Cutaneous and subcutaneous mycosis

mycosis, plural mycoses, in humans and other animals, an infection

caused by any fungus that invades the tissues, causing superficial,
subcutaneous, or systemic disease. Many different types of fungi can
cause mycosis, and some types, such as Cryptococcus and Histoplasma,
can cause severe, life-threatening infections.

What are cutaneous mycoses?

Cutaneous mycoses are a group of superficial fungal infections affecting
the skin and its appendages, including the hair and nails. The term
mycoses generally refers to an infection caused by fungi, also known as
mycetes, while cutaneous refers to the involvement of the skin.

Fungi are a diverse group of living organisms that can be found nearly
everywhere: in the environment, parasitizing animals and plants; in the
soil; and on and inside the human body. Normally, the fungi that live on
the skin’s surface are relatively harmless, but in certain cases, they may
grow out of control or penetrate the skin through a wound, causing an
infection.

Since fungi thrive in warm, moist environments, cutaneous mycoses are

more likely to affect the feet, groin, armpits, and other skin folds --
body areas that are favorable for fungal growth. Additionally, certain
environmental conditions (e.g., warm and humid climates, crowded
places, communal showers, locker rooms) can provide an excellent
breeding ground for the growth and spread of many fungal diseases.
What causes cutaneous mycoses?
There are several types of fungal infections of the skin. Most cutaneous
mycoses are caused by dermatophytes, a group of filamentous fungi
that colonize and infect keratinized tissues, including the outermost
layer of skin (i.e., stratum corneum), hair, and nails. Dermatophytes are
commonly found in the environment and are spread from one person
to another through direct skin contact or, more rarely, through contact
with an infected animal or soil. Although there are a number of
dermatophyte species, most dermatophyte infections are caused by
fungi of the Trichophyton, Microsporum, and Epidermophyton genera.

Dermatophyte infections of the skin are also called tineas, or ringworm,

due to the ring-like appearance of the skin lesions they typically
produce. Some tineas have distinctive names descriptive of the affected
body part. For instance, tinea corporis (i.e., ringworm) affects the arms,
trunk, and legs; tinea capitis (i.e., scalp ringworm) affects the scalp and
hair shafts; tinea cruris (i.e., jock itch) affects the groin area and inner
thighs; and tinea pedis (i.e., athlete’s foot) affects the feet.

In addition to dermatophytes, cutaneous mycoses may also be caused

by yeasts of the Candida genus. Candida is naturally present on the skin
and mucous membranes. When the amount of Candida is low, it is
harmless, but when it starts to overgrow, it can damage the skin and
nearby tissues, resulting in a superficial skin infection. A weakened
immune system is often the reason for Candida overgrowth. As a result,
candidiasis typically affects individuals with immunosuppressive
conditions (e.g., diabetes, HIV infection), who are more vulnerable to
opportunistic infections.
More rarely, cutaneous mycoses can be due to infection by non-
dermatophytic fungi, like an Aspergillus species. Aspergillus is a family
of molds consisting of many different species, some of which can cause
a condition known as aspergillosis. Cutaneous aspergillosis is a rare
form of locally invasive disease that typically occurs when invasive
aspergillosis spreads to the skin from somewhere else in the body, such
as the lungs. Primary infection of the skin --such as after a surgery,
trauma, or burn wound -- may also occur but is much less common.

What are the signs and symptoms of cutaneous mycoses?

Signs and symptoms of cutaneous mycoses vary depending on the
infectious agent, location of the infection, and severity of the infection.

Tinea infections often present with an itchy rash that has a central
clearing surrounded by an inflamed, scaly border. Also called ringworm,
these lesions have their characteristic ring-like appearance because
they tend to grow in an outward pattern. Despite their characteristic
appearance, tineas may still be hard to distinguish from other
cutaneous mycoses, including Candida infections.

Cutaneous candidiasis often presents as red skin patches with small

satellite lesions that usually affect skinfold areas (e.g., armpits, groin,
under the breasts). Candida can also affect the nails, causing them to
harden and turn yellow.

Finally, cutaneous aspergillosis can present with distinctive skin wounds,

known as eschars, in the affected area.
How are cutaneous mycoses diagnosed and treated?
Many cutaneous mycoses can be diagnosed by their clinical appearance
upon physical examination. However, if the diagnosis is unclear, it may
be confirmed with additional diagnostic tests, including direct
microscopy, fungal cultures, or Wood’s lamp examination.

Microscopic observation of skin scrapings, hair, or nails, is often

performed to detect the presence of fungi. The samples are usually
prepared with a potassium hydroxide (KOH) solution that dissolves the
keratin found in tissues, so the branching filaments of the fungi (hyphae)
or fungal spores can be seen under the microscope. In individuals who
do not respond well to initial treatment, the specimens may be grown
on a Sabouraud dextrose agar plate, a growth medium that supports
fungal growth while limiting the growth of most bacteria. Finally,
Wood’s lamp examination uses an ultraviolet light to detect areas of
fluorescence that may be caused by certain types of fungi.

Treatment of cutaneous mycoses varies depending on the underlying

cause of infection. In general, most cutaneous mycoses require
treatment with antifungal medications (e.g., azole antifungals,
amphotericin, terbinafine). Antifungal medications may be topical or
oral, and the type recommended generally depends on the severity of
the infection. Additional measures that can help prevent repeated
fungal infections include following treatment recommendations closely,
practicing good hygiene, wearing clothing that allows air circulation
next to the skin, and keeping the skin clean and dry.
What are the most important facts to know about cutaneous
mycoses?
Cutaneous mycoses are a group of superficial fungal infections affecting
the skin, hair, and nails. They may be caused by different kinds of fungi,
including dermatophytes, yeasts of the Candida genus, and other non-
dermatophytic fungi. Signs and symptoms depend on the specific fungal
infection. For instance, dermatophyte infections (tineas) present with
itchy, ring-like lesions at the site of infection, while cutaneous
candidiasis can present with a localized rash in skinfold areas. Diagnosis
of cutaneous mycoses is often suspected upon clinical examination of
the lesions, and it can be confirmed with additional tests, including
direct microscopy, fungal cultures, and Wood’s lamp examination. An
individual may reduce their susceptibility to mycoses by practicing good
hygiene, wearing clothing that allows air circulation next to the skin,
and keeping the skin clean and dry. Treatment generally requires
topical or oral antifungal medications.

Subcutaneous Mycosis
The “subcutaneous” mycoses are due to a large and diverse group of
organisms that cause disease when implanted or otherwise introduced
into the dermis or subcutis. Chromoblastomycosis, mycetoma,
sporotrichosis, and lobomycosis are discussed in detail in this section.
Another chronic subcutaneous fungal infection is basidiobolomycosis,
which is caused by Basidiobolus ranarum. Although this organism is an
environmental saprophyte that is found worldwide, the associated
infection occurs most commonly in children living in tropical and
subtropical climates. The most common portal of entry is the skin,
typically after arthropod bites or minor trauma. Clinically, the disease
manifests as a solitary, painless, indurated subcutaneous nodule or
swelling of the thigh or buttock. The classic treatment is saturated
solution of potassium iodide (SSKI; seeCh. 100), although successful
results have been reported with oral azole antifungals and
trimethoprim–sulfamethoxazole. Surgical excision is not recommended.
A related organism,Conidiobolus coronatus, causes an infection that
has similar clinical features but typically affects the face, especially the
nasal region. Although not a true fungal disease, protothecosis is
treated with antifungal agents and is due to implantation.Prototheca
(usuallyP. wickerhamii) is a genus of achlorophyllic algae that can be
introduced into the skin via trauma, often in the setting of exposure to
contaminated water. Common clinical presentations include solitary
cutaneous plaques (sometimes eczematous), nodules or ulcers, as well
as olecranon bursitis. The extremities are the most frequent sites of
involvement. Although immunocompetent patients typically have
chronic, stable disease, patients who are immunocompromised can
have widespread involvement, including algemia. Protothecosis is
difficult to treat; surgical excision and systemic antifungals (e.g.
amphotericin B) are more effective in immunocompetent hosts.
Chromoblastomycosis