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FUNGAL
SKIN
INFECTIONS
II
IHAB YOUNIS, M.D.

B.Cutaneous mycoses
Infections that extend deeper into
the epidermis, as well as hair and
nail and caused by dermatophytes:

Tinea
Tinea
Tinea
Tinea
Tinea
Tinea

capitis
corporis
manus
cruris
pedis
unguium

Tinea capitis
Etymology: L. [caput] head

 Tinea capitis is the most common

pediatric dermatophyte infection
worldwide
The age predilection is believed to
result from the presence of
Malassezia furfur which is part of
normal flora, and from the fungistatic
properties of fatty acids of short and
medium chains in postpubertal sebum

Hair invasion by
dermatophytes

Ectothrix invasion: Arthroconidia on the

exterior of the hair shaft. The cuticle of
the hair is destroyed and infected hairs
fluoresce under a Woods lamp
Endothrix hair invasion: Arthroconidia
within the hair shaft only. The cuticle of
the hair remains intact and infected
hairs do not fluoresce under a Woods
lamp

Hair
Ectothrix

Conidia
Hair
Endothrix
Conidia

Types

1-Scaly type:
Erythematous
papule(s) around the hair
shaft appear initially
Subsequently, one or
several patches of scaly
alopecia are seen where
the hairs are broken just
above the level of scalp
The hair looks lusterless
as it is covered with
arthrospores

2-Black dots type:

It is an endothrix infection,
so hairs become notably
fragile and break easily at
the level of the scalp
The rest of the infected
follicle looks like
"black dots". Variable
degrees of scaling and
inflamm-ation are seen

3-Kerion :
Scattered painful pruritic pustular
folliculitis generally associated with
regional lymphadenopathy and even
fever
In about 2-3 %, boggy
nodules studded with
broken hairs and purulent
sticky material "kerion"
appear
Scarring alopecia develops
subsequently

4-Favus :Etymology: L. honeycomb

Dense masses of mycelium
and epithelial debris forming
yellowish cup-shaped crusts
called scutula
The scutulum develops
at the surface of a hair
follicle with the shaft in
the center of the raised
lesion

 Removal of these crusts reveals an

oozing,moist, red base

After a period of years, atrophy of

the skin occurs leaving a cicatricial
alopecia and scarring

Tinea corporis (circinata)

Etiology
Affects the glabrous skin (ie, skin
regions except the scalp, groin, palms,
and soles)
T rubrum is the most common
infectious agent in the world
May result from contact with infected
humans, animals, or inanimate objects
(eg contact with sports facilities)

Clinically

Patients can be asymptomatic or

pruritic
Begins as an erythematous, scaly
plaque that may rapidly worsen
and enlarge
Central
resolution
causes the
lesion to
be annular

 Scales, crusts, vesicles, and papules

often develop, especially in the
advancing border

 Infections due to zoophilic or

geophilic dermatophytes may
produce a more intense
inflammatory
response than
those caused
by anthropophilic
fungi

 Majocchi granuloma manifests as

perifollicular, granulomatous
nodules typically in a
distinct location, which is
the lower two thirds of the
leg in females

 Tinea imbricata (Imbricate=

Ovelapping) is recognized clinically
by its distinct scaly plaques
arranged in concentric rings

Tinea Cruris
Crus=Fold

Etiology
Transmitted by fomites, such as
contaminated towels or hotel bedroom
sheets
Autoinoculation occurs in 50 % of cases
from tinea manuum or tinea pedis
Risk factors for initial infection or
reinfection include wearing tight-fitting
or wet clothing or undergarments
Tinea cruris is 3 times more common in
men than in women

Clinically
Patients complain of pruritus and
rash in the groin. A history of
previous episodes of a similar
problem usually is elicited
Large patches of erythema with
central clearing are centered on
the inguinal creases

 Lesions extend to the thighs , lower

abdomen , pubic area & buttocks

The penis & scrotum typically are

spared

 Scales demarcate sharply the edge

 In acute infections, the rash may

be moist and exudative
Chronic infections typically are dry
with a papular annular or arciform
border and barely perceptible scale
at the margin

 Chronic infections
modified by the
application of topical
corticosteroids are
more erythematous,
less scaly, and
may have
follicular pustules

 In response to the infection, the

active border has an increased
epidermal cell proliferation with
resultant scaling
This creates a partial defense by
way of shedding the infected skin
and leaving new, healthy skin
central to the advancing lesion

Tinea pedis
Etymology: L. foot

Etiology
The first report of tinea pedis was
in 1908 by Whitfield, who, with
Sabouraud, believed that tinea
pedis is caused by the same
organisms that produce tinea
capitis and that it is a very rare
infection !
T rubrum being the most common
cause worldwide

 Tinea pedis is thought to be the

world's most common
dermatophytosis. Rippon states
that 70% of the population will be
infected with tinea pedis at some
time
Childhood tinea pedis is rare

Risk factors
A hot, humid, tropical environment
Prolonged use of occlusive footwear
Certain activities, such as swimming
and communal bathing, may also
increase the risk of infection
A defect may be present in the immune
system, such as in cell-mediated
immunity, that predisposes some
individuals to tinea pedis, but this is not
certain

Clinical types
1- Interdigital type
2- Chronic hyperkeratotic
type(moccasin)
3-Inflammatory/vesicular type

1- Interdigital type:

The most characteristic type, with

erythema, maceration, fissuring, and
scaling, most often between the fourth
and fifth toes & often
is accompanied by
pruritus
The dorsal surface of
the foot is usually clear,
but some extension onto the plantar
surface of the foot may occur

2-Chronic hyperkeratotic
type(moccasin)
Chronic plantar
erythema with slight
scaling to diffuse
hyperkeratosis that
can be asymptomatic
or pruritic
Both feet are usually
affected

 Typically, the dorsal surface of the

foot is clear, but, in severe cases,
the condition may extend
onto the sides of the
foot

3-Inflammatory/vesicular type:
Painful, pruritic vesicles or bullae
Most often on the
instep or anterior
plantar surface
After they rupture,
scaling with
erythema persists
Cellulitis,lymphangitis
and adenopathy can
complicate this type

 Dermatophytid reactions are

associated with vesicular tinea pedis
They mimic dyshidrosis (pompholyx)
They develop on the palmar surface of
one or both hands and/or the sides of
the fingers as papules, vesicles, and,
occasionally,
bullae or
pustules may
occur, often
in a symmetrical
fashion

 This is an allergy or hypersensitivity

response to the infection on the foot,
and it contains no fungal elements. The
specific explanation of this phenomenon
is still unclear
Distinguishing between a dermatophytid
reaction and dyshidrosis can be difficult.
Therefore, a close inspection of the feet
is necessary in patients with vesicular
hand dermatoses
The dermatophytid reaction resolves
when the tinea pedis infection is treated,
and treatment of the hands with topical
steroids can hasten resolution

Tinea Manuum
Etymology: L. hand

 It is less common than tinea pedis

Erythema and hyperkeratosis of
the palms and fingers affecting the
skin diffusely is the commonest
variety, and is unilateral in about
half
the cases
The accentuation of the
flexural creases is a
characteristic feature

 Other clinical variants include crescentic,

exfoliating scales, circumscribed,
vesicular patches, discrete, red papular
and follicular scaly patches, and
erythematous, scaly sheets on the dorsal
surface of the hand. The latter forms are
more likely to be zoophilic
When the palms are
infected, the feet are also
commonly infected. A typical
pattern of involvement is
either one hand and both feet or both
hands and one foot

Tinea Barbae

Etiology
The mechanism that causes tinea barbae is
similar to that of tinea capitis. In both
diseases, hair and hair follicles are invaded
by fungi, producing an inflammatory
response
Currently, tinea barbae is infrequent around
the world
Tinea barbae was observed more frequently
in the past when infection frequently was
transmitted by barbers who used unsanitary
razors, so it was termed barber's itch

Inflammatory deep type- 1

(kerion)
It is the most common clinical
presentation
caused primarily by zoophilic
dermatophytes
Most patients show solitary plaques or
nodules; however, multiple plaques are
relatively common
Usually localized on the chin, cheeks, or
neck, involvement of the upper lip is
rare

 The characteristic lesion is an

inflammatory reddish nodule with
pustules and draining sinuses on
the surface. Hairs are loose or
broken, and depilation is easy
and painless

 Over time, the surface of the

indurated nodule is covered by
exudate and crust
This variety of tinea barbae usually
is associated with generalized
symptoms, such as regional
lymphadenopathy, malaise, and
fever

Noninflammatory superficial-2
type
Caused by anthropophilic
dermatophytes
This variety is less common
and resembles bacterial
folliculitis
Typically, erythematous patches
show an active border composed
of papules, vesicles, and/or crusts.
Hairs are broken next to the skin

Tinea Unguium and

Onychomycosis

 Tinea unguium is clinically defined

as a dermatophyte infection of the
nail
plate
Onychomycosisincludes all
infection of the nail caused by any
fungus, including
nondermatophytes and yeasts

Etiology
It accounts for 20 % of all nail disease
Approximately 30 percent of patients
with dermatophyte infections on other
parts of their body also have tinea
unguium
The most common dermatophytes
causing tinea unguium worldwide are T.
rubrum, T.
mentagrophytes ,E. floccosum &Candida

Clinically
Characteristically, infected nails
coexist with normal-appearing nails
Four types are recognized:

Distal subungual onychomycosis

Proximal subungual onychomycosis
White superficial onychomycosis
Candidal onychomycosis

Distal subungual
onychomycosis

It is the most common type and

starts by invasion of the stratum
corneum of the hyponychium
and distal nail bed
Infection moves proximally in the
nail bed and invades the ventral
surface
of the nail plate

 Subungual hyperkeratosis results

from a hyperproliferative reaction of
the nail bed in response to the
infection
Invasion of the nail
plate results in a
progressively
dystrophic nail unit

Proximal subungual
onychomycosis
It is the least common variant of
onychomycosis
It starts by fungal invasion of the
stratum corneum of
the proximal nail fold
and subsequently the
nail plate

White superficial
onychomycosis

Well-delineated opaque "white

islands" on the plate
Patches coalesce to involve the
entire nail plate. The nail becomes
rough, soft and crumbly

Sporotrichosis

Etiology
Caused by Sporothrix schenckii
The organism derives its name from R B
Schenck, who first reported the infection
in 1898
Sporothrix typically exists as a
saprophytic mold on vegetative matter
in humid climates worldwide
It is a dimorphic fungus i.e. the
organism exhibits mycelial forms at
25C and a yeast form at 37C

 Cutaneous infection often results

from a puncture wound involving
thorns or other plant matter
Other more unusual reported
causes include squirrel bites and
trauma induced by liposuction

Clinically
1-Lymphocutaneous type
It is the most common presentation
Symptoms usually arise within 3 weeks
of injury
A subcutaneous nodule develops at the
site of inoculation and may ulcerate as
the result of central abscess formation
Satellite lesions form along the
associated lymphatic chain and
lymphadenopathy subsequently
develops

2-Fixed (nonlymphatic) type:

scaly, acneform, verrucous or ulcerative
nodule that remains localized
Satellite lesions
and
lymphadenopathy do not
occur in this form

3-Disseminated type
Can result in pyelonephritis,
orchitis, mastitis, arthritis,
synovitis, meningitis or osseous
infection

Mycetoma
(Madura foot)

Etiology
Gill first described the disease in the
Madura district of India in 1842
In 1813, Pinoy described the mycetoma
produced by actinomycetes (aerobic
bacteria) and classified mycetomas as
those produced by true fungi
(eumycetoma) versus those due to
aerobic bacteria (actinomycetoma). Both
types have similar clinical findings
Causative agents are implanted
subcutaneously, usually after a
penetrating injury

True fungi
Filamentous
(eumycetoma) 40% bacteria
(actinomycetoma)
60%
Dark grain:
Madurella mycetomatis
Madurella grisea
Leptosphaeria
senegalensis
Curvularia lunata
Pale grain:
Scedospor.
apiospermum
Neotestudina rosatii
Acremonium spp.

Actinomadura madurae
Actinomadura pelletieri
Streptomyces
somaliensis
Nocardia brasiliensis
Nocardia otitidiscaviarum
Nocardia asteroides

Clinically
The skin is usually darker and firmer than
the surrounding areas
Nodules, abscesses, and fistulae draining
a clear viscous or purulent exudate can
be seen
Granules of the microorganisms (sulpher
granules) may occasionally be seen The
most common site is the feet
In advanced cases, destruction of bone
within an infected area may be almost
complete, and gross deformity may result

Lab diagnosis of fungal

infections

Clinical Material
Patients with suspected dermatophytosis of
skin:

any ointments or other local

applications present should first be
removed with alcohol
Using a blunt scalpel, firmly scrape
the lesion, particularly at the
advancing border. In cases of
vesicular tinea pedis, the tops of any
fresh vesicles should be removed as
the fungus is often plentiful in the
roof of the vesicle

 In patients with suspected

dermatophytosis of nails:
The nail should be pared and
scraped using a blunt scalpel
until the crumbling white
degenerating portion is reached
Any white keratin debris beneath
the free edge of the nail should
also be collected

 Up to 30% of suspicious material

collected from nail specimens may
be negative by either direct
microscopy or culture
Repeat collections should always
be considered in cases of
suspected dermatophytosis with
negative laboratory reports

Direct Microscopy
Skin Scrapings, nail scrapings and
epilated hairs should be examined
using 10% KOH

Culture
Specimens should be inoculated
onto primary isolation media, like
Sabouraud's dextrose agar
containing cycloheximide and
incubated at 26-28C for 4 weeks.
The growth of any dermatophyte is
significant

Wood's lamp examination

It consists of UV light of
wavelength above 365nm filtered
through glass which contains about
9% nickel oxide
Value: generally of limited
usefulness, because most
dermatophytes currently seen do
not fluoresce

 May have value in the following

situations:
For diagnosing a brown, scaly rash in
the scrotum or axilla: erythrasma
fluoresces a brilliant coral red,
whereas tinea cruris or cutaneous
candidal infections do not fluoresce
For diagnosing tinea versicolor, which
fluoresces pale yellow to white
For diagnosing tinea capitis caused
by two zoophilic Microsporum species
that fluoresce blue-green

Histopathology

PAS stain: Spores & hyphae in the keratin

Tinea versico;or:
Spaghetti & meat
balls