1. FUNGAL SKIN INFECTIONS
Özlem Akın, M.D.
Yeditepe University Hospital
Dermatology Department

2. Tinea Capitis Ringworm of the scalp
Occurs chiefly in schoolchildren and less commonly in infants and adults
M>F
Hair can be infected with Trichophyton and Microsporum fungi.
M. canis is the commonest dermatophyte fungus to cause tinea capitis. This fungus is zoophilic i.e. it grows naturally on an animal rather than a human. M canis tinea capitis is due to contact with an infected kitten or rarely an older cat or dog.
T. tonsurans has also become a common cause of tinea capitis; this is passed on from one person to another as it naturally infects humans (i.e. it is anthropophilic). It frequently causes no symptoms and is commonly found in adult carriers.

3. Tinea Capitis
Anthropophilic infections such as T. tonsurans are more common in crowded living conditions. The fungus can contaminate hairbrushes, clothing, towels and the backs of seats. The spores are long lived and can infect another individual months later.
Zoophilic infections are due to direct contact with an infected animal and are not generally passed from one person to another.
Geophilic infections usually arise when working in infected soil but are sometimes transferred from an infected animal.

4. Tinea Capitis Tinea capitis may present in several ways.
Dry scaling – like dandruff but usually with moth-eaten hair loss
Black dots – the hairs are broken off at the scalp surface, which is scaly
Smooth areas of hair loss
Kerion – very inflamed mass, like an abscess
Favus – yellow crusts and matted hair
Carrier state no symptoms and only mild scaling (T. tonsurans).

9. Tinea Capitis
Tinea capitis may result in swollen lymph glands at the sides of the back of the neck.
Untreated kerion and favus may result in permanent scarring (bald areas).
It can also result in an id reaction, especially just after starting antifungal treatment.

10. Tinea Capitis Diagnosis
Tinea capitis is suspected if there is a combination of scale and bald patches.
Wood's light fluorescence is helpful but not diagnostic as it is only positive if the responsible organism fluoresces, and fluorescence is sometimes seen for other reasons.
The diagnosis of tinea capitis should be confirmed by microscopy and culture of skin scrapings and hair pulled out by the roots.

12. Tinea Capitis Treatment of carriers
If the child has an anthropophilic infection, all family members should be examined for signs of infection. Brushings of scaly areas of the scalp should be taken for mycology. Sometimes it is best for the whole family to be treated whether or not fungal infection is proven.
It is advisable for parents of classmates and other playmates to be informed so their children may be examined and treated if necessary. In some countries, infected children are not allowed to attend school. Elsewhere children with tinea capitis can attend school providing they are receiving treatment.

13. Tinea Capitis
Carriers may have no symptoms. Treatment of carriers is necessary to prevent spread of infection. Antifungal shampoo twice weekly for four weeks may be sufficient but if cultures remain positive, oral treatment is recommended.
Suitable shampoos include:
2.5% selenium sulfide
1% to 2% zinc pyrithione
2% ketoconazole

14. Tinea Capitis
Tinea capitis requires treatment with an oral antifungal agent.
Griseofulvin is probably the most effective agent for infection with Microsporum canis, Scalp Trichophyton infections may successfully be eradicated using oral terbinafine, itraconazole or fluconazole for 4 to 6 weeks. However, these medications are not always successful and it may be necessary to try another agent.
Intermittent treatment may also be prescribed e.g. once weekly dosages.

15. Tinea Pedis
The feet are the most common area infected by certain fungi called dermatophytes, causing tinea pedis or athlete’s foot. Athlete’s foot is a very common problem experienced by up to 70% of the population at some time in their life.
common in adult males, but uncommon in women.
can also affect children before puberty, regardless of sex. Athlete’s foot seems to occur most often in people who have some characteristic of their immune system which predisposes them to infections regardless of the precautions they take to prevent infection. Once an infection is established, the person becomes a carrier and is more susceptible to recurrences and complications.

16. Tinea Pedis Predisposing factors
exposure to the spores at home or during recreational activities
occlusive footwear
wearing the same pair of socks or shoes for long periods
hyperhidrosis
immune deficiency (e.g. medication such as azathioprine, or infection with HIV)
poor circulation resulting in cold feet e.g. due to lymphoedema

17. Tinea Pedis divided into three categories: Chronic interdigital
Chronic scaly (moccasin type)
Acute vesicular

18. Tinea Pedis Chronic Interdigital Athlete’s Foot
This is the most common type of athlete’s foot.
It is characterized by scaling, maceration, and fissures most commonly in the web space between the 4th and 5th toes.
Tight-fitting, non-porous shoes compress the toes, creating a warm, moist environment in the web spaces.
Many times the infecting fungus interacts with bacteria causing a more severe infection that extends onto the foot.
With this type of athlete’s foot, itching is typically most intense when the socks and shoes are removed.

19. Tinea Pedis Moccasin Type Athlete’s Foot caused by Trichophyton rubrum
This dermatophyte causes dry, scaling skin on the sole of the foot.
The scale is very fine, and silvery, and the skin underneath is usually pink and tender.
The hands may also be infected, although the usual pattern of infection is two feet and one hand, or one foot and two hands.
This type of athlete’s foot is often seen in people with eczema or asthma.
It is associated with fungal nail infections which may lead to recurrent skin infections.

20. Tinea Pedis Acute Vesicular Athlete’s Foot
least common type of athlete’s foot, caused by Trichophyton mentagrophytes
often originates in people who have a chronic interdigital toe web infection.
characterized by the sudden onset of painful blisters on the sole or top of the foot.

27. Tinea Pedis
The diagnosis is confirmed by microscopy and culture of skin scrapings.

28. Tinea Pedis
Treatment
Mild cases, especially interdigital toe web infections, can be treated with topical antifungal creams or sprays such as clotrimazole, ciclopirox, terbinafine, naftifine.
Topical medications should be applied twice a day until the rash is completely resolved.
More serious infections and moccasin type should be treated with oral antifungal medications such as terbinafine or itraconazole for 2 to 6 months.
All oral antifungal medications can affect the liver; therefore, blood tests should be performed monthly to evaluate liver function.

29. Tinea Pedis If treatment is unsuccessful consider whether you have:
Untreated infection eg of the nails (onychomycosis).
Reinfection from contact with spores in your surroundings or clothing.
An untreated infected family member.
An alternative explanation for your symptoms such as dermatitis or psoriasis

30. Tinea Cruris The rash starts in the groin fold usually on both sides.
If the rash advances, it usually advances down the inner thigh.
The advancing edge is redder and more raised than areas that have been infected longer.
The advancing edge is usually scaly and very easily distinguished or well demarcated.
The skin within the border turns a reddish-brown and loses much of its scale.
Tinea cruris caused by T. rubrum does not involve the scrotum or penis.
If those areas are involved, the most likely agent is Candida albicans, the same type of yeast that causes vaginal yeast infections.

32. Tinea Cruris is a fungal infection of the skin in the groin.
The warm, moist environment is the perfect place for the fungus to grow.
Therefore, wearing sweaty, wet clothing in the summer time or wearing several layers of clothing in the wintertime causes an increased incidence.
Men are affected more often than women.

33. Tinea Cruris Differential diagnosis intertrigo erythrasma
seborrheic dermatitis
inverse psoriasis

34. Tinea Cruris Treatment
Mild cases can be treated with topical antifungal creams or sprays such as clotrimazole, ciclopirox, terbinafine, naftifine.
Topical medications should be applied twice a day until the rash is completely resolved (2-4 weeks).
Extensive disease should be treated with oral antifungal medications such as terbinafine (1-2 week) or itraconazole (1 week).

35. Tinea Cruris Prevention:
Wear loose fitting clothing made of cotton or synthetic materials designed to wick moisture away from the surface.
Avoid sharing clothing and towels or washcloths.
Allow the groin to dry completely after showering before covering with clothes.
Antifungal powders or sprays may be used once a day to prevent infection.

36. Tinea Corporis
includes all superficial dermatophyte infections of the skin other than those involving scalp, beard, face, hands, feet and groin.
characterized by one or more circular, sharply circumscribed, slightly erythematous, dry, scaly, usually hypopigmented patches.
an advancing scaling edge usually prominent
progressive central clearing produces annular outlines that give them the name “ringworm”
T. rubrum, M. canis, and T. mentagrophytes are common causes, although it can be cauesed by any of the dermatophytes.

40. Tinea Corporis
The diagnosis is confirmed by microscopy and culture of skin scrapings.
Differential diagnosis:
pityriasis rozea
impetigo
nummular dermatitis
secondary and tertiary syphilids
seborrheic dermatitis
psoriasis

41. Tinea Corporis
Specific topical and oral treatment is the same as that described earlier for tinea cruris

42. Tinea Faciei Fungal infection of the face Frequently misdiagnosed
Typical annular rings usually lacking and the lesions are exquisitely photosensitive
Frequently misdiagnosis of lupus erythematosus is made
Erythematous, slightly scaling, indistinct borders may be present at the periphery of the lesions, and are the best location for KOH examination

44. Tinea Faciei
If topical corticosteroids have been used, fungal foliculitis is a frequent finding.
A biopsy may be required to establish the diagnosis
Usually infection is caused by T. rubrum, M. canis, or T. Mentagrophytes.
If fungal foliculitis is present, oral medication is required.
If no fungal foliculitis is present, infection generally responds well to topical therapy.
Oral agents are appropriate for wide spread infections.

45. Tinea Barbae Ringworm of the beard (=tinea sycosis)
Not a common disease
Occurs chiefly among those in agricultural pursuits, especially those in contact with farm animals
Mostly one-sided on the neck or face
Two clinical types:
Deep, nodular, suppurative lesions
Superficial, crusted, partially bald patches with folliculitis

48. Tinea Barbae Diagnosis: Differential diagnosis: Treatment:
KOH examination
Culture
Differential diagnosis:
Staphylococcal folliculitis (sycosis vulgaris)
Herpetic infections
Treatment:
Like tinea capitis, oral antifungal agents are required
oral agents are used in the same doses and for the same durations as in tinea capitis

49. Tinea Manum
Generally is dry, scaly, and erythematous type that is suggestive of T. rubrum infection
Other areas are frequently affected at the same time
However, moist, vesicular, and eczematous type caused by T. Mentagrophytes, which is seen more often on feet, may at times occur on the hand.
As a rule both hands are involved and eruption tends to be symmetrical

53. Tinea Manum Differential diagnosis: Diagnosis:
Allergic contact or irritant dermatitis
Pompholyx
Atopic dermatitis
Psoriasis
Diagnosis:
KOH examination
Culture

54. Tinea Manum Treatment:
Mild cases can be treated with topical antifungal creams such as clotrimazole, ciclopirox, terbinafine, naftifine.
More serious infections should be treated with oral antifungal medications such as terbinafine 250 mg/day for 2 weeks; or itraconazole, 200 mg twicw daily for 1 week; or fluconazole, 150 mg once weekly for 4 weeks.

55. Onychomycosis Fungal infection of the nails
It is increasingly common with increased age.
It rarely affects children.
Onychomycosis can be due to:
Dermatophytes such as Trichophyton rubrum (T rubrum), T. interdigitale. The infection is also known as tinea unguium.
Yeasts such as Candida albicans.
Moulds especially Scopulariopsis brevicaulis and Fusarium species.

56. Onychomycosis may affect one or more toenails and/or fingernails
most often involves the great toenail or the little toenail.
It can present in one or several different patterns:
Lateral onychomycosis. A white or yellow opaque streak appears at one side of the nail.
Subungual hyperkeratosis. Scaling occurs under the nail.
Distal onycholysis. The end of the nail lifts up. The free edge often crumbles.
Superficial white onychomycosis. Flaky white patches and pits appear on the top of the nail plate.
Proximal onychomycosis. Yellow spots appear in the half-moon (lunula).
Complete destruction of the nail.

60. Onychomycosis
Tinea unguium often results from untreated tinea pedis or tinea manum
It may follow an injury to the nail.
Differential diagnosis:
Bacterial infection especially Pseudomonas aeruginosa, which turns the nail black or green.
Psoriasis
Eczema or dermatitis
Lichen planus
Viral warts
Onycholysis
Onychogryphosis (nail thickening and scaling under the nail), common in the elderly.

61. Onychomycosis
Fingernail infections are usually cured more quickly and effectively than toenail infections.
Mild infections affecting less than 80% of one or two nails may respond to topical antifungal medications but cure usually requires an oral antifungal medication for several months. Combined topical and oral treatment is probably the most effective regime.

62. Tinea Versicolor also known as pityriasis versicolor
superficial fungal infection of the skin that is often confused with other common rashes.
The yeasts, Pityrosporum orbiculare and Pityrosporum ovale, are a part of the normal skin flora. They reside in the stratum corneum and hair follicles and have an affinity for sebaceous glands. Certain factors can cause these yeasts can convert to a pathogenic form known as Malassezia furfur, which causes the rash of tinea versicolor.

63. Tinea Versicolor Some of these predisposing factors include:
Removal of the adrenal gland
Cushing's disease
Pregnancy
Malnutrition
Burns
Steroid therapy
Suppressed immune system
Oral contraceptives
Excess heat
Excess humidity

64. Tinea Versicolor
can occur at any age, but is most common in adolescence and early adulthood, a time when the sebaceous glands are more active
also more common in tropical and semi-tropical climates.
has a recurrence rate of 80% after 2 years.

65. Tinea Versicolor
The rash of tinea versicolor is a hypopigmented, hyperpigmented, or red flat eruption that may coalesce into large patches with an adherent fine scale.
This rash occurs mainly on the trunk, but can also occur on the extremities.
Hypopigmentation occurs because the yeast produces a chemical that turns off the melanocytes, resulting in decreased melanin production.
The hyperpigmentation or redness occur as a result of the inflammatory response in the skin.

69. Tinea Versicolor Diagnosis
A KOH test shows a characteristic "spaghetti and meatballs" appearance under the microscope.
Under a Wood's light examination, the yeast fluoresces pale yellow.
A fungal culture can be performed after adding oil to the culture medium, but it is rarely necessary.

71. Tinea Versicolor Differential Diagnosis: Vitiligo Pityriasis alba
Seborrheic Dermatitis
Syphilis
Pityriasis Rosea
Nummular eczema
Guttate psoriasis

72. Tinea Versicolor Treatment
Because the yeast inhabits the top layer of the skin, topical antifungal medications are very effective.
If the rash is extensive, oral antifungal medications may be needed.
It is important to note that even though the pathogenic yeast has been eradicated after treatment, the hypopigmentation may persist for weeks until the melanocytes start to produce melanin again.
Because this rash has a high recurrence rate, medication may be needed periodically to prevent recurrence.

73. Cutaneous candidiasis
Candidiasis (moniliasis) is skin infection with Candida sp, most commonly Candida albicans. Infections can occur anywhere and are most common in skinfolds and web spaces, on the genitals, cuticles, and oral mucosa. Most candidal infections are of the skin and mucous membranes, but invasive candidiasis is common in immunosuppressed patients and can be life threatening.
Etiology
Candida is a group of about 150 yeast species. C. albicans is responsible for about 70 to 80% of all candidal infections. Other significant species include C. glabrata, C. tropicalis, C. krusei, and C. dubliniensis.
Candida is a ubiquitous yeast that resides harmlessly on skin and mucous membranes until dampness, heat, and impaired local and systemic defenses provide a fertile environment for it to grow.

74. Cutaneous candidiasis
Risk factors for candidiasis include:
Hot weather
Restrictive clothing
Poor hygiene
Infrequent diaper or undergarment changes in children and elderly patients
Altered flora from antibiotic therapy
Inflammatory diseases (such as psoriasis) that occur in skinfolds
Immunosuppression resulting from corticosteroids and immunosuppressive drugs, pregnancy, diabetes, other endocrinopathies (eg, Cushing's disease, hypoadrenalism, hypothyroidism), blood dyscrasias, or T-cell defects

75. Cutaneous candidiasis
Candidiasis occurs most commonly in intertriginous areas such as the axillae, groin, and gluteal folds (eg, diaper rash), in digital web spaces, in the glans penis, and beneath the breasts.
Vulvovaginal candidiasis is common in women
Candidal nail infections and paronychia may develop after improperly done manicures and in kitchen workers and others whose hands are continually exposed to water
In obese people, candidal infections may occur beneath the pannus (abdominal fold).
Oropharyngeal candidiasis is a common sign of local or systemic immunosuppression.
Chronic mucocutaneous candidiasis typically affects the nails, skin, and oropharynx. Patients have cutaneous anergy to Candida, absent proliferative responses to Candida antigen (but normal proliferative responses to mitogens), and an intact antibody response to Candida and other antigens. Chronic mucocutaneous candidiasis may occur as an autosomal recessive illness associated with hypoparathyroidism and Addison's disease (Candida-endocrinopathy syndrome).

76. Cutaneous candidiasis
Symptoms and Signs
Intertriginous infections manifest as pruritic, well-demarcated, erythematous patches of varying size and shape; erythema may be difficult to detect in darker-skinned patients. Primary patches may have adjacent satellite papules and pustules. Perianal candidiasis produces white maceration and pruritus ani. Vulvovaginal candidiasis causes pruritus and discharge
Candidal infection is a frequent cause of chronic paronychia, which manifests as painful red periungual swelling. Subungual infections are characterized by distal separation of one or several fingernails (onycholysis), with white or yellow discoloration of the subungual area
Oropharyngeal candidiasis causes white plaques on oral mucous membranes that may bleed when scraped.
Perlèche is candidiasis at the corners of the mouth, which causes cracks and tiny fissures. It may stem from chronic lip licking, thumb sucking, ill-fitting dentures, or other conditions that make the corners of the mouth moist enough that yeast can grow.
Chronic mucocutaneous candidiasis is characterized by red, pustular, crusted, and thickened plaques resembling psoriasis, especially on the nose and forehead, and is invariably associated with chronic oral candidiasis.

82. Cutaneous candidiasis
Diagnosis
Clinical appearance
Potassium hydroxide wet mounts
Positive culture is usually meaningless because Candida is omnipresent.

84. Cutaneous candidiasis
Treatment:
General hygiene is vital to the treatment of cutaneous candidiasis.
Keeping the skin dry and exposed to air is helpful. Weight loss may eliminate the problem in obese people, and good sugar control in diabetics may also be helpful.
Topical (applied directly to the skin) antifungal medications may be used to treat infection of the skin, mouth, or vagina.
Oral antifungal medications may be necessary for folliculitis, nail infection, or severe candida infections involving the mouth, throat, or vagina.