Chapter 7

Superficial Mycoses
 SUPERFICIAL MYCOSES
The superficial mycoses are usually confined to the outermost
layer of skin, hair, mucosa and do not invade living tissues
Cutaneous Mycoses – infection occurs in hair,
skin and nails
• Infections are generally restricted to the tissues containing
keratin and can evoke cellular immune responses that may
be expressed in the deeper layers of the skin.

• The clinical manifestations of these infections are also

referred to as "ringworm," describing ring-like skin lesions.

• Acquisition is from soil, animals or person to person.

Infections are encouraged by hot and humid conditions and
poor hygiene.
Cutaneous mycoses
• Infections that extend deeper into the epidermis, as well as
hair and nail
• caused by dermatophytes:
• Tinea capitis
• Tinea corporis
• Tinea manus
• Tinea cruris
• Tinea pedis
• Tinea unguium
oDermatophytosis - "ringworm" disease of the
nails, hair, and/or stratum corneum of the skin
caused by fungi called dermatophytes.

oDermatomycosis - more general name for any

skin disease caused by a fungus.
The three genera belonging to the "dermatophytes" or fungi
causing cutaneous infections:

• Microsporum: infects hair and skin

• Trichophyton: infects hair, skin and nails (note: “tri” in name
& infection of all three keratin containing tissues)
• Epidermophyton: infects nails and skin

(note: all three genera can infect the skin)

Infections by Dermatophytes
• Severity of ringworm disease depends on:
• (1) strains or species of fungus involved
• (2) sensitivity of the host to a particular pathogenic fungus.

• More severe reactions occur when a dermatophyte crosses non-host lines (e.g.,
from an animal species to man).

• Among dermatophytes there appears to be a evolutionary transition from a

saprophytic to a parasitic lifestyle.
• Geophilic species - keratin-utilizing soil saprophytes (e.g., M. gypseum, T. ajelloi).
• Zoophilic species - keratin-utilizing on hosts - living animals (e.g., M. canis, T. verrucosum).
• Anthropophilic species - keratin-utilizing on hosts - humans (e.g., M. audounii, T. tonsurans)
Clinical manifestations of ringworm infections are called
different names on basis of location of infection sites
• tinea capitis - ringworm infection of the head, scalp, eyebrows,
eyelashes
• tinea favosa - ringworm infection of the scalp (crusty hair)
• tinea corporis - ringworm infection of the body (smooth skin)
• tinea cruris - ringworm infection of the groin (jock itch)
• 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)
Species found in different anamorphic genera are the cause of
different clinical manifestations of ring worm

• 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.
Major sources of ringworm infection
• Schools, military camps, prisons.
• Warm damp areas (e.g., tropics, moisture accumulation in clothing
and shoes).
• Historical note: More people were shipped out of the Pacific Theater
in WWII back to U.S. because of ringworm infection then through
injury.
• Animals (e.g., dogs, cats, cattle, poultry, etc.).
CLINICAL MANIFESTATIONS OF RINGWORM
SYMPTOMS AND TREATMENT

• Tinea pedis - Athletes' foot infection

• between toes or toe webs (releasing of clear fluid) - 4th and 5th toes are most
common.
• Soreness and itching of any part of the foot.
• In one study - 85 % of college students carried a ringworm fungus.
• Common disease but fairly recent was not recognized until late 19th century.
• Spread of disease correlated with introduction and generalized distribution of T.
rubrum into Europe and America probably due to massive movement of peoples
due to colonial occupation, slave trade, and World War II.
• Origin of T. rubrum may have been South-Eest Asia or Africa.
• Fungi probably transmitted host to host through
infected squamas; flat, keratinised, dead cells shed
from the outermost layer of a stratified squamous
epithelium.

• Three causal agents, T. rubrum (source of inoculum

comes from people with chronic infections, because
fungus not long-lived in squamas), T. mentagrophytes,
and Epidermophyton floccosum (source of inoculum
comes from long-lived arthrospores that reside in
squamas deposited in rugs and carpets (fomites).
CLINICAL MANIFESTATIONS OF RINGWORM
SYMPTOMS AND TREATMENT
• Three Grades of Infection

• Grade I - Subclinical
• An itching between toes,

• skin may be soft and macerated, blistering my occur.

• Treatment - keeping feet dry and clean, drying between the toes lightly each
time you bathe to remove some skin.

• Application of fungicidal powders or ointments containing (1) salicylic acids to

promote peeling of the skin and/or (2) tonaftate or other topical fungicides.
CLINICAL MANIFESTATIONS OF RINGWORM
SYMPTOMS AND TREATMENT

• Grade II

• Host is conscious of a burning sensation while walking and standing.

• Soaks are recommended (paints or liquids) such as 1:4000 KMnO4 (stains the
skin purple) or topical fungicides.

• Remove clear liquid from blisters by having a doctor puncture near the base
or unroofing the blister.

• Dusting powder in morning to help keep feet dry.

Tinea Pedis – Athlete’s Foot Infection
CLINICAL MANIFESTATIONS OF RINGWORM
SYMPTOMS AND TREATMENT
• Grade III
• A secondary bacterial infection sets in.
• Patient should go to bed.
• Use systemic antibiotics to fight bacterial infection.
• Use of soaks and compresses.
• After infection subsidies, go to treatments as for Grade I or II infections.
• For persistent cases, (T. rubrum is usually the culprit), resort to systemic
griseofulvin therapy or other antifungal systemic drugs (i.e., Lamisiltrademark
or terbinafine HCl)
• Griseofulvin is fungistatic, so it won't kill the fungus, just inhibit its growth.
• Improvement occurs in 2-6 weeks as long as 6 months.
• Sometime griseofulvin treatment is ineffective.
• Some patients may not tolerate terbinafine HCL depending on sensitivity
to drug.
CLINICAL MANIFESTATIONS OF RINGWORM
SYMPTOMS AND TREATMENT

• Allergic reactions are sometimes associated with tinea pedis and other ringworm
infections.
• dermatophytid - an "id" allergic reaction.
• toxins get into blood stream and reaches a site other than the site of infection.
• blistering occurs on fingers and hands.
• in diagnosis, rule out allergic reaction to poison ivy, detergents or other
substances.
• during diagnosis, look for tinea (pedis, often) on the body.
• treat the primary site of infection where the antigen is being produced.
• treat secondary site - blisters.
CLINICAL MANIFESTATIONS OF RINGWORM
SYMPTOMS AND TREATMENT
• Tinea corporis - body ringworm
• Generally restricted to stratum corneum of the smooth skin.
• Symptoms result form fungi metabolites such as toxin/allergens.
• Disease found throughout the world.
• Produces concentric or ring-like lesions on skin, and in severe cases these are
raised and may become inflamed.

• All forms of tinea corporis caused by T. rubrum, T. mentagrophytes, T. tonsurans,

M. canis, and M. audouinii are treatable with topical agent containing tolnaftate,
ketoconazole, miconazole, etc...
• Disease transmitted through infected scales hyphae or arthroconidia on the skin.
• Also transmitted through direct contact between infected humans or animals, by
fomites (any agent such a bedding or clothing capable of retaining a pathogen
and transmitting to a new host).

• Transfer form on area to the body to another (from tinea pedis to tinea corporis).
• Tinea Corporis normally resolves itself in several months.

• T. verrucosum and T. violaceum infections require more vigorous treatment

including cleaning of area to remove of scales and older fungicidal topical
applications of ammoniated mercury ointment, 3 % salicylic and sulfuric acid, or
tincture of iodine for several weeks.

• Widespread tinea corporis and more severe types (lesions) require systemic
griseofulvin treatment (about 6 weeks for effective treatment).
Tinea corporis – body ringworm
CLINICAL MANIFESTATIONS OF RINGWORM
SYMPTOMS AND TREATMENT

• Tinea cruris - ringworm of the groin and surrounding region

• More common in men than women.

• Infection seen on scrotum and inner thigh, the penis is usually not infected.
• Epidemics associated with grouping of people into tight quarters - athletic teams,
troops, ship crews, inmates of institutions.
• Predisposing factors include persistent perspiration, high humidity, irritation of
skin from clothes, such as tight fitting underwear or athletic supporters, pre-
existing disease, such as diabetes and obesity.
• Several causes of tinea cruris include:
• T. rubrum (does not normally survive long periods outside of host),
• E. flocossum (usually associate with epidemics because resistant
arthroconidia in skin scales can survive for years on rugs, shower
stalls, locker room floors),
• T. mentagrophytes (usually of animal origin, such as rodents),
• and Microsporum gallinae (rarely seen - usually found on gallinaceous
birds like turkeys and chickens).
Diagnosis and treatment

• If lesion "weep", it is likely caused by a yeast, such as, Candida albicans, and
not by a dermatophyte, especially if infections are seen in a woman.
• KOH examination of skin scrapings.
• Culture of dermatophyte from skin scrapings.

Treatment

• Tolnaftate (Tinactin trademark) treatment protocol for tinea corporis.

• Relief of symptoms occur within 3 days and treatment continued until all signs
of disease are gone.
• Area is sensitive so the other care needs to be taken into to add to irritation
of region.
CLINICAL MANIFESTATIONS OF RINGWORM
SYMPTOMS AND TREATMENT

• Tinea unguium - ringworm of the nails

• Tinea unguium or onchomycosis can take two forms:

• Leukonychia mycotica - superficial white onychomycosis, invasion of fungus
restricted to patches or pits on surface of the toenail.
• Invasive subungual dermatophytosis - lateral or distal edges first involved,
followed by establishment of the infection beneath the nail plate. Invasion of
nail plates by dermatophytes.

• Onychomycosis (infection of nails caused by non-dermatophytic fungi and yeasts)

• Most commonly caused by T. rubrum, then E. floccosum or other Trichophyton
species.
• Treatment:

• Resistant to treatment, rarely resolves spontaneously.

• Topical treatments - poor record of cure.
• Ablation - surgical or chemical removal of nail.
• Systemic griseofulvin therapy can lead to remission (usually a year or more
of treatment required - results vary about 29 % cure rate).
• Use of other systemic antifungal (i.e., Lamisiltrademark or terbinafine HCl).
• Filing down the nail to paper thin consistency and soaking or painting with
KMnO4 (1:4000), phenol, 10 % salicylic acid, or 1% iodine is useful adjunct
to systemic griseofulvin treatment.
Tinea Unguium – Nail Infection
CLINICAL MANIFESTATIONS OF RINGWORM
SYMPTOMS AND TREATMENT

• Tinea capitis - ringworm of the scalp, eyebrows and eyelashes

• Caused by species of Microsporum and Trichophyton.

• Fungus grows into hair follicle.

• Using a Wood's lamp, on hair Microsporum species tend to fluoresce green while
Trichophyton species generally do not fluoresce.

• Lack of fluorescence does not mean it isn't Microsporum.

• Subculture any strands of hair that fluoresce to help identify the causal agent.
• Ectothrix infection - fragmentation of mycelium into conidia (called
arthroconidia) around the hair shaft or just beneath the cuticle with destruction
of the cuticle. This type of infection caused by M. audounii, M. canis, M.
ferrugineum, T. mentagrophytes, T. verrucosum and T. megninii.

• Endothrix infection - arthroconidia formation occurs by fragmentation of hyphae

within hair shaft with destruction of the cuticle. This type of infection caused by
T. tonsurans (most common cause), T. violaceum, T. rubrum, and T. gourvillii. All
these pathogen species are anthropophilic.

• "Gray patch ringworm" ectothrix common disease in children usually not

associated with inflammation.

• Zoophilic and geophilic dermatophytes infections on man associate with

inflammation. Microsporum canis, T. verrucosum, and T. mentagrophytes
(zoophilic); M. gypseum and M. fulvum (geophilic species).
• Treatment of Tinea Capitis

• Ectothrix infections often resolve on their own.

• Endothrix infections may become chronic and may continue into adulthood.
• Topical treatments are ineffective (don't bother using tonaftate or topical
griseofulvin)

• Fungistatic agents are somewhat effective (miconazole, clotrimazole) in

combination to systemic administration of griseofulvin.

• Vigorous daily scrubs of scalp help removal of infectious debris. Do not use this
treatment on patients with porphyria (an accumulation of blood pigment called
porphyrins in blood stream and urine) or is hypersensitive to griseofulvin.
Tinea Capitis

Gray Patch
Ectothrix and Endothrix

Fluorescing hair (under Wood's lamp)

is seen in dogs and cats infected with
some dermatophytes