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Dermatomycoses:

from head to toe


PROLOGUE: A BIOLOGICAL
GUIDE
For a long time fungi were regarded as a
primitive branch of the vegetable kingdom.
Nowadays they are viewed as a separate group,
alongside plants, animals, protists and
prokaryote organisms.
Fungi are everywhere, occurring both in the sea,
in fresh water and on land. There are some
100,000 known species. They constitute an
important link in the organic chains of nature by
converting dead and decaying matter into new
raw materials for plants.
FUNGI AND YEASTS
In principle, the term 'fungi' is the name given to a large group
of organisms with biological characteristics such as the
presence of a cell membrane, a cell wall and a eukaryotic
nucleus, and the absence of chlorophyll (the green colouring
matter of plants). This means that the yeasts also form part of
the fungi group. Strictly speaking, therefore, it is incorrect to
speak of 'fungi and yeasts'. For the practicalities of daily life,
however, a pragmatic subdivision has been devised in which
yeasts are called 'yeasts' and nonyeasts are referred to as
'fungi'. Furthermore, the term 'fungus' usually has a negative
undertone, whereas yeasts are viewed in a somewhat more
positive light. Bakers' yeast is an essential ingredient, but bread
mould -- the fungus that often grows on stale bread -- indicates
decay.
Less than 100 of the approximately 100,000 species of fungus
are pathogenic for human beings.
FROM SAPROPHYTE TO
PARASITE
The absence of chlorophyll (the green pigment in plants) is
central to the way in which fungi grow and live, for it precludes
CO2-assimilation and photosynthesis. Fungi are therefore
dependent upon an exogenous source of organic matter for
their own metabolism. Usually this is dead or decaying organic
waste.
As long as the growth of fungi is not achieved at the expense of
living tissue, we call them saprophytes. Otherwise, i.e. when
they attack living plants or animals, we speak of a parasitic
lifestyle. And that can cause a fungus to become pathogenic.
Nevertheless, there are more aspects involved than the
properties and lifestyle of the fungus alone. A fungus almost
never infects a host without reason. There has to be a favorable
climate, and that is largely determined by the host himself. The
properties of the host, for example the environment of the skin
and its defense mechanisms, are extremely important.
FORM AND REPRODUCTION
Fungal cells have a cell wall and a true nucleus, which
means that they are classified as one of the eukaryotes.
Unlike higher animals and plants, the fungi have only a single
set of genetic material: they are haploid.
From the morphological viewpoint the fungi constitute a
heterogeneous group of organisms. On the one hand, there
are the multicellular forms which grow as ramified threads or
filaments, called hyphae, with both sexual and asexual
reproduction. On the other hand there are the single-celled
organisms, the yeasts, whose principal method of
reproduction is asexual. Some yeasts also form ramified but
nonmulticellular structures which are designated by the term
'pseudohyphae'.
Sporulation is an important property of fungi. In that form
they can easily survive. When a flourishing period is followed
by an interval of adverse conditions, the spores can then be
disseminated; they subsequently remain in a state of rest
until a favorable environment is restored. This is why fungi
can be obstinate and difficult to control.
CLASSIFICATION OF THE FUNGI

A definitive classification is not possible until


the perfect stage has been identified and
described. The classification is arranged in six
groups (see table), three of which are relevant
to disorders in human beings.
The last group, Fungi Imperfecti, is a group with
no identified sexual reproduction and whose
perfect stage is therefore unknown.
The actinomycetes are gram-positive bacteria
which cause, inter alia, pseudomycoses.
CLASSIFICATION OF THE FUNGI
Etiology of dermatomycoses
Dermatophytons of 3 genera: Trichophyton,
Microsporum and Epidermophyton

Keratophytons of some yeast species:


Pityrosporum ovale, Pityrosporum orbiculare,
Malassezia furfur.

Candida genus (Candida albicans).

Pseudofungi (Corynebacterium minutissimum


and Actinomyces israelii.

Moulds (Scopulariopsis, Aspergillus,


Penicillium, etc.)
FUNGI AS PATHOGENIC ORGANISMS
Of all the known species of fungus, only a few are pathogenic. Furthermore,
the presence of such a fungus in or on the human body does not
automatically mean that there is mention of pathology. The presence of
Candida spp., for example, can be demonstrated in human faeces without
there being any question of an infection. Fungi are therefore not inevitably
pathogenic. The truth of this statement is underlined by the increasing
number of immuno-compromised patients. AIDS, transplantations and
chemotherapy can lead to reduced immune system function. Precisely at
times such as these, fungi seize their opportunity and launch an attack. At
first sight the result may appear to be a harmless case of thrush, but it may
also be a systemic infection which is difficult to treat, such as a disseminated
Aspergillus infection, sometimes with a fatal outcome.

Disorders caused by fungi are called mycoses. They are usually classified
according to the site where they appear. There is a large group of disorders
which affect the skin. Many fungi, such as the dermatophytes, go no deeper
than the horny layer of the skin: these are the superficial infections. When
fungi are also demonstrated deeper in the tissues, these are referred to as
subcutaneous infections. If organic systems or organs are affected, they are
called systemic infections. It will be obvious that the latter group is the most
life-threatening. In terms of frequency, however, systemic fungal infections
are the rarest.
DERMATOMYCOSES - DEFINITION
AND CHARACTERISTICS
Dermatomycoses are infections of the skin, hair or nails by fungi.
The principal causative agents are dermatophytes, which are
subdivided into three groups (genera): Microsporum spp.,
Trichophyton spp. and Epidermophyton floccosum. The three
genera are distinguished by the form of the spores, or
macroconidia.
Trichophyton: thin-walled, smooth, four to six septa
Microsporum: thick-walled, with projections five to more septa
Epidermophyton: thick-walled, pear to oval shaped four or fewer
septa
Besides the dermatophytes, yeasts are also capable of causing
skin disorders. The most frequent agents in this case are Candida
spp. and Pityrosporum.
Infections are increasingly being caused by species of fungus
which are classified neither as yeasts nor dermatophytes
moulds. An example of this is Scopulariopsis brevicaulis, which can
occur in nails.
DERMATOPHYTES -
CLASSIFICATION
DERMATOPHYTES - DEVELOPMENT
OF A DERMATOPHYTOSIS
As already mentioned in the introduction, fungal
infections do not occur without reason.
As dermatophytes are not commensals, a prerequisite
for the development of an infection is exposure to the
fungus. This is possible, for example, by direct contact
with infected persons or animals, but it is more often a
question of contact with fungal spores. These spores are
contained in epithelial (skin) elements of infected
persons everywhere in our environment. The floors of
communal shower stalls and changing rooms are major
sources of infection. For the development of an infection,
however, more is needed than contact alone.
Dermatophytes prefer warm, moist conditions. This is
why a dry, intact skin constitutes a virtually impenetrable
barrier. But the chance of infection is encouraged by
everything that has an adverse influence on the
situation.
DERMATOPHYTES THEIR HOST
Dermatophytes do not have an exclusive preference for
human beings. Some of the infections in humans even
originate in (domestic) animals.
On the basis of the original host, a distinction is made
between anthropophilic, zoophilic and geophilic
dermatophytes. This distinction is very important, chiefly
because in the event of infection of human beings by
zoophilic dermatophytes, the source of the infection (the
animal) must be co-treated.
In the case of geophilic infections one can try to avoid
further contact with the source.
A point worthy of mention is that zoophilic
dermatophytes in human beings frequently evoke a more
intense inflammatory reaction than an infection by
anthropophilic species. The latter have adapted
themselves better to life in the human epidermis and are
regarded to a lesser degree as invasive organisms which
have to be opposed.
DERMATOPHYTES
THEIR HOST
DERMATOPHYTES - PREFERRED
SITES OF INFECTION
Most dermatophytes have been found to have a
preference for certain situs. A preference for growth in
and around the hair, in the horny layer of skin, in the
moist, warm folds of the skin, or just under the nails.
Trichophyton species have been found to have the
greatest adaptability, or perhaps they are merely the
least fastidious. They are capable of causing tinea
capitis, corporis, barbae, pedis, plantaris and tinea
unguium.

Epidermophyton floccosum occurs principally in the large


flexure lines and around the foot. Microsporum chiefly
attacks the scalp and glabrous skin. It rarely occurs in
flexure lines or the nails. Furthermore, the preferred sites
of infection of dermatophytes are, to a certain extent,
also determined by the situs where the skin comes into
contact with the fungal spores.
Microsporum preferred situs
KERATINOPHILIA
A major characteristic of dermatophytes is their keratinophilia.
They only grow in the dead, horny layer of the skin. They do not
reach deeper tissue or deeper parts of the skin. Dermatophytes
can only be found in the epidermis, hair shaft, nail plate and nail
bed. However, this does not mean that no changes occur in the
deeper layers of skin. After all, the clinical picture that emerges is
caused by the inflammatory reaction which occurs deeper in the
dermis.

Now, it seems fairly logical to assume that keratinophilic fungi,


such as dermatophytes, do not grow deeper into the skin
because there is no keratin present in the deeper layers.
However, it is open to question whether this keratinophilia also
means that these fungi are keratin-dependent. There are
indications that it is not the absence of keratin but rather the
presence of serum factors that inhibits the growth of
dermatophytes deeper into the skin. It is also not known whether
keratin is converted by an enzyme (a keratinase) of the
dermatophyte itself. It is presumed that mechanical factors -- by
pressure from the hyphae themselves -- also damage the keratin.
DERMATOPHYTES AND THE SKIN
The classical picture of a dermatophyte infection of the skin
is a round patch with peripheral activity: the fungus spreads
peripherally. This process is attended by the formation of
waste matter and toxins which function as a mediator in
inflammatory reactions. The inflammation clears towards the
centre and there is a progressive decline in the number of
hyphae which are found. The conditions for the growth of
fungi apparently become less favourable. Fewer hyphae
does not however mean that there are also fewer fungi.
Obviously, the central hyphae are older and spores have
been formed within them. In this case the hyphae assume
the form of a string of beads and then fragment. These
elements are much more difficult to find by microscopy than
hyphae.
It is still not clear why dermatophytes grow almost
exclusively towards the periphery. In some way or another,
perhaps immunological, the central portion offers more
resistance or is less attractive to the dermatophyte than skin
which has not yet been infected.
DERMATOPHYTES AND THE SKIN
DERMATOPHYTES AND THE NAILS
A dermatophyte infection of the nail often starts at the free margin
of the nail or the lateral nail fold. Where the feet are concerned,
these are precisely the places where pressure is exerted by
footwear and where damage can readily occur. From there the
dermatophyte grows into the nail plate to the base of the nail, as
a result of which the nail plate can become thickened, friable and
even totally destroyed, forced up by the underlying
hyperkeratinization.
One result of the infection of this particular nail is that nail growth
is inhibited. And that growth was already fairly limited:
dermatophyte infections have a predilection for nails which have
a poor growth rate due to other reasons. And since nail growth is
essential for a cure, obviously the healing process is prolonged.
During treatment and the healing process, the dermatophyte
retraces its steps as it were: from the base to the free margin of
the nail. Besides the difference in direction, however, there is also
an important difference in the rate of activity, for the gradual
replacement of the infected nail is now determined by the (much
slower) growth rate of the nail and not by the (high) growth rate of
the dermatophyte. The development of an onychomycosis
therefore progresses much faster than the corresponding healing
process.
DERMATOPHYTES AND THE NAILS
DERMATOPHYTES AND THE HAIR
A number of dermatophytes can penetrate into the hair
follicle and some of them can even invade the hair. The
process by which dermatophytes grow, which helps to
explain the clinical picture, can be examined under the
microscope.

Endothrix: In this form of growth the fungus develops from


the stratum corneum into the follicle. The hyphae
subsequently develop in the hair shaft and attack the entire
structure of the hair. The fungus grows further into the
radix pili, or root of hair, as a result of which the hairs are
filled, as it were, with mycelial threads and spores ( see
illustration a ). Owing to the growth of the hair itself, the
swollen and spore-filled portions of the hair shafts reach
the surface of the skin, where they break off. There is
therefore no question of stubble. This form of growth, with
the presence of spores in the hair, is known as endothrix
growth and occurs, inter alia, in infections by Trichophyton
violaceum.
Endothrix spore growth
DERMATOPHYTES AND THE HAIR
Ectothrix: The second form of growth is called
ectothrix growth. In this case, the hyphae tend to
grow primarily around the hairs, thereby
producing a veritable sheath of spores. The size
of the spores varies quite considerably. An
example of a fungus with small-spored ectothrix
growth is Microsporum canis, while Trichophyton
mentagrophytes is large-spored. Ectothrix
growth results in the hairs breaking off a few
millimetres above the surface of the skin; this is
because the basic structure is not so severely
infected. This gives the skin a stubbled
appearance.
Small-spored ectothrix growth
Large-spored ectothrix growth
DERMATOPHYTES AND THE HAIR
In favus, caused by Trichophyton schoenleinii,
there is no sporulation in the hairs and limited
formation of mycelium. Consequently, in this
infection hairs are able to grow to their normal
length.
Not all dermatophytes are capable of growing
into the hair follicle: Epidermophyton floccosum
is an example of such a dermatophyte.
Microsporum canis, on the other hand, has no
difficulty whatever in invading the follicle.
Summary of the different forms
of growth of dermatophytes in hair
YEASTS
The two major species of yeast capable of
causing skin infections are Candida albicans
and Pityrosporum ovale.
The most striking property of these yeasts is that
they are commonly part of the normal flora. We
are therefore dealing with real opportunists. This
also means that the way in which an infection
develops is quite different to an invasion by
dermatophytes.
As mentioned earlier, with dermatophytes some
form of exposure to the fungus and its spores is
necessary before an infection can develop. In
the case of yeast infections, however, particular
importance attaches to predisposing factors.
CANDIDA
There are about 100 known species of the Candida genus. Not all Candida
species are present in human beings as commensals or pathogens, not by
any manner of means. It is only in exceptional cases that another yeast than
Candida albicans plays a role. C. albicans is normally present as a
commensal in the mouth, the gastrointestinal tract and the vagina.
When is there mention of an infection (e.g. thrush or vaginal candidosis) and
what changes are involved? In an infection there is a multiplication of the
number of yeast cells: far more than when Candida is merely present as a
commensal. Furthermore, commensal Candida is only present in yeast form,
whereas in infections (pseudo)hyphae are also found (see image 1). And in
an infection there are also signs of pathology, for example inflammation.
There are various predisposing factors which are conducive to the transition
from commensal to pathogenic. A moist skin, a high pH and the presence of
sugars and certain amino acids create a favourable climate for Candida.
In the host, reduced cellular immunity is a major predisposing factor.
Diabetes mellitus is also frequently implicated in Candida infections.
However, it is open to question whether a properly adjusted patient runs a
higher risk of candidosis. A good example of the effect of sacchariferous
substances is found, inter alia, among bakers and workers in the
confectionery industry. Candida paronychia is an occupational disease in
these people. A damaged skin is another important factor. Macerated skin,
as in moist flexure lines, is a preferred site for Candida.
Pseudohyphae of C.albicans
(in vaginal mucosa of rat)
PITYROSPORUM
It is a lipophilic yeast which only grows when oil, glycerin or glyceryl
monostearate is added to the culture medium. Pityrosporum is chiefly
found as a commensal on areas of the skin containing a relatively large
number of sebaceous glands. The yeast can assume various
morphological forms. Until quite recently this led to the assumption that
Pityrosporum ovale, Pityrosporum orbiculare and Malassezia were three
different organisms. Now, however, it is known that they are different
forms of growth of one and the same yeast: P. ovale. In this scenario
Pityrosporum is the yeast form while Malassezia furfur, formerly always
described as the causative agent of pityriasis versicolor, is the mycelial
form.
In pityriasis versicolor, just as in candidosis, there are several conductive
factors. The principal one is the climate. In tropical regions we see
incidences of 40 to 50%, as opposed to temperate climates where not
even one per cent is achieved. Furthermore, the infection usually
develops in the summer months; the use of sunscreens is said to be a
conducive factor.
It has recently been established that P. ovale also plays a role in
seborrhoeic dermatitis. Patients with this infection have a high
concentration of P. ovale on the skin, as a result of which inflammatory
reactions occur. Dandruff is regarded as a form of seborrhoeic
dermatitis.
DERMATOMYCOSES -
CLASSIFICATION
Dermatomycoses can be classified in various ways. The simplest of all
would seem to be a systematic arrangement on the basis of the
causative agents. In a classification of this nature, the disorders are
designated by reference to the individual genus: trichophytosis,
epidermophytosis, microsporosis, candidosis (candidiasis) and
pityrosporosis.
A classification focused more on the epidemiology and method of
dissemination is one that is based on the original host of the various
fungi. This produces such terms as anthropophilic, zoophilic and
possibly geophilic agents: fungi which therefore have human beings,
an animal or the soil as their primary habitat.
Closer to actual practice is a classification on the basis of the clinical
picture, designated, for example, by the severity of the inflammation:
mild, moderate or severe. The most widely used classification is largely
based on the site of the clinical picture. As mentioned earlier, the
largest group of dermatomycoses consists of disorders which are caused
by dermatophytes. They are designated by the name 'tinea'. A distinction
is made between the tinea group (dermatophyte infections), which is
subdivided according to the site of the infection, and a group of yeast
infections, in which the subclassification is on the basis of the causative
agent (see table).
DERMATOMYCOSES
REFERENCE SYSTEM FOR THE
DERMATOMYCOSES
TINEA CAPITIS
In tinea capitis, also called ringworm of the
scalp, the lesions are typically ring-shaped and
the skin and hair are infected. The hairs break
off and leave bald patches.

Four subgroups of tinea capitis can be


distinguished:
- Microsporosis
- Trichophytosis (herpes tonsurans)
- Favus
- Kerion
TINEA CAPITIS
MICROSPOROSIS
Microsporosis is an infection caused by Microsporum spp.
which occurs most frequently in school-going children. It is
transmitted from one child to another, but sometimes it can
also be a family infection. In the event of a recurrence, it is
therefore of the utmost importance to localize the source of
the infection -- certainly not forgetting the family pets. The
commonest Microsporum species are M. canis and M.
audouinii.
Clinical picture: The disorder begins as a small plaque with
thin grey scaling. There are short, broken hairs which are only
a few millimetres long, producing on palpation the effect of a
brush with short, stiff bristles. Sometimes there are severe
inflammatory symptoms, such as erythema and swelling. The
signs depend primarily on the pathogenic organism. M. canis,
for example, being a zoophilic fungus, produces more severe
inflammation than M. audouinii. Furthermore, there may be a
concomitant tinea corporis. The plaque becomes larger within
a few weeks. New lesions appear and may become confluent.
After relatively rapid growth at the onset of the disorder the
expansion generally comes to a halt. After puberty a
spontaneous regression occurs without scars or lesions.
MICROSPOROSIS
TRICHOPHYTOSIS
Children are especially prone to attack by trichophytosis or
herpes tonsurans, but it can also infect adults.
Trichophytosis is an exotic disease from Turkey and
Morocco and seldom occurs in more temperate climates.
The major causative agents of herpes tonsurans are
Trichophyton tonsurans and T. violaceum.

Clinical picture: Clinical findings usually comprise a large


number of small grey patches. In most cases erythema is
absent or only mild. The patches are characterized by
partial hair loss. The hairs are broken off on the surface of
the skin and are only visible as a small stub. They may be
found in coexistence with long, healthy hairs. The lesions
are covered with a layer of grey scales and may become
confluent, thereby causing an irregular pattern. As in
microsporosis, spontaneous healing can occur after
puberty.
TRICHOPHYTOSIS
FAVUS
Favus is caused by Trichophyton schoenleinii and is most
frequently found in subtropical regions. In more temperature
climates the disorder has practically been eliminated thanks to
griseofulvin, which made effective treatment possible.

Clinical picture: Favus is a disorder with a unique clinical


picture. It begins as a red scaling patch on the scalp which
develops until it covers an area several centimetres in
diameter. The next stage is the formation of scutula: yellow,
cup-shaped crusts with a diameter of one to two
centimetres.A salient feature is that the hairs are not broken
off and the length of some of them is quite normal. They are
nevertheless infected: the hairs lose their gloss and are
arranged on the scalp in irregular tufts. As the patch increases
in size, total and irreversible hair loss occurs in the central
region. The 'mouse smell' is mentioned in all textbooks. The
impetiginous form of favus is characterized by moist crusts
with underlying accumulations of pus. A secondary coccal
infection frequently occurs and makes the differential
diagnosis with impetigo more difficult. There is no tendency to
healing after puberty as in microsporosis.
FAVUS
KERION
Kerion occurs at all ages. The causative agents of this
disorder are Trichophyton verrucosum and T. gypseum.

Kerion begins as an erythematous annular patch which


gradually elevates itself above the surrounding skin. It is
clearly circumscribed, while the slightly nodular surface
is covered with pustules ( see image 3 ). Pus is released
when pressure is applied. It is associated with
occasional pain. A kerion infection is not restricted to the
scalp. Infections of this nature are also possible in the
beard area.

If left untreated, the condition will persist for several


weeks or months. Then the symptoms will gradually
diminish. An atrophic scar may remain after healing,
while the sustained hair loss will not be fully replaced.
However, superinfections can seriously complicate this
relatively benign process.
KERION
TINEA BARBAE
Tinea barbae is quite often seen in dairy farmers, who
become infected through contact with cows while
milking. Tinea barbae is usually caused by T.
mentagrophytes or T. verrucosum.
Clinical picture: Tinea barbae is also called trichophyte
sycosis. In principle, tinea barbae and tinea capitis are
one and the same infection. The agents are
dermatophytes which attack the hair and skin, with
severe inflammatory plaques possibly attended by
scaling and incrustation. Kerion also occurs in
association with tinea barbae. The infection can last
for months and there is a real risk of bacterial
superinfection.
TINEA BARBAE
TINEA CORPORIS
Every dermatophyte can be the causative agent of tinea
corporis, in other words Microsporum spp., Trichophyton spp.
and Epidermophyton floccosum. The nature of the
dermatophyte may help to indicate the source. Zoophilic fungi
(for example, M. Canis or T. mentagrophytes) may have been
contracted from an infected pet animal.
Clinical picture: Tinea corporis, which was formerly also called
herpes circinatus, is a tinea or ringworm disorder of glabrous
skin. The general characteristics are annular scaling patches
and a slowly expanding edge with inflammation which is
frequently somewhat elevated. The lesions are clearly
circumscribed and vesicles may also occur. The patient may
also complain of itch and a burning sensation. The lesion
spreads peripherally and tends to heal in the centre. One or
several weeks after infection with dermatophyte spores, the
visible lesion appears. After several months, depending in part
on the species of fungus involved, spontaneous healing can
occur. Chronic infections are also possible, however, and T.
rubrum infections are notoriously obstinate.
TINEA CORPORIS
TINEA CRURIS
Tinea cruris is usually caused by Epidermophyton
floccosum or Trichophyton rubrum. The disorder
occurs quite often in association with tinea pedis.
These are mostly T. rubrum infections. Furthermore,
tinea pedis is frequently the underlying cause of
reinfection. Tinea cruris is more common in men than
in women, probably because the male population is
also more susceptible to tinea pedis.
Clinical picture: Tinea cruris begins with arcuate
erythematous plaques in the perineal fold which
spread to the thighs. Itch and a burning sensation are
the patient's major complaints. Scaling is not always
present and vesicles are rare. The scrotum may also
be affected, while T. rubrum can spread to the anal
region and the abdomen.
TINEA CRURIS
TINEA PEDIS PLANTARIS AND
TINEA MANUS PALMARIS
The causative agents are the same as in tinea
pedis. The relevant fungi are therefore
Trichophyton mentagrophytes, T. rubrum and
Epidermophyton floccosum.
Clinical picture: Dermatophyte infections of the
palm and sole show erythematosquamous
aberrations. These are frequently attended by
deeper, brownish pustules. After they have
broken, they dry up with considerable scaling.
The course of the infection is quite often
chronic.
TINEA PEDIS PLANTARIS AND
TINEA MANUS PALMARIS
TINEA PEDIS INTERDIGITALIS
In tinea pedis three species of fungus play a role: Trichophyton
mentagrophytes, T. Rubrum and Epidermophyton floccosum. Infection is
produced by direct contact with a fungus. There are ample sources of
infection in our society. In particular, the floors of communal showers at work
and leisure centres, and especially in swimming pools. Furthermore, the
rough surface of springboards has proved to be a major source of infection:
it is regularly in contact with many feet and is difficult to clean. If the 'climate'
is favourable after infection, tinea pedis will be able to develop and become
established. Infection is mainly encouraged by warm, moist conditions.
Footwear is a major factor in this respect. Sandals which allow the air to
circulate are preferable to shoes which fully enclose the feet. Once it is
present, the fungus can easily survive via spores in skin fragments which
find their way into the seams of the shoes. Socks can be an ongoing source
of infection, even after washing. In the summer, when less confining
footwear is worn, the complaints frequently decrease and the lesions dry up.
However, the symptoms soon return again.
Clinical picture: Tinea pedis is known by various names. It is popularly called
athlete's foot. Tinea pedis can best be described as an intertriginous
dermatitis with scaling of the skin, cracking and maceration -- especially of
the skin in the space between the toes, which is an ideal breeding ground for
dermatophytes. The infection usually begins in the fourth interdigital space.
The lesion can subsequently spread to the lower and upper surfaces of the
toes and even to the entire sole of the foot. The patient complains of itch, an
unpleasant smell and a manifest inflammatory reaction.
TINEA PEDIS INTERDIGITALIS
TINEA UNGUIUM
The principal agent is Trichophyton rubrum, which is frequently
also the cause of tinea pedis. However, Epidermophyton
floccosum, Trichophyton menthagrophytes, T.tonsurans and
T.schoenleinii can also be the causative agent.
Clinical picture: The usual clinical findings are atrophy,
discoloration and subungual hyperkeratosis. Onychomycosis
may be the patient's only disorder, but in many cases the skin is
also affected. Tinea pedis is frequently attended by an
onychomycosis of the toenails. The nail plate is usually invaded
from the corner between the lateral side and the edge of the
nail. From there the disorder spreads towards the cuticle. The
nail is frequently raised due to the development of a subungual
hyperkeratosis. The initial lesion is small and consists merely of
a discoloured spot (yellow or white). As it grows towards the
base of the nail, this is attended by more discoloration (brown
or black) and the nail is raised. The nail becomes brittle and
friable. Onycholysis can occur and the entire nail plate can be
destroyed. Although it usually starts with just one nail, after
some time other nails are also frequently infected.
TINEA UNGUIUM
CANDIDOSIS
The Candida species are yeasts. Candida albicans is the most widely
known and most pathogenic species of yeast. C. albicans is normally
present as a commensal in human beings, especially in the
gastrointestinal tract and in some women also in the vagina.
Clinical picture: In skin disorders, Candida infections are most often
found in the large and small flexure lines; this is frequently referred to
as intertrigo. Erythema, which has a quite dark red colour, and
exudation occur deep in the crease or fold, on the apposed surfaces
of the skin. The lesion subsequently spreads and is irregularly
circumscribed. The skin is severely macerated and erosions may
develop. Small 'islands off the coast', or satellite lesions, and
pustulation may also be present. Sometimes there is a clear exudate,
but it can also be greyish white and viscid. The patient often
experiences itch and a burning pain. Infection of the mucosa and the
adjacent skin are quite often concomitant. The course of a Candida
infection is frequently chronic, albeit varied. The infection can spread
extensively and affect large areas of the body. The skin can also be
severely eroded. Besides dermatological problems, Candida species
are also capable of causing other syndromes. Vaginal candidosis is a
particularly well-known example. Vulvitis, thrush and angular
stomatitis (perlche) or a systemic candidosis can also occur.
CANDIDOSIS
PITYRIASIS VERSICOLOR
For a long time the causative agent of pityriasis versicolor was called
Malassezia furfur. We now know that this is the same as
Pityrosporum ovale. P.ovale is dependent upon oil or fat for its
growth. This yeast species is always present on the skin of human
beings as a commensal, especially in ear wax, on the scalp and at
other sites where many sebaceous glands are present. In more
temperate climates, pityriasis versicolor is a typical summer disorder.
Higher temperatures and sweat secretion and the use of sunscreens
are conducive factors for this lipophilic yeast. Pityriasis versicolor is
not a communicable disease. The incidence lies between 0.5 and
5%, but in subtropical regions it may well be 10 times as high.
Clinical picture: Pityriasis versicolor is a disorder which is particularly
noticeably because of the discoloration of the skin. By comparison
with untanned skin the patches are darker, but on tanned skin they
are lighter. The colour can vary from yellow to brown, red or whitish.
After some time the patches coalesce. A second major characteristic
is the very fine scaling, which is sometimes only apparent after
scraping with a spatula. 'Pityron' is Greek for 'bran'. Patients are
usually not so susceptible to itch or inflammation. They have the
greatest difficulty of all with the disfiguring aspect.
PITYRIASIS VERSICOLOR
PITYRIASIS VERSICOLOR
DIAGNOSIS
The examination of dermatomycoses can be subdivided
into two parts:
Dermatological examination, which is primarily a
question of observation, can be supplemented with
examination using Wood's light.
The second part is mycological examination. The
simplest technique is the KOH preparation, but cultures
are also part of the diagnostic armamentarium. Direct
microscopical examination frequently causes problems
in general practice, but making and evaluating a KOH
preparation is quite easy, providing a number of
conditions are met. Taking specimens is a crucial part of
the procedure. Employing the correct method for taking
specimens is also important when one intends to have
the material cultivated.
MACROSCOPICAL EXAMINATION
The classical picture of dermatophytosis has already been
mentioned. It is an annular lesion which spreads centrifugally, is
sharply defined, displays peripheral activity and tends to heal in
the centre. Usually the periphery is slightly elevated. Scaling is
present and the patient may complain of itch and a burning
sensation. It is good policy also to check other sites for lesions,
such as the scalp or the feet and hands.

Part of the severity of the symptoms has its origins in the depth
of the mycosis. A number of fundamental characteristics of
dermatomycoses are: erythema, vesicula, scaling, scabs,
pustules, atrophy, dystrophy, hypertrophy and dyschromia. Of
course, these characteristics are exhibited in many other skin
disorders.

The aforesaid classical picture is usually easy to identify. If


these characteristics are absent, it is of the utmost importance
to include a dermatomycosis in the differential diagnosis and to
perform a mycological examination.
WOOD'S LIGHT
Wood's light (named after Robert Williams Wood, an American physicist) is
a lamp which radiates ultraviolet light with a wavelength between 330 and
365 nm. It is actually an ultraviolet lamp combined with a special filter
(Wood's filter). In certain dermatomycoses, fluorescence is exhibited when
the lesion is illuminated with Wood's light in a completely darkened room. All
residues of creams and ointments must first be removed from the infected
area because these preparations may themselves have fluorescent
properties. The skin which is examined with Wood's light must therefore be
thoroughly cleaned first. Even lesions which are almost or actually invisible
to the naked eye can easily be observed under Wood's light. This
immediately highlights a major advantage of this lamp. If an infection is
suspected of being epidemic, the lamp makes it possible to check a large
group fairly quickly, for example whole schools of other members of a family.

The use of Wood's light is limited by the fact that only a few dermatophytes
cause fluorescence. M. canis produces a bright yellowish green
fluorescence. The anthropophilic dermatophytes T. schoenleinii and M.
audouinii also fluoresce. In pityriasis versicolor a yellowish white to yellowish
brown fluorescence can be seen. Erythrasma -- which is not a
dermatomycosis but is certainly important in the differential diagnosis of
tinea cruris -- also produces fluorescence (coral-red) ( see image 3 ). The
other dermatophyte infections, however, do not fluoresce, and this is also
the case with candidoses.
WOOD'S LIGHT
LABORATORY EXAMINATION
To determine whether there is indeed a
dermatophyte or yeast present, a microscopical
examination must be performed.
The most direct and simplest method is to make
a preparation on the basis of potassium
hydroxide (KOH preparation). However, this
examination is insufficient in itself to enable the
causative agent to be identified with absolute
certainty.
To discover the name of the fungus, a culture is
necessary. For the highest possible yield, a
number of key items have to be taken into
account in an examination of this nature.
Scraping the edge of lesion for
microscopic examination
Aspergillus fumigatus: microscopy
Culturing: a) T.rubrum; b) E.floccosum;
c) T.mentagrophytes; d) M.canis
Main systemic antifungals
Poliens:
Amphotericine B (1956)
Nystatine (1951)
Miscellaneous:
Flucytosine (1957)
Grizeofulvine (1958)
Potassium iodide (1811)
Azoles:
Imidazole Myconazole (1969); Ketokonazole (1977)
Triazoles Itraconazole (1980); Fluconazole (1982)
Alilamines:
Terbinafine
Morfolines:
Amorolfine (1989)