SUPERFICIAL

MYCOSES
MOHAMED ANSAR CK
MSc MLT Microbiology
• These are superficial cosmetic fungal infections of the skin or
hair shaft.
Disease Causative organisms Incidence

Pityriasis versicolor
Seborrhoeic dermatitis Malassezia spp.
Common
including Dandruff and (a lipophilic yeast)
Follicular pityriasis

Tinea nigra Hortaea werneckii Rare

White piedra Trichosporon spp. Common

Black piedra Piedraia hortae Rare

Dermatophytoses Dermatophytes Common

Malasseziosis
• Malassezia species are basidiomycetous yeasts and form
part of the normal skin flora of humans and animals.
• Majority of the species are lipid-dependent (lipophilic).
• Malassezia species may cause various skin manifestations
including pityriasis versicolor, seborrhoeic dermatitis, dandruff,
atopic eczema and folliculitis.
Pityriasis versicolor

• This is a chronic, superficial fungal disease of the skin(stratum

corneum) characterised by well-demarcated white, pink or
brownish lesions, and covered with thin furfuraceous scales.
• The colour varies according to the normal pigmentation of the
patient, exposure of the area to sunlight, and the severity of the
disease.
• Flat round scaly patches of hypo to hyperpigmentation.
• Lesions are non pruritic
• Lesions occur on the trunk, shoulders and arms, rarely on the
neck and face.
• Young adults are affected most often, but the disease may
occur in childhood and old age.
• Disease more common in humid areas.
• Previously in Sri Lanka – considered as mark of beauty
• Gomara – tears of liquid gold
Pityriasis folliculitis:
• Hair follicle infection.
• This is characterised by follicular papules and pustules localised
to the back, chest and upper arms, sometimes the neck, and
more seldom the face.
• These are itchy and often appear after sun exposure.
Seborrhoeic dermatitis and dandruff
• Patients with neurological diseases such as Parkinson's
disease and those with AIDS are commonly affected.
• Clinical manifestations are characterised by erythema and
scaling in areas with a rich supply of sebaceous glands -- the
scalp, face, eyebrows, ears and upper trunk.
• Lesions are red and covered with greasy scales and itching is
common in the scalp.
Seborrhoeic dermatitis
Lab diagnosis
Wood’s lamp examination
• Fluoresce a pale greenish yellow or golden yellow colour under
Wood's ultra-violet light.
• Direct microscopy:
Skin scrapings taken from patients with Pityriasis versicolor
stain rapidly when mounted in 10% KOH, glycerol and Parker
ink solution and show characteristic clusters of thick-walled
round, budding yeast-like cells and short angular hyphal forms
up to 8um in diameter .
• Spaghetti and meat ball appearance or banana and grapes
appearance
Culture:
• M. furfur is a lipophilic yeast, therefore in vitro growth must be
stimulated by natural oils or other fatty substances.
• The most common method used is to overlay Sabouraud's
dextrose agar containing cycloheximide (actidione) with olive oil
or alternatively to use a more specialized media like Dixon's
agar which contains glycerol mono-oleate (a suitable substrate
for growth).
• Other media – Leeming and Notman media , Dutta and
Dikshit media.
• Typical fried egg colonies after 5-7 days incubation at 32-35 OC.
 Colony on Dixon media
Colony on SDA
• Urease test positive.
• ELISA, PCR,RFLP, MALDI TOF
• Animal Pathogenicity – Guinea pig and Swiss albino mice
Treatment :
• Topical lotions like selenium sulfide shamboo, ketoconazole shamboo
or cream , terbinafine cream for 2 weeks.
Tinea nigra
• A superficial fungal infection of skin characterised by brown to
black macules which usually occur on the palmar aspects of
hands and occasionally the plantar (sole) and other surfaces of
the skin.
• Painless and non scaly patches
• World-wide distribution, but more common in tropical regions of
Central and South America, Africa, South-East Asia and
Australia.
• The aetiological agent is Hortaea werneckii a common
saprophytic fungus, black coloured yeast like fungus.
• Palm - tinea nigra palmaris
• Sole - tinea nigra plantaris
Lab diagnosis
• Clinical material:
Skin scrapings.
• Direct microscopy:
Skin scrapings should be examined using 10% KOH or
calcofluor white mounts.
• Masson – Fontana stain .
• Culture:
Clinical specimens should be inoculated onto primary isolation
media, like Sabouraud's dextrose agar.
• Initially colonies are brown , rapidly become olive to shiny , greenish
black tar-like, producing metallic sheen (drop of oil).
• PCR
• Animal pathogenicity – Guinea pigs

Treatment
Whitefield’s ointment or salicylic acid ointment,
itraconazole,cotrimazole.
White Piedra
• White piedra is a superficial cosmetic fungal infection of the hair
shaft caused by Trichosporon.
• Infected hairs develop soft greyish-white nodules along the
shaft.
• White nodules are formed on the hair shaft, which are less firmly
attached.
• White piedra is found worldwide, but is most common in tropical
or subtropical regions.
• Agent: Trichosporon beigelii
• T.beigelii is an urease positive, yeast like fungus;
• produces creamy white colonies, containing hyaline septate hyphae
intervening with rectangular arthrospores.
• Hair fragments should be implanted onto primary isolation
media, like Sabouraud's dextrose agar. Colonies
of Trichosporon spp. are white or yellowish to deep cream
colored, smooth, wrinkled, velvety, dull colonies
Black Piedra
• It is characterized by formation of black nodules, which are firmly
attached to the hair shaft.
• Black piedra is a superficial fungal infection of the hair shaft
caused by Piedra hortae.
• it is an ascomycetous fungus forming hard black nodules on
the shafts of the scalp, beard, moustache and pubic hair.
• It is common in Central and South America and South-East Asia
• Darkly pigmented nodules that may partially or completely
surround the hair shaft.
• Hair fragments should be implanted onto primary isolation
media, like Sabouraud's dextrose agar. Colonies of Piedra
hortae are dark, brown-black and take about 2-3 weeks to
appear.
• Septate hyphae with ascospores present.
Colony on SDA
DERMATOPHYTES
• Dermatophytoses – caused by dermatophytes.
• Dermatomycoses – caused by non-dermatophytic fungi skin.

• Dermatophytoses (or tinea or ringworm) is the most common

superficial mycoses affecting skin, hair and nail; caused by a group of
related fungi (called dermatophytes) that are capable of infecting
keratinized tissues.
GENUS INFECTED AREA
Trichophyton Hair, Skin, Nail

Microsporum Hair, Skin

Epidermophyton Skin, Nail

• Depending on the usual habitat (humans, animals, or soil),
dermatophytes are classified as follows ;

 Anthropophilic: these are the fungal species exclusively infecting

humans.
 Zoophilic: They infect animals as well as birds.
 Geophilic: These fungal species are frequently isolated from soil.
Pathogenesis
• Dermatophyte infection is acquired by direct contact with soil,
animals or humans infected with fungal spores.
• Then the spores are carried to different areas due to scratching of the
inoculated site.
• Predisposing factors include moist humid skin and tight-ill fitting
underclothing.
Skin:
• Dermatophytes grow in a centrifugal pattern in the stratum corneum;
leading to the formation of characteristic well-demarcated annular or
ring-shaped pruritic scaly skin lesions with central clearing and raised
edges.
• Scaling, erythema, and rarely blister formation may occur.
Nails:
• They invade the nails through the lateral or superficial nail plates and
then spread throughout the nails.
Hair shafts:
• Dermatophytes can invade within the hair shaft or may be found
surrounding it.
• Hairs become brittle and areas of alopecia may appear.
• A deep and persistent suppurative folliculitis may be produced-
Majocchi granuloma
• Males are more commonly infected than females as progesterone is
inhibitory to dermatophyte growth.
• Depending on the site of involvement, various clinical types of
dermatophytic or tinea or ring worm infections are produced.
 AFFECTED AREA
DISEASE

Tinea barbae (barber’s itch) Bearded areas of face and neck.

Tinea corporis (Tinea glabrosa) Ringworm of smooth or non-hairy skin.

Tinea imbricata Special type of Tinea corporis characterized

by Extensive concentric rings of
papulosquamous scaly patches.

Tinea capitis Ringworm of the scalp.

Tinea cruris (jock itch) Infection of groin and perineum.

Tinea pedis Ringworm of Foot

(athlete’s foot)
Tinea manuum Infection of hands
Tinea ungium Infection of Nails
Tinea capitis;
• Kerion- boggy lesions on scalp: ( T. verrucosum)
• Favus – cup like crust (scutula) around follicle : (T. schoenleinii)
• Ectothrix – arthrospores formed on surface of hair shaft : (M. canis,
T.mentagraphytes )
• Endothrix – arthrospores formed within the hair shaft : (T. tonsurans ,
T.violaceum )

kerion favus
DISEASE COMMON CAUSATIVE AGENT
Tinea Capitis Any species of Microsporum and Trichophyton

Favus Trichophyton schoenleinii, Trichophyton violaceum, Microsporum

gypseum.
Tinea barbae Trichophyton rubrum, Trichophyton mentagrophytes, Trichophyton
verrucosum

Tinea imbricata Trichophyton concentricum

Tinea corporis Trichophyton rubrum
Tinea cruris Epidermophyton floccosum, Trichophyton rubrum.

Tinea pedis Trichophyton rubrum, Epidermophyton floccosum

Ectothrix hair infection Microsporum species,Trichophyton rubrum, Trichophyton mentagrophytes

Endothrix hair infection Trichophyton schoenleinii, Trichophyton tonsurans, Trichophyton

violaceum
Dermatophytid or ld Reaction ;
• Occasionally, hypersensitivity to dermatophyte antigens may occur,
which leads to the appearance of secondary eruption in sensitized
patients because of the circulation of allergenic products.
• However, these lesions are distinct from the primary ringworm lesions
as they occur distal to primary site and fungal culture often turns
negative.
Lab diagnosis
Woods Lamp Examination ;
• Certain dermatophytes fluoresce when the infected lesions are
viewed under Wood's lamp.
• It is usually positive for various Microsporon species and Trichophyton
schoenleinii.
• Other dermatophytes do not fluoresce under Wood's lamp.
• Fluorescence is due to the presence of pteridine pigment in cell wall.
Specimen Collection ;
• Skin scrapings, hair plucks and nail clippings are obtained from the
active margin of the lesions and are kept in folded black paper.
• Hairs should be plucked, but not cut.
Direct Examination ;
• The specimen is mounted in KOH (10% for skin scrapings or hair , 20-
40% for nail clippings) or calcofluor white stain and is examined for
the presence of thin septate hyaline hyphae with arthroconidia.
• When hair is involved, the arthroconidia may be found on the surface
of the hair shaft (ectothrix) or within the shaft ( endothrix).
Culture;
• Specimen should be inoculated on to SDA containing cycloheximide
and incubated at 26-28 oC for 4 weeks.
• Potato dextrose agar is used to stimulate the sporulation.
Identification by;
• Macroscopic appearance of the colonies such as- rate of growth,
texture, pigmentation, and colony topography.
• Microscopic appearance: the colonies are teased and LPCB mount is
made to demonstrate the hyphae and spores (or conidia).
• Conidia: two types of spores or conidia are observed such as small
unicellular microconidia, and large septate macroconidia; Both are
used for the identification of species.
• Special hyphae: Dermatophytes possess thin septate hyaline hyphae;
some species have specialized hyphae such as spiral hyphae, racquet
hyphae and favic chandeliers hyphae.
Other tests
Hair perforation test:
• It is positive for Trichophyton mentagraphytes and Microsporum canis.
• The test is performed by inoculating a colony into a petri dish containing
water, yeast extract, and hair.
• Fungi pierce the hair producing wedge shaped perforations.
• Urease test: Trichophyton mentagraphytes is urease positive.
• Dermatophyte test medium and Dermatophyte identification
medium: They are used for presumptive identification. these tests are
based on the colour change in the medium due to the production of
alkali metabolites.
• Molecular methods: PCR can be used to detect species-specific genes
( e.g. chitin synthase gene)
• Skin test: It is done for detecting hypersensitivity to dermatophyte
antigen (trichophytin).
Treatment
• Oral terbinafine or itraconazote are the drugs of choice for treatment
of dermatophytosis.
• Alternate: Oral griseofulvin and ketoconazole may be given.
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