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Dermatophytosis and Other Fungal Infections

Definition

Tinea capitis: Dermatophyte (fungal) infection of the scalp and its follicles.

Tinea corporis/Tinea cruris: Dermatophyte infection of the skin of the trunk, limbs or face in tinea corporis, only the groin in tinea cruris.

Tinea pedis: Fungal infection of the skin of the feet, including toes.

Cutaneous candidiasis (Moniliasis): Infection of skin, skin appendages, and mucous membranes with C. albicans; a yeast.

Tinea versicolor: A superficial, asymptomatic skin infection caused by P. orbiculares (Malassezia furfur), a normal skin inhabitant.

History

Symptoms

Tinea capitis: Scaly patches, hair loss with pruritis, pain, and tenderness. Symptoms are dependent on the degree of inflammation. Spots start small and spread out, becoming confluent.

Tinea corporis/Tinea cruris: Slowly spreading, scaly, red-rash spots, involving the neck, face, or arms. Typically on the trunk and legs as well. Variable pruritis.

Tinea pedis: Pruritis, dry or moist peeling of skin of the feet and toes in patches, or involve the entire sole. Sometime pimples, redness, and foul smell.

Cutaneaus candidiasis (Moniliasis): White substance in the mouth, genital red rash, or pruritis. Occurs under the arms, beneath the panniculus of abdomen, or under the breasts. Red, itchy, scaly areas may occur between the fingers or toes. Tender red swellings at fingernails and nail changes. Sores at mouth comers.

Tinea versicolor: White or brown spots on back and/or chest for many weeks. Sometimes itches, especially if warm (e.g., after hot shower or bath). May have noticed it the same season the previous year or have a recurrent history of the same.

Age

Tinea capitis: Usually children or rarely adults.

Tinea corporis/Tinea cruris: Any.

Tinea pedis: Any, but not common in infants. Cutaneaus candidiasis (Moniliasis): Any.

Tinea versicolor: Usually young adults, some teens too.

Onset

Tinea capitis: Subacute to chronic.

Tinea corporis/Tinea cruris: Sudden with steady progression.

Tinea pedis: Insidious to acute.

Cutaneous candidiasis (Moniliasis): Congenital to sudden and spreading.

Tinea versicolor: Both acute and chronic.

Duration

Tinea capitis: Chronic, weeks to months.

Tinea corporis/Tinea cruris: Indefinite, but with progression to new and larger growing lesions.

Tinea pedis: Weeks to months.

Cutaneous candidiasis (Moniliasis): Days to months.

Tinea versicolor: Weeks, months, or even years.

Intensity

Tinea capitis: Single, small lesion to confluent lesions involving most or all of scalp.

Tinea corporis/Tinea cruris: One to multiple lesions on the body with corporis; slight pruritis. Cruris exhibits single lesions to patches covering the entire groin area; significant pruritis.

Tinea pedis: Boggy peeling between fourth and fifth toes or all toes, patches over sole to entire moccasin pattern. Involves one or both feet.

Cutaneous candidiasis (Moniliasis): Single local lesions on sites of involvement, to widespread and including systemic and internal infections. Minor and self-limiting in the healthy patient.

Tinea versicolor: Single discrete lesions in groups up to large (30 cm) lesions in confluent areas.

Aggravating Factors

Tinea capitis: None.

Tinea corporis/Tinea cruris: Heat, moisture.

Tinea pedis: Occlusion, warmth and moisture as in hot, humid weather.

Cutaneous candidiasis (Moniliasis): Moisture, warmth, and occlusion. Skin breakdown.

Tinea versicolor: Heat, humidity, perspiration, poor hygiene, occlusion.

Alleviating Factors

Tinea capitis: None.

Tinea corporis/Tinea cruris: None.

Tinea pedis: Meticulous hygiene of feet. Thorough cleansing and drying. Foot powders and antifungal treatment.

Cutaneous candidiasis (Moniliasis): Topical treatment.

Tinea versicolor: Using salicylic acid-sulfur soap and scrubbing scales off.

Associated Factors

Tinea capitis: Single, small lesion to confluent lesions involving most or all of the scalp.

Tinea corporis/Tinea cruris: Animal contact, or contaminated soil. Tinea pedis: Communal showering.

Cutaneous candidiasis (Moniliasis): Diabetes mellitus, obesity, hyperhidrosis, maceration, immune deficits (depressed T-cell lymphocytes), oral contraceptives, pregnancy, systemic antibiotics, systemic and topical corticosteroids, chronic debilitation, chemotherapy carcinoma, or leukemia. Pertinent if patient is often in water, a baker or a bartender.

Tinea versicolor: Cushing syndrome or elevated cortisol from prolonged corticosteroid therapy. Skin lipids may play a role.

Physical Examination

Skin

Tinea capitis: Roundish, grayish, scaly patches, with hairs broken off at scalp surface. Or diffusely broken off hairs near scalp leaving black dots at follicles and a whitish scale. Inflammed nodules or thickened boggy skin with purulence and often crusting (in kerions) may be present. Large patches of alopecia, and thick yellowish brown scale or scutula on atrophic scarred scalp, often with erosions is called favus.

Tinea corporis/Tinea cruris: Papulosquamous, erythematous, sharply marginated, single, or multiple lesions. Have raised annular borders with some scaling and often clearing centers as they advance to larger and confluencing sizes. May acutely have papulo-vesicular component. Lesions are found classically on trunk and limbs, and occasionally on face for tinea corporis. Tinea cruris lesions occur in the groin and high thigh area.

Tinea pedis: Fissuring, boggy maceration in toe webs (especially laterally), dry red scaling in local patches or in moccasin pattern of entire foot. Exhibit vesicles, pustules, and or bullae of small or large areas with inflammation. Foul smell may be present with any, but most common with toe web disease. The vesicopustular or bullous type often have a secondary bacterial infection. With these inflammatory infections an id or dermatophytid reaction may develop on the hands, with a dry, scaling, vesicular eruption, or an indiscrete pruritic trunk eruption.

Cutaneous candidiasis (Moniliasis): Dislodgeable white exudates or plaques on oral mucous membranes, lips, tongue; on red base membranes. (See Gynecology section for vaginal disease.) Occur in diaper area in infants as bright red macular lesions with sharp or diffuse borders, or a tissue-like collarette scale in patches with small satellite or vesicular lesions. Same for all intertrigenous or body fold involvement. On penis, usually presents with tiny pustules on glans penis and/or fine linear erosions on reddish, slightly swollen scaly foreskin. Tender red swelling with or without pustule at base of nails and yellowish brown white nail, discoloration of lateral, distal, or proximal nail matrix.

Tinea versicolor: Sharply marginated, roundish, fawntan, brownish or off-white macules from 1 cm to confluent multicentimeter patches. Usually on upper trunk and arms and neck, but occasionally onto abdomen and proximal legs. A fine superficial scaling is evident or becomes apparent with gentle scraping. No inflammation present. Rare on the face.

Pathophysiology

Tinea capitis: Infection of scalp, skin, and follicles by invasion of susceptible hosts by one of the following dermatophytes: Trichophyton tonsurans, T. mentagrophytes, T. schoenleinii or fiavum, Microsporum audouinii, or M. canis. Contact with a person, animal, or fomites contaminated with fungal germ required.

Tinea corporis/Tinea cruris: Contact skin infection, usually with the dermatophytes T. rubrum or T. mentagrophytes.

Tinea pedis: Skin of feet (especially between toes) and soles is invaded by dermatophytes, most commonly T. rubrum, T. mentagrophytes. and Epidermophyton floccosum. This process triggers host defensive mechanisms including hyperproliferation of skin cells and inflammation.

Cutaneous candidiasis (Moniliasis): Stratum corneum and epidermal mvasion with candidal blastoconidia with or without acute inflammatory cells. Polymorphonucleocytes increase and microabscesses form around organisms but epidermal proliferation desquamates away the lesions.

Evidences of neutrophil and macrophage cell migration. C. albicans is the most common cause but C. tropicalis and others is possible.

Tinea versicolor: Hyphae and spores dimorph and proliferate in the skin, and released phenolic compounds that lead to inhibition of tyrosinase which inhibits epidermal melanocytes resulting in hypomelanosis. Hyperpigment may be a process of hyperkeratotic lesions.

Diagnostic Studies

Laboratory

Fungal cultures: Help identify specific dermatophyte or candida species.

Radiology: Not applicable.

Other

Tinea capitis: KOH preparation with 10 percent KOH: Warmed on a glass slide with scrapings from lesion borders and viewed under direct microscopy, reveals hyphae, spores, mycelia of fungi.

Direct woods (filtered UV light): Fungi glow or fluoresce green, bluish green, grayish green, or coral orange on the skin.

Tinea corporis/Tinea cruris: KOH preparation with 10 percent KOH: With scrapings from advancing borders oflesion reveals mycelia/hyphae of fungi under direct microscopy.

Tinea pedis: KOH preparation: Will be positive for hyphae-branching linear strands, arthrospores, or occasionally budding cells. Accomplished by placing skin scrapings on slide, applying a drop of 10 to 20 percent hydrogen peroxide, heating gently, and observing under microscope after about 5 minutes. Not for identification of specific organism but to verify fungal presence.

Cutaneous candidiasis (Moniliasis): KOH preparation: Reveals blastoconidia, the hyphae and budding spores that distinguish candida

species.

Tinea versicolor: KOH preparation: Of scales on a slide and warmed reveals a spaghetti and meatballs pattern of hyphae and spores. Direct woods (filtered UV light): Fungi fluoresce a yellowish orange wherever the dimorphic fungus is colonizing the skin. The organism produces a coproporphyrin metabolite, thus the fluorescence.

Differential Diagnosis

Traumatic

Tinea pedis: Pressure rubbing blisters no lasting inflammation. No fungus demonstrable on KOH preparation. Only one or two lesionS localized at rubbing sites.

Cutaneous candidiasis (Moniliasis): Bums and blisters will be KOH negative and culture' negative for Candida. Location and history help rule out.

Tinea capitis/Tinea corporis/Tinea cruris/Tinea versicolor: Not applicable. Infectious

Tinea capitis: Bacteria may complicate kerions and favus and will show on culture.

Tinea corporis/Tinea cruris: Same infection of hands called tinea manuum. Bacterial infections are negative for fungi by test.

Tinea pedis: Bacteria with fungus very common in pustular inflammatory types and needs to be treated along with fungus. KOH and culture negative for fungus if only bacterial or viral infection.

Herpes Simplex: More pain than itch sensation and no fungus identifiable by KOH preparation or culture.

Cutaneous candidiasis (Moniliasis): Folliculitis may be bacterial or possibly P. orbiculare but negative for Candida. Dermatophyte may look similar, especially in the nails. Cultures differentiate.

Tinea versicolor: Not applicable.

Metabolic

Tinea capitis: Other alopecias tend to be less scaly and have negative fungal diagnostic studies.

Tinea corporis/Tinea cruris: Subacute cutaneous lupus erythematosus:

More widespread with larger lesions all negative by culture or KOH preparation.

Tinea pedis/Cutaneous candidiasis (Moniliasis)/Tinea versicolor: Not applicable.

Neoplastic

Tinea corporis/Tinea cruris: Mycosis fungoides may appear similar but all are negative on KOH preparation and/or fungal culture.

Tinea capitis/Tinea pedis/Cutaneous candidiasis (Moniliasis)/Tinea versicolor: Not applicable.

Vascular: Not applicable.

Congenital

Cutaneous candidiasis (Moniliasis): Seborrheic dermatitis at birth: Resembles candida but cultures negative.

Tinea capitis/Tinea corporis/Tinea cruris/Tinea pedis/Tinea versicolor: Not applicable.

Acquired

Tinea capitis: Seborrheic dermatitis: Usually less discretely circumscribed; alopecia rare. Negative fungal cultures.

Tinea pedis: Dishydrotic eczema: No fungus on KOH preparation or culture May occur around sides, on dorsum of feet, or near the ankle. Cutaneous candidiasis (Moniliasis): Leukoplakia and oral lichen planus more lace-like pattern and negative for Candida on culture.

Tinea versicolor: Vitiligo is usually white and doesn't have delicate scale of tinea versicolor. Hypomelanosis of cleared psoriasis, eczemas, and so forth. Does not have the same fine, demonstrable scale and differs in distribution. KOH preparation negative.

Tinea corporis/Tinea cruris: Not applicable.

Treatment

Tinea capitis: Griseofulvin 250 mg twice a day for 1 to 3 months. Children 5 mg/lb/day 1 to 3 months or ketoconazole 200 to 400 mg every day for adults. Frequent hair washing with ketoconazole, salicylic acid, tar, or zinc shampoo to clear scale. Treatment should continue 1 to 2 weeks after signs, symptoms, and tests are normal.

Tinea corporis/Tinea cruris: Topical treatment for few or isolated lesions is generally adequate. Any of the following preparations may be successful at resolving the infection applied 1 or 2 times a day.

Imidazoles: Clotrimazole (Lotrimin/Mycelex), Miconazole nitrate (Monistat-Dermatologic), Econazole nitrate (Spectazole), Ketoconazole (Nizoral), Sulconazole (Exelderm) Iodinated trichlorophenols: Haloprogin (Halotex) Allylamine: Naftifine (Naftin) Nonimidazoles: Ciclopiroxolamine (Loprox Terbinafine (Lamasil) For resistant or extensive lesions, an oral antifungal is indicated for 4 to 6 weeks at appropriate dose per weight, given once daily with food.

For adults: Ultramicrosize griseofulvin 330 to 375 mg/day or ketoconazole 200 to 400 mg/day.

For children: Griseofulvin suspension at 5 mg/lb/day. (Comes in 125 mg/5 m1 strength.) If oral treatment is prolonged, monitor liver enzymes for possible side-effects.

Tinea pedis: Burow's wet dressing helps the acute vesiculo-bullous eruptions, Domeboro-Bluboro or Pediaboro. Drying powders with antifungal (e.g., tolnaftate) can be helpful daily on the toes or soles. Must use one of the topicals as listed above under tinea corporis /cruris.

Chronic or deep extensive infection may require griseofulvin 500 mg orally twice a day with food or Nizoral 200 to 400 mg orally every day. Try to decrease heat, moisture, and occlusive footwear by change of footwear (e.g., sandals).

Cutaneous candidiasis (Moniliasis): Oral candidiasis: Oral Nystatin suspension 200,000 to 400,000 units 3 to 4 times daily. Swish 5 minutes and swallow; or clotrimazole troches dissolved in the mouth swished and swallowed. For perleche use a topical cream or ointment containing an imidazole (miconazole, clotrimazole, ketoconazole, or econazole).Clean any dentures with Peridex.

Genital candidiasis: Use topical imidazole (miconazole, clotrimazole, ketoconazole, or econazole) twice a day. In chronic infection, use oral ketoconazole 200 to 400 every day for 14 days, and repeat if necessary. Oral nystatin 500,000 units four times a day may also be used. Consider circumcision in males.

Intertriginous-diaper candidiasis: Use topical imidazole cream twice a day, air dry areas, use loose clothing, and avoid plastic diapers. Absorbent powders may be helpful (e.g., talc, zeasorb).

Paronychial and onychial Candidiasis: Avoid immersion in water and dry thoroughly. Topical imidazoles or nystatin in cream or lotion twice a day. Lotions penetrate nail folds better. Oral ketoconazole 200 to 400 mg daily for 3 to 6 months with blood monitoring of liver function monthly. For chronic or systemic disease consider intravenous amphotericin B.

Tinea versicolor: Selenium sulfide 2 percent, overnight and daily regimens helps but has high recurrence rate.Imidazole creams are helpful once or twice daily but expensive for extended areas. Ketoconazole 200 mg two tablets one day every week for 1 to 2 months works well, especially if exercising and sweating an hour or so after taking dose of medication and not showering for several hours.

More effective still is two tablets 2 times weekly while continuing the exercise. Continue 4 to 6 weeks and most will not recur.

Pediatric Considerations

Tinea capitis: Usually seen in prepubertal children. Topical antifungal agents are ineffective and treatment with oral griseofulvin (10 mg/kg/ day) for a minimum of 6 to 8 weeks is required.

Tinea corporis( ringworm): Usually seen in children. Treatment is With topical antifungal agent (clotrimazole, miconazole) for 2 to 4 weeks.

Tinea pedis: Is seen rarely in childhood but frequently in postpubertal adolescents. Atopic dermatitis may mimic tinea pedis in prepubertal children.

Cutaneous candidiasis (Moniliasis): C. albicans is a common source of infection in infancy. Candida frequently infects the diaper area and may infect the oral mucosa where it appears as thick, white patches on an erythematous base (thrush). An antifungal cream may be used in the diaper area. In oral thrush, a suspension of nystatin should be applied directly to the mucosa with a finger or cotton applicator. If a breastfeeding infant is seen with thrush, the mother should be questioned about symptoms of dry, reddened, painful nipples, an indication that yeast is being passed back and forth between the infant and the mother's breast.

Obstetrical Considerations

Oral medications are contraindicated in the pregnant patient. Check medication reference before instituting any therapy.

Candidiasis is more prevalent in pregnant women, commonly seen in infections of the perineum and the vagina. Pregnancy increases the glycogen content of the vaginal epithelium and promotes a greater degree of acidity. This can lead to an overgrowth of yeast. Approximately 30 to 35 percent of pregnant women have demonstrable yeast organisms in the vagina.

The newest antifungal medication, terconazole, is safe to use during pregnancy. In contrast, ketoconazole is contraindicated.

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