Postgraduate Medicine

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Superficial fungal infections

Stephen O. Kovacs & Luciann L. Hruza

To cite this article: Stephen O. Kovacs & Luciann L. Hruza (1995) Superficial fungal infections,
Postgraduate Medicine, 98:6, 61-75, DOI: 10.1080/00325481.1995.11946086

To link to this article: https://doi.org/10.1080/00325481.1995.11946086

Published online: 05 Dec 2017.

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Download by: [UNIVERSITY OF ADELAIDE LIBRARIES] Date: 13 December 2017, At: 23:09
 Symposium
Second of four articles
on skin disorders
Downloaded by [UNIVERSITY OF ADELAIDE LIBRARIES] at 23:09 13 December 2017
Superficial
fungal infections
Getting rid of lesions
that don't want to go away
Preview
Didn't mother always tell you to wear
shower shoes in the locker room? She was
right. Athlete's foot is one of several fungal
diseases that thrive in hot, humid environ-
ments. The human body itself can create
warm, damp conditions where skin folds or
rubs. The authors describe clinical presenta-
tions of fungal infections commonly seen by
primary care physicians, treatment regimens
to relieve patient discomfort, and tips for
daily routine care to prevent recurrence.
VOL 98/NO 6/DECEMBER 1995/POSTGRADUATE MEDICINE • SUPERFICIAL FUNGAL INFECTIONS
Stephen 0. Kovacs, MD
Luciann L.. Hruza, MD
•!• Dermatophytes are the organisms that cause super-
ficial fungal infections in humans. The clinical pic-
ture of a specific infection is related to the part of the
body involved; thus, descriptive terms may refer to the
anatomic area, such as tinea capitis, tinea corporis,
tinea cruris, tinea pedis, and tinea manuum. Derma-
tophyte infections are very communicable through
casual contact with an infected person, animal, or
object. Many species of dermatophytes belong to the
genera of superficial fungal infections: Trichophyton,
Microsporum, and Epidermophyton. However, most
fungal diseases in the United States are caused by only
a few of these species.
Diagnosis involves physical examination, micro-
scopic evaluation of skin scrapings, and culture of
skin lesions. Fungal disease can be diagnosed within
minutes after scraping the active edge of a suspected
lesion onto a microscope slide, adding a drop of 10%
potassium hydroxide solution, and heating. This test
(the KOH preparation) is positive when hyphae (in
fungal infection) (figure 1) or hyphae and spores (in
candida! infection or tinea versicolor) are visualized.
Fungal culture is done by imbedding skin scrapings
into Sabouraud glucose agar. Culture is more sensi-
tive and specific than microscopic KOH evaluation
but requires a 3- to 4-week wait for results.
Once the diagnosis has been made or is strongly
suspected from results of a KOH evaluation, many
oral and topical antifungal agents may be used for
treatment. Oral antifungal agents, such as griseoful-
vin, ketoconazole (Niwral), itraconazole (Sporanox),
and fluconazole (Diflucan), are used to treat tinea
capitis, extensive tinea corporis, and tinea unguium.
Oral agents are also used in patients who are diabetic
or immunocompromised or who respond poorly to
topical antifungals. 1 Some commonly used topical
agents are ketoconazole 2% (Nizoral), oxiconazole
nitrate 1% (Oxistat), dotrimazole 1% (Lotrimin,
Mycelex), and econazole nitrate 1% (Spectazole)
creams.
continued
61
 Tinea capitis lesions are
circumscribed areas of alopecia,
often with fine scales and
sometimes with mild to moderate
erythema at the border.
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Figure 1. Hyphae visualized on low- Figure 2. Black-dot tinea capitis, result- Figure 3. Well-circumscribed, round,
power (x 10) microscopy of potassium ing when Trichophyton tonsurans infection erythematous plaque with central clearing
hydroxide preparation, indicating leads to friable hair shafts and breakage. typical of tinea corporis.
presence of fungal disease.

Although combination creams are available that
include an antifungal and a corticosteroid (Lotrisone,
Mycolog-11, Myco-Triacet II), they have very little
utility in treatment of fungal disease; the steroid
component often prolongs recovery by encouraging
fungal growth and may cause significant atrophy. If a
combination topical agent is used before the diag-
nosis is firmly established, a fungal culture or KOH
preparation may be false-negative, and accurate
diagnosis can be very difficult.
Tinea capitis
Since the 1940s, Trichophyton tonsurans, introduced
into the United States from Central and South Amer-
ica, has become the most prevalent cause of tinea
capitis in this country. T tonsurans infection is the
most common cause of black-dot tinea capitis, which
describes remnant hairs after the organism has
invaded hair shafts and caused them to break off
dose to the scalp (figure 2). Microsporum canis is
Stephen 0. Kovacs, MD
Luciann L. Hruza, MD
Dr Kovacs is a resident in dermatology and Dr Hruza ts an
instructor of medicine, division of dermatology, Washington
University School of Medicine, St Louis.
another common cause of tinea capitis and can pro-
duce fever, pain, and lymphadenopathy.
CUNICAL PRF.SENTI\.TION-The incidence of tinea
capitis has been increasing steadily since the 1970s,
and in the United States, black children are most
often affected. 1 Typical patients are between ages 4
and 14 and are from households of lower socioeco-
nomic status (possibly relating to overcrowding). The
organism is typically spread from child to child or pet
to child. Lesions are circumscribed areas of alopecia,
often with fine scales and sometimes with mild to
moderate erythema at the border of the plaque. In
some children, a delayed inflammatory hypersensitiv-
ity reaction occurs, known as a kerion, which appears
as a boggy, elevated, oozing plaque on the scalp. Tinea
capitis is usually nonscarring, except with severe
secondary bacterial infection or kerion formation.
DIFFERENTIAL DIAGNOSis--Seborrheic dermatitis,
atopic dermatitis, psoriasis, pseudopelade (scarring
alopecia), and alopecia areata are the most important
disorders to exclude.
TREATMENT-Oral treatment with microsized
griseofulvin (Fulvicin U/F, Grifulvin V, Grisactin)
(10 to 20 mg/kg daily for 6 to 8 weeks) is mandatory
for satisfactory results, because topical treatment is
ineffective. If baseline complete blood cell count or
continued on page 68

62 SUPERFICIAL FUNGAL INFECTIONS • VOL 98/NO 6/DECEMBER 1995/POSTGRADUATE MEDICINE

 Excessive perspiration is the
most common predisposing
factor for tinea corporis in adults.
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results of liver enzyme studies are abnormal, caution
should be used in prescribing griseofulvin, and lab-
oratory values should be followed closely. Drug inter-
actions with griseofulvin include increased effects of
alcohol, decreased effects of warfarin sodium (Cou-
madin, Panwarfin, Sofarin), and decreased effi-
cacy of estrogen-containing contraceptives.
Ketoconazole and itraconazole are second-line oral
antifungal agents that may be used for tinea capitis. 3
Liver enzyme and bilirubin levels should be mea-
sured regularly with both agents. These drugs may
increase the effects of warfarin, cyclosporine (Sand-
immune), oral hypoglycemics, and digoxin (Lan-
oxicaps, Lanoxin). In contrast, the effects of keto-
conazole and itraconazole are decreased by rifarnpin
(Rifadin, Rimactane), isoniazid (Nydrazid), pheny-
toin (Dilantin), histamine 2 blockers, and anti-
cholinergics. These two drugs should not be admin-
istered to patients taking astemiwle (Hismanal) or
terfenadine (Seldane) because of the possibility of
cardiac arrhythmias.
A shampoo containing an antifungal agent, such
as selenium sulfide or ketoconazole, may be used
with the oral regimen. Monthly fungal cultures of
the scalp help guide therapy. Treatment of family
members is important, because up to 50% of those
living with an infected child may also be infected. 4
Tinea corporis
The most common causative agents in tinea corporis
are Trichophyton rubrum, Trichophyton mentagrophytes,
andM canis.
CLINICAL PRFSENDITION-Tinea corporis is spread
by contact with an infected person, animal, clothing,
or furniture and occurs most often in children.
Humid environments facilitate infection, and exces-
sive perspiration is the most common predisposing
factor in adults. The typical clinical presentation
consists of round, erythematous, scaly, pruritic
plaques with central clearing distributed on the torso
or extremities (figure 3).
68 SUPERFICIAL FUNGAL INFECTIONS • VOL 98/NO 6/DECEMBER 1995/POSTGRADUATE MEDICINE
DIFFERENTIAL DIAGNOSis-Nummular eczema,
granuloma annulare (indurated plaques without
scales), and drug allergy should be sought.
TREATMENT-Limited involvement with tinea
corporis is treated with a topical antifungal agent
(table 1), such as clotrimazole, econazole, ketocona-
zole, miconazole nitrate 2% (Monistat-Derm,
Micatin), oxiconazole, naftifine hydrochloride 1%
(Naftin), terbinafine hydrochloride 1% (Larnisil), or
ciclopirox olamine 1% (Lo prox). For extensive
involvement, ultramicrosized griseofulvin (Fulvicin
PIG, Grisactin Ultra, Gris-PEG) (0.5 to 1 g daily) or
ketoconazole (200 to 400 mg daily) in divided doses
may be needed. Ketoconazole is contraindicated in
patients taking nonsedating antihistamines.
Tinea cruris
Tinea cruris is caused most often by T rubrum, T
mentagrophytes, or Epidermophyton jloccosum. It is not
uncommon to find a concomitant infection with the
same organism at another body site. Mixed bacterial
and fungal infections in intertriginous sites are also
common.
CLINICAL PRESENTATION-Tinea cruris, also
known as jock itch, affects males much more often
than females. It is acquired by direct physical con-
tact with an infected person or object or by self-
inoculation. Humid climates predispose to the dis-
ease. Obesity, occlusive garments (eg, tight-fitting
pants, athletic supporters), and wet swimsuits can
facilitate dermatophyte growth. 5
The typical presentation consists ofbilateral, asym-
metric, erythematous plaques (figure 4) spreading
peripherally in the medial aspects of the proximal
thighs and the buttocks. Plaques often have central
clearing and an active, erythematous border in which
papules and vesicles may be seen. Patients complain
of pruritus or a burning sensation. Infection in the
groin may spread to the body, causing tinea corporis.
Involvement of the penis or scrotum is not seen in
tinea cruris and suggests candidal infection.
 Tinea cruris may spread from
the groin to the body, causing tinea
corporis, but involvement of the
penis or scrotum suggests candidal
infection.
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Table 1. Topical antifungal therapy for superficial dermatomycoses

Agent Recommended for:

Dermatophyte Candidiasis Tinea versicolor
Polyene
Nystatin (Mycostatin, Nilstat) X

lmidazoles
Clotrimazole 1% (Lotrimin, Mycelex) X X X

Econazole nitrate 1% (Spectazole) X X X

Ketoconazole 2% (Nizoral) X X X

Miconazole nitrate 2% X X X
(Monistat-Derm, Micatin)

Oxiconazole nitrate 1% (Oxistat) X X X

Allylamines
Naftifine HCI 1% (Naftin) X

Terbinafine HCI1% (Lamisil) X

Miscellaneous
Ciclopirox olamine 1% (Loprox) X X X

DIFFERENTIAL DIAGNOSIS-Candidiasis, sebor- Tinea pedis and tinea manuum

rheic dermatitis, erythrasma (an inflammatory reac-
tion to Corynebacterium minutissimum), psoriasis,
benign familial pemphigus, and lichen simplex
chronicus should be ruled out.
TREATMENT-Topical antifungal creams are the
treatment of choice. Clotrimazole, econazole, keto-
conazole, miconazole, oxiconazole, naftifine, terbin-
afine, or ciclopirox olamine should be applied one or
two times daily for 4 weeks. Treatment also includes
use of absorbent powders and loose-fitting garments
to decrease moisture in the groin. An oral antibiotic
is often needed to control mixed bacterial-fungal
infection.
T rubrum, T mentagrophytes, and E floccosum are the
fungal organisms that most commonly affect the feet
and hands. When inflammatory, vesiculobullous
eruptions are present, T mentagrophytes is most often
the infecting agent.
CLINICAL PRESENTATION-Also known as ath-
lete's foot, tinea pedis is the most common fungal
infection in the general population. It occurs most
often in humid environments, especially in the sum-
mer months. Dermatophytes are commonly ac-
quired through infected shower stalls, locker room
floors, or carpeting, and occlusive footwear provides
an excellent environment for growth. Pruritus, burn-
continued on page 13

VOL 98/NO 6/DECEMBER 1995/POSTGRADUATE MEDICINE • SUPERFICIAL FUNGAL INFECTIONS 69

 For tinea pedis, a topical antifungal
should be applied to the total foot
once or twice daily for 3 to 4 weeks.
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ing, interdigital maceration, and fissuring are the
usual complaints. Two presentations of tinea pedis
are common, and both appear in a moccasin-type
distribution: dry, scaly, mildly erythematous plaques
over the plantar aspects (figure 5), and vesiculobul-
lous eruptions with scales. Vesiculobullous tinea
pedis can result from treatment of tinea pedis with
topical steroids (figure 6). When tinea unguiurn is
present, tinea pedis may become chronic because of
persistent reinfection from the toenails. When tinea
pedis is bilateral, involvement of one hand is com-
mon (figure 5).
DIFFERENTIAL DIAGNOSI5--Dyshidrotic eczema,
contact dermatitis, atopic dermatitis, Reiter's syn-
drome, candidiasis, psoriasis, and palmar-plantar
keratoderma should be excluded.
TREATMENT-Occlusive footwear should be
avoided if possible, and socks should be changed
often, especially when they become damp from
perspiration. Application of absorbent powders and
aluminum chloride solutions for hyperhidrosis of
the feet and palms is helpful. Topical antifungals
(eg, clotrimazole, econazole, ketoconazole, micona-
zole, oxiconazole, naftifine, terbinafine, ciclopirox)
are the treatment of choice and are applied to the
total foot once or twice daily for 3 to 4 weeks. Tinea
pedis should always be treated in patients with
peripheral vascular disease, chronic lymphedema,
or diabetes mellitus because of the increased risk
of cellulitis. For fulminant cases of vesicular tinea
pedis, the use of oral antifungal agents is necessary. 6
Chronic tinea pedis secondary to tinea unguium may
require intermittent topical antifungal therapy for
prophylaxis.
Candidiasis
Candida albicans is the most common pathogen
involved in candidiasis.
CLINICAL PRESENTATION-Most of the general
population is colonized by some candida! organisms,
but only patients with symptoms have disease.
VOL 98/NO 6/DECEMBER 1995/POSTGRADUATE MEDICINE • SUPERFICIAL FUNGAL INFECTIONS
. Predisposing factors to candidiasis include antibiotic
therapy, ill-fitting dentures, pregnancy, old age,
immune defects, diabetes mellitus, hypoparathyroid-
ism, hypothyroidism, and iron or zinc deficiency. 7
Major cutaneous manifestations of candidiasis are
intertrigo, folliculitis, paronychia, tinea unguium,
and perioral dermatitis. Cutaneous candidiasis occurs
in moist, intertriginous areas (eg, axillae, groin), and
red plaques with satellite papules or pustules are
pathognomonic (figure 7). Candida! paronychia may
occur in patients whose hands are chronically wet (eg,
house cleaners, meat cutters) and produces erythema,
swelling, and pain. Professional manicurists may
transmit candida! infection from person to person on
contaminated tools.
Mucous membrane involvement includes acute
pseudomembranous candidiasis (thrush) and per-
leche. Perleche is characterized by erythema, pain,
fissuring, and maceration at the corners of the mouth
in patients who lick their lips frequently or wear
dentures.
DIFFERENTIAL DIAGNOSis--Mucositis, drug al-
lergy, leukoplakia, and herpes simplex may mimic
oral candidiasis, whereas tinea or bacterial infec-
tion, erythrasma, seborrheic dermatitis, eczema, and
psoriasis may present similarly to cutaneous candi-
diasis.
TREATMENT-In immunocompetent hosts, oral
candidiasis is effectively controlled with clotrimazole
troches (Mycelex) or nystatin troches (Mycostatin
Pastilles), as well as with swish-and-swallow nystatin
solution (Nilstat). Oral fluconazole may also be used,
in an initial dose of200 mg followed by 100 mg four
times a day for 5 to 7 days. Cutaneous candidiasis is
best treated with topical dotrimazole, econazole,
ketoconazole, miconazole, oxiconazole, nystatin
(Mycostatin, Nilstat), or ciclopirox olamine.
Tinea versicolor
The lipophilic organism Pityrosporum orbiculare is
the sole cause of tinea versicolor. A KOH preparation
continued
73
 Persons with asymptomatic tinea
versicolor may seek medical help
because of an inability to tan
in areas affected by the disease.
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Figure 4. Bilateral, erythematous, scaly

plaques on groin, representing common Figure 6. Bullous tinea pedis, which is
clinical presentation of tinea cruris. secondary to infection with Trichophyton
mentagrophytes or to corticosteroid treat-
ment of tinea pedis.

Figure 5. Scaly, mildly erythematous

plaques in moccasin-type distribution
typical of tinea pedis. This patient's one-
hand, two-foot involvement is also
common in tinea pedis.

of a scraping demonstrates the typical "spaghetti and DIFFERENTIAL DIAGNOSis-Seborrheic dermati-

meatballs" appearance of the hyphae and spores,
which represents the dimorphic fungal and yeast
nature of this organism.
CUNICAL PRESENTATION-Tinea versicolor most
often presents in children and young adults as scaly
hypopigmented or hyperpigmented macules on the
trunk and proximal extremities (figure 8), although
the neck and face may also be involved. Scales are
often very fine and may be produced by scraping the
surface with the edge of a tongue depressor or the
fingernail of a gloved hand (the fingernail sign). 7 The
infection is common in the spring and summer
because humidity and heat are contributing factors.
Sometimes, asymptomatic patients seek help because
of concern over an inability to tan in involved areas,
and even after successful treatment, affected skin may
remain hypopigmented. Tinea versicolor may also
present as folliculitis.
tis, vitiligo, pityriasis alba, and pityriasis rosea should
be ruled out.
TREATMENT-First-line therapy for tinea versi-
color is daily application of selenium sulfide 2.5%
lotion (Exsel, Selsun) from the neck to the knees.
The lotion is left on for 5 to 10 minutes and then
washed off. Treatment is continued for 2 weeks.
Recurrence is common, so some patients benefit fiom
follow-up application of the lotion once or twice a
month. Daily 5-minute application of ketoconazole
shampoo for 2 weeks may be beneficial. Topical
clotrimazole, econazole, ketoconazole, miconazole,
oxiconazole, or ciclopirox olamine may also be used.
Oral ketoconazole in a single 400-mg dose has been
found to be highly effective in treatment of tinea ver-
sicolor but has not been approved by the Food and
Drug Administration for this indication. Recurrence
is also common with this method.

74 SUPERPICIAL FUNGAL INnCnGNS • VOL 98/NO 6/DECEMBER 1995/POSTGRADUATE MEDICINE

 Red plaques with satellite
papules or pustules, often
occurring in intertriginous
areas, are pathognomonic
of candidiasis.
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Summary
Systematic analysis of possible dermatophyte and
candidal skin infections leads to an accurate
diagnosis and prompt treatment with a specific
regimen. The first steps are thorough skin exami-
nation and evaluation with a potassium hydrox-
ide preparation. Tmea corporis, tinea cruris, tinea
pedis, cutaneous candidiasis, and tinea versicolor
can be treated with many topical antifungal
agents, whereas tinea capitis requires oral griseo-
fulvin therapy. Frequendy used topical medica-
tions for tinea and candidal infections include
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VOL 98/NO 6/DECEMBER 1995/POSTGRADUATE MEDICINE • SUPERFICIAL FUNGAL INFECTIONS
Figure 7. Red, scaly plaques with satel-
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intertriginous areas, which are pathogno-
monic of cutaneous candidiasis.
Figure 8. Hypopigmented and hyper-
pigmented macules commonly seen with
tinea versicolor. Scrapings reveal fine
scales.
clotrimazole (Lotrimin, Mycelex), econazole ni-
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-® fun credit on this article. See CME Quiz.
Mailing address: Luciann L. Hruza, MD, 1040 N Mason
Rd, Suite 120, StLouis, MO 63141.
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