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DERMATOMIKOSIS

Pendahuluan
• Dermatomikosis
• Mikosis superfisialis
• Dermatofitosis
• Non-dermatofitosis
• Kandidosis atau kandidiasis
• Pitiriasis versikolor atau tinea versikolor
• Mikosis profunda atau mikosis subkutan atau
mikosis sistemik
DERMATOFITOSIS
Dermatofitosis
• Ability to form molecular attachments to
keratin and use it as a source of nutrients 
colonize keratinized tissue  stratum
corneum; hair; nails
• Classified : habitat and clinical pattern of
infection
• 3 genus : Microsporum, Trichophyton,
Epidermophyton
Habitat
• Geophilic
– Organism originate in the soil
– Spread by spores : blankets and grooming tools
– Microsporum gypseum
• Zoophilic
– Found on animals; transmitted to humans;
domestic and animal pets
– Exposed areas: scalp, beard, face and arms
– Microsporum canis (cats and dogs)
Habitat
• Anthropophilic
– Epidemic
– Transmitted from person to person via direct
contact or fomites
– Trichophyton rubrum; T. Tonsurans; E.
floccosum
Clinical patterns of dermatophytosis
• Tinea capitis
• Tinea barbae
• Tinea facialis
• Tinea corporis
• Tinea cruris
• Tinea manum et pedis
• Onychomycosis
Diagnostic procedures
• Wood’s lamp
• Microscopic
examination
– KOH 10-20%
• Hair : must be plucked not
cut  KOH  covered
with coverslip and slightly
warmed
– Ectothrix  arthroconidia
around the hair shaft
– Endothrix  arthroconidia
w/i the hair shaft
Diagnostic procedures
• Skin and nails
– Scraping with the dull
edge of the scalpel
outward from the
advancing margin of
lesion
– Clipping of the entire
thickness of dystrophic
areas of nail, as
proximal from the distal
as possible
– KOH  septate,
branching hyphae
Diagnostic procedures
• Culture
– Medium : Sabouroud
Dextrose Agar (SDA);
Dermatophyte Test
Medium
– Incubated at room
temperature 26°C for
up to 4 weeks before
being discarded as no
growth
– Identification of
species
Tinea Capitis
• Dermatophytosis of scalp and associated hair
• Trichophyton and Microsporum except
T.concentricum
• Children >> : aged 3-14 y.o
• Transmission : personal hygiene, overcrowding,
low socioeconomic status
• Fomites : combs, caps, pillowcases, toys and
theater seats
4 types of Tinea Capitis
• Inflammatory
• Non-inflammatory
• Black-dot
• Favus
Tinea capitis; inflammatory type
• M.gypseum & M.canis
• Pustular folliculitis;
kerion;
• Pain; posterior cervical
lymphadenopathy; fever
• Scarring alopecia
Tinea capitis; non-inflammatory type
• Anthropophilic ectothrix 
M.audoinii
• Inflammation is minimal
• Hairs in affected areas turn
to grey; breakoff just above
the level of scalp
• Well-defined, round
hyperkeratotic scaly areas of
alopecia  gray patch
Tinea capitis; black dot type
• Anthropophilic endothrix
 T.tonsurans &
T.violaceum
• Least inflammatory
• Hair loss +/-
• Hairs broken at the level
of scalp  black dot
• Affected areas are usually
multiple/polygonal with
poorly demarcated finger-
like margin
• Normal hairs commonly
remain w/i patches of
alopecia
Tinea capitis; favosa type
• T.schoenleinii
• Adolescence; adulthood
• Scalp;glabrous skin
• Patchy follicular
erythema, slightly
scaling, thick yellow
crust (scutula) Ø 1cm
• Unpleasant cheese-like
/mousy odor
• Atrophic alopecia
Tinea barbae
• Only in males
• Barber’s razors; direct
exposure to cattle, horses,
dogs; farmers; ranchers
• Zoophilic 
T.mentagrophytes,
T.verrucosum
• Clinical finding : unilateral;
beard area; upper lip
• 3 forms exist : (a)
inflammatory; (b)
superficial; circinate
Tinea barbae; circinate type
Tinea corporis
• All glabrous skin
except palms, soles,
groin
• T.rubrum;
T.concentricum
• Clinical finding :
– Annular lesion with
scale across the entire
erythematous border;
advances
centrifugally
– Serpiginous and
annular ”ring-worm
like”
Tinea cruris
• Groin, pubic area, perineal,
perianal skin
• Direct contact or fomites
• Exacerbated : occlusion,
warm & moist climates
• Men 3x > women
• T.rubrum & E.floccosum
• Clinical finding :
– Pruritus
– Multiple erythematous
papulovesicles with well
marginated, raised border
Tinea pedis et manus
• T.pedis  feet
• T.manus  palmar and interdigital areas of
hand
• T.rubrum >>, T.mentagrophytes,
E.floccosum
• T.pedis has 4 clinical form
• Chronic intertriginous type
– Most common
– Athlete’s foot
– Pruritus, malodor, interdigital
maceration
– Between lateral three toes
– Scaling, erosion, erythema
• Chronic hyperkeratotic
type
– “moccasin type”
– Thick skin, soles, and
the lateral and medial
aspects of the feet
– Bilateral erythema;
patchy or diffuse
scaling
• Vesico-bullous type
– Thin skin, Sole, periplantar areas
– Tense vesicle larger than 3mm;
vesiculopustules or bullae
• Acute-ulcerative type
– Rampant bacterial co-infection
– Plantar surface
– Vesiculopustules and large areas of purulent
ulceration
– Cellulitis, lymphangitis, lymphadenopathy,
fever
Onychomycosis
• Infection of the nail caused by
– Dermatophyte fungi
– Non-dermatophyte fungi
– Yeasts
• Tinea unguium  dermatophyte infection of the
nail plate  T.rubrum; T.mentagrophytes
• 4 clinical forms :
– Distal subungual onychomycosis
– Proximal subungual onychomycosis
– White superficial onychomycosis
– Candidal onychomycosis
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• Distal subungual
onychomycosis
– Hyponychium and
distal nail bed
– Whitish to
brownish-yellow
opafication at distal
edge of the nail
– Subungual
hyperkeratosis
– Dystrophic nails
• Proximal subungual
onychomycosis
– Proximal nail fold
– White to beige opacity
on the proximal nail
plate
– Subungual
hyperkeratosis
– Leukonychia
– Proximal onycholysis
– Destruction of the nail
• White superficial
onychomycosis
– Dorsal nail plate
– White to dull yellow
sharply bordered patches
anywhere on the surface
of the toenail
• Candidal onychomycosis
– Hyponichial epithelium to
affect the entire thickness
of the nail plate
Treatment
Topical Systemic
Tinea capitis Selenium sulfide Children :
Zinc pyrithione Griseofulvin
Ketokonazole 20-25 mg/kg/day (microsize)
15 mg/kg/day (ultramicrosize)
Adults :
Fluconazole 6mg/kg/day
Itraconazole 3-5 mg/kg/day
Terbinafine 3-6mg/kg/day
Tinea barbae Topical antifungal Griseofulvin 1g/day
Itraconazole 200mg/day
Terbinafin 250mg/day
Fluconazole 200mg/day
Tinea corporis et Allylamin Adults :
cruris Imidazol Fluconazole 150mg/day
Tolnaftat Itraconazole 100mg/day
Terbinafine 250mg/day
Ciclopirox
Griseofulvin 500mg/day
Children :
Griseofulvin 10-20mg/kg/day
Topical Systemic
Tinea pedis et Allylamin Terbinafin 250mg/day
manuum Imidazol Itraconazole 200mg twice/day
Tolnaftat Fluconazole 150mg/week
Ciclopirox
Benzylamine
Onychomyco Ciclopirox Terbinafin 250mg/day
sis Amorolfine Itraconazole 200mg/day
Fluconazole 150-300mg once
/week
Pitiriasis versikolor
• Tinea versikolor; dermatomycosis furfuracea;
tinea flavea; liver spots; chromophytosis ; panu ;
panau
• Etiology : Malassezia furfur; M.globosa
• PV  infeksi oportunistik pada kulit
• Faktor predisposisi :
– Lingkungan yg lembab dan hangat
– Kontrasepsi oral
– Herediter
– Kortikosteroid sistemik
– Imunosupresi
– Hiperhidrosis
– Malnutrisi
Infeksi Malassezia sp 3 bentuk
• 1. tinea versikolor papuloskuamosa
• 2. folikulitis pityrosporum
• 3. tinea versikolor inversa
Pitiriasis versikolor
• Clinical finding :
– pruritus  mild or absent
– Chest, back, abdomen,
proximal extremities >>
– Face, scalp, genitalia <<
– Efl:
• hypo-; hyperpigmentation;
erythema macules
• Scales  dust like
/furfuraceous
• Finger nail sign (+)
Pitiriasis versicolor
• Pitiriasis alba
• Pitiriasis rosea
• Dermatitis seboroik
• Infeksi dermatofita
• Vitiligo
• Kusta tipe PB
Pitiriasis versikolor
• Lab :
– Wood’s lamp
– KOH 10% 
spaghetti and
meatballs
appearance
– Culture : SDA +
olive oil
Management
• Topical
– 2,5% selenium sulfide shampoo
– Azole antifungal
– Topical terbinafine 1% sol
• Systemic
– Ketokonazole PO 200mg for 7 days
– Itraconazole PO 200-400mg for 3-7 days
Candidiasis
• Diverse group of infections caused by
Candida albicans or by other members of
the genus Candida
• Skin, nails, mucous membrane,
gastrointestinal tract, systemic disease
Clinical manifestations
• Oral candidiasis
• Vaginal and vulvovaginal candidiasis
• Balanitis and balanospostitis candida
• Cutaneous candidiasis
• Disseminated candidiasis
Oral candidiasis
• Acute pseudomembrane candidiasis
or thrush  most common form of
OC
• f/ predis : DM, KS sistemik, AB,
keganasan, imunodefisiensi
• Discrete white patches that may
become confluent on the buccal
mucosa, palate, tongue and
ginggivae
• Microscopic : pseudohyphae &
blastospore
Candidal cheilosis
• Perleche; angular
cheilitis
• Erythema, fissuring,
soreness, maceration
at the angles of the
mouth
Cutaneous candidiasis
• Predisposing conditions
– Obesity
– Wearing of occlusive clothing
– DM
– Occupational factor
• Location : genitocrural, axillary, gluteal,
interdigital, inframammary areas, between
folds of skin on the abdominal wall
• Efl :
– Pruritic,
– Erythematous macerated
skin in intertrigonous areas
with satellite vesicopustules
• Lab :
– KOH 10%  budding
yeast and pseudohyphae
– Culture : SDA +antibiotic
 whitish mucoid colonies
grow w/i 2-5 days
Management
• General : Controlling predisposing conditions
• Oral candidiasis:
– Nystatin susp 400.000-600.000 units 4 times a day
– Oral azoles
• Cutaneous candidiasis :
– Topical antifungal
– Systemic antifungal : fluconazole, itraconazole,
ketokonazole, terbinafine
If you want more to know :
• Tinea nigra palmaris
• Piedra (white/black)
• Tinea imbrikata
• Deep fungal infection
• Oportunistic fungal infection