DERMATOLOGY NOTES

Presented by:
Dr. Mandeng Ma Linwa Edgar
Dermatology Resident
DERMATOLOGY NOTES

 Skin: Basic structure and Function

 Cutaneous Signs and Diagnosis
 Dermatoses resulting from physical factors
 Pruritus and Neurocutaneous dermatoses
 Atopic dermatitis, eczema and non-infectious immunodeficiency disorders
 Contact dermatitis and drug eruptions
 Erythema and urticaria
 Connective tissue diseases
 Mucinoses
 Seborrehic dermatitis, Psoriasis, recalcitrant palmoplantar eruptions, pustular dermatitis and
erythroderma
DERMATOLOGY NOTES

 Pityriasis rosea, pityriasis rubra, pilaris and other papulosquamous and hyperkeratotic
diseases
 Lichen planus and related conditions
 Acne
 Bacterial infections
 Diseases resulting from fungi and yeasts
 Mycobacterial diseases
 Hansen’s disease
 Syphilis, yaws, bejel and pinta
 Viral diseases
DERMATOLOGY NOTES

 Parasitic infestations, stings and bites

 Chronic blistering dermatoses
 Nutritional diseases
 Diseases of subcutaneous fat
 Endocrine diseases
 Abnormalities of dermal fibrous and elastic tissue
 Errors in metanolism
 Genodermatoses and congenital anomalies
 Dermal and subcutaneous tumors
DERMATOLOGY NOTES

 Epidermal nevi, neoplasms and cysts

 Melanocytic nevi and neoplasms
 Macrophage/monocyte disorders
 Cutaneous lymphoid hyperplasia, cutaneous t-cell lymphoma, other malignant lymphomas and
allied diseases
 Diseases of the skin appendages
 Disorders of cutaneous vascular diseases
 Disturbances of pigmentation
 Dermatologic surgery
 Cutaneous Laser surgery
 Cosmetic dermatology
Skin: Basic structure and Function
 Diseases resulting from fungi and yeasts
DERMATOPHYTES

 An estimated 20–25% of the world’s population has some form of fungal infection, usually
an anthropophilic Trichophyton infection, making fungal infections the most common type
of infection worldwide.
 Most mycotic infections are superficial and are limited to the stratum corneum, hair, and
nails. In contrast, most deep mycoses are evidence of dissemi­nated infection, typically
with a primary pulmonary focus.
 There are a few deep mycoses that result from direct inoculation into the skin by a thorn or
other foreign body. These include cutaneous lymphangitic sporotrichosis, primary
cutaneous phaeohyphomy­cosis, and chromomycosis.
Diseases resulting from fungi and yeasts
 Diseases resulting from fungi and yeasts
DERMATOPHYTES

 The major fungi that cause only stratum corneum, hair, and nail infection are the
dermatophytes.
 They are classified in three genera: Microsporum, Trichophyton, and Epidermophyton.
 Superficial fungal infections are divided into: tinea capitis (ringworm of the scalp/black
dot type and kerion), tinea barbae (ringworm of the beard), tinea faciei , tinea
corporis ,tinea manus , tinea pedis , tinea cruris , onychomycosis (fungus infection of the
nails).
Diseases resulting from fungi and yeasts
DERMATOPHYTES

DIAGNOSIS
Wood’s light
 Ultraviolet (UV) light of 365 nm wavelength is obtained by passing the beam through a
Wood’s filter composed of nickel oxide ­containing glass. This apparatus, commonly known
as the Wood’s light, is commonly used to demonstrate fungal fluorescence.
 Fluorescent­positive infections are caused by M. audouinii, M. canis, M. ferrugineum, M.
distortum, and T. schoenleinii. In a dark room the skin under this light fluo­resces faintly
blue, and dandruff commonly is bright blue– white. Infected hair fluoresces bright green or
yellow–green. The fluorescent substance is a pteridine. Large spore endothrix organisms
(such as T. tonsurans and T. violaceum) and T. ver- rucosum (a cause of large spore
ectothrix) do not fluoresce.
Diseases resulting from fungi and yeasts
 Diseases resulting from fungi and yeasts
DERMATOPHYTES

DIAGNOSIS
Laboratory examination
 For demonstration of the fungus in a highly inflammatory plaque, two or three loose hairs are
carefully removed with epilating forceps from the suspected areas. If fluorescence occurs, it is
important to choose these hairs.
 Bear in mind that hairs infected with T. tonsurans do not fluoresce. In “black dot” ringworm or in
patients with seborrheic scale, small broken fragments of infected hair will adhere to a moist gauze
pad rubbed across the scalp. The hairs are placed on a slide and covered with a drop of a 10–20%
KOH solution. Then a cover­slip is applied, and the specimen is warmed until the hairs are
macerated.
 Exact identification of the causative fungus is generally determined by culture, although molecular
sequencing offers a more rapid alternative. For culture, several infected hairs are planted on
Sabouraud dextrose agar, Sabouraud agar with chloramphenicol, Mycosel agar, or dermatophyte
test medium (DTM).
 Diseases resulting from fungi and yeasts
DERMATOPHYTES

TREATMENT
 A meta­analysis of published studies shows mean efficacy for griseofulvin treatment of about 68% for
Trichophyton spp and 88% for Microsporum. For the ultra­micronized form, doses start at 10 mg/kg/day.
The tablets can be crushed and given with ice cream. Grifulvin V oral suspen­sion is less readily
absorbed. The dose is 20 mg/kg/day. Treatment should continue for 2–4 months, or for at least 2 weeks
after negative laboratory examinations are obtained.
 For Trichophyton infections, terbinafine is commonly effective in doses of 3–6 mg/kg/day for 1–4
weeks. Alternate dosing schedules for terbinafine include one 250 mg tablet for patients over 40 kg, 125
mg (half of a 250 mg tablet) for those 20–40 kg, and 62.5 mg (one­quarter of a 250 mg tablet) for those
under 20 kg.
 Microsporum infections require higher doses and longer courses of therapy with terbinafine.
Itraconazole has been shown to be effective in doses of 5 mg/ kg/day for 2–3 weeks, and fluconazole at
doses of 6 mg/kg/ day for 2–3 weeks. Reports of heart failure with itraconazole have limited its use.
 Selenium sulfide shampoo or ketoconazole shampoo left on the scalp for 5 min three times a week can
be used as adjunc­tive therapy to oral antifungal agents to reduce the shedding of fungal spores. Combs,
brushes, and hats should be cleaned carefully and natural bristle brushes must be discarded.
 Diseases resulting from fungi and yeasts

FUNGAL INFECTIONS
 Classified into: superficial (invade stratum corneum, hair and nails), subcutaneous (usually due to
implantation) and deep (systemic) infection. Further subdivided into true and opportunistic pathogens
DEFINITIONS
 Yeast: unicellular fungus, round to ovoid organisms with asexual reproduction (budding or binary fission),
pseudohyphae (long chain of yeast cells with constrictions rather than true septae), form moist colonies
 Mold: multicellular filamentous fungus with hyphae (tubular branching cells, regular septae),
reproduction via spore development and dispersal; can be geophilic (growth primarily in soil), zoophilic
(predominantly infects animals), or anthrophilic (infects humans), cell membrane with unique sterol
(ergosterol).
Dimorphic fungi: grow as either yeast or mold, depending on environmental conditions (yeast form in tissue at 37°C,
but mycelial form in environment at 25°C.
Dematiaceous fungi: fungi with pigmented hyphae (green, brown, or black); appearance of brown-black coloration on
artificial culture media
 Mycelium: large intertwined mass of hyphae; different types (see below)
Diseases resulting from fungi and yeasts
 Diseases resulting from fungi and yeasts

 Spores: reproducing bodies of fungi; asexual or sexual

o Asexual spores: often characteristic for particular species, thus used as basis for
identification; 2 types: sporangiospores and conidia
• Conidia: free spores produced directly from hyphae or supporting conidiophores, different
types
 Diseases resulting from fungi and yeasts

Direct Stains
Potassium hydroxide (KOH): dissolves keratin but leaves behind the hyphae (faster if dimethyl
sulfoxide [DMSO] added)
Chlorazol black E: chitin-specific blue-black stain
Calcofluor: colorless dye, binds cellulose and chitin in fungal cell walls, seen under fluorescent
microscope (apple-green fluorescence).

Histology
Gomori methenamine silver (GMS): outlines fungal elements black
Periodic acid-Schiff (PAS): outlines fungal elements magenta with green background
Fontana-Masson: stains dematiaceous fungi
Mucicarmine: stains capsule of Cryptococcus neoformans pin
 Diseases resulting from fungi and yeasts

Media
• Sabouraud Dextrose Agar (SDA): gold standard (peptone, glucose, water, agar)

• Modified SDA (Mycosel or Mycobiotic): SDA + cycloheximide + chloramphenicol

o Cycloheximide inhibits saprophytic fungi (Prototheca, H. werneckii, Scytalidium, Candida other than
albicans, C. neoformans) o Chloramphenicol inhibits bacteria

• Dermatophyte Test Medium (DTM): peptones, dextrose, cycloheximide, phenol red,

chlortetracycline, and gentamicin
o Dermatophytes turn media from amber to red color due to alkaline by-products
o Non-dermatophytes cause media to turn yellow (or stay amber-colored
 Diseases resulting from fungi and yeasts

SUPERFICIAL MYCOSES
 Includes only fungi invading keratinized tissues (hair, nails, stratum corneum)
 Divided into non-inflammatory (tinea versicolor, tinea nigra, piedra) and inflammatory
(dermatophytosis, candidiasis)
 Diseases resulting from fungi and yeasts

Pityrosporum Folliculitis (Malassezia Folliculitis)

On rare occasions, M. furfur may infect hair follicles
Presents as monotonous acne-like folliculocentric papules typically over
back, occasionally evolving into pustules → heal with brown, easily removed crust

 Treatment: topical imidazole, fluconazole 400 mg × 1 or ketoconazole 400 mg

 Diseases resulting from fungi and yeasts

Tinea Versicolor (Pityriasis Versicolor)

Malassezia furfur (yeast form: Pityrosporum ovale or P. orbiculare)
Yeast part of normal cutaneous flora, but pathogenic when transforms into mycelial form; requires lipid
enrichment when growing
M. furfur produces azelaic acid (a dicarboxylic acid) → blocks melanin synthesis causing ↓
pigmentation
Presents as hyper- and hypopigmented macules and patches with fine scale in lipid-rich areas of skin;
common in summer; facial lesions common in infants
KOH: ‘ziti and meatballs’ (short, thick hyphae with grape-like spores); culture requires lipid
enrichment (olive oil overlay); Wood’s light shows pale yellow fluorescence
 Treatment: topical imidazoles, selenium sulfide, zinc pyrithione, or ketoconazole 400 mg qweek ×
2 doses
 Diseases resulting from fungi and yeasts

Tinea Nigra
Dematiaceous fungus: Hortaea werneckii (formerly known as Exophiala werneckii,
Phaeoannellomyces werneckii, and Cladosporium werneckii)
Geophilic: transmission likely acquired via direct contact with soil or decaying vegetation
Presents as one or more sharply-demarcated hyperpigmented to gray macules or patches with fine scale
on the palms or soles; can be mistaken for melanoma (but former has advancing border with darker
pigmentation compared to center)
Pigment within stratum corneum (scrapes off easily) and golden brown hyphae seen on KOH; black
shiny colony on culture
 Treatment: topical imidazoles or allylamines
 Diseases resulting from fungi and yeasts

Piedra
Superficial infection of hair shaft where fungal elements adhere to form nodes along hair shaft.
Two types: black piedra and white piedra
Black piedra: Piedraia hortae; presents with tiny dark concretions on hairs shafts distributed
irregularly; culture shows black velvety colony
White piedra: Trichosporon cutaneum (formerly T. beigelii) most common; other species include T.
ovoides, T. inkin, and T. asahii); presents with light brown, less adherent nodules coating hair shaft
(beard, axilla, pubic hairs)
Of note, T. cutaneum can cause fungemia with systemic disease in immunocompromised patients
 Treatment: shaving/cutting hair, topical imidazoles
 Diseases resulting from fungi and yeasts

DERMATOPHYTOSIS
Three genera of fungi with capability of invading keratinized tissue:
Microsporum, Trichophyton and Epidermophyton.
Dermatophytes may produce keratinolytic enzymes (such as keratinase), which allows for the
breakdown of keratin.
Sebum has an inhibitory effect of dermatophytes.
 Diseases resulting from fungi and yeasts

Tinea Corporis
T. rubrum most common; may spread from fungal infection of feet (T. rubrum, T. mentagrophytes), infected
animal (M. canis), or soil (M. gypseum).
Presents as erythematous, sharply marginated, scaly plaque with raised, advancing border; typically with
central clearing and annular or arcuate shape
 Clinical variants
o Tinea imbricata: T. concentricum, presents with distinct scaly plaques arranged in concentric rings
o Tinea profunda: marked inflammatory response to a dermatophyte (analogous to kerion on scalp)
o Tinea incognito: dermatophyte infection without obvious signs of inflammation (usually due to prior
treatment with topical corticosteroid
o Majocchi’s granuloma: T. rubrum (most common), granulomatous C folliculitis due to dermatophyte
entering hair follicles (usually due to prior topical corticosteroid use), treat with oral antifungal
 Treatment: topical therapy usually adequate (imidazole, allylamine); if extensive or involving hair
follicles can use oral terbinafine or itraconazole
 Diseases resulting from fungi and yeasts

Tinea Cruris
Erythematous patch typically with raised, serpiginous scaly border and central clearing involving upper
inner thighs and crural folds; scrotum rarely involved
 Treatment: topical antifungal cream
 Diseases resulting from fungi and yeasts

Tinea Barbae (Tinea Sycosis)

Uncommon infection of hair caused by M. canis, T. mentagrophytes or T.verrucosum
Presents as painful inflammatory nodular swellings typically involving beard or moustache area
 Treatment: oral antifungal
 Diseases resulting from fungi and yeasts

Tinea Faciei
Seen more commonly in children with T. rubrum, T. mentagrophytes or M. canis
Erythematous serpiginous plaques with scaling on face, sometimes annular
 Treatment: topical antifungal cream (oral antifungal treatment if any follicular involvement)
 Diseases resulting from fungi and yeasts

Tinea Capitis
Common dermatophyte infection in scalp of children
Two types: endothrix and ectothrix.
T. tonsurans (endothrix) most common cause; 2nd most common is M. canis (highly inflammatory) and M. audouinii.

• Ectothrix: fungal spores coat outside of hair and cuticle destroyed; may or may not fluoresce with Wood’s light
(365 nm, mercury lamp with nickel chromium oxide filter.
• Endothrix: spores within hair shaft, cuticle intact, hairs can break at surface (‘black dot’ tinea).
o T. rubrum (causes both endo/ecto), T. gourvilli, T. yaounde, T. tonsurans, T. soudanense, T. violaceum
Favus: rare variant of endothrix with yellow cup-shaped crusting (scutula) on scalp; arthroconidia and airspaces within hair
shaft
o T. schoenleinii, T. violaceum, M. gypseum
Kerion: variant of endothrix with boggy inflammatory plaques, ± scarring alopecia
 Treatment: oral antifungal for at least 6-8 weeks
Diseases resulting from fungi and yeasts
 Diseases resulting from fungi and yeasts

Tinea Pedis
Commonly due to T. rubrum (relative noninflammatory)
Different types
oMoccasin type (T. rubrum, E. floccosum): dull erythema with scaling involving sole and sides
of foot, may be focal
o Bullous type (T. mentagrophytes): multilocular bullae often located along the instep (arch)
Interdigital type (T. rubrum, T. mentagrophytes): erythema, macera- tion, and fissuring of the
o

webspace.
Dermatophytid (‘id’) reaction may occur due to inflammatory tinea pedis

 Treatment: topical antifungal, if extensive use oral terbinafine 250 mg qd × 2 weeks

 Diseases resulting from fungi and yeasts

Onychomycosis
Infection of the nail plate, most commonly due to T. rubrum, but also by other dermatophytes, yeast and
nondermatophytic molds
Four types:
oDistal subungual onychomycosis: involvement of distal nail bed and hyponychium; typically due to T.
rubrum
oWhite superficial onychomycosis (WSO): chalky white superficial infection of nail plate; mainly due
to T. mentagrophytes (of note,
T. rubrum more common in HIV patients)
oProximal subungual onychomycosis: least common form, presents with areas of leukonychia in
proximal nail plate near lunula; usually due to T. rubrum; can be a sign of HIV infection
oCandida onychomycosis: destruction of nail and massive nail bed hyperkeratosis, typically seen in
patients with mucocutaneous candidia- sis; due to C. albicans
 • Treatment: oral terbinafine 250 mg qd × 6-8 weeks for fingernails and 12-16 weeks for toenails
 Diseases resulting from fungi and yeasts

Microsporidium
M. audouinii
Infection: formerly #1 cause of tinea capitis in children
Colony: gray-white color → reverse salmon-red color; ‘mouse fur appearance’
Hyphae: ± pectinate hyphae (resembles broken comb), racquet hyphae
Conidia: poorly shaped, thick-walled and barrel-shaped and pointed ends
Misc: (−) polished rice growth.