Efi.

Gelerstein 2011

Topic 16. Fungal diseases of the skin and its appendages Dermatophyte (Thrychophyton, Microsporum, Epidermophyton) Candida, Cryptococcus (yeast) Mucor, Aspergillus (mold) Actinomyces, Nocardia Histoplasma, Blastomyces (dimorph)

Laboratory and special examinations 1. Collect sample with scalpel blade 5-20% KOH-heated 2. Culture 3. Wood (black) light (Microsporia, Corynebact. Minutissimum) 4. Histology (PAS (periodic acid-Schiff), methenamine silver, Gram+) 5. I.c. test id reactions 6. Color, morphology of the colonies 7. Sabouraud culture medium (Trychophyton 14-21, Candida 2-6 days) Dermatophyte infections (ringworm) More than 40 species, appr.:10 common causes of human infection 1. Antropophilic Thrychophyton rubrum Thrychophyton mentagrophytes T. schnleini T. tonsurans T. violaceum, Microsporum audouinii, Epidermophyton floccosum 2. Zoophilic T. eguinum T. verrucosum Microsporum canis 3. Geophilic Microsporum gypseum, M. manum Cause Three genera of dermatophyte fungi cause tinea infections (ringworm). - Trichophyton - skin, hair and nail infections. - Microsporum - skin and hair. - Epidermophyton - skin and nails. Dermatophytes invade keratin only, and the inflammation they cause is due to metabolic products of the fungus or to delayed hypersensitivity

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Dermatophytosis Keratinase enzyme producing Innate immunity (KC, PMNs) Host factors (atopy, steroids, ichtyosis, immunosuppression) Environment (sweating, occlusion, expiration, humidity) Prevention! Transmission: person to person antropophilic, animal to human zoophilic, soil to human geophilic Classification of Dermatophytosis Epidermomycosis Tinea facialis Tinea corporis Tinea cruris Tinea manus Tinea pedis Foliculitis (Mycosis nodularis) Tinea capitis, barbae, Majocchi granuloma Kerion Celsi Favus Microsporia

Onychomycosis Trichomycosis

Tinea pedis: (Athletes foot) Most common fungal infection in humans! Caused by sharing washing places, swimming pools. Causative agents: T. rubrum, T mentagrophytes, T.floccosum Clinical signs: 1. Soggy interdigital scaling (4th-5th interspace) 2. Diffuse dry scaling of the soles (usually T. rubrum) 3. Recurrent episodes of vesication id reaction (usually T. mentagrophytes or T. floccosum). Ulcerative type (secondary bacterial infection, Candida) Tinea manum: T. rubrum, T. mentagrophytes, T. Floccosum Unilateral 1 hand 2 feet Dyshidrotic, hyperkeratotic Eradicate tinea unguium

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Tinea cruris, corporis T. floccosum, T. rubrum, T. verrucosum, M. canis, M. gypseum Pruritic superficial infection of the groin Annular - ringworm Zoophileic infection more inflammatory, deeper, marked vesiculation, crusting peripheral enlargement, central clearing Tinea capitis T. tonsurans, M. canis Endothrix Trichophyton 1. Black dot type 2. Kerion type (honeycomb) Ectothrix Microsporia 1. Gray patch type 2. Hyperkeratosis 3. Wood light Epidemic (schools, institutions) 1. M. audouinii antropophil 2. M. canis zoophil Favus T. schoenleini, T.quinckeanum 1. Scutulum, fetid odor 2. Deep infection-atrophy, scarring alopecia 3. Therapy - Antimycotic plus adjunctive steroid (prednisone 1 mg/kg/day 1-2 weeks) - Antibiotics for 2 bacterial infection (Strepto) - Surgery: drain pus from Kerion lesions Tinea barbae Pustulosus folliculitis T. verrucosum, T. Mentagrophytes Granulomatous lesion (Majocchis granuloma)

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Antimycotic therapy: Drug Amphotericin B Nystatin Natamycin (Pimafucin) Miconazole Clotrimazole Econazole Tioconazol Ketoconazole (Nizoral) Itraconazole (Orungal) Fluconazole (Diflucan, Mycosyst) Terbinafine (Lamisil, Terbisil) Griseofulvin Flucytosin Amorolfin (Loceryl), Tolnaftat (Chinofungin), Cyclopiroxolamine (Batrafen) Used for Systemic Candida infection Candida Candida, Dermatophyton Superficial infections Used as Local, i.v Local Local Local

Superficial Systemic infections Superficial Systemic Superficial Systemic infection Dermatophyton Dermatophyton Candida Cryptococcus Superficial infection

Local, Oral Oral Oral, i.v. Local, oral Oral Oral, i.v. Local

Systemic antimycotic therapy: Cytochrome P450 metabolisation, interactions: terfenadin, astemizol, cizaprid, lovastatin, midazolam, triazolam, Syncumar, digoxin, cyclosporin, methylprednisolon, vinca-alkaloids, tacrolimus, Ca-channel blockers, quinidin, tricyclic antidepressants, beta- blockers, SSRI, MAOi. Rifampicin stimulates, cimetidin inhibits / decreases the cytochrom P450 system Gastric hypoacidity inhibits absorbtion Onychomycosis - Diseases of the nail bed Paronychia- inflammation involving the folds of tissue around the finger nails Acrodermatitis enteropathica (Zn replacement) Unguis incarnates - Therapy: conservative, surgical Therapy of Onychomycosis: 1. Lamisil 250mg/day - 6 w (hand), 12 weeks (foot) 2. Orungal 2x2 capsule for 7 days, 3 weeks break 2 months (hand), 4 months (foot)

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Candida infections: Part of the normal flora Predisposition: immunosuppression, diabetes, dark, humid environment, maceration Mycotic intertrigo Genital infections: balanoposthitis, balanitis, vulvitis, vulvovaginitis Diaper dermatitis Folliculitis Paronychia Oropharyngeal Candidiasis Atrophic, pseudomemranous, leukoplakia, angulus infectiosus oris Deep mucosal Candidiasis: esophagus, tracheobronchial Invasive Candidiasis: neutropenia, sustained catheter (In vagina Candida without symptoms - doesnt need therapy) Chronic mucocutaneous Candidiasis Decreased cellular immunoreactivity against Candida antigens Often together with endocrine diseases: 1. Hypoparathyroidism, hypoadrenalism, 2. Hypothyroidism, diabetes mellitus 3. IPEX syndrome Foxp3 mutation (Immunodysregulation Polyendocrinopathy Enteropathy Xlinked syndrome) Pityriasis versicolor Pityrosporum ovale or Malassezia furfur (yeast) Foliculitis, seborrhoeic dermatitis Primarily predisposition Wood - light: green Dicarboxyl acid, inhibits the function of tyrosinase enzyme , hypomelanosis Cryptococcosis Cryptococcus neoformans soil, defecation of pigeon Abscess hematogenous spreading on the skin molluscum contagiosum-like papules Lung: aspecific symptomes CNS: symptomes of meningitis, presence of fungus or fungal antigen in the liquor Cryptococcus neoformans Diagnosis made by staining / culture / serology Therapy: 1. Fluconazol Or together 2. Amphotericin B 3. Amphotericin B + flucytosin

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Aspergillosis Aspergillus fumigatus, Aspergillus niger infections are rare despite the high frequency of this mould in the environment hematologic, HIV-infected and immune suppressed patients Skin: abscess, outer ear Lung: eosinophilia Surgical elimination of aspergilloma Skin lesions examination: The following tips will help improve your skills in diagnosing skin lesions: 1. Develop a logical and systemic approach to skin examination 2. Try to examine the skin in a room with daylight. Examine the entire skin surface during the first dermatologic examination. This should include: Palms and soles, ears, submammary, interdigital, axillary, inguinal, genital, and perianal skin. Adjacent mucosa including lips, mouth, conjunctivae, nasal mucosa, and in some instances anus. Skin appendages (hair and nails) as well as scalp. Screening for malignant melanoma and other skin malignancies. Assessment of general skin appearance (color, texture, dryness, hydration, odor). Evidence for exposure to sunlight, nicotine, other noxious agents. 3. Match objective evidence to subjective complaints 4. A total skin examination 5. Look with your fingers. 6. Determine the anatomic location of the lesion (epidermal, dermal or subcutaneous, skin appendages, blood vessels, or nerves involved? 7. Determine the primary symptom 8. Become skilled in using simple diagnostic aids History of present skin condition Duration Site at onset, details of spread Itch / Burning / Pain Wet, dry, blisters Exacerbating factors General health at present Ask about fever Past history of skin disorders Past general medical history Inquire specifically about asthma and hay fever Family history of skin and other disorders If positive inherited vs. infection/infestation Social and occupational history Hobbies Travels abroad Relationship of rash to work and holidays Alcohol intake Drugs used to treat present skin condition Topical / Systemic / Physician prescribed / Patient initiated