MLM 313 MICROBIOLOGY III

(MYCOLOGY)

Cutaneous Mycoses
Level 300 – Semester 1

Lecturer:
Lawrence Annison
 Cutaneous Mycoses
• These are fungal infections limited to the keratinized
tissues of the skin, hair or nails and extend deeper into
the epidermis without penetration of deeper tissues.

• No living tissue is invaded, however a variety of

pathological changes occur in the host because of the
presence of the infectious agent and its metabolic
products.
Tineas
• A group of medically important cutaneous mycoses
called tineas or ringworm are caused by dermatophytes, fungal
moulds that require keratin, a protein found in skin, hair, and
nails, for growth.

• Dermatophytes are grouped by their natural habitat or reservoir

as either:

 Anthropophilic
• The common anthropophilic species are primarily parasitic on
man.

• They are unable to colonise other animals and they have no

other environmental sources.

• Anthropophilic dermatophytes are so well adapted to living on

human skin that they provoke a minimal inflammatory reaction.
E.g. Trichophyton rubrum.
 Zoophilic
• Zoophilic species are primarily parasitic on animals and
infections may be transmitted to humans following
contact with the animal host.

• Zoophilic infections usually elicit a strong host response

and on the skin where contact with the infective animal
has occurred i.e., arms, legs, body or face. E.g.
Trichophyton equinum).

 Geophilic
• Geophilic species normally inhabit the soil where they
are believed to decompose keratinaceous debris. E.g.
Trichophyton gloriae.

• Zoophilic or geophilic dermatophytes will often provoke

a more vigorous inflammatory reaction when they
attempt to invade human skin.
• There are nine genera of dermatophytes, recognised
by the nature of their macroconidia. The common
dermatophytes infecting humans are:

• Human infections are caused by Trichophyton,

Epidermophyton, and Microsporum. Other genera
are Arthroderma, Ctenomyces, Lophophyton,
Nannizzia, Guarromyces and Paraphyton.

• Dermatophytes are commonly found in the

environment and in soils and are frequently
transferred to the skin via contact with infected
humans or animals

• Indirect contact with detached skin or hair in items

such as clothing, towels, combs/brushes exist.
Fungal spores can also spread on hair.
• There are about 50 species. Their spores can live for more than a year in human
skin scales in the environment.
 Anthropophilic organisms include:
• T. rubrum
• T. interdigitale
• T. tonsurans
• M. audouinii
• T. violaceum
• M. ferrugineum
• T. schoenleinii
• T. megninii
• T. soudanense
• T. yaoundei

 Zoophilic organisms include:

• M. canis (originating from cats and dogs)
• T. equinum (originating from horses)
• T. erinacei (originating from hedgehogs and other animals)
• T. verrucosum (originating from cattle)
• M. nanum (originating from pigs)
• M. distortum (a variant of M. canis).

• Geophilic organisms include:

• Nannizzia gypsea
• M. fulvum.
• Many dermatophytes grow well in moist, dark
environments.

• For example, tinea pedis (athlete’s foot)

commonly spreads in public showers, and the
causative fungi grow well in the dark, moist
confines of sweaty shoes and socks.

• Likewise, tinea cruris (jock itch) often spreads in

communal living environments and thrives in
warm, moist undergarments.

• Tineas on the body (tinea corporis) often produce

lesions that grow radially and heal towards the
center. This causes the formation of a red ring,
leading to the misleading name of ringworm.
• Tineas on most areas of the body are generally
called ringworm, but tineas in specific locations
may have distinctive names and symptoms.

• Keep in mind that these names—even though they

are Latinized—refer to locations on the body, not
causative organisms.

• Tineas can be caused by different dermatophytes

in most areas of the body. Dermatologists often
use the term tinea or ringworm to refer to a variety
of lesions of the skin or scalp.

• Tinea infections are categorized clinically by the

affected anatomic site (e.g. tinea capitis, scalp;
tinea pedis, feet).
Dermatophytosis
• Dermatomycosis is any fungal infection of the skin
such as secondary spread from systemic mycoses,
infection by Candida sp. or colonization of a variety
of soil inhabiting fungus. E.g. cutaneous candidiasis
caused by Candida.

• Dermatophytosis (tinea or ringworm) of the scalp,

glabrous skin, and nails, is a superficial fungal
infections of the keratinized tissues of the skin
caused by a closely related group of fungi known as
dermatophytes.

• They have the ability to utilise keratin as a nutrient

source allowing them to infect skin, hair and nails.
• They have a unique enzymatic capacity. They
secrete keratinase that digests keratin and elicit an
inflammatory response that limits infection.

• Dermatophytoses are characterized by itching,

scaling skin patches.

• The disease process in dermatophytosis is unique

for two reasons:

• Firstly, no living tissue is invaded.

– The keratinised stratum corneum is simply colonised.
However, the presence of the fungus and its metabolic
products usually induces an allergic and inflammatory
eczematous response in the host.
• The type and severity of the host response is
often related to the species and strain of
dermatophyte causing the infection.

• Secondly, the dermatophytes are the only fungi

that have evolved a dependency on human or
animal infection for the survival and
dissemination of their species.

• Although all three genera attack the skin,

Microsporum does not infect nails and
Epidermophyton does not infect hair.
- Trichophyton
• These infect skin, hair and nails.

• They cause athlete's foot, jock itch, and similar

infections of the nail, beard, skin and scalp.

• Trichophyton fungi are molds. Trichophyton rubrum

(ascomycetes) is the most common cause of tinea.

- Microsporum
• These may infect skin and hair, rarely nails.

• They cause tinea capitis, tinea corporis, and other

dermatophytoses.
• Microsporum canis is one of the most common
dermatophytes.

- Epidermophyton
• These infect skin and nails and rarely hair.

• E.g. Epidermophyton floccosum (ascomycetes).

- Tinea pedis (athlete's foot)
• Athlete's foot is a common irritable skin infection of the
feet. It commonly occurs in people whose feet have
become sweaty while confined within tight-fitting shoes.

• Infections by anthropophilic dermatophytes are usually

caused by the shedding of skin scales containing viable
infectious hyphal elements [arthroconidia] of the fungus.

• Desquamated skin scales may remain infectious in the

environment for months or years. Therefore transmission
may take place by indirect contact long after the
infective debris has been shed.
• Substrates like carpet and matting that hold skin
scales make excellent vectors.

• Thus, transmission of dermatophytes

like Trichophyton rubrum, T. interdigitale and
Epidermophyton floccosum is usually via the feet.

• In this site infections are often chronic and may

remain subclinical for many years only to become
apparent when spread to another site, usually the
groin or skin.

• It is important to recognise that the toe web spaces

are the major reservoir on the human body for
these fungi and therefore it is not practical to treat
infections at other sites without concomitant
treatment of the toe web spaces.
• This is essential if a "cure" is to be achieved.

• It should also be recognised that individuals

with chronic or subclinical toe web infections
are carriers and represent a public health risk to
the general population, in that they are
constantly shedding infectious skin scales.

• The infected tissue is initially between the toes

but can spread to the nails, which become
yellow and brittle.
- Tinea cruris (‘jock itch’, crotch itch)
• Tinea cruris refers to dermatophytosis of the genitals,
inner thighs and buttocks.

• Disease manifestations are similar to ringworm, except

that lesions occur in the groin area where they can
spread from the upper thighs to the genitals.

• It occurs predominantly but not exclusively in adult

males and is usually due to spread of the fungus from the
feet.

• Symptoms usually include a red raised rash with a scaly

well-defined border.
• Hair follicles can become inflamed in hairy
individuals resulting in bumps (nodules, papules,
pustules) within the plaque.

• The plaque may affect the scrotum in men and

labia majora in women. The penis is usually not
affected.

• Affected people experience intense itching in the

groin which can extend to the anus.

• Risk factors include excessive sweating, diabetes

and obesity.

• The usual causative agents are T. rubrum, T.

interdigitale and E. floccosum.
- Tinea corporis (‘ringworm’)
• Tinea corporis refers to dermatophytosis of the glabrous
[smooth] skin.

• It is usually an itchy, circular rash with clearer skin in the

middle.

• Tinea corporis can affect any part of the body excluding

the hands, feet, scalp, and face (although infection of
legs or arms may occur)

• Lesions appear as advancing rings with scaly centers.

• It is common in adolescent and young adult males.

• It may be caused by anthrophophilic species
such as T. rubrum usually by spread from
another body site or by geophilic and zoophilic
species such as M. gypseum and M.
canis following contact with either
contaminated soil or an animal host.
- Tinea capitis (“scalp ringworm”)
• Tinea capitis refers to dermatophytosis of the scalp and hair.

• It occurs when fungi enter hair follicles and often hair shafts. It
may also affect eyelashes and eyebrows.

• Tinea capitis usually causes itchy, scaly, bald patches on the

head characterized by dry ring-like, scaly, itchy, erythematous
lesions on the scalp and may present as areas of alopecia.

• The disease is predominantly found in children and can spread

rapidly in a family or school.

• The disease is caused predominately by Trichophyton

tonsurans and the zoophilic Microsporum canis.
• Three types of in vivo hair invasion are
recognised:
 Ectothrix invasion is characterised by the
development of arthroconidia on the outside of
the hair shaft.
• The cuticle of the hair is destroyed and infected hairs
usually fluoresce a bright greenish yellow colour under
Wood's ultraviolet light.
• Common agents include Microsporum canis, Nannizzia
gypsea (formerly Microsporum gypseum), Trichophyton
equinum and T. verrucosum.
 Endothrix hair invasion is characterised by the
development of arthroconidia within the hair
shaft only.
• The cuticle of the hair remains intact and infected hairs
do not fluoresce under Wood's ultraviolet light.
• All endothrix producing agents are anthropophilic
e.g. Trichophyton tonsurans and T. violaceum.
 Favus (latin for ‘honeycomb’”) usually caused
by Trichophyton schoenleinii, produces favus-
like crusts or scutula and corresponding hair
loss.
 Also called tinea favosa, it is the severe form of tinea
capitis.
• jj
- Tinea barbae (beard ringworm)
• Tinea barbae, also known as tinea sycosis, is a rare
fungal infection that affects the skin, hair, and hair
follicles in the beard and mustache areas of the face
and neck.

• It generally affects only adult men.

• Tinea barbae is usually caused by the zoophilic

Trichophyton verrucosum.
- Tinea unguium (dermatophyte onychomycosis)
• Tinea unguium, is an infection of nail tissue of the hands
or the feet.

• Onychomycosis makes the nails look thickened,

discolored and brittle.

• Usually, the problems caused by this condition are

cosmetic.

• It is important to stress that only 50% of dystrophic nails

have a fungal aetiology, therefore it is essential to
establish a correct laboratory diagnosis by either
microscopy and/or culture, before treating a patient with
a systemic antifungal agent.
• Trichophyton rubrum and T. interdigitale are the
dominant dermatophyte species involved.

• Dermatophyte onychomycosis may be classified

into two main types:
o (1) superficial white onychomycosis in which invasion is
restricted to patches or pits on the surface of the nail;
o (2) invasive, subungual onychomycosis in which the lateral,
distal or proximal edges of the nail are first involved, followed
by establishment of the infection beneath the nail plate.
• Distal subungual onychomycosis is the most
common form of dermatophyte onychomycosis.
– The fungus invades the distal nail bed causing hyperkeratosis of the
nail bed with eventual onycholysis (nail separates from its nail bed),
and thickening of the nail plate.
• As the name suggests, lateral subungual
onychomycosis begins at the lateral edge of the
nail and often spreads to involve the entire nail bed
and nail plate.

• In proximal subungual onychomycosis, the fungus

invades under the cuticle and infects the proximal
rather than the distal nail bed causing yellowish-
white spots which slowly invade the lunula and
then the nail plate.
Lab. Diagnosis
Clinical material:
• Skin Scrapings, nail scrapings and epilated hairs.

Direct microscopy
• Skin scrapings, nail scrapings and epilated hairs should
be examined using 15% KOH and Parker ink or
calcofluor white mounts

• It demonstrates hyphae and conidia characteristic of the

dermatophytes.

• Certain fungi (Microsporum) fluoresce under UV light.

Culture:
• Specimens should be inoculated onto primary
isolation media, like Sabouraud's dextrose agar
containing cycloheximide (Cycloheximide is widely used to
inhibit protein synthesis in eukaryotic cells studied in-vitro) and

incubated at 26-28C for 4 weeks.

• The growth of any dermatophyte is significant.

Treatment
• Removal of infected skin, followed by topical
application of antifungal antibiotics, such as
miconazole, clotrimazole, is the first course of
treatment.

• Tolnaftate (Tinactin – topical) and Echinocandins

(caspofungin) are also effective.

• Refractory infections usually respond well to oral

griseofulvin and itraconazole (Sporanox).
• Infections of the hair and nails usually require
systemic (oral) therapy.

• Oral antifungals such as as Itraconazole and

Terbinafine (Lamisil) are the drugs of choice
for onychomycosis.