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FUNGAL INFECTION

Lies Marlysa Ramali, dr. SpKK(K)


Dermatology-Venereology Department
Faculty of Medicine Padjadjaran University/
Dr. Hasan Sadikin Hospital

MYCOSES
Superficial Subcutaneous
Deep/systemic
Involving
stratum
corneum,
hair, nails.

Involving
dermis
and/ or
subcutaneous
tissue

Hematogenous
spread of
pathogeni
c or
opportunic
organism

Superficial Fungal
Infection

Superficial mycoses
1. Non-dermatophytes fungal infection:
Pytiriasis versicolor
Black/white piedra
Tinea nigra palmaris
2. Dermatophyte fungal infection:
Tinea capitis
Tinea corporis, etc.
3. Candida infection.

Introduction
Superficial mycoses involving skin (stratum corneum),
nails, and hair.
Tropical

country : high prevalence

Influenced
Prevalence

by predisposing factors

at RSHS:
10.5 -11 % patient of dermatologyvenereology clinic
58.94 %
dermatofitosis
33.55 %
pitiriasis versikolor

Tinea (Pityriasis) versicolor


Def: * superficial fungal infection of the skin
* E/: Ragi/yeast: Malassezia sp. (M.furfur,
M.pachydermatis, M.sympodialis,
M.obtusa, M.globosa, M.restricta,
M.slooffiae, M nana, M.dermatis,
M.yamatoensis, M.caprae)
* Fungi : saprophyte
* predisposing factors:
endogenous: genetic
Exogenous : weather (warm),

Pathogenesis
Saprophytic yeast

Converts to

Predominantly
parasitic mycelial
form associated
with clinical
diseases

Transition influenced

Exogen: warm

by:

humidity

Endogen: heredity

Cushings

disease
Immunosupressi
on
malnourished
state

Clinical manifestation
Mild, chronic, asymptomatic(-)
Predilection: all part of the body, >>
trunk, axilla, face, neck
Fine scale patch: vary in color

Laboratory Findings
1. Woods lamp : orange-yellowish
fluorencent
2. 10% KOH preparation (20% KOH+ Parker
Ink):
Short cigar-butt hyphae (spaghetti and

meatballs)

Roud spores >

Differential diagnosis
Most likely:
Pityriasis alba
Pityriasis rosea
Seborrheic dermatitis
Dermatophyte infections
Consider
Erythrasma
Vitiligo
Psoriasis
Pityriasis rubra pilaris

TREATMENT
Topical: - 25%Na tiosulfat solution
- 1%-2% Azole derivative cream,
- Terbinafine cream
- Selenium sulfide (1.8-2.5%)
shampoo
- 2% ketokonazole shampoo
Systemic: (with extensive, reccurent disease),
- Ketokonazole 200 mg 7-10 days p.o
- Ketokonazole 400 mg single dose
- Itrakonazole 200-400 mg 3-7 days

Pityriasis
versicolor

Pityriasis versicolor

Woods Lamp

Laboratory examination
Skin Scrapping

Laboratory examination
KOH preparation

Laboratory examination KOH


preparation

Malassezia sp.

Malassezia sp.

DERMATOPHYTOSIS
- Skin, nail, hair >>> Kronik
-Fungal infection cause by dermatophytes
fungi:
E/ Dermatophytes : Microsporum sp.
Habitat:
Geophilic
Trichophyton sp.
: Zoophilic
Epidermophyton
:
Terminology
based onsp.anatomical
Antropophilic
site

t.kapitis

t.fasialis *
t.barbae

t.
t.
t.
t.
t.

korporis/glabrosa
kruris
manus
pedis
unguium

Patogenesis
Fungi eukariotic
Antigenic substance

Stratum corneum

microlesion,
hydration,
maseration

arthroconidia attachment with


keratinocyte ( 4-6 hours) germination
7 days
Hyphae penetration tissue damage
1-3 weeks

Extention of the lesions

Skin lesion
Geophilic/zoophilic : acute, severe: erythema,
edema, vesicles.
Antropophilic : chronic, scales,
hyperpigmentation
Initial lesion as erythematous papules
extend to periphery

x
central
healing
konfluen

- Well-defined
- raised - anular
Active border
- erythema, papules

Sometimes
polycyclic
shape

TINEA CAPITIS
> > children , there are 3 clinical
manifestation:
1. Grey patch ringworm (> M.canis)
woods light
- Scaly, gray patches
f+
- hairs broken off several mm from scalp
2. Black dot ringworm
f- black dot patches
- hairs broken off at the level of scalp

TINEA KORPORIS

Affected glabrous skin, except face, hands,


feet, and tinea cruris area.

TINEA KRURIS

Affected
inguinalm,
buttocks,
perineum, and perianal.

TINEA MANUS
Affected palm and hands

pubis,

TINEA PEDIS
1. Interdigital type scaling, erythema, and
maceration of the interdigital and subdigital skin
of the feet, and in particular between the lateral
3rd and 4th and 5th toes
2. Dyshydrotic type: vesicles , pustules
3. papulo-squamous hyperkeratotic
- soles and lateral and medial aspect of the
feet. - patchy or diffuse scaling

ONIKOMIKOSIS
1. Onikomikosis sub ungual distalis
(OSD/OSDL)
2. Onikomikosis sub ungual proksimal (OSP)
3. Onikomikosis superfisial putih (OSPT)
4. Onikomikosis kandida (OK)
# 1 s/d 4 ODT
total)

(Onikomikosis distrofik

# Endoniks
T. unguium -e/dermatophytes
ONIKOMIKOSIS

Dermatophytosis lab examination


1. Woods lamp:
T. capitis
2. Microscopic: 10%KOH
20% KOH + Parker ink blueblack

hifa

artrospora

3. Culture: Sabouraud glucose agar : 2Mg-1


Bl.
4. Biopsi/PA for nails.

Sample
- Skin
- Nails
- Hairs
Skin clean up with 70%alcohol cotton
swab
- scrape the lesion from the center to
the edge.
- Choose active lesion
- Micr : Long branched, septated
hyphae,
arthrospores
DOUBLE
CONTOUR

Hair: plucked hair and placed on a glass


slide 10%-20% KOH.
- Micr : Endotrix
Ectotrix

Nails cut nail and soak nail and nail


debris in 20-40%KOH for 24hours
- Dermatophytes : long hyphae
- Candidosis : yeast cells,
budding cell

Dermatophytosis treatment
a. General : reducing predisposing factors,
increased personal hygiene.
Avoid :
Using tight, layered cloths, over
sweating, and prevent obesity
Contact with sick person or animal
Shared combs, towel.
Treat sick person/animal
2% ketokonazole shampoo could
prevent reccurent t. capitis
Use the shampoo with all household
reduce transmission.

b. Topical antifungal
Azol

(krim ketokonazol
2%, krim mikonazol
2%, krim bifonazol,
sertakonazol dll)
Alilamin: krim

Unguentum

Whitfield:
Ac. salicylicum 36
%
Ac. benzoikum 6
12 %

terbinafin 1%

Benzilamin:

butenafin & tolnaftat


1-2x/hari

* Asam undesilenat
rare (recovery rate
27% )

c. Systemic antifungal
S.E : hepatotoxic
Indication:
- T. kapitis,widespread or recalcitran
t.korporis/kruris luas
- T. kruris with e/ Trychophyton rubrum
- T. pedis, T.manus, onikomikosis
1. Griseofulvin
500mg/hari
2. Gol. azol : ketokonazol, itrakonazol &
flukonazol
3. Gol. alil-amin: terbinafin: 250mg/hari

Onikomikosis:
Treatment depend on infected nail (3-18
month)
Systemic: griseofulvin 500 mg/h . 1 tab 500/
4 tab 125
ketokonazol 200 mg/h . . . . . . .
1 tab
itrakonazol 100 mg/h . . . . . . .
1 kaps
itrakonazol 2x200 mg/h - 7 days in 1
months
(pulse dose)
Restricted lesion: superfisial/ 1/3 nail
* Cyclopiroxolamine (nail laquer)

Systemic treatment for nail


Duration of treatmenthe t depend on:
1. Age :
2. Finger nails heal faster than toe nails.
3. The 1st nail heal faster than the 5th nail
4. Type of onikomycosis

Tinea kapitis

Tinea capitis from Trichophyton schoenleinii (favus).


Yelowish, adherent crusts and scales, known as scutula.
May be complicated by athrophy, scarring, and permanent
hair loss.

Tinea barbae. Scattered, discrete, follicular pustules

Tinea barbae, kerion. Sharply demarcated red nodule (4 x 6 cm).


The surface is moist anad studded with multiple yellowish
pustules. Regional lymph nodes are not enlarged.

Otomikosis

Tinea korporis

Tinea imbrikata

Tinea imbrikata

Tinea kruris

Tinea kruris

Tinea manus

Polycyclic pattern of an eruption composed of scaling


papules with involvement of the tumb nail; the nail
exhibits destruction of the nail plate

Tinea pedis

T. pedis + T. unguium

Tinea pedis

Superficial white scales in a


moccasin type distribution.
Note arciform pattern of the
scales which is characteristic

The area is marcerated has


opaque white scales and some
erosions

Onikomikosis Subungual Distal Lateral

OSDL/DLSO oleh T. rubrum

Onikomikosis Superfisial Putih

Onikomikosis sub ungual proksimal

Onikomikosis Superfisial Putih

Onikomikosis sub ungual


proksimal oleh T. rubrum

Onikomikosis Endoniks

Onikomikosis Total dengan Distrofi


Primer

D. Leroy
(Caen)

Onikomikosis Total dengan Distrofi Sekunder

Tinea unguium. Yellow-white subungual


Hyperkeratosis is seen associated with
distal onycholysis

Fungal melanonychia due to


Candida guilliermondii

Collection of specimens from a nail by a


curette after removal of onycholytic nail plate

Tinea pedis (T.rubrum )

Psoriasis kuku

Pitting and onycholysis

Characteristic oil stain and


distal onycholysis

Kelainan kuku / Nail disorder

Dermatofita

Kultur SBA

Pem. Sediaan langsung KOH

A.

Hifa panjang
Artrospora (40x)

B.

C. Artrospora (100x)

Hasil kultur

A. Mikrokonidia

B. Makrokonidia

Hasil kultur

A. Makrokonidia

Hasil kultur

A. Mikrokonidia

B. Makrokonidia

Hasil kultur

A. Chlamydospora

Hasil kultur

A. Mikrokonidia

3. Candidiasis/Candidosis
-The Disease : acute, subacute, chronic
-E/ Candida > C.albicans
Endogen

Physiologic: pregnancy,
hormonal contraception
Malnutrition
Drugs: antibiotic, steroid

Predisposing
Iritation

Eksogen
Weather, Warm, humidity

Klasifikasi

1. Skin, nail
2. Mucous membran
3. Systemic

INTERTRIGINOUS CANDIDOSIS
- Affected skin folds : axilla, inguinal, etc.
- erythematous patch, well difined, vesicles,
erosion, satelite lesion.
- Chronic: lichenification,
hyperpigmentation(rare)
- symptomps : itchy

ONIKIA PARONIKIA
- > people who habitually immerse their
hands in water.
- Paronychia: redness, swelling and
terderness of the proximal and lateral
nailfolds, retaction of cuticle, pain.
- Nail :
- Thick , hard, dull
- Brown, debris ( - )
TRUSH
> Infant
mouth : ulcer wich is covered by
membrane
PERLECHE Fissures at the corner of the

LAB EXAMINATION
- Microscopic: yeast cell, budding cell
- Culture
PENATALAKSANAAN
- >< predisposing factor
- Wet lesion: wet dressing
- Topical: - Azole derivatives cream, gentian
violet solution.
- Systemic: extensive nail disorder
- ketokonazol, itrakonazol, flukonazol

Candida

Candida

C.albicans

KANDIDOSIS KUTIS INTERTRIGINOSA

Intertrigo. Confluent and discrete, erythematous, eroded


areas with pustular and erosive areas ellite lessions

KANDIDOSIS KUTIS
INTERTRIGINOSA

KANDIDOSIS KUTIS INTERTRIGINOSA

VULVITIS KANDIDA

Candidal vulvitis. The vulva is bright red and satellite lessions


are seen extending out onto the medial thights

BALANITIS KANDIDA

KANDIDIASIS INTERDIGITALIS

Candidiasis (interdigital). Erythematous eroded areas between


the fingers occuring in a waitress

Angular Cheilitis

Kandidiasis Pseudomembran

Kandidiasis Pseudomembran

Kandidiasis Hipertrofik

Kandidiasis
mukokutan
kronik

Kandidiasis mukokutan kronik

MIKOSIS
MIKOSIS
SUBKUTAN
SUBKUTAN

INFEKSI SUBKUTAN - KROMOMIKOSIS


- Kronik,
cutaneous, subcutaneous,
L>P
- E/ dematiaceous fungi : - Fonsecaea
pedrossoi
- Phialophora
verrucosa
- Cladosporium carionii
> Feet: work without footwear
- Farmer History of trauma +
G/ erythematous papules

getting bigger

wart, exudate
DD/ TVC : Tuberkulosis verukosa kutis

Kromomikosis

Kromomikosis

Sporotrikosis

Kromomikosis vs TVC

Kromomikosis
vs.
TVC

Parakoksidioidomikosis

Parakoksidioido
mikosis

Lobomikosis

Misetoma

Misetoma

Misetoma

Misetoma

Misetoma

Skrofuloderma

Tuberkulosis
verukosa
kutis

SYSTEMIC MYCOSIS

SYSTEMIC MYCOSIS
Insidence - ~ Immunity state
for example : AIDS
Primary: systemic infection
skin: secondary
Skin manifestation: unspecific
Tx/ - amfoterisin B
- Itrakonazol
- Flukonazol

Histoplasmosis

Kriptokokosis

Penisiliosis

Penisiliosis

Penisiliosis

Anti mikotik
SEDIAAN

DERMA
TOFITA

CANDI
DA

T.V

GRISEOFULVIN

MIKONAZOL 2%

KLOTRIMAZOL

KETOKONAZOL

TS

TERBINAFIN

TS

<

<

TOLNAFTAT

AMFOTERISIN.B.

NYSTATIN

SELENIUM SULFIDE SS

SODIUM HIPOSULFIT

UNG. WHITFIELD

CYCLOPYROXOLAMIN

ITRA/FLUKONAZOL

STRUKTUR JAMUR

Ds

Thank you
V

Ms

re

U
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