Chapter 15
Diseases Resulting
from Fungi and Yeasts
Andrews’ Diseases of
the Skin
JoAnne M. LaRow,
D.O.
Superficial mycoses
 AKA dermatophytes
 Classified into three genera: Microsporum,
Trichophyton, Epidermophyton
 Mycoses caused by dermatophytes are called
dermatophytosis, tinea, ringworm
 On certain parts of body tinea has certain features
characteristic of that site
 Hence the division into seven types (1)tinea
capitis, (2)tinea barbae, (3)tinea faciei, (4)tinea
corporis, (5) tinea manus, (6) tinea pedis, (7) tinea
cruris, (8)onychomycosis
 Superficial mycoses can be divided into causative
dermatophyte Management is rarely assisted by ID of genus and
species
Susceptibility
 They are soil saprophytes that have acquired
ability to digest keratinous material in soil,
becoming “keratinophilic fungi”
 Some have evolved to parasitize keratinous tissues
of animals frequently in contact with soil and have
lost their ability to survive in soil (zoophilic fungi)
 Anthropophilic dermatophytes are believed to
have evolved from zoophilic fungi, adapting to
human keratin and losing their ability to digest
animal keratin
 Environmental conditions help promote
propagation of many opportunistic fungi
 Host factors are also significant
Host factors
 Immunosuppressed pts
 Pts with AIDS may have severe forms
 Genetic susceptibility to certain forms of fungal
infections may be related to types of keratin or
degree or mix of cutaneous lipids produced
 Surface antigens-ABO system-one study of 108
culture proven dermatophytosis pts noted that pts
with type A blood were prone to chronic disease
 Human steroid hormones can inhibit growth of
dermatophytes (androgens like androstenedione)
 One group believes this high susceptibility of
Trichophyton rubrum & Epidermophyton
floccosum to intrafollicular androstenedione is a
reason why these species do not cause tinea capitis
Antifungal therapy
 Consider spectrum of activity of antifungal
 Pharmacokinetic profile of the agent
 Clinical type of infection
 Additionally, safety, compliance and cost
 Griseofulvin is still therapeutic option but
studies are showing that newer antifungals
are more efficacious
Imidazoles
 Clotrimazole, miconazole, sulconazole,
oxiconazole, and ketoconazole
 Mostly used for topical tx
 Inhibit cytochrome P450 14-alpha-demethylase
(an essential enzyme in ergosterol synthesis)
 Ketaconazole has wide spectrum against
dermatophytes, yeasts, and some systemic
mycoses
 Ketaconazole has the potential for serious drug
interactions and a higher incidence of
hepatotoxicity during long-term daily therapy
Allylamines
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Naftifine, terbinafine, butenafine
Mode of action similar to thiocarbamates
Inhibites squalene epoxydation
Terbinafine has less activity against Candida
species in vitro studies then triazoles, but is
effective clinically
 Terbinafine is ineffective in the oral tx of tinea
versicolor but is effective topically
 Few drug interactions have been reported,
bioavailability is unchanged in food,
hepatotoxicity, leukopenia, severe exanthems, and
taste disturbances occur uncommonly but should
be monitored for clinically and by lab testing if
continuous dosing over 6 weeks occurs
Polyene
 Nystatin
 Irreversibly binding to ergosterol-an
essential component of fungal cell
membranes
Triazoles
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Itraconazole
Fluconazole
Affect P450 system
Numerous drug interactions occur
Need to know pt’s current meds
Broadest spectrum to dermatophytes and Candida
species, and Malassezia furfur
 Itraconazole is fungistatic-food increases its
absorption , antacids and gastric acid secretion
suppressors produce erratic or lowered absorption
 Pulse dosing limits concern over lab abnormalities
 Fluconazoles’s absorption is unaffected by food
Tinea Capitis
 Occurs chiefly in children – less commonly in
infants and adults
 Boys more frequently than girls; except in
epidemics caused by Trichophyton tonsurans
where there is equal frequency
 Divided into inflammatory and noninflammatory
 Tinea capitis can be caused by all pathogenic
dermatophytes except Epidermophyton floccosum
and T. concentricum
 In U.S. most caused by T. tonsurans(replacing
Microsporum audouinii) & M. canis
Noninflammatory
 M. audouinii infections present as the classic form
 Characterized by multiple scaly lesions (“graypatch”), stubs of broken hair, and a minimal
inflammatory response
 Occasionally glabrous skin, eyelids, and eyelashes
are involved
 Sometimes observed in epidemics in schools and
orphanages
 Over past 30 yrs, M. audouinii infections are being
replaced by increasing numbers of “black-dot”
ringworm, caused primarily by T. tonsurans and
occassionally by T. violaceum
 In the U.S. T. tonsurans is the most common cause
Tinea Capitis
 “Black dot” ringworm, caused by T.
tonsurans & occasionally T. violaceum
presents as multiple areas of alopecia
studded with black dots representing
infected hairs broken off at or below the
surface of the scalp
 Black dot tinea
 Black dot ringworm caused by
Trichophyton tonsurans
Inflammatory
 Usually caused by M. canis
 Can be caused by T. mentagrophytes, T. tonsurans,
M. gypsem, or T. verrucosum
 M. canis infection begins as scaly, erythematous,
papular eruptions with loose and broken-off hairs,
followed by various degrees of inflammation
 A localized spot accompanied by pronounced
swelling, with developing bogginess and
induration exuding pus develops-kerion celsii
 A delayed type hypersensitivity reaction to fungal
elements
 With extensive lesions fever, pain, and regional
lymphadenopathy may occur
Kerion
 Widespread “id” eruptions may appear
concomitantly on trunk and extremities
 These are vesicular, lichenoid, or pustular
 Kerion may be followed by scarring and
permanent alopecia in areas of inflammation and
suppuration
 Systemic steroids for short periods will greatly
diminish the inflammatory response and reduce
the risk of scarring
 Kerion: inflammatory rxn of tinea capitis caused
by Microsporum canis or Trichophyton
mentagrophytes
 Kerion
caused by
Microsporum
canis
 Kerion: heavily crusted, hairless plaque
 Permanent scarring alopecia post kerion
 Kerion:
red,
oozing,
hairless
plaque
Favus
 Rare in the U.S.
 Appears mainly on the scalp, but may occur on
glabrous skin and nails
 On scalp, concave sulfur-yellow crusts from
around loose, wiry hairs
 On glabrous skin lesions are pinhead to 2 cm in
diameter with cup-shaped crusts called scutulaeusually pierced by a hair as on the scalp
 Scutula have a distinctive mousy odor
 Nail involvement causes brittle, irregularly
thickened, and crusted nail changes
 Not seen typically in North America(has been
reported in Kentucky and Canada)
 Called witkop in South Africa by the Bantus
 Favus of scalp showing scutulae
 Scarring after favus infection
Etiology
 Tinea capitis can be cause by any one of several
species: T. tonsurans, M. audouinii, and M. canis
 First two are spread from human to human
 Latter is caught from animals such as kittens and
dogs
 Most frequent invaders of scalp are endothrix
types-T. tonsurans(black-dot ringworm) and T.
violaceum
 T. tonsurans alone affects adults(chiefly women)
regularly; others affect children
 Ectothrix found on scalp are T. verrucosum & T.
mentagrophytes (less frequently seen is T.
megninii-southwest Europe)
Pathogenesis
 Incubation period lasts 2 to 4 days
 Hyphae grow downward into the follicle, on the
hair’s surface, and the intrafollicular hyphae break
up into chains of spores
 Period of spread (4 days to 4 months) during
which lesions enlarge and new lesions appear
 At about 3 weeks hairs break off a few millimeters
above the surface
 Intrapilary hyphae descend to exact upper limit of
keratogenous zone and here form Adamson’s
“fringe” on the twelfth day
 External portions of intrapilary hyphae segment
into chains of ectothrix spores
Pathogenesis
 No new lesions develop during the refractory
period (4 months to several yrs)
 Clinical appearance is constant-with host and
parasite in equilibrium
 This is followed by a period of involution in
which the formation of ectothrix spores and
intrapilary hyphae gradually diminishes
 Asymptomatic carrier states among young black
children may occur
 There has been a lack of correlation between
number of asymptomatic carriers and index casessuggesting that carrier cases are not primary mode
of transmission of T. tonsurans
Histology
 Extensive inflammation leading to
follicular destruction
 Medium power: dense inflammation consists of
mixed cell types
 Neutrophils and other inflammatory cells
surround this small follicle.
 Fungal elements are present within hair shaft
Diagnosis
 Ultraviolet of 365 nm wavelength is obtained by
passing a beam through a Wood’s filter composed
of nickel oxide-containing glass
 This apparatus a Wood’s light , is available
commercially
 A simple form is the 125-volt purple bulb
 In a dark room the skin under this light fluoresces
faintly blue; however, infected hairs fluoresces
bright green, beads on the hairs contrasting
strongly with the dark field
 Bare, scaly areas show a turquoise blue color
 Fluorescent-positive infections are caused by :M.
audouinii, M. canis, M. ferrugineum, M.
distortum, T. schoenleinii
Diagnosis
 Hairs infected with T. tonsurans & T. violaceum
and others of endothrix do not fluoresce
 The fluorescent substance is pteridine
 For microscopic demonstration of the fungus, two
or three loose hairs are removed
 Hairs are placed on slide with a drop of 10-20%
solution of KOH
 A cover slip is applied, specimen is warmed until
hairs are macerated
 Examine under low, then high power
 Xylol is as satisfactory as KOH and need not be
warmed
 Scales or hairs cleared with it can still be cultured
Diagnosis
 Fungus invades hair shaft in two ways-(1)
ectothrix involvement in which hair is surrounded
with a sheath of tiny spores
 Examples of these types are: Microsporum
species, T. mentagrophytes & T. verrucosum (T.
verrucosum is the fungus most frequently acquired
by humans from cattle and causes a severe
inflammatory tinea barbae in men or tinea capitis
in children)
 Other mode of infection is endothrix type-where
arthrospores are formed inside the hair shaft
 This type is seen in T. tonsurans, T. violaceum,
and T. schoenleinii infections
 Final and exact identification of causative fungus
 Such identification is largely epidemiologic and
academic-tx is the same
 Several infected hairs are placed on Sabouraud’s
glucose agar or Dermatophyte Test Medium
(DTM)
 On DTM a distinctive growth appears within 1-2
weeks
 Diagnosis is usually made by gross appearance of
culture
 When questionable the culture is examined under
a microscope for characteristic morphologic forms
 DTM contains antibiotics to reduce growth of
contaminants and a colored pH indicator to denote
the alkali-producing dermatophytes
DTM
 A few nonpathogenic saprophytes will also
produce alkalinization and in the occasional case
of onychomycosis of toenails caused by airborne
molds, a culture medium containing an antibiotic
may inhibit growth of the true pathogen
 Cultures are best taken by rubbing the lesion
vigorously with a sterile cotton swab moistened
with sterile water and them streaked over the agar
surface
 Ectothrix type in Microsporum canis-note
small spores around hair shaft
 Endothrix spores in hair with Trichophyton
tonsurans
 Endothrix in T. scoenleinii showing
characteristic bubbles of air
 Endothrix infection, (low-power KOH
mount): arthroconidia noted within hair
shaft
 Endothrix infection (high-power KOH
mount) showing total hair shaft
involvement
T. tonsurans
 This microoraganism grows slowly in
culture to produce a granular or powdery
yellow to red, brown, or buff colony
 Crater formation with radial grooves may
be produced
 Microconidia may be seen regularly
 Dx confirmed by the fact that cultures
grow poorly or not at all without thiamine
T. mentagrophytes
 Cultural growth is velvety or granular or fluffy,
flat or furrowed, light buff, white, or sometimes
pink
 Back of the culture can vary from buff to dark
red
 Round microconidia borne laterally and in
clusters confirm dx within 2 weeks
 Spirals are sometimes present
 Macroconidia may be seen
T. verrucosum
 Growth is slow and cannot be observed
well for at least 3 weeks
 Colony is compact, glassy, velvety, ,
heaped or furrowed, and usually white, but
may be yellow or gray
 Chlamydospores are present in early
cultures
 Microconidia may be seen
M. audouinii
 Gross appearance shows a slowly groing, matted,
velvety, light brown colony
 Back of which is reddish brown to orange
 Under microscope a few large multiseptate
macroconidia (macroaleuriospores) are seen
 Microconidia (microaleuriospores) in a lateral
position on hyphae are clavate
 Racquet mycelium, chlamydospores, and
pectinate hyphae are seen sometimes
M. canis
 Culture shows profuse, fuzzy, cottony, aerial
mycelia tending to become powdery in the center
 Color is buff to ligth brown
 Back of colony is lemon to orange-yellow
 Numerous spindle-shaped multiseptate
microconidia and thick-walled macroconidia are
present
 Clavate microconidia ae found along with
chlamydospores and pectinate bodies
Treatment
 Griseofulvin of ultramicronized form, 10
mg/kg/day, is the daily dose recommended for
children
 Grifulvin V is the only oral suspension available
for children unable to swallow tablets-dose is 20
mg/kg/day
 Tx should continue for 2-4 months, or for at least
2 weeks after a negative microscopic and culture
examinations are obtained
 Griseofulvin does not primarily affect the delayed
type hypersensitivity reaction responsible for the
inflammation in kerion
 For this, systemic steroids, to minimize scarring,
can be given simultaneously
 Numerous other studies exist that demonstrate the
effectiveness of other oral agents, such as
itraconazole, terbinafine, and fluconazole
 These studies report these meds to be excellent
alternatives, but the total reported experience to
date is low
 Selenium sulfide shampoo or ketaconazole
shampoo three times weekly can be used as
adjunctive therapy to oral antifungal agents
 Herbert recommends culture of family members,
caution regarding sharing potentially contaminated
fomites, and simultaneous tx of all persons
infected clinically or by culture
 Drake et al recommend tx family members with
ketaconazole shampoo, selenium sulfide shampoo,
or povidine-iodine even if they are asymptomatic
Prognosis
 Recurrence usually does not take place when
adequate amounts of griseofulvin, fluconazole, or
terbinafine have been taken
 Exposure to infected persons, asymptomatic
carriers, or contaminated fomites will increase
the relapse rate
 Without medication there is spontaneous clearing
at about age 15, except with T. tonsurans which
persists into adult life
Tinea Barbae
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AKA Tinea sycosis, barber’s itch
Ringworm of the beard
Uncommon
Occurs chiefly among those in agricultural
pursuits
 Especially those in contact with farm animals
 Involvement is mostly one-sided on neck or face
 Two clinical types are: deep, nodular, suppurative
lesions; and superficial , crusted, partially bald
patches with follicultis
Tinea Barbae
 Superficial crusted type causes mild
pustular folliculitis with broken-off hairs
(T. violaceum) or without broken-off hairs
(T. rubrum)
 Affected hairs are loose, dry, and brittle
 When extracted bulb appears intact
Tinea Barbae
 Deep type develops slowly and produces nodular
thickenings and kerion-like swellings
 Caused mostly by T. mentagrophytes or T.
verrucosum
 Swellings are usually confluent and form diffuse
boggy infiltrates with abscesses
 Overlying skin is inflammed, hairs are loose or
absent, pus may be expressed through the
remaining follicular openings
 Lesions are limited to one part of face or neck in
men
 Upper lip is not usually involved, although
mustache area may be occasionally
Diagnosis-Tinea Barbae
 Confirmed by microscopic findings of the
fungus and by standard culture techniques
for dermatophyte infections
 Rarely, Epidermophyton floccosum may
cause widespread verrucous lesions known
as verrucous epidermophytosis
 Verrucous epidermophytosis from Epidermphyton
floccosum
 Complete resolution after 48 days of griseofulvin
Differential Diagnosis
 Sycosis vulgaris-lesions are pustules and
papules, pierced in the center by a hair,
which is loose and easily extracted after
suppuration has occurred
 Contact dermatitis
 Herpes infections
 Tinea barbae-Trichophyton mentagorphytes
Treatment-Tinea Barbae
 Oral antifungals are required
 Topical agents as adjunctive therapy
 Micronized or ultramicronized griseofulvin
orally: dosage of 500–1000 mg or 350-700
mg respectively
 Tx usually for 4-6 weeks
Treatment-Tinea Barbae
 Other orals that have been effective: ketoconazole,
fluconazole, itraconazole, and terbinafine
 Topical antifungals should be applied from the
beginning of tx
 Affected parts should be bathed thoroughly in
soap and water
 Healthy areas that are not epilated may be shaved
or clipped
 When kerion is present a short course of systemic
steriod therapy may help reduce inflammation and
risk of scarring
Tinea Faciei
 Fungal infection of the face (apart from the beard)
 Frequently misdiagnosed since typical ringworm
is only uncommonly seen on the face
 Instead, erythematous, slightly scaling, indistinct
borders are usually seen
 Diagnosis is easily established by direct
microscopic examination
 Usually caused by T. rubrum. T. mentagrophytes,
or M. canis
 Tinea faciei caused by T. nanum has been
described in hog farmers and should be considered
an occupational source
 Tinea faciei
(Microsporum canis)
in a child
 Tinea
corporis
involving the
face (tinea
faciei)
Treatment
 Topical clotrimazole, naftifine, micronazole,
ciclopirox olamine cream, econazole,
oxiconazole, ketaconazole, sulconazole, or
terbinafine ususally bring about a prompt
response
 Oral griseofulvin administered for 2-4 weeks, as
well as fluconazole, itraconazole, or terbinafine
are all effective particularly in combination with
topical therapy
Tinea Corporis(Tinea Circinata)
 Includes all superficial dermatophyte infections
of the skin other than those involving the scalp,
beard, face, hands, feet, and groin
 Sites of prediliction are neck, upper and lower
extremities, and trunk
 Can be caused by any dermatophyte
 Characterized by one or more circular, sharply
circumcsribed, slightly erythematous, dry, scaly,
usually hypopigmented patches
 Tinea corporis in a
child, caused by
Microsporum canis
Tinea Corporis
 Lesions may be slightly elevated, particularly at
the border, where they are more inflamed and
scaly than at the central part
 Progressive central clearing produces annular
outlines that give them the name “ringworm”
 Lesions may widen to form rings many
centimeters in diameter
 In some cases concentric circles form rings in one
another, making intricate patterns (tinea imbricata)
 Multiple disseminated patches of both dry
(macular) and moist (vesicular) types of tinea
circinata are encountered in which much of skin
surface is involved
 Widespread tinea corporis may be the presenting
sign of AIDS
 Tinea corporis
(Trichophyton
rubrum)
 Note sharp margins
and central clearing
 Tinea corporis: large gyrate plaque with
advancing border, perhaps worsened by
diapering
Histopathology
 Rarely the question of microscopic
pathology may arise
 Better ways to make diagnosis
 But if compact orthokeratosis is found in a
section, a search for fungal hyphae should
be performed
 This is diagnostic
Etiology-Tinea Corporis
 Various organisms may cause this type of fungal
infection
 Microsporum canis, T. rubrum, T.
mentagrophytes-most common
 T. rubrum is is the most common dermatophyte
in the U.S. and worldwide
 T. tonsurans has experienced a dramatic rise as a
cause of tinea corporis as it has for tinea capitis
 In children, M. canis is the cause of the moist
type of tinea circinata
Epidemiology
 Tinea corporis is frequently seen in childrenparticularly those exposed to animals with
ringworm(M. canis), especially cats, dogs and
less commonly, horses and cattle
 In adults excessive perspiration is the most
common factor
 Incidence is especially high in hot, humid areas
of the world
Diagnosis-Tinea Corporis
 Relatively easy via microscopic findings of
fungus after skin scraping
 Skin scrapings can be cultured on a suitable
medium
 Growth of fungus is apparent within a week or
two at most and, most of the time is identifiable
by gross appearance of the culture
 Identification of the fungus is of epidemiologic
interest, and is not helpful in managing the
infection
Treatment-Tinea Corporis
 When tinea corporis is caused by T. tonsurans, M.
canis, T. mentagrophytes, or T. rubrum ,
griseofulvin, terbinafine, itraconazole, and
fluconazole are all effective
 The ultra-micronized form may be used at a dose
of 350-750 mg once/day for 4-6 weeks
 This dose may be increased to twice daily if
needed
 Terbinafine, itraconazole, and fluconazole are
effective
 Terbinafine at 250 mg/day for two weeks
 Itraconazole 200 mg B.I.D. for one week
 Fluconazole 150 mg once/week for 4 weeks
Treatment(cont)
 When only 1-2 patches occur, topical tx is
effective
 Sulconazole (Exelderm), oxiconazole (Oxistat),
miconazole (Monistat cream or lotion, or Micatin
cream), clotrimazole (Lotrimin or Mycelex
cream), econazole (Spectazole), naftifine (Naftin),
ketaconazole (Nizoral), ciclopirox olamine
(Loprox), terbinfine (Lamisil), and butenafine
(Mentax) are available and effective
 Most are between 2-4 weeks with twice daily use
 Econazole, ketaconazole, oxiconazole, and
terbinafine may be used once daily
 With terbinafine the course can be shortened to 1
week
Treatment
 Creams are more effective than lotions
 Sulconazole may be less irritating in folded areas
 Castellani paint (which is colorless if made
without fuchin) is very effective
 Salicylic acid 3% -5%, or half-strength Whitfiels’s
ointment, both standbys 30 yrs ago, are little used
today
 Addition of a low-potency steroid cream during
the initial 3-5 days of therapy will decrease
irritation rapidly without compromising the
effectiveness of the antifungal
Other Forms of Tinea Corporis
 Trichophytic Granuloma or Perifollicular
Granuloma or Majocchi’s Granuloma or Tinea
Incognito
 A deep, pustular type of tinea circinata
resembling a carbuncle or kerion observed on the
glabrous skin
 A circumscribed, annular, raised, crusty, and
boggy granuloma
 Follicles are distended with viscid purulent
material
 Tichophyton
mentagrophytes
infection on lower leg
of American soldier in
Vietnam
Trichophytic Granuloma
 Occur most frequently on shins or wrists
 Caused most often by T. rubrum or T.
mentagrphytes infecting hairs at sites of
involvement
 Other dermatophytes have been reported:T.
epilans, T. violaceum, M. audouinii, M. gypseum,
M. ferrugineum, and M. canis
 In immunosuppressed pts lesions may be deep
and nodular
 Early on such a deep lesion may be pale, circular
edematous plaque, often KOH- and culture-neg.
 Majocchi’s granuloma occurs naturally in
situations of occlusion or may be related to
superficial trauma ie shaving
 Diagnosis is made by demonstration of fungus
via direct macroscopic potassium hydroxide slide
and by culture or by clinical suspicion
 Occasionally diagnosis is made on bx specimen
 Tx is same as for tinea corporis-except that even
that even for localized lesions oral therapy is
needed
 Majocchi’s granuloma H&E pale luestaining fungal hyphae within hair shaft
 Majocchi’s granuloma: PAS reveals multiple
organisms that have replaced a fragment of hair
shaft embedded in a sea of neutrophils
Tinea Imbricata (Tokelau)
 Superficial fungal infection limited to southwest
Polynesia, Melansia, Southeast Asia, India, and
Central America
 Characterized by concentric rings of scales
forming extensive patches with polycyclic borders
 Eruption begins with 1 or several small, rounded
macules on trunk and arms
 Small macular patch splits in center and forms
large, flaky scales attached at the periphery
 Resultant ring spreads peripherally and another
brownish macule appears in the center and
undergoes the process again
Tinea Imbricata
 When fully developed the eruption is
characterized by concentrically arranged rings or
parallel undulating lines of scales overlapping
each other like shingles on a roof (imbrex means
shingle)
 Causative fungus is T. concentricum
 TOC is griseofulvin- in same form as for tinea
corporis
 Other options are terbinafine, fluconazole, and
itraconazole
 Several courses of therapy may be needed
 May need to remove pt from hot, humid
environment
 Tinea imbricata in New Guinea native
 Tinea imbricata: concentric rings of scale
caused by T. concentrium
Tinea Cruris
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AKA jock itch
Most common in men
On upper and inner thighs
Begins as a small erythematous and scaling or
vesicular and crusted patch
Spreads peripherally and partly clears in the center
Characterized by its curved, well-defined border,
especially at lower edge
Border ma have vesicles, pustules, or papules
May extend downward on thighs and backward on
the perineum or anus
Penoscrotal fold or sides of scrotum are seldom
involved
 Tinea cruris in a man
 Tinea cruris in a woman
Etiology-Tinea Cruris
 T. mentagrophytes & E. floccosum & T. rubrum
usual cause
 Infection with Candida albicans may closely
resemble tinea cruris
 Most useful distinguishing feature it posses are
the regular occurrence of small “daughter”
macules, centrally desquamating to form
collarette scales, satellite pustules, scattered
along the periphery of the main macule
Epidemiology &Tx
 Heat and high humidity
 Tight jockey shorts, which prevent evaporation of
the increased perspiration produced during warm
weather
 Tx: reduce perspiration and enhance evaporation
from crural area
 Keep as dry as possible by wearing underclothing
and trousers
 Plain talcum powder or antifungal powders are
helpful
 Specific topical and oral tx is same as that
described under tinea corporis
 Tinea in diapered area
Tinea of Hands and Feet
 Popularly called athlete’s foot
 Most common fungal disease(by far)
 Primary lesions often are macerated, slightly scaly,
with occasional vesiculation, and fissures between
the toes
 Most commonly the third toe web is involved
 Pt usually seeks relief because of itching
 If allowed to progress may lead to overgrowth of
gram-negative organisms
 Eventually leading to an ulcerative, exudative
process
 Tinea pedis showing interdigital scalping
 T. mentagrophytes
 Interdigital scaling with vesiculation
caused by T. mentagrophytes
 Trichophyton mentagrophytes produces an acutely
inflammatory condition
 If invasion of skin of toes or soles, an acutely
vesicualr or bullous eruption may occur
 Vesicular eruption tends to spread by extension
and unless checked, may involve the entire sole
 Vesicles usually 2-3 mm in diameter-sometimes
they coalesce to form bullae of various sizes
 These are firm to touch and have a bluish tint
 They do not rupture spontaneously but dry up as
the acute stage subsides-leaving yellowish brown
crusts
 Burning and itching of vesicles may cause great
discomfort-relieved by opening tense vesicles
 Dermatophytos
is of the soles
 Trichophyton
mantagrophyte
s
 Acute
vesiculobullou
s eruption on
sole caused by
Trichophyton
mentagrophyte
s
Tinea Pedis
 Vesicles contain clear tenacious fluid the
consistency of glycerin
 Extensive or acute eruptions on soles may become
incapacitating
 Fissures between toes may become secondarily
infected with pyogenic cocci
 This may lead to attacks of lymphangitis and
inguinal adenitis
 Hyperhidrosis is frequently present
 Sweat on soles and in between has a high pH, and
keratin damp with a good culture medium for the
fungus
TP-Trichophyton rubrum
 T. rubrum causes the
majority of cases
 Produces a relatively
noninflammatory type of
dermatophytosis
characterized by a dull
erythema and prnounced
scaling involving the
entire sole and sides of
feet
 Producing a moccasin or
sandel appearance
 Tinea pedis and
onychomycosis in
father/son pair.
 Father shows classic
moccasin distribution
of tinea pedis and son
shows distal
subungual
onychomycosis
Tinea manus
 Tinea infection of hands
that is dry, scaly, and
erythematous may occur
 Suggestive of infection
with T. rubrum
 Other areas are frequently
affected at the same time
 Trichophyton rubrum infections
 Moist, vesicular, eczematous types characterize
infection with T. mentagrophytes
 Organism seen more frequently on the feet-but can
be on the hand
 T. rubrum & T. mentagrophytes are the two most
common types of fungus causing hand and feet
dermatophytosis
 Occurring more frequently perhaps than true
fungus is dermatophytid of hands
 These commonly begin as groups of minute, clear
vesicles on palms and fingers
 Itching may be intense
 As a rule, usually both hands are involved
however there are cases in which only one hand is
affected
Differential diagnosis
 Allergic contact or irritant dermatitis-especially
occupational
 Pompholyx
 Atopic dermatitis
 Psoriasis
 Lamellar dyshidrosis
 Eczematoid or dyshidrotic lesions of unknown
cause on hands should prompt a search for
clinical evidence of dermatophytosis of feet etc.
Etiology
 T. rubrum most frequent causative fungus
 Culture of organism are usually fluffy-but can be
granular or folded
 Backside of culture is usually deep red; sometimes
no color is produced
 Microconidia are found in clusters and singly on
the hyphae
 Macroconidia, chlamydospores, coils, and racquet
hyphae are rarely seen
 Less frequent causes are T. mentagrophytes and E.
floccosum
Diagnosis
 Demonstration of fungus by microscopic
examination of scrapings
 Cultures made from affected skin
 However, failure to find fungus does not exclude a
fungal cause
 Tissue is scrapped off and placed on a glass slide
 When lesion is a vesicle, it is clipped off close to
the margin by a small, pointed scissors; when dry
or scaly, material is scraped off with a scalpel or
curet(obtain material from deep beneath the
surface of chronic eruptions)
 A drop of 20% KOH added
 Gentle heat applied until scales are macerated
Diagnosis
 Mycelium may be seen under low power, but
better observation of both hyphae and spores is
obtained by use of high dry objective with reduced
illumination
 Lines of juncture of normal epidermal cells are
hyaloid and greenish, and nay be easily mistaken
for fungus structures
 If you wonder whether it is really mycelium or not
it is not
 Rapid staining method using 100mg of chlorazol
black E dye in 10 ml of dimethyl sulfoxide
(DMSO) and adding it to 5% aqueous solution of
KOH can be helpful
 Fungus filaments under KOH mount
Diagnosis(continued)
 Solution is then prepared in same way as ordinary
KOH solution
 Viewed under bright illumination; hyphae and
spores are green against a gray background
 Other portion is planted on Sabouraud’s glucose
agar or Mycosel agar, and cultured at room
temperature
 Adequate growth for id occurs in 5-14 daysdepending on type of fungus
 Taplin et al revised the medium-DTM for
diagnosis
 DTM inhibits growth of bacterial and saprophytic
contaminants
DX-continued
 Alkaline metabolized of the dermatophytes change
color of the pH indicator in medium from yellow
to red
 If a dermatophyte is present medium will turn red
 Saprophytes turn medium green
 C. albicans does not cause any color change, but
produces a typical yeast colony
 One often finds the so-called mosaic fungus
 It is caused by overlapping cell borders
 A positive KOH preparation should reveal definite
hyphal elements traversing several epidermal cells
 Mosaic fungus
Prophylaxis
 Hyperhidrosis is a predisposing factor
 Dry toes after bathing
 Dryness is essential if re-infection is to be
avoided
 Use good antiseptic powder on feet after bathingparticularly between toes
 Tolnaftate powder or Zeasorb medicated powders
for feet
 Plain talc, cornstartch, or rice powder may be
dusted into socks and shoes to keep feet dry
Treatment
 Clotrimazole, miconazole, sulconazole,
oxiconazole, econazole, ketaconazole, naftifine,
terbinafine, butenafine-all effective
 Severs disease with significant maceration wet
dressings or soaks with solutions such aluminum
acetate, one part to 20 parts of water are beneficial
 Antiinflammatory effects of corticosteroids are
markedly beneficial
 Topical antibiotic ointments, such as gentamicin,
effective against gram-negative organisms, are
helpful additions in tx of the moist type of
interdigital lesions
 In ulcerative type of gram-neg toe web infections,
systemic floxins are needed
Tx
 Keratolytic agents, such as salicylic acid, lactic
acid lotions, and Carmol are therapeutic when
fungus is protected by a thick layer of overlying
skin (ie soles)
 Tx of fungal infection of feet and hands with
griseofulvin is effective when infection is caused
by pathogens such as T. mentagrophytes, T.
rubrum, E. floccosum, and others
 Not effective in tx of Candida albicans
 Griseofulvin is only effective against
dermatophytes
 When infection is caused by T. mentagrophytes
griseofulvin does not decrease inflammatory rx
Tx-doses
 Griseovulvin in ultramicronized particles taken
orally in doses of 350-750 mg daily
 Doage for children is 10 mg/kg/day
 Period of tx depends on response
 Repeated KOH scrapings and culture should be
neg
 Recommended adult doses for newer agents:
terbinafine, 250 mg/day for 2 weeks;
itraconazole, 200 mg twice daily for 1 week;
fluconazole, 150 mg once weekly for 4 weeks
Onychomycosis(Tinea Ungium)
 Fungal infection of nail
 Represents up to 30% of diagnosed superficial
fungal infections
 Etiologic agents are species: Epidermophyton,
Microsporum, and Trichophyton fungi
 May also be caused by other dermatophytes,
yeasts, and nondermatophytic molds
 Nondermatophytic molds usually involve toenails
and are rarely seen in fingernails
Onychomycosis
 Frequently clinical appearance of onychomycosis
caused by one species of fungus is
indistinguishable from that caused by another
 However, various clues could allow one to
speculate as to organism responsible
 Four classic types:1.) distal subungual
onychomycosis: primarily involves distal nail bed
and hyponychium, with secondary involvement
of underside of nail plate of fingernails and
toenails
 Onychomycosis caused by Trichophyton
rubrum
Trichophyton mentagrophytes
 2.) white superficial
onychomycosis(leukonyc
hia trichophytica):this is
an invasion of the toenail
plate on the surface of the
nail
 It is produced by
T.mentagrophytes,species
of Cephalosporium and
Aspergillus, and
Fusarium oxysporum
fungus
Onychomycosis
 3.) Proximal subungual onychomycosis: involves
the nail plate mainly from proximal nail fold,
producing a specific clinical picture
 It is produced by T. rubrum & T. megninii and
may be an indication of HIV infection
 4.) Candidaonychomycosis involves all the nail
plate; it is due to Candida albicans and is seen in
pts with chronic mucocuataneous candidiasis
 Onychomycosis caused by Candida
albicans in mucocutaneous candidiasis
Onychomycosis
 Onychomycosis caused by
T. rubrum is usually a
deep infection
 Disease usually starts at
distal corner of nail and
involves the junction of
nail and its bed
 First a yellowish
discoloration occurs,
which may spread until
entire nail is affected
 Beneath discoloration nail
plate becomes loose from
nail bed
 Gradually entire nail becomes brittle and separated
from its bed due to piling up of keratin
subungually
 Nail may break off, leaving an undermined
remnant that is black and yellow from dead nail
and fungi that are present
Onychomycosis
 Caused by T. mentagrophytes is usually
superficial, and there is no paronychial
inflammation
 Infection generally begins with scaling of nail
under overhanging cuticle and remains localized
to a portion of nail
 However, in time whole nail may be involved
 Leukonychia trichophytica is name given to this
fungal infection
 Small, chalky white spots appear on or in nail
plate
 May be multiple and variously shaped or just a
single spot
 Superficial so that they may be shaved off easily
 Nail lesions caused by C. albicans there is usually
paronychia
 Begins under lateral or proximal nail fold-small
amount of pus may be expressed
 Adjacent cuticle is swollen, pink, and tender on
pressure
 Fingernails more commonly infected than toenails
 Encountered mostly in homemakers, canners, and
others who have hands in water a great deal
 Nail plate does not become friable, yellow, or
white as in trichophyton infections
 Remains hard and glossy unless
immunocompromise is present
 Associated paronychia is characteristic
 Distal subungal, onchomycosis occurring
simulataneously with superficial white
onchmycosis
 Superficial white onchomycosis
Differential
 Scopulariopsis brevicaulis infrequently
 Infection usually begins at lateral edge of nail,
burrows beneath plate, produces large quantities of
cheesy debris
 Hendersonula toruloidea & Scaytalidium
hyalinum have been reported to cause
onychomycosis, as well as moccasin-type tinea
pedis
 Other fugi: T. violaceum, T. schoenleinii, & T.
tonsurans
Diagnosis
 Microscopic and culture
 Immediate examination of very thin
shavings taken from diseased portions of
nail
 Cover slip, KOH, heat gently
 Culture medium-Mycosel agar or DTM
Treatment
 Terbinafine 250 mg/day for 6 weeks (fingernails)
12 weeks for toenails
 Itraconazole, 200 mg twice daily for 1 week of
each month for 2 months (fingernails) & 3 months
for toenails
 Fluconazole experience is less-but 150 –300 mg
once weekly for 6-12 months
 Griseofulvin? Therapy continued until nails are
clinically normal
 Low success rates 15-30% for toenails and 5070% for fingernails
 Griseofulvin does not tx nail disease caused by
candida
Candidiasis
 Candida proliferates in both budding and
mycelial forms in outer layers of the stratum
corneum where horny cells are desquamating
 Organism usually is found outside living portion
of the epidermis
 It does not attack hair, rarely involves nail, and is
incapable of breaking up the stratum corneum
 It is largly an opportunisitic organism, able to
behave as a pathogen mainly in impaired immune
status, or in body folds
 Moiture promotes its growth, in moist lip corners
Diagnosis
 Demonstration of the pathogenic yeast C. albicans
establishes the diagnosis
 Under microscope KOH prep may show spores
and peeudomycelium
 On gram stain yeast forms are dense, grampositive, ovoid bodies, 2-5 um in diameter
 In culture C. albicans should be differentiated
from other forms of Candida that are only rarely
pathogenic
 Culture on Sabouraud’s glucose agar shows a
growth of creamy, grayish, moist colonies in about
4 days
 In time colonies form small, rootlike penetrations
into agar
 Mycelium and spores of Candida albicans
Candidiasis
 KOH mount from infant with thrush showing
pseudohyphae and yeast forms
Topical Anticandidal Agents
 These include, but are not limited to:
clotrimazole (Lotrimin, Mycelex), econazole
(Spectazole), ketaconazole (Nizoral), miconazole
(MonistatDerm Lotion, Micatin), oxiconazole
(Oxistat), sulconazole (Exelderm), naftifine
(Naftin), terconazole (vaginal candidiasis only),
cicloprox olamine (Loprox), butenafine
(Mentax), nystatin, and topical amphotericin B
lotion
 Terbinafine has been reported to be less active
against Candidaspecies by some authors
Oral Candidiasis (Thrush)
 Mucous membrane of the mouth may be involved
in healthy newborn & marasmic infant
 Newborn infection may be acquired from contact
with vaginal tract of mother
 Grayish white membranous plaques are found on
surface
 Base of plaques are moist, reddish, and macerated
 It is spread angles of mouth may become
involved, and lesions in intertriginous areas may
occur, especially in marasmic infants
 Diaper areas is especially susceptible to this
 Most of intertriginous areas and even exposed skin
may be involved
 In adults the buccal mucosa, lips, and tongue may
become involved
 Papillae of tongue are atrophied, surface is
smooth, glazed, and bright red
 Sometimes there are small erosions on edges
 Frequently infection extends onto angles of the
mouth to form perleche(seen in elderly,
debilitated, and malnourished pts, and diabetics
 It is often the first manifestation of AIDS
 Is present in nearly 100% of all untreated pts with
full-blown AIDS
 Observation of oral “thrush” in an adult with no
known predisposing factors warrants a search for
other evidence of infection with HIV, such as
lymphadenopathy, leukopenia, or HIV antibodies
in serum
 One predisposing factor to oral thrush is broadspectrum antibiotics
 During the 1980s there was a dramatic increase in
number and severity of cases of oropharyngeal
candidiasis
 Reported increase of 4.7 times, from 0.34 to 1.6
cases per 1000 pediatric admission, and the
number of deaths among pts tx with
oropharyngeal candidiasis increased fivefold
 Greatest increase was among 15-44 yr old pts at
thirteenfold
 Rate of increase between 1985 & 1989 among pts
with HIV infection was tenfold, compared with a
twofold increase among pts with malignancies or
transplants
 Thrush with extension to vermilion border
Tx
 Various tx options are available
 Babies with thrush may be allowed to suck on a
clotrimazole suppository inserted into the slit tip
of a pacifier four times a day for 2-3 days
 An adult can let tablets of clotrimazole or Mycelex
troches dissolve in the mouth
 In the immunocompromised goal is to reduce
symptoms since continuous oral systemic therapy
has led to a clinically relevant problem of drug
resistance
 Fluconazole, 100-200 mg/day for 5-10 days with
doubling the dose if it fails, or itraconazole, 200
mg daily for 5-10 days with doubling the dose if it
fails-both are available in liquid forms
Perleche
Perleche
 Or more aptly, angular cheilitis
 Maceration with transverse fissuring of oral
commissures
 Earliest lesions are ill-defined, grayish white,
thickened areas with slight erythema of the
mucous membrane at the oral commissure
 When more fully developed thickening has a
bluish white or mother-of-pearl color and may be
contiguous with a wedge-shaped erythematous
scaling dermatitis of the skin portion of
commissure
 Fissures, maceration, and rust formation occur
 Soft, pinhead-sized papules may appear
 Involvement is bilateral-usually
Perleche
 Analogous to intertrigo elsewhere, that may come
from infection by C. albicans, by coagulasepositive Staphylococcus aureus, or from manifold
other causes
 Similar changes may be seen in riboflavin
deficiency, and iron deficiency anemia
 Identical fissuring occurs in persons with
malocclusion caused by ill-fitting dentures and in
the aged whom atrophy of alveolar ridges has
occurred
 Seen in children who drool, lick their lips, or suck
their thumb
Tx
 Depends on the cause
 If due to C. albicans anticandidal creams and
lotions
 Occasionally diabetes complicates this disease,
which will persist until diabetes is brought under
control
 It can be seen in AIDS pts with or without thrush
 Antibiotic topical meds are used when a bacterial;
infection is present
 If due to vertical shortening of lower third of the
face, dental or oral surgical intervention may help
 Injection of collagen into depressed sulcus at the
oral commissure may be helpful
 Softform implants are a more permanent tx
Candidal Vulvovaginitis
 C. albicans is a common inhabitant of vaginal
tract
 May cause severe pruritus, irritation, and extreme
burning
 Labia may be erythemtous, moist, and macerated
and cervix hyperemic, swollen, and eroded,
showing small vesicles on its surface
 Vaginal discharge is not usually profuse but is
frequently thick and tenacious
 May develop during in pregnancy, in diabetes, or
secondary to therapy with a broad- spectrum
antibiotic
 Recurrent vulvovaginal candidiasis has been
associated with long-term tamoxifen tx
Candidal Vulvovaginitis
 Candidal balanitis may be present in an
uncircumcised sexual partner
 If not recognized, repeated reinfection of a partner
may occur
 Diagnosis is by clinical symptoms and findings as
well as demonstration of fungus via KOH
microscopic exam & culture
 Tx is frustrating & disappointing due to
recurrences
 Oral fluconazole 150 mg times 1 dose;
Fluconazole, 100mg/day for 5-7 days,
itraconazole, 200 mg/day for 2-3 days..other
options
Tx
 Topical options include miconizole
(Monistat cream), nystatin vaginal
suppositories or tablets (Mycostatin), or
clotrimazole (Gyne-Lotrimin or Mycelex
G) vaginal tablets inserted once daily for 7
days
Candidal Intertrigo
 Pruritic intertriginous eruptions caused by C.
albicans may arise between folds of genitals; in
groins or armpits; between buttocks; under large
pendulous breasts; under overhanging abdominal
folds; or in umbilicus
 Pinkish intertriginous moist patches are
surrounded by a thin, overhanging fringe of
somewhat macerated epidermis (“collarette” scale)
 Some eruptions in inginal area may resemble tinea
cruris, but usually there is less scaliness and a
greater tendency to fissuring
 Topical anticandidal preparations are usually
effective
 Recurrence is common
Pseudo Diaper Rash
 In infants, C. albicans infection may start in
perianal region and spread over entire area
 Dermatits is enhanced by maceration produced by
wet diapers
 Scaly macules and vesicles with maceration in
involved areas cause burning, pruritis, and
extreme discomfort
 Diaper friction may contribute to skin irritation
and compromised function of stratum corneum
 Diagnosis may be suspected by finding
involvement of folds and occurrence of many
small erythematous desquamating “satellite” or
“daughter” lesions scattered around edges
Diagnosis
 Direct KOH microscopic and culture exams
 Swabbing is inadequate for making smears; one
must scrape surface to remove the horny material
 Floor of opened pustules may be similarly scraped
for specimens
 Such exams are rarely needed, however
 Pierard-Franchimont et al showed a decrease in
candidal cultures and skin irritation after use of a
miconazole nitrate-containing paste for prevention
of diaper dermatitis
 Pseudo diaper rash also responds well to topical
antifungals that cover Candida species
Congenital Cutaneous
Candidiasis
 Infection of an infant during passage through birth
canal
 Eruption usually noted within first few hrs of
delivery
 Erythematous macules progress to thin-walled
pustules, which rupture, dry, and desquamate
within a week of so
 Lesions are usually widespread, involving trunk,
neck, and head, at times palms and soles, icluding
nail folds
 Oral cavity and diaper area are spared
Congenital Cutaneous
Candidiasis
 This is in contrast to the usual type of neonatal
infections
 Differential dx: listeriosis, syphilis,
staphylococcal and herpes infections, ETN,
transient neonatal pustular melanosis, miliaria
rubra , drug eruption, congenital icthyosiform
erythroderma (neonatal pustular disorders)
 If suspected early amniotic fluid, placenta, and
cord should be examined for evidence of
infection
 Infants with disease limited to skin have
favorable outcomes
CCC
 Disseminated infection is suggested by (1) bw
<1500g (2) evidence of respiratory distress or labs
indicating neonatal sepsis (3) tx with broadspectrum antibiotics (4) extensive instrumentation
during delivery or invasive procedures in neonatal
period (5) positive systemic cultures, or (6)
evidence of an altered immune response
 Infants with congenital cutaneous candidiasis with
any of these 6 criteria would be considered for
systemic antifungal therapy
 More than 16 cases of systemic disease have been
reported, resulting in 2 deaths
 Most did well with a combination of topical and
oral antifungal therapy-uncomplicated cases
topicals only are needed
Perianal Candidiasis
 When pruritis ani is present C.albicans should be
suspected
 Frequently entire GI tract is involved
 Can be precipitated by oral antibiotic therapy
 Perianal dermatitis with erythema, oozing, and
maceration is present
 Psychogenic etiology is more common than is
candidiasis
 Differential dx: psoriasis, seborrheic dermatitis,
streptococcal and staphylococcal infections, and
contact dermatits-extramammary Paget’s disease
 Fungicides, meticulous cleansing of perianal
region after bowel movements, topical
corticosteroids and antipruritics (Atarax)
Candidal Paronychia
 Chronic inflammation of nail fold produces
occasional discharge of thin pus, cushionlike
thickening of paronychial tissue, slow erosion of
lateral borders of nails, gradual thickening and
brownish discoloration of nail plates, and
development of pronounced transverse ridges
 Mostly fingernails are affected, frqently only one
nail
 Usually chronic acute forms have been reported
 Caused by C. albicans ,but a secondary mixed
bacterial infection can occurthose who frquently
have hands in water or who handle moist objects
are affected; cooks,
dishwashers,bartenders,nurses,canners, etc
CP
 Manicuring nails sometimes is responsible for
mechanical or chemical injuries leading to
infection
 Ingrown toenails with chronic paronychia
 Seen in pts with diabetes
 Avoid chronic moisture exposure; get diabetes
under control
 Oral fluconazole once weekly or pulse dose
itraconazole should be effective
 Anticandidal lotions are probably preferable to
creams and may also be effective
 Topical therapy should continues for 2-3 months
to prevent recurrence
Erosia Interdigitalis
Blastomycetica
 Oval-shaped area of macerated white skin on web
between and extending onto sides of fingers
 Usually at center of lesion are one or more fissures
with raw, red bases
 With progression macerated skin peels off, leaving
painful, raw,denuded area surrounded by a collar
of overhanging white epidermis
 Nearly always affects third web
 Moisture beneath rings macerates skin and
predisposes to infection
 Also seen in diabetics, those who do housework,
launderers, and others exposed to macerating
effects of water and strong alkalis
EIB
 Intertriginous lesions between the toes are similar
 Usually white, sodden epidermis that is thick and
does not peel off freely
 On feet fourth interspace is most often involved
 Areas are apt to be multiple
 Clinically indistinguishable from tinea pedis
 Dx made by culture
 Tx is with topical anticandidal preparations
Chronic Mucocutaneous
Candidiasis
 A heterogeneous group of pts whose infection
with Candida is chronic but superficial
 Onset before age 6
 Onset in adult life may herald the occurrence of
thymoma
 Cases are either inherited or sporadic
 When inherited an endocrinopathy is often found
 Msot cases have well-defined limited defects of
cell-immunity
 Oral lesions are diffuse and perleche and lip
fissures are common
CMC




Entire thickness of nail plates is involved
Nails become thickened and dystrophic
There is associated paronychia
Hyperkeratotic, hornlike, or granulomatous
lesions are often seen
 Systemic fluconazole, itraconazole, or
ketaconazole is needed for prolonged and
repeated and higher doses than usual
 Management protocols vary and experience is
limited
Systemic Candidiasis
 Capable of producing severe, destructive,
disseminated disease, invariably when host
defenses are down
 High risk pts: pts with malignancies, AIDS pts,
transplant pts requiring immunosuppressive drugs,
pts receiving oral cortisone, pts who have had
multiple surgical operations especially cardiac, pts
with indwelling catheters, and heroin addicts
 Initial sign is varied: FUO,pulmonary
infiltrates,GI bleeding, endocarditis, renal failure,
meningitis, osteomyelitis, endophthalmitis,
peritonitis, or a disseminated maculopapular
eruption
SC
 Cutaneous findings are erythematous macules that
become papular, pustular, and hemorrhagic, and
may progress to necrotic, ulcerating lesions
resembling ecthyma gangrenosum
 Deep abscesses may occur
 Trunk and extremities are usual sites of
involvement
 Proximal muscle tenderness is a common finding
 Demonstration of microorganisms or a positive
culture plus clinical picture will aid diagnosis
 Candida colonization of endotracheal tubes in
low-birth-wt neonates predisposes to systemic
disease
SC
 If candida is cultured within the first week of life
there is a high rate of systemic disease
 There is a 50% chance of systemic disease if 1 or
more cultures is positive
 Mortality has declined from 80% in the 1970’s to
40% in the 1990’s because of early empiric
antifungals and better prophylaxis
THE END
Thank You