9/24/13
Superficial Fungal Infections
Cutaneous Fungal Infections
Bradley W. Bakotic, DPM, DO
Rosalind-Franklin University
Scholl College of Podiatric Medicine
Superficial Fungal Infections
Dermatophytes
A unique group of organisms capable of
infecting non-viable keratin
Infections = dermatophytoses
Epidermomycosis = Tinea
Trichomycosis
Onychomycosis
Tinea versicolor is a misnomer (more
appropriately pityriasis versicolor) actually
caused by yeast malassezia
Superficial Fungal Infections
Dermatophytoses
Three genera of dermatophytes
Trichophyton
Microsporum
Epidermophyton
More than 40 recognized species
Roughly 10 are common causes of human disease
Many are geographic in distribution
T rubrum is endemic to SE Asia, but now more common
in Europe and N America
The most common of all mucocutaneous
infections
Usually caused by overgrowth of
commensural organisms
Often precipitated by a change in the
skins microenvironment
Changes in other resident organisms
Changes in humidity
Changes in immunological status
Superficial Fungal Infections
Dermatophytoses
Age of Onset
Tinea capitis > children
Tinea cruris > adults
Onychomycosis > directly related to advancing age
Race
Tinea capitis more common in black children
Corporal tinea less common in black adults
Superficial Fungal Infections
Dermatophytoses
Trichophyton rubrum is the most common
cause of epidermal dermatophytosis and
onychomycosis in industrialized nations
Trichophyton tonsurans is the most common
cause of tinea capitis in N America and
Europe (recently surpassing M audouinii)
T rubrum is the most common cause of
dermatophytic folliculitis
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Superficial Fungal Infections
Dermatophytoses
Three routes of transmission
Person to person (fomites) = Anthropophilic
Animal to person = Zoophilic
Soil to person = Geophilic
Classification
Epidermomycosis (tinea facialis, tinea corporis,
tinea cruris, tinea manus, tinea pedis
Onychomycosis (dermatophytes, yeasts, molds)
Trichomycosis (Majocchis granuloma, tinea
barbae, tinea capitis
Superficial Fungal Infections
Dermatophytoses
Laboratory examinations
Dermatopathology
Woods lamp (Microsporum sp. green
fluorescence)
Fungal cultures
KOH preparation
Superficial Fungal Infections
Dermatophytoses
Pathogenesis
Synthesis of keratinases that digest keratin
Organisms held in check by cell-mediated
immunity and PMN leukocytes
Predisposing factors: atopy, steroid use, icthyosis
Local factors predisposing: hyperhidrosis,
occlusion, high humidity
Superficial Fungal Infections
Dermatophytoses
Management:
Topical antifungal
Applied bid 3cm beyond affected area
Applied 1 week after complete resolution of lesions
May be used under occlusion
Oral antifungal (used after failure of topical)
Required for treatment of t. capitis and t. unguium
May be used as a short term course for recalcitrant tines
pedis
Excreted in keratin
Potential side affects and drug interactions
Tinea Pedis
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Superficial Fungal Infections
Tinea Pedis
Most common age: 20-50 years
Males > Females
Predisposing factors
Hot humid environment
Occlusive footwear
Excessive sweating
Transmission
Barefoot walking on contaminated surfaces
Superficial Fungal Infections
Tinea Pedis
Interdigital type (most common 4th webspace)
Dry scaly
Maceration
Moccasin type (T rubrum)
Fine white scale, well demarcated, papules on margin
Inflammatory/ Bullous type
Vesicles or bullae (occasionally pustular)
May be secondarily infected with staph (>pustular)
May be associated with id reaction
Ulcerative type
Extension of inter-digital type
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Superficial Fungal Infections
Tinea Pedis
Laboratory examination
Dermatopathology
Woods lamp (neg. rules out erythrasma)
Culture
KOH preparation
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Superficial Fungal Infections
Tinea Pedis
Ddx:
Interdigital type: erythrasma, impetigo, pitted
keratolysis, candidia intertrigo, pseudomonas
Moccasin type: Psoriasis, eczematous dermatitis,
pitted keratolysis, keratoderma
Inflammatory / Bullous type: Bullous impetigo,
allergic contact dermatitis, dyshidrotic eczema,
bullous disease
Superficial Fungal Infections
Tinea Pedis
1st Line Management
Cidal > static topical antifungals
Applied to skin beyond the clinical infection
The treatment of tinea pedic (particularly
hyperkeratotic tinea) potentiated by urea
2nd line Management
Oral antifungals (terbinafine)
Superficial Fungal Infections
Tinea Pedis / Tinea Nigra
Infection caused by a dematiaceous
(pigmented) fungus
Non-dermatophytes
May be confused with acral melanosis or
melanoma in situ
Superficial Fungal Infections
Tinea Manuum
Chronic infection of hands
Often unilateral
Commonly involving the dominant hand
Usually associated with tinea pedis
Physical exam
Accentuation of palmar creases
Fissures
Well-demarcated borders with central clearing
Superimposed lichen simplex chronicus
Ddx: Atopic dermatitis, LSC, ICD, psoriasis,
SCC in-situ
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Superficial Fungal Infections
Tinea Cruris
Subacute or chronic infection of groin
Epidemiology
Adults
Males > females
T rubrum, T mentagrophytes
Warm humid environment
Physical exam
Usually associated with tinea pedis / onychomycosis
Geographic patches / plaques
Ddx: Erythrasma, intertrigo, Candida, inverse
psoriasis, tinea versicolor, Langerhans cell
histiocytosis
Superficial Fungal Infections
Tinea Corporis
Dermatophyte infection of the trunk, legs, arms, and / or
neck
Epidemiology
All ages
Common in animal workers
T rubrum most commonly
Associated with tinea pedis
Physical exam
Small to large sharply marginated plaques with or without
pustules or vesicles.
Peripheral expansion with central clearing
Ddx: ACD, atopic dermatitis, psoriasis, seborrheic
dermatitis, mycosis fungoides, tinea versicolor
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Superficial Fungal Infections
Tinea Facialis
Dermatophytosis of the glabrous facial skin
The most commonly misdiagnosed form of
dermatophytosis
Epidemiology
Children
T tonsurans in children with tinea capitis
T mentagrophytes and T rubrum most common
Related to animal exposure
Physical Exam:
well-delineated patch with central clearing
Ddx: Seborrheic dermatitis, ACD, ICD, Atopic, phototoxic
dermatitis, lymphocytic infiltrate, erythema migrans,
PMLE, phototoxic drug eruption
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Superficial Fungal Infections
Tinea Incognito
Bona-fide cases of tinea where organisms are
not seen in biopsies/KOH/Cx
A flare is experienced when tinea is mistakenly treated
with corticosteroid
Often confused with eczematous dermatitis or
psoriasis
Superficial Fungal Infections
Dermatophytosis of hair
Tinea capitis
scalp
Tinea Barbae
beard
Majocchis granuloma
Trunk / extremities
Superficial Fungal Infections
Tinea capitis
Epidemiology
Toddlers and school-age kids
Uncommon after 16 years
More common in blacks than in whites
May become epidemic in overcrowded schools
90% of cases are T. tonsurans, less commonly M.
canis
M audouinii previously the most common cause
Transmission: person-person, animal-person
Risk factors for favus: malnutrition, debilitation
Superficial Fungal Infections
Dermatophytosis of hair
Tinea capitis
scalp
Tinea barbae
beard
Majocchis granuloma
Trunk / extremities
Ectothrix: mycelia and arthroconidia involve
surface of hairs
Endothrix: mycelia and arthroconidia within
hair shaft
Superficial Fungal Infections
Tinea capitis
Ectothrix
Microsporum species (audouinii, canis)
Endothrix
Trichophyton species (tonsurans, violaceum in Europe
and Asia)
Black dot tinea capitis resembles seb derm
Kerion:
Endothrix associated acute inflammatory reaction
allergic inflammatory plaques, usually purulent
Favus:
Endothrix with air spaces within hair shaft
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Superficial Fungal Infections
Tinea capitis
Non-inflammatory lesions
M. audouinii (child to child)
Inflammatory
T. tonsurans, M. canis
Partial hair loss is common in all forms tinea
capitis
Ectothrix: gray patch tinea capitis
Endothrix: Black dot tinea capitis
Oral anti-fungals mandated as treatment
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Superficial Fungal Infections
Tinea Barbae
Adult males only
T. verrucosum, T. mentagrophytes
Common in farmers and animal handlers
Physical exam
Pustular folliculitis
Papules may coalesce to form plaques
Regional lymphadenopathy in long-standing lesions
Ddx: Staph aureus folliculitis, furuncle,
carbuncle, acne, rosacea
Management: oral antifungals
Superficial Fungal Infections
Majocchis granuloma
Dermatophytic folliculitis
Foreign body-like reaction in response to
dermatophytes and follicular material in dermis.
Often arise in association with tinea of other
sorts
Superficial Fungal Infections
Candidiasis
Usually C. albicans
Other species in the immunocompromised (C.
globrata)
Frequently colonize GI tract (20% oropharyngeal;
40-67% fecal)
Vaginal colonization rate about 13%
Antibiotics increase carriage rate, load,
propensity for invasion
Other: hormones (the pill), pregnancy, IUD)
Not part of the normal skin flora
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Superficial Fungal Infections
Candidiasis
Most common in the young and elderly
Predisposing host factors:
Immunocompromised
DM
Obesity
Hyperhidrosis / maceration
Endocrine disorders
Superficial Fungal Infections
Candidiasis
Management
Fluconazole
Itraconazole
Ketoconazole
Labs
KOH / Dermatopathology
Culture: only presumptive, need corresponding clinical
Superficial Fungal Infections
Cutaneous Candidiasis
Intertrigo
Pustule quickly become eroded centrally
Beneath breasts, gluteal, groin
Interdigital
Initial pustule becomes eroded possible fissuring
Surrounded by thick white skin (macerated appearing)
May be associated with paronychia / onychia
Diaper dermatitis
Erythema and edema with pustules and erosion late
Occluded skin (beneath cast etc.)
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Superficial Fungal Infections
Cutaneous Candidiasis
Prevention
Keep dry
Benzoyl peroxide wash to reduce colonization
Miconazole powder
Treatment
Castellanis paint
Topical anti-fungals (Nystatin, Imidazole cream)
Oral anti-fungals (Fluconazole, Itraconazole)
Superficial Fungal Infections
Oropharyngeal Candidiasis
C. albicans
Seen in healthy persons with alterations in
normal floral (>) or the immunocompromised
May lead to erosion, invasion, and candidemia
Immunocompromised
50% of those with HIV
95% of those with AIDS (60% relapse)
40% bone marrow transplant recipients
Superficial Fungal Infections
Oropharyngeal Candidiasis
Deep forms (invasive) associated with advanced
immunocompromised status
May be the presenting sign of HIV infection
Physical Exam:
Pseudomembranous candidiasis (thrush, will wipe off)
Erythematous (atrophic) candidiasis
Candidal leukoplakia (plaques that will not wipe off)
Angular candidiasis
Ddx:
Thrush: LP, hairy leukoplakia
Atrophic: LP
Superficial Fungal Infections
Genital Candidiasis
90% C albicans
20% of women carry vaginally
Experienced by 75% of women
Usually patients have no risk factors
May be associated with:
Pregnancy
Sexual activity / inactivity
Old age
May be sexually transmitted
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Superficial Fungal Infections
Superficial Fungal Infections
Genital Candidiasis
Chronic Mucocutaneous Candidiasis
In women may be recurrent (1 wk prior to
menses)
Persistent and recurrent
Involving mucous membranes and skin
Associated with either immunocompromised
status or young age
Largely refractory to therapy
Burning, dyspareunia, dysuria
PE: erosions, discharge, thrush-like plaques
In men associated with uncircumcised status
Burning, itching
PE: pustules and erosions
Ddx
Women: Trichomoniasis, bacterial vaginosis, LP,
et A
Men: Inverse psoriasis, eczema
LS
Superficial Fungal Infections
Acute Candidemia
Often stems from GI overgrowth with invasion
May extensively involve skin and mucous
membranes
May be life threatening in immunocompromised
persons
Superficial Fungal Infections
Pityriasis Versacolor
Malassezia furfur (P. ovale)
Lipophilic yeast
Normal skin floral in post-puberty persons
Opportunistic: P Versicolor and Malassezia folliculitis
Not contagious
Young and middle aged adults
Predisposing factors
High temperature / humidity (summer months)
Corticosteroid therapy
Immunodeficiency
Superficial Fungal Infections
Pityriasis Versacolor
Organism changes from blastospore to mycelial
form
Dicarboxylic acids formed from the breakdown of
fatty acids interfere with tyrosinase function
Usually not symptomatic
Physical Exam
Macules to patches
hyperpigmented in fair skinned persons
Hypopigmnted in dark skinned persons
Trunk
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Superficial Fungal Infections
Pityriasis Versacolor
Ddx:
Vitiligo, pityriasis alba, mycosis fungoides, tuberculoid
leprosy
Tinea corporis, seborrheic dermatitis, eczema, guttate
psoriasis, pityriasis rosea
Labs
KOH
Dermatopathology
Woods lamp (blue green)
Management
Selenium sulfide shampoo
Ketoconazole shampoo / Azole creams
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Mycetoma (madura foot)
Deep Fungal Infections
Mycetoma (madura foot)
Heterogenous group of causative agents
Eumycetoma (true fungi)
Botryomycosis (bacteria)
Actinocycosis (actinomyces)
Epidemiology
Young and middle aged adults
90% males
Rural agricultural workers
Deep Fungal Infections
Mycetoma (madura foot)
Transmission
Inoculation with soil, often also with wood, other
Natural history
Weeks to years incubation
Expand for decades
Painless
No systemic symptoms
Etiology varies by region
S America: Nocardia brasiliensis
Africa: M. mycetomatis
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Deep Fungal Infections
Mycetoma (madura foot)
Eumycetoma
Most common
Pseudallescheria boydii, Madurella grisea / mycetomatis
Others: phialophora jeanselmei, acremonium, fusarium
Botryomycosis
Caused by bacteria (not true mycetoma)
Staph aureus often implicated
Actinomycetoma
Caused by actinomycetales organisms
Actinomyces
Nocardia
Others: Actinomadura, Streptomyces
Deep Fungal Infections
Mycetoma (madura foot)
Labs:
KOH: assess granules (Medlar bodies (copper))
Dermatopathology
Culture
Imaging studies: assess bony involvement
Course is relentless
Management:
Surgery
Antimicrobial therapy 9mos-1year
Chromomycosis
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Deep Fungal Infections
Chromomycosis (chromoblastomycosis)
Chronic localized infection caused by pigmented
fungi
Epidemiology
Adults thru middle age (Ag. workers)
Males > females
Dematimaceous fungi possess melanin in walls
Fonsecaea pedrosoi (most common), F compacta,
Phialophora verrucosa, Cladosporium carrionii
Transmission
Inoculation with soil contaminated FB (thorn/splinter)
Deep Fungal Infections
Chromomycosis (chromoblastomycosis)
Physical exam:
Solitary scaly nodule evolves to additional nodules
over years
Further evolves to plaques
Lymphatic spread chronic lymphedema
Ddx: blastomycosis, sporotrichosis, mycetoma,
FB, SCC
Labs:
Smear for Medlar bodies
Dermatopathology
Culture (6 weeks)
Deep Fungal Infections
Chromomycosis (chromoblastomycosis)
Course
Recurrence common after oral antifungal therapy
(itraconazole)
Secondary bacterial infections common
Late complication: SCC
Sporotrichosis
Management
Heat
Surgery
Systemic antifingals (amphotericin B)
Oral antifungals (itraconazole)
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Deep Fungal Infections
Sporotrichosis
Sporothrix schenckii
Dimorphic fungus (yeast plants; hyphae humans)
Epidemiology
Males > workers
Florists, Ag. workers, farmers, landscapers
Transmission
Inoculation by soil contaminated foreign body (rose)
Rarely inhalation may lead to systemic Dss
Scratches from cats, armadillo (Uruguay)
Deep Fungal Infections
Sporotrichosis
Risk factors
Local Dss: DM, ETOH
Disseminated Dss: HIV, Carcinoma, lymphoma,
immunosuppressive therapy
Pathogenesis
After inoculation: grows locally and extends through
lymphatics, distant (hematogenous) extension does
not occur from inoculation sporotrichosis
Incubation 3 weeks begin as painless nodule
Deep Fungal Infections
Sporotrichosis
Physical exam
Subcutaneous pustule or nodule at inoculation site
Painless ulcer develops
Lymphadenopathy
Verrucous plaques develop
Erythematous cord along lymphatics
Disseminated sporotrichosis
Hematogenous spread to skin usually from lung / GI
May also go to joints, meninges, eyes
Deep Fungal Infections
Sporotrichosis
Ddx
Plaque: Mycobacterial infection, FB, syphilis,
blastomycosis, chromomycosis, mycetoma
Nodular Lymphangitic: M. marinum, Nocardia sp.,
Leishmania brasiliensis, Francisella sp.
Labs:
KOH
Grams stain
Dermatopathology
culture
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Deep Fungal Infections
Sporotrichosis
Course
Chronic
Responds to therapy but relapses common
Management
Oral Itraconazole
Systemic Amphotericin B
Deep Fungal Infections
Systemic fungal infections (respiratory) with
secondary skin involvement
Cryptococcosis (European blastomycosis)
Worldwide
HIV
Histoplasmosis (Ohio valley Dss / Darlings Dss)
Ohio/Mississippi valley
North American Blastomycosis
May also be localized
Eastern US
Disseminated Coccidioidomycosis
S CA
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