced against
dermatophytes, but the more important response is based on cell mediated immunity. Patients
predisposed include young animals that are not yet fully immunocompetent, those in lactation or
pregnancy and those with debilitating or immunosuppressive disease (e.g. FIV/FeLV). Ectoparasites
support dermatophyte infection and spread. Scratching not only damages the skin, allowing
penetration of the spores, but also spreads contaminated skin fragments in the environment.

Clinical picture
The cat is, in general, a more tolerant host of M. Canis than the dog. The alopecic lesions often
show minimal inflammation and asymptomatic carriers are not uncommon.
Dermatophytosis in the cat is a polymorphic disease who’s severity depending on the immune status
and reaction of the patient. Feline dermatophytosis may present anywhere from an asymptomatic
carrier to an infection that devastates the deep tissues and, hence, dermatophytosis needs to be
considered as a differential diagnosis in almost all feline dermatoses. The presence or absence of
pruritus is not useful in diagnosis as some cases can present with severe pruritus.
The most common forms of feline dermatophytosis are:
a) Asymptomatic carriers who display no obvious lesions but return a positive fungal culture.
Often, these cases are suspected when an in-contact person or animal develops dermatophytosis.
Asymptomatic carriers, especially in the Persian breeds, may develop after apparent cure of a
clinical case.
b) Focal areas of non-inflammatory alopecia with broken hairs in the center and easily epilated
hair at the periphery. This is the most common manifestation, especially in kittens. The areas
most in contact with the carrier mother (face, ears and feet) are common sites of infection.
c) Small crusts and scales, often pruritic, and similar to miliary dermatitis. This form can be
provoked by microlesions from close clipping.
d) Annular lesions with inflammation and papules at the periphery and regrowth of hair centrally.
This is the most common form in dogs and humans but less so in cats.
e) Generalized diffuse alopecia with variable levels of scale, inflammation, pruritus and crusts.
This form is most common in immunocompromised cats.
f) Pseudomycetomas are granulomatous ulcerated nodules, mainly described in Persian cats. The
nodules are often generalized.

In the dog, M. canis infection presents as one or more rounded localized areas of alopecia or
generalized with desquamation, inflammation and pruritus. Some generalized cases , especially in
the Yorkshire terrier, may present with greasy scales consistent with seborrhea oleosa . In other
cases, a secondary infection occurs resulting in furunculosis, kerion and granuloma formation.
Infection with T. mentagrophytes or M. gypsium is less common and often involves the areas of the
body in contact with the soil reservoir (limbs and muzzle). Dogs who spend a lot of time outdoors
are predisposed.. The lesions are often quite pruritic and may show evidence of self trauma from
licking or scratching and kerion formation (ulcerated nodules with furunculosis, exudate and crusts)
is common. T. mentagrophytes or M. gypsium can infect the nails or nail beds. Onychomycosis
presents as loss of nails (onychomadesis) or deformed growth (onychogryphosis) and discharge
from the nail bed if secondarily infected.
T. mentagrophytes or M. persicolor can infect the skin of the face producing pustular/papular crusty
lesions on the nasal planum resulting in a depigmenting dermatitis. These lesions are very similar
to those of pemphigus foliaceus, an important differential diagnosis. Dermatophyte
pseudomycetoma is very rare in the dog, a few cases caused by M. gypsium have been recognized.

Diagnosis
Given the great variability of clinical presentations the list of differential diagnosis is long. In the
dog, focal disease needs to be differentiated from demodecosis and bacterial folliculitis and other
causes of focal alopecia. Generalized dermatophytosis with alopecia adds the differentials of
hormonal disease or diffuse superficial pyoderma. Dermatophyte kerion lesions can easily be
confused with foreign body granulomas, ulcerating tumors (e.g. histiocytoma), lick granuloma or
deep pyoderma. Involvement of the nasal planum in cases of infection with M. persicolor or T.
mentagrophytes can appear like discoid lupus erythematosus or pemphigus foliaceus. The pruritic
form of dermatophytosis mimics allergic skin disease. Onychomycosis needs to be differentiated
from bacterial infections and lupoid or idiopathic onychodystrophy.
In the cat miliary dermatitis is a sign of many skin disorders including allergy (fleas, atopic
dermatitis and dietary), skin parasites (Cheyletiella and other mites), bacterial folliculitis and fatty
acid deficiency. Dermatophyte pseudomycetoma should be differentiated from sterile nodular
panniculitis or deep bacterial or fungal infections. Given that dermatophytosis is both a hazard for
in contact animals and a zoonosis, the clinician should carefully evaluate all suspicious cases.

Therapy
In an animal with a normal immune system dermatophytosis is a self-limiting disease that resolves
within a period of months to years, however all cases should be treated. Dermatophytes are not part
of the normal skin flora. Especially in the case of M. Canis, spread to other animals, contamination
of the environment and contagion to humans are significant issues. M. Canis is a significant
zoonosis, particularly dangerous to children and immunosuppressed individuals. Over 50% of
persons exposed to infected cats will develop dermatophytosis and 15% of human dermatophyte
infections are of animal origin.
Contrary to past opinions, systemic therapy is always required even in the case of localized disease.
Fungi can be isolated from “normal” skin located well away from an obvious lesion and systemic
therapy results in more rapid cure. Topical therapy reduces the number of spores and hyphae on the
skin. These fungal elements are not exposed to circulating systemic antifungal agents until the drug
has been incorporated into new keratin. Topical therapy reduces environmental contamination and
contagion, shortens the duration of systemic therapy and reduces the risk of relapse. The usual
therapeutic protocol is systemic therapy combined with 1-2 times a week shampooing or soaking
with a topical fungicide.

Topical therapy
Prior to beginning treatment, clipping the coat is vital. The hair should be clipped with a 2-3cm
margin from localized lesions but in the case of generalized dermatophytosis or patients with a long
coat the whole animal should be clipped. The clipping may need to be repeated monthly. Clipping
should be done carefully as trauma to the epidermis provides a portal of entry for dermatophytes.
Topical treatment should be applied 1-2 times weekly until cured. The more effective topical
treatments include the azole derivatives (miconazole, ketoconazole, econazole and enilconazole)
and lime sulfur. Recent evidence casts doubt on the effectiveness of chlorhexidine in
dermatophytosis. Enilconazole is highly effective and has resulted in negative fungal cultures after
only two applications but is only registered for use in dogs and horses. Enilconazole has been
extensively used in cats but adverse reactions, including death, have been reported after even a
single application. Commercial shampoos containing econazole or miconazole are now registered
for cats and are to be preferred over medications for humans. Chlorhexidine foams and shampoos
are useful if at high percentage (over 2%). Povidone iodine is irritant and stains the coat. Creams
are generally of reduced value as they are licked off. Creams or lotions are useful in animals too
young for systemic therapy. In-contact animals should be considered infected and treated at least
with topical therapy.

Systemic therapy
The drugs currently used for systemic therapy of dermatophytosis are griseofulvin, ketoconazole,
itraconazole and terbinafine.
Griseofulvin
Griseofulvin is still widely used in veterinary medicine and will cure nearly all cases of M. Canis
and many cases of T. mentagrophytes. Griseofulvin acts on the microtubules of the fungal cell
inhibiting mitosis and hence, is fungistatic rather than fungicidal and is effective only against
actively dividing fungal cells. The clearance of the fungus relies on an exfoliation of the infected
keratin and hair and an effective immune system. Prior to therapy, cats should be checked for FIV
and FeLV.
Absorption of griseofulvin is enhanced by being given with a fatty meal. Ultramicrosized forms of
griseofulvin are better absorbed at can be used at a lower dose. In man, griseofulvin enters the
stratum corneum by passive diffusion and active secretion by the apocrine glands, remaining there
for 36-72 hours after administration. Because of this short duration of action and its fungistatic
action, griseofulvin should be given daily for at least 6 weeks. Treatment should be continued at
least until the lesions have resolved and preferably confirmed by a negative culture. The standard
dose for cats is 40-50 mg/kg/day and dogs 50-100mg/kg/day. The use of the ultramicrosized form
allows a reduction to 1/3 of these dose rates.
The drug may produce gastrointestinal side effects, in which case, the clinician may wish to switch
to an alternative drug. Lethal bone marrow suppression can occur in cats especially Siamese,
Himalayan and Abyssinian breeds and cats positive to FIV and FeLV. Alternative drugs
(itraconazole) should be considered in these breeds and individuals. Cats receiving griseofulvin
should be have their hematological parameters monitored monthly. Delayed toxic reactions, with
systemic signs, weeks after therapy has been stopped have been reported. Griseofulvin is highly
teratogenic and must not be used in breeding animals. Griseofulvin should not be given before six
weeks of age.

Ketoconazole
Ketoconazole is a fungistatic imadazole that inhibits ergosterol synthesis in the fungal and yeast cell
membrane. Ketoconazole is better absorbed with acidic food such as tomato juice. Skin levels are
maintained for at least 10 days after administration and thus ketoconazole can be given for a shorter
period than griseofulvin. The standard dose for cats is 5mg/kg BID and 5-10mg/kg BID for dogs
and maintained for at least 30 days.
Up to 50% of strains of M. canis are resistant to ketoconazole and the drug offers no advantages
over griseofulvin for routine use. Ketoconazole has a role in dogs that fail to tolerate griseofulvin or
in cases of resistant Trichophyton infection.
In cats, and sometimes in dogs at high dose rates, the drug causes elevations in liver enzymes and
occasional hepatotoxicity. Ketoconazole inhibits steroid hormone synthesis, resulting in adrenal
suppression and lowered testosterone levels. Gastrointestinal side effects also occur. Ketoconazole
should not be used in pregnant animals or patients under six weeks of age.

Itraconazole
Itraconazole has a similar but more specific action similar to ketoconazole. It is much more
effective and less toxic than ketoconazole or griseofulvin. Itraconazole accumulates in the skin and
levels in the sebaceous glands may be ten times that of plasma. Therapeutic levels persist in the
epidermis for 2-4 weeks after administration. Itraconazole is best absorbed with food and given at a
dose rate of 5-10mg/kg daily. The drug is available in 100mg capsules and, in some countries, as a
10mg/ml solution. The capsules may be opened, mixed with butter and stored in the refrigerator to
dose smaller patients. Because of its accumulation and persistence in skin, itraconazole can be used
on an alternate week schedule (1 week on, 1 week off) for a total of 6-8 weeks. Itraconazole is the
drug of choice for pseudomycetoma of the Persian cat. The granulomas may be so well
encapsulated that the drug fails to penetrate effectively. In such cases, itraconazole should be given
until the nodules have shrunk to a size suitable for surgical resection and then continued for at least
4-6 weeks post surgery.
Gastrointestinal side effects occur with itraconazole together with mild elevations in liver enzymes.
A slight rise in ALT indicates good absorption but levels above 200IU/l suggest the dose should be
lowered or therapy suspended. A lack of any rise in ALT indicates that the drug is being given at too
low a dose or not on a full stomach. An idiopathic vasculitis, with deep crater like ulcers, has been
reported in dogs on prolonged high doses. In a recent study, 7.5% of dogs treated with itraconazole
at 10mg/kg developed signs of vasculitis while dogs treated with 5mg/kg were not affected. There is
no evidence of teratogenic side effects but there have been no studies to confirm the safe use of
itraconazole in pregnancy. Fluconazole has not been well studied in animals with dermatophytosis,
and currently there is no evidence of any superiority to itraconazole.

Terbinafine
Terbinafine is fungicidal with actions against the fungal cell wall and membrane. Normal dose rates
quoted are between 10-20mg/kg daily but dose rates of 30-40mg/kg day have produced faster cure
rates in a study with cats. The drug accumulates in sebum, keratinocytes and hair follicles and
maintains therapeutic levels for up to 2-3 weeks after administration. Terbinafine is indicated in
cases of resistant M. canis infections or in cases of onychomycosis where traditional therapy
required 6-12 months of treatment. Terbinafine has poor activity against yeasts. Liver enzyme
elevation can occur but the drug is regarded as safe and highly effective. No studies have indicated
that terbinafine is superior to itraconazole.

Monitoring therapy
Standard treatment is systemic treatment for at least six weeks combined with once or twice a week
topical therapy. After five weeks, the topical therapy can be suspended. On the sixth week, perform
a fungal culture from material collected using the McKenzie toothbrush technique. While awaiting
the results, the systemic therapy should be continued. Should the culture be negative then treatment
can be suspended. If positive, treatment should continue for a further four weeks and then a further
culture taken. Should this also be positive then the clinician should consider an alternative
antifungal agent and re-evaluate the program of environmental decontamination.

Environmental decontamination
Spores remain viable in the environment for up to 18 months but the most important contaminant is
pieces of infected hair. It is essential to decontaminate the environment of the patient, limit the area
in which the animal has access and to minimize contact with other animals and persons.
Disinfectants showing the best results are either 1:10 solutions of common bleach (diluted to 0.05 -
0.5% sodium hypochlorite) or enilconazole spray (marketed for Aspergillus control in poultry
houses). Chlorhexidine alone is ineffective as an environmental decontaminant. Curtains and
carpets can be vacuumed then steam cleaned with added disinfectant. This process should be
repeated monthly. All surfaces should be cleaned twice weekly with a disinfectant solution and any
combs or other objects in contact with an infected animal should be soaked for at least 10 minutes
in a bleach solution. Air conditioning ducts should be disinfected and the filters changed.