Fungal Infection of the Skin
Dr. Mohamad Nasr
Lecturer Of
Dermatology & Venereology
Topics Covered
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Tinea infections with special attention to scalp, feet and
nails
Basic diagnostic techniques
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KOH
Culture
Woods light
Differentials to consider.
Basic Treatment
Tinea Versicolor
Candidiasis
Dermatophytosis
“Ringworm" disease of the nails, hair, and/or stratum
corneum of the skin caused by fungi called
dermatophytes.
Etiological agents
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Microsporum - infections on skin and hair (not
the cause of TINEA UNGUIUM)
Epidermophyton - infections on skin and nails
(not the cause of TINEA CAPITIS)
Trichophyton - infections on skin, hair and
nails.
Clinical manifestations of ringworm
 Infections
named depending on
location of infection.
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Tinea capitis; ringworm infection of the scalp.
Tinea corporis; ringworm infection of the body
(smooth skin)
Tinea cruris; ringworm infection of the groin.
Tinea unguium; ringworm infection of the nails.
Tinea barbae; ringworm infection of the beard.
Tinea manuum; ringworm infection of the hand.
Tinea pedis; ringworm infection of the foot (athlete's
foot).
Tinea corporis - body ringworm
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Skin lesion pink-red, scaly, annular patch with
expanding border (active border).
Tinea cruris - ringworm of the groin
Tinea capitis - ringworm of the scalp
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Types:
1.
Scally.
Black dot.
Favus.
Kerion.
2.
3.
4.
Scally type;
Black dot type;
Kerion;
Favus;
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caused by T. schoenleinii.
Tinea Capitis Treatment
•Must treat hair follicle
•Topical not effective
•Systemic agents
•Griseofulvin for children ;12.5 mg/kg.
•Imidazoles, terbinafine.
•Steroids for inflamed lesions like Kerion.
•Treat until no visual evidence, culture (-)… plus 2 weeks
•Average of 6-8 weeks of treatment.
Other oral anti-fungal for patients who do not
tolerate or respond to Griseofulvin.
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Terbinafine (Lamisil) 3 to 6mg/kg once a day
for 2 to 4 weeks.
Fluconazol: 6mg/kg/day once daily for 6wk
Itraconazole: 5mg/kg/day,once daily or divided
into two doses,for 2 to 4 weeks
Tinea pedis - Athletes' foot infection
Between toes or toe webs - 4th
and 5th toes are the most
common.
Types;
1. Interdigital type.
2. Hyperkeratotic type.
3. Vesiculobullous type.
Tinea Pedis: Treatment
•Dry Feet
•Alternate shoes, Absorbent powders, Change socks
•Scale my be reduced with keratolytic
•Topicals and/or Systemics.
•Topical: terbinafine may be more effective than azoles.
Steroids if inflamed.
•Systemic allyamines or azoles
Tinea Manuum
Onychomycosis
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15-20% of those between 40-60 yrs.
infected.
No Spontaneous remissions
General Appearance:
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Typically begins at distal nail corner
Thickening and opacification of the nail plate
Nail bed hyperkeratosis
Onycholysis
Discoloration: white, yellow, brown
Edge of the nail itself becomes severely eroded.
Some or all nails may be infected
Tinea unguium - ringworm of the nails
Onychomycosis
Types:
1.
2.
Distal Subungal
White superficial
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3.
Proximal Subungal
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4.
Chalky white patches
May indicate HIV infection
Total dystrophic
Onychomycosis
Onychomycosis with Onycholysis
White Onychomycosis
Candidaisis of nail
Paronychia
Psoriasis
Middle of nail, oils spots, pitting.
Treatment of Onychomycosis.
Topical Treatment:
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Can be effective for limited involvement and for
prevention.
Treatment of Onychomycosis
Oral therapy
•Effective. Relapse rate 15-20 % in one year.
•Lamisil 250mg. 6 weeks/12 weeks.
•Baseline labs and one month.
•CBC (neutropenia), Liver function.
•Itraconazole.
•Pulse dosing fingernails - (200 mg bid 1 wk q mo.) x 2
Tinea Faciales
Diagnostic Tests
KOH Preparations
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A slide.
Scrape border of lesion.
Apply 1-2 drops of KOH 20% and heat gently
Examine at 40x
Look for hyphae
Fungal Cultures
DTM
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(Dermatophyte Test Medium)
Yellow to red is (+).
Sabouraud’s
agar Media
Wood’s Light
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Tinea Capitis
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Blue green florescent with M. Canis.
Not useful for Trichophyton (Most Common)
Other Areas:
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Useful to diagnose as erythrasma (coral red/pink).
Tinea versicolor may be pale yellow.
Less helpful if patient recently bathed.
Tinea Versicolor
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Numerous, well-marginated, oval-to-round
macules with a fine white scale when scraped.
Pigmentary alteration uniform in each
individual.
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Scattered over the trunk and neck. Seldom the
face.
Pityrosporum orbicularis, M. furfur
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Red
Hypo pigmented
Hyperpigmented
Normal flora of skin
Asymptomatic.
Tinea Versicolor
More
apparent
in the
summer.
Tinea
Vesicolor
Hyperpigmented
Variety
Looks Like: intertrigo,
erythrasma ….
Tinea Versicolor - Differential
•Vitiligo
•Pityriasis Alba
•Pityriasis Rosea
Vitiligo
White
without
scale.
Pityriasis Alba
Frequently on face,
KOH neg. Few
lesions.
May have fine white
scale.
Pityriasis Rosea
•Papules or
plaques with
Collarette of
scale, KOH (-),
Woods light
neg.
Tinea Versicolor
Diagnosis:
•Scrape lightly – fine white scale
•KOH Positive for short hyphae and spores
(Spaghetti and meatballs)
•Woods Light – pale yellow white fluoresce.
•Culture rarely done.
Tinea Vesicolor – Woods Light
Yellow White
Tinea Versicolor Microscope
Tinea Versicolor-Treatment
Topical; for limited involvement.
•Selenium Sulfide Shampoos: lather 10
minutes wash off x 7 days.
•Ketoconazole 2% shampoo: 5 minutes 1-3
days.
•Imidazoles topicals to body qd-bid for 2-4
wks.
•Terbinafine spray.
Tinea Versicolor-Treatment
Oral; for extensive
•Itraconazole: 200 mg for 7days
•Fluconazole: 300 mg once
•Ketoconazole: 200 mg for 10 days
Tinea Versicolor-Treatment
Notes
•Hypopigmentation resolves slowly
•No scale when scraped indicates cure.
•Sunlight helps restore pigment
•Prophylaxis before summer in some patients.
•Selenium shampoo’s
Candidiasis
•Candida Albicans
•Normal Flora
•Occurs in moist areas especially where skin touches.
•Presentation: primary lesion is a red pustule.
•Most Common: pustules dissect horizontally through the
stratum corneum leaving a red, glistening denuded surface
with long continuous border with satellite lesions.
Candidiasis
•Immunosuppression of any type (disease,
steroids, D.M. or Antibiotics).
•Diagnosis: History of predisposing factors
and/or classic appearance of lesions at typical
locations.
Clinical picture;
1.
2.
Oral candidiasis; thrush & perleche.
Cutaneous candidiasis;
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3.
4.
Intertrigo.
Erosio-interdigitalis blastomycetica.
Paronychia.
Genital candidiasis;
Systemic candidiasis;
Thrush
Angular cheilitis
Intertrigo
Intertrigo
Erosio-interdigitalis blastomycetica
Candidiasis
•KOH for pseudohyphae and spores
•May be impossible to tell visually from tinea.
•Woods Light
•Culture.
•Remember yeast part of normal flora.
Treatment of Candidiasis
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Keep dry –powder, cotton ball between toes.
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Topical – azoles.
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Systemic – fluconazole; 150 mg once.
Itraconazole; 200 mg bid for 1 day
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Occasionally co-administration of a weak topical
steroid may be helpful.
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Diaper rash
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Angular chelitis.
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