Fungal infections of the skin

Dr. M. Dissanayake

Classification of mycosis
Superficial mycosis Dermatophytosis Tinea versicolor Tinea nigra Candidiasis
Deep mycosis Subcutaneous Mycetoma Chromomycosis Sporotricosis Rhinosporidiosis Phycomycosis Systemic Candidiasis Aspergilosis Cryptococcosis Histoplasmosis Blastomycosis

Definition and classification of dermatophytes

Dermatophytes are keratinophilic fungi whose activity is confined to the skin (stratum corneum) hair and nails. Generically classified into Genus Tricophyton: Genus microsporum:
Tricophyton rubrum Tricophyton mentagrophytes Microsporum gypsum Microsporum canis Epidermophyton floccosum

Genus epidermophyton:

Sources of Dermatophytes
Anthropophilic Tricophyton rubrum Tricophyton mentographyte Tricophyton schoenleinii Microsporum audouinii Tricophyton

Zoophilic

Microsporum canis Tricophyton mentographyte Tricophyton verrucosum

Geophilic
Microsporum gypseum

Sites of Dermatophyte infection

Tinea capitis (scalp) Tinea barbae (beard) Tinea faciei (face) Tinea corporis (trunk) Tinea cruris (groin) Tinea manuum (hand) Tinea pedis (feet) Tinea unguium (nails)

INFECTION

By Dermatophytes

ringworm of the face

Tinea corporis

Tinea plantaris chronica Mocassin-Type

athletes foot, ringworm of the foot

Types of Tinea unguium

Distal-subungual type

Superficial-white type

Proximal-white type

Total dystrophic type

Asymptomatic cat as carrier of T.mentagrophytes

Microsorum canis very contageous

Differentialdiagnosis Mycosis-Eczema

Factors predisposing to dermatophyte infection

Environmental factors: Hot and Humid climate Local factors: Trauma, infection, Moisture, Tight and/ or Synthetic
Garments

Personal factors: Excessive Sweating, Poor Hygiene, Obesity

Immunosuppressant

Diagnosis of dermatophytosis
Diagnosis of dermatophytosis is essentially clinical
Investigations to confirm the diagnosis

Microscopic investigation of scrapings Culture in Sabourouds dextrose agar Woods lamp examination

KOH-preparation
of skin, nail, or epilated hair

1 drop 15 % KOH solution on glass slide Cover with glass Slightly warm up microscopy with 10x10 under dimmed light

Trichophyto n rubrum

Therapy of Tinea
1958 Griseofulvin
1959 Fluconazol 1991 Itraconazol

1992 Terbinafin

Major antimycotic drugs

Class Benzofuranes Example Griseofulvin Indication Route Dermatophyte oral infection (except nail) T. versicolor oral dermatophytes & Topical candidiasis cream, shampoo Imidazole Ketaconazole

Thiazoles

Itraconazole Flucanazole

Htdrxypyridones Ciclopiroxol amine Allylamines Terbinafine

Dermatphytes Oral & vaginal candidiasis Dermatophyte Onycomycosis Dermatophytes Onycomycosis

oral oral
Topical Topical & oral

Topical antifungal therapy Dermatophytes Yeast

Thiocarbamat

Tolnaftate

Polyene

Nystatin Ampotericin B Natamycin

Broad spectrum Dermatophytes Yeasts, maulds & bacteria

Pyridine Azole

Ciclopirox Clotrimazole Ecanazole ketaconazole Terbinafine

Allylamine

Preventive measures against Dermatophytosis

Avoid: Tight fitting clothes, synthetic undergarments and socks Closed footwear Advised Maintain good personal hygiene Loose clothing and cotton undergarments and socks Use open foot wear

Tinea versicolor (pityriasis versicolor)

Caused by the yeast like organism: Pityrsporum ovale. This microaerophilic, lipophilic resident of the normal follicle only occasionally becomes pathogenic.

Growth is encouraged by heightened rates of sebum secretion or there is depressed immunity.

Tinea Versicolor
Clinically, pale, scaling develop insidiously over the skin of the chest and back in young adults although other sites can get affected too. Diagnosis is made by identification microscopically of grape-like clusters of spores and a mesh work of pseudomycelium in the scraping. Skin patches often fluoresce an apple green in Woods light.

Malassezia species
Direct examination of scales in 15 % KOH: characteristic round and budding blastospores and short curved hyphae Spagetti and meatballs
Culture on SAB-Agar with thin layer of sterile olive oil

Treatment of T. versicolor
Topical Imidazole creams (e.g. micanazole, clotrmazole, ecanazole) applied once daily over 6 weeks Ketaconazole shampoo to wash once daily for 5 days Older remedies- 20% sodium thiosulphate and selinium disulphate shampoo Oral Ketaconazole 200mg /day for 10 days Itraconazole 200mg/day for 7-15 days

Candidiasis
Candidiasis is an acute or chronic, superficial or disseminated mycotic infection caused by the fungus candida albicans and occasionally by other species of candida. It commonly involves skin and the mucous membranes and sometimes the viscera.

Morphology of candida albicans

In human beings candida is a commensal flora of the mouth, GI tract, and the vaginal mucosa. When host-commensal relationship is altered the yeast turns pathogenic cause infection.

Factors predisposing to candidiasis

Local factors: Tissue damage, moisture, Warmth, maceration, topical steroids, prolong catheterization, tracheotomy. Physiological states: infancy, pregnancy, Old age Metabolic and endocrinal factors

Iron deficiency, Diabetes mellitus, obesity, Cushings syndrome, Addison's Disease

Immunocompromised status

Clinical findings
Oral candidiasis
1. 2. 3. 4. 5. Acute pseudomembranous or thrush. Chronic atrophic candidiasis, often under a denture. Acute atrophic candidiasis- HIV/AID. Chronic hyperplastic candidiasis D.D. leucoplakia. Angular chelitis

Clinical finding
Genital candidiasis- vulvovaginitis/ balanitis exclude diabetes mellitus Candidal intertrigo- Typical sites include the groin, axillae and beneath the breast. Good clinical clue is the presence of satellite pustules. Diaper candidiasis Candida paranychia

Chronic Mucocutaneous candidiasis(CMC)

A distinct syndrome characterized by persistent, superficial candidial infection of the skin, nail and mucous membrane of the mouth and genitals refractory to conventional therapy. Manifestation of primary defect in cell mediated immunity

Diagnosis of candidiasis
1. Direct examination under the microscope mount in 10% KOH solution Gram + yeast and pseudohyphae. More brilliantly seen under GMS stain or PAS in histopathology sections 2. Culture on Sabourauds Dexrose Agar White creamy colonies in 2-3 days

Germ tube test candida albicans can be identified within 2 hours( wet mount prepared from yeast incubated in human serum for 2 hours.

Preventive measures against candida

Avoid Prolong working in water Tight-fitting clothes, synthetic undergarments and socks Closed and tight footwear

Advised Good personal hygiene Use gloves with cotton liners while working in water Use cotton underwear and socks Use open footwear Thoroughly dry the intertriginous areas Simultaneously treat the sexual partner even if asymptomatic in case of balanitis and vaginitis

Candidiasis- Therapy
Systemic Flucanazole is the most widely used systemic agent. 150mg single dose for vulvovaginitis 50-100mg daily for 7- 14 days- oral candidiasis Nystatin- ( Polyene anitimycotic agent) oral rinses Orally for boel infections Amphotecin B IV or flucanazole orally for systemic infection Topical Azole creams, lotions Nystatin