Chapter

Three
Cutaneous mycoses
 Cutaneous mycoses

• Cutaneous mycoses involves deep epidermis and

keratinized body areas (skin, hair, nails).
• Cutaneous mycoses are two types, such as:
• Dermatomycosis: refers to certain fungal infection
of the skin, hair and nail caused by dermatophytes
and certain opportunistic fungi
• Dermatophytosis - "ringworm" disease of the nails,
hair, and/or stratum corneum of the skin caused by
fungi called dermatophytes.
 Cutaneous mycoses
• Fungi of dermatophyte group invade only
cutaneous (nonviable) skin and its appendages
such as hair and nails alone or in combination
• Penetration below the granular layer of the
epidermis is rare.
• A single species is able to cause more than
one type of clinical infection.
• Conversely, a single clinical form, may be
caused by more than one dermatophyte
species
 Cutaneous mycoses

• Dermatophytoses are caused principally by species

of three closely related genera of keratin-metabolizing
filamentous fungi; namely:
 Trichophyton: attack the hair, nail and skin
 Epidermophyton: attacks only the skin and
nails
 Microsporium: attack only the hair and skin.
• The morphology and pathogenicity of the species are
similar.
 Cutaneous mycoses

• The symptoms of dermatophytosis vary, depending

on the infecting organism, affected tissues (e.g.,
skin, hair or nails), area of the body and host
reactions.
• In unhaired (glabrous) skin, the lesions are
usually characterized by inflammation that is most
severe at the edges, with erythema, scaling and
occasionally blister formation.
• The central area may clear, resulting in the
formation of a classic “ringworm” lesion.
 Cutaneous mycoses
• Cutaneous mycoses are perhaps the most common
fungal infection of humans and are usually referred
as tinea (Latin for “worm” or “ring worm”).
• The gross appearance of the lesion is that of an
outer ring of an active, progressing infection with
central healing in the ring.
 Cutaneous mycoses
• Transmission is enhanced by conditions of
moisture and sweating.
high
• Dermatophytes are contagious.
• Dermatophytes are transmit by direct or indirect
contact.
• Indirect transfer can occur from the swimming pool
floor, showers, brushes, etc.
• Direct transfer can occur by the viable fungus
(containing hyphae or conidia) in the keratin fragments
of skin, hair, and nails.
 Cutaneous mycoses
• When the hair is infected, the pattern of fungal invasion
can be either ectothrix, endothrix, or favic depending
on the dermatophytic species.
• In the ectothrix pattern, arthroconidia are formed on
the outside of the hair and cuticle of hair are destroyed
• Infected hair fluoresce greenish yellow under wood’s
lamp.
• In the endothrix pattern, arthroconidia are formed
inside the hair and hair cuticle remains intact.
 Cutaneous mycoses

• Infected hair don’t fluoresce under wood’s lamp

• In the favic pattern, hyphae, arthroconidia, and
empty spaces resembling air bubbles
(“honeycomb” pattern) are formed inside the
hair.
Cutaneous mycoses
Cutaneous mycoses
 Identification of
dermatophytes
• Dermatophytes produces macro and microconidia.
• Shape and type of conidia helps for identification of
genus.
 Dermatophytes ecology
1. Arthropophilic organisms are acquired from other humans.
- Causes relatively non inflammatory infection,
- Highly adapted to human
- Elicit relatively mild and chronic infections,
- Difficult to eradicate, respond poorly to treatment.
2. Geophilic organisms are acquired from the soil.
3. Zoophilic organisms are acquired from animals and
• Geophilic and zoophilic dermatophytes,
- Less adapted to human hosts,
- Causes acute inflammatory infection
- Resolve more quickly.
Dermatophytes ecology
 Clinical presentation of
cutaneous mycoses
• Restricted to keratinized layer of the skin (epidermis), hair, or
nails.
• Elicit an inflammatory response, resulting in more serious
skin diseases with uncomfortable painful and sometimes
even crippling symptoms include
- Irritation, erythema (redness of the skin), edema
(swelling), and vesiculation.
- Itching, scaling or ring like patches of the skin;
- Brittle or broken hairs;
- An infected nail gets discolored, thickened, raised,
and friable.
• Clinically, the tineas or ringworm are classified
according to the anatomic site or structure affected:

1. Tinea capitis - ringworm infection of the head, scalp, eyebrows,

eyelashes
2. Tinea favosa - ringworm infection of the scalp (crusty hair)
3. Tinea corporis - ringworm infection of the body (smooth skin)
4. Tinea cruris - ringworm infection of the groin (jock itch)
5. Tinea unguium - ringworm infection of the nails
6. Tinea barbae - ringworm infection of the beard
7. Tinea pedis - ringworm infection of the foot (athlete's foot).
8. Tinea manuum: Infection of the palmar aspect of hands.
9. Tinea facie: Infection of the non-bearded area of the face.
 Pathogenesis of
Dermatophytes
• Virulence factors of dermatophytes are arthroconidium (asexual spores),
enzymes (keratinase, protease, lipase), and mannan of the fungal cell wall.
• Adherence
- Arthroconidium (asexual spores produced by dermatophytes) adheres to
the surface of the tissue.
• Penetration
- After the adherence, dermatophytes secrete various enzymes like
proteases, lipases, elastases, collagenases, phosphatases, and esterases
to degrade the complex compounds into simple ones. It helps in the
penetration of the stratum corneum.
• Development of host response
- Dermatophytes have mannan, which suppresses the inflammatory
response. It also inhibits the proliferation of the keratinocytes, which
allows for establishing the persistent infection.
 Tinea
capitis
• Also referred as ring worm of the scalp and hair.
• Fungus grows into hair follicle and hair shaft
• Caused by species of Trichophyton and Microsporum
• Lesions range from dry, scaly patches of alopecia to
inflammatory pustules and kerions.
• Is characterized by scaly, erythematous lesions, alopecia
and sometimes deep, ulcerative, kerion like eruptions.
• The infection begins with hyphal invasion of the skin of the
scalp,
• Subsequent spread down the keratinized wall of the hair
follicle.
 Source and epidemiology

Epidemiology
• Tinea capitis has a worldwide distribution.
• It is most frequent in prepubescent children.
⚫ Mainly affects and quickly disseminated among
children.
⚫ It occurs most often in those living under
crowded conditions.
⚫ The clinical presentations offer a practical way
of classifying the disease.
• Are four types: gray patch, black dot,
inflammatory,
 Source and epidemiology

Source of infection
⚫ Have specific geographical distribution.
⚫ Anthropophilic species spread directly
by means of infected hairs on hats, caps,
upholstery, combs or barber clippers.
⚫ Zoophilic species transmitted from animals
to man (puppies and kitten).
 1. Gray Patch Tinea
Capitis
• The hallmark is a round or oval, sharply demarcated
patch of partial alopecia.
• The hair is reduced to short stubble by the tendency
of
infected hairs to break off just above the skin.
• Several patches may coalesce to form extensive areas of
hair loss.
• Due to M. canis and is still common worldwide.
• Microsporum spp. cause ectothrix infections.
• It produces a yellow–green fluorescence under Wood’s
light examination.
Gray Patch Tinea
Capitis
 2. Black Dot Tinea
C apitis
• Endothrix infection of hair causes the shafts to break off at or
below the surface of the scalp, leaving only arthroconidia
laden stubs visible.
• When the hairs are black, this result in the appearance of
black dots.
• Lesions are often multiple, scattered, irregularly shaped
patches of alopecia with indistinct borders.
• Scaling may be a prominent feature.
• Trichophyton tonsurans is by far the most common;
• T. violaceum is sometimes the causative organism but T.
rubrum is only rarely isolated.
• Do not fluoresce under Wood’s light examination.
Black Dot Tinea
Capitis
 3. Inflammatory Tinea
Capitis
• Caused by T. tonsurans; it’s an inflammatory disease.
• Zoophilic and geophilic species may induce a severe
combined inflammatory and hypersensitivity reaction called a
kerion.
• The lesions may be tender and painful.
• Begin as small furuncles, which over a short period, enlarge
and become more inflamed and develop abscess and pus.
• In worst cases, kerions become a sharply delineated,
indurated, granulomatous tumefaction, sometimes referred
to as a “boggy mass.” (soft & watery mass)
• Untreated kerion may result in permanent scarring alopecia.
 Inflammatory Tinea
Capitis

• Systemic manifestations include adenopathy,

fever, and malaise.
 4. Favus tinea capitis
(Tinea favosa)
• Favus is a chronic ringworm infection affecting hair follicle.
• Endothrix and inflammatory hair infection.
• Caused almost exclusively by T. schoenleinii.
• It is characterized by the formation of yellowish cup-
shaped crusts or scutulae,
• These cup-shaped crusts are composed of hyphae, WBC,
and epidermal cells.
• Produce a mousy odor, serous exudate and secondary bacterial
infections may be present.
• Considerable scarring of the scalp, and sometimes
permanent alopecia.
 Favus tinea
capitis
• It’s prevalent in parts of Africa, Asia, and South America.
• The infected hairs produce a bluish-white fluorescence
under Wood’s light.
 Laboratory diagnosis
• Identification:
• In skin, they are diagnosed by the presence of hyaline, septate,
branching hyphae or chains of arthroconidia.
• In cultures on Sabouraud’s agar, they form characteristic colonies
consisting of septate hyphae and two types of asexual spores,
microconidia and macroconidia on short conidiophores.
• Differentiation into the three genera is based mainly on the
nature of
macroconidia.
• In culture, the many species are closely related and often difficult to
identify.
• Dermatophytes are identified by their colonial appearance and
microscopic morphology after growth at 25°C on SDA. (They can’t
grow above 37°C).
 Laboratory diagnosis

Samples: Infected hair with nodule or scalp scrapings.

Direct Examination
• The routine method of diagnosis is by the examination of KOH
mounts.
• Specimens are placed on a slide in a drop of 10 % KOH, with or
without calcofluor white, which is a nonspecific fungal cell wall stain
viewed with a fluorescent microscope.
• A coverslip is added, and the specimen is examined immediately and
again after 20 minutes.
• Regardless of the infecting species, branched septate hyphae or
chains of arthroconidia (arthrospores) are seen.
 Laboratory diagnosis

Microsporum
• Infected hairs show the fungus as a mosaic sheath of
small spores surrounding the hair shaft. (Ectothrix)
• Immediately recognized by the presence of large,
spindle-shaped, echinulate (covered with small
spines), rough-walled macroconidia with thick walls
containing four or more septa, as well as lesser
numbers of small and club-shaped
microconidia.
• Infected hair shafts fluoresce yellow-green using a
Wood’s lamp.
 Laboratory diagnosis
Trichophyton
• Hairs infected with Trichophyton species show arthrospores arranged
in parallel rows inside or outside the hair and appearing either in
chains of small arthrospores or chains of large arthrospores .
• Trichophyton do not fluoresce under the ultraviolet (UV) light of a
Wood’s lamp.
• In this genus, the microconidia are diagnostic while the macroconidia
are not.
• There are two characteristic arrangements of the microconidia the "en
thyrse" and "en grappe" arrangements.
• Help distinguish this organism from similarly appearing genera:
• En grape refers to microconidia in clumps at the ends of the hyphae.
• En thyrse refers to microconidia that form along
the sides of the hyphae.
 Microsporum
audouinii
Microorganisms Fluorescence Color

Microsporum audouinii Bright-green

Microsporum canis Bright-green

Microsporum ferrugineum Blue-green

Microsporum distortum Blue-green

Microsporum gypseum Dull-yellow

Trichophyton schoenleinii Dull-green

Malassezia furfur Golden-yellow

Corynebacterium minutissimum Coral-red

Dermatophytes Colony morphology Microscopic observation
Tear-drop, microconidia, a few long,
Trichophyton rubrum Velvety, red pigment on reverse
pencil-shaped macroconidia

Clusters of microconidia cigar-shaped

Trichophyton White to tan, cottony or powdery,
macroconidia with terminal rat-tail
mentagrophytes pigment variable
filaments

Trichophyton Powdery to cream or yellow with Abundant microconidia, thick-walled,

tonsurans central furrows irregular macroconidia
Trichophyto Hyphal swellings, chlamydopsores,
Smooth, waxy, brownish
n favic chandelier
schoenleinii
Trichophyto Very slow growing, waxy, violet to
Distorted hyphae, conidia rare
n violaceum purple pigment
Microsporum Thick-walled chlamydospores, conidia
Velvety, brownish, slow growing
audouinii rare and irregular

Abundant, thick-walled spindle-

Microsporum canis Cottony, orange pigment on reverse shaped macroconidia with up to 15
septa

Microsporum Powdery, buff-colored Yellowish- Abundant, thin-walled macroconidia

gypseum green with 4-6 septa
Epidermatphyto Slow growing, powdery, greenish-
Club-shaped macroconidia in clusters
floccosum brown
Dermatophytes Colony morphology Microscopic observation
Tear-drop, microconidia, a few long,
Trichophyton rubrum Velvety, red pigment on reverse
pencil-shaped macroconidia

Clusters of microconidia cigar-shaped

Trichophyton White to tan, cottony or powdery,
macroconidia with terminal rat-tail
mentagrophytes pigment variable
filaments

Trichophyton Powdery to cream or yellow with Abundant microconidia, thick-walled,

tonsurans central furrows irregular macroconidia
Trichophyto Hyphal swellings, chlamydopsores,
Smooth, waxy, brownish
n favic chandelier
schoenleinii
Trichophyto Very slow growing, waxy, violet to
Distorted hyphae, conidia rare
n violaceum purple pigment
Microsporum Thick-walled chlamydospores, conidia
Velvety, brownish, slow growing
audouinii rare and irregular

Abundant, thick-walled spindle-

Microsporum canis Cottony, orange pigment on reverse shaped macroconidia with up to 15
septa

Microsporum Powdery, buff-colored Yellowish- Abundant, thin-walled macroconidia

gypseum green with 4-6 septa
Epidermatphyto Slow growing, powdery, greenish-
Club-shaped macroconidia in clusters
floccosum brown
Method Primary Use Advantages Disadvantages

Acid fast stain Detection of Tissue homogenates are difficult to

Detects Nocardia and some
and partial mycobacteria and observe because of background
isolates of B.dermatitidis
acid fast stain Nocardia, respectively staining

Can be mixed with KOH:

Requires use of fluorescence
Calcofluor white Detection of fungi detects fungi rapidly because
microscope
of bright fluorescence

Will detect most fungi if Some fungi stain weakly

Gram stain Detection of bacteria
present in that specimen (e.g. Cryptococcus
spp)
Detection Positive in less than 50% of cases
If present, is diagnostic
India Ink of Cryptococcus of meningitis, not sensitive in non-
of cryptococcal
neoformans in CSF HIV meningitis
meningitis
Clearing of some specimen make take
Potassium Clearing of specimen
Rapid detection of fungal hours, experience required since
hydroxide to make fungi more
elements background artifacts are often
(KOH) mount readily visible
confusing

Methenamine Detection of fungi in Best stain to detect fungal Requires a specialized staining
silver stain histologic section elements method

Periodic acid- Stain fungal elements well;

Schiff (PAS) Detection of fungi hyphae of molds and yeasts
stain can be readily
distinguished
Examination of bone
Detects H.capsulatum and C.
Wright stain marrow or
neoformans
peripheral blood
 Microsporum
Dermatophytes
audouinii
Trichophyton rubrum
Colony morphology

Velvety, red pigment on reverse

Trichophyton White to tan, cottony or powdery,
mentagrophytes pigment variable
Powdery to cream or yellow with
Trichophyton tonsurans
central furrows
Trichophyton schoenleinii Smooth, waxy, brownish
Very slow growing, waxy, violet to
Trichophyton violaceum
purple pigment
Microsporum audouinii Velvety, brownish, slow growing
Microsporum canis Cottony, orange pigment on reverse
Powdery, buff-colored Yellowish-
Microsporum gypseum
green
Slow growing, powdery, greenish-
Epidermatphyto floccosum
brown
Microscopic observation
Tear-drop, microconidia, a few long,
pencil-shaped macroconidia
Clusters of microconidia cigar-
shaped macroconidia with terminal
rat-tail filaments
Abundant microconidia, thick-walled,
irregular macroconidia
Hyphal swellings, chlamydopsores,
favic chandelier
Distorted hyphae, conidia rare
Thick-walled chlamydospores,
conidia rare and irregular
Abundant, thick-walled spindle-
shaped macroconidia with up to 15
septa
Abundant, thin-walled macroconidia
with 4-6 septa
Club-shaped macroconidia in
clusters
 Microsporum
audouinii
• An anthropophilic fungus causing non-inflammatory infections of scalp
and skin especially in children.
• This species may be difficult to identify due to the lack of
sporulation.
• Bizarre - shaped macroconidia: thick walled club or spindle shaped,
and multiseptate, with rough surface, often pointed on the end.
• Microconidia rare, intercalary/ terminal chlamydospores.
• The most distinctive microscopic finding is terminal
chlamydospores.
• They also form hyphal forms of pectinate (comb-like) and
racquet hyphae (segmented series of hyphae with swollen tips).
Microsporum
audouinii
 Microsporum
audouinii
• Grow more slowly about two weeks.
• They produce a velvety aerial mycelium that is colorless to light gray
to tan.
• Reverse side is salmon pink or orange brown.
• Growth on rice grains is scant and characterized by a brown
discoloration of the rice.
• Infected hair shafts fluoresce yellow-green using a Wood’s
lamp.
 Microsporum
•
canis
Primarily a pathogen of animals (zoophilic).
• Fluoresces a bright yellow-green under a Woods lamp.
• Macroconidia: Thick walled, spindle shaped, large, multiseptate
rough walled with curved tip and knobby projections,
• Sparse few microconidia: clavate, smooth walled, and
literally attached hyphae.
• Arthroconidia surrounding the ectothrix hair shaft.
 Microsporum
canis
• It is rapid growing
• Center of colony has white to buff granular or
cottony surface over bright- yellow feathery
periphery.
• Reverse side is bright yellow or yellow orange.
• Abundant growth and sporulation on polished rice
grains.
 Microsporum
gypsum
• M. gypseum, a free-living organism of the soil (geophilic).
• Do not fluoresce under a Wood lamp.
• Macroconidia: numerous, thick –walled, ellipsoidal
multiseptate (3-9) with spiny surface and rounded tips.
• Micrconidia: few or absent , clavate, smooth walled.
 Microsporum
gypsum
• Grows rapidly as a flat, irregularly fringed colony with a
coarse, powdery surface that appears to be buff or
cinnamon color.
• Reverse side is conspicuously orange to brownish.
 Trichophyton
mentagrophytes
• Zoophilic species with a cosmopolitan distribution.
• Characteristic of an ectothrix type of invasion.
• Microconidia: numerous, small, spherical and arranged
in grape like clusters,
• Coiled, spiral hyphae may be observed,
• Macrocondia: rare thin walled, smooth and cigar
shaped.
• Produces inflammatory skin or scalp lesions in
humans, particularly in rural workers.
• Kerion of the scalp and beard may occur.
• Do not fluoresce under Wood’s ultra-violet light.
Trichophyton
mentagrophytes
 Trichophyton
mentagrophytes
• Produces two distinct colonial forms: the downy
variety and the granular variety.
• The rapidly growing colonies may be fluffy or granular
and
flat.
• Color is white or tan to pink with light yellow
periphery.
• Reverse side is yellow-brown to red- brown color.
 Trichophyton
•
tonsurans
Trichophyton tonsurans is an anthropophilic fungus.
• Causes inflammatory or chronic non-inflammatory finely scaling
lesions of skin, nails and scalp.
• Microconidia: Abundant or club-shaped with flat
bottoms;
teardrop vary in size but usually larger than
other
dermatophytes;
• Macroconidia: rare smooth walled, cylindrical.
Trichophyton
tonsurans
 Trichophyton
tonsurans
• Flat powdery, granular, and cream, tan, yellow-rose, or
rust-colored colony, wrinkled appearance.
• The colony surface shows radial folds and often
develops a
bowl like depression in the center, with deep fissures.
• Reverse side is yellow to tan or rust red appearance.
 Trichophyton
rubrum
• It is anthropophilic & affects human feet, skin, &
fingernails, causing chronic infections on these body
parts.
• Microscopically, endothrix and ectothrix invasion may
be observed on infected hair.
• Two types: T. rubrum downy type and T. rubrum
granular type.
Microconidia: Usually present in large numbers, small,
tear shaped borne laterally along strands of hyphae.
• Macroconidia: rare, narrow with smooth, thin-walled
parallel sides (pencil shaped and contain 2 - 8 septa.).
Trichophyton
rubrum
 Trichophyton
rubrum
— Colonies are slow growing, flat or heaped at the center with
a white to buff color, fluffy surface turning pink-tan.
— The characteristic cherry/wine-red color on the
reverse
side of the colony after 3 to 4 weeks of incubation.
 Trichophyton
verrucosum
• It is zoophilic pathogen and ectothrix invasion of hair
worldwide.
• Usually causes highly inflammatory lesion involving the scalp,
beard or exposed areas of the body.
• Unlike other dermatophytes, this fungus grows best at 37°C.
• Colonies (SDA) are slow growing, small, button or disc-shaped,
white to cream-coloured, with a suede-like to velvety surface, a
raised center, and flat periphery with some submerged growth.
• Reverse pigment may vary from non-pigmented to yellow.
• Broad, irregular hyphae with many terminal and intercalary
chlamydospores are present.
• Chlamydospores are in chains, referred to as “chains of
pearls”.
 Trichophyton
verrucosum
• Macroconidia are only rarely produced, but when present have a
characteristic tail or string-bean shape.
• Occasional strains produce clavate to pyriform microconidia borne singly
along the hyphae.
 Trichophyton
violaceum
• Trichophyton violaceum is an anthropophilic
fungus.
• Causing inflammatory or chronic non-
inflammatory finely scaling lesions of skin, nails,
beard and scalp, producing the so-called “black
dot” tinea capitis.
• Distribution is world-wide, invaded hairs show an
endothrix infection and do not fluoresce under
Wood’s ultra-violet light.
 Trichophyton
violaceum
• Colonies (SDA) are very slow growing, glabrous or waxy, heaped
and folded and a deep violet in colour.
• Cultures often become pleomorphic, forming white sectors and
occasional non-pigmented strains may occur.
• Hyphae are relatively broad, tortuous, much branched and
distorted.
• No conidia are usually seen, although occasional pyriform
microconidia have been observed on enriched media.
• Numerous chlamydospores are usually present, especially in
older cultures.
 Trichophyton
violaceum
• Colonies (SDA) are very slow growing, glabrous or waxy, heaped
and folded and a deep violet in colour.
• Cultures often become pleomorphic, forming white sectors and
occasional non-pigmented strains may occur.
• Hyphae are relatively broad, tortuous, much branched and
distorted.
• No conidia are usually seen, although occasional pyriform
microconidia have been observed on enriched media.
• Numerous chlamydospores are usually present, especially in
older cultures.
 Tinea
Favosa
• Inflammatory tinea capitis fungal infection caused almost exclusively by
infection with T. schoenleinii
• An anthropophilic fungus.
• Usually limited to the scalp where it produces characteristic yellowish,
cup-shaped crusts (scutula) which have a peculiar “mousy” odor.
• Scutula: are composed of hyphae, neutrophils, and epidermal cells.
Geographical distribution
 Tinea favosa has a world wide distribution.
Source of infection
⚫ Infections are common among members of the same family.
 Pathogenesis and clinical
picture
• Tinea favosa is most common in the scalp where it begins as
minute, subcuticular, pinpoint, yellowish-red puncta, which
develops into yellowish, cup-shaped, elevated crusts of
varying size.
• The hair soon becomes involved, appears lusterless and
ultimately shed.
• If untreated, the disease spread all over the scalp with resultant
scaring and baldness (alopecia).
• Favus is a chronic, scarring form of tinea capitis characterized
by saucer-shaped crusted lesions or scutula and permanent
hair loss.
• Invaded hairs remain intact and fluoresce a pale greenish
yellow under Wood’s ultra-violet light.
 Laboratory diagnosis

• Trichophyton schoenleinii
• Colonies (SDA) are slow growing, waxy or suede-like with a
deeply folded honeycomb-like thallus and some sub-surface
growth.
• The thallus is cream-coloured to yellow to orange brown.
• Without any color on the reverse side.
• Main identifying characteristics include lack of both micro- and
macroconidia.
• The formation of “favic chandeliers” which are antler-like
structures at the tips of hyphae.
Trichophyton
schoenleinii
 Epidemophyton
•
floccosum
Only one pathogenic species in this genus.
• Epidemophyton floccosum is numerous club-shaped, smooth
walled macroconidia with two to four cells occurring is singly
or in clusters of three to four;
• Microcondia absent.
 Epidemophyton
floccosum
⚫ E. floccosum is an anthropophilic dermatophyte with a
world-wide distribution which often causes tinea pedis,
tinea cruris, tinea corporis and onychomycosis.
⚫ On SDA: Colonies are usually slow growing, greenish-
brown or khaki coloured with a suede-like surface, raised
and folded in the centre, with a flat periphery and
submerged fringe of growth.
⚫ Reverse side is yellow-brown or dark orange with folds.
⚫ Key features include characteristic greenish-brown or
khaki coloured cultures, the production of smooth, thin-
walled, club-shaped macroconidia and the absence of
microconidia.
Epidemophyton
floccosum
 Tinea barbae
• Tinea barbae is a chronic fungal infection of the bearded
area of the face and neck, hence being restricted to adult
males.
• Synonyms: barbers’ itch, ringworm of the beard,
tinea sycosis, trichophytosis barbae
• The most common causes are T. mentagrophytes and T.
verrucosum.
• Characterized by both superficial lesions, resembling those
of tinea corporis, and deeper types of infection resulting
from involvement of the hair follicles.
 Tinea barbae

Geographical distribution
• Tinea barbae, frequently seen in Europe, has recently
become prevalent in USA particularly in areas where
cattle are raised or fed.
Source of infection
• The infection is transmitted from cattle to man i.e. usually
zoophilic and an occupational hazard for farm workers.
• Farmers are highly affected by this infection
 Pathogenesis

⚫ Superficial type of tinea barbae produces lesions which

closely resemble those of tinea corporis on glabrous
skin
⚫ There is a scaling central area surrounded by an active
vesicllopstular border.
⚫ The hair in such infected areas may be brittle
and lusterless.
⚫ Deep type of infection is characterized by the presence of
deep follicular pustules, which result in abscess
formation, and production of nodular, kerion like lesions.
 Tinea
cruris
• Dermatophyte infections of the groin, perianal and
pubic region.
• Aka: Dhobie’s itch, jock itch, ringworm of the groin,
tinea
inguinalis.
• Tinea cruris presents with sharply demarcated lesions with a
raised erythematous margin and thin dry epidermal scaling.
• The lesions are pruritic, but the lesions will become painful
if maceration and superinfection occur.
• Associated with anthropophilic species dermatophytes
such as; T. rubrum and E. floccosum less commonly T.
mentagrophytes and T. verrucosum are involved.
 Geographical distribution
• Find in all parts of the world, but is more common in tropics.
• More commonly seen in men.
Source of infection
• The infection may be acquired from:
• Public lavatory seats, sharing of cloths, & during
sexual intercourse

• Predisposing factors: perspiration, irritation from clothing,

diabetes, leucorrhea and friction resulting from obesity.
 Pathogenesis

⚫ The classic type of tinea cruris is characterized by

well- marginated, elevated, rapidly spreading
erythematous lesions with central clearing on the
inside of the thighs, intense pruritis.
⚫ Lesions with raised erythematous borderand
brown scaling.
⚫ Lesions may be unilateral or
bilateral, symmetrical or asymmetrical.
⚫ Occasionally, the axillae may be involved
and present a picture similar to that seen in the groin.
 Tinea pedis (athlete’s
foot)
• Refers to contagious dermatophyte infections of the feet, principally
involving the toe webs and soles.
• These infections often involve the interdigital spaces, but chronic
diffuse peeling can affect the entire sole.
• It is mostly seen in individuals whose feet are sweaty because of
tightfitting shoes.
• Geographical distribution:
• It is distributed worldwide and is most commonly found in
hot,
tropical, urban regions.
• Caused by T. mentagrophytes, T. rubrum and E.
floccosum (less commonly)
• In children, T. tonsurans is often implicated in tinea pedis.
 Tinea pedis (athlete’s
foot)
• Source of infection
• The disease is passed from person to person through the
floor of communal baths, swimming pools, gymnasiums and
by towels
• Circulatory instability, vascular stasis of extremity, ill-fitting
heavy shoes or infrequent change in socks or shoes
predispose to infection
• Men are affected more often than women.
• Urban people are affected than rural people who go bare
foot.
 Pathogenesis and clinical
picture
⚫ There are three clinical varieties of Tinea pedis:
1. Intertriginous type
• It is the commonest form of tinea pedis characterized by
itching, peeling, maceration and fissuring of the toe webs.
• Characterized by slow developing maceration, sogginess,
and fissuring of inter digital spaces usually beginning
between the 4th and 5th toe and spreading to others.
• A foul odour is sometimes present.
• Hot, humid climates and hyperhidrosis may increase the
risk of infection.
 Pathogenesis and clinical
picture
2. Squamous or hyperkeratotic type
• It is characterized by areas of pink skin
covered with fine white scaling.
• The soles, sides of the feet and heels usually show well-defined,
red or purplish scaly patches with no vesiculation.
• Thick, hyperkeratotic scale with fissures may develop.
• Hyperkeratosis is usually limited to the heels, soles and
lateral borders of the feet.
• Vesicles and pustules are absent.
• The condition is usually bilateral and may be asymptomatic.
 Pathogenesis and clinical
picture
3. Acute vesiculo-pustullar-bullous type
• Vesicular or vesiculobullous tinea pedis is characterized by the
development of vesicles, usually beginning on the sole, the
instep and the interdigital clefts.
• Characterized by sudden appearance groups of deep-seated,
pruritic vesicles, vesiculopustules and bullae.
• Pustules are seen on the instep or mid-anterior plantar
surface
• The eruptions vary in size, may be isolated or coalesce
into vesicles or bullae, and are initially filled with a clear
fluid.
• Secondary bacterial infection is common.
 Pathogenesis and clinical
picture
4. Ulcerative infection:
• It is characterized by maceration and ulceration of large areas
of the soles.
• White hyper- keratosis and strong odour are common.
• Bacterial superinfection, usually with gram-negative
organisms, is frequent and should be taken into account in
treating this condition.
• These conditions usually represent secondary
infection following fissuring or maceration of a toe
cleft.
• The secondary infection may induce inflammation and
further maceration.
 Tinea
corporis
• Tinea corporis refers to dermatophyte infections involves the
glabrous (hairless) skin of the trunk, legs and arms.
• The infection is limited to the stratum corneum of the
epidermis.
• The fine hair present on glabrous skin may be invaded, and
the
hair follicle may serve as a reservoir for the fungus.
• It is characterized by either inflammatory or non
inflammatory lesions on glabrous skin.
• Etiological agents: E. floccosum & many species of
Trichophyton and Microsporum are causative organisms of
Tinea corporis.
 Tinea
corporis
• Geographical distribution:
• It is distributed worldwide, most prevalent in tropical and sub-tropical
regions.
• Shows no preference for certain age groups, races or ethnicities.
• Patients with systemic diseases are predisposed; e.g. diabetes mellitus or
HIV infection patients.
• Other risk factors include outdoor occupations, close association
with animals, and contact sports.
Source of infection
• The usual sources of infections are other affected parts of the body, infected
persons in intimate contact; and infected animals.
• Geophilic infections associated with contact of soil.
• Tinea corporis is more common in males than females.
 Pathogenesis and clinical
picture
• Tinea corporis refers to annular lesions with raised borders originating
on
the glabrous skin.
• Lesions may be singular, multiple or confluent, and exhibit a range of
inflammatory responses, ranging from scaling and minimal erythema to
highly inflammatory lesions composed of pustules, vesicles, and
marked erythema.
• Inflammation is often greatest at the advancing edge of the lesion, with
a certain amount of central clearing.
• Accounts for most dermatophytic infections of human.
• Generally restricted to stratum corneum of the smooth skin.
• Symptoms result from fungi metabolites such as toxin / allergens.
• Produces concentric or ring-like lesions on skin, and in severe cases
these are raised and may become inflamed.
 Pathogenesis and clinical
picture
• All lesions of tinea corporis are usually pruritic.
• Produces varieties of clinical manifestation which
vary widely from non-inflammatory, scaly plaques to
inflammatory pustules.
1. Annular type (Ring shaped)
• Lesions may be single or multiple, the center is inactive,
pink scaly, while the margin is active, raised, and reddish
and well defined, vesiculo-pustular and scaly.
2. Hypertiform variety
• Small vesicular lesions studded together with numerous
micropapules and vesicles.
 Pathogenesis and clinical
picture
3. Plaque form scaly red
• Plaques with pronounced vesiculation and crusting.
4. Kerion type: also called Tinea profunda; manifested by
deep granulomatous lesions (resembles scalp kerions)
5. Follicular type
• It resembles miliaria and severely itchy.
• The course is often accompanied with constant
and severe chronic pruritis.
Pathogenesis and clinical
picture
 Pathogenesis and clinical
picture
Plaque form scaly red
Hypertiform variety
 Pathogenesis and clinical
picture

Follicular form Tinea profunda

 Tinea
unguium
• DEFINITION: Tinea unguium is a infection of fingernails
or toenails by dermatophyte fungi.
• Onychomycosis is a broader term that also encompasses
nail infections by nondermatophyte moulds, yeasts, and
occasionally bacteria.
• Most frequently caused by
 Trichophyton rubrum,
 Trichophyton mentagrophytes and
 Epidermophyton floccosum;
⚫ Characterized by dry, brittle, friable nails.
 Tinea
unguium
Geographical distribution
• Tinea unguium occurs in all parts of the world.
• Prevalence increases with increasing age over 60 years.
• Possible explanations include decreased immune function,
poor peripheral circulation, prolonged exposure to the
infective agents, and inability to maintain hygienic foot care.
• Risk factors include nail trauma, peripheral vascular
disease, diabetes mellitus, immunosuppression,
hyperhidrosis, and older age.
Source of infection
• Geophilic infections associated with contact of soil.
 Pathogenesis and clinical
picture
• Infections usually begin distally or at the lateral edge of the nail,
and beneath the nail there is accumulation of a cheesy epidermal
derities in which the causative fungus can be demonstrated.
• The affected nails are discolored, lusterless, brittle, thickened, and
friable and may become pitted and grooved as a result of
paronychial inflammation.
• Trichophyton rubrum infections usually involve the entire thickness
of the nail plate and may eventually destroy the entire nail.
• Toenails are affected more often than fingernails and one or more
nails may be affected.
• Onychomycosis is a broader term that also encompasses nail
infections by non-dermatophyte moulds, yeasts, and occasionally
bacteria.
 Clinical Presentations of
Tinea Unguium
(Onychomycosis)

• DLSO: distal lateral subungual onychomycosis; WSO: white superficial

onychomycosis; PSO: proximal subungual onychomycosis; PWSO: proximal
white subungual onychomycosis.
Pathogenesis and clinical
picture
Summar
y
Summary
Summary
 Summar
1. y
What are the three closely related genera, which causes dermatophytoses? Compare and contrast them.
2. What is the difference between Endothrix and Ectothrix?
3. An organism cultured from a case of tinea capitis in a 5-year-old child produced wooly colonies with
bright yellow rim and reverse side. Macroconidia predominated appeared spindle shaped and
multiseptate, with thick walls, warty projections, and curve tips. The most likely identification is:
a) Trichophyton tonsurans
b) Epidermophyton floccosum
c) Microsporum canis
d) Microsporum gypseum
4. A case of tinea unguium produced green brown, velvety colonies that were gently folded.
Microscopically, the fungus produced numerous thin-walled macroconidia with three and four cells.
Microcondia were absent. The organism is most likely:
a) Trichophyton tonsurans
b) Epidermophyton floccosum
c) Microsporum canis
d) Trichophyton mentagrophytes
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