Académique Documents
Professionnel Documents
Culture Documents
net/publication/236865866
CITATIONS READS
3 1,818
5 authors, including:
Some of the authors of this publication are also working on these related projects:
All content following this page was uploaded by Pradyot Prakash on 02 June 2014.
1
Department of Microbiology, 2Department of Forensic Medicine, Institute of Medical Sciences, Banaras Hindu
University, Varanasi-221005, India.
Abstract
Cutaneous fungal infections are a widespread public health concern affecting millions of people all across the world.
Nearly half of those affected will experience multiple episodes of infection requiring numerous rounds of treatment.
Tinea pedis is a common superficial fungal skin infection of the feet. It is emerging as an important and a significantly
prevalent infection in an increasingly aging population and immunocompromised patients. This mycotic infection is
contagious, frequently misdiagnosed and often inadequately treated. Considering the uprising prevalence of tinea
pedis, in this review article predisposing factors, etiologic agents involved in pathogenesis, clinical presentation of
the disease, proper diagnostic tests and the treatment options commercially available are reviewed.
Key Words: Tinea pedis; Dermatophytes; KOH Mount; PAS Reaction
T. mentagrophytes (20%), Epidermophyton floccosum with maceration, denudation of the skin and oozing.
(10%) and more rarely by M. canis and T. tonsurans.
4.4. Vesicobullous Tinea pedis: It is the least common
However, the true etiology in any given patient may be
form of this infection. Patients with this type of tinea
complicated by the presence of saprophyte fungi, yeast
pedis experience small vesicles and blisters on
and /or bacteria. It has been observed that 9% of the
erythematous base, usually near the instep and adjacent
cases of tinea pedis are caused by infecting agents other
plantar surface of the feet sometimes pustules are also
than dermatophyte. Nondermatophyte fungi Malassezia
found in this type but characteristically they are small
furfur, bacterium Corynebaceterium minutissimum and
and associated with clear vesicles. Vesicles filled with
yeast such as Candida species were also found to be
pus rather than clear fluid are indicative of secondary
responsible for tinea pedis.11,12
bacteraemia usually Staphylococcus aureus.10
4. Clinical Presentation Other variants include interdigital infections in which
There are four distinct clinical types of tinea pedis - inter-
dermatophyte damages the stratum corneum and causes
digital, hyperkeratotic, ulcerative and vesicular, each with
subsequent maceration and leukokeratosis resulting from
a characteristic pattern of skin manifestations. (Fig. 1)
overgrowth of bacteria such as Micrococcus, Sedantarious,
4.1. Interdigital Tinea pedis: It occurs in two forms, Brevibacterium epidermidis, C. minutisimum.13, 14
most common form of this infection usually arise in the
5. Differential Diagnosis
interspaces between 4th and 5th toes, occasionally
In clinical practise, diagnosis of tinea pedis is often
spreading to the underside of the foot. First type of
based on clinical presentation, direct microscopic ex-
interdigital tinea pedis, known as Dermatophytosis
amination of skin scrapings and mycology culture.15 Der-
simplex, is largely asymptomatic and presents as dry,
matophytosis of the foot may be symptom of a number
scaly, minimally peeling interspaces with occasional
of conditions similar in appearance to tinea pedis, rein-
pruritus. The second form Dermatophytosis complex is
forcing the need to positively identify infection through
symptomatic and usually presents with wet, macerated
testing. The clinical differential diagnosis of cutaneous
interdigital spaces along with fissuring of the interspace,
eruptions of the foot includes many look-alike condi-
hyperkeratosis, leukokeratosis and erosions.
tions, such as contact dermatitis, psoriasis, dyshydrosis,
eczema, atopic dermatitis, keratoderma, lichen planus
and some bacterial infections like C. minutissimum,
Streptococcal cellulitis etc. are also commonly confused
with tinea pedis.
6. Laboratory Diagnosis
An accurate diagnosis of tinea pedis should include
proper diagnostic tests in addition to clinical diagnosis.
Appropriate identification and treatment of tinea pedis
upon a patient initial presentation has the potential to
Figure-1: Tinea pedis - On the sole of the foot significantly reduce patient discomfort, risk of transmis-
4.2. Hyperkeratotic or Moccasin type Tinea pedis: This sion and morbidity associated with the infection.17 Diag-
consists of scaling and hyperkeratosis involving the nostic accuracy of the tests, fungal culture on SDA and
plantar and lateral aspect of the foot, resembling a KOH preparation of skin scrapings varies from 50-70%.13
slipper. Infection with moccasin type tinea pedis is 6.1. KOH Mount
generally bilateral and is often accompanied by subun-
Direct microscopic examination for fungal elements is
gual onychomycosis. This type of infection is thought to
considered to be rather insensitive method, with
be due to Trichophyton rubrum, usually in patient with
approximately 15% false negative, depending on the
an atopic background or a hereditary predisposition to
inappropriate testing material, insufficient scraping
infection.1, 13
amount, outdated or defective KOH solution and the
4.3. Ulcerative Tinea pedis: There is an acute ulcera- experience of the observer.18 Upon microscopic
tive process usually affecting the soles and associated examination finding septate or branched hyphae,
Asian Journal of Medical Sciences 2 (2011) 134-138
arthrospore, or in some cases, budding cells provides be standardized for routine clinical laboratories.
evidence of fungal infection. PCR – RFLP is a technique with poor discriminative
power to make an easy and specific diagnosis. Real time
6. 2. Culture
PCR appears to be promising but is not practical enough
Culture of suspected tinea pedis lesions are performed
for a large number of laboratories that are either small
on Sabouraud’s dextrose agar (SDA).The acidic pH of 5.6
scale or very tightly budgeted. Nested PCR for skin
for this medium inhibits many species of bacteria and
dermatophytoses was observed to be more sensitive for
can be made more selective with an addition of a
the detection of dermatophytes than culture isolation,
chloramphenicol supplement. The culture can take 2-4
KOH microscopy, and single-round PCR. Further nested
weeks to complete.19 Dermatophyte test medium (DTM)
PCR is helpful for the diagnosis of cases with
is used for selective isolation and recognition of
dermatophytoses which were recently treated with
dermatophytic fungi is another diagnostic option, which
antifungal agents and showed uncultivable filaments and
relies on colour indication that changes from orange to
also grew as spurious moulds which were difficult to
red to signify the presence of dermatophytes. Results of
identify.26 It may therefore be concluded that nested
DTM have been shown to be only about 60% accurate.20
PCR targeting the CHS1 gene may be considered the gold
6.3. Periodic Acid Schiff Stain/ PAS Reaction Test standard for detection of dermatophytes in patients
It is the preferred test for the diagnosis of tinea pedis with dermatophytoses.27
infection. The PAS stain reliably demonstrates the 6. 6. Mass Spectrometry
polysaccharides- laden wall of the fungal organism
Matrix assisted laser desorption/ ionization time of flight
associated with this condition and is one of the most
(MALDI -TOF) technique has been applied for the rapid
widely used technique for detecting protein bound
and reliable identification of microorganism including
carbohydrate (glycoprotein). This test is performed by
dermatophytes belonging to the texa Trichophyton
exposing tissue of various substrates to a series of
rubrum, T.tonsurans and Microsporum canis. This
oxidation– reduction reactions, as an end result, positive
approach detects highly abundant proteins in a mass
elements such as carbohydrates, basement membrane
range between 2 and 20 kDa, serving as taxon specific
material become candy apple red. These PAS positive
biomarkers. The striking advantage of mass spectral
components contrast sharply against a pink blue
approaches over genetical or morphological procedures
background. Unlike SDA or DTM cultures, PAS results are
is the very simple and straight forward sample
available in approximately 15 minutes. PAS has also been
preparation procedure and the short time required for
found to be the most reliable diagnostic test for tinea
analysis. The complete analysis including sample
pedis, with 98.8% efficacy and least cost effective. 21
preparation and data evaluation is completed within
6. 4. Confocal Microscopy minutes.28
New and more sensitive techniques are being 7. Prevention
investigated, such as confocal microscopy, but these
Tinea pedis or Athlete's foot is one of the most common
techniques may not be ready for widespread use for
of all foot ailments. Good patient education, with
some time.22Confocal microscopy is a non-invasive
simple instructions as to the importance of foot hygiene,
technique that provides high resolution images of intact
can help prevent and minimize the progression of tinea
skin comparable to routine histology, without requiring
pedis. Good education consists of proper hygiene
specimen preparation.
instructions, emphasizing the importance of drying the
6. 5. Molecular Methods feet, practicing good nail care, and wearing properly
Recently, molecular biology-based techniques, such as fitting shoes with clean dry socks. It is important to
PCR followed by restriction fragment length promote preventive measures, thereby avoiding possible
polymorphism (RFLP), Real time PCR and multiplex PCR infections through interpersonal contact as well as using
assay have been adapted for detection of dermatophytes common sport spaces.29 The use of antifungal foot
from clinical specimen. 23, 24, 25 These molecular methods powders is controversial but may be helpful for persons
have a good potential to directly detect dermatophytes susceptible to tinea pedis who have frequent exposures
in clinical specimens, however these methods are yet to to areas where the fungus is suspected. Proper diagnosis
and treatment of persons having underlying conditions
Asian Journal of Medical Sciences 2 (2011) 134-138
Table-1:Topical therapies for the treatment of Tinea Pedis 5. Maruyama R, Hiruma M., Yamauchi K et al. An
epidemiological and clinical study of untreated
AGENT FORMULATION FUNGICIDAL OR FREQUENCY OF patients with tinea pedis within a company of Japan.
FUNGISTATIC APPLICATION
Allylamines
Mycoses 2003; 46:208-12.http://dx.doi.org/10.1046/
Naftifine 1 % cream, Fungicidal Once or twice j.1439-0507.2003.00864.x PMid:12801364
Terbinafine gel daily
Benzylamines Once or twice 6. Ogasawara Y, Hiruma M et al. Clinical and
Butenafine 1% cream Fungicidal daily mycological study of occult tinea pedis and Tinea
Imidazoles unguium in dermatological patients from Tokyo.
Econazole 1% cream Fungistatic Once or twice
Ketoconazole daily Mycoses 2003; 46:114-9 http://dx.doi.org/10.1046/
Miconazole 2% cream j.1439-0507.2003.00855.x PMid:12870199
Sertaconazole
Miscellaneous 7. Loo D S. Cutaneous fungal infections in the elderly.
Ciclopirox 1% cream Fungistatic Twice daily Dermatologic Clinics 2004; 22:33-50.
Tolnaftate
http://dx.doi.org/10.1016/S0733-8635(03)00109-8
In severe cases, oral antifungal drugs may be preferred
8. Rinaldi M G. Dermatophytosis: Epidemiological and
for the treatment of tinea pedis infection. Newer agents
Microbiological update. Journal of the American
the triazoles, fluconazoles, itraconazole and allylamine
Academy of Dermatology 2000; 43: S120-S24.
have broad spectrum activity against tinea pedis. 20, 22
http://dx.doi.org/10.1067/mjd.2000.110378
8. Conclusion 9. Carlo CJ, Mac Williams Bowe P. Tinea pedis (athlete?s
Tinea pedis is commonly called “atheletes foot”. It is foot) 2007. Available at: http://www.bhchp.org.
caused by a fungus that grows predominantly in warm
10. Al Hasan M. Fitzgerald SM et al .Dermatology for the
moist environments and causes this infection that
practicing allergist: tinea pedis and its complica-
usually involves feet and toes. Tinea pedis affects a
tions, Clinical and Molecular Allergy 2004; 2:5
large number of people, and its prevalence is steadily
http://dx.doi.org/10.1186/1476-7961-2-5
increasing. Mainstay of treatment includes antifungal
PMid:15050029 PMCid:419368
creams, solutions, sprays, powders, and in severe cases,
oral antifungal drugs. Maintaining good foot hygiene, 11. Hainer B L., Dermatophyte infection. American Fam-
recognizing potential infection reservoirs, and vigilance ily Physician 2003; 67:101-8. PMid:12537173
in keeping the feet dry, including management of foot 12. Rich P. Harkless LB et al. Dermatophyte test medium
perspiration and judicious selection of socks and shoes, culture for evaluating toe nail infections in patients
and other measures may prove beneficial in manage- with diabetes. Diabetes care 2003; 26(5):1480-4.
ment and prevention. http://dx.doi.org/10.2337/diacare.26.5.1480
PMid:12716808
Asian Journal of Medical Sciences 2 (2011) 134-138
13. Leyden I J, Aly R. Tinea pedis. Seminars in 24. Arabatzis M, Bruijnesteijn LE et al. Diagnosis of
Dermatology 1993; 12(4): 280-284 PMid:8312143 common dermatophyte infections by a novel
multiplex real-time polymerase chain reaction
14. The Merck Manual. Fungal skin infection 2007.
detection/identification scheme.British Journal of
15. Lousbergh D. Buntinx F et al. Diagnosing Dermatology 2007;157: 681-9.http://
dermatomycosis in general practice. Family Practice dx.doi.org/10.1111/j.1365 -2133.2007.08100.x
1999; 16: 611-5 http://dx.doi.org/10.1093/ PMid:17672875
fampra/16.6.611PMid:10625138
25. Brillowska DA, Saunte DM et al. Five-hour Diagnosis
16. Sweeney SM, Wiss K, Mallory SB. Inflammatory tinea of Dermatophyte Nail Infections with Specific
pedis/manuum masquerading as bacterial cellulitis. Detection of Trichophyton rubrum. Journal of
Arch Pediatrics Adolescent Medicine 2002; 156 Clinical Microbiologyl 2007; 45:1200-1204. http://
(11):1149-52.PMid:12413346 dx.doi.org/10.1128/JCM.02072-06 PMid:17267633
17. Noble SL, Forbes RC et al. Diagnosis and management PMCid:1865842
of common Tinea infection. American Family Physi- 26. Weitzman I, Summerbell RC: The Dermatophytes.
cian 1998; 58: 177-8. PMid:9672436 Clinical Microbiology Reviews 1995; 240-59
18. Liu D, Coloe S et al. Application of PCR to the PMid:7621400 PMCid:172857
identification of dermatophyte fungi. Journal of 27. Garg J, Tilak R et al, Rapid detection of dermato-
Medical Microbiology 2000; 49: 493-497. phytes from skin and hair. BMC Research Notes 2009.
PMid:10847201
28. Erhard M, Hipler U C et al. Identification of
19. FDA Advisory committee. Topical therapies efficacy dermatophyte species causing onychomycosis and
and labelling issues for athletes foot drug products tinea pedis by MALDI-TOF mass spectrometry.
2004. Experimental dermatology 2008; (4):356-61http://
20. Rich P, Harkless LB et al. Dermatophyte test medium dx.doi.org/10.1111/j.1600 -0625.2007.00649.x
culture for evaluating toenail infections in patients PMid:17979969
with diabetes. Diabetes Care 2003; 26; 1480-4. 29. Meritxell P A, Josep Mar?a T A et al. Prevalence of
http://dx.doi.org/10.2337/diacare.26.5.1480 Tinea pedis, tinea unguium of toe nails and tinea
PMid:12716808 capitis in school children from Barcelona. Revista
21. Lilly K K, Koshnik RL et al. Cost effectiveness of Iberoamericana de Micolog? a 2009; 26(4):228-32.
diagnostic tests for toenail onychomycosis: A repeated
measure single blinded cross sectional evaluation of 7
diagnostic tests. Journal of the American Academy of
Dermatology 2006; 55(4): 620-26. http://
dx.doi.org/10.1016/j.jaad.2006.03.033
PMid:17010741