1. Fungal skin infections
Dr. M. Arif Abid

2. Tinea Versicolor Description
A common infection caused by the lipophilic yeast Pilyrosporum orticulan(Malassezia furfur).
The organism is part of the normal skin flora,
is possibly contagious and people with oily skin may be more susceptible Excess heat and humidity predispose to infection

3. Tinea Versicolor History
More common during the years of higher sebaceous activity(adolescence and young adulthood).
Very common especially in tropical and semitropical regions.
Varies in activity for years, diminishes or disappears with advancing age.
May itch, but is usually asymptomatic.
Appearance is often the patient's major Concern

4. Tinea Versicolor Skin Findings
Numerous small, circular, white, or brown scaling papules on the upper trunk.
May extend to involve the upper arms, neck, and abdomen.
Facial involvement more common in the skin of children and African-American people
Powdery scale that may not be obvious on inspection can easily be shown by.

5. Tinea Versicolor Skin Findings
Lesions are hypopigmented in tanned skin, and pink or fawn colored in untanned skin.
Color is uniform in each person but may vary between people.
Wood's light examination shows hypopigmented areas of infection and a faint yellow-green fluorescence.

6. Tinea Versicolor Treatment
Topical treatment is indicated for limited disease.
Seleneim sulfide 2.5% apply for 20 minte then washed off
This can be repeated every day for 7 consecutive days.
Ketoconazole 2% shampoo is applied to dampened skin, lathered and left on for 5 minutes, and then rinsed.
This has a clinical response rate of about 70% when used as a single application or daily for 3 days.
Zinc pyrithione soap(ZNP bar is applied in the shower lathered and left on for 5 minutes, then rinsed
This is a low-cost, convenient treatment

7. Tinea Versicolor
Miconazole, clotrimazole, econazole or ketoconazole creams/lotions applied to the entire affected area at bedtime for 2-4 weeks
Oral treatment is used in:
extensive disease
who do not respond to topical treatment
frequent recurrences.
Cure rates may be greater than 90%.
Itraconazole 200 mg every day for 5-7 days, taken with food to enhance absorption.
Ketoconazole 200mg every day for 5 days, taken at breakfast with a fruit juice.
Fluconazole 150 mg(two capsules per week for 2 weeks).

8. Pityrosporum(Malassezia) Folliculitis
Description
infection of the hair follicle caused by the yeast Pityrosporum known as Malassezia furfur, the same organism that causes tinea versicolor
A discrete, sometimes itchy, papulopustular eruption, which is localized mainly to the upper portion of the trunk and shoulders.

9. Pityrosporum(Malassezia) Folliculitis
History
occurs in young and middle-aged adultsprimary event, with yeast overgrowth as a secondary consequence.
Diabetes mellitus, systemic chemotherapy, and administration of broad-spectrum antibiotics or corticosteroids are predisposing factors.

10. Pityrosporum(Malassezia) Folliculitis
Skin Findings
symptomatic or slightly itchy dome shaped monomorphic follicular papules and pustules, mm in diameter.
occurs on the upper back, chest, and upper arms.
More common in the tropics, where it presents with follicular papules, pustules, nodules, and cysts.

11. Pityrosporum(Malassezia) Folliculitis
Treatment Selenium sulfide shampoo(Selsun) is applied and showered off 20 minutes later, this is repeated each day for 3 days to clear and then once each week for maintenance.

12. Tinea of the Nails Description
Tinea of the nails is a fungal infection of the nail plate of the finger or toe caused by many different species of fungus once established,
it tends to become chronic and asymptomatic.

13. Tinea of the Nails History Prevalence increases with age.
It affects 15-20% of the population aged years.
Life-ong infection, with no spontaneous remission
Trauma especially from tight-fitting shoes, predisposes to infection
A large mass composed of thick nail plate and underlying debris may cause discomfort with footwear.

14. Tinea of the Nails Skin Findings
There are four distinct clinical patterns of infection.
These patterns are not exclusive and may occur simultaneously in the same or in adjacent nail plates.
Nail infection may occur simultaneously with hand or foot tinea or may occur as an isolated phenomenon

15. Clinical type of onychomycosis
1. Distal subungual onychomycosis
2. White superficial onychomycosis
3.Proximal subungual onychomycosis

16. Tinea of the Nails 1. Distal subungual onychomycosis
This is the most common pattern.
Fungi invade the distal area of the nail bed,
The distal plate turns yellow or white as an accumulation of hyperkeratotic debris causes the nail to rise and separate from the underlying bed.

17. Tinea of the Nails White superficial onychomycosis
Caused by surface invasion of the nail plate
The nail surface is soft, dry and Powdery, and can easily be scraped away.
The nail plate is not thickened and remains adherent to the nail bed

18. Tinea of the Nails 3.Proximal subungual onychomycosis
Micro-organisms enter the posterior cuticle area of the nail fold and invade the nail plate from below,
The surface of the nail plate remains intact
Hyperkeratotic debris causes the nail to separate
Trichophyton rubrum is the most common cause
This is the most common pattern seen in patients with human immunodeficiency virus infection

19. Tinea of the Nails Candida Onychomycosis
Nail plate infection caused by Candida albicans is seen almost exclusively in chronic mucocutaneous candidiasis-a rare disease.
It generally involves a of the fingernails.
The nail plate thickens and turns yellow to brown

20. Tinea of the Nails
Laboratory Potassium hydroxide (KOH) examination of subungual debris and nail plate will confirm presence of hyphae. Fungal culture will confirm the species of fungus and establish the presence of dermatophytes organisms

21. Tinea of the Nails Treatment
Topical antifungal treatments are only marginally effective.
Prolonged use of a topical antifungal agent, after clinical response of onychomycosis to an oral agent, may prevent nail re-infection
Terbinafine 250 mg daily for fingernails for 6 weeks, toenails for 12 weeks
Itraconazole 200mg every day for fingernails for 6 weeks, toenails for 12 weeks, or pulse-dosing 200 mg twice daily for 1 week on and 3 weeks off
Fluconazole 300mg once a week for 6-9 months or until the nail is normal.

22. Cutaneuos fungal infections
Description
Fungal Infections a Dermatophyte fungi are main cause
Tinea is the clinical term for dermatophyte infection
Dermatophytes have the ability to infect and survive only on dead keratin that is the top layer of the skin(stratum corneum), the hair and the nails
They cannot survive in the mouth or vagina where the keratin layer does not form.
They are responsible for the vast majority of fungal infections of the skin, nails, and hair
Genetic susceptibility may predispose a patient to infection.

23. Cutaneuos fungal infections
Classifications
Biologic
There are three genera:
Microsporum,
Trichophyton
Epidermophyton.
Origin :
Anthropophilic dermatophytes grow only on human skin, hair, or nails.
Zoophilic varictics originate from animals, but may infect humans.
Geophilic dermatophytes live in soil but may infect humans.

24. Cutaneuos fungal infections
Type of Inflammation
Zoophilic and geophilic dermatophytes elicit a brisk inflammatory response.
Anthropophilic fungi elicit a mild response
Type of Hair Invasion
Some species are able to infect the hair shaft
Endothrix pattern-fungal plac inside hyp the hair shaft.
Ectothrix pattern hac inside fungal hyp and on the surface of the hair shaft.

25. Cutaneuos fungal infections
Body Region
Dermatophytes produce a variety of disease patterns that vary with the location. It is important to know the general patterns of inflammation in different body regions These are:
Tinea of the foot (tinea pedis)
Tinca of the groin(tinea cruris)
Tinea of the body(tinea corporis)
Tinca of the face(tinea faciei).
Tinea of the hand(tinea manuum)
Tinea of the scalp tinea capitis). Tinea of the beard(tinea barbac),
Tinea of the nails(onychomycosis).

26. Tinea the Foot(Tinea Pedis)
Description
The feet are the most common area infected by dermatophytes.
There are many different clinical presentations.
This is also referred to as athlete's History Common in young and middle-aged adults and uncommon in prepubertal children More common in adult men than in Women Predisposing factors Sbocs promote warmth and sweating. which encourage fungal growth Locker room floors contain fungal elements. Communal baths may create an ideal condition for repeated exposure to infected material

27. Tinea the Foot(Tinea Pedis)
History
Common in young and middle-aged adults and uncommon in prepubertal children
More common in adult men than in Women Predisposing factors
Communal baths may create an ideal condition for repeated exposure to infected material

28. Tinea the Foot(Tinea Pedis)
Skin Findings
Tinea of the feet may present with the classic ringworm pattern, but most infections are found in the toe webs or on the soles
There are three classic clinical presentations:
interdigital tinea pedis(toe web infection)
chronic scaly infection of the plantar surface
acute vesicular inca pedis.

29. Tinea the Foot(Tinea Pedis)
Skin Findings…
1. Interdigital Tinea Pedis (Toe Web infection)
The web between the fourth and fifth toes is most commonly involved though any web space may be infected.
Tight-fitting shoes compress the toes, creating a warm, moist environment the webs become dry, scaly, and fissured or white, macerated, and soggy.
Itching is most intense when the shoes and socks are removed.
Lesions out of the web space onto the plantar surface or the dorsum of the feet

30. Tinea pedis 2. Chronic Scaly Infection of the Plantar Surface
Plantar hyperkeratotic or moccasin-type tinea pedis is a chronic form of tinea that is resistant to treatment.
The entire sole is usually infected and covered with a fine,silvery white scale.
The skin is pink and tender, and/or pruritic
Trichophyton rubrum is the usual pathogen

31. Tinea pedis 3. Acute Vesicular Tinea Pedis
A highly inflammatory infection may originate from a more chronic web infection
Vesicles evolve rapidly on the sole or on the dorsal foot.
vesicles may fuse into bullae or remain intact as collections of fluid under the thick scale of the sole,
Secondary bacterial infection occurs,

32. Toenail fungal infection(onychomycosis) may accompany tinea pedis"Id reaction" a second wave of vesicles may follow in the same areas or at distant sites such as the arms, chest, and along the sides of the fingers.
These itchy sterile vesicles represent an allergic response to the fungus and are termed a dermatophytid or id reaction occasionally, the id reaction is the only clinical manifestation of a fungus infection

33. Majocchi's granuloma
Majocchi's granuloma is a deep fungal infection of the hair follicle, typically occurring on the lower legs, more often in women; shaving and superficial trauma are believed to play a role.

34. Tinea of the Body (tinea corporis)
infection infection of the body trunk and limbs is called tinea corporis
History
More common in warm climates
epidemics can occur among wrestlers.

35. Tinea corporis Findings skin
lesions differs in size degree of inflammation, and depth of involvement
Ther are two general clinical patterns f
Roudnd annular lesions (classic ringworm)
Deep inflammatory lesions, geund

36. Round Annular Lesions (Classic Ringworm)
lesions begin as flat scaly papules which slowly develop a raised border that may also expands at variable rates in all directions
Advancing scaly border may have red raised papules or vesicles.
The central area becomes brown or hypopigmented and less scaly as the active border
Red papules may occur in the central area enlarge to seven annular lesions may involve large areas of the body surface
Larger lesions tend to be mildly itchy or asymptomatic

37. Tinea corporis Deep Inflammatory Lesions
Zoophilic fungi from animals such as Trichophyton tensurasum from cattle may produce a very inflammatory skin infection has
The round, intensely inflamed lesion a uniformly elevated, red, boggy, pustular surfacc
The pustules are follicular and represent deep penetration of the fungus into the hair follicle.
Secondary bacterial infection can occur, usually with Staphylococcus aureus.
The process ends with brown hyperpigmentation and scarring.

38. Tinea of the hands ( Tinea Manuum)
Fungal infection of the hand
Children are rarely affected
Itching or moderate minimal or intense or absent
May be insidious and progress slowly over a period of weeks, months or years.

39. Tinea mannum Skin Findings
Tinea involving the dorsal hand has all of The classic features of classic ringworm lesions of the body.
A raised, red, scaly advancing border is
typical Papules or vesicles may be present at the border or in the central area,
Tinea involving the palm has the same appearance as the dry diffuse, keratotic form of tinea on the soles.
Frequently seen in association with tinea pedis
The usual pattern of infection is the involvement of one hand and two feet, or two hands and one foot.
Hyperkeratotic tinea of the palms may be asymptomatic and the patient may be unaware of the infection attributing the dry, thick, scaly surface to hard physical labor

40. Tinea of the Scalp (Tinea capitis)
Description
Tinea of the scalp is caused by the invasion of the stratum corneum and the hair shaft with fungal hyphae.

41. Tinea capitis
History
More than 90% of tinea capitis in the United States is caused by Trichopbyton tonsurans
Tinea capitis occurs most frequently in children,
It is seen in crowded inner cities, especially in African-American or Hispanic people.
It is acquired by close contact with an infected person, often in the same household Spores are shed in the air, and remain viable for long periods on combs, brushes, blankets, and telephones. lu Zoophilic rum canis infection Microspol is acquired from infected household pets (particularly cats).

42. Skin Findings
Trichophyton tonsurans has four different clinical infection patterns. 1. Seborrheic Dermatitis Type
The most common type resembles schorrheic dermatitis
There is diffuse or patchy, fine, white, adherent scale on the scalp.
Adenopathy is often present.
Potassium hydroxide examination is often negative culture is necessary to make diagnosis.

43. Tinea capitis Inflammatory Tinea capitis (Kerion)
One or more inflamed boggy tender areas of alopecia with pustules.
Scarring alopecia may occur.
Fever occipital adenopathy, and leukocytosis may occur.
Treatment may have to be started based on clinical appearance.

44. Tinea capitis Black Dot" Pattern
This is uncommon but highly specific tinea capitis.
Large areas of alopecia are present without inflammation.
There is a mild to moderate amount of scalp scale.
occipital adenopathy may be presen
Arthrospores weaken the hair and cause it to break off at the scalp surface resulting in a "black dot" appearance.

45. Gray patch

46. Tinea capitis Pustular Type
There are pustules or scabbed areas without scaling or significant hair loss.
Cultures and potassium hydroxide wet mounts may be negative.

47. Thank you