OS 212.

3: Locomotion and Sensation

LEC 06.2: Fungal Infections of the Skin
Exam #1|Dr.Adolfo Bormate, Jr. | August 14,2012
OUTLINE
Direct Microscopy
Scales from skin lesions, keratinous debris from
nails, broken hairs

Potassium Hydroxide (KOH) smear (5-20% KOH

solution)
o Wood Lamp

Hairs infected with Microsporum would give a

greenish fluorescence

Useful in T. capitis infections (they will fluoresce

says sir)

Fungal Infections
Dermatophytoses
A.
Tinea corporis
B.
Tinea cruris
C.
Tinea facialis
D. Tinea pedis
E.
Tinea manuum
F.
Dermatophytosis of
hair/Trichomycosis
G. Tinea unguium
H.
Tinea versicolor
Candida
A.
Candidal Intertrigo

*mostly from Sirs powerpoint

I. FUNGAL INFECTION
Superficial Infections: (the only topic focused on by
sir)
o Skin (Epidermis, Hair and Nails)
o Mucosae (Oropharynx; Anogenital Mucosae)
o Can go deeper in immunocompromised
o Dermatophytes, Candida, Malassezia, etc.
Deep Fungal Infections
o Mycetoma; chromomycosis; sporotrichosis
Systemic Fungal Infection
o Usually in immunocompromised
o Primary lung infection disseminate
hematogenously to many organs including the
skin.

Ex. Cryptococcosis; Histoplasmosis; North

American blastomycosis; Coccidiomycosis;
Penicillinosis

II. DERMATOPHYTOSES
Dermatophytes: infects non viable keratinized
structures.
o Epidermis (Stratum Corneum; Epidermomyosis;
RINGWORM)

T. facialis, T. corporis, T. cruris, T. manus, T. pedis

o Hair (trichomycosis)

T. capitis, T. barbae, Majocchis granuloma

o Nail (onychomycosis)

T. unglum
Tinea = Dermatophytosis = Dermatophyte Infection
o Tinea versicolor is not a dermatophyte infection
Dermatophytes
o Trichophyton; Microsporum; Epidermophyton
genera
o Trichophyton rubrum most common cause of
epidermal dermatophytosis and onychomycosis
Transmission of Dermatophytoses
o Sources:

Another person (thru fomites or direct skin to

skin contact)

Animals

Soil
o Predisposing Factors:

Host factors: Atopy CMI deficiency for T.

rubrum;
Topical and/or systemic
immunosuppression

Local factors: sweating, occlusion, occupational

exposure, high humidity
Pathogenesis of Dermatophytoses
o Dermatophytes synthesize keratinases which
digest keratin
o CMI and PMN action counteract pathogenecity
o Clinical presentation influenced by:

Location

Immune response

Species of fungi
Laboratory Exams

Huang.Katha,Royce

Fungal Cultures
Samples on sabourauds glucose medium
More specific but takes more time
o Dermpath

Useful in onychomycosis; debris or clippings; or

biopsy specimen stained with Periodic Acid Schiff
(PAS) or methenamine silver
Management of Dermatophytoses In General
o Topical antifungal preparations

Effective for treatment of dermatophytosis of

skin but NOT for those of hair and nails

Apply at least 3 cm beyond

Most topical agents are comparable

o Systemic antifungal agents

For infections of keratinized skin; use if lesions

are extensive or if infections has failed to
respond to topical preparations

Usually required for treatment of tinea capitis

and tinea unguium

Also may be required for inflammatory tineas and

hyperkeratotic moccasin-type tinea pedis

Hepatotoxic
o

A. TINEA CORPORIS
Infection of trunk. Legs, arms or neck (excluding hands,
feet, groin
Trichophyton rubrum, most common agent
Transmission of Tinea corporis:
o Autoinoculation from other parts of body
(pedis/capitis) - usual
o Direct or indirect from another person (tinea
gladiatorum)
o Contact with animals or contaminated soil
Lesions of Tinea corporis:
o Sharply marginated scaly plaques with or without
pustules at margins; active borders
o Peripheral enlargement with central clearing
creating a annular or arcuate lesion
o Zoophilic infection usually more inflammatory

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OS 212.3: Locomotion and Sensation

LEC 06.2: Fungal Infections of the Skin
Exam #1|Dr.Adolfo Bormate, Jr. | August 14,2012
Labs: as discussed (ie. Microscopy, Cultures etc.)
Treatment: as discussed (ie. Antifungal agents)
Figure 1. Tinea Corporis Lesions
DDX of Tinea corporis:
o Psoriasis
o Pityriasis rosea
o Gyrate erythemas
o Basically any annular lesion (acc to sir)
LAB: Microscopy
Management: Antifungal agents
B. TINEA CRURIS
Chronic or subacute dermatophytosis of groin, pubic
regions and thigh
Aka Jock itch, more common in males>females
Lesions of Tinea cruris: large scaly, well demarcated
plaque with central clearing
o Papules/pustules at the margin

D. TINEA PEDIS
Aka Athletes foot
Dermatophytic infection of the feet
Male>females
Commonly affects 20-25yo
Predisposing factors: hot humid weather, occlusive
footwear, excessive sweating, walking barefoot can
also be a predisposing factor
Transmission of T. pedis: barefoot on contaminated
floors
May last for several years

Tinea Pedis: Interdigital Type

Most common between the 4th and 5th toes

May spread to adjacent areas
Dry Scaling Type and Wet Type
DDX:
o Erythrasma
o Impetigo
o Pitted keratolysis

Figure 2. Tinea Cruris Lesions

Associated with T. pedis
o So if patient consults for T. cruris, also check the
feet for alipunga
DDX of T. cruris:
o Erythrasma
o Intertrigo
o Intertriginous psoriasis
Treatment:
o Topical antifungal agents
o Systemic if recurrent or fails to respond to topicals
C. TINEA FACIALIS/TINEA FACEI
Lesions: Well circumscribed macule/plaque with
elevated borders and central clearing; scaling often
minimal

Figure 3. Tinea Facialis Lesion

DDX of T. facialis:
o Seborrheic dermatitis
o Contact dermatitis
o Lupus erythematous

Huang.Katha,Royce

Figure 4. Tinea Pedis: Interdigital Type (L-Dry

Scaling Type: scaling, R-Wet Type: macerated toe
webs with peeling/fissuring)
Tinea Pedis: Moccasin Type
Located on heels, soles and lateral borders of the feet
(ballet slipper distribution)
Erythema with small papules on the margins and fine
white scaling
One or both feet
DDX:
o Psoriasis
o Pitted keratolysis

Figure 5. Tinea Pedis: Moccasin Type (note

superficial white scales in moccasin-type distn,
arciform pattern of scales characteristic)
Tinea Pedis: Bullous Type
Vesicles or bullae
Pus indicates bacterial superinfection

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OS 212.3: Locomotion and Sensation

LEC 06.2: Fungal Infections of the Skin
Exam #1|Dr.Adolfo Bormate, Jr. | August 14,2012
With rupture, (+) ragged ring-like border
Distribution: sole, instep, webspaces

Figure 7. Two feet-One Hand Presentation of

Trichophyton rubrum

Figure 6. Tinea Pedis: Bullous Type (R-ruptured

vesicles, bullae, erythema and erosion on plantar
aspect of great toe)
Management of Tinea Pedis
Prevention: not walking in wet places, use of shower
shoes while bathing, washing feet with benzyl
peroxide (BPO) bar directly after shower
Usually topical agents arent so effective except in
interdigital type
Moccasin type usually difficult to treat with topical
agents therefore use systemic agents: Terbinafine,
Itraconazole, Fluconazole
Systemic antifungal agents: indicated for extensive
infection, for failures of topical treatment, or for
those with tinea unguium and moccasin-type
tinea
Secondary prophylaxis: important in preventing
recurrence of interdigital and moccasin types of
tinea pedis; daily washing of feet while bathing with
BPO bar is effective and inexpensive; antifungal
powders, alcohol gels
Course and Prognosis of Tinea Pedis

F. DERMATOPHYTOSIS OF HAIR/TRICHOMYCOSIS
Dermatophytes may invade hair follicles and shaft
o Tinea capitis (scalp)
o Tinea barbae
o Dermatophytic Folliculitis
o Majocchi granuloma
Tinea Capitis

Trichomycosis of scalp
Aka: ringworm of the scalp
Mostly pre adolescents
Transmission:
o Person to person
o Animal to person
o Via fomites
Pathogenesis:
o Fungi trapped in hair colonization trauma aids
inoculation
o Stratum corneum initially invaded followed by hair
shaft infection. Involves other hair follicles
o Range of manifestations: Inflammatory, non
inflammatory lesions
o Clinical manifestation influenced by type of
invasion, host resistance and degree of
inflammatory host response

Usually chronic
May be portal of entry for cellulitis or lymphangitis
Without secondary prophylaxis, recurrence
E. TINEA MANUUM
Dermatophytosis of the hand
Often unilateral, dominant hand
Usually associated with Tinea pedis
Lesions:
o Well demarcated scaly patches, hyperkeratosis and
scaling of palmar creases; central clearing and
demarcated borders
o Papules and vesicles on palms and lateral fingers in
dyshidrotic type
DDX of T. manuum:
o Irritant or allergic contact dermatitis
o Psoriasis
Management:
o Almost similar to T. pedis because palms and soles
both have thick s. corneum so use systemic
agents: Terbinafine, Itraconazole, Fluconazole
o Systemic antifungal agents: because of thickness
of palmar s. corneum and esp. if associated with T.
unguium of fingernails, T. manuum is impossible to
cure with topical agents
o Note: eradication of fingernail onychomycosis
requires longer use

Huang.Katha,Royce

Figure 8. Diagram of Ectothrix (R) and Endothrix

(L) Hair
Classification of T. capitis Infections
o Ectothrix Infection:

Invasion occurs outside hair shaft

Hyphae fragment into arthroconidia leading to

cuticle destruction

Caused by Microscporum spp.

o Endothrix Infection:

Infection occurs within hair shaft without cuticle

destruction

Arthroconidia found within hair shaft

Caused by Trichophyton spp.

o Black dot Tinea capitis

variant of endothrix resembling seborrheic

dermatitis
o Kerion:

Variant of endothrix with boggy inflammatory

plaques
o Favus:

Variant of endothrix with arthroconidia and

airspaces within hairshaft

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OS 212.3: Locomotion and Sensation

LEC 06.2: Fungal Infections of the Skin
Exam #1|Dr.Adolfo Bormate, Jr. | August 14,2012
Ectothrix Tinea Capitis: Gray Patch Tinea Capitis
Various species including Microsporum spp (audouinii,
canis, ferrugineum) show green fluorescence of
Woods lamp
Partial alopecia, with umerous broken-off hairs
Dull gray(caot of arthospores)
Fine scaling with sharpmargins
Minimal Inflammatory Response
DDX:
o Alopecia areata
o Seborrheic dermatitis
o Psoriasis

DDX:
o Cellulitis
o Carbuncle
o Furuncles

Figure 11. Kerion

Endothrix Tinea Capitis: FAVUS

Figure 9.Tinea Capitis Gray Patch type

Trichophyton schoenleinii
Initially: perifollicular erythema and matting of hair
Thick yellow crust (scutula, composed of debris and
hyphae); pierced by remaining hair shafts
DDX:
o Impetigo
o Crusted Scabies

Endothrix T. Capitis: Black Dot Tinea capitis

Usually Trichophyton tonsurans and Trichophyton
violaceum
Broken-off hair near the surface accounts for the dots
(swollen hair shaft)
Diffuse and poorly circumscribed
Low-grade folliculitis may be present
DDX: seborrheic dermatitis

Figure 12. Favus (note numerous yellow scutula)

Laboratory Examinations

Figure 10. Black Dot Tinea Capitis Caused By

Trychophyton tonsurans
Endothrix Tinea Capitis: KERION
Usually caused by zoophilic ( Trichophyton
verrucosum, Trichophyton mentagrophytes) or
geophilic species
Inflammatory mass with boggy purulent inflamed
nodules and plaques
Remaining hairs are loose, do not break but easily
pulled out
Crusting and matting of adjacent hairs
Extremely painful w/ purulent discharge from multiple
openings
(+) lymphadenopathy
Heals with scarring

Huang.Katha,Royce

Wood Lamp
o performed in patient with scaling scalp lesions or
hair loss of undetermined
o For the ff. causative agents: M. canis, M. audouinii
bright green hair shafts with ectothrix infection
Direct Microscopy
o Specimens: hair roots and skin scales
o Pluck hairs and use toothbrush to gather
specimens
o Skin scales contain hyphae and arthrospores
o Hair

Ectothrix: arthrospores seen surrounding hair

shaft in cuticle

Endothrix: spores within hair shaft

Favus: loose chains of athrospores and air spaces

in hair shaft
Fungal Culture
o Takes time (growth of dermatophytes usually seen
in 10-14 days)

Ectothrix: Trichophyton tonsurans, T. violaceum,

T. soudanense, T. schoenleinii

Endothrix: Microsporum spp. T. mentagrophytes,

T. verrucosum

Favus: T. schoenleinii most commonly, also T.

violaceum, M. gypseum
Bacterial Culture
o Rule out bacterial superinfection
o Usually S. aureus or GAS
Treatment

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OS 212.3: Locomotion and Sensation

LEC 06.2: Fungal Infections of the Skin
Exam #1|Dr.Adolfo Bormate, Jr. | August 14,2012
Oral antifungal agents
o Griseofulvin is the drug of choice in US
o Short term Terbinafine, Itraconazole and
Fluconazole comparable to efficacy and safety to
Griseofulvin
Adjunctive therapy
o Prednisone because of amount of inflammation
(for 14 days)

Figure 15. Superficial White Onychomycosis

Proximal Subungual Onychomycosis (PSO)
Begins as a white spot beneath the proximal nail fold
White discoloration fills lunula and then moves distally
to involve more portions of the undersurface of nail
More common: toenails

Course
Chronic untreated Kerion ad Favus can lead to scarring
or permanent alopecia
Treatment of T. capitis allows regrowth
G. TINEA UNGUIUM
Dermatophytic infection of the nail apparatus
80% occur on the feet

Figure 16. Proximal Subungual Onychomycosis

Labs
Figure 13. (L-R) Distal Subungual
Onychomycosis, Proximal Subungual
Onychomycosis, White Superficial
Onychomycosis
Distal (and lateral) Subungual Onychomycosis =
DLSO
white patch in distal and lateral undersurface, with
sharply demarcated borders
Progresses nail turns opaque and thickened, friable
and cracked with underlying hyperkeratotic debris in
hyponychium
Toenails>fingernails
1st and 5th toenail most frequently involved

Figure 14. Distal and Lateral Subungual

Onychomycosis

Superficial White Onychomycosis = SWO/WSO

White chalky plaque on the proximal nail plate
Almost exclusively on toenails; rarely on fingernails

Clinical impression must be confirmed by lab testing

Clinical diagnosis is not adequate because
onychomycosis is saidto account for only 50% of nail
dystrophies
Microscopy: use KOH smear
Fungal culture: specific
Histology of nail clippings: sensitive
Treatment
Must prove fungal infection first before starting
treatment
Debridement especially if hyperkeratotic
o DLSO nail and hyperkeratotic bed should be
removed
Topical agents not effective for SWO
Systemic agents used
H. TINEA VERSICOLOR/PITYRIASIS VERSICOLOR
Caused by Malassexia spp. (humid environment and
lipid for growth)
Malassezia furfur (previously knows as P. ovale, P.
orbiculare)
An opportunistic infection with overgrowth of resident
microflora
Predisposing factors:
o Warm climate; hyperhidrosis
o Oily skin
o Glucocorticoid treatment
o Immunodeficiency
Pathogenesis:
o With presence of predisposing factors, Malassezia
transforms from blastopores to mycelial form
o Enzyme in Malassezia promotes fatty acid
oxidation of skin surface lipids forming a
dicarboxylic acids (azelaic acid) as a metabolite
which in turn inhibits tyrosinase in epidermal
melanocytes hypopigmentation
o Shielding of skin by yeasts from sun (?-theyre not
sure yet)

Tinea versicolor:
o Sharply marginated macules/patches with fine
scaling

Huang.Katha,Royce

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OS 212.3: Locomotion and Sensation

LEC 06.2: Fungal Infections of the Skin
Exam #1|Dr.Adolfo Bormate, Jr. | August 14,2012
o
o
o

Hypopigmented (on tanned skin); light brown on

untanned skin
Favors trunk, upper arms, neck, abdomen, axillae,
groin
Usually asymptomatic, occasionally mildly pruritic

Figure 17. Tinea Versicolor

Labs:
o Direct Microscopy with KOH smear
o Dermatopathology

Yeast and hyphal forms in stratum corneum

o Biopsy specimens incidental finding in biopsies of
other conditions

Hypopigmentation may persist for months after

eradication of infection

III. CANDIDA
CANDIDAL INTERTRIGO
Candida albicans, yeast with many forms
Frequently colonize the GI tract
Interplay of host (immunocompromised, DM, obesity,
heat, maceration, steroids, debilitation) and
immunologic factors
Cutaneous candidiasis: in moist, occluded areas esp. in
patients with predisposing factors
Starts as pustules on erythematous base that become
eroded and confluent
Demarcated erythematous patches with small pustular
lesions at the periphery (satellite pustulosis)
Affects inframammary, axillae, groin, perineal and
intergluteal areas

Figure 18. Spaghetti and Meatballs Appearance

of Malassezia in a KOH prep
Treatment:
o Topical agents:

Selenium sulfide lotion or shampoo

Ketoconazole shampoo

Azole creams (ketoconazole, econazole,

micronazole, clotrimazole)

Terbinafine (1% solution)

o Systemic Therapy:

None of these agents is approved for use in

Pityriasis in Versicolor in the US

Ketoconazole, Fluconazole, Itraconazole

o Secondary Prophylaxis:

Ketoconazole shampoo

Selenium sulide lotion or shampoo

Salicylic acid/sulfur bar

Pyrithione zine (bar or shampoo)

Ketoconazole

Huang.Katha,Royce

Figure 19. Candidal Intertrigo (note satellite

pustulosis)
Labs: Direct microscopy with KOH: pseudohyphae and
yeast forms
Treatment: Intertrigo may be treated with topical
nystatin and imidazole creams

END
Huang: AA!
Katha: AKMN!
Royce: AFTG!

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LEC 0X: TITLE

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