ACADEMY OF FAMILY PHYSICIANS OF MALAYSIA

POSTGRADUATE DIPLOMA IN
FAMILY MEDICINE

MODULE 13
Dermatology & STI

2nd Edition

Author:

Assoc. Prof. Dr. Chandran Rajagopal

MBBS, FCGP, FRSH,MAMS (Vienna), DRM ,Dip Ven,Dip STD&AIDS,
Diploma in Dermatology, Diplomate in Restorative & Aesthetic Medicine(Miami,
USA), Certified Master trainer AARAM USA,
Fellow American Academy of Dermatology
Fellow American Academy of Restorative & Aesthetic Medicine
Fellow American Academy Aesthetic and Restorative Surgery
Member Academy of Family Physicians of Malaysia
Fellow Indian Academy Medical Specialists(Family Medicine)
Certified Trainer,Teaching of Family Medicine (AFPM)
Certified Physican in management of Estrogen deficiency ,menopause and HRT ,
College of Physicians and Surgeons, University of Columbia,New York

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Chapter 5
Skin Infections Caused by Fungi
Dermatophytes

Approximately 90 per cent of fungal skin infections are caused by 'dermatophytes', which are parasitic fungi
affecting the skin, hair, or nails.

There are three groups of dermatophytes, called Trichophyton (affects skin, hair and nails), Microsporum (a
type of fungus that causes ringworm epidemics in children) and Epidermophyton (A fungal which grows on
the outer layer of the skin and is the cause of tinea). These infections are mostly seen after puberty with the
exception of Tinea capitis, which is a fungal infection involving scalp hair, seen in children.

Dermatophytes also produce what is widely known as 'Ringworm', in which the fungi limit themselves to dead
Keratin, a protein found on the skin.

Fungi that have developed to live on animals can also infect us, and will usually cause much more
inflammation and redness because our immune system sees them as a foreign invasion and goes into attack.

Other skin infections are caused by yeasts such as Candida. Another known as Malassezia furfur, or
Pityrisporum ovalae, is a type of fungus that causes brownish patches on the skin This particular yeast resides
on skin that has a high (oily) sebum content such as the face, scalp and chest. It is responsible for dandruff of
the scalp as well as a rash on the body called Tinea versicolor. Candida can also settle in the moist folds of
skin, and is found normally in the skin.

Description:

Dermatophytosis (tinea or ringworm) of the scalp, glabrous skin, and nails is caused by a closely related group
of fungi known as dermatophytes which have the ability to utilise keratin as a nutrient source, i.e. they have a
unique enzymatic capacity [keratinase].

The disease process in dermatophytosis is unique for two reasons: Firstly, no living tissue is invaded the
keratinised stratum corneum is simply colonised. However, the presence of the fungus and its metabolic
products usually induces an allergic and inflammatory eczematous response in the host.

The type and severity of the host response is often related to the species and strain of dermatophyte causing the
infection. Secondly, the dermatophytes are the only fungi that have evolved a dependency on human or animal
infection for the survival and dissemination of their species.

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Clinical manifestations:

The common anthropophilic species are primarily parasitic on man (Table 1). They are unable to colonise
other animals and they have no other environmental sources. On the other hand, geophilic species normally
inhabit the soil where they are believed to decompose keratinaceous debris.

Some species may cause infections in animals and man following contact with soil. Zoophilic species are
primarily parasitic on animals and infections may be transmitted to humans following contact with the animal
host (Table 1).

Zoophilic infections usually elicit a strong host response and on the skin where contact with the infective
animal has occurred ie arms, legs, body or face.

Table 1. Ecology of Common Human Dermatophyte Species.

Species Natural habitat Incidence

Epidermophyton floccosum Humans Common

Trichophyton rubrum Humans Very Common

Trichophyton interdigitale Humans Very Common

Trichophyton tonsurans Humans Common

Trichophyton violaceum Humans Less Common

Trichophyton concentricum Humans Rare*

Trichophyton schoenleinii Humans Rare*

Trichophyton soudanense Humans Rare*

Microsporum audouinii Humans Less Common*

Microsporum ferrugineum Humans Less Common*

Trichophyton mentagrophytes Mice, rodents Common

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 Trichophyton equinum Horses Rare

Trichophyton erinacei Hedgehogs Rare*

Trichophyton verrucosum Cattle Rare

Microsporum canis Cats Common

Microsporum gypseum Soil Common

Microsporum nanum Soil/Pigs Rare

Microsporum cookei Soil Rare

* Geographically restricted.

Tinea pedis

Infections by anthropophilic dermatophytes are usually caused by the shedding of skin scales containing viable
infectious hyphal elements [arthroconidia] of the fungus. Desquamated skin scales may remain infectious in
the environment for months or years. Therefore transmission may take place by indirect contact long after the
infective debris has been shed.

Substrates like carpet and matting that hold skin scales make excellent vectors. Thus, transmission of
dermatophytes like Trichophyton rubrum, T. interdigitale and Epidermophyton floccosum is usually via the
feet. In this site infections are often chronic and may remain subclinical for many years only to become
apparent when spread to another site, usually the groin or skin.

It is important to recognise that the toe web spaces are the major reservoir on the human body for these fungi
and therefore it is not practical to treat infections at other sites without concomitant treatment of the toe web
spaces. This is essential if a "cure" is to be achieved. It should also be recognised that individuals with chronic
or subclinical toe web infections are carriers and represent a public health risk to the general population, in that
they are constantly shedding infectious skin scales.

Tinea pedis caused by T. rubrum. Sub-clinical infection (left) showing mild maceration under the little toe and
more severe infection showing extensive maceration of all toe web space

Tinea is transmitted via the feet by desquamated skin scales in substrates like carpet and matting.

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Tinea cruris

Tinea cruris refers to dermatophytosis of the proximal medial thighs, preum and buttocks. It occurs more
commonly in males and is usually due to spread of the fungus from the feet. Thus the usual causative agents
areT. rubrum, T. interdigitale and E. floccosum.

Tinea unguium (dermatophyte onychomycosis)

Trichophyton rubrum and T. interdigitale are the dominant dermatophyte species involved. In countries like
Australia, UK and USA the incidence of dermatophyte onychomycosis has been estimated to be about 3% of
the population, increasing up to 5% in the elderly, with some subgroups such as miners, servicemen and
sportsmen etc having an incidence of up to 20% due to the use of communal showers and changing rooms.

It is important to stress that only 50% of dystrophic nails have a fungal aetiology, therefore it is essential to
establish a correct laboratory diagnosis by either microscopy and/or culture, before treating a patient with a
systemic antifungal agent.

Dermatophyte onychomycosis may be classified into two main types; (1) superficial white onychomycosis in
which invasion is restricted to patches or pits on the surface of the nail; and (2) invasive, subungual
dermatophytosis in which the lateral, distal or proximal edges of the nail are first involved, followed by
establishment of the infection beneath the nail plate. Distal subungual onychomycosis is the most common
form of dermatophyte onychomycosis. The fungus invades the distal nail bed causing hyperkeratosis of the
nail bed with eventual onycholysis, and thickening of the nail plate.

As the name suggests, lateral subungual onychomycosis begins at the lateral edge of the nail and often spreads
to involve the entire nail bed and nail plate. In proximal subungual onychomycosis, the fungus invades under
the cuticle and infects the proximal rather than the distal nail bed causing yellowish-white spots which slowly
invade the lunula and then the nail plate.

Tinea corporis

Tinea corporis refers to dermatophytosis of the glabrous skin and may be caused by anthrophophilic species
such as T. rubrum usually by spread from another body site or by geophilic and zoophilic species such as M.
gypseumand M. canis following contact with either contaminated soil or an animal host

Tinea capitis

Tinea capitis refers to dermatophytosis of the scalp. Three types of in vivo hair invasion are recognised:

1. Ectothrix invasion is characterised by the development of arthroconidia on the outside of the hair shaft. The
cuticle of the hair is destroyed and infected hairs usually fuoresce a bright greenish yellow colour under
Wood's ultraviolet light. Common agents include M. canis, M. gypseum, T. equinum and T. verrucosum.

2. Endothrix hair invasion is characterised by the development of arthroconidia within the hair shaft only. The
cuticle of the hair remains intact and infected hairs do not fluoresce under Wood's ultraviolet light. All
endothrix producing agents are anthropophilic eg T. tonsurans and T. violaceum.

3. Favus usually caused by T. schoenleinii, produces favus-like crusts or scutula and corresponding hair loss.

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Laboratory diagnosis

Clinical Material

Skin Scrapings, nail scrapings and epilated hairs. For a laboratory diagnosis, clinicians should be aware of the
need to generate an adequate amount of suitable clinical material. Unfortunately many specimens submitted
are either of an inadequate amount or are not appropriate to make a definitive diagnosis. The laboratory needs
enough specimen to perform both microscopy and culture. Routine turn around times for direct microscopy
should be less than 24 hours, however culture may take several weeks.

In patients with suspected dermatophytosis of skin [tinea or ringworm] any ointments or other local
applications present should first be removed with an alcowipe. Using a blunt scalpel, tweezers, or a bone
curette, firmly scrape the lesion, particularly at the advancing border. In cases of vesicular tinea pedis, the tops
of any fresh vesicles should be removed as the fungus is often plentiful in the roof of the vesicle.

In patients with suspected dermatophytosis of nails [onychomycosis] the nail should be pared and scraped
using a blunt scalpel until the crumbling white degenerating portion is reached. Any white keratin debris
beneath the free edge of the nail should also be collected.

Skin and nail specimens may be scraped directly onto special black cards which make it easier to see how
much material has been collected and provide ideal conditions for transportation to the laboratory.

Black collection cards showing a suitable amount of nail material for a good sample.

It must be stressed that up to 30% of suspicious material collected from nail specimens may be negative by
either direct microscopy or culture. A positive microscopy result showing fungal hyphae and/or arthroconidia
is generally sufficient for the diagnosis of dermatophytosis, but gives no indication as to the species of fungus
involved. Culture is often more reliable and permits the species of fungus involved to be accurately identified.
Repeat collections should always be considered in cases of suspected dermatophytosis with negative
laboratory reports.

Culture

Specimens should be inoculated onto primary isolation media, like Sabouraud's dextrose agar containing
cycloheximide (actidione) and incubated at 26-28C for 4 weeks. The growth of any dermatophyte is
significant.

Serology

Not required for diagnosis.

Identification

Characteristic clinical, microscopic and culture features. See descriptions of individual species for details.

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Causative agents:

Epidermophyton floccosum, Microsporum audouinii, Microsporum canis, Microsporum canis var. disortum,
Microsporum cookei, Microsporum equinum, Microsporum ferrugineum, Microsporum fulvum, Microsporum
gallinae, Microsporum gypseum, Microsporum nanum, Microsporum persicolor, Microsporum sp.,
Trichophyton concentricum, Trichophyton equinum, Trichophyton mentagrophyes var. nodulare,
Trichophyton mentagrophytes var. erinacei, Trichophyton mentagrophytes var. interdigitale, Trichophyton
mentagrophytes var. mentagrophytes, Trichophyton mentagrophytes var. quinckeanum, Trichophyton rubrum,
Trichophyton rubrum downy strain, Trichophyton rubrum granular strain, Trichophyton schoenleinii,
Trichophyton soudanense, Trichophyton sp., Trichophyton tonsurans, Trichophyton verrucosum,
Trichophyton violaceum

Management

Treatment of dermatophytosis is often dependant on the clinical setting. For instance uncomplicated single
cutaneous lesions can be adequately treated with a topical antifungal agent, however topical treatment of scalp
and nail infections is often ineffective and systemic therapy is usually needed to cure these conditions. Chronic
or widespread dermatophyte infections, acute inflammatory tinea and "Moccasin" or dry type T.
rubrum infection involving the sole and dorsum of the foot usually also require systemic therapy. Ideally,
mycological confirmation of the clinical diagnosis should be gained before systemic antifungal treatment is
commenced. Oral treatment options for dermatophytosis are listed below (Table 2).

Table 2. Oral treatment options for cutaneous fungal infections.

Infection Recommended Alternative

Terbinafine 250 mg/day
Tinea unguium
6 weeks for finger nails,
[Onychomycosis]
12 weeks for toe nails.
Griseofulvin 500mg/day
Tinea capitis [not less than 10 mg/kg/day]
until cure [6-8 weeks].
Griseofulvin 500 mg/day until
cure [4-6 weeks], often
Tinea corporis
combined with a topical
imidazole agent.
Tinea cruris Griseofulvin 500 mg/day
until cure [4-6 weeks].
Griseofulvin 500mg/day
Tinea pedis
until cure [4-6 weeks].
Chronic and/or
widespread Terbinafine 250 mg/day
non-responsive for 4-6 weeks.
tinea.
Itraconazole 200 mg/day/3-5 months or 400 mg/day for one
week per month for 3-4 consecutive months.
Fluconazole 150-300 mg/ wk until cure [6-12 months].
Griseofulvin 500-1000 mg/day until cure [12-18 months].
Terbinafine 250 mg/day/4 wks.
Itraconazole 100 mg/day/4wks.
Fluconazole 100 mg/day/4 wks
Terbinafine 250 mg/day for 2-4 weeks.
Itraconazole 100 mg/day for 15 days or 200 mg/day for
1week.
Fluconazole 150-300 mg/week for 4 weeks.
Terbinafine 250 mg/day for 2-4 weeks.
Itraconazole 100 mg/day for 15 days or 200 mg/day for
1week.
Fluconazole 150-300 mg/week for 4 weeks.
Terbinafine 250 mg/day for 2-4 weeks.
Itraconazole 100 mg/day for 15 days or 200 mg/day for
1week.
Fluconazole 150-300 mg/week for 4 weeks.
Itraconazole 200 mg/day for 4-6 weeks.
Griseofulvin 500-1000 mg/day until cure [3-6 months].

Please consult the relevant product information sheet for prescribing details.

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 Further reading:

Hay, R.J. 1992. Clinical manifestations and management of superficial fungal infection in the compromised
patient. In Fungal Elewski, B.E. 1992. Cutaneous fungal infections. Topics in dermatology. Igaku-Shoin,
New York and infection in the compromised patient, edited by D.W. Warnock and M.D. Richardson. John
Wiley & Sons.

Kwon-Chung, K.J. and J.E. Bennett. 1992. Medical Mycology. Lea & Febiger, Philadelphia and London.

MacKenzie, D.W.R., W. Loeffler, A. Mantovani and T. Fujikura. 1986. Guidelines for the diagnosis,
prevention and control of dermatophytosis in man and animals. World Health Organisation
WHO/CDS/VPH/86.67. Geneva, Switzerland.

Oral

Intertrigo (inflammatory skin disease involving body folds)

Vulvovaginitis

Diaper rashes

Paronychia

Chronic Mucocutaneous Candidiasis

1) Oral Candida

Also known as oral thrush.

Commonly seen in the first year of life on the inner cheeks and along the gums and roof of the mouth.
Cream-coloured crumbling curd-like white patches, which can be easily removed by scraping off the surface,
leaving a red base.
May cause some ulceration and erosion in those who are immunosuppressed.
May extend down the throat into the pharynx and esophagus.
May be seen in combination with herpes, and is more common in those who are neutropenic (blood disorder)
or who have AIDS.

a) Acute Atrophic Candidiasis - patients usually complain of soreness in the mouth.May show as a smooth
patch of skin on the tongue. Most commonly seen after the use of oral antibiotics or HIV infection.
b) Leukoplakia - this will be a persistent, firm, irregular, white patch particularly seen on the cheek and
tongue.
Leaves a slightly sore, roughened, surface
More common in men who are middle aged.
Increased risk if you smoke or have a condition called Chronic Mucocutaneous Candidiasis (skin and mucous
involvement).

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c) Angular Cheilitis - this is seen in the corners of the mouth with redness.
Affected area is often sore, usually caused by a fold of skin at the corners of the mouth retaining moisture.
More common if you have had dental work or wear dentures.

3) Vulvovaginitis

2) Intertrigo
 This occurs in the flexures or folds of the skin.
 Usually seen in those who are overweight.
 There is redness and moisture in the skin fold.
 Small pustules (round raised area of inflamed skin filled with pus) or papules (a protuberance) that
situate around the main area of redness.
 You may experience peeling, itching and soreness
 Can be confused with seborrheic dermatitis, psoriasis, Hailey-Hailey, or Darier's disease. - vaginal
yeast or thrush is common.

 Usually soreness and itching, with a thick, cream or white discharge.

 There is pain on intercourse.

 In some individuals there may be just redness. Rashes can sometimes extend on to the groin area.
 Common with pregnancy and increases in frequency in those using the birth control pill.
 When condition is chronic the skin may have a thin glazed atrophic appearance.
 In men, there is inflammation of the head of the penis (balanitis), and often small red papules or
sometimes pustules.
· Commonly flares after sexual activity, with some soreness and signs and symptoms can occur
intermittently.

4) Diaper Candidiasis

- sometimes seen in babies who have diaper rashes; however, not all diaper rashes are caused by
Candida.

 When Candida is present there are often small fragile pustules. These pustules are often dry and peel,
leaving a scaling on the fringe. This produces small satellites around the main area of the rash.

 There is a rare condition called acrodermatitis enteropathica. This is secondary to zinc deficiency. This
should always be considered when a diagnosis of diaper Candida is made. Occasionally there is a
condition called nodular granulomatous Candida.

 It is also called granulomatous gluteale infantum. This is seen as firm reddish nodules that may be as
large as 1-2cm, and is normally seen on the vulva and buttocks.

 There may not be much else to see on the skin and it may occur after the majority of the rash has
cleared. Most of the time this will clear spontaneously over time.

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5) Paronychia

- this Candida infection around the nails is usually seen in those who have their hands in water or in
those who are in contact with and handle food.

Common in pastry chefs as food or organic debris encourages the yeasts to grow.

The area around the nail is usually red and swollen and the cuticle has disappeared.

There is sometimes a pustular discharge and the site will be tender. In time the nail will discolour and will lift
off the nail base and produce what is called lateral onycholysis.

6) Chronic Mucocutaneous Candidiasis

- this is a persistent Candida infection, that is unresponsive to medical treatment.

Appears in the mouth and the skin.

Usually starts during infancy or childhood. May be accompanied with a persistent oral thrush, which
sometimes can be hypertrophic, (increase in size) or it can produce thickened plaques in the mouth.

Others will present with an intertrigo flexural persistent Candida infection (inflamed skin surfaces)There are
some who will show chronic paronychia with redness around the nail folds.

This is a genetic condition, that can be either recessive or dominant. It can also be secondary to a number of
endocrine disorders such as hypothyroidism or hypoparathyroidism.

There is also a late onset variant that is seen in individuals with connective tissue disease such as systemic
lupus.

The immunological defects are usually seen in those who have white cells that are unable to phagocytose (kill)
yeasts.

The defects will be seen in polymorphs (immune system) and macrophage (healing) function. There is usually
a deficiency in the enzyme found in white blood cells (myeloperoxidase).

Topical treatment: When fungus affects the skin of the body or the groin, many antifungal creams can clear
the condition in around two weeks. Examples of such preparations include those that
contain clotrimazole(Cruex cream, Desenex cream, Lotrimin cream, lotion, and
solution),miconazole (Monistat-Derm cream), ketoconazole (Nizoral cream), econazole
(Spectazole), naftifine (Naftin), and terbinafine (Lamisil cream and solution).

These treatments are effective for many cases of foot fungus as well. Many of these antifungal creams are
available as over-the-counter preparations. It is usually necessary to use topical medications for at least two
weeks.

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Oral treatment options for cutaneous fungal infections.

Itraconazole 200 mg/day/3-5 months or 400 mg/day for one

Terbinafine 250 mg/day
6 weeks for finger nails, week per month for 3-4 consecutive months.
12 weeks for toe nails. Fluconazole 150-300 mg/ wk until cure [6-12 months].
Griseofulvin 500-1000 mg/day until cure [12-18 months].

Tinea unguium
[Onychomycosis]

Griseofulvin 500mg/day Terbinafine 250 mg/day/4 wks.

Tinea capitis [not less than 10 mg/kg/day] Itraconazole 100 mg/day/4wks.
until cure [6-8 weeks]. Fluconazole 100 mg/day/4 wks

Griseofulvin 500 mg/day until

Terbinafine 250 mg/day for 2-4 weeks.
cure [4-6 weeks], often
Tinea corporis Itraconazole 100 mg/day for 15 days or 200 mg/day for 1week.
combined with a topical
Fluconazole 150-300 mg/week for 4 weeks.
imidazole agent.

Terbinafine 250 mg/day for 2-4 weeks.

Griseofulvin 500 mg/day
Tinea cruris Itraconazole 100 mg/day for 15 days or 200 mg/day for 1week.
until cure [4-6 weeks].
Fluconazole 150-300 mg/week for 4 weeks.

Terbinafine 250 mg/day for 2-4 weeks.

Griseofulvin 500mg/day
Tinea pedis Itraconazole 100 mg/day for 15 days or 200 mg/day for 1week.
until cure [4-6 weeks].
Fluconazole 150-300 mg/week for 4 weeks.

Chronic and/or
widespread Terbinafine 250 mg/day Itraconazole 200 mg/day for 4-6 weeks.
non-responsive for 4-6 weeks. Griseofulvin 500-1000 mg/day until cure [3-6 months].
tinea.

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