Chapter 15Chapter 15
Diseases Resulting fromDiseases Resulting from
Fungi and YeastsFungi and Yeasts
Andrews’ Diseases of ...
Superficial mycosesSuperficial mycoses
► AKA dermatophytesAKA dermatophytes
► Three genera:Three genera: Microsporum, Tric...
Host factorsHost factors
► Immunosuppressed ptsImmunosuppressed pts
► AIDSAIDS
► Genetic susceptibility may be related to ...
ImidazolesImidazoles
► Clotrimazole, miconazole, sulconazole,Clotrimazole, miconazole, sulconazole,
oxiconazole, and ketoc...
AllylaminesAllylamines
► Naftifine, terbinafine, butenafineNaftifine, terbinafine, butenafine
► Inhibites squalene epoxyda...
PolyenePolyene
►NystatinNystatin
►Irreversibly binding to ergosterol-anIrreversibly binding to ergosterol-an
essential com...
TriazolesTriazoles
► Itraconazole, FluconazoleItraconazole, Fluconazole
► Affect P450 systemAffect P450 system
► Numerous ...
Tinea CapitisTinea Capitis
► Occurs chiefly in schoolchildrenOccurs chiefly in schoolchildren
► Boys more frequently than ...
NoninflammatoryNoninflammatory
► M. audouiniiM. audouinii infections present as the classicinfections present as the class...
Noninflammatory Tinea CapitisNoninflammatory Tinea Capitis
►““Black dot” ringworm, caused byBlack dot” ringworm, caused by...
►Black dot tineaBlack dot tinea
►Black dot ringworm caused byBlack dot ringworm caused by
Trichophyton tonsuransTrichophyton tonsurans
InflammatoryInflammatory
► Usually caused byUsually caused by M. canisM. canis
► Can be caused byCan be caused by T. menta...
KerionKerion
► Kerion may be followed by scarring andKerion may be followed by scarring and
permanent alopecia in areas of...
► Kerion: inflammatory rxn of tinea capitis caused byKerion: inflammatory rxn of tinea capitis caused by
Microsporum canis...
►Kerion causedKerion caused
byby
MicrosporumMicrosporum
caniscanis
►Kerion: heavily crusted, hairless plaqueKerion: heavily crusted, hairless plaque
►Permanent scarring alopecia post kerionPermanent scarring alopecia post kerion
►Kerion:Kerion:
red,red,
oozing,oozing,
hairlesshairless
plaqueplaque
FavusFavus
► Rare in the U.S.Rare in the U.S.
► Most severe form of dermatophyte hairMost severe form of dermatophyte hair...
►Favus of scalp showing scutulaeFavus of scalp showing scutulae
Favus with scarring alopecia andFavus with scarring alopecia and
scutulascutula
►Scarring after favus infectionScarring after favus infection
EtiologyEtiology
► Tinea capitis can be cause by any one ofTinea capitis can be cause by any one of
several species:severa...
DiagnosisDiagnosis
► Wood’s lightWood’s light
 Ultraviolet of 365 nm wavelength is obtained by passing aUltraviolet of 36...
DiagnosisDiagnosis
► KOHKOH
 Two or three loose hairs are removedTwo or three loose hairs are removed
 Hairs are placed ...
DTMDTM
► DTM contains cycloheximide to reduce growth ofDTM contains cycloheximide to reduce growth of
contaminants and a c...
►Ectothrix type inEctothrix type in Microsporum canis-Microsporum canis-
note small spores around hair shaftnote small spo...
► Endothrix spores in hair withEndothrix spores in hair with TrichophytonTrichophyton
tonsuranstonsurans
►Endothrix inEndothrix in T. scoenleiniiT. scoenleinii showingshowing
characteristic bubbles of aircharacteristic bubbles ...
►Endothrix infection, (low-power KOHEndothrix infection, (low-power KOH
mount): arthroconidia noted within hair shaftmount...
T. tonsuransT. tonsurans
►This microoraganism grows slowly in cultureThis microoraganism grows slowly in culture
to produc...
T. mentagrophytesT. mentagrophytes
► Culture growth is velvety or granular or fluffy, flatCulture growth is velvety or gra...
T. verrucosumT. verrucosum
►Growth is slow and cannot be observed wellGrowth is slow and cannot be observed well
for at le...
M. audouiniiM. audouinii
► Gross appearance shows a slowly growing,Gross appearance shows a slowly growing,
matted, velvet...
M. canisM. canis
► Culture shows profuse, fuzzy, cottony, aerialCulture shows profuse, fuzzy, cottony, aerial
mycelia tend...
TreatmentTreatment
► Griseofulvin of ultramicronized form, 10Griseofulvin of ultramicronized form, 10
mg/kg/day, is the da...
Tinea BarbaeTinea Barbae
► AKA Tinea sycosis, barber’s itchAKA Tinea sycosis, barber’s itch
► UncommonUncommon
► Occurs ch...
Tinea BarbaeTinea Barbae
►Superficial crusted typeSuperficial crusted type
 mild pustular folliculitis with broken-off ha...
Tinea BarbaeTinea Barbae
► Deep typeDeep type
 Caused mostly byCaused mostly by T. mentagrophytesT. mentagrophytes oror T...
Diagnosis-Tinea BarbaeDiagnosis-Tinea Barbae
►ClinicalClinical
►Confirmed by microscopic findings and byConfirmed by micro...
► Verrucous epidermophytosis fromVerrucous epidermophytosis from
Epidermphyton floccosumEpidermphyton floccosum
► Complete resolution after 48 days of griseofulvinComplete resolution after 48 days of griseofulvin
Differential DiagnosisDifferential Diagnosis
►Sycosis vulgaris-lesions are pustules andSycosis vulgaris-lesions are pustul...
►Tinea barbae-Tinea barbae-Trichophyton mentagorphytesTrichophyton mentagorphytes
Treatment-Tinea BarbaeTreatment-Tinea Barbae
►Oral antifungals are requiredOral antifungals are required
►Topical agents a...
Treatment-Tinea BarbaeTreatment-Tinea Barbae
► Other orals that have been effective:Other orals that have been effective:
...
Tinea FacieiTinea Faciei
► Fungal infection of the face (apart from theFungal infection of the face (apart from the
beard)...
► Tinea facieiTinea faciei
((Microsporum canisMicrosporum canis))
in a childin a child
►TineaTinea
corporiscorporis
involvinginvolving
the facethe face
(tinea faciei)(tinea faciei)
TreatmentTreatment
► Topical antifungalsTopical antifungals
► Oral griseofulvin administered for 2-4 weeks, asOral griseof...
Tinea Corporis(Tinea Circinata)Tinea Corporis(Tinea Circinata)
► All superficial dermatophyte infections of the skinAll su...
► Tinea corporis in aTinea corporis in a
child, caused bychild, caused by
Microsporum canisMicrosporum canis
Tinea CorporisTinea Corporis
► In some cases concentric circles form rings inIn some cases concentric circles form rings i...
► Tinea corporisTinea corporis
((Trichophyton rubrum)Trichophyton rubrum)
► Note sharp marginsNote sharp margins
and centr...
►Tinea corporis: large gyrate plaque withTinea corporis: large gyrate plaque with
advancing border, perhaps worsened byadv...
HistopathologyHistopathology
►Better ways to make diagnosisBetter ways to make diagnosis
►But if compact orthokeratosis is...
Etiology-Tinea CorporisEtiology-Tinea Corporis
►Microsporum canis, T. rubrum, T.Microsporum canis, T. rubrum, T.
mentagrop...
EpidemiologyEpidemiology
► Tinea corporis is frequently seen in children-Tinea corporis is frequently seen in children-
pa...
Treatment-Tinea CorporisTreatment-Tinea Corporis
► When tinea corporis is caused byWhen tinea corporis is caused by T.T.
t...
Treatment(cont)Treatment(cont)
►When only 1-2 patches occur, topical txWhen only 1-2 patches occur, topical tx
is effectiv...
TreatmentTreatment
► Creams are more effective than lotionsCreams are more effective than lotions
► Sulconazole may be les...
Other Forms of Tinea CorporisOther Forms of Tinea Corporis
► Trichophytic Granuloma or PerifollicularTrichophytic Granulom...
► TichophytonTichophyton
mentagrophytesmentagrophytes
infection on lower leginfection on lower leg
of American soldier ino...
►Majocchi’s granuloma H&E pale blue-Majocchi’s granuloma H&E pale blue-
staining fungal hyphae within hair shaftstaining f...
► Majocchi’s granuloma: PAS reveals multipleMajocchi’s granuloma: PAS reveals multiple
organisms that have replaced a frag...
Tinea Imbricata (Tokelau)Tinea Imbricata (Tokelau)
► Superficial fungal infection limited toSuperficial fungal infection l...
Tinea ImbricataTinea Imbricata
► When fully developed the eruption isWhen fully developed the eruption is
characterized by...
►Tinea imbricata in New Guinea nativeTinea imbricata in New Guinea native
►Tinea imbricata: concentric rings of scaleTinea imbricata: concentric rings of scale
caused bycaused by T. concentricumT....
Tinea CrurisTinea Cruris
► AKA jock itchAKA jock itch
► Most common in menMost common in men
► On upper and inner thighsOn...
►Tinea cruris in a manTinea cruris in a man
►Tinea cruris in a womanTinea cruris in a woman
Etiology-Tinea CrurisEtiology-Tinea Cruris
►T. mentagrophytesT. mentagrophytes && E. floccosum & T.E. floccosum & T.
rubru...
TreatmentTreatment
► Reduce perspiration and enhanceReduce perspiration and enhance
evaporation from crural areaevaporatio...
►Tinea in diapered areaTinea in diapered area
Tinea PedisTinea Pedis
► AKA athlete’s footAKA athlete’s foot
► Most common fungal disease(by far)Most common fungal disea...
► Tinea pedis showing interdigital scalpingTinea pedis showing interdigital scalping
► T. mentagrophytesT. mentagrophytes
►Interdigital scaling with vesiculation caused byInterdigital scaling with vesiculation caused by
T. mentagrophytesT. ment...
►DermatophytosisDermatophytosis
of the solesof the soles
►TrichophytonTrichophyton
mantagrophytesmantagrophytes
►AcuteAcute
vesiculobullousvesiculobullous
eruption on soleeruption on sole
caused bycaused by
TrichophytonTrichophyton
me...
TP-TP-Trichophyton rubrumTrichophyton rubrum
► T. rubrumT. rubrum causes thecauses the
majority of casesmajority of cases
...
► Tinea pedis andTinea pedis and
onychomycosis inonychomycosis in
father/son pair.father/son pair.
► Father shows classicF...
Tinea manusTinea manus
► Tinea infection of handsTinea infection of hands
that is dry, scaly, andthat is dry, scaly, and
e...
►Trichophyton rubrumTrichophyton rubrum infectionsinfections
Differential diagnosisDifferential diagnosis
► Allergic contact or irritant dermatitis-especiallyAllergic contact or irrit...
► Fungus filaments under KOH mountFungus filaments under KOH mount
►Mosaic fungusMosaic fungus
ProphylaxisProphylaxis
► Hyperhidrosis is a predisposing factorHyperhidrosis is a predisposing factor
► Dry toes after bat...
TreatmentTreatment
► Topical antifungalsTopical antifungals
► With significant maceration wet dressings orWith significant...
TxTx
► Keratolytic agents, such as salicylic acid,Keratolytic agents, such as salicylic acid,
lactic acid lotions, and Car...
Tx-dosesTx-doses
► Griseovulvin in ultramicronized particles takenGriseovulvin in ultramicronized particles taken
orally i...
Onychomycosis(Tinea Unguium)Onychomycosis(Tinea Unguium)
► Onychomycosis encompasses both dermatophyteOnychomycosis encomp...
OnychomycosisOnychomycosis
► Four classic types:Four classic types:
► 1.) distal subungual onychomycosis: primarily1.) dis...
►Onychomycosis caused byOnychomycosis caused by TrichophytonTrichophyton
rubrumrubrum
Trichophyton mentagrophytesTrichophyton mentagrophytes
► 2.) white superficial2.) white superficial
onychomycosis(leukonyc...
OnychomycosisOnychomycosis
► 3.) Proximal subungual onychomycosis: involves3.) Proximal subungual onychomycosis: involves
...
►Onychomycosis caused byOnychomycosis caused by CandidaCandida
albicansalbicans in mucocutaneous candidiasisin mucocutaneo...
OnychomycosisOnychomycosis
► Onychomycosis causedOnychomycosis caused
byby T. rubrumT. rubrum is usually ais usually a
dee...
► Gradually entire nail becomes brittle and separatedGradually entire nail becomes brittle and separated
from its bed due ...
►A: Distal subungal, onchomycosis occurringA: Distal subungal, onchomycosis occurring
simulataneously with superficial whi...
DifferentialDifferential
► Allergic contact dermatitisAllergic contact dermatitis
► PsoriasisPsoriasis
► Lichen planusLich...
TreatmentTreatment
► PO terbinafine, fluconazole, and itraconazolePO terbinafine, fluconazole, and itraconazole
► Griseofu...
CandidiasisCandidiasis
► CandidaCandida proliferates in both budding and mycelialproliferates in both budding and mycelial...
DiagnosisDiagnosis
► Demonstration of the pathogenic yeastDemonstration of the pathogenic yeast C.C.
albicansalbicans esta...
►Mycelium and spores ofMycelium and spores of Candida albicansCandida albicans
CandidiasisCandidiasis
► KOH mount from infant with thrush showingKOH mount from infant with thrush showing
pseudohyphae a...
Topical Anticandidal AgentsTopical Anticandidal Agents
► These include, but are not limited to: clotrimazoleThese include,...
Oral Candidiasis (Thrush)Oral Candidiasis (Thrush)
► Newborn infection may be acquired fromNewborn infection may be acquir...
► Frequently infection extends onto angles ofFrequently infection extends onto angles of
the mouth to form perleche(seen i...
►Thrush with extension to vermilion borderThrush with extension to vermilion border
TxTx
► Babies with thrush may be allowed to suck onBabies with thrush may be allowed to suck on
a clotrimazole suppository...
PerlechePerleche
► AKA angular cheilitisAKA angular cheilitis
► Maceration with transverse fissuring of oralMaceration wit...
PerlechePerleche
PerlechePerleche
► Analogous to intertrigo elsewhereAnalogous to intertrigo elsewhere
► Similar changes may be seen in rib...
TxTx
► If due toIf due to C. albicansC. albicans anticandidal creams andanticandidal creams and
lotionslotions
► Glycemic ...
Candidal VulvovaginitisCandidal Vulvovaginitis
► Pruritus, irritation, and extreme burningPruritus, irritation, and extrem...
Candidal VulvovaginitisCandidal Vulvovaginitis
► Candidal balanitis may be present in anCandidal balanitis may be present ...
TxTx
►Topical options include miconizole (MonistatTopical options include miconizole (Monistat
cream), nystatin vaginal su...
Candidal IntertrigoCandidal Intertrigo
► Pinkish intertriginous moist patches arePinkish intertriginous moist patches are
...
Pseudo Diaper RashPseudo Diaper Rash
► In infants,In infants, C. albicansC. albicans infection may start ininfection may s...
Congenital CutaneousCongenital Cutaneous
CandidiasisCandidiasis
► Infection of an infant during passage throughInfection o...
Congenital CutaneousCongenital Cutaneous
CandidiasisCandidiasis
► Differential dx: listeriosis, syphilis, staphylococcalDi...
CCCCCC
► Disseminated infection is suggested by (1) bwDisseminated infection is suggested by (1) bw
<1500g (2) evidence of...
Perianal CandidiasisPerianal Candidiasis
► Frequently entire GI tract is involvedFrequently entire GI tract is involved
► ...
Candidal ParonychiaCandidal Paronychia
► Cushionlike thickening of paronychial tissue,Cushionlike thickening of paronychia...
CPCP
► Manicuring nails sometimes is responsible forManicuring nails sometimes is responsible for
mechanical or chemical i...
Erosia InterdigitalisErosia Interdigitalis
BlastomyceticaBlastomycetica
► Oval-shaped area of macerated white skin onOval-...
Chronic MucocutaneousChronic Mucocutaneous
CandidiasisCandidiasis
► A heterogeneous group of pts whose infectionA heteroge...
Systemic CandidiasisSystemic Candidiasis
► High risk pts: pts with malignancies, AIDS,High risk pts: pts with malignancies...
SCSC
► Cutaneous findings are erythematousCutaneous findings are erythematous
macules that become papular, pustular, andma...
SCSC
► If candida is cultured within the first week of lifeIf candida is cultured within the first week of life
there is a...
THE ENDTHE END
Thank YouThank You
Chapter 15 Diseases Resulting from Fungi and Yeasts
Chapter 15 Diseases Resulting from Fungi and Yeasts
Chapter 15 Diseases Resulting from Fungi and Yeasts
Chapter 15 Diseases Resulting from Fungi and Yeasts
Chapter 15 Diseases Resulting from Fungi and Yeasts
Chapter 15 Diseases Resulting from Fungi and Yeasts
Chapter 15 Diseases Resulting from Fungi and Yeasts
Chapter 15 Diseases Resulting from Fungi and Yeasts
Chapter 15 Diseases Resulting from Fungi and Yeasts
Chapter 15 Diseases Resulting from Fungi and Yeasts
Chapter 15 Diseases Resulting from Fungi and Yeasts
Chapter 15 Diseases Resulting from Fungi and Yeasts
Chapter 15 Diseases Resulting from Fungi and Yeasts
Chapter 15 Diseases Resulting from Fungi and Yeasts
Chapter 15 Diseases Resulting from Fungi and Yeasts
Chapter 15 Diseases Resulting from Fungi and Yeasts
Chapter 15 Diseases Resulting from Fungi and Yeasts
Chapter 15 Diseases Resulting from Fungi and Yeasts
Chapter 15 Diseases Resulting from Fungi and Yeasts
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Chapter 15 Diseases Resulting from Fungi and Yeasts

  1. 1. Chapter 15Chapter 15 Diseases Resulting fromDiseases Resulting from Fungi and YeastsFungi and Yeasts Andrews’ Diseases of the SkinAndrews’ Diseases of the Skin Adam Wray, D.O.Adam Wray, D.O. February 8, 2005February 8, 2005
  2. 2. Superficial mycosesSuperficial mycoses ► AKA dermatophytesAKA dermatophytes ► Three genera:Three genera: Microsporum, Trichophyton,Microsporum, Trichophyton, EpidermophytonEpidermophyton ► Division into seven types (1)tinea capitis,Division into seven types (1)tinea capitis, (2)tinea barbae, (3)tinea faciei, (4)tinea(2)tinea barbae, (3)tinea faciei, (4)tinea corporis, (5) tinea manus, (6) tinea pedis, (7)corporis, (5) tinea manus, (6) tinea pedis, (7) tinea cruris, (8)onychomycosistinea cruris, (8)onychomycosis
  3. 3. Host factorsHost factors ► Immunosuppressed ptsImmunosuppressed pts ► AIDSAIDS ► Genetic susceptibility may be related to types ofGenetic susceptibility may be related to types of keratin or degree/mix of cutaneous lipids producedkeratin or degree/mix of cutaneous lipids produced ► Surface antigens-ABO system-one study of 108Surface antigens-ABO system-one study of 108 culture proven dermatophytosis pts noted type Aculture proven dermatophytosis pts noted type A blood prone to chronic diseaseblood prone to chronic disease ► Human steroid hormones can inhibit growth ofHuman steroid hormones can inhibit growth of dermatophytes (androgens like androstenedione)dermatophytes (androgens like androstenedione) ► One group believes this high susceptibility ofOne group believes this high susceptibility of Trichophyton rubrum & Epidermophyton floccosumTrichophyton rubrum & Epidermophyton floccosum toto intrafollicular androstenedione is a reason why theseintrafollicular androstenedione is a reason why these species do not cause tinea capitisspecies do not cause tinea capitis
  4. 4. ImidazolesImidazoles ► Clotrimazole, miconazole, sulconazole,Clotrimazole, miconazole, sulconazole, oxiconazole, and ketoconazoleoxiconazole, and ketoconazole ► Mostly used for topical txMostly used for topical tx ► Inhibit cytochrome P450 14-alpha-Inhibit cytochrome P450 14-alpha- demethylase (an essential enzyme indemethylase (an essential enzyme in ergosterol synthesis)ergosterol synthesis) ► Ketaconazole has wide spectrum againstKetaconazole has wide spectrum against dermatophytes, yeasts, and some systemicdermatophytes, yeasts, and some systemic mycosesmycoses ► Ketaconazole has the potential for seriousKetaconazole has the potential for serious drug interactions and a higher incidence ofdrug interactions and a higher incidence of hepatotoxicity during long-term daily therapyhepatotoxicity during long-term daily therapy
  5. 5. AllylaminesAllylamines ► Naftifine, terbinafine, butenafineNaftifine, terbinafine, butenafine ► Inhibites squalene epoxydationInhibites squalene epoxydation ► Terbinafine has less activity againstTerbinafine has less activity against CandidaCandida species in vitro studies then triazoles, but isspecies in vitro studies then triazoles, but is effective clinicallyeffective clinically ► Terbinafine is ineffective in the oral tx of tineaTerbinafine is ineffective in the oral tx of tinea versicolor but is effective topicallyversicolor but is effective topically ► Few drug interactions have been reportedFew drug interactions have been reported ► Bioavailability is unchanged in foodBioavailability is unchanged in food ► Hepatotoxicity, leukopenia, severe exanthems,Hepatotoxicity, leukopenia, severe exanthems, and taste disturbances uncommon, but shouldand taste disturbances uncommon, but should be monitored for clinically and by lab testing ifbe monitored for clinically and by lab testing if continuous dosing over 6 weekscontinuous dosing over 6 weeks
  6. 6. PolyenePolyene ►NystatinNystatin ►Irreversibly binding to ergosterol-anIrreversibly binding to ergosterol-an essential component of fungal cellessential component of fungal cell membranesmembranes
  7. 7. TriazolesTriazoles ► Itraconazole, FluconazoleItraconazole, Fluconazole ► Affect P450 systemAffect P450 system ► Numerous drug interactions occurNumerous drug interactions occur ► Need to know pt’s current medsNeed to know pt’s current meds ► Broadest spectrum to dermatophytes andBroadest spectrum to dermatophytes and CandidaCandida species, andspecies, and Malassezia furfurMalassezia furfur ► Itraconazole is fungistatic-food increases itsItraconazole is fungistatic-food increases its absorption , antacids and gastric acidabsorption , antacids and gastric acid secretion suppressors produce erratic orsecretion suppressors produce erratic or lowered absorptionlowered absorption ► Pulse dosing limits concern over labPulse dosing limits concern over lab abnormalitiesabnormalities ► Fluconazoles’s absorption is unaffected byFluconazoles’s absorption is unaffected by foodfood
  8. 8. Tinea CapitisTinea Capitis ► Occurs chiefly in schoolchildrenOccurs chiefly in schoolchildren ► Boys more frequently than girls; exceptBoys more frequently than girls; except epidemics caused byepidemics caused by TrichophytonTrichophyton tonsuranstonsurans where there is equal frequencywhere there is equal frequency ► Divided into inflammatory andDivided into inflammatory and noninflammatorynoninflammatory ► Tinea capitis can be caused by allTinea capitis can be caused by all pathogenic dermatophytes exceptpathogenic dermatophytes except Epidermophyton floccosumEpidermophyton floccosum andand T.T. concentricumconcentricum ► In U.S. most caused byIn U.S. most caused by T. tonsuransT. tonsurans
  9. 9. NoninflammatoryNoninflammatory ► M. audouiniiM. audouinii infections present as the classicinfections present as the classic formform ► Characterized by multiple scaly lesionsCharacterized by multiple scaly lesions (“gray-patch”), stubs of broken hair(“gray-patch”), stubs of broken hair ► Over past 30 yrs,Over past 30 yrs, M. audouiniiM. audouinii infections areinfections are being replaced by increasing numbers ofbeing replaced by increasing numbers of “black-dot” ringworm, caused primarily by“black-dot” ringworm, caused primarily by T.T. tonsuranstonsurans and occasionally byand occasionally by T. violaceumT. violaceum ► In the U.SIn the U.S. T. tonsurans. T. tonsurans is the most commonis the most common causecause
  10. 10. Noninflammatory Tinea CapitisNoninflammatory Tinea Capitis ►““Black dot” ringworm, caused byBlack dot” ringworm, caused by T.T. tonsurans &tonsurans & occasionallyoccasionally T. violaceumT. violaceum presents as multiple areas of alopeciapresents as multiple areas of alopecia studded with black dots representingstudded with black dots representing infected hairs broken off at or below theinfected hairs broken off at or below the surface of the scalpsurface of the scalp
  11. 11. ►Black dot tineaBlack dot tinea
  12. 12. ►Black dot ringworm caused byBlack dot ringworm caused by Trichophyton tonsuransTrichophyton tonsurans
  13. 13. InflammatoryInflammatory ► Usually caused byUsually caused by M. canisM. canis ► Can be caused byCan be caused by T. mentagrophytes, T.T. mentagrophytes, T. tonsurans, M. gypsem, or T. verrucosumtonsurans, M. gypsem, or T. verrucosum ► M. canisM. canis begin as scaly, erythematous,begin as scaly, erythematous, papular eruptions with loose and broken-offpapular eruptions with loose and broken-off hairs, followed by varying degrees ofhairs, followed by varying degrees of inflammationinflammation ► A localized spot accompanied by pronouncedA localized spot accompanied by pronounced swelling, with developing bogginess andswelling, with developing bogginess and induration exuding pus develops-induration exuding pus develops-kerion celsiikerion celsii  A delayed type hypersensitivity reaction to fungalA delayed type hypersensitivity reaction to fungal elementselements ► With extensive lesions fever, pain, andWith extensive lesions fever, pain, and regional lymphadenopathy may occurregional lymphadenopathy may occur
  14. 14. KerionKerion ► Kerion may be followed by scarring andKerion may be followed by scarring and permanent alopecia in areas of inflammation andpermanent alopecia in areas of inflammation and suppurationsuppuration ► Systemic steroids for short periods will greatlySystemic steroids for short periods will greatly diminish the inflammatory response and reducediminish the inflammatory response and reduce the risk of scarringthe risk of scarring
  15. 15. ► Kerion: inflammatory rxn of tinea capitis caused byKerion: inflammatory rxn of tinea capitis caused by Microsporum canis or TrichophytonMicrosporum canis or Trichophyton mentagrophytesmentagrophytes
  16. 16. ►Kerion causedKerion caused byby MicrosporumMicrosporum caniscanis
  17. 17. ►Kerion: heavily crusted, hairless plaqueKerion: heavily crusted, hairless plaque
  18. 18. ►Permanent scarring alopecia post kerionPermanent scarring alopecia post kerion
  19. 19. ►Kerion:Kerion: red,red, oozing,oozing, hairlesshairless plaqueplaque
  20. 20. FavusFavus ► Rare in the U.S.Rare in the U.S. ► Most severe form of dermatophyte hairMost severe form of dermatophyte hair infectioninfection ► Most frequently cause byMost frequently cause by T. schoenleiniiT. schoenleinii ► Hyphae and air spaces seen within hair shaftHyphae and air spaces seen within hair shaft ► Bluish white fluorescence under Wood’s lightBluish white fluorescence under Wood’s light ► Thick, yellow crusts composed of hyphae andThick, yellow crusts composed of hyphae and skin debris (‘scutula’)skin debris (‘scutula’) ► Scarring alopecia may developScarring alopecia may develop
  21. 21. ►Favus of scalp showing scutulaeFavus of scalp showing scutulae
  22. 22. Favus with scarring alopecia andFavus with scarring alopecia and scutulascutula
  23. 23. ►Scarring after favus infectionScarring after favus infection
  24. 24. EtiologyEtiology ► Tinea capitis can be cause by any one ofTinea capitis can be cause by any one of several species:several species: T. tonsurans, M. audouiniiT. tonsurans, M. audouinii (human to human)(human to human), and M. canis, and M. canis (animals to(animals to human)human) ► Endothrix types-Endothrix types-T. tonsuransT. tonsurans(black-dot(black-dot ringworm) andringworm) and T. violaceumT. violaceum ► Ectothrix found on scalp areEctothrix found on scalp are T. verrucosum &T. verrucosum & T. mentagrophytesT. mentagrophytes
  25. 25. DiagnosisDiagnosis ► Wood’s lightWood’s light  Ultraviolet of 365 nm wavelength is obtained by passing aUltraviolet of 365 nm wavelength is obtained by passing a beam through a Wood’s filter composed of nickel oxide-beam through a Wood’s filter composed of nickel oxide- containing glasscontaining glass  A simple form is the 125-volt purple bulbA simple form is the 125-volt purple bulb ► Fluorescent-positive infections are caused by :Fluorescent-positive infections are caused by :T.T. sschoenleinii, M.choenleinii, M. ccanis, M.anis, M. aaudouinii, M.udouinii, M. ddistortum, M.istortum, M. fferrugineumerrugineum ► Hairs infected withHairs infected with T. tonsurans & T. violaceumT. tonsurans & T. violaceum andand others of endothrix do not fluoresceothers of endothrix do not fluoresce ► The fluorescent substance is pteridineThe fluorescent substance is pteridine
  26. 26. DiagnosisDiagnosis ► KOHKOH  Two or three loose hairs are removedTwo or three loose hairs are removed  Hairs are placed on slide with a drop of 10-20%Hairs are placed on slide with a drop of 10-20% solution of KOHsolution of KOH  A cover slip is applied, specimen is warmed untilA cover slip is applied, specimen is warmed until hairs are maceratedhairs are macerated  Examine under low, then high powerExamine under low, then high power ► Scales or hairs cleared with it can still beScales or hairs cleared with it can still be culturedcultured
  27. 27. DTMDTM ► DTM contains cycloheximide to reduce growth ofDTM contains cycloheximide to reduce growth of contaminants and a colored pH indicator to denotecontaminants and a colored pH indicator to denote the alkali-producing dermatophytesthe alkali-producing dermatophytes ► Some clinically relevant nondermatophyte fungiSome clinically relevant nondermatophyte fungi are cycloheximide sensitive (are cycloheximide sensitive (Candida tropicalis,Candida tropicalis, Scopulariopsis brevicaulis, CryptococcusScopulariopsis brevicaulis, Cryptococcus neoformans, Pseudoallescheria boydii,neoformans, Pseudoallescheria boydii, Trichosporon beigeliiTrichosporon beigelii andand AspergillusAspergillus spp.)spp.)
  28. 28. ►Ectothrix type inEctothrix type in Microsporum canis-Microsporum canis- note small spores around hair shaftnote small spores around hair shaft
  29. 29. ► Endothrix spores in hair withEndothrix spores in hair with TrichophytonTrichophyton tonsuranstonsurans
  30. 30. ►Endothrix inEndothrix in T. scoenleiniiT. scoenleinii showingshowing characteristic bubbles of aircharacteristic bubbles of air
  31. 31. ►Endothrix infection, (low-power KOHEndothrix infection, (low-power KOH mount): arthroconidia noted within hair shaftmount): arthroconidia noted within hair shaft ►Endothrix infection (high-power KOH mount)Endothrix infection (high-power KOH mount) showing total hair shaft involvementshowing total hair shaft involvement
  32. 32. T. tonsuransT. tonsurans ►This microoraganism grows slowly in cultureThis microoraganism grows slowly in culture to produce a granular or powdery yellow toto produce a granular or powdery yellow to red, brown, or buff colonyred, brown, or buff colony ►Crater formation with radial grooves may beCrater formation with radial grooves may be producedproduced ►Microconidia may be seen regularlyMicroconidia may be seen regularly ►Dx confirmed by the fact that cultures growDx confirmed by the fact that cultures grow poorly or not at all without thiaminepoorly or not at all without thiamine
  33. 33. T. mentagrophytesT. mentagrophytes ► Culture growth is velvety or granular or fluffy, flatCulture growth is velvety or granular or fluffy, flat or furrowed, light buff, white, or sometimes pinkor furrowed, light buff, white, or sometimes pink ► Back of the culture can vary from buff to dark redBack of the culture can vary from buff to dark red ► Round microconidia borne laterally and in clustersRound microconidia borne laterally and in clusters confirm dx within 2 weeksconfirm dx within 2 weeks ► Spirals are sometimes presentSpirals are sometimes present ► Macroconidia may be seenMacroconidia may be seen
  34. 34. T. verrucosumT. verrucosum ►Growth is slow and cannot be observed wellGrowth is slow and cannot be observed well for at least 3 weeksfor at least 3 weeks ►Colony is compact, glassy, velvety, ,Colony is compact, glassy, velvety, , heaped or furrowed, and usually white, butheaped or furrowed, and usually white, but may be yellow or graymay be yellow or gray ►Chlamydospores are present in earlyChlamydospores are present in early culturescultures ►Microconidia may be seenMicroconidia may be seen
  35. 35. M. audouiniiM. audouinii ► Gross appearance shows a slowly growing,Gross appearance shows a slowly growing, matted, velvety, light brown colonymatted, velvety, light brown colony ► Back of which is reddish brown to orangeBack of which is reddish brown to orange ► Under microscope a few large multiseptateUnder microscope a few large multiseptate macroconidia (macroaleuriospores) are seenmacroconidia (macroaleuriospores) are seen ► Microconidia (microaleuriospores) in a lateralMicroconidia (microaleuriospores) in a lateral position on hyphae are clavateposition on hyphae are clavate ► Racquet mycelium, chlamydospores, andRacquet mycelium, chlamydospores, and pectinate hyphae are seen sometimespectinate hyphae are seen sometimes
  36. 36. M. canisM. canis ► Culture shows profuse, fuzzy, cottony, aerialCulture shows profuse, fuzzy, cottony, aerial mycelia tending to become powdery in the centermycelia tending to become powdery in the center ► Color is buff to light brownColor is buff to light brown ► Back of colony is lemon to orange-yellowBack of colony is lemon to orange-yellow ► Numerous spindle-shaped multiseptateNumerous spindle-shaped multiseptate microconidia and thick-walled macroconidia aremicroconidia and thick-walled macroconidia are presentpresent ► Clavate microconidia are found along withClavate microconidia are found along with chlamydospores and pectinate bodieschlamydospores and pectinate bodies
  37. 37. TreatmentTreatment ► Griseofulvin of ultramicronized form, 10Griseofulvin of ultramicronized form, 10 mg/kg/day, is the daily dose recommendedmg/kg/day, is the daily dose recommended for childrenfor children ► Grifulvin V is the only oral suspensionGrifulvin V is the only oral suspension available for children unable to swallowavailable for children unable to swallow tablets-dose is 20 mg/kg/daytablets-dose is 20 mg/kg/day ► Tx should continue for 2-4 months, or for atTx should continue for 2-4 months, or for at least 2 weeks after a negative microscopicleast 2 weeks after a negative microscopic and culture examinations are obtainedand culture examinations are obtained ► Griseofulvin does not primarily affect theGriseofulvin does not primarily affect the delayed type hypersensitivity reactiondelayed type hypersensitivity reaction responsible for the inflammation in kerionresponsible for the inflammation in kerion ► For this, systemic steroids, to minimizeFor this, systemic steroids, to minimize scarring, can be given simultaneouslyscarring, can be given simultaneously
  38. 38. Tinea BarbaeTinea Barbae ► AKA Tinea sycosis, barber’s itchAKA Tinea sycosis, barber’s itch ► UncommonUncommon ► Occurs chiefly among those in agricultureOccurs chiefly among those in agriculture ► Involvement is mostly one-sided on neck orInvolvement is mostly one-sided on neck or faceface ► Two clinical types are: deep, nodular,Two clinical types are: deep, nodular, suppurative lesions; and superficial , crusted,suppurative lesions; and superficial , crusted, partially bald patches with folliculitispartially bald patches with folliculitis
  39. 39. Tinea BarbaeTinea Barbae ►Superficial crusted typeSuperficial crusted type  mild pustular folliculitis with broken-off hairs (mild pustular folliculitis with broken-off hairs (T.T. violaceum)violaceum) or without broken-off hairs (or without broken-off hairs (T.T. rubrum)rubrum)  Affected hairs are loose, dry, and brittleAffected hairs are loose, dry, and brittle  When extracted bulb appears intactWhen extracted bulb appears intact
  40. 40. Tinea BarbaeTinea Barbae ► Deep typeDeep type  Caused mostly byCaused mostly by T. mentagrophytesT. mentagrophytes oror T.T. verrucosumverrucosum  Swellings are usually confluent and form diffuseSwellings are usually confluent and form diffuse boggy infiltrates with abscessesboggy infiltrates with abscesses  Pus may be expressedPus may be expressed  Lesions are limited to one part of face or neck inLesions are limited to one part of face or neck in menmen
  41. 41. Diagnosis-Tinea BarbaeDiagnosis-Tinea Barbae ►ClinicalClinical ►Confirmed by microscopic findings and byConfirmed by microscopic findings and by standard culture techniquesstandard culture techniques ►Rarely,Rarely, Epidermophyton floccosumEpidermophyton floccosum maymay cause widespread verrucous lesions knowncause widespread verrucous lesions known asas verrucous epidermophytosisverrucous epidermophytosis
  42. 42. ► Verrucous epidermophytosis fromVerrucous epidermophytosis from Epidermphyton floccosumEpidermphyton floccosum
  43. 43. ► Complete resolution after 48 days of griseofulvinComplete resolution after 48 days of griseofulvin
  44. 44. Differential DiagnosisDifferential Diagnosis ►Sycosis vulgaris-lesions are pustules andSycosis vulgaris-lesions are pustules and papules, pierced in the center by a hair,papules, pierced in the center by a hair, which is loose and easily extracted afterwhich is loose and easily extracted after suppuration has occurredsuppuration has occurred ►Contact dermatitisContact dermatitis ►Herpes infectionsHerpes infections
  45. 45. ►Tinea barbae-Tinea barbae-Trichophyton mentagorphytesTrichophyton mentagorphytes
  46. 46. Treatment-Tinea BarbaeTreatment-Tinea Barbae ►Oral antifungals are requiredOral antifungals are required ►Topical agents as adjunctive therapyTopical agents as adjunctive therapy ►Micronized or ultramicronizedMicronized or ultramicronized griseofulvin orally: dosage of 500–1000griseofulvin orally: dosage of 500–1000 mg or 350-700 mg respectivelymg or 350-700 mg respectively ►Tx usually for 4-6 weeksTx usually for 4-6 weeks
  47. 47. Treatment-Tinea BarbaeTreatment-Tinea Barbae ► Other orals that have been effective:Other orals that have been effective: ketoconazole, fluconazole, itraconazole, andketoconazole, fluconazole, itraconazole, and terbinafineterbinafine ► Topical antifungals should be applied fromTopical antifungals should be applied from the beginning of txthe beginning of tx ► Affected parts should be bathed thoroughly inAffected parts should be bathed thoroughly in soap and watersoap and water ► Healthy areas that are not epilated may beHealthy areas that are not epilated may be shaved or clippedshaved or clipped ► When kerion is present a short course ofWhen kerion is present a short course of systemic steriod therapy may help reducesystemic steriod therapy may help reduce inflammation and risk of scarringinflammation and risk of scarring
  48. 48. Tinea FacieiTinea Faciei ► Fungal infection of the face (apart from theFungal infection of the face (apart from the beard)beard) ► Must have high index of suspicionMust have high index of suspicion  Mistaken for seb derm, contact derm, lupus, orMistaken for seb derm, contact derm, lupus, or photosensitive dermatosisphotosensitive dermatosis ► Erythematous, slightly scaling, indistinctErythematous, slightly scaling, indistinct borders are usually seenborders are usually seen ► Usually caused byUsually caused by T. rubrum. T.T. rubrum. T. mentagrophytes, or M. canismentagrophytes, or M. canis
  49. 49. ► Tinea facieiTinea faciei ((Microsporum canisMicrosporum canis)) in a childin a child
  50. 50. ►TineaTinea corporiscorporis involvinginvolving the facethe face (tinea faciei)(tinea faciei)
  51. 51. TreatmentTreatment ► Topical antifungalsTopical antifungals ► Oral griseofulvin administered for 2-4 weeks, asOral griseofulvin administered for 2-4 weeks, as well as fluconazole, itraconazole, or terbinafine arewell as fluconazole, itraconazole, or terbinafine are all effective particularly in combination with topicalall effective particularly in combination with topical therapytherapy
  52. 52. Tinea Corporis(Tinea Circinata)Tinea Corporis(Tinea Circinata) ► All superficial dermatophyte infections of the skinAll superficial dermatophyte infections of the skin except the scalp, beard, face, hands, feet, andexcept the scalp, beard, face, hands, feet, and groingroin ► Sites of predilection are neck, upper and lowerSites of predilection are neck, upper and lower extremities, and trunkextremities, and trunk ► Characterized by one or more circular, sharplyCharacterized by one or more circular, sharply circumcsribed, slightly erythematous, dry, scaly,circumcsribed, slightly erythematous, dry, scaly, usually hypopigmented patchesusually hypopigmented patches
  53. 53. ► Tinea corporis in aTinea corporis in a child, caused bychild, caused by Microsporum canisMicrosporum canis
  54. 54. Tinea CorporisTinea Corporis ► In some cases concentric circles form rings inIn some cases concentric circles form rings in one another, making intricate patterns (tineaone another, making intricate patterns (tinea imbricata)imbricata) ► Widespread tinea corporis may be theWidespread tinea corporis may be the presenting sign of AIDSpresenting sign of AIDS
  55. 55. ► Tinea corporisTinea corporis ((Trichophyton rubrum)Trichophyton rubrum) ► Note sharp marginsNote sharp margins and central clearingand central clearing
  56. 56. ►Tinea corporis: large gyrate plaque withTinea corporis: large gyrate plaque with advancing border, perhaps worsened byadvancing border, perhaps worsened by diaperingdiapering
  57. 57. HistopathologyHistopathology ►Better ways to make diagnosisBetter ways to make diagnosis ►But if compact orthokeratosis is found in aBut if compact orthokeratosis is found in a section, a search for fungal hyphae shouldsection, a search for fungal hyphae should be performedbe performed ►This is diagnosticThis is diagnostic
  58. 58. Etiology-Tinea CorporisEtiology-Tinea Corporis ►Microsporum canis, T. rubrum, T.Microsporum canis, T. rubrum, T. mentagrophytesmentagrophytes-most common-most common ►T. rubrumT. rubrum is is the most commonis is the most common dermatophyte in the U.S. and worldwidedermatophyte in the U.S. and worldwide ►T. tonsuransT. tonsurans has experienced a dramatichas experienced a dramatic rise as a cause of tinea corporis as it has forrise as a cause of tinea corporis as it has for tinea capitistinea capitis ►In children,In children, M. canisM. canis is the cause of theis the cause of the “moist” type of tinea circinata“moist” type of tinea circinata
  59. 59. EpidemiologyEpidemiology ► Tinea corporis is frequently seen in children-Tinea corporis is frequently seen in children- particularly those exposed to animals withparticularly those exposed to animals with ringworm(ringworm(M. canis)M. canis), especially, especially CATSCATS, dogs and, dogs and less commonly, horses and cattleless commonly, horses and cattle ► In adults excessive perspiration is the mostIn adults excessive perspiration is the most common factorcommon factor  Personal hx or close contact with tinea capitis or tineaPersonal hx or close contact with tinea capitis or tinea pedis is another important factorpedis is another important factor ► Incidence is especially high in hot, humid areas ofIncidence is especially high in hot, humid areas of the worldthe world
  60. 60. Treatment-Tinea CorporisTreatment-Tinea Corporis ► When tinea corporis is caused byWhen tinea corporis is caused by T.T. tonsurans, M. canis, T. mentagrophytes, or T.tonsurans, M. canis, T. mentagrophytes, or T. rubrumrubrum , griseofulvin, terbinafine,, griseofulvin, terbinafine, itraconazole, and fluconazole are all effectiveitraconazole, and fluconazole are all effective ► The ultra-micronized form may be used at aThe ultra-micronized form may be used at a dose of 350-750 mg once/day for 4-6 weeksdose of 350-750 mg once/day for 4-6 weeks ► This dose may be increased to twice daily ifThis dose may be increased to twice daily if neededneeded ► Terbinafine, itraconazole, and fluconazole areTerbinafine, itraconazole, and fluconazole are effectiveeffective ► Terbinafine at 250 mg/day for two weeksTerbinafine at 250 mg/day for two weeks ► Itraconazole 200 mg B.I.D. for one weekItraconazole 200 mg B.I.D. for one week ► Fluconazole 150 mg once/week for 4 weeksFluconazole 150 mg once/week for 4 weeks
  61. 61. Treatment(cont)Treatment(cont) ►When only 1-2 patches occur, topical txWhen only 1-2 patches occur, topical tx is effectiveis effective ►Most are between 2-4 weeks with twiceMost are between 2-4 weeks with twice daily usedaily use ►Econazole, ketaconazole, oxiconazole,Econazole, ketaconazole, oxiconazole, and terbinafine may be used once dailyand terbinafine may be used once daily ►With terbinafine the course can beWith terbinafine the course can be shortened to 1 weekshortened to 1 week
  62. 62. TreatmentTreatment ► Creams are more effective than lotionsCreams are more effective than lotions ► Sulconazole may be less irritating in foldedSulconazole may be less irritating in folded areasareas ► Castellani paint (which is colorless if madeCastellani paint (which is colorless if made without fuchin) is very effectivewithout fuchin) is very effective ► Salicylic acid 3% -5%, or half-strengthSalicylic acid 3% -5%, or half-strength Whitfield’s ointment, both standbys 30 yrsWhitfield’s ointment, both standbys 30 yrs ago, are little used todayago, are little used today ► Addition of a low-potency steroid creamAddition of a low-potency steroid cream during the initial 3-5 days of therapy willduring the initial 3-5 days of therapy will decrease irritation rapidly withoutdecrease irritation rapidly without compromising the effectiveness of thecompromising the effectiveness of the antifungalantifungal
  63. 63. Other Forms of Tinea CorporisOther Forms of Tinea Corporis ► Trichophytic Granuloma or PerifollicularTrichophytic Granuloma or Perifollicular Granuloma or Majocchi’s Granuloma or TineaGranuloma or Majocchi’s Granuloma or Tinea IncognitoIncognito ► A deep, pustular type of tinea circinata resemblingA deep, pustular type of tinea circinata resembling a carbuncle or kerion observed on the glabrousa carbuncle or kerion observed on the glabrous skinskin ► A circumscribed, annular, raised, crusty, andA circumscribed, annular, raised, crusty, and boggy granulomaboggy granuloma ► Follicles are distended with viscid purulentFollicles are distended with viscid purulent materialmaterial
  64. 64. ► TichophytonTichophyton mentagrophytesmentagrophytes infection on lower leginfection on lower leg of American soldier inof American soldier in VietnamVietnam
  65. 65. ►Majocchi’s granuloma H&E pale blue-Majocchi’s granuloma H&E pale blue- staining fungal hyphae within hair shaftstaining fungal hyphae within hair shaft
  66. 66. ► Majocchi’s granuloma: PAS reveals multipleMajocchi’s granuloma: PAS reveals multiple organisms that have replaced a fragment of hairorganisms that have replaced a fragment of hair shaft embedded in a sea of neutrophilsshaft embedded in a sea of neutrophils
  67. 67. Tinea Imbricata (Tokelau)Tinea Imbricata (Tokelau) ► Superficial fungal infection limited toSuperficial fungal infection limited to southwest Polynesia, Melanesia, Southeastsouthwest Polynesia, Melanesia, Southeast Asia, India, and Central AmericaAsia, India, and Central America ► Characterized by concentric rings of scalesCharacterized by concentric rings of scales forming extensive patches with polycyclicforming extensive patches with polycyclic bordersborders ► Small macular patch splits in center andSmall macular patch splits in center and forms large, flaky scales attached at theforms large, flaky scales attached at the peripheryperiphery ► Resultant ring spreads peripherally andResultant ring spreads peripherally and another brownish macule appears in theanother brownish macule appears in the center and undergoes the process againcenter and undergoes the process again
  68. 68. Tinea ImbricataTinea Imbricata ► When fully developed the eruption isWhen fully developed the eruption is characterized by concentrically arrangedcharacterized by concentrically arranged rings or parallel undulating lines of scalesrings or parallel undulating lines of scales overlapping each other like shingles on aoverlapping each other like shingles on a roof (imbrex means shingle)roof (imbrex means shingle) ► Causative fungus isCausative fungus is T. concentricumT. concentricum ► TOC is griseofulvin- in same form as forTOC is griseofulvin- in same form as for tinea corporistinea corporis ► Other options are terbinafine, fluconazole,Other options are terbinafine, fluconazole, and itraconazoleand itraconazole ► Several courses of therapy may be neededSeveral courses of therapy may be needed ► May need to remove pt from hot, humidMay need to remove pt from hot, humid environmentenvironment
  69. 69. ►Tinea imbricata in New Guinea nativeTinea imbricata in New Guinea native
  70. 70. ►Tinea imbricata: concentric rings of scaleTinea imbricata: concentric rings of scale caused bycaused by T. concentricumT. concentricum
  71. 71. Tinea CrurisTinea Cruris ► AKA jock itchAKA jock itch ► Most common in menMost common in men ► On upper and inner thighsOn upper and inner thighs ► Begins as a small erythematous and scalingBegins as a small erythematous and scaling or vesicular and crusted patchor vesicular and crusted patch ► Spreads peripherally and partly clears in theSpreads peripherally and partly clears in the centercenter ► Penoscrotal fold or sides of scrotum arePenoscrotal fold or sides of scrotum are seldom involved; penis not involvedseldom involved; penis not involved
  72. 72. ►Tinea cruris in a manTinea cruris in a man
  73. 73. ►Tinea cruris in a womanTinea cruris in a woman
  74. 74. Etiology-Tinea CrurisEtiology-Tinea Cruris ►T. mentagrophytesT. mentagrophytes && E. floccosum & T.E. floccosum & T. rubrumrubrum usual causeusual cause ►Frequently associated with tinea pedis b/cFrequently associated with tinea pedis b/c of contaminated clothingof contaminated clothing ►Heat and high humidityHeat and high humidity ►TightTight jockey shortsjockey shorts!!
  75. 75. TreatmentTreatment ► Reduce perspiration and enhanceReduce perspiration and enhance evaporation from crural areaevaporation from crural area ► Keep as dry as possible by wearing looseKeep as dry as possible by wearing loose underclothingunderclothing ► Plain talcum powder or antifungal powdersPlain talcum powder or antifungal powders ► Specific topical and oral tx is same as thatSpecific topical and oral tx is same as that described under tinea corporisdescribed under tinea corporis
  76. 76. ►Tinea in diapered areaTinea in diapered area
  77. 77. Tinea PedisTinea Pedis ► AKA athlete’s footAKA athlete’s foot ► Most common fungal disease(by far)Most common fungal disease(by far) ► Primary lesions often are macerated withPrimary lesions often are macerated with occasional vesiculation, and fissures betweenoccasional vesiculation, and fissures between the toesthe toes ► Extreme pruritusExtreme pruritus
  78. 78. ► Tinea pedis showing interdigital scalpingTinea pedis showing interdigital scalping ► T. mentagrophytesT. mentagrophytes
  79. 79. ►Interdigital scaling with vesiculation caused byInterdigital scaling with vesiculation caused by T. mentagrophytesT. mentagrophytes
  80. 80. ►DermatophytosisDermatophytosis of the solesof the soles ►TrichophytonTrichophyton mantagrophytesmantagrophytes
  81. 81. ►AcuteAcute vesiculobullousvesiculobullous eruption on soleeruption on sole caused bycaused by TrichophytonTrichophyton mentagrophytesmentagrophytes
  82. 82. TP-TP-Trichophyton rubrumTrichophyton rubrum ► T. rubrumT. rubrum causes thecauses the majority of casesmajority of cases ► Produces a relativelyProduces a relatively noninflammatory type ofnoninflammatory type of dermatophytosisdermatophytosis characterized by a dullcharacterized by a dull erythema and pronouncederythema and pronounced scaling involving the entirescaling involving the entire sole and sides of feetsole and sides of feet ► Producing a moccasin orProducing a moccasin or sandal appearancesandal appearance
  83. 83. ► Tinea pedis andTinea pedis and onychomycosis inonychomycosis in father/son pair.father/son pair. ► Father shows classicFather shows classic moccasin distribution ofmoccasin distribution of tinea pedis and sontinea pedis and son shows distal subungualshows distal subungual onychomycosisonychomycosis
  84. 84. Tinea manusTinea manus ► Tinea infection of handsTinea infection of hands that is dry, scaly, andthat is dry, scaly, and erythematous may occurerythematous may occur ► Suggestive of infectionSuggestive of infection withwith T. rubrumT. rubrum ► Other areas are frequentlyOther areas are frequently affected at the same timeaffected at the same time
  85. 85. ►Trichophyton rubrumTrichophyton rubrum infectionsinfections
  86. 86. Differential diagnosisDifferential diagnosis ► Allergic contact or irritant dermatitis-especiallyAllergic contact or irritant dermatitis-especially occupationaloccupational ► PompholyxPompholyx ► Atopic dermatitisAtopic dermatitis ► PsoriasisPsoriasis ► Lamellar dyshidrosisLamellar dyshidrosis ► Eczematoid or dyshidrotic lesions of unknownEczematoid or dyshidrotic lesions of unknown cause on hands should prompt a search forcause on hands should prompt a search for clinical evidence of dermatophytosis of feet etc.clinical evidence of dermatophytosis of feet etc.
  87. 87. ► Fungus filaments under KOH mountFungus filaments under KOH mount
  88. 88. ►Mosaic fungusMosaic fungus
  89. 89. ProphylaxisProphylaxis ► Hyperhidrosis is a predisposing factorHyperhidrosis is a predisposing factor ► Dry toes after bathingDry toes after bathing ► Tolnaftate powder or Zeasorb medicated powdersTolnaftate powder or Zeasorb medicated powders for feetfor feet ► Plain talc, cornstartch, or rice powder may bePlain talc, cornstartch, or rice powder may be dusted into socks and shoes to keep feet drydusted into socks and shoes to keep feet dry
  90. 90. TreatmentTreatment ► Topical antifungalsTopical antifungals ► With significant maceration wet dressings orWith significant maceration wet dressings or soaks with solutions such as aluminumsoaks with solutions such as aluminum acetate, one part to 20 parts of wateracetate, one part to 20 parts of water ► Anti-inflammatory effects of corticosteroidsAnti-inflammatory effects of corticosteroids are markedly beneficialare markedly beneficial ► Topical antibiotic ointments effective againstTopical antibiotic ointments effective against gram-negative organisms (gentamicin), in txgram-negative organisms (gentamicin), in tx of the moist type of interdigital lesionsof the moist type of interdigital lesions ► In ulcerative type of gram-neg toe webIn ulcerative type of gram-neg toe web infections, systemic floxins are neededinfections, systemic floxins are needed
  91. 91. TxTx ► Keratolytic agents, such as salicylic acid,Keratolytic agents, such as salicylic acid, lactic acid lotions, and Carmol are therapeuticlactic acid lotions, and Carmol are therapeutic when fungus is protected by a thick layer ofwhen fungus is protected by a thick layer of overlying skin (ie soles)overlying skin (ie soles) ► Griseofulvin is only effective againstGriseofulvin is only effective against dermatophytesdermatophytes ► When infection is caused byWhen infection is caused by T.T. mentagrophytesmentagrophytes griseofulvin does notgriseofulvin does not decrease inflammatory rxdecrease inflammatory rx
  92. 92. Tx-dosesTx-doses ► Griseovulvin in ultramicronized particles takenGriseovulvin in ultramicronized particles taken orally in doses of 350-750 mg dailyorally in doses of 350-750 mg daily ► Dosage for children is 10 mg/kg/dayDosage for children is 10 mg/kg/day ► Period of tx depends on responsePeriod of tx depends on response ► Repeated KOH scrapings and culture should beRepeated KOH scrapings and culture should be negneg ► Recommended adult doses for newer agents:Recommended adult doses for newer agents: terbinafine, 250 mg/day for 2 weeks; itraconazole,terbinafine, 250 mg/day for 2 weeks; itraconazole, 200 mg twice daily for 1 week; fluconazole, 150200 mg twice daily for 1 week; fluconazole, 150 mg once weekly for 4 weeksmg once weekly for 4 weeks
  93. 93. Onychomycosis(Tinea Unguium)Onychomycosis(Tinea Unguium) ► Onychomycosis encompasses both dermatophyteOnychomycosis encompasses both dermatophyte and nondermatophyte nail infectionsand nondermatophyte nail infections ► Represents up to 30% of diagnosed superficialRepresents up to 30% of diagnosed superficial fungal infectionsfungal infections ► Etiologic agents are:Etiologic agents are: Epidermophyton,Epidermophyton, Microsporum, and TrichophytonMicrosporum, and Trichophyton fungifungi
  94. 94. OnychomycosisOnychomycosis ► Four classic types:Four classic types: ► 1.) distal subungual onychomycosis: primarily1.) distal subungual onychomycosis: primarily involves distal nail bed and hyponychium, withinvolves distal nail bed and hyponychium, with secondary involvement of underside of nail platesecondary involvement of underside of nail plate of fingernails and toenailsof fingernails and toenails
  95. 95. ►Onychomycosis caused byOnychomycosis caused by TrichophytonTrichophyton rubrumrubrum
  96. 96. Trichophyton mentagrophytesTrichophyton mentagrophytes ► 2.) white superficial2.) white superficial onychomycosis(leukonychiaonychomycosis(leukonychia trichophytica):this is antrichophytica):this is an invasion of the toenail plateinvasion of the toenail plate on the surface of the nailon the surface of the nail ► It is produced byIt is produced by T.mentagrophytes,T.mentagrophytes, speciesspecies ofof Cephalosporium andCephalosporium and Aspergillus, and FusariumAspergillus, and Fusarium oxysporumoxysporum fungusfungus
  97. 97. OnychomycosisOnychomycosis ► 3.) Proximal subungual onychomycosis: involves3.) Proximal subungual onychomycosis: involves the nail plate mainly from proximal nail foldthe nail plate mainly from proximal nail fold ► It is produced byIt is produced by T. rubrum & T. megniniiT. rubrum & T. megninii and mayand may be an indication of HIV infectionbe an indication of HIV infection ► 4.) Candida onychomycosis involves all the nail4.) Candida onychomycosis involves all the nail plate; it is due toplate; it is due to Candida albicansCandida albicans and is seen inand is seen in pts with chronic mucocuataneous candidiasispts with chronic mucocuataneous candidiasis  Associated paronychiaAssociated paronychia  Adjacent cuticle is pink, swollen, and tenderAdjacent cuticle is pink, swollen, and tender  Fingernails > toenailsFingernails > toenails
  98. 98. ►Onychomycosis caused byOnychomycosis caused by CandidaCandida albicansalbicans in mucocutaneous candidiasisin mucocutaneous candidiasis
  99. 99. OnychomycosisOnychomycosis ► Onychomycosis causedOnychomycosis caused byby T. rubrumT. rubrum is usually ais usually a deep infectiondeep infection ► Disease usually starts atDisease usually starts at distal corner of nail anddistal corner of nail and involves the junction ofinvolves the junction of nail and its bednail and its bed ► First a yellowishFirst a yellowish discoloration occurs,discoloration occurs, which may spread untilwhich may spread until entire nail is affectedentire nail is affected ► Beneath discolorationBeneath discoloration nail plate becomes loosenail plate becomes loose from nail bedfrom nail bed
  100. 100. ► Gradually entire nail becomes brittle and separatedGradually entire nail becomes brittle and separated from its bed due to piling up of keratin subunguallyfrom its bed due to piling up of keratin subungually ► Nail may break off, leaving an undermined remnantNail may break off, leaving an undermined remnant that is black and yellow from dead nail and fungi thatthat is black and yellow from dead nail and fungi that are presentare present
  101. 101. ►A: Distal subungal, onchomycosis occurringA: Distal subungal, onchomycosis occurring simulataneously with superficial whitesimulataneously with superficial white onchmycosisonchmycosis ►B: Superficial white onchomycosisB: Superficial white onchomycosis
  102. 102. DifferentialDifferential ► Allergic contact dermatitisAllergic contact dermatitis ► PsoriasisPsoriasis ► Lichen planusLichen planus ► 20 nail dystrophy20 nail dystrophy ► Darier’s diseaseDarier’s disease ► Reiter’s diseaseReiter’s disease ► Norwegian scabiesNorwegian scabies ► Nondermatophyte onychomycosisNondermatophyte onychomycosis
  103. 103. TreatmentTreatment ► PO terbinafine, fluconazole, and itraconazolePO terbinafine, fluconazole, and itraconazole ► Griseofulvin continued until nails are clinicallyGriseofulvin continued until nails are clinically normalnormal ► Low success rates 15-30% for toenails andLow success rates 15-30% for toenails and 50-70% for fingernails50-70% for fingernails ► Griseofulvin does not tx nail disease causedGriseofulvin does not tx nail disease caused by candidaby candida ► 3% thymol in EtOH3% thymol in EtOH
  104. 104. CandidiasisCandidiasis ► CandidaCandida proliferates in both budding and mycelialproliferates in both budding and mycelial forms in outer layers of the stratum corneumforms in outer layers of the stratum corneum where horny cells are desquamatingwhere horny cells are desquamating ► It does not attack hair, rarely involves nail, and isIt does not attack hair, rarely involves nail, and is incapable of breaking up the stratum corneumincapable of breaking up the stratum corneum ► It is largely an opportunisitic organismIt is largely an opportunisitic organism ► Moisture promotes its growthMoisture promotes its growth  Lip cornersLip corners  Body foldsBody folds
  105. 105. DiagnosisDiagnosis ► Demonstration of the pathogenic yeastDemonstration of the pathogenic yeast C.C. albicansalbicans establishes the diagnosisestablishes the diagnosis ► Under microscope KOH prep may showUnder microscope KOH prep may show spores and pseudomyceliumspores and pseudomycelium ► Culture on Sabouraud’s glucose agar showsCulture on Sabouraud’s glucose agar shows a growth of creamy, grayish, moist colonies ina growth of creamy, grayish, moist colonies in about 4 daysabout 4 days ► In time colonies form small, root-likeIn time colonies form small, root-like penetrations into agarpenetrations into agar
  106. 106. ►Mycelium and spores ofMycelium and spores of Candida albicansCandida albicans
  107. 107. CandidiasisCandidiasis ► KOH mount from infant with thrush showingKOH mount from infant with thrush showing pseudohyphae and yeast formspseudohyphae and yeast forms
  108. 108. Topical Anticandidal AgentsTopical Anticandidal Agents ► These include, but are not limited to: clotrimazoleThese include, but are not limited to: clotrimazole (Lotrimin, Mycelex), econazole (Spectazole),(Lotrimin, Mycelex), econazole (Spectazole), ketaconazole (Nizoral), miconazole (MonistatDermketaconazole (Nizoral), miconazole (MonistatDerm Lotion, Micatin), oxiconazole (Oxistat),Lotion, Micatin), oxiconazole (Oxistat), sulconazole (Exelderm), naftifine (Naftin),sulconazole (Exelderm), naftifine (Naftin), terconazole (vaginal candidiasis only), cicloproxterconazole (vaginal candidiasis only), cicloprox olamine (Loprox), butenafine (Mentax), nystatin,olamine (Loprox), butenafine (Mentax), nystatin, and topical amphotericin B lotionand topical amphotericin B lotion ► Terbinafine has been reported to be less activeTerbinafine has been reported to be less active againstagainst CandidaCandida species by some authorsspecies by some authors
  109. 109. Oral Candidiasis (Thrush)Oral Candidiasis (Thrush) ► Newborn infection may be acquired fromNewborn infection may be acquired from contact with vaginal tract of mothercontact with vaginal tract of mother ► Grayish white membranous plaques areGrayish white membranous plaques are found on surfacefound on surface ► Base of plaques are moist, reddish, andBase of plaques are moist, reddish, and maceratedmacerated ► Diaper areas is especially susceptible to thisDiaper areas is especially susceptible to this ► Most of intertriginous areas and evenMost of intertriginous areas and even exposed skin may be involvedexposed skin may be involved
  110. 110. ► Frequently infection extends onto angles ofFrequently infection extends onto angles of the mouth to form perleche(seen in elderly,the mouth to form perleche(seen in elderly, debilitated, and malnourished pts, anddebilitated, and malnourished pts, and diabetics)diabetics) ► It is often the first manifestation of AIDSIt is often the first manifestation of AIDS ► Is present in nearly 100% of all untreated ptsIs present in nearly 100% of all untreated pts with full-blown AIDSwith full-blown AIDS ► ““Thrush” in an adult with no knownThrush” in an adult with no known predisposing factors warrants a search forpredisposing factors warrants a search for other evidence of infection with HIV, such asother evidence of infection with HIV, such as lymphadenopathy, leukopenia, or HIVlymphadenopathy, leukopenia, or HIV antibodies in serumantibodies in serum Oral candidiasis (Thrush)Oral candidiasis (Thrush)
  111. 111. ►Thrush with extension to vermilion borderThrush with extension to vermilion border
  112. 112. TxTx ► Babies with thrush may be allowed to suck onBabies with thrush may be allowed to suck on a clotrimazole suppository inserted into thea clotrimazole suppository inserted into the slit tip of a pacifier four times a day for 2-3slit tip of a pacifier four times a day for 2-3 daysdays ► An adult can let tablets of clotrimazole orAn adult can let tablets of clotrimazole or Mycelex troches dissolve in the mouthMycelex troches dissolve in the mouth ► Fluconazole, 100-200 mg/day for 5-10 daysFluconazole, 100-200 mg/day for 5-10 days with doubling the dose if it fails, orwith doubling the dose if it fails, or itraconazole, 200 mg daily for 5-10 days withitraconazole, 200 mg daily for 5-10 days with doubling the dose if it fails-both are availabledoubling the dose if it fails-both are available in liquid formsin liquid forms
  113. 113. PerlechePerleche ► AKA angular cheilitisAKA angular cheilitis ► Maceration with transverse fissuring of oralMaceration with transverse fissuring of oral commissurescommissures ► Soft, pinhead-sized papules may appearSoft, pinhead-sized papules may appear ► Involvement is bilateral-usuallyInvolvement is bilateral-usually
  114. 114. PerlechePerleche
  115. 115. PerlechePerleche ► Analogous to intertrigo elsewhereAnalogous to intertrigo elsewhere ► Similar changes may be seen in riboflavinSimilar changes may be seen in riboflavin deficiency, and iron deficiency anemiadeficiency, and iron deficiency anemia ► Identical fissuring occurs in persons withIdentical fissuring occurs in persons with malocclusion caused by ill-fitting denturesmalocclusion caused by ill-fitting dentures and in the aged whom atrophy of alveolarand in the aged whom atrophy of alveolar ridges has occurredridges has occurred ► Seen in children who drool, lick their lips, orSeen in children who drool, lick their lips, or suck their thumbsuck their thumb
  116. 116. TxTx ► If due toIf due to C. albicansC. albicans anticandidal creams andanticandidal creams and lotionslotions ► Glycemic control in diabetesGlycemic control in diabetes ► Antibiotic topical meds are used when aAntibiotic topical meds are used when a bacterial; infection is presentbacterial; infection is present ► If due to vertical shortening of lower third ofIf due to vertical shortening of lower third of the face, dental or oral surgical interventionthe face, dental or oral surgical intervention may helpmay help ► Injection of collagen into depressed sulcus atInjection of collagen into depressed sulcus at the oral commissure may be helpfulthe oral commissure may be helpful ► Vytone!!Vytone!!
  117. 117. Candidal VulvovaginitisCandidal Vulvovaginitis ► Pruritus, irritation, and extreme burningPruritus, irritation, and extreme burning ► Labia may be erythemtous, moist, andLabia may be erythemtous, moist, and macerated and cervix hyperemic, swollen, andmacerated and cervix hyperemic, swollen, and eroded, showing small vesicles on its surfaceeroded, showing small vesicles on its surface ► Vaginal discharge is not usually profuse but isVaginal discharge is not usually profuse but is frequently thick and tenaciousfrequently thick and tenacious ► May develop during pregnancy, in diabetes, orMay develop during pregnancy, in diabetes, or secondary to therapy with a broad- spectrumsecondary to therapy with a broad- spectrum antibioticantibiotic ► Recurrent vulvovaginal candidiasis has beenRecurrent vulvovaginal candidiasis has been associated with long-term tamoxifen txassociated with long-term tamoxifen tx
  118. 118. Candidal VulvovaginitisCandidal Vulvovaginitis ► Candidal balanitis may be present in anCandidal balanitis may be present in an uncircumcised sexual partneruncircumcised sexual partner ► If not recognized, repeated reinfection of aIf not recognized, repeated reinfection of a partner may occurpartner may occur ► Diagnosis is by clinical symptoms andDiagnosis is by clinical symptoms and findings as well as demonstration of fungusfindings as well as demonstration of fungus via KOH microscopic exam & culturevia KOH microscopic exam & culture ► Tx is frustrating & disappointing due toTx is frustrating & disappointing due to recurrencesrecurrences ► Oral fluconazole 150 mg times 1 dose;Oral fluconazole 150 mg times 1 dose; Fluconazole, 100mg/day for 5-7 days,Fluconazole, 100mg/day for 5-7 days, itraconazole, 200 mg/day for 2-3 days..otheritraconazole, 200 mg/day for 2-3 days..other optionsoptions
  119. 119. TxTx ►Topical options include miconizole (MonistatTopical options include miconizole (Monistat cream), nystatin vaginal suppositories orcream), nystatin vaginal suppositories or tablets (Mycostatin), or clotrimazole (Gyne-tablets (Mycostatin), or clotrimazole (Gyne- Lotrimin or Mycelex G) vaginal tabletsLotrimin or Mycelex G) vaginal tablets inserted once daily for 7 daysinserted once daily for 7 days
  120. 120. Candidal IntertrigoCandidal Intertrigo ► Pinkish intertriginous moist patches arePinkish intertriginous moist patches are surrounded by a thin, overhanging fringe ofsurrounded by a thin, overhanging fringe of somewhat macerated epidermis (“collarette”somewhat macerated epidermis (“collarette” scale)scale) ► May resemble tinea cruris, but usually there isMay resemble tinea cruris, but usually there is less scaliness and a greater tendency toless scaliness and a greater tendency to fissuringfissuring ► Topical anticandidal preparations are usuallyTopical anticandidal preparations are usually effectiveeffective ► Recurrence is commonRecurrence is common
  121. 121. Pseudo Diaper RashPseudo Diaper Rash ► In infants,In infants, C. albicansC. albicans infection may start ininfection may start in perianal region and spread over entire areaperianal region and spread over entire area ► Dermatits is enhanced by macerationDermatits is enhanced by maceration produced by wet diapersproduced by wet diapers ► Diaper friction may contribute to skin irritationDiaper friction may contribute to skin irritation and compromised function of stratumand compromised function of stratum corneumcorneum ► Suspected by finding involvement of folds andSuspected by finding involvement of folds and occurrence of many small erythematousoccurrence of many small erythematous desquamating “satellite” or “daughter” lesionsdesquamating “satellite” or “daughter” lesions scattered around edgesscattered around edges
  122. 122. Congenital CutaneousCongenital Cutaneous CandidiasisCandidiasis ► Infection of an infant during passage throughInfection of an infant during passage through birth canalbirth canal ► Eruption usually noted within first few hrs ofEruption usually noted within first few hrs of deliverydelivery ► Erythematous macules progress to thin-Erythematous macules progress to thin- walled pustules, which rupture, dry, andwalled pustules, which rupture, dry, and desquamate within a weekdesquamate within a week ► Lesions are usually widespread, involvingLesions are usually widespread, involving trunk, neck, and head, at times palms andtrunk, neck, and head, at times palms and soles, including nail foldssoles, including nail folds ► Oral cavity and diaper area are sparedOral cavity and diaper area are spared
  123. 123. Congenital CutaneousCongenital Cutaneous CandidiasisCandidiasis ► Differential dx: listeriosis, syphilis, staphylococcalDifferential dx: listeriosis, syphilis, staphylococcal and herpes infections, ETN, transient neonataland herpes infections, ETN, transient neonatal pustular melanosis, miliaria rubra , drug eruption,pustular melanosis, miliaria rubra , drug eruption, congenital icthyosiform erythroderma (neonatalcongenital icthyosiform erythroderma (neonatal pustular disorders)pustular disorders) ► If suspected early amniotic fluid, placenta, andIf suspected early amniotic fluid, placenta, and cord should be examined for evidence of infectioncord should be examined for evidence of infection ► Infants with disease limited to skin have favorableInfants with disease limited to skin have favorable outcomesoutcomes
  124. 124. CCCCCC ► Disseminated infection is suggested by (1) bwDisseminated infection is suggested by (1) bw <1500g (2) evidence of respiratory distress or<1500g (2) evidence of respiratory distress or labs indicating neonatal sepsis (3) tx withlabs indicating neonatal sepsis (3) tx with broad-spectrum antibiotics (4) extensivebroad-spectrum antibiotics (4) extensive instrumentation during delivery or invasiveinstrumentation during delivery or invasive procedures in neonatal period (5) positiveprocedures in neonatal period (5) positive systemic cultures, or (6) evidence of an alteredsystemic cultures, or (6) evidence of an altered immune responseimmune response ► Infants with congenital cutaneous candidiasisInfants with congenital cutaneous candidiasis with any of these 6 criteria would bewith any of these 6 criteria would be considered for systemic antifungal therapyconsidered for systemic antifungal therapy
  125. 125. Perianal CandidiasisPerianal Candidiasis ► Frequently entire GI tract is involvedFrequently entire GI tract is involved ► Can be precipitated by oral antibiotic therapyCan be precipitated by oral antibiotic therapy ► Perianal dermatitis with erythema, oozing, andPerianal dermatitis with erythema, oozing, and maceration is presentmaceration is present ► Psychogenic etiology is more common than isPsychogenic etiology is more common than is candidiasiscandidiasis ► Differential dx: psoriasis, seborrheic dermatitis,Differential dx: psoriasis, seborrheic dermatitis, streptococcal and staphylococcal infections,streptococcal and staphylococcal infections, contact dermatits, and extramammary Paget’scontact dermatits, and extramammary Paget’s diseasedisease ► Fungicides, meticulous cleansing of perianalFungicides, meticulous cleansing of perianal region after bowel movements, topicalregion after bowel movements, topical corticosteroids and antipruritics (Atarax)corticosteroids and antipruritics (Atarax)
  126. 126. Candidal ParonychiaCandidal Paronychia ► Cushionlike thickening of paronychial tissue,Cushionlike thickening of paronychial tissue, slow erosion of lateral borders of nails, gradualslow erosion of lateral borders of nails, gradual thickening and brownish discoloration of nailthickening and brownish discoloration of nail plates, and development of pronouncedplates, and development of pronounced transverse ridgestransverse ridges ► Frequently only one nailFrequently only one nail ► A secondary mixed bacterial infection can occurA secondary mixed bacterial infection can occur with those who frequently have hands in waterwith those who frequently have hands in water or who handle moist objects; cooks,or who handle moist objects; cooks, dishwashers, bartenders, nurses, canners, etcdishwashers, bartenders, nurses, canners, etc
  127. 127. CPCP ► Manicuring nails sometimes is responsible forManicuring nails sometimes is responsible for mechanical or chemical injuries leading tomechanical or chemical injuries leading to infectioninfection ► Ingrown toenails with chronic paronychiaIngrown toenails with chronic paronychia ► Seen in pts with diabetesSeen in pts with diabetes ► Avoid chronic moisture exposure; get diabetesAvoid chronic moisture exposure; get diabetes under controlunder control ► Oral fluconazole once weekly or pulse doseOral fluconazole once weekly or pulse dose itraconazole should be effectiveitraconazole should be effective ► Topical therapy should continue for 2-3 monthsTopical therapy should continue for 2-3 months to prevent recurrenceto prevent recurrence
  128. 128. Erosia InterdigitalisErosia Interdigitalis BlastomyceticaBlastomycetica ► Oval-shaped area of macerated white skin onOval-shaped area of macerated white skin on web between and extending onto sides ofweb between and extending onto sides of fingersfingers ► With progression macerated skin peels off,With progression macerated skin peels off, leaving painful, raw,denuded area surroundedleaving painful, raw,denuded area surrounded by a collar of overhanging white epidermisby a collar of overhanging white epidermis ► Nearly always affects third webNearly always affects third web ► Moisture beneath rings macerates skin andMoisture beneath rings macerates skin and predisposes to infectionpredisposes to infection ► Also seen in diabetics, those who doAlso seen in diabetics, those who do housework, launderers, and others exposed tohousework, launderers, and others exposed to macerating effects of water and strong alkalismacerating effects of water and strong alkalis
  129. 129. Chronic MucocutaneousChronic Mucocutaneous CandidiasisCandidiasis ► A heterogeneous group of pts whose infectionA heterogeneous group of pts whose infection withwith CandidaCandida is chronic but superficialis chronic but superficial ► Onset before age 6Onset before age 6 ► Onset in adult life may herald the occurrence ofOnset in adult life may herald the occurrence of thymomathymoma ► When inherited an endocrinopathy is often foundWhen inherited an endocrinopathy is often found ► Most cases have well-defined limited defects ofMost cases have well-defined limited defects of cell-immunitycell-immunity ► Oral lesions are diffuse and perleche and lipOral lesions are diffuse and perleche and lip fissures are commonfissures are common
  130. 130. Systemic CandidiasisSystemic Candidiasis ► High risk pts: pts with malignancies, AIDS,High risk pts: pts with malignancies, AIDS, transplant pts requiring immunosuppressivetransplant pts requiring immunosuppressive drugs, pts on oral cortisone, pts who have haddrugs, pts on oral cortisone, pts who have had multiple surgical operations especially cardiac,multiple surgical operations especially cardiac, pts with indwelling catheters, and heroinpts with indwelling catheters, and heroin addictsaddicts ► Initial sign is varied: FUO, pulmonary infiltrates,Initial sign is varied: FUO, pulmonary infiltrates, GI bleeding, endocarditis, renal failure,GI bleeding, endocarditis, renal failure, meningitis, osteomyelitis, endophthalmitis,meningitis, osteomyelitis, endophthalmitis, peritonitis, or a disseminated maculopapularperitonitis, or a disseminated maculopapular eruptioneruption
  131. 131. SCSC ► Cutaneous findings are erythematousCutaneous findings are erythematous macules that become papular, pustular, andmacules that become papular, pustular, and hemorrhagic, and may progress to necrotic,hemorrhagic, and may progress to necrotic, ulcerating lesions resembling ecthymaulcerating lesions resembling ecthyma gangrenosumgangrenosum ► Deep abscesses may occurDeep abscesses may occur ► Trunk and extremities are usual sites ofTrunk and extremities are usual sites of involvementinvolvement ► Proximal muscle tenderness is a commonProximal muscle tenderness is a common findingfinding
  132. 132. SCSC ► If candida is cultured within the first week of lifeIf candida is cultured within the first week of life there is a high rate of systemic diseasethere is a high rate of systemic disease ► There is a 50% chance of systemic disease if 1 orThere is a 50% chance of systemic disease if 1 or more cultures is positivemore cultures is positive ► Mortality has declined from 80% in the 1970’s toMortality has declined from 80% in the 1970’s to 40% in the 1990’s because of early empiric40% in the 1990’s because of early empiric antifungals and better prophylaxisantifungals and better prophylaxis
  133. 133. THE ENDTHE END Thank YouThank You

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