Course Code: Course TitleMLS-028

Module #2 Student Activity Sheet

Lesson title: SUPERFICIAL MYCOSES Materials:

Learning Targets:
At the end of the module, students will be able to:
1. classify various agents causing superficial
mycosis according to morphology and mode of
transmission.
2. distinguish specific method used in the identifying
various fungi causing superficial mycosis
3. explain the pathophysiology of various superficial
mycosis.
4. practice consistently on how to prevent and
control superficial mycosis
Module, Reference Book, Manual, Lap top
References:
References:
1. Beneke, Everett (1999). Smith, Ph.D. Scope of
Monograph on Human Mycoses, Kalamazoo, Michigan;
Upjohn Company
2. Bulmer, glenn(1995). Fungus Disease in the Orient,3rd
ed. Manila: Rex Bookstore
3. McPherson and Pincus. (2018). HENRY’s Clinical
Diagnosis and Management by Laboratory Methods 23rd
ed.,Singapore: Elsevier Pte.Ltd.

Internet source:
Biron,Health Group(20211);Superficial Mycoses-Direct
Examination
https://www.biron.com/en/glossary/superficial-mycoses-
culture/
Dermatology Research and Practice Volume 2016
https://www.hindawi.com/journals/drp/2016/9509705/

A. LESSON PREVIEW/REVIEW
Superficial mycoses are fungal infections of the skin, hair, and nail that invade only the stratum corneum
and the superficial layers of the skin.

Introduction
Superficial(surface) mycoses are skin infections caused by fungi and yeasts. The majority of these fungi and
yeasts on the skin are normal. It is their excessive proliferation that can cause lesions, which are usually benign, but
which can affect quality of life (itching, odour, appearance, etc.)
Superficial mycoses are examined in two stages. The first involves a direct microscope examination to detect the
presence of mycelial elements (filaments that indicate the presence of fungi) and Yeasts (Candida). Regardless of the
results of the direct examination, the specimen is then cultured to confirm the presence or absence of potentially
pathogenic fungi and yeasts.

B.MAIN LESSON
SUPERFICIAL MYCOSES
- Limited or confined to the outermost layer of the skin, hair and nails
- Does not invade living tissue
- Causes
✔ Profuse sweating
✔ Poor hygiene
✔ Poor immunity

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 Course Code: Course TitleMLS-028
Module #2 Student Activity Sheet

DISEASES ASSOCIATED WITH SUPERFICIAL MYCOSES

1. Keratomycosis (Keratitis/ Keratomycosis/ Keratitis)

- First described by Leber (Aspergillus species) in 1879
- Major cause of blindness in Asia
- Incidence low in Britain & North USA
- 6-53% of all cases of ulcerative keratitis in Asia
- Can occur alone or coexist with a bacterial infection (14.1%)
(Basak et al. India J. Ophthalmol.2005 Jun;53(2):143)
- Earlier phaeoid fungi (Dematiaceous) not considered to be significant but now are important cause of
keratomycosis.

- Clinical picture:
✔ White corneal plaques with the development of satellite lesions and endothelial plaques

- Etiologic agent:
✔ Yeasts: Candida species
✔ Filamentous fungi: Fusarium, Aspergillus, Alternaria, Curvularia, Penicillium, Mucor

- Pathogenesis:
✔ Fungi gain entry into stroma through a defect in epithelial barrier.
✔ In stroma, cause tissue necrosis & host inflammatory reaction.
✔ Fungus can penetrate deep into stroma & through intact descemet’s membrane.
✔ Blood borne growth inhibiting factors may not reach avascular structures of eye cornea so fungi continues
to grow & persists (i.e. why conjunctival flap help in control of fungal infection)

- Risk Factors:
✔ Trauma (M/C)
✔ Contact lens use: Cosmetic lens – filamentous
Therapeutic lens – Yeasts
Overall bacterial infection more common with contact lens users
✔ Topical medications: Corticosteroids
Broad spectrum antibiotics
✔ Corneal Sx- penetrating keratoplasty, LASIK
✔ Chronic Keratitis – in cases of Herpes simplex, Herpes zoster, Vernal/Allergic keratitis
✔ Immunocompromised State – in cases of HIV, Leprosy

Laboratory Diagnosis:

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 Course Code: Course TitleMLS-028
Module #2 Student Activity Sheet

✔ Stains: Gram stain

Giemsa stain
Grocott’s Methamine silver
PAS stain
Lectins
✔ Fluorescent Microscopy: Acridine orange
Calcoflour white
✔ Smear: Potassium Hydroxide Wet Mount (10-20% KOH)
⮚ Yeast : yeast cells with strands of pseudohyphae
⮚ Filamentous: clear septate hyphae
✔ Culture Media: Should include same media for general infections
For Keratitis Work up: Sheep blood agar
Chocolate agar
Saboraud’s Dextrose agar
Thioglycollate broth
Brain Heart Infusion broth/solid media
✔ NOTE: Positive culture expected in 90% cases: within 72 hours in 83% cases
Within 1 week 97% cases
✔ Increasing humidity of medium by placing inoculated agar plates in plastic bags enhances fungal growth.
✔ Newer methods: Electron microscopy
Polymerase Chain Reaction (PCR)
✔ Scraping:
Advantages: Provide initial debridement of organisms
Improve penetration of drugs
✔ Methods: Surgical blade
Diamond tipped motorized burr
Diagnostic Superficial Keratectomy/Corn Biopsy
Femtosecond Laser
27 guage hypodermic needle ( 6-0 silk culture)
Anterior chamber tap: Hypopyon or endothelial plaque
Note: It is done in minor OT with topical anaesthesia
2-3 mm dermatologic trephine on anterior corneal stroma incorporating both clinically
infected
And adjacent clear cornea. (avoiding visual axis).
- Management:
✔ Antifungals: (note this is true to all fungal infections)
⮚ Polyenes: Amphotericin B, Natamycin
Mode of action : binds to ergosterol in fungal cell membrane & cause the membrane to
become leaky.)
⮚ Azoles: Ketaconazole, fluconazole, Voriconazole
Mode of action: inhibits CYP P450 14 a-demethylase enzyme involved in conversion of
lanosterol to ergosterol
⮚ Pyrimidines: Flusytosine
Mode of action: causes faulty RNA synthesis & non competitive inhibitor of Thymidylate
synthesis
⮚ Allylamines: Terbinafine
Mode of action: Ergosterol Biosynthesis inhibitor
⮚ Echinocandins: Capsofungin, Micafungin
Mode of action: Cell wall synthesis inhibitors, D-glucan synthesis inhibitors

2. Otomycosis/ Mycotic Otitis Externa

- Clinical picture: Chronic fungal infection of the outer ear canal
- Filamentous fungi: Aspergillus, Mucor, Penicillium and Rhizopus
- Microscopic ID: Presence of hyphae or yeast cells
- Organism responsible: Candida albicans, Candida tropicalis
Aspergillus fumigatus, Aspergillus niger

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 Course Code: Course TitleMLS-028
Module #2 Student Activity Sheet

- Symptoms of otomycosis includes: pain, itchiness, redness, hearing loss, discharge from ears, swelling,
physical narrowing of ear canal

3. Piedras (Chignon disease, Tinea nodosa, Biegel’s Disease)

BLACK PIEDRA WHITE PIEDRA

Occurs on scalp Found primarily on facial and genital hairs

Etiologic agent; Piedraia hortae Etiologic agent: Tricosporon beigelii

Microscopic appearance: 10-290% KOH- hard and Microscopic appearance: white nodules lager and softer
black nodules resembling nits of lice

Septate dematiaceous hyphae Septate not dematiaceous

Open nodules containing oval asci with 8 ascospores Hyphae; tend to break into arthospores

4. Tinea nigra/ Keratomycosis nigricans palmaris/ Tinea nigra palmaris/Pytyriasis nigra/Microsporis nigra

- Clinical picture: Superficial infection on the palm of the hands or the sole of the foot
- Etiologic agent: Clasdosporium wernickii or Hortae or Exophiala or Phaeoannellomyces werneckii
- Outstanding Characteristics: 10-20% KOH: Strongly dematiaceous septate hyphae

5. Pityriasis versicolor
- Clinical picture: Patchy brown desquamating rash involving mainly the trunk, arms, shoulder and face “ blotchy
appearance
- Characteristic microscopic appearance: in 10-20% KOH
Clusters of short angular hyphae along with some yeast cells “spaghetti
and meatballs appearance”

CHECK FOR UNDERSTANDING (25 minutes)

Answer the following questions:
1. What was the first fungi that was described by Leber that causes Keratomycosis

2. What is the etiologic agent of White Piedra

3. What is the appearance of the organism causing Pityriasis versicolor

4. Invades the keratinized areas of the body as skin, hair and nails

5. What is the outstanding feature of etiologic agent causing cutaneous mycoses

6. An antifungal in which the mechanism of action is to inhibit CYP P450 14 a-demethylase enzyme

7. What are the 2 species of Candida that causes Otomycosis

8. Clinical picture of Pityriasis versicolor

9. Athletes foot is treated for one to two weeks with?

10. Term used to denote gray colored or dark colored fungi

This document is the property of PHINMA EDUCATION

 Course Code: Course TitleMLS-028
Module #2 Student Activity Sheet

C. LESSON WRAP-UP
Superficial mycosis is a disease of the skin and its appendages caused by fungi. It comprises dermatophytosis,
candidiasis, and pityriasis versicolor .They have the affinity to keratin rich tissues and produce dermal inflammatory
response, intense itching, and cosmetically poor appearance. Superficial mycoses are common worldwide. They are
thought to affect 20% to 25% of the world’s population, and the incidence of superficial mycoses continues to increase. An
etiological agent of superficial fungal infections consists of dermatophytes, yeasts, and nondermatophyte molds.
Dermatophyte is responsible for most superficial fungal infection and the expected lifetime risk of getting a dermatophyte
infection is between 10 and 20.

The dermatophytes are a group of closely related fungi infecting skin, hair, and nails in living host including man.
They produce an infection called dermatophytosis, also known as ringworm or tinea. The skin infections caused by
nondermatophytic fungi are known as dermatomycoses whereas hair and nail are known as piedra and onychomycosis,
respectively.

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