Superficial fungal skin

infections

DR ASTER K.(MD)

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• Fungal infections can be
I. Superficial
II. Subcutaneous
III. Systemic

Superficial fungal infections

• Infections of the hair, nail and stratum corneum
• Dermatomycosis- superficial fungal infection
by any fungus

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 CLINICAL FORMS
1. Tinea capitis
2. Tinea barbae
3. Tinea corporis
4. Tinea cruris
5. Tinea manuum
6. Tinea pedis
7. Tinea unguium

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 Tinea capitis
• Dermatophytosis of scalp and associated hair
• Most common cause is M.canis
• 3-14 yrs of age
• Children of african decent
• Decreased personal hygiene, overcrowding,
low socioeconomic status
• Sharing of combs, caps, pillow, toys
• Asymptomatic carriers
• Bacterial super infection can occur

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• Clinical findings
– Noninflammatory type
• Gray patch type
• Black dote type
– Inflammatory type
• Pustular
• Kerion
• T.favus

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1. Gray patch type
• Appearance is like a “wheat field”
• Gray lusterless hair from sheath of
anthroconidia
• Minimal inflammation

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2. Black dot type
• Least inflammatory
• Multiple areas of poorly demarcated areas of
alopecia

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3. Inflammatory type
• Hypersensitivity rxn to infection
• Pustular folliculitis
• Kerion- boogy inflammatory mass with
oozing pus, fever ,pain ,pruritus , cervical lap

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4. T. favus
• Associated with malnutrition and poor
hygiene
• Thick yellow crust with in hair follicle leading
to scaring alopecia

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 T. barbe
• Males
• Transmitted by barbers razor previously now
zoonotic transmission
• Clinical findings
– Unilateral and affects mostly bearded areas
than mustache areas
– Three types
I. Inflammatory type
• Zoophilic, analogous to kerion of T.capitis
• Nodular bogy mass with purulent discharge
resulting in scaring alopecia
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ii. Superficial type

• Perifolicullar papules and pustules

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iii. Circinate type
• Actively spreding vesiculo pustular border with
central scaling
Ddx- bacterial folliculitis,
periorbital dermatitis

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 T.corporis

• Dermatophytosis of the glabrous skin

except the soles palms and groin
• Occlusive clothing, warm, humid climates,
frequent skin-to-skin contact, and minor
trauma
• Most common cause is T.rubrum

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• Clinical findings
– Classically- Annular
lesion with scale across
the entire erythematous
border which is vesicular
and advance
centrifugally with
centrally clearing and
scaling
– It has different variants
both inflammatory and
noninflammatory eg: T.
faciale
• Ddx- Nummilar eczema,
P.rosea, lichen planus

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 Tinea faciei
• Relatively uncommon dermatophyte
infection of glabrous skin of the face
• Usually seen in children

• The most frequently misdiagnosed from

the dermathopytoses

• The causative agents

– e.g. T. tonsurans, T. rubrum, and M. canis
 T.cruris
• Dermatophytosis of genitalia, pubic area,
perianal area, grion
• Second most common type
• Autoinoculation, direct contact, fomite
• M>F
• Adults
• Warm, humid occlusive environment
aggravates it
• Mostly from T.rubrum, E. floccusom
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Clinical findings
Multiple erythematous papulovesicles with well marginated raised border
Ddx- S.dermatitis, psoriasis, Erthrasma

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 T. pedis and manus

• T.pedis – dermatophytosis of the soles of

the feet and the interdigital web spaces

• T.manus- dermatophytosis of the palmar

and interdigital areas of the hand

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• Most common type of dermatophytosis
• 10% prevalence

• Occlusive foot ware

• Direct contact with soil person

• Most common etiology is T.rubrum

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T. MANUS OR T.CORPORIS?

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• Clinical findings
Four types of T.pedis

1. Chronic intertrigenoius type(interdigital

type)
• Most common presentation
• Maceration, erythema, scale of interdigital
and sub digital skin mostly in between lateral
thee toes

• Athletes foot

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2. Chronic hyperkeratotic type(moccasin
type)
• Usually bilateral diffuse or patchy scaling
limited to the thick skin, sole and lateral and
medial aspects of the foot

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• Unilateral T.manus occur with this type giving
to what is called two feet one hand
syndrome 36
3. Vesiculobullous type
• Tense vesicles larger than 3 mm in diameter,
vesiculopustules, or bullae on the thin skin of the
sole and periplantar areas

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4. Acute ulcerative type
• When there is bacterial coinfection
• Usually in diabetic and
immunocompromised pts

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 Onycomycosis
• Infection of the nail caused by any form of
fungi

• T.ungium is detmatophytic infection of the

nail

• 2-8% prevalence

• Most common form of onychopathy

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• Dermatophytes are most common
(90%)causes commonly T.rubrum, others
like E.floccosum

• Toenail infections are several-fold more

common than fingernail infections

• Yeasts and molds are also causes

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Clinical findings
Four types
1. Distal subungal
• Subungal hyperkeratosis
• onycholysis

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2. Proximal subungal
• Direct invasion under the proximal nail fold
• Usually in HIV infected pts

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3. White superficial
• Direct invasion into the superficial nail plate

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4. Candidial onychomycosis
• Invade via the hyponychial epithelium to affect
the entire thickness of the nail plate.
• Usually in immunocompromised pts

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• Investigations
– KOH- hypha

– Culture- sabouraud dextrose agar

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Wood lamp
• Treatment
– Topical antifungal
– Systemic antifungal
T.capitis
• Grisofulvin 20-25 mg/kg/day for 6-8 wks
• Fluconazole 6 mg/kg/day for 3-6 weeks
• Itraconazol 3-5 mg/kg/day for 4-6 weeks
• Terbinafin 3-6 mg/kg/day (Trichophyton 2- 4 weeks,
Microsporum 4-8 weeks)
• Adjuvant ketoconazole 2% shampoo
• If there is bacterial super infection antibiotic
treatment should be provided

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T.barbe
• Griseofulvin at 1 g daily for 2 to 4 weeks
• Fluconazole 200 mg daily for 4 to 6 weeks
• Itraconazole 200 mg daily for 2 to 4 weeks
• Terbinafine 250 mg daily for 2 to 4 weeks
T.corporis/ T.cruris
• Topical therapy is recommended for a localized infection
• Topical therapy once or twice a day for at least 2-4 weeks.
 Clotrimazole 1% cream
 Ketoconazole 2% cream
 Miconazole 2% cream or lotion
• Systemic is for extensive lesions
• Fluconazol 150-200 mg/week for 2-4 weeks
• Itraconazole, 100 mg daily for 15 days
• Terbinafine, 250 mg daily for 2 weeks
• Griseofulvin 500 mg daily for 2 to 6 weeks
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T. pedis
• First line therapy is with topical agents bid for 1-6 weeks
 Clotrimazole 1%
 Ketoconazole 2%
 Econazole 1%
 Ciclopirox 1%
 Terbinafine 1%
• Systemic antifungals specially for those where topicals have failed,
recalcitrant or extensive, mocassin variants, onychomycosis,
diabetes, peripheral vascular disease, or Immunocompromised
patients
 Fluconazole:
 Adult; 150-300 mg/day for up to 4 weeks
 Pediatrics; 3-6 mg/kg/day for 2-4 weeks
• Antibiotics for those with bacterial super infection

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 Onychomycosis
• Oral antifungals are generaly requeired
• Fluconazole 150-300mg/week for 3 to 9mo for
fingernail & to 12mo for toenail infection...why?
• Fluconazole 6 mg/kg/week in children

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Tinea versicolor (ptriasis versicolor)
• An opportunistic infection of the skin by a
yeast
• M=F
• Commonly in adolescent and adults
• M.furfur
– Part of the normal flora of the skin
– Under warm, humid environment, oral
contraceptive use, immunosuppression,
malnutrition, cushing disease, hereditary
predelication or hyperhidrosis it cause infection

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• Clinical findings
1. Papulosquamous T.versicolor
• Hypo or hyper pigmented macules with dust
like scaling over the chest, back, abdomen,
proximal extremity

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2. Inverse T.versicolor
• Over flexure areas
Ddx- P.alba, P.rosea, S.
dermatitis ,vitiligo
• Lab examination
– KOH – hypha
– Microscopy – spaghetti and meat ball appearance
– Woods lamp – yellow fluorescence
• Treatment
– Topical
• 2% ketoconazole shampoo
• 2.5% selenium sulfide shampoo
– Systemic- for frequent recurrence, failed topical
treatment and extensive skin involvment
• 200 mg ketoconazole po for 7 days
• Fluconazole 400 mg po stat

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 REFERENCE

• Fitzpatrick's Dermatology in general medicine 8th

edition

• Bolognia dermatology 3rd edition

• Rook’s text book of dermatology 8th edition

• Andrew’s disease of the skin 10th edition

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