atypical and unusual presentation of dermatophytosis

1. PRESENTED BY
DR A M MUSADDIK HOSSAIN KHAN
MD (PHASE B RESIDENT)
DEPARTMENT OF DERMATOLOGY AND
VENEREOLOGY
BSMMU
Welcome to seminar presentation

2. ATYPICAL AND UNUSUAL PRESENTATION
OF DERMATOPHYTOSIS

4. PATHOGENESIS
Fungal
metabolites,
enzymes,
antigens
diffuse
through the
viable layer of
the epidermis
Inflammatory
reaction
Papule,
pruritus,
erythema

6. TYPES

7. FACTORS
Host
Environment
Agent
Pharmacologic
factor

8. AGENT FACTOR
 Dermatophyte species
 Invasive capacity and enzymes
 Ability to withstand adverse conditions and evade host
immune responses
 Antifungal resistance
 Biofilm formation –process whereby microorganisms
irreversibly attach to and grow on a surface and
produce extracellular polymer that facilitates
attachment and matrix formation resulting in alteration
of the phenotype of the organism with respect to
growth rate and gene transcription

9. AGENT FACTOR

10. HOST FACTOR
 Obesity
 Site of invasion
 Physiological variation of host skin barrier
 Age of patient
 Immunosuppressive state

11. HOST FACTOR
 Excessive sweating
 Sun exposure
 Frequent washing
 Comorbid condition
 CARD9 deficiency

12. HOST FACTOR
• Physical barriers (epidermal keratinization,
epidermal keratinocyte turnover, ph, fatty acids
from sebaceous glands, and body temperature)
• Innate and adaptive immunity
• Serum component
Normal
defenses that
prevent the
deeper
invasion are

13. ENVIRONMENTAL FACTORS
 Hot and humid climate
 Low socioeconomic status
 Overcrowding
 Sharing of clothes and footwear
 Poor hygiene and sanitary conditions
 Migration of population

14. ENVIRONMENTAL FACTORS
 Three main sources of infection by dermatophytes are
humans, animals, and soil
 Dermatophytes have the ability to utilize keratin from
human and animal tissues, or debris from dead animal
sources found in soil, such as feathers, skin, or nails
 Transmission occurs almost exclusively through indirect
contact, as the dermatophytes initially contaminate the
patient’s environment and subsequently facilitates the
spread of infection to others

15. TYPICAL ANNULAR LESION

16. ATYPICAL CLINICAL VARIANT
 Erythema multiforme-like
 Seborrheic dermatitis-like
 Lupus erythematosus-like
 Dermatitis herpetiformis-like
 Rosacea-like
 Eczematous dermatitis-like
 Psoriasis-like
 Polymorphous light
eruption-like
 Purpuric tinea corporis

17. ATYPICAL CLINICAL VARIANT
 Molluscum like
 Cystic granuloma
tricophyticum
 Tinea pseudoimbricata
 Scutula like
 Bullous lesion
 Impetigo-like
 Pseudomembranous lesion
 Pustular lesion
 Blepharo ciliaris
 Deep dermal infection
 Recurrence

18. ATYPICAL CLINICAL VARIANT
 More common in immunocompromised individuals
 Also seen in immunocompetent persons
 Tinea has now qualified for the category of great
mimicker similar to syphilis, sarcoidosis, and mycosis
fungoides
 There are few case series of atypical tinea infection
from different countries. In one of such reports, Atzori
et al. observed eczema-like tinea as the most common
atypical manifestation of tinea

19. ATYPICAL CLINICAL VARIANT
 With atypical tinea lesions, 20% had previous cutaneous
illnesses such as atopic dermatitis, contact dermatitis,
lichen planus, and psoriasis, asthma, allergic rhinitis,
intestinal inflammatory illnesses.
 Chronic renal insufficiency were present in 15%
 Not applied topical corticosteroids or taking on
systemic therapy that could have modified primary
morphology 23%

20. The diagnosis in these atypical cases can occasionally be
missed by false-negative results from culture or even the
KOH preparation. The presence of Periodic
acid-Schiff-positive fungi in stratum corneum or hair follicles
along with spongiotic dermatitis and neutrophils in the
stratum corneum on histopathology is helpful in making the
diagnosis in these difficult cases.

21. SEBORRHEIC DERMATITIS-LIKE TINEA

22. VESICULO-BULLOUS LESIONS OF TINEA
Intense inflammation caused by
zoophilic organism and delayed
type of hypersensitivity reaction

23. PSORIASIS-LIKE LESIONS OF TINEA

24. ECZEMATOUS DERMATITIS-LIKE
LESIONS OF TINEA
use of immunosuppressants
decreases the fungus-induced
local inflammation, and this may
allow the fungus to grow slowly
with less erythema or scaling
causing a modification of the
typical manifestation of tinea

25. TINEA IMBRICATA

26. TINEA PSEUDOIMBRICATA

27.  Impetigo like
Predisposed at the site of minor trauma and incorrect
topical steroid administration
 Purpuric tinea corporis
Venous insufficiency, traumatic scratching, virulent
strains of dermatophytes and host immune response,
immune reaction to fungi which causes damage to blood
vessels

28. Molluscum like
Broad, pleomorphic hyphae with scattered budding
arthrospores in the dermis rather than forming thin walled
septate hypha and manifested in dimorphic form in dermis
associated with reduced immune response
Scutula like
Host immune response plays a role. Keratinized tissues are
colonized and illness is due to consequence of the host’s
reaction to the metabolic products of the organism rather
than of living-tissue invasion

29. Cystic granuloma trichophyticum
SLE patients, decreased complement (C3 and C4) and
reduction in the neutrophilic chemotactic factor
Tinea pseudoimbricata
Prolonged use of topical steroids causing local
immunosuppression and reinfection due to early discontinuation
of antifungal have been hypothesized T-cell hyporeactivity and
lack of delayed type of hypersensitivity to dermatophytes have
been implicated

30. Pseudomembranous like
Immunosuppression, locally prevailing hot and humid
conditions and the hormone levels as most of the
cases have been described on scrotum in males
Pustular lesion
Classical ringworm appearance of tinea masked by
application of topical corticosteroids and concomitant
use of emollients
Rosacea like
Long-term application of topical corticosteroids

31. RESEMBLING LE
Host defenses against
dermatophytes (T-cell-mediated
immunity and nonspecific
immunological mechanisms) are
strongly stimulated leading to an
autoimmune cascade

32. TINEA RECIDIVANS: APPEARANCE OF
LESIONS AT THE PERIPHERY OF THE OLD
HEALED LESION

33. TINEA RECIDIVIANS
 Initial response to treatment and relapse within a week
of stopping treatment or while on treatment. It is
characterized by lesions appearing at the periphery of
the healing patches .
 Steroid abuse in the form of combination formulations
may be one of the most important predisposing factors
in these resilient forms of dermatophytosis. It is being
proposed that these manifestations are due to resilient
organisms rather than resistant organisms

34. NODULAR LESIONS OF DEEP
DERMATOPHYTOSIS IN A RENAL
TRANSPLANT PATIENT
Use of coarse brush and poorly
controlled atopic dermatitis in
non immunocompromised
patient, immunosuppression and
physical trauma like shaving,
pricking

35. DEEP DERMATOPHYTOSIS
Deep dermatophytosis is a rare clinical entity
characterized by infection of the dermis, subcutis, and
internal visceral organs. It is characterized by nodular
lesions with an indolent course, an association with
superficial fungal infection and the absence of hair
follicle involvement. Deep dermatophytosis is a separate
entity and distinct from majocchi’s granuloma

36. DEEP DERMATOPHYTOSIS
In extremely rare cases such as specific genetic
predisposition or specific immune defects, lymphatic
spread has been documented, causing
mycetoma/pseudomycetoma and even dissemination to
extracutaneous sites. The growing population of
immunocompromised patients has led to an increase in
cases of deep (dermal/subcutaneous) dermatophytosis.

37. DEEP DERMATOPHYTOSIS
Very rarely, they may cause a life-threatening infection by
invading the lymph nodes. Primary immunodeficiency
with a genetic origin is also recognized as a predisposition
to deep dermatophytosis. The role of CARD9 gene
mutations is being investigated in human antifungal
immunity

38. CARD9
Involved in the regulation of multiple downstream
pathways having antifungal response, is noted to be
associated with severe fungal infections of varied clinical
presentations ranging from deep dermatophytosis to
recurrent dermatophytic infection of skin and nails.

42. TAKE HOME MESSAGE
 Dermatophyte infection is very common
 Typical annular lesion are commonly seen
 Atypical features are emerging
 Superficial dermatophytosis is becoming a great
mimicker
 Chronic or recurrent form is alarming
 All the factors should be emphasized during treatment