SUPERFICIAL MYCOSESSUPERFICIAL MYCOSES

Sevtap Arikan, MDSevtap Arikan, MD

SUPERFICIAL MYCOSESSUPERFICIAL MYCOSES

DermatophytosisDermatophytosisPityriasis versicolor Pityriasis versicolor KeratomycosisKeratomycosisTinea nigraTinea nigraBlack piedraBlack piedraWhite piedraWhite piedra

DERMATOPHYTOSISDERMATOPHYTOSIS(=Tinea = Ringworm)(=Tinea = Ringworm)

Infection of the skin, hair or nails Infection of the skin, hair or nails caused by a group of keratinophilic caused by a group of keratinophilic fungi, called dermatophytesfungi, called dermatophytes

¨ MicrosporumMicrosporum Hair, skinHair, skin¨ EpidermophytonEpidermophyton Skin, nailSkin, nail¨ TrichophytonTrichophyton Hair, skin, nailHair, skin, nail

DERMATOPHYTESDERMATOPHYTES

Digest keratin by their Digest keratin by their keratinaseskeratinases

Resistant to cycloheximideResistant to cycloheximide Classified into three groups Classified into three groups

depending on their usual depending on their usual habitathabitat

DERMATOPHYTESDERMATOPHYTES

ANTROPOPHILICANTROPOPHILIC Trichophyton rubrum...Trichophyton rubrum...GEOPHILICGEOPHILIC

Microsporum gypseum...Microsporum gypseum...ZOOPHILICZOOPHILIC

Microsporum canisMicrosporum canis: cats and dogs: cats and dogsMicrosporum nanumMicrosporum nanum: swine : swine Trichophyton verrucosum:Trichophyton verrucosum: horse and horse and swine…swine…

DERMATOPHYTOSISDERMATOPHYTOSISPathogenesis and Pathogenesis and ImmunityImmunity

Contact and traumaContact and trauma MoistureMoisture Crowded living conditionsCrowded living conditions Cellular immunodeficiency Cellular immunodeficiency

(chronic inf.)(chronic inf.) Re-infection is possible (but, Re-infection is possible (but,

larger inoculum is needed, the larger inoculum is needed, the course is shorter )course is shorter )

DERMATOPHYTOSISDERMATOPHYTOSISClinical ClassificationClinical Classification

Infection is named according to Infection is named according to the anatomic location involved:the anatomic location involved:

a. Tinea barbaea. Tinea barbae e. Tinea pedis e. Tinea pedis (Athlete’s foot)(Athlete’s foot)

b. Tinea corporis f. Tinea manuumb. Tinea corporis f. Tinea manuumc. Tinea capitis c. Tinea capitis g. Tinea unguiumg. Tinea unguiumd. Tinea cruris d. Tinea cruris

(Jock itch)(Jock itch)

DERMATOPHYTOSISDERMATOPHYTOSISClinical manifestationsClinical manifestations

Skin:Skin: Circular, dry, Circular, dry, erythematous, scaly, itchy lesions erythematous, scaly, itchy lesions

Hair:Hair: Typical lesions,”kerion”, Typical lesions,”kerion”, scarring, “alopecia”scarring, “alopecia”

Nail:Nail: Thickened, deformed, Thickened, deformed, friable, discolored nails, friable, discolored nails, subungual debris accumulation subungual debris accumulation

FavusFavus (Tinea favosa) (Tinea favosa)

DERMATOPHYTOSISDERMATOPHYTOSISTransmissionTransmission

Close human contactClose human contact Sharing clothes, combs, Sharing clothes, combs,

brushes, towels, bedsheets... brushes, towels, bedsheets... (Indirect)(Indirect)

Animal-to-human contact Animal-to-human contact (Zoophilic)(Zoophilic)

DERMATOPHYTOSISDERMATOPHYTOSISDiagnosisDiagnosis

I. ClinicalI. Clinical

AppearanceAppearance

Wood lamp (UV, 365 nm) Wood lamp (UV, 365 nm)

II. Lab II. Lab

A. Direct microscopic A. Direct microscopic examinationexamination

(10-25% KOH)(10-25% KOH)

Ectothrix/endothrix/favic hairEctothrix/endothrix/favic hair

DERMATOPHYTOSISDERMATOPHYTOSISDiagnosisDiagnosis

B. CultureB. CultureMycobiotic agar Mycobiotic agar Sabouraud dextrose agar Sabouraud dextrose agar

DERMATOPHYTESDERMATOPHYTESIdentificationIdentification

A. Colony characteristicsA. Colony characteristicsB. Microscopic morphologyB. Microscopic morphology

MacroconidiumMacroconidiumMicroconidiumMicroconidiumMicrosporum----Microsporum---- fusiform---------------(+)fusiform---------------(+)EpidermophytonEpidermophyton clavate-----------------(-)clavate-----------------(-)Trichophyton-- -Trichophyton-- -(few)cylindrical/ --- --(+) (few)cylindrical/ --- --(+)

clavate/fusiform clavate/fusiform single, single, in in clustersclusters

DERMATOPHYTESDERMATOPHYTESIdentificationIdentification

C. Physiological testsC. Physiological tests In vitro hair perforation testIn vitro hair perforation test Special amino acid and vitamin Special amino acid and vitamin

requirementsrequirements Urea hydrolysisUrea hydrolysis Growth on BCP-milk solids-glucose Growth on BCP-milk solids-glucose

mediummedium Growth on polished rice grainsGrowth on polished rice grains Temperature tolerance and enhancementTemperature tolerance and enhancement

DERMATOPHYTOSISDERMATOPHYTOSISTreatmentTreatment

Topical Topical Miconazole, clotrimazole, Miconazole, clotrimazole, econazole, terbinafine...econazole, terbinafine...

OralOralGriseofulvinGriseofulvinKetaconazoleKetaconazoleItraconazoleItraconazoleTerbinafineTerbinafine

PITYRIASIS PITYRIASIS VERSICOLORVERSICOLOR

Superficial chronic infection of Superficial chronic infection of Stratum corneumStratum corneum

Etio:Etio: Malassezia furfur Malassezia furfur (Pityrosporum orbiculare)(Pityrosporum orbiculare) (Lipophilic yeast)(Lipophilic yeast)

Clinical findings:Clinical findings: Hyperpigmented or depigmented Hyperpigmented or depigmented maculae on chest, back, arms, maculae on chest, back, arms, abdomenabdomen

PITYRIASIS PITYRIASIS VERSICOLORVERSICOLOR

Systemic infection (parenteral Systemic infection (parenteral lipid solution)lipid solution)

Micr.:Micr.: Short hyphae, yeast cellsShort hyphae, yeast cells Culture:Culture: Yeast (suppl.: olive Yeast (suppl.: olive

oil)oil) Treatm.:Treatm.: Topical selenium Topical selenium

sulfide sulfideOral ketaconazoleOral ketaconazole

Oral itraconazoleOral itraconazole

KERATOMYCOSISKERATOMYCOSIS(=Mycotic keratitis)(=Mycotic keratitis)

Posttraumatic / postsurgical Posttraumatic / postsurgical corneal inf. corneal inf.

Etio:Etio: Saprophytic fungi Saprophytic fungi ((AspergillusAspergillus, , Fusarium, Fusarium, Alternaria, Candida), Alternaria, Candida), Histoplasma capsulatumHistoplasma capsulatum

Clinical findings:Clinical findings: Corneal ulcer Corneal ulcer

KERATOMYCOSISKERATOMYCOSIS

Micr.: Micr.: Hyphae in corneal Hyphae in corneal scrapingsscrapings

Treatm.: Treatm.: Surgery (keratoplasty)Surgery (keratoplasty)

Topical pimaricinTopical pimaricin

NystatinNystatin

Amphotericin BAmphotericin B

TINEA NIGRATINEA NIGRA

Superficial chronic infection of Superficial chronic infection of Stratum corneumStratum corneum

Etio:Etio: HortaeHortae (Exophiala) (Exophiala) werneckii werneckii (pigmented)(pigmented)

Frequent in tropical areasFrequent in tropical areas Clinical findings: Clinical findings: Brownish Brownish

maculae on palms, fingers, facemaculae on palms, fingers, face

TINEA NIGRATINEA NIGRA

Micr.:Micr.:Septate hyphae and Septate hyphae and yeast cells (brown in color)yeast cells (brown in color)

Culture:Culture: Black colonies Black colonies

Treatm.:Treatm.: Topical salicylic acid, Topical salicylic acid, tincture of iodinetincture of iodine

BLACK PIEDRABLACK PIEDRA

Fungal infection of the scalp hairFungal infection of the scalp hair Etio:Etio: Piedraia hortae Piedraia hortae Frequent in tropical areasFrequent in tropical areas Clinical findings: Clinical findings: Discrete, hard, Discrete, hard,

dark brown to black nodules on dark brown to black nodules on the hairthe hair

BLACK PIEDRABLACK PIEDRA

Micr.Micr. Septate pigmented hyphae, Septate pigmented hyphae, and asci; unicellular and fusiform and asci; unicellular and fusiform ascospores with polar filament(s)ascospores with polar filament(s)

Culture:Culture: Brown to black colonies Brown to black colonies Treatm.:Treatm.: Topical salicylic acid, Topical salicylic acid,

azol cremesazol cremes

WHITE PIEDRAWHITE PIEDRA

Fungal infection of facial, Fungal infection of facial, axillary or genital hairaxillary or genital hair

Etio:Etio: Trichosporon Trichosporon (yeast)(yeast) Frequent in tropical and Frequent in tropical and

temperate zonestemperate zones

WHITE PIEDRAWHITE PIEDRA

Clinical findings: Clinical findings: Soft, white to Soft, white to yellowish nodules loosely yellowish nodules loosely attached to the hairattached to the hair

Micr.: Micr.: Intertwined septate Intertwined septate hyphae, blasto- and hyphae, blasto- and arthroconidiaarthroconidia

Culture:Culture: Soft, creamy colonies Soft, creamy colonies Treatm.:Treatm.: Shaving, azoles Shaving, azoles