Clinics in Dermatology (2010) 28, 197–201

Epidemiology of superficial fungal infections

Mahreen Ameen, MD
St. John's Institute of Dermatology, Guy's and St. Thomas' Hospitals NHS Trust, Westminster Bridge Rd, London SE1 7EH,
United Kingdom

Abstract Fungal infections of the skin, hair, and nails are common worldwide, and their incidence
continues to increase. The principal causative agents are dermatophytes, and their geographic
distribution is variable. This is reflected in the differing patterns of dermatophytoses seen in different
parts of the world. The epidemiology of dermatophyte infection has changed as a result of migration,
lifestyle, drug therapy, and socioeconomic conditions. This contribution discusses global patterns of
dermatophyte infection and the changing epidemiology of the causative agents.
© 2010 Elsevier Inc. All rights reserved.

Introduction
Superficial mycoses are common worldwide. They are
believed to affect 20% to 25% of the world's population, and
the incidence continues to increase.1 They are predominantly
caused by dermatophytes, and the causative species vary with
geographic region. Some species are distributed worldwide,
such as Trichophyton rubrum, T. mentagrophytes var.
interdigitale, Microsporum canis, and Epidermophyton
floccosum. Others have partial geographic restriction, such
as T schoenleinii (Eurasia, Africa), T soudanense (Africa),
T violaceum (Africa, Asia, and Europe), and T concentricum
(Pacific Islands, Far East, and India).
Most cases of tinea unguium, tinea cruris, tinea corporis,
and tinea pedis are caused by T rubrum, which is the
commonest dermatophyte in most developed countries2,3 as
well as in urban areas of some developing countries.4
M canis is the predominant dermatophyte in Central and
Southern Europe as a result of the high rate of tinea capitis. In
Asia, T rubrum and T mentagrophytes are the most
commonly isolated dermatophytes, and as in Europe, this
is as a result of the high prevalence of tinea pedis and tinea
unguium.5,6 In Latin America, Africa, and the Middle East,
the pattern of dermatophyte infection is a much more
E-mail address: mahreenameen@hotmail.com.
variable, and there are some strong regional associations. For
example, M audouinii is the most prevalent pathogen in
Africa overall; however, T violaceum infection is highly
endemic in the horn of Africa as well as in North and South
Africa, and T soudanense infection in northwestern central
tropical Africa.7-9
The epidemiology of dermatophyte infection is likely to
alter with changing patterns of migration, growth in tourism,
and changes in socioeconomic conditions. Dermatophytes
endemic to Asia and Africa, such as T soudanense,
T violaceum, and M audouinii, have increased in frequency
in Europe and North America as a result of migration.
Changes to the epidemiology of causative agents are also a
reflection of changing patterns of dermatophytosis. For
example, a century ago in Europe, tinea capitis was the
principal dermatophytosis, but tinea pedis became far more
common towards the late 20th century, and the incidence of
tinea capitis decreased.
Few studies have investigated the etiology of superficial
fungal infections in the developing world, and consequently,
there is less knowledge of any changes to their epidemiol-
ogy. It is difficult to ascertain reliably the overall incidence
and prevalence of the various skin diseases caused by
superficial mycoses in different parts of the world because
studies of one region of the country may not be a true
representation of the overall disease pattern of that country;
furthermore, incidence and prevalence figures may only be

0738-081X/$ – see front matter © 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.clindermatol.2009.12.005
198
representative of the population sampled, which may have
associated risk factors for infection.
Knowledge of the predominant causative species provides
a clearer understanding of risk factors for superficial fungal
infections and future epidemiologic trends. Improvements in
living conditions have generally been associated with a
decline in zoophilic dermatophyte and an increase in
anthropophilic dermatophyte infections. The epidemiology
of tinea capitis and tinea pedis (together with onychomy-
cosis) has undergone the most radical changes and will
therefore be discussed in detail. Epidemiologic changes in
the prevalence of tinea corporis, tinea cruris, tinea manuum,
and tinea faciei have been less extensively studied. Their
prevalence and the dermatophytes responsible for causing
them may reflect local trends in tinea capitis and tinea pedis,
which may be the source of infection.
In Western Europe, T rubrum is the most frequently
isolated dermatophyte in cases of tinea corporis and tinea
cruris. T rubrum is also the most common cause of tinea
pedis and tinea unguium, which may act as a reservoir of
infection predisposing to tinea corporis or cruris through
autoinoculation. Anthropophilic tinea capitis is often asso-
ciated with tinea corporis, and T tonsurans may therefore
become an important agent of tinea corporis in the future. An
example of the association between tinea capitis and tinea
corporis has occurred in Libya, where T violaceum is
responsible for almost half of all cases of tinea corporis7 and
is probably a reflection of the high prevalence of T violaceum
tinea capitis in the population.10
Tinea capitis
Tinea capitis is the dermatophytosis whose epidemiology
has perhaps changed the most significantly, especially in
Western countries. In many parts of the world, tinea capitis is
the most common superficial mycosis in children of school
age. After the advent of oral griseofulvin in the late 1950s
and improvements in surveillance, there was a marked
decline in its incidence in developed countries.11 In recent
decades, however, its incidence has dramatically increased,
and significant changes have occurred in the dermatophytes
responsible for infection. In the late 19th and early 20th
centuries, M audouinii, followed by M canis, was the main
causative agent in Western and Mediterranean Europe,
whereas T schoenleinii was the predominant agent in Eastern
Europe.12 Anthropophilic dermatophytes, in particular
T tonsurans, have now emerged as the dominant agents in
many regions. T tonsurans has worldwide distribution and
causes principally tinea capitis, but it may also cause tinea
corporis and tinea unguium.
In the United States of America, T tonsurans is now
responsible for up to 50% of all dermatophyte infections and
90% of cases of tinea capitis, replacing Microsporum spp as
the principal agent of tinea capitis.13,14 T tonsurans is
believed to have entered the southwestern United States of
M. Ameen
America from Central America and the Caribbean in the
1950s, and within a decade, it had established itself in urban
regions.13 A survey from Chicago demonstrated its emer-
gence from the mid-1950s.15 A similar pattern emerged in
Canada, and by the mid-90s, the incidence of T tonsurans in
urban regions had increased by more than eightfold within
only a decade and was responsible for almost 80% of all
cases of tinea capitis.16
In the rest of the Americas, the principal agents of tinea
capitis are M canis and T tonsurans. In the southern region
of Brazil, M canis is responsible for 60% of cases.17 In the
northeast, however, T tonsurans accounted for 74% of cases
and M canis for just a fraction of cases of tinea capitis.18 In
Mexico, M canis is the commonest agent, followed by
T tonsurans.19 In Peru, M canis is the most common.20
In Europe, M canis remains the commonest agent for
tinea capitis overall. Its incidence is increasing, and it is the
dominant agent in southern Europe, with countries such as
Austria, Spain, Italy, and Greece reporting the highest
numbers and proportions of M canis cases.21-23 Hungary,
Germany, and Poland also report high incidences of M canis
tinea capitis.24-26 Its main reservoir of infection is cats.
There has been a significant increase in and shift toward
anthropophilic tinea capitis cases, with marked increases in
T tonsurans infection in several European cities. In
Amsterdam, Madrid, Birmingham, and London, it has now
already established itself or is an emerging dominant agent
for tinea capitis.27-30 In Birmingham, T tonsurans repre-
sented 36%, 56%, and 72% of all cases of tinea capitis in
1991, 1992, and 1993, respectively.28 By 2002 in London,
more than 60% of tinea capitis cases were due to
T tonsurans,30 and a more recent United Kingdom study
collating the reports from several centers demonstrated that
T tonsurans comprised 83% of cases of tinea capitis.2
Increasing numbers of previously nonendemic dermato-
phytes have been detected in African immigrants, such as
T soudanense in Austria and the United Kingdom, and
T violaceum in Greece and Italy.2,12,23,31 In France, in
particular in Paris, the main anthropophilic dermatophytes
are those that originate from Africa, such as T soudanense
and M audouinii,32 although there have been epidemics of
T tonsurans infection. In the Netherlands, Sweden, and
Belgium, there have been increases in M canis tinea capitis,
but there are also increases of anthropophilic tinea capitis
caused by T violaceum, T soudanense, and T tonsurans,
which is a reflection of immigration patterns, particularly
from East Africa.29,33,34
The most common species responsible for tinea capitis in
Australia and New Zealand are M canis and T tonsurans.
M canis was previously the dominant agent, but the incidence
of T tonsurans infection has steadily increased.35 In addition
since the early 1990s, T soudanense, T violaceum, and
M audouinii tinea capitis have been increasingly reported
in children who have immigrated from East Africa, in
particular, with evidence for transmission of these agents to
local populations.36,37
Epidemiology of superficial fungal infections
The incidence of tinea capitis in Asia has decreased in
recent decades as a result of improved sanitary and
socioeconomic conditions. Anthropophilic dermatophytes
are the predominant agent of tinea capitis in India: In the
North, T violaceum and M audouinii are the dominant
agents, followed by T schoenleinii and T tonsurans,38 and in
the South, T violaceum is the principal infective agent.39 In
Eastern Nepal, where tinea capitis accounts for only 4.6% of
all dermatophyte infections, T violaceum is responsible for
49%.40 In the rural regions of Western China, T violaceum
and T schoenleinii are the commonest species,41 whereas in
developed cities, such as Shanghai, the predominant species
are M canis, followed by T violaceum and T tonsurans.42
T violaceum, T soudanense, and to a lesser extent,
M audouinii and M langeronii, are the main dermatophytes
responsible for tinea capitis in sub-Saharan Africa. In
general, T violaceum is the principal agent in North and
East Africa, and T soudanense in Central Africa; however,
there are exceptions, and the pattern is likely to be far more
variable. In South Africa, T violaceum is the commonest
cause of tinea capitis in the province of KwaZulu Natal and
was isolated in 90% of cases.8 In neighboring Mozambique,
however, where the prevalence of tinea capitis is 12%,
M audouinii was isolated in 88% of cases.43 In Ethiopia,
where up to 60% of children are affected by tinea capitis,
T violaceum is the dominant agent.9 In central Nigeria,
T soudanense is the dominant dermatophyte responsible for
one-third of cases.44 In the Ivory Coast, T soudanense and
M langeronii were the most prevalent etiologic agents, in
63.6% and 31.3% of cases respectively. In Guinea, another
West African country where T soudanense and M audouinii
had been the principal agents several decades ago,
T violaceum is now responsible for 57% of cases.45
In the Middle East, T violaceum is responsible for most
cases of tinea capitis, accounting for 83% of cases in the
West Bank of Israel and for 39% in Iraq.46,47 In Libya,
T violaceum it is responsible for 64% of cases and M canis is
responsible for 25%. 10 In Saudi Arabia, where the
prevalence of tinea capitis is 22%, the principal causative
agent is M canis.48 In Kuwait, M canis is the predominant
dermatophyte isolated in 62.5% of cases, followed by
T violaceum in 19.3% and T tonsurans in 13.1%.49
Several studies have demonstrated that T tonsurans
infection has had a significant effect on the changing
epidemiology of tinea capitis globally. It appears to have a
predilection for Afro- American and Afro-Caribbean chil-
dren in both North America and Europe.30,50 A study in
London demonstrated that 91% of T tonsurans tinea capitis
occurred in Afro-Caribbean children.30 In Amsterdam,
too, children from the Afro-Caribbean community were
primarily affected.29
The emergence of T tonsurans infection in developed
countries has been attributed to low socioeconomic status,
crowded living conditions, and the sharing of combs.30 The
practice of tight braiding, which may expose the stratum
corneum of scalp skin to fungal spores, and the application of
199
oils, which may adhere to and retain spores, may also
increase the risk of spread.51 Some authors have concluded
that the mechanism of spread and reasons for the emergence
of T tonsurans tinea capitis are still unclear and remain
speculative.12 In addition, T tonsurans can exist as an
asymptomatic carrier state in children, acting as a reservoir of
infection, which may explain its rapid increase in prevalence
in several populations.51
Tinea pedis and onychomycosis
Tinea pedis and onychomycosis are becoming more
common as a result of changes in lifestyle, including
increased urbanization, the use of communal bathing
facilities, and occlusive footwear. The increasing incidence
of diabetes and HIV infection are also important contribu-
tory factors.52 Certain occupations (miners, soldiers) and
recreational activities (marathon runners) place participants
at a higher risk of tinea pedis.53-55 In Europe, there has been
a dramatic increase in the incidence of both tinea pedis and
onychomycosis since the end of World War II, which has
been attributed to the return of soldiers from the Far East.56
The prevalence of tinea pedis and onychomycosis is now
more than 50% in Northern and Central Europe and
approximately 25% in the Mediterranean.57 Tinea pedis is
much more common than onychomycosis. Some studies
suggest that the population prevalence of onychomycosis in
Western societies ranges from 2% to 8%58,59; however,
there appear to be large variations in prevalence, with
reports of 4.1% in Denmark,60 8.0% in Canada,61 and
12.4% in Germany.62
Onychomycosis is caused by dermatophytes, nonderma-
tophyte molds, and yeasts. Dermatophytes are the main
causative agent in temperate climates, and Candida and
nondermatophyte molds in tropical regions. 1 Overall,
dermatophytes are most commonly implicated, accounting
for 90% of toenail infections and 50% of fingernail
infections, and T rubrum is responsible for most cases
worldwide.52 The predominant dermatophytes causing tinea
pedis are T rubrum, followed by T mentagrophytes var
interdigitale and E floccosum. In 2005, these dermatophytes
comprised 90% of isolations in the United Kingdom.2
T rubrum accounts for 66% of all isolated strains in Finland
for 80% to 90% in Germany.57,63 As a consequence of the
marked increased prevalence of tinea pedis and onychomy-
cosis, T rubrum is now the principal dermatophyte in many
European countries.
In the United States of America, T rubrum is the second
most common dermatophyte after T tonsurans. Tinea pedis
and tinea unguium are also common in the rest of the
Americas, comprising 30% and 25%, respectively, of all
superficial dermatophytoses in Mexico, for example.64 In
Australia and Asia too, increased incidences of tinea pedis
and onychomycosis have resulted in prevalences of tinea
pedis that are comparable to that of Europe, and similarly,
200
T rubrum and T interdigitale dermatophytes are the principal
causative agents. There are, of course, considerable varia-
tions. The prevalence of tinea pedis in Singapore is 27%,6
and a 39% incidence was reported in a study from
northwestern China.5 In contrast, tinea pedis is relatively
uncommon in India and is the least prevalent of all the
dermatomycoses.65 In rural Africa too, tinea pedis is
uncommon, which is perhaps a reflection of a lack of
associated risk factors such as the use of occlusive footwear
and associated recreational activities.
Conclusions
The epidemiology of superficial fungal infections has
changed significantly in the last century and reflects changes
in socioeconomic conditions, lifestyle, and migration. With
effective antifungal therapy and improved socioeconomic
conditions, the anthropophilic agents of tinea capitis,
M audouinii and T schoenleinii, have been eradicated from
most developed countries; however, they have been replaced
by the current epidemic of T tonsurans tinea capitis, which
will be a significant challenge to control. T rubrum is the
main causative agent of tinea pedis, tinea unguium, tinea
corporis, and tinea cruris, and given the growing incidence of
tinea pedis and tinea unguium, it is likely to remain the
dominant dermatophyte worldwide. Knowledge of epidemi-
ologic trends of dermatophytoses and understanding their
causation can lead to the implementation of public health
measures to halt the increase in these infections.
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