SKIN AND SOFT TISSUE INFECTIONS
Superficial fungal
infections
Roderick Hay
Abstract
Superficial fungal infections or mycoses are common treatable condi-
tions seen in everyday clinical practice, although they can present
differently in immunosuppressed patients. Dermatophyte or ringworm
infections, superficial candidiasis of the mouth, skin or genital tract
and infections caused by Malassezia, such as pityriasis versicolor,
are the main conditions. Although they present with typical clinical
changes, diagnosis can generally be confirmed by direct microscopy
or culture of suitable samples. Treatment largely depends on the use
of azole (imidazole/triazole) or allylamine antifungals, applied in short
courses topically or for longer periods orally, depending on the site
and severity of the infection.
Keywords Dermatophytosis; fungal infections; Malassezia infection;
MRCP; superficial candidiasis; superficial mycoses
Introduction
Superficial fungal infections include common skin diseases as
well as rare infections confined to specific geographical areas or
groups of patients.1 Together, however, they are the fourth most
common cause of human disease and the most common infection
globally. The principal diseases are:
 dermatophytosis (ringworm e tinea capitis, tinea pedis)
 superficial candidiasis (cutaneous, oropharyngeal, vaginal)
 disease caused by Malassezia spp. (pityriasis versicolor,
seborrhoeic dermatitis).
Dermatophytosis
Dermatophyte fungi are organisms that digest keratin. They
belong to three principal genera e Trichophyton, Microsporum
and Epidermophyton. They are also grouped according to their
sources of infection: geophilic (soil), zoophilic (animals) and
anthropophilic (humans). Transmission is indirect through
desquamated epidermis or hairs, or direct through bodily contact.
Dermatophytosis (tinea) is an infection of skin and the kera-
tinized structures (hair, nails) arising from it. In the skin, the
archetypal lesion is annular with central healing (ringworm).
Clinical descriptions are based on the site of infection. Tinea
pedis is estimated to affect up to 15% of the healthy population,
and fungal nail disease (onychomycosis, see MEDICINE 2017; 45:
390e395) >15% depending on age.
Roderick Hay DM FRCP FRCPath FMedSci is Emeritus Professor of
Cutaneous Infection at King’s College London, UK. Research
interests: dermatological epidemiology and fungal disease.
Competing interests: Professor Hay has been a Consultant for Mayne
Pharma.
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Key points
C Superficial fungal infection is the fourth most common cause
of human disease
C Dermatophyte or ringworm infections respond to antifungals,
but only oral agents are effective in scalp infection (tinea
capitis)
C Fluconazole-resistant Candida species are increasingly found
in vaginal candidiasis
C The yeast Malassezia is implicated in causing dandruff and
seborrhoeic dermatitis
C Laboratory confirmation of infection is still dependent on mi-
croscopy and culture
 Dermatophyte lesions can scale and itch. In tinea corporis,
the lesion can be annular.
 In tinea pedis, skin erosions or blisters develop in the web
spaces, and the soles can be covered with dry scales.2
 Lesions of tinea cruris in the groin have a prominent rim.
 Tinea capitis (scalp ringworm; Figures 1 and 2) is a disease
of childhood presenting with alopecia and scaling on the
scalp. Its incidence has increased in the UK, Europe and
the USA because of the spread of anthropophilic species,3
particularly Trichophyton tonsurans.
 In untreated or severely immunosuppressed individuals
with AIDS, dermatophytosis can lead to widespread or
atypical infections, as well as rapidly spreading white
onychomycosis involving the whole nail plate.
Dermatophytosis is often confused with other common skin
conditions forming rings (e.g. eczema, annular erythemas,
granuloma annulare). Tinea capitis can also be difficult to
recognize because the hair loss is often patchy and confined to
small areas or single hairs. The diagnosis of dermatophytosis
should be confirmed in the laboratory.
Superficial candidiasis
Superficial Candida infections are usually caused by Candida
albicans. This organism is a common commensal in the mouth,
vagina and gastrointestinal tract in healthy individuals. The
prevalence of carriage is greater in hospitalized patients and
those who are immunocompromised.
Oropharyngeal candidiasis (oral thrush): has typical symptoms
and signs of soreness and white patches on an erythematous
background (plaque type). An erythematous variety exists; this
does not have plaques, but sore areas of erythema are typical.
Acute or chronic infection can occur in immunocompromised
individuals. Other predisposing factors include antibiotic therapy
and dentures.
Vaginal candidiasis (vaginal thrush): is a common infection,
with clinical appearances similar to those of oropharyngeal dis-
ease, plus discharge. Pruritus can also occur, and recurrent
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 SKIN AND SOFT TISSUE INFECTIONS
Figure 1 Inflammatory tinea capitis caused by Microsporum canis
acquired from a cat.
Figure 2 Tinea capitis caused by an anthropophilic fungus (Tricho-
phyton tonsurans). Signs such as scaling can be minimal.
episodes are common. Women with vaginal thrush seldom have
underlying predisposing factors.
Candidiasis of the skin: is often confined to body folds,
including the interdigital spaces of the hands or feet. Typically,
small satellite pustules lie distal to the periphery of the rim of the
rash. Chronic paronychia (nail fold infections) can be caused by
Candida (Figure 3).
Malassezia infection
Malassezia spp. are common surface commensals of greasy skin
(e.g. scalp, chest). They are associated with pityriasis versicolor,
seborrhoeic dermatitis and folliculitis.4 Malassezia infection can
complicate chronic central venous cannulation, mainly in neo-
nates, manifesting as pulmonary infiltrates on chest imaging.
Pityriasis versicolor: is a scaly, hypo- or hyperpigmented rash
on the trunk (Figure 4). It is common in tropical regions and in
patients who have recently taken a holiday in a sunny climate.
The patches can resemble vitiligo, but the presence of scaling is
typical.
Seborrhoeic dermatitis: is a common scaly condition affecting
the face (including the nasolabial folds), the front of the chest
and the scalp (dandruff). Severe seborrhoeic dermatitis is
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Figure 3 Chronic Candida paronychia. In this patient, the infection is
centred on the nail fold.
Figure 4 Pityriasis versicolor caused by Malassezia. Scaling can be
difficult to see in such cases.
particularly common in patients with AIDS or chronic neuro-
logical conditions such as Parkinson’s disease.
Malassezia folliculitis: is an itchy, follicular rash on the upper
back and shoulders that can resemble acne.
Laboratory diagnosis
The key to diagnosis is the demonstration of the organisms in
skin scales, hair or nails. Scrapings are taken with a scalpel or
nail clippers. They are examined in potassium hydroxide or a
fluorescent stain such as Calcofluor, and can be cultured on
Sabouraud’s medium. Skin scales, hair and nails can be sent to a
laboratory folded in a card (transport packs are available). Ma-
terial from mucosal surfaces is best sent on a moistened swab.
Routine molecular diagnostic measures are not available.
Management
Topical antifungals (e.g. terbinafine, imidazoles such as clotri-
mazole; Table 1) are necessary for most circumscribed in-
fections. Treatment lasts 1e4 weeks. Nail infections require
systemic treatment with terbinafine 250 mg daily for 6 weeks to 3
months, or itraconazole 200 mg twice daily for 1 week every
month for 3 months (pulsed therapy).
2 Ó 2017 Published by Elsevier Ltd.
 SKIN AND SOFT TISSUE INFECTIONS

nystatin, amphotericin). Oral fluconazole or itraconazole

Antifungal therapy may be necessary in more severe infections and in
Antifungal Site of action immunocompromised patients; however, there are
important interactions with other drugs, such as ciclo-
Topical treatments for all sporin and rifampicin. Resistance to fluconazole is a
superficial mycosesa recognized problem, particularly in infections caused by
CImidazoles (cream, ointment, Cell membrane e Candida krusei or Candida glabrata (increasingly seen in
powder) (e.g. clotrimazole, 14a-demethylase vulvovaginal candidiasis), and long-term suppressive
miconazole, econazole, treatment with this drug should be avoided.5
ketoconazole)  The usual treatment for pityriasis versicolor is a topical
CAllylamine antifungals Cell membrane e azole or terbinafine. In extensive infections, itraconazole,
(e.g. terbinafine) squalene epoxidase 200 mg/day for 5 days, can be used. A
Oral treatments
CTriazoles (itraconazole, Cell membrane e
KEY REFERENCES
fluconazole) e all superficial 14a-demethylase
1 Hay RJ, Ashby HR. Fungal infections. In: Griffiths CE, Barker J,
mycoses
CTerbinafine e
Bleiker T, Chalmers R, Creamer D, eds. Rook’s textbook of
Cell membrane e
dermatology. Chichester: Wiley Blackwell, 2016: 32.1e329643.
dermatophytosis squalene epoxidase
CGriseofulvin e
2 Canavan TN, Elewski BE. Identifying signs of tinea pedis: a key to
Inhibition of mitotic
understanding clinical variables. J Drugs Dermatol 2015; 14(suppl
dermatophytosis spindle formation
10): S42e7.
(tinea capitis)
3 Fuller LC, Barton RC, Mohd Mustapa MF, et al. British Association
a
Topical polyenes (e.g. nystatin, amphotericin) are sometimes used for oral of Dermatologists’ guidelines for the management of tinea capitis.
or vaginal infections in non-immunocompromised patients. Br J Dermatol 2014; 171: 454e63.
4 Velegraki A, Cafarchia C, Gaitanis G, Iatta R, Boekhout T. Malas-
Table 1
sezia infections in humans and animals: pathophysiology, detec-
tion, and treatment. PLoS Pathog 2015; 11: e1004523.
 Tinea capitis is treated with griseofulvin, terbinafine or 5 Sobel JD. Recurrent vulvovaginal candidiasis. Am J Obstet Gyne-
itraconazole. Terbinafine, at conventional dosage, is more col 2016; 214: 15e21.
effective in Trichophyton infections, and griseofulvin or
itraconazole in Microsporum infections.
 Treatment of Candida infections in immunocompetent
patients involves topical azoles or polyene antifungals (e.g.

TEST YOURSELF
To test your knowledge based on the article you have just read, please complete the questions below. The answers can be found at the
end of the issue or online here.

Question 1 Question 2
A 4-year-old girl presented with three areas of hair loss on the A 46-year-old man presented with discoloured toenails. He had a
scalp. These were mildly itchy. She was of African origin. On long history of recurrent athlete’s foot.
clinical examination, there were areas on her scalp where the On clinical examination, he had has dystrophic toenails on six
hair was sparse, and there were broken hairs with erythema and toes, which were thickened and pale yellow to white in colour.
scaling. The nail folds were not swollen. He also had scaling on the soles
of the feet. There was no other skin abnormality.
What is the most appropriate next step?
A. Advise an antidandruff shampoo What is the most likely diagnosis?
B. Advise an oral antifungal agent A. Fungal nail infection
C. Send hair and skin scrapings to the microbiology B. Psoriasis
laboratory C. Eczema
D. Advise betamethasone cream to apply to the scalp D. Trauma
E. Advise local application of terbinafine cream E. Paronychia caused by Candida

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 SKIN AND SOFT TISSUE INFECTIONS

Question 3 On clinical examination, she had a white vaginal discharge and

erythema and inflammation of the vaginal mucosa.
A 30-year-old woman presented with recurrent vaginal
discharge. She had had six episodes of vulvovaginal candidiasis
What is the most appropriate next step?
over the previous year, each treated with fluconazole, but the
A. Advise another course of fluconazole
time between each episode of infection had been decreasing. On
B. Change the antifungal treatment to oral terbinafine
the last occasion, she had been treated there was little response.
C. Perform an HIV test
She had no history of other illnesses and was not taking any
D. Investigate for a primary immunodeficiency.
other medicines.
E. Take a vaginal swab to identify any yeast isolated

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Please cite this article in press as: Hay R, Superficial fungal infections, Medicine (2017), http://dx.doi.org/10.1016/j.mpmed.2017.08.006