Dr.

James

Definition
Dermatophytes : are keratinophilic fungi they possess

keratinase allowing them to utilize keratin as a nutrient & energy source

They infect the keratinized (horny) outer layer of the scalp,

glabrous skin, and nails causing tinea or ringworm

Although no living tissue is invaded (keratinized stratum

only colonized) the infection induces an allergic and inflammatory eczematous response in the host

Background
Lesions

on skin and sometimes nails have a characteristic circular pattern that was mistaken by ancient physicians as being a worm down in the tissue

These lesions are still today called

ringworm

infections even though the etiology is known to be a fungus rather than a worm Dermatomycosis Dermatophytosis (Cutaneous fungal infections)

Classical Ringworm Lesion

 Three important genera Trichophyton - Skin, hair, nail Epidermophyton - Skin, nail Microsporum - Skin, hair All 3 organisms infect /attack skin

Microsporum does not infect nails

Epidermophyton does not infect hair, they do not invade

underlying non-keratinized tissues

 Poor nutrition hygiene, a tropical climate,deblitating

disease, atopy, & contact with infected animals, people,or fomites all predispose to fungal infection. Acute infection tends to be associated with rapid development of a delayed hypersensitivity to intradermal Trichophyton antigen. Protective cell mediated immunity is acquired by 80% of patients after primary infection.

Possible Causes for These Lesions

Direct contact with a person who has a fungal

infection Direct contact with fungi contaminated items (bedding clothes, towels, brushes, etc.) Direct contact with soil containing fungi Contact with pets that have a fugal infection

Possible Etiologic Agents

Microsporum audouinii (scalp and body)
Microsporum gypseum (feet, hands, body, scalp, rarely nails) Micropsorum canis (body in adults, scalp in children,rarely

nails)
Trichophyton mentagrophytes (feet, body, nails, scalp, hands,

groin, does not infect hair)

Epidermophyton floccosum (groin, body, epidemic athletes

foot, occasionally nails, does not infect hair)

Clinical Significance
DERMATOPHYTOSIS
Characterized by

Itching, scaling of skin patches that can become inflamed and weeping

Infection in different sites may be due to different

organisms but is given one name

Clinical Classification
Tinea corporis - ringworm infection of the body Tinea pedis - ringworm infection of the foot Tinea cruris - ringworm infection of the groin Tinea unguium - ringworm infection of the nails Tinea capitis - ringworm infection of the head, scalp,

eyebrows, eyelashes
Tinea favosa - ringworm infection of the scalp Tinea manuum - ringworm infection of the hand Tinea barbae - ringworm infection of the beard

Tinea Capitis
Ringworm of the scalp, eyebrows and eyelashes

Tinea Capitis
Children most common cases. (3-7 yrs.)
Fungus grows into hair follicle It always requires systemic medication - griseofulvin Fungistatic agents are somewhat effective (miconazole, clotrimazole) Alopecia in affected areas Endothrix invasion of hair shaft Using a Wood's lamp on hair Microsporum species tend to fluoresce green Trichophyton species generally do not fluoresce

Tinea Capitis
Presentations of Tinea Capitis
1. 2.

Non-inflammatory black dot type Seborrheic type

3.

Pustular

4. Inflammatory (Kerion) 5.

Favus is a distinctive infection with grey, crusting lesions

Tinea Capitis

Black Dot Type :

Large Areas of Alopecia without inflammation Mild scaling Occipital lymphadenopathy Black dot hairs. At first glance may look like Alopecia areata

Tinea Capitis

Tinea Capitis
Seborrheic type :
Common

resembles dandruff Close exam for broken hairs, black dots Lymphadenopathy Frequently negative KOH (70%) Culture often necessary for DX

Tinea Capitis
Kerion :
Inflamed,

deep boggy swelling and tender. M. Canis common etiology Systemic symp: Fever, Lymphadenopathy. Scaring alopecia may occur KOH often negative May look bacterial

Tinea Capitis - Kerion

Tinea Capitis
Pustular :

Discrete pustules and crusted areas No significant hair loss or scale Often KOH negative Frequently treated as bacterial at first

Tinea Capitis

TINEA CAPITIS

Tinea barbae

Tinea barbae
("Barber's itch, Ringworm of the beard, and "Tinea

sycosis ) is a fungal infection of the hair. Tinea barbae is due to a dermatophytic infection around the bearded area of men. Generally, the infection occurs as a follicular inflammation, or as a cutaneous granulomatous lesion, i.e. a chronic inflammatory reaction. It is one of the causes of Folliculitis. It is most common among agricultural workers, as the transmission is more common from animal-to-human than human-to-human. The most common causes are T. mentagrophytes and T. verrucosum

Tinea barbae

Tinea Pedis Athletes Foot Infection

Tinea Pedis
Most common of all fungal diseases
30-70% population having been infected at some time Generally, a diease of adults

Causative fungi may be found in shoes, flooring &

shoes. Occlusive footwear is a predisposing factor. Simple contact is not sufficcient for infection. Concomitant distruption of skin barrier is necessary.
Groups: M > F. Young and middle aged

Tinea Pedis
T. Rubrum most common etiology
4th and 5th toes are most common Pruritus is the most common symptom Fissures may be painful & also predisposed to secondary

bacterial infection. This is of particular importance in patients with diabetes, chronic lymphedema, and venous stasis.
Patient is susceptible to reoccurrence Onychomycosis and tinea pedis associated.

 Tinea pedis may take several forms.

Interdigital scaling & macceration with fissures is most

common. Widespread fine scaling in a moccasin distribution is also frequent. The scaling usualy extends up onto the sides of the feet & lower heel, where it exhibits a characteristic , well defined , polycyclic scaling border. A highly inflammatory, vesicular, or bullous eruption is uncommon.

Tinea Pedis
Differential:
Eczema, contact dermatitis Psoriasis. Erythrasma and Candida (esp in web spaces.) Pitted keratolysis

Tinea manuum

Tinea manuum
Ringworm infection of the hand

Most often a mild erythema with hyperkeratosis &

scaling over the palmer surfaces. Hand infection almost always accompanies foot involvement. Unilateral involvement of one hand & both feet is so characteristic that it immediately suggests this diagnosis. Inflammatory lesions on the feet may cause a sterile vesicular id reaction on the hands, which may be confused with primary fungal infection.

Tinea manuum

Tinea Unguium Nail Infection ( (Onychomycosis)

Onychomycosis
Seen in 40% of patients with fungal infections in other

locations. No Spontaneous remissions General Appearance: Typically begins at distal nail corner Thickening and opacification of the nail plate Nail bed hyperkeratosis Onycholysis Discoloration: white, yellow, brown Edge of the nail itself becomes severely eroded. Some or all nails may be infected (fingernail<toenail) Often accompanying tinea pedis

Onychomycosis
4 Types:
1. Distal Subungal (most common) 2. White superficial

T. Mentagrophytes and molds Chalky white patches May indicate HIV infection

3. Proximal Subungal

4. Candidaonychomycosis

Normally hands with accompanying paronychia

Candidaisis of nail

Onychomycosis
Differential Diagnosis: (50% of thick nails not classic fungus.)
Allergic contact (nail polish, food items) Psoriasis

Lichen Planus
Molds Nail dystrophies (ex nephrogenic) Drugs

Tinea Corporis - body ringworm

 Affects all ages , but children are most susceptible. Most prevalent in hot, humid climate & in rural areas.

Tinea corporis resolves itself in several months Symptoms result from fungal metabolites such as toxin/allergens Concentric or ring-like lesions on skin Generally restricted to stratum corneum of the smooth skin In severe cases these are raised and may become inflamed

 Typical lesion start as eryththematous macules or

papules that spread outward and develop into annular & arciform lesions with well defined scaling or vesicular borders and central clearing.
Most common on face, arms & shoulders.

Transfer form on area to the body to another (from

tinea pedis to tinea corporis).

Tinea Corporis

Tinea Cruris Jock Itch

More common in men than women.
Infection seen on scrotum and inner thigh, the penis

is usually not infected.

Predisposing factors include persistent perspiration, high

humidity, irritation of skin from clothes, such as tight

fitting underwear or athletic supporters, pre-existing

disease such as diabetes and obesity

Tinea Cruris
Epidemics associated with grouping of people

into tight quarters - athletic teams, troops, ship crews, inmates of institutions.
Several causes of tinea cruris include T. rubrum

(does not normally survive long periods outside of host), E. flocossum (usually associate with epidemics because resistant arthroconidia in skin scales can survive for years on rugs, shower stalls, locker room floors),

Tinea Cruris

Tinea Cruris

 The clinical hallmark is single or multiple patches of hair

loss, sometimes with a black dot pattern, which may be accompanied by signs of inflammation such as scaling, pustules and itching

Tinea favosa
Ringworm infection of the scalp

(crusty hair)

Clinical manifestations
Skin: Circular, dry, erythematous, scaly, itchy

lesions
Hair:

Typical

lesions,

kerion,

scarring,

alopecia
Nail: Thickened, deformed, friable, discolored

nails, sub-ungual debris accumulation

Favus (Tinea favosa)

Lab Diagnosis
Nail clippings, skin scrapings, hair /follicle

Placed in sterile container preferably, or between 2 slides No role for swabs KOH ( 10-25% ) will be added in the lab to dissolve tissue material Lactophenol blue stain to see if fungal hyphae seen

 For full identification culture on selective media

required Sabouraud dextrose agar (SDA) SDA with cycloheximide or chloramphenicol Low pH 5.0 May require 10-14 days for growth Macroscopic and microscopic identification of colonies

Prophylactic measures
Interdigital areas should be dried thoroughly after

bathing, & talc or antifungal powder should then be applied. Footwear should fit well & be nonocclusive (avoid sneakers & plastic or rubber footwear). Patient with hyperhidrosis should wear absorbent cotton socks & avoid wool and nonwicking synthetic fibres. (control of hyperhidrosis is vital) Clothes & towels should be changed frequently and laundered in hot water.

Treatment
Topical

Miconazole, clotrimazole, econazole, terbinafine... Oral Griseofulvin Ketaconazole Itraconazole Terbinafine

QUIZ..

Tinea pedis

Tinea unguium

Tinea corporis

Tinea cruris

Tinea barbae