DERMATOMYCOSES

DR AYANBEKU T.S.
BSc; MBChB;FMCPath
 Outline
• Introduction
• Epidermiology
• Pathogenesis
• Development of a dermatophytosis
• Laboratory Diagnosis
• Pityriasis versicolor
• Conclusion
 INTRODUCTION

• Dermatomycoses are superficial fungi infections of

the stratum corneum of the skin or of keratinized
appendages, such as hair or nails, arising from it

• The most important of these are the

dermatophytes, a group of about 40 related fungi
that belong to three genera:
– Microsporum,
– Trichophyton, and
– Epidermophyton
 INTRODUCTION cont.
• The last genus of these dermatophytes is
represented by only a single species,
Epidermophyton floccosum

• Most of the 39 dermatophyte species, are

parasitic and can cause disease in either
humans or animals

• The dermatophytes are often described

according to their primary source of infection :
 INTRODUCTION cont.
– Zoophilic- if the source is from animal eg
Microsporum canis (dogs and cats), Microsporum
gallinae (fowl), Microsporum nanum (pigs),
Trichophyton equinum (horses), and Trichophyton
verrucosum (cattle).

– Anthropophilic- if the source is from human eg

Epidermophyton floccosum, Trichophyton rubrum,
and Trichophyton tonsurans,

– Geophilic,- if the source is from soil eg Microsporum

gypseum
 INTRODUCTION cont.
• Most Dermatophytes are unable to grow
at 37°C or in the presence of serum
thereby restricted to nonviable skin

• Other superficial infections are caused

by Candida and Malassezia spp. Or less
common organisms (e.g.,Piedraia )
 Epidemiology
• Globally, 900,000 million individuals are affected by the
superficial fungal infections of the skin

Age Incidence:
– Tinea capitis is mainly a disease of childhood, and cases rarely
occur after puberty.
– However, this infection may occur in adults and may also be
associated with scarring alopecia
– Preponderance of the disease in children is thought to be the
presence of medium chain fatty acids (C8 to C12) in sebum that
inhibit the growth of dermatophytes in postpubertal individuals
– In contrast, tinea pedis is usually seen in adolescents or young
adults
 Pathogenesis
• Transfer of infecting organisms from soil,
animals, or humans is accomplished by means of
arthrospores, formed by dermatophyte hyphae
in vitro and in vivo

• Direct contact between the infected individual

and another individual is not necessary for the
development of dermatophytosis in the latter.

• Susceptibility to infection is not universal

 Pathogenesis cont.

• Different dermatophyte species vary in their ability to

elicit an immune response, this may be because there
is variation in the ability of different dermatophyte
species to stimulate release of cytokines such as
interleukin-12 from keratinocytes in vitro, Eg
– T. rubrum, cause chronic or relapsing infections, and
others, including T. verrucosum, lead to long-term
resistance to reinfection

• Some dermatophytes produce glycopeptides, which are

capable of reversibly inhibiting T-lymphocyte
blastogenesis in vitro
 DEVELOPMENT OF A DERMATOPHYTOSIS

• Dermatophytes prefer warm, moist

conditions

• This is why a dry, intact skin

constitutes a virtually impenetrable
barrier. But the chance of infection is
encouraged by everything that has an
adverse influence on the situation
 Clinical Manifestations
• The archetypal lesion
of dermatophytosis
is an annular scaling
patch with a raised
margin that exhibits
a variable degree of
inflammation, the
center is usually less
inflamed than the
edge
 .

The word “tinea” is used to refer to

dermatophyte infections, and it is usually
followed by the Latin description of the
appropriate site
 Some Clinical Features of Dermatophyte
Infection
Skin Disease Location of Lesions Clinical Features Fungi Most
Frequently
Responsible

Tinea corporis Non-hairy, smooth skin Circular patches with Trichophyton

(ringworm) advancing red, rubrum,
vesiculated border, and Epidermophyton
central scaling. Pruritic floccosum
Tinea pedis Interdigital spaces on Acute: itching, red T rubrum,
(athlete’s foot) feet of persons wearing vesicular. Chronic: Trichophyton
shoes itching, scaling, fissures mentagrophytes, E
floccosum
Tinea cruris Groin Erythematous scaling T rubrum, T
(jock itch) lesion in intertriginous mentagrophytes, E
area. Pruritic floccosum
 Some Clinical Features of Dermatophyte
Infection cont.
Skin Disease Location of Lesions Clinical Features Fungi Most
Frequently
Responsible
Tinea capitis Scalp hair. Circular bald patches with T mentagrophytes,
Endothrix: fungus short hair stubs or broken Microsporum
inside hair shaft. hair within hair follicles. canis, Trichophyton
Ectothrix: Kerion rare. Microsporum- tonsurans
fungus on surface infected hairs fluoresce
of hair
Tinea barbae Beard hair Edematous, erythematous T mentagrophytes, T
lesion rubrum,
Trichophyton
verrucosum
Tinea unguium Nail Nails thickened or T rubrum, T
(onychomycosi crumbling distally; mentagrophytes, E
s) discolored; lusterless. floccosum
Usually associated with
tinea pedis
 Some Clinical Features of Dermatophyte
Infection cont
Skin Disease Location of Lesions Clinical Features Fungi Most Frequently
Responsible
Dermatophyti Usually sides and Pruritic vesicular to No fungi present in
d (id flexor aspects of bullous lesions. lesion. May
reaction) fingers. Palm. Any Most become secondarily
site on body commonly infected
associated with with bacteria
tinea pedis
 PREFERRED SITES OF INFECTION

Most dermatophytes have been found to have a

preference for certain situs.
• A preference for growth in and around the
hair,
• in the horny layer of skin,
• in the moist,
• warm folds of the skin, or
• just under the nails.
 PREFERRED SITES OF INFECTION

• Trichophyton species have been found to

have the greatest adaptability

• Epidermophyton floccosum occurs

principally in the large flexure lines and
around the foot.

• Microsporum chiefly attacks the scalp

and glabrous skin.
 Macroconidia in genera Trichophyton,
Microsporum, and Epidermophyton
• Microsporum: thick-
walled, with projections
five to more septa

• Trichophyton: thin-
walled, smooth, four to
six septa

• Epidermophyton: thick-
walled, pear to oval
shaped four or fewer
septa
 Laboratory diagnosis
• Demonstration of fungal element in
clinical specimen by microscopy under of
10% direct KOH mount and confirmation
by culture

• The specimens include skin scrapings

and nail clippings or hair taken from the
areas suspected to be infected by
dermatophytes
Three types of hair infections can be
demonstrated in microscopy
• Ectothrix infection: presence of
a layer of arthrospores on the
surface of hair shaft. It is
caused by M. audouinii, M. canis,
& Trichophyton mentagrophytes
• Endothrix: The clusters of
arthrospores are found entirely
within the hair shaft in
endothrix infection .It is caused
by Trichophyton tonsurans, T.
violaceum, and Trichophyton
schoenleinii
• Favus: In favus, there is sparse
hyphal growth and formation of
air spaces within hair shaft. It
is caused by T. violaceum, T.
schoenleinii, and M. gypseum.
Hair shaft showing ectothrix infection (×100).
Hair shaft showing endothrix infection (×100)
 Culture
• The clinical specimens are cultured by inoculation on
SDA, inoculated and incubated at 25–30°C for 3 weeks.
At 25°C most of the pathogenic fungi grow well, while
saprophytic fungi and bacteria are inhibited

• Dermatophytes are identified based on

– (a) colony morphology,
– (b) pigment production, and
– (c) presence of microconidia and macroconidia.

•
 Other tests
• Hair perforation test: used to differentiate T.
rubrum from T. mentagrophytes; M. canis from
Microsporum equinus

• Urease test: Urease test is carried out to

differentiate T. mentagrophytes from T. rubrum. T.
mentagrophytes is Urease positive

• Growth on rice grains: This test is useful to

differentiate M. canis from M. audouinii. M. canis
usually grows well and formsany conidia on rice grain,
whereas M. audouinii fails to grow
 TREATMENT cont.
DERMATOPHYTOSIS, TREATMENT
CLINICAL DISEASE
PATTERN
Tinea pedis Topical cream/ointment: terbinafine, imidazoles (miconazole,
Interdigital econazole, clotrimazole, etc.), undecenoic acid, tolnaftate
Oral: terbinafine, 250 mg/day for 2-4 wk;
“Dry type itraconazole, 400 mg/day for 1 wk per month =(repeated if
necessary); fluconazole 200 mg weekly for 4-8 wk
Tinea corporis Topical cream/ointment: terbinafine, imidazoles
Small, well-defined (e.g., miconazole, econazole, clotrimazole)
lesions
Larger lesions Oral: terbinafine, 250 mg/day for 2 weeks;
itraconazole, 200 mg/day for 1 wk;
fluconazole, 250 mg weekly for 2-4 wk
 TREATMENT cont.
DERMATOPHYTOSIS, CLINICAL TREATMENT
DISEASE PATTERN

Tinea capitis Griseofulvin, 10-20 mg/kg/day for min. 6 wk

Terbinafine <20 kg: 62.5 mg/day
20-40 kg: 125 mg/day
>40 kg: 250 mg/day
Itraconazole, 4-6 mg/kg pulsed dose weekly
Onychomycosis Fluconazole, 3-8 mg/kg pulsed dose weekly
Fingernails Terbinafine, 250 mg daily for 6 wk
Itraconazole, 400 mg/day for 1 wk each month,
repeated for 2-3 mo
Fluconazole, 200 mg weekly for 8-16 wk
Toenails Terbinafine, 250 mg daily for 12 wk
Itraconazole, 400 mg/day for 1 wk each month,
repeated for 2-4 mo
Fluconazole, 200 mg weekly for 12-24 wk
 PITYRIASIS VERSICOLOR
• Pityriasis versicolor, aka tinea versicolor,

• It is a superficial infection caused by Malassezia

species, which are lipophilic yeasts that are normal
commensals on the skin surface

• The infection is confined to the trunk or proximal

aspects of the limbs. It does not cause hair and nail
plate invasions

• Malassezia yeasts grow in the presence of medium-

chain fatty acids
 PITYRIASIS VERSICOLOR cont
Therapy
– topical azole or
terbinafine
– 2% selenium sulfide
lotion or 20% sodium
thiosulfate applied
daily for 10 to 14 days.
– itraconazole is 200 mg
daily for 5 days
– the pigmentary changes
may return to normal
only after many months
DERMATOPHYTES
tinea corporis tinea facie
tinea ungruiun

tinea capitis

tinea ungruiun
 IN
CONCLUSION

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