1. Superficial fungal skin infections
Objectives:
1- Identify the clinical types of dermatophytosis
2-Clarify types of antifungal and indications for each one
3-Identify Pityrosporum infection
4- Clarify risk factors for candidal infection
5-Identify the clinical types of candidiasis
2. Fungal diseases of the skin are fairly common and these diseases may be
superficial or deep.
The three superficial fungi that affect the skin are:
1. Dermatophyte infection (tinea or ringworm infection).
2. Pityrosporum infection (Pityriasis versicolor).
3. Candidiasis (moniliasis).
Dermatophytosis: (tinea or ringworm infection)
Dermatophytes are moulds that belonging to three genera of Fungi
imperfecti that affect the skin and appendages which are: Trichophyton,
microsporum and epidermophytone.
The microorganism may be transmitted or acquired from human
(anthrophilic), from animals (zoophilic) or from soil (geophilic).
Clinical types:
The clinical classification usually depends on the site of involvement:
1. Tinea capitis:
Is infection of the scalp by dermatophytes in which there is
invasion of the hair shaft by the microorganism, it may be
3. transmitted from animals (microsporum canis) or from human and it
is more in children (rare in infants and adults).
Four clinical variants of Tinea capitis are present, two of them are of
the non inflammatory type (not lead to scar formation) and the other
two types are of the inflammatory type (lead to scar formation).
A. Scaly (gray patch) type: (Non inflammatory)
Where there is a circular patch (patches) of hair loss with easily
broken off hair, the area is of dull gray colour with fine scales and a
fairly sharp .
B. Black dot type: (Non inflammatory)
Where the affected infected hairs are broken at the surface of the
scalp leading to black discoloration, the disease presents with
patches of hair loss with minimal scales and a low grade folliculitis
may be seen.
C. Kerion celsii: (Inflammatory type)
The most sever form of reaction, it presents as painful boggy
inflammatory mass with hair loss, the hair follicles may show
4. discharging pus with sinus formation in some occasions, thick crustation
with matting of hair may be commonly seen, it may be multiple and
lymphadenopathy is usually seen.
Scarring as well as permanent alopecia may be seen. A short course of
systemic steroid can be given in this type (with the proper oral
antifungal drug) to decrease the severity of inflammation and to
decrease the risk of scarring.
D. Favus: (Inflammatory type)
Is characterized by the presence of a yellowish cup shape crustation
(scutula) which had mousy odor and developed around the hair which
pierce it centrally.
Extensive patchy hair loss with scarring and atrophy among patches of
normal hair usually result.
DDX:
I. Any cause of alopecia like alopecia areata, trichotillomania,
traumatic hair loss …….etc.
II. Seborrheic dermatitis.
III. Psoriasis.
IV. Lichen planus.
5. Wood's light, which was traditionally used to diagnose scalp
ringworm, can detect infection with only Microsporum sp. The
greenish fluorescence seen under the light is due to an ectothrix
infection of hairs, in which fungal spores form a sheath on the
outside of the hair. T tonsurans causes an endothrix infection
with the spores inside the hair shaft, and there is no
fluorescence.
Diagnosis therefore relies on mycological analysis of scalp scale
and broken off infected hairs. Samples for analysis can be
obtained by scraping the affected area with the blunt side of a
scalpel (to avoid slicing through the infected hairs) on to a piece
of paper. This technique requires some practice.
.
6.
7. 2. Tinea barbae:
It is infection of the beard and the moustache areas of the face in adult
males with invasion of the coarse hairs.
Clinically, there is an inflammatory pustular folliculitis and
the beard or moustache hair are surrounded by papules or pustules
with exudation or crustation, the hair in the affected area is loss and
easily removed and the disease is usually unilateral.
DDX:
I. Carbuncle.
II. Bacterial folliculitis.
III. Acne.
8. 3. Tinea faciei:
Is an infection of the skin of the face (excluding the male
moustache and beard areas). Erythema is usually present with or without
scales and the border of the lesions are usually indistinct, the lesions
may be rounded with raised margin and pustules may present.
DDX:
I. LE.
II. PLE.
III. Seborrheic dermatitis.
IV. Contact dermatitis.
9. 4. Tinea corporis: (Tinea circinata)
Is an infection of the glabrous skin including the neck, the trunk
and the extremities excluding the palms, the soles, the groin, the face,
the scalp and the beard.
Clinically, there is annular (circinate) plaque (plaques) which is
characteristic , usually sharply marginated with raised edge and
central clearing and the terminal hair in the affected parts may be
invaded.
DDX:
I. Seborrheic dermatitis.
II. Psoriasis.
III. Disciod eczema.
IV. Pityriasis rosea.
V. Syphilis.
VI. Lichen simplex chronicus
10. 5. Tinea manum: Is
a ringworm infection of the palm, different clinical forms are
present as hyperkeratosis of palms which are affected diffusely
(the commonest) and it may be unilateral in about one half of
the patients. The disease
may presents also as exfoliative scaliness or as vesicular patches
DDX:
I. Eczema.
II. Psoriasis.
III. Syphilis.
IV. Pityriasis rubra pilaris.
V. Familial palmar hyperkeratosis.
VI. Reiter’s disease.
VII. Lichen planus.
11. 6. Tinea cruris:
Is a groin infection with ringworm, it is more in males, it increases
with humidity, in hot weather, in those wearing tight shorts ….…etc.
Clinically, there are erythematous plaques with sharp margin extending
from the groin to the thigh with scales. Vesiculation may occur, the lesions
may be inflammatory with pustule formation and the lesions may extend to
the abdomen, the buttocks, the perineum .
DDX:
I. Candidal infection.
II. Erythrasma.
III. Flexural Psoriasis.
IV. Seborrheic dermatitis.
V. Contact dermatitis.
VI. Intertrigo.
12. 7. Tinea pedis: (Athlete foot)
Is an infection of the feet with dermatophytes, it is fairly
common especially among the athletes and those wearing socks and
shoes for prolonged periods, increased in swimming bathes …..etc.
Many clinical forms are present, the commonest is :
Interdigital form which is characterized by peeling, maceration and
fissuring affecting the lateral toe cleft and sometimes spread to the
undersurface of the toes, itching is common.
Hyperkeratosis (which is chronic and resists treatment) where the soles,
the heels and the sides of the feet are affected, hyperhydrosis increases
the severity of the symptoms.
Associated nail infection is common and this form may simulate
other causes of plantar hyperkeratosis.
13. Vesicular or the vesiculobullous form
which may be extensive and maceration as well as fissuring
is present (bacterial infection may follow).
DDX:
I. Erythrasma.
II. Candidiasis.
III. Soft corn.
IV. Contact dermatitis.
14. 8. Tinea unguium: Is
nail plate invasion by ringworm infection where there is nail plate
discoloration, subungual hyperkeratosis, nail destruction
……etc. Three variants
are present: A. Proximal
subungual onychomycosis. B. Distal
subungual onychomycosis.
C. White superficial onychomycosis.
15. 9. Tinea incognito: (Steroid modified tinea) Where
the classical features of the disease are lost due to topical or systemic
corticosteroid.
Clinically, there is suppression in the inflammatory response with
diminution in the raised margin and loss of scales , skin discoloration
can be seen at the affected site with or without pustulation, later, the
affected site may also show atrophy, striae, telengectasia ….etc due to
prolonged use of corticosteroids. The history is important in diagnosing
this condition.
16. Dermatophytid: (Id reaction)
Is a non infective cutaneous eruption represents an allergic response to a
distant focus of fungal infection.
The essential criteria for diagnosis:
1. Previous ringworm infection which becomes highly inflamed before
the appearance of the rash. (kerion , tinea pedis)
2. A distinctive eruption which is demonstrably free of ringworm.
3. Spontaneous disappearance of the rash when ring worm infection
settle with or without treatment.
Many clinical variants of id reaction are present like:
1. Lichenoid papules.
2. Pompholyx like eruption on palms and soles.
3. Erythema multiforme.
4. Erythema nodosum.
5. Urticaria.
6. Erysipelas like eruption.
7. Folliculitis.
8. Morbiliform rash.
9. Scarletiniform rash.
17. DX:
1. Clinical.
2. Wood’s light examination: Used for Tinea capitis only.
Infection with Microsporum species shows a brilliant green color and with
Trichophyton schoenleinii (favus) shows a paler green color. Pityriasis
versicolor fluoresce pale white yellow fluorescence
It is important in detecting subclinical infection, in assessing response to
treatment and in assessing spontaneous cure.
3.Direct examination: By
doing scraping for scales or taking hair or nail for examination and add 10
– 30 % KOH (potassium hydroxide) we can see hyphae under microscope.
4. Culture: As
Sabouraud’s glucose media or DTM …….etc and this needs 1 – 2 weeks to
give the needed result
18. Treatment:
1. Control of infection and avoidance of the predisposing or the
causative factors are important (like increased perspiration,
increased humidity and increased maceration).
2.Topical treatment:
May be used alone or in association with the oral therapy. A.
Imidazole group, which is a broad spectrum antifungal as
clotrimazole, miconazole, econazole, oxiconazole ….etc. B.
whitfield ointment, which is a combination of benzoic acid and
salicylic acid in 2:1 ratio.
C. Cicloperox olamine. D.
Tolnaftate.
E. Naftifine. F.
Castellani’s paint.
G. Others.
Topical treatment is not effective in treating scalp and nail infection.
19. 3. Oral treatment:
I. Griseofulvin: Is a penicellium derivative, it is fungistatic drug acts on
dermatophytes only, it is given orally with fatty meal in a dose of 10 – 20
mg/kg/day, it presents in micronized and ultra micronized forms. It
may lead to headache, photosensitivity reaction .
Main indications are:
A. Tinea unguium.
B. Tinea capitis.
C. Failure of topical treatment.
D. Wide spread infection.
E. Tinea incognito.
F. Chronic infection with tinea
manum
Skin infection for 2 – 6 weeks (4
weeks).
Hair infection for 2 – 4 months (6 - 12
weeks).
Finger nail infection for 4 – 8 months
(6 months).
Toe nail infection for 10 – 18 months
(12 months).
20. .
II. Ketoconazole:
Which is hepatotoxic.
III. Triazole group:
As flouconazole and itraconazole. IV.
Allylamines: As
terbinafine.
II, III and IV are used for shorter duration than that of
griseofulvin.
4. Others:
Like antihistamines, antibiotics for secondary bacterial infection,
drying agents like potassium permanganate for vesicular lesions,
antifungal powder …….etc.
21.
22. Pityriasis versicolor:
Is a mild chronic infection of the skin . The disease doesn’t affect the hair
shaft, the nails or the mucous membranes.
Etiology:
Malassezia fur fur which represents the mycelial phase of the lipophilic
yeast Pityrosporum orbiculare (a normal flora), is the cause.
Clinical features:
The disease of young adults affecting face ,trunk, neck and the abdomen.
extremities…etc. It is widely spread in immune compromised people .
It is sharply demarcated macules (and or patches), sometimes slightly
erythematous, mild itching , characterized essentially by fine branny scales.
The eruption showed large confluent areas, scattered oval patches
brownish color in pale skin patients and hypopigmented in dark skin
patients (so named versicolor ).
23. Diagnosis:
1. Clinical.
2. Wood’s light examination: a pale (golden) yellow fluorescence.
3. Direct examination of the scales with KOH:
Showed a spherical spores and coarse thick hyphae leading to what
called a spaghetti and meat balls appearance.
DDX:
1. Vitiligo.
2. Seborrheic dermatitis.
3. Pityriasis rosea.
4. Secondary syphilis.
5. Tinea circinata.
6. Pityriasis alba.
24. Treatment:
Vary from days to weeks according to the type of the treatment.
A. Topical:
1. Selenium sulphide shampoo or lotion (2.5%).
2. Topical imidazoles.
3. Ketoconazole shampoo
4. Others:
As Whitfield ointment, topical terbenafine, sulphur preparation, zinc
pyrethrine shampoo ….………..etc.
B. Systemic (Oral):
Especially for widespread and resistant cases.
1.Ketoconazole.
2.Triazoles as flouconazole and itraconazole.
25. Candidiasis (Moniliasis)
Is an infection caused by yeast like fungi called Candida
albicans and occasionally by other species of candida.
It usually affects the skin, the mucous membranes and
sometimes the nails (not the hair) . Candida can be a normal
commensal flora that presents in the gut, the vagina, the skin
and the mouth.
Risk factors for candidal infection:
1. Increased moisture and humidity.
2. Extremes of ages.
3. AIDS and other immune suppressed conditions.
4. Malignancies.
5. Debilitated and malnourished conditions.
6. DM.
7. Corticosteroids.
26. 8. Prolonged use of certain antibiotics like tetracycline.
9. Multiple surgeries.
10. Pregnancy.
Laboratory diagnosis:
1. Direct examination with KOH:
Showed buds (spores) with pseudohyphae and occasionally a
true hyphae.
2. Gram stain:
Showed a Gram positive staining.
3. Culture:
In Sabaroud’s media.
27. Clinical types:
Oral thrush:
Presents with a sharply defined patches of grayish white
pseudomembranes which when removed showed an Underlying
erythematous base, it affects the buccal epithelium, the tongue, the gums or
the palate and in sever cases the thrush extends to the pharynx or the
esophagus with erosions and ulcerations in some occasions. It is commonly
seen in infants, in old age people, in immune compromised people and it is
considered as the commonest secondary infection in those with AIDS.
28. Angular cheilitis: (Perleche)
It Presents with ill defined thick areas, slight erythema, maceration and
transverse fissuring at the oral comissures, crustation may be also seen. The
disease is usually bilateral and moisture can be an important factor. This
condition can be caused by causes other than Candidiasis as riboflavin
deficiency, iron deficiency anemia, Staphylococcal infection, ill fitted dentures or
due to atrophy of the alveolar ridges in old age people.
29. Candidal intertrigo:
Presents with erythema, moist exudation starting deep in the skin folds
with an irregular edge with pustules that ruptured later and become
erosions. The presence of satellite lesions (pustules or papules) is classical
and itching is usual. This condition may simulate tinea, seborrheic
dermatitis, flexural psoriasis and erythrasma
Candidal paronychia:
It affects housewives whom hands are frequently immersed in water
(chronic). Typically, several fingers are commonly affected leading to red
swollen nail folds with loss of cuticle , detachment of nail fold from the
dorsal surface of the nail plate ,pain and tenderness. Nail dystrophy, brown
nail plate discoloration, transverse ridging and onycholysis can be seen
30. Erosio interdigitale blastomysetica:
Presents with macerated white skin of the webs between fingers with
central fissuring and a raw erythematous bases. It usually affects the
third finger web, it is more in diabetic patients, in housewives and those
working in moist environments. On the feet, the fourth space is largely
affected and it may be difficult to distinguish from tinea pedis
Candidal onychomycosis:
There is onycholysis, paronychia , complete nail plate destruction and
nail dystrophy (in some occasions).
31. Napkin’s Candidiasis:
It usually affects the skin of the buttock and the genitalia of infants,
usually due to wet diaper.
Classically, there are pustules, vesicles, maceration, irregular border
and satellite lesions
Granuloma gluteale infantum:
It represents a peculiar reaction to candidal infection.
Potent topical steroids, microorganisms other than candida may also
lead to this condition. There is bluish or brownish nodules following
napkin’s eruption of the napkin area ( buttocks, genitalia, upper
thighs and pubic area).
32. Candidal vulvovaginitis:
Presents with itching, irritation or burning sensation with thick
white creamy discharge as well as erythema of the vaginal
mucous membranes and the vulval skin that may spread to the
perineum. It is more in pregnant and it is largely confined to the
sexually active people and the condition may be recurrent and
chronic
Perianal candidiasis:
Anal pruritis usually leads to suspicion of candidiasis.
The patient usually presents with perianal dermatitis ,erythema,
maceration, pruritus and burning sensation.
33. Congenital candidiasis:
Appears during the passage of the fetus through an infected birth
canal at delivery and the rash appears within hours of delivery with
macules that changed into pustules which later dry and desquamate.
Chronic mucocutaneous candidiasis:
Is a persistent candidal infection of the mouth, the skin and the nails
that’s refractory to the conventional topical therapy. It presents
with oral thrush, paronychia, cutaneous involvement as well as
perleche ………….etc. It may be associated with different varieties of
other types of infection.
Others:
As conjugal balanitis, glossitis ……….etc.
34. Treatment:
1. General principles: Be
aware of the possible risk and susceptibility factors both localized and
generalized.
2. Therapeutic agents:
A. Local (Topical): May
present in a cream, lotion, lozenge, suspension, chore, vaginal tablets,
vaginal pessary and even in an ointment form. Includes:
1. Imidazole group.
2. Nystatin.
3. Naftifine.
4. Cicloperox olamine.
5. Natamycin.
35. B. Systemic:
1. Amphoterecin B.
2. Nystatin.
3. Ketoconazole.
4. Terbenafine.
5. Triazoles as flouconazole and itraconazole.
6. Flucytosine.
Onychomycosis as well as chronic mucocutaneous candidiasis
are usually respond to systemic and not to topical therapies.
