FUNGAL SKIN INFECTIONS Özlem Akın, M.D. Yeditepe University Hospital Dermatology Department

Tinea Capitis Ringworm of the scalp Occurs chiefly in schoolchildren and less commonly in infants and adults M>F Hair can be infected with Trichophyton and Microsporum fungi. M. canis is the commonest dermatophyte fungus to cause tinea capitis. This fungus is zoophilic i.e. it grows naturally on an animal rather than a human. M canis tinea capitis is due to contact with an infected kitten or rarely an older cat or dog. T. tonsurans has also become a common cause of tinea capitis; this is passed on from one person to another as it naturally infects humans (i.e. it is anthropophilic). It frequently causes no symptoms and is commonly found in adult carriers.

Tinea Capitis Anthropophilic infections such as T. tonsurans are more common in crowded living conditions. The fungus can contaminate hairbrushes, clothing, towels and the backs of seats. The spores are long lived and can infect another individual months later. Zoophilic infections are due to direct contact with an infected animal and are not generally passed from one person to another. Geophilic infections usually arise when working in infected soil but are sometimes transferred from an infected animal.

Tinea Capitis Tinea capitis may present in several ways. Dry scaling – like dandruff but usually with moth-eaten hair loss Black dots – the hairs are broken off at the scalp surface, which is scaly Smooth areas of hair loss Kerion – very inflamed mass, like an abscess Favus – yellow crusts and matted hair Carrier state no symptoms and only mild scaling (T. tonsurans).

Tinea Capitis Tinea capitis may result in swollen lymph glands at the sides of the back of the neck. Untreated kerion and favus may result in permanent scarring (bald areas). It can also result in an id reaction, especially just after starting antifungal treatment.

Tinea Capitis Diagnosis Tinea capitis is suspected if there is a combination of scale and bald patches. Wood's light fluorescence is helpful but not diagnostic as it is only positive if the responsible organism fluoresces, and fluorescence is sometimes seen for other reasons. The diagnosis of tinea capitis should be confirmed by microscopy and culture of skin scrapings and hair pulled out by the roots.

Tinea Capitis Treatment of carriers If the child has an anthropophilic infection, all family members should be examined for signs of infection. Brushings of scaly areas of the scalp should be taken for mycology. Sometimes it is best for the whole family to be treated whether or not fungal infection is proven. It is advisable for parents of classmates and other playmates to be informed so their children may be examined and treated if necessary. In some countries, infected children are not allowed to attend school. Elsewhere children with tinea capitis can attend school providing they are receiving treatment.

Tinea Capitis Carriers may have no symptoms. Treatment of carriers is necessary to prevent spread of infection. Antifungal shampoo twice weekly for four weeks may be sufficient but if cultures remain positive, oral treatment is recommended. Suitable shampoos include: 2.5% selenium sulfide 1% to 2% zinc pyrithione 2% ketoconazole

Tinea Capitis Tinea capitis requires treatment with an oral antifungal agent. Griseofulvin is probably the most effective agent for infection with Microsporum canis, Scalp Trichophyton infections may successfully be eradicated using oral terbinafine, itraconazole or fluconazole for 4 to 6 weeks. However, these medications are not always successful and it may be necessary to try another agent. Intermittent treatment may also be prescribed e.g. once weekly dosages.

Tinea Pedis The feet are the most common area infected by certain fungi called dermatophytes, causing tinea pedis or athlete’s foot. Athlete’s foot is a very common problem experienced by up to 70% of the population at some time in their life. common in adult males, but uncommon in women. can also affect children before puberty, regardless of sex. Athlete’s foot seems to occur most often in people who have some characteristic of their immune system which predisposes them to infections regardless of the precautions they take to prevent infection. Once an infection is established, the person becomes a carrier and is more susceptible to recurrences and complications.

Tinea Pedis Predisposing factors exposure to the spores at home or during recreational activities occlusive footwear wearing the same pair of socks or shoes for long periods hyperhidrosis immune deficiency (e.g. medication such as azathioprine, or infection with HIV) poor circulation resulting in cold feet e.g. due to lymphoedema

Tinea Pedis divided into three categories: Chronic interdigital Chronic scaly (moccasin type) Acute vesicular

Tinea Pedis Chronic Interdigital Athlete’s Foot This is the most common type of athlete’s foot. It is characterized by scaling, maceration, and fissures most commonly in the web space between the 4th and 5th toes. Tight-fitting, non-porous shoes compress the toes, creating a warm, moist environment in the web spaces. Many times the infecting fungus interacts with bacteria causing a more severe infection that extends onto the foot. With this type of athlete’s foot, itching is typically most intense when the socks and shoes are removed.

Tinea Pedis Moccasin Type Athlete’s Foot caused by Trichophyton rubrum This dermatophyte causes dry, scaling skin on the sole of the foot. The scale is very fine, and silvery, and the skin underneath is usually pink and tender. The hands may also be infected, although the usual pattern of infection is two feet and one hand, or one foot and two hands. This type of athlete’s foot is often seen in people with eczema or asthma. It is associated with fungal nail infections which may lead to recurrent skin infections.

Tinea Pedis Acute Vesicular Athlete’s Foot least common type of athlete’s foot, caused by Trichophyton mentagrophytes often originates in people who have a chronic interdigital toe web infection. characterized by the sudden onset of painful blisters on the sole or top of the foot.

Tinea Pedis The diagnosis is confirmed by microscopy and culture of skin scrapings.

Tinea Pedis Treatment Mild cases, especially interdigital toe web infections, can be treated with topical antifungal creams or sprays such as clotrimazole, ciclopirox, terbinafine, naftifine. Topical medications should be applied twice a day until the rash is completely resolved. More serious infections and moccasin type should be treated with oral antifungal medications such as terbinafine or itraconazole for 2 to 6 months. All oral antifungal medications can affect the liver; therefore, blood tests should be performed monthly to evaluate liver function.

Tinea Pedis If treatment is unsuccessful consider whether you have: Untreated infection eg of the nails (onychomycosis). Reinfection from contact with spores in your surroundings or clothing. An untreated infected family member. An alternative explanation for your symptoms such as dermatitis or psoriasis

Tinea Cruris The rash starts in the groin fold usually on both sides. If the rash advances, it usually advances down the inner thigh. The advancing edge is redder and more raised than areas that have been infected longer. The advancing edge is usually scaly and very easily distinguished or well demarcated. The skin within the border turns a reddish-brown and loses much of its scale. Tinea cruris caused by T. rubrum does not involve the scrotum or penis. If those areas are involved, the most likely agent is Candida albicans, the same type of yeast that causes vaginal yeast infections.

Tinea Cruris is a fungal infection of the skin in the groin. The warm, moist environment is the perfect place for the fungus to grow. Therefore, wearing sweaty, wet clothing in the summer time or wearing several layers of clothing in the wintertime causes an increased incidence. Men are affected more often than women.

Tinea Cruris Differential diagnosis intertrigo erythrasma seborrheic dermatitis inverse psoriasis

Tinea Cruris Treatment Mild cases can be treated with topical antifungal creams or sprays such as clotrimazole, ciclopirox, terbinafine, naftifine. Topical medications should be applied twice a day until the rash is completely resolved (2-4 weeks). Extensive disease should be treated with oral antifungal medications such as terbinafine (1-2 week) or itraconazole (1 week).

Tinea Cruris Prevention: Wear loose fitting clothing made of cotton or synthetic materials designed to wick moisture away from the surface. Avoid sharing clothing and towels or washcloths. Allow the groin to dry completely after showering before covering with clothes. Antifungal powders or sprays may be used once a day to prevent infection.

Tinea Corporis includes all superficial dermatophyte infections of the skin other than those involving scalp, beard, face, hands, feet and groin. characterized by one or more circular, sharply circumscribed, slightly erythematous, dry, scaly, usually hypopigmented patches. an advancing scaling edge usually prominent progressive central clearing produces annular outlines that give them the name “ringworm” T. rubrum, M. canis, and T. mentagrophytes are common causes, although it can be cauesed by any of the dermatophytes.

Tinea Corporis The diagnosis is confirmed by microscopy and culture of skin scrapings. Differential diagnosis: pityriasis rozea impetigo nummular dermatitis secondary and tertiary syphilids seborrheic dermatitis psoriasis

Tinea Corporis Specific topical and oral treatment is the same as that described earlier for tinea cruris

Tinea Faciei Fungal infection of the face Frequently misdiagnosed Typical annular rings usually lacking and the lesions are exquisitely photosensitive Frequently misdiagnosis of lupus erythematosus is made Erythematous, slightly scaling, indistinct borders may be present at the periphery of the lesions, and are the best location for KOH examination

Tinea Faciei If topical corticosteroids have been used, fungal foliculitis is a frequent finding. A biopsy may be required to establish the diagnosis Usually infection is caused by T. rubrum, M. canis, or T. Mentagrophytes. If fungal foliculitis is present, oral medication is required. If no fungal foliculitis is present, infection generally responds well to topical therapy. Oral agents are appropriate for wide spread infections.

Tinea Barbae Ringworm of the beard (=tinea sycosis) Not a common disease Occurs chiefly among those in agricultural pursuits, especially those in contact with farm animals Mostly one-sided on the neck or face Two clinical types: Deep, nodular, suppurative lesions Superficial, crusted, partially bald patches with folliculitis

Tinea Barbae Diagnosis: Differential diagnosis: Treatment: KOH examination Culture Differential diagnosis: Staphylococcal folliculitis (sycosis vulgaris) Herpetic infections Treatment: Like tinea capitis, oral antifungal agents are required oral agents are used in the same doses and for the same durations as in tinea capitis

Tinea Manum Generally is dry, scaly, and erythematous type that is suggestive of T. rubrum infection Other areas are frequently affected at the same time However, moist, vesicular, and eczematous type caused by T. Mentagrophytes, which is seen more often on feet, may at times occur on the hand. As a rule both hands are involved and eruption tends to be symmetrical

Tinea Manum Differential diagnosis: Diagnosis: Allergic contact or irritant dermatitis Pompholyx Atopic dermatitis Psoriasis Diagnosis: KOH examination Culture

Tinea Manum Treatment: Mild cases can be treated with topical antifungal creams such as clotrimazole, ciclopirox, terbinafine, naftifine. More serious infections should be treated with oral antifungal medications such as terbinafine 250 mg/day for 2 weeks; or itraconazole, 200 mg twicw daily for 1 week; or fluconazole, 150 mg once weekly for 4 weeks.

Onychomycosis Fungal infection of the nails It is increasingly common with increased age. It rarely affects children. Onychomycosis can be due to: Dermatophytes such as Trichophyton rubrum (T rubrum), T. interdigitale. The infection is also known as tinea unguium. Yeasts such as Candida albicans. Moulds especially Scopulariopsis brevicaulis and Fusarium species.

Onychomycosis may affect one or more toenails and/or fingernails most often involves the great toenail or the little toenail. It can present in one or several different patterns: Lateral onychomycosis. A white or yellow opaque streak appears at one side of the nail. Subungual hyperkeratosis. Scaling occurs under the nail. Distal onycholysis. The end of the nail lifts up. The free edge often crumbles. Superficial white onychomycosis. Flaky white patches and pits appear on the top of the nail plate. Proximal onychomycosis. Yellow spots appear in the half-moon (lunula). Complete destruction of the nail.

Onychomycosis Tinea unguium often results from untreated tinea pedis or tinea manum It may follow an injury to the nail. Differential diagnosis: Bacterial infection especially Pseudomonas aeruginosa, which turns the nail black or green. Psoriasis Eczema or dermatitis Lichen planus Viral warts Onycholysis Onychogryphosis (nail thickening and scaling under the nail), common in the elderly.

Onychomycosis Fingernail infections are usually cured more quickly and effectively than toenail infections. Mild infections affecting less than 80% of one or two nails may respond to topical antifungal medications but cure usually requires an oral antifungal medication for several months. Combined topical and oral treatment is probably the most effective regime.

Tinea Versicolor also known as pityriasis versicolor superficial fungal infection of the skin that is often confused with other common rashes. The yeasts, Pityrosporum orbiculare and Pityrosporum ovale, are a part of the normal skin flora. They reside in the stratum corneum and hair follicles and have an affinity for sebaceous glands. Certain factors can cause these yeasts can convert to a pathogenic form known as Malassezia furfur, which causes the rash of tinea versicolor.

Tinea Versicolor Some of these predisposing factors include: Removal of the adrenal gland Cushing's disease Pregnancy Malnutrition Burns Steroid therapy Suppressed immune system Oral contraceptives Excess heat Excess humidity

Tinea Versicolor can occur at any age, but is most common in adolescence and early adulthood, a time when the sebaceous glands are more active also more common in tropical and semi-tropical climates. has a recurrence rate of 80% after 2 years.

Tinea Versicolor The rash of tinea versicolor is a hypopigmented, hyperpigmented, or red flat eruption that may coalesce into large patches with an adherent fine scale. This rash occurs mainly on the trunk, but can also occur on the extremities. Hypopigmentation occurs because the yeast produces a chemical that turns off the melanocytes, resulting in decreased melanin production. The hyperpigmentation or redness occur as a result of the inflammatory response in the skin.

Tinea Versicolor Diagnosis A KOH test shows a characteristic "spaghetti and meatballs" appearance under the microscope. Under a Wood's light examination, the yeast fluoresces pale yellow. A fungal culture can be performed after adding oil to the culture medium, but it is rarely necessary.

Tinea Versicolor Differential Diagnosis: Vitiligo Pityriasis alba Seborrheic Dermatitis Syphilis Pityriasis Rosea Nummular eczema Guttate psoriasis

Tinea Versicolor Treatment Because the yeast inhabits the top layer of the skin, topical antifungal medications are very effective. If the rash is extensive, oral antifungal medications may be needed. It is important to note that even though the pathogenic yeast has been eradicated after treatment, the hypopigmentation may persist for weeks until the melanocytes start to produce melanin again. Because this rash has a high recurrence rate, medication may be needed periodically to prevent recurrence.

Cutaneous candidiasis Candidiasis (moniliasis) is skin infection with Candida sp, most commonly Candida albicans. Infections can occur anywhere and are most common in skinfolds and web spaces, on the genitals, cuticles, and oral mucosa. Most candidal infections are of the skin and mucous membranes, but invasive candidiasis is common in immunosuppressed patients and can be life threatening. Etiology Candida is a group of about 150 yeast species. C. albicans is responsible for about 70 to 80% of all candidal infections. Other significant species include C. glabrata, C. tropicalis, C. krusei, and C. dubliniensis. Candida is a ubiquitous yeast that resides harmlessly on skin and mucous membranes until dampness, heat, and impaired local and systemic defenses provide a fertile environment for it to grow.

Cutaneous candidiasis Risk factors for candidiasis include: Hot weather Restrictive clothing Poor hygiene Infrequent diaper or undergarment changes in children and elderly patients Altered flora from antibiotic therapy Inflammatory diseases (such as psoriasis) that occur in skinfolds Immunosuppression resulting from corticosteroids and immunosuppressive drugs, pregnancy, diabetes, other endocrinopathies (eg, Cushing's disease, hypoadrenalism, hypothyroidism), blood dyscrasias, or T-cell defects

Cutaneous candidiasis Candidiasis occurs most commonly in intertriginous areas such as the axillae, groin, and gluteal folds (eg, diaper rash), in digital web spaces, in the glans penis, and beneath the breasts. Vulvovaginal candidiasis is common in women Candidal nail infections and paronychia may develop after improperly done manicures and in kitchen workers and others whose hands are continually exposed to water In obese people, candidal infections may occur beneath the pannus (abdominal fold). Oropharyngeal candidiasis is a common sign of local or systemic immunosuppression. Chronic mucocutaneous candidiasis typically affects the nails, skin, and oropharynx. Patients have cutaneous anergy to Candida, absent proliferative responses to Candida antigen (but normal proliferative responses to mitogens), and an intact antibody response to Candida and other antigens. Chronic mucocutaneous candidiasis may occur as an autosomal recessive illness associated with hypoparathyroidism and Addison's disease (Candida-endocrinopathy syndrome).

Cutaneous candidiasis Symptoms and Signs Intertriginous infections manifest as pruritic, well-demarcated, erythematous patches of varying size and shape; erythema may be difficult to detect in darker-skinned patients. Primary patches may have adjacent satellite papules and pustules. Perianal candidiasis produces white maceration and pruritus ani. Vulvovaginal candidiasis causes pruritus and discharge Candidal infection is a frequent cause of chronic paronychia, which manifests as painful red periungual swelling. Subungual infections are characterized by distal separation of one or several fingernails (onycholysis), with white or yellow discoloration of the subungual area Oropharyngeal candidiasis causes white plaques on oral mucous membranes that may bleed when scraped. Perlèche is candidiasis at the corners of the mouth, which causes cracks and tiny fissures. It may stem from chronic lip licking, thumb sucking, ill-fitting dentures, or other conditions that make the corners of the mouth moist enough that yeast can grow. Chronic mucocutaneous candidiasis is characterized by red, pustular, crusted, and thickened plaques resembling psoriasis, especially on the nose and forehead, and is invariably associated with chronic oral candidiasis.

Cutaneous candidiasis Diagnosis Clinical appearance Potassium hydroxide wet mounts Positive culture is usually meaningless because Candida is omnipresent.

Cutaneous candidiasis Treatment: General hygiene is vital to the treatment of cutaneous candidiasis. Keeping the skin dry and exposed to air is helpful. Weight loss may eliminate the problem in obese people, and good sugar control in diabetics may also be helpful. Topical (applied directly to the skin) antifungal medications may be used to treat infection of the skin, mouth, or vagina. Oral antifungal medications may be necessary for folliculitis, nail infection, or severe candida infections involving the mouth, throat, or vagina.