MYCOSES, FUNGUS DISEASES OF MAN

General Information
Dermatomycoses take second place after pyodermas in the general structure of dermatological disease
incidence, which is just what determines the urgency of their study and the organization of their control.
Fungi are widely spread in nature. Only a small part of them, however, are pathogenic for animals or
humans. Fungi are related to lower plants but are distinguished from them by the lack of chlorophyll and the
inability to assimilate carbon dioxide.
The main group of pathogenic fungi is formed by lower plant micro-organisms forming branching
double-contour threads of mycelium (measuring to 40-50 urn and more in length and 1 to 6 um in thickness)
and multiplying by means of spores. They parasitize in the soil, on plants, and in animals and man. These fungi
are subdivided into large groups: anthropophilic fungi, which only parasitize on the human skin and its
appendages, and zooanthropophilic fungi, which parasitize on human and animal skin and its append ages. The
first group includes, for instance, Trichophyton viola-ceum and T. crateriforme which cause superficial and
chronic tricho-phytoses, Microsporum ferrugineum the causative agent of 'rust' microsporosis, and Achorion
schoenleini which causes favus. The second group includes T. gypseum and T. faviforme which cause
trichophytosis in calves, mice and other animals and the infiltra-tive-suppurative form of trichophytosis in
man, and Microsporum lanosum inducing a disease in dogs, cats, and man.
Yeast-like fungi of the genus Candida form a special group. Their distinguishing features are that they do
not form spores but multiply by budding, and the threads formed by them have no real branchings and because
of that are called pseudomycelium.
Fungi, which are pathogenic for humans and affect the skin, are called dermatophytes, whereas the
diseases caused by them are known as dermatophytoses, or dermatomycoses.
Epidemiology. Infection with fungi occurs either directly from a sick human or animal (direct route of
infection), or through various objects and belongings of sick persons or objects used in the care of animals
(indirect route of infection). Some fungus diseases (superficial trichophytosis, microsporosis, etc.) prevail
among children of kindergarten age and schoolchildren, others (epidermo-phytosis, rubromycosis, deep
systemic mycoses, etc.) are prevalent among adults. Some fungus diseases are characterized by mass seasonal
infection (e.g. high incidence of infection with M. lanosum in the autumn and high incidence of zoophilic
trichophytosis in the summer) and seasonal character of exacerbation of the process (e.g. tinea pedis, or
ringworm of the feet, in the spring and summer). The climate and soil conditions of the given locality have an
effect on the spread of dermatomycoses. This explains the geographic features of the spread of some of these
diseases. Besides, it has lately been noted that the rise and decrease in the incidence of various mycoses have a
cyclic (rhythmic) character. All this has to be taken into account in elaborating rational measures for the control
of dermatomycoses in different regions and republics.
Pathogenesis. Despite the abundance of fungi in the surroundings of man, only a few of them possess
marked pathogenicity. Moreover, it should be recognized that they are facultatively pathogenic forms because
favourable factors are needed for the disease to develop: the age, sometimes the sex, the condition of endocrine
glands activity, pH of the water-lipid mantle, sweat chemism, and increased sweating. In children, for instance,
the keratin of the epidermal and hair cells undergoing keratinization is insufficiently dense and compact, which
facilitates the development and vital activity of the keratophils that have gained entry.
Infectious and chronic diseases reduce body reactivity, change sweat chemism and the condition of the
skin and hair and in this way lead to nervous and endocrine disorders and promote the transformation of
saprophytic fungal flora (e.g. yeast-like fungi of the Candida genus) to pathogenic forms.
Classification. There is no generally accepted classification of derm a torn yc oses because different
authors take into account various factors (the morphological properties of fungi which are pathogenic for
humans, the attitude toward nutrient media, the features of the clinical picture and course of dennatomycoses,
etc.). The clinical classification suggested by A. M. Arievich and modified and made more precise by Sheklakov
is now used for didactic purposes in the USSR. According to this classification, all human dermato'my-coses are
divided into four large groups: (1) keratomycoses (pityria-sis versicolor and, very conditionally, erythrasma,
trichosporosis nodosa [piedra], trichomycosis axillaris); (2) derm atomy coses (epi-dermophytosis,
rubromycosis, trichophytosis, microsporosis and fa-vus), which form the most representative group of fungus
skin diseases of highest social and epidemiological significance; (3) candidia-ses (of the skin, mucous
membranes, and viscera); (4) deep (systemic) mycoses forming large but relatively rare group of fungus dis-
eases.

KERATOMYCOSES
This group of fungus diseases is characterized by involvement of only the homy epidermal layer (Gk.
kerat horn, mykes fungus), very low contagiosity, and the absence of pronounced inflammatory phenomena. By
the established tradition, erythrasma is related to this group, although sufficient data have been gained to the
effect that Corynebacterium organisms and not fungi are its causative agents. Trichosporosis nodosa and
trichomycosis axillaris are also included in this group.

Pityriasis Versicolor
Aetiology and pathogenesis. The causative agent Pityrosporum orbiculare, or Malassezia fair fur is found
in the homy layer of the epidermis and the ostia of the follicles. When the diseased scales are examined with
the microscope, the fungus is seen as short, rather thick twisted threads of mycelium and clumps of round
spores with a double-contour capsule arranged as bunches of grapes. It is very difficult to obtain cultures of the
fungus, and growth has been produced in only occasional cases. It is assumed that increased sweating, the
chemical composition of the sweat, disturbed physiological des qua mat ion of the horny layer, and the
individual predisposition of the skin are of definite significance in the pathogenesis of the disease. It has been
suggested that the disease is encountered more frequently in persons suffering from pulmonary tuberculosis.
This point of view, however, is not universally accepted. The disease is prevalent among young men and
women. In children, particularly in those under 7 years of age, it is a rare occurrence. It may develop in weak
children, in those with diabetes mellitus, tuberculosis, vegetoneurosis with increased sweating and in the
prepuber-tal and pubertal periods.
Pityriasis versicolor is marked by low contagiosity. Clinical picture and course. Yellowish-brownish-pink
spots with no inflammatory phenomena form on the skin, at the ostia of the hair follicles and gradually grow in
size. They then coalesce and cover large skin areas and have microscalloped edges. The colour of the spots
gradually turns dark-brown, sometimes cafe au lait. This colour range served as the basis for the name of the
disease (versicolor). The spots are not elevated above the skin surface, cause no subjective complaints
(sometimes there is a mild itching) and are attended with bran-like scaling (hence the name pityriasis furfu-
raceous) which is easily detected by scratching of the skin (Besnier-Meshchersky's sign).
There is usually no symmetry in the arrangement of the spots in pityriasis versicolor. The chest and the
back are the favoured sites, less frequently the spots are found on the neck, abdomen, the sides of the trunk, and
the lateral surfaces of the arms. Lately, with the use of a mercury vapour lamp supplied with Wood's glass (see
below) in the diagnosis of the disease, the spots of pityriasis versicolor are quite often detected (especially in a
diffuse process) on the scalp but with no involvement of the hair. This may possibly be among the causes of the
frequent recurrences of the disease, despite the seemingly successful therapy. Pityriasis in children of pre-
school age or in adolescents of the pubertal period is characterized by the involvement of extensive skin areas
on the neck, chest, in the axillae, on the abdomen, back, the upper and lower limbs, and the scalp. The disease is
of a long duration (months and years). Recurrences are frequent after clinical cure. It should be borne in mind
that patients may be cured rapidly by sunrays and in such cases the skin in places of previous eruptions does not
become tanned and white spots form (pseudoleucoderma).
Histopathology. In the absence of inflammatory phenomena, there is looseness of the horny layer, in
which threads of mycelium and spores of the fungus are found.
The diagnosis presents no difficulties and is often made on the basis of the characteristic clinical picture.
In difficult cases, auxiliary diagnostic methods are used. Baltser's iodine test is one of them: when the skin is
painted with a 5 per cent iodine tincture, the affected areas with the loosened horny layer are stained more
intensively than the healthy skin areas. Solutions (1-2 per cent) of aniline dyes are sometimes used instead of
iodine. Besnier-Mesh-chersky's sign may be tested: when the spots are scratched desqua-mative lamella are
produced because the horny layer is loose. Clinically latent foci of affection are detected by means of mercury
vapour lamp whose rays are passed through a glass impregnated with nickel oxide (Wood's glass). The
examination is conducted in a dark room in which the spots of pityriasis versicolor produce dark-brown or
reddish-yellow fluorescence. With the detection of the clinically asymptomatic lesions, including those on the
scalp, a more rational treatment will be prescribed and recurrences prevented in some of the patients. The
diagnosis may also be verified by the detection of fungus components in microscopy of scales treated with 20-
30 per cent potassium or sodium hydroxide solution.
Pityriasis versicolor sometimes has to be differentiated from syphilitic roseola (in which the lesions are
rose-coloured and disappear from pressure and there is no scaling; other symptoms of syphilis and positive
serological tests are taken into account) and Gibert's pityriasis (rose-coloured spots arranged on Langer's lines
of skin tension; they are rhomboid or slightly elongated with peculiar scaling in the centre resembling cigarette
paper and are called medallions). Secondary, or false leucoderma, which forms after treatment of pityriasis
versicolor, is differentiated with true syphilitic leucoderma. In the latter disease, coalescent hyperpigmented
spots do not form, the lesion has the character of a lace net and is mostly located on the neck, in the axillae, and
the sides of the trunk; blood serological tests are positive, and there are other manifestations of secondary
recurrent syphilis.
Treatment. Keratolytic and fungicidal agents are rubbed into the affected skin areas. Salicylic (5 per cent)
or resorcinol (3-5 per cent) alcohol and sulphuric (10-20 per cent) or salicylic (3-5 per cent) ointment may be
prescribed. Favourable results have been obtained with Andriasyan's solution (Urotropini 10.Q, Glycerin! 20.0,
Sol. Ac. acetici8% 70) which does not stain the skin and has no irritating properties. The solutions and
ointments are rubbed into the skin for four to six days after which the patient takes a bath with tar soap and
changes his underwear. Ultraviolet irradiation has a beneficial effect. Diffuse forms are treated by
DemyanovichTs method, i.e. with 60 per cent sodium thiosulphate solution and 6 per cent hydrochloric acid as
in the management of scabies. In treating children, the percentage of the agents used is lowered to 40 and 4,
respectively.
For the prevention of recurrences, the affected skin areas are rubbed with 1-2 per cent salicylic or 2 per
cent boric acid-salicylic alcohol once a day for several weeks after the treatment has been completed or
treatment is repeated in one or two months.
Prevention. Increased sweating is treated and body-hardening measures are prescribed. Patients should
avoid overheating. Skin hygiene should be strictly observed. As a preventive measure, rubbing of the skin with
vodka or 8 per cent vinegar once or twice a week is prescribed after recovery*

Erythrasma
Aetiology and pathogenesis. Erythrasma is considered by tradition in the group of keratomycoses though it
is now established that Corynebacterium minutissimum, the causative agent of the disease, is not related to
fungi, while the disease itself is a pseudomycosis. The Corynebacterium organisms are found only in the horny
layer of the epidermis and do not affect the hair or nails. Microscopy of scales removed from the diseased skin
areas reveals fine twisted threads of various length resembling mycelium and cocci-like cells (as clusters or
chains of round spores). The individual properties of the body, increased sweating, dampness and high
temperature of the air, changes in skin pH in the alkaline direction, maceration, and rubbing are important
factors in the pathogenesis of the disease. The micro-organism is a saprophyte, possesses low virulence and is
therefore also found on healthy skin of individuals under ordinary conditions. Infection may be transmitted
through bedclothes and underwear and bath and during sexual intercourse.
Clinical picture and course. Light-brown or brick-red patches appear and then coalesce to form large foci
with clearly demarcated, sometimes scalloped or arch-like outlines. There are no inflammatory phenomena. The
surface of the patches is either smooth or is covered with fine furfuraceous scales. A slight elevation is some-
times seen on the edges of the focus and the centre of the focus is either pale or brownish pigmentation forms.
There are no subjective disorders as a rule though sometimes the disease is attended with mild itching. The
itching may occur in the summer when inflammation develops on the surface of the lesions because of
increased sweating and poor hygienic habits. Erythrasma is localized in the large skin folds. The
inguinofemoral-scrotal region is the most common site in males and the axillae and the folds under the
mammary glands and around the umbilicus in females. Erythrasma is very rare ia children. The disease follows
a chronic course with frequent recurrences, especially in sweating, obese, and untidy individuals. Since there
are no subjective disorders, the disease is often not recognized and is discovered only during examination by a
physician.
The histopathological changes are the same as those in pityriasis versicolor.
The diagnosis is based on the characteristic localization of the patches and their brownish-reddish colour
and scalloped outlines. Bacterioscopy is rarely undertaken. Luminescence diagnosis is used extensively. It
consists in irradiation with a mercury vapour lamp fitted with. Wood's glass; in its rays the foci produce a coral-
red or brick-red fluorescence because the causative agent of erythrasma secretes water-soluble porphyrins in the
process of vital activity. Inguinal epidermophytosis is marked by elevated edges, a border of macerated
epidermis on the periphery of the foci, vesicles, inflammatory phenomena, and itching. The continuous edge of
the focus distinguishes erythrasma from rubromycosis of the inguinofemoral folds, in which the foci have an
irregular inflammatory swelling of the edges, the skin of the feet and the nails is involved as a rule, and there is
itching of various intensity. Erythrasma is distinguished from pityriasis versicolor by the localization and colour
of the foci and the character of fluorescence produced on irradiation with a luminescent lamp. Intertrigo is
marked by acute inflammatory manifestations and clearly demarcated foci.
Treatment. The same agents as in pityriasis versicolor are applied in the treatment but in lower
concentration because the erythrasma lesions are localized in more delicate skin folds. The application of 5 per
cent erythromycin ointment is particularly recommended because in erythrasma, as distinct from fungus skin
lesions, it produces a marked therapeutic effect. The ointment is rubbed into the skin for 12 to 18 days. In a
diffuse process, 1.0 g of erythromycin is given daily per os.
Prevention. The skin is wiped with 2 per cent boric acid-salicylic alcohol and powdered with an acid
powder (5-10 per cent boric acid).

DBRMATOMYCOSES
This is a large group of fungus diseases, in which not only the skin but its appendages are involved. All
dermatomycoses causing fungi are contagious to a greater or lesser degree and widely spread in nature. The soil
is evidently a reservoir of infection for some of them (zoophilic Trickophytons and Microsporum lanosum). The
study of dermatomycoses is of great epidemiological importance while the organization of their control is a
problem of social state significance.

Epidermophytosis (Epidermophytia)
Epidermophytosis is a contagious disease of the superficial layers of the smooth skin and the nail plates
caused by fungi of the genus Epidermophyton. The hair is not involved.Two clinical forms of epidermophytosis
are distinguished: epidermophytosis of the large folds, or epidermophytosis (tinea) inguinalis, and
epidermophytosis of the feet, or tinea pedis.
Epidermophytosis of the Large Skta Folds,
or Epidermophytosis (Tinea) Inguinalis, or Tinea Crniis
(Epidermophytia Plicarum, sen Epidermophytia Inguinalis)
Aetiology. The causative agent is the fungus Epidermophyton inguinale Sabouraud (E. floccosum).
Epidemiology. Contamination occurs in public baths and from using a common bath and sponges. The
causative agent may be conveyed to humans by means of bed-clothes, oil-cloth, bed-pans, thermometers, towels
and sponges shared with a sick individual.
Pathogenesis. Increased sweating in the inguinofemoral folds and axillae, particularly in obese individuals
and in those with diabetes me 11 it us, moistening of the skin with compresses are factors which facilitate the
development of the disease. The disease is encountered most frequently among men; children and adolescents
rarely nave it.
Clinical picture and course. The lesions are localized in the femo-roscrotal folds, on the medial surface of
the thighs, on the pub is, and in the axillae. In some cases the pathological process may spread to the skin on the
chest, abdomen (between the skin folds in obese individuals), under the mammary glands in females, etc. Red in-
flammatory, scaling spots the size of a lentil appear first. As the result of peripheral growth they give rise to large
oval foci with a hyperaemic, macerated surface and an elevated oedematous edge, which is sometimes covered
with vesicles, crusts, and scales. Later the foci may coalesce and form extensive areas of affection the size of a
palm with geographic outlines. The centre of the foci pales gradually and becomes slightly depressed. There is a
border of desquamating macerated epidermis on the edges. The patients are troubled by mild itching which
increases during exacerbations. The disease has a sudden onset as a rule, but then it takes a chronic course and
may continue for months and years with periodical exacerbations (particularly in the hot season and in excessive
sweating). In view of the similarity of the clinical picture with that in eczema, old authors called the disease
eczema marginatum.
The diagnosis is made on the basis of the typical clinical picture, localization of the process, acute onset,
chronic course, and the detection of threads of septate mycelium on microscopy of scrapings from the surface of
the lesions (the best material for examination is the desquamating epidermis taken from the periphery of the le -
sion). The disease is distinguished from erythrasma by the difference in the clinical picture and course. Chronic
trichoptiytosis of the smooth skin is usually not localized in the folds. Superficial yeast lesions with a similar
clinical picture are differentiated by the findings of microscopy of scrapings from the surface of the foci. Rubro-
mycosis is differentiated by the results of cultural examination
Treatment. In the acute period, when there are signs of czema-tization, cold lotions with a 3 per cent
boric acid solution or 0.25 per cent silver nitrate solution are applied externally. If there is no eczematization,
painting the foci with 1-2 per cent iodine tincture for several days, even in the acute period, is recommended,
after which 3-5 per cent sulphur-tar or boric acid-tar ointment is prescribed for two or three weeks. It is
advisable to apply fungicidal agents: Nitrofungin, Mycoseptin, Amycazole, Undecin and Zincundan ointments,
2-5 per cent Castellani's paint, Wilkinson's ointment half-and-half with naphthalan, and Octathione ointment. In
the acute period, hyposensitization therapy should also be conducted (oral medication with 10 per cent calcium
chloride solution, 0.5 g of sodium thiosulphate given three times a day, etc.).
For the prevention of recurrences after the achievement of a clinical cure, the skin in the region of the
cured lesions is painted with 2 per cent iodine tincture daily or every other day.

Epidermophytosis of the Feet, or Tinea Pedis (Epidermophytosis Pedum)

Tinea pedis is a widespread disease encountered in all countries of the world. Its incidence among some
population groups (swimmers, workers of public baths and showers, athletes, workers at hot shops, coal mines,
etc.) is high and, according to different authors, reaches 60 to 80 per cent. The rural population acquires the
disease less frequently than does the urban population. The disease is relatively rare in children (in 3.9 per cent
of examined children under the age of 15 years). At the age of 16 to 18, however, its incidence is already 17.3
per cent.
Aetiology. The causative agent is the fungus Trichophyton men-tagrophytes, a variant of T. interdigitale,
which was previously called Epidermophyton Kaufmann-Wolf. Only by tradition is the foot disease caused by
T. interdigitale called epidermophytosis of the feet. In distinction from Epidermophyton inguinale, this fungus
affects the hair in a test tube.
Epidemiology. The disease is contagious and is transmitted by sick individuals to healthy persons in
public baths, swimming pools, showers, and on the beach through infected mats, spreads, flooring, wash
basins, and benches. Footwear, socks, and stockings worn by an individual with the disease are contagious, and
sharing footwear is therefore dangerous. The threads of the mycelium and the spores of the fungus are
contained in great amounts in the scales of the epidermal horny layer, which the sick person 'loses' in abun-
dance as a result of which an unfavourable epidemiological situation is created.
Pathogenesis. The conversion of the fungus from a saprophytic to a pathogenic state is promoted by
increased sweating of the feet, flat foot, tight interdigital spaces, improperly fitted footwear (this is one of the
causes of outbreaks of the disease among recruits), sores, intertrigo, anatomico-physiological properties of the
skin typical of each definite age, chemism of the sweat, and alkaline shift in sweat pH. Disturbed function of
the central and peripheral nervous and endocrine systems, angiopathies, acrocyanosis and other disorders of the
lower limb vascular apparatus, ichthyo-tic skin lesions, and hypovitaminosis are the endogenic factors, which
are favourable for the development of tinea pedis. Mechanical and chemical traumas of the skin on the feet,
unfavourable meteorological conditions, and a high environmental temperature are also significant. The degree
of the virulence and pathogenicity of the fungal strain should also be taken into account.
Clinical picture and course. The following clinical varieties of tinea pedis are distinguished: squamous,
intertriginous, dyshidrot-ic and unguium. Epidermophytids are distinguished as a manifestation of an allergic
reaction. Some mycologists of today do not acknowledge the existence of a subclinical form of epidermophyto-
sis and consider the condition to be either a carrier state (if the causative agent is detected but there are no
clinical symptoms of the disease) or a squamous form without obvious symptoms. The separation of
epidermophytosis of the feet into forms is conventional because a combination of several clinical variants is
often encountered or one form may change to another.
The squamous form. Moderate scaling on a slightly hyperaemie skin is found on the arches of the feet.
The scaling may be restricted to small areas or may extend over large surfaces. Some patients complain of
slight itching felt now and again. Quite often the disease remains unnoticed by the person and because of this it
is particularly dangerous epidemiologically. In exacerbation of the process, the squamous form may change to
the dyshidrotic form and, vice versa, the dyshidrotic form may terminate by the squamous form. At the onset of
the disease, the process is always unilateral but later the other foot may also become involved.
The intertriginous form may occur independently but more frequently it develops when there is a mildly
pronounced squamous form. The process begins in the interdigital folds, usually between the fourth and the
little, less frequently between the third and fourth toes. In some cases the disease spreads to the other interdigital
folds and then to the flexor surface of the toes and the dorsal surface of the foot. Cracks surrounded on the
periphery by a whitish separating horny layer of the epidermis form in the interdigital folds. Weeping surfaces,
itching of various intensity, and sometimes (when there are erosions) pain appear.
Very often the process persists for a long time, with remissions in the winter and exacerbations in the
warm seasons. The formation of cracks and the looseness of the horny layer in the intertriginous form are
conducive to the entry of streptococcal infection and the development of chronic recurrent erysipelas of the legs
and thrombophlebitis.
The dyshidrotic form is characterized by the formation of a group of vesicles on the arch of the foot. The
vesicles resemble soft-boiled sago grains, they have a hard top and their size ranges from the size of a pin head
to that of a small pea. The vesicles coalesce and form multilocular bullae in whose place eroded surfaces with a
ridge of macerated epidermis on the periphery form. The process may extend to the lateral and medial surfaces
of the foot and thus forms a single pathological focus with the intertriginous form. The subjective symptoms are
itching and pain. With the occurrence of secondary infection the contents of the vesicles turn cloudy, pus is
discharged when the vesicles open, and lymphangitis and lymphadenitis may develop. As the inflammatory
reaction gradually subsides, the excoriations undergo epithelization, new vesicles do not form, and the focus of
affection acquires a squamous character. In severe cases with secondary infection, the patients have to be
hospitalized. A characteristic feature is unilateral localization of the process. This form is distinguished by a
protracted torpid course, recurrences and exacerbations mainly developing in the spring and summer.
Podvysotskaya described for the first time exacerbation of a dyshidrotic (less frequently intertriginous)
variant of the disease complicated by secondary pyogenic infection (acute epidermophytosis). It is characterized
by an eruption of a great number of vesiculo-bul-lous lesions on the soles and toes; the skin of the toes is
oedematous and swollen. Acute epidermophytosis is attended with a feeling of indisposition, headache, a
temperature reaction, inguinal lymphadenitis, and the eruption of epidermophytids, i.e. secondary generalized
allergic lesions. The disease lasts about one or two months and responds to treatment rather easily, though
recurrences are possible.
Epidermophytosis, or ringworm of the nails (Tinea unguium). The initial changes form on the free
margin of the nail plate as yellow spots and bands. The whole plate then thickens and turns yellow or ochre-
yellow, crumbles and breaks easily, and horny material accumulates under it (subungual hyperkeratosis). In
some cases the plate becomes thin and is separated from the nail bed (onycholysis). The nail plates of the big
and little toes are affected most frequently. The finger nails are never involved in the process. It is claimed that
the nail plates are affected in approximately 20 to 30 per cent of patients with epidermophytosis.
Histopathology. In dyshidrotic epidermophytosis, small foci of spongiosis and vacuolization of the cells of
the prickle-cell layer are found in the epidermis, which leads to separation of the cells and the formation of
loculi. The vesicles merge and form large bullae some of which rupture while others transform to a structureless
homogeneous mass. Mild inflammatory reactions are often encountered in the papillary layer of the dermis.
Threads of the fungal mycelium may be found in the horny layer.
Diagnosis. With a characteristic clinical picture and threads of the fungal mycelium found by microscopy
the diagnosis is easily made. Hyperdiagnosis is quite frequent, when the bullous lesions on the feet and the
maceration (in dyshidrosis, eczema of the feet, candidiasis of the interdigital folds, intertrigo, etc.) are mistaken
for intertriginous or dyshidrotic epidennophytosis, while psoriat-ic lesions, eczema tiloticum, various mildly
pronounced hyper-keratoses, etc. are erroneously diagnosed as the squamous form of tinea pedis.
Dyshidrosis lamellosa sicca is distinguished from squamous epidermophytosis by the symmetrical
arrangement of the lesions, the absence of inflammatory phenomena, and no threads of fungal mycelium in the
scales. The psoriatic papules and patches are greatly infiltrated and are characterized by sharply circumscribed
foci of affection and macrolamellar scaling, and there are psoriatic lesions on other parts of the body. The
papules of the secondary period of syphilis in the stage of resolution may resemble squamous epidermophytosis,
but they are either arranged separately or form figures (rings, garlands), have a dense-elastic consistence, and
are attended with other manifestations of infection (alopecia, leucoderma, papu-loroseolous lesions on the trunk,
limbs, oral cavity, and genitals, polyadenitis, and positive results of serological tests).
Intertriginous eczema and intertriginous candidiasis in distinction from intertriginous epidermophytosis
are marked by considerable prevalence of vesiculation, weeping, maceration, and positive results of microscopy
for Candida albicans in candidiasis.
Dyshidrotic eczema is distinguished from dyshidrotic epidermophytosis by a bilateral affection and
extension of the inflammatory phenomena to the sides and dorsal surface of the foot.
Epidermophytosis of the nails is characterized by asymmetrical localization, affection of the nail plates of
only the big and little toes, and no changes of the finger nails. Rubromycosis of the nails is characterized by
involvement of almost all the toe and finger nails, while trophic changes are marked by symmetry and drastic
dystrophic changes of all nail plates with pronounced deformities.
In epidennophytosis, skin tests with intracutaneous injection of epidermophytin are positive.
 Microscopic diagnosis. It is advisable to collect the macerated separating epidermis on the periphery of
the lesions for examination in dyshidrotic and intertriginous epidermophytosis of the large folds. If there are
vesicles and bullae, their tops are cut off with a pair of sterile scissors and examined. In the squamous form,
scales are scraped off the lesions and examined. The horny material is scraped off the nail plates with a scalpel,
or cut off with a pair of scissors along the free edge of the nail plate, or collected on a glass slide after treatment
with a drill. The pathological material is soaked in 20 to 30 per cent caustic alkali solution (KOH or NaOH) and
examined with a 'dry system' microscope under high magnification. The components of the fungus are seen as
double-contour threads of mycelium of various size and round or square spores (arthrospores). The mycelium of
a pathogenic fungus in the scales should be differentiated from the mosaic fungus (which is believed to be a
product of cholesterol disintegration) found on the margins of the epithelial cells in the form of loops; it consists
of uneven segments (pleomorphism of segments) which dissolve gradually in the alkali (whereas the
components of the fungus are seen better with time). Microscopy makes it possible to distinguish
epidermophytosis from candidiasis, which is characterized by the presence of budding yeast cells in the
preparation. However, the microscopic picture of the threads of the fungal mycelium in epidermophytosis,
rubromycosis, and trichophytosis is similar and they are differentiated by cultural diagnosis (growth of cultures
on nutrient media) in special bacteriological laboratories.
Epidermophytids are secondary allergic eruptions occurring because the fungus Trichophyton
mentagrophytes, a variant of T. in-terdigitale, possesses potent toxico-allergenic properties and sensitizes the
patient's organism imperceptibly for a long time. In acute forms of epidermophytosis, sensitization occurs not
only because of increased absorption of the products of vital activity of the fungus but also as a consequence of
the sensitizing effect of the products of the patient's own changed protein. In view of this, in 60 per cent of cases
epidermophytids occur in patients with dyshidrotic epidermophytosis, though they are also sometimes
encountered in the intertriginous and even the squamous forms. Epidermophytids occur close to the foci of
epidermophytosis (regional), but may be generalized. They are mostly localized on the palms and fingers. The
morphological character of the epidermophytids may be diverse: erythemato-squamous, urticario-exudative,
dyshidrotic (vesicular), pustular or eczematous. Vesicular and squamous epidermophytids occur mostly on the
palms, the urticario-exudative and erythemato-squamous on the face, trunk and limbs. Generalized
epidermophytids are often attended with general symptoms: temperature reaction, chill, indisposition, and
sometimes severe itching. Eczematous and dyshidrotic epidermophytids may take a protracted course and in
inadequate treatment, transform to eczema.
Treatment. The treatment varies depending on the clinical form of tinea pedis, but the condition common
for all forms is as follows: the more acute the process, the lower must be the concentration of the fungicidal
and disinfectant agents. Treatment of acute epidermophytosis is conducted on the same principles as treatment
of acute eczema: hyposensitization therapy (calcium preparations, antihis-taminics, vitamins,
autohaemotherapy) and topical anti-inflammatory treatment (cooling lotions or warm foot baths with
potassium permanganate); the lesions are previously treated (the bullae and vesicles are opened, the tops are
removed, the separating epidermis is cut off, etc.). Acute dyshidrotic epidermophytosis attended with
epidermophytids is managed by a complex of hyposensitization therapy (calcium chloride orally or
intravenously, intravenous infusion of sodium hyposulphate, injections of vitamins Bx and B6,
autohaemotherapy, diphenylhydramine hydrochloride, diazoline, di-prazine, etc.) and corticosteroid hormones
(prednisolone, triamcinolone or dexamethasone) prescribed in small doses. Sulphonamides are given for five
to seven days when a pyogenic infection develops (purulent content of the vesicles and bullae). The
prescription of antibiotics in such cases is undesirable because they may lead to exacerbation of
epidermophytosis and the development of epidermophytids.
With gradual abatement of the inflammation (in the dyshidrotic and intertriginous forms of
epidermophytosis) treatment with des-quamative and fungicidal agents is applied, increasing gradually their
concentration: 3-5 per cent sulphur-tar or salicylic-tar pastes, beta-naphthalan ointment, Zincundan, Undezin
or Afungil ointments. Ointments which cause separation of the horny layer are prescribed in squamous
epidermophytosis: Whitfield's ointment (Ac. benzoici 1.0-2.0, Ac. salicylici 2.0-3.0, Vaselini 30.0) or Arie-
vich's ointment (Ac. lactici 6.0, Ac. salicylici 12.0, Vaselini ad 100.0). After the horny material is rejected,
Andriasyan's solution (Urotropini 10.0 Glycerini 20.0, Sol. ac. acetici 8% 70.0) or Castel-lani's paint (Fuscini
basici spirituose concentrati 20.0, Sol. ac. car-bolici 5% 190.0, Ac. borici 2.0, Acetoni puri 10.0, Resorcini
20.0), nitrofungin, and fungicidal ointments (0.05-1.0 per cent nitrofuri-len, sulphur-salicylic-tar, octathione,
Undezin, Zincundan, etc.) are applied. After the use of fungicidal solutions and ointments in intertriginous
epidermophytosis, various powders are applied (di-mazole, dequalinium or the following prescription: Sulfur
pp., Ac. salicylici aa 1.5, Ac. borici 5.0, Zinci oxydati, Talci pulv. aa 25.0). The treatment of tinea unguium is
discussed in the section dealing with the treatment of onychomycoses in rubromycosis. Instead of radical
removal of the few nail plates infected with the fungus Epidermophyton, painting with iodine tincture is
prescribed to prevent the spread of the fungus.
Rubromycosis, or Rubrophytia

Aetiology. Some authors believe that the causative agent of rubromycosis takes an intermediate position
between the fungus Epi-dermophyton and the fungus Trichophyton. That is associated with the fact that it is
capable of affecting the downy hair (like Trichophyton). Lately, however, it is more frequently related to the
genus Trichophyton, which is reflected in its name T. purpureum, or rub-rum (but not Epidermophyton rubrum
as it was called previously).
Epidemiology. The anthropophilic fungus T. purpureum is highly contagious. Countries of the Far East
and South and East Asia. (Japan, China, India) were endemic foci of rubromycosis for a lengthy period of time.
Occasional cases of rubromycosis were registered in the USSR before World War II. A considerable growth in
the morbidity is recorded in all European countries and the USA after 1945. In the USSR, rubromycosis
accounts for 60-70 to 90 per cent of all cases with mycosis of the feet, while the incidence of its generalized
forms is 15 to 20 per cent and more that of rubromycosis of the feet and hands. It is believed that the routes of
infection and spread are the same as those in epidermophytosis. The high epidemiological significance of
rubromycosis is associated with the infection being probably transmitted through towels, gloves, mittens, and
through hand shaking. The disease prevails in adults, though reports of rubromycosis among children have been
growing lately.
Pathogenesis. A considerable role in the development of the disease is attached to increased dryness of
the skin, hyperkeratosis, and diminished resistance of the horny layer keratin and downy hair. Abnormalities in
the function of the endocrine glands and various neurovegetative dysfunctions are often encountered in patients
with rubromycosis, which facilitate not only the development but, which is still more important, the
generalization of the process. There are indications that antibiotics, cytostatic agents, and corti-costeroids used
in the treatment of other diseases play a definite role in the pathogenesis of rubromycosis.
Clinical picture and course. There are several clinical varieties of the disease: rubromycosis of the feet,
rubromycosis of the feet and hands, generalized rubromycosis, and rubromycosis of the nail plates.

Rubromycosis of the Feet

The foot is the most common localization of the disease. The lesions appear first in the interdigital folds
all of which, or almost all, are involved (as distinct from epidermophytosis). The process then extends to the
skin on the soles which becomes infiltrated.
dry, and diffusely hyperaemic, the skin furrows are clearly seen and are marked by furfuraceous scaling.
The process also spreads to the sides and dorsal surfaces of the feet and toes. In children, this form of
rubromycosis is often attended with pronounced exudative phenomena, which may lead to diagnostic errors.
Affection of the skin on the feet leads sooner or later to involvement of the nail plates in the process as a rule. In
other cases, the process begins with affection of the nail plates and then spreads to the skin on the feet.

Rubromycosis of the Feet and Hands]

The disease first appears on the skin of the feet and only later the hands and the finger nails become
involved. Initial penetration of the skin on the hands.,by the fungus is less frequent. The clinical picture of the
disease is almost similar to that in affection of the skin on the feet, but is less in intensity (because the hands are
washed repeatedly). There is an interrupted swelling on the periphery of the foci, which is often found also on
the back of the hands.

Rubromycosis of the Nail Plates

The disease is often encountered. In some cases it is an isolated affection of the nails, in others it is
combined with affection of the skin on the feet and hands or with generalized rubromycosis. Involvement of
many nail plates in the process is a characteristic feature, quite often all the finger and toe nails are affected. In
the nor-motrophic type of rubromycotic onychia, the thickness of the nail plate remains normal; the lesion
occurs on the free edge or the sides of the nail as white or yellowish bands; similar bands may show through the
thickness of the nail plate. The hypertrophic type of the disease is marked by thickening of the nail plate, which
crumbles and breaks easily, and by subunguinal hyperkeratosis; the above-mentioned bands may also be
encountered. In the atrophic type of onychia, the nail plate is thinned out, its greater part is destroyed and only
the part next to the nail wall remains. Sometimes the nail plate is separated from the nail bed as in onycholysis.
The diagnosis in typical affection of the feet, hands, and nail plates is not difficult, the more so since it is
easily verified by microscopy of the pathological material.
Rubromycosis of the skin on the feet and interdigital folds without involvement of the skin on the hands
and the nail plates has to be differentiated with intertriginous and squamous forms of tinea pedis the clinical
picture of which may be similar in essence. In rubromycosis, however, hyperkeratosis is more pronounced and
there is furfuraceous scaling in the skin furrows, while in intertriginous form of tinea pedis the inflammation is
more conspicuous and there are secondary allergic eruptions. As it is pointed out above, epidermophytosis of
the nails is characterized by involvement of only the nails of the big and little toes and intactness of the finger
nails. In trichophytosis of the nails, the process begins on the smooth skin around the nail plate and then extends
to the nail in a relatively short time (in a few months); the nail changes in colour, crumbles, breaks, and in the
developed stage resembles rub-rophytic onychomycosis. The most pathognomonic sign of favus of the nails is
slow involvement (over a period of several years) of the nail plate in the process; a small yellowish-brown spot
appears in the centre of the nail at first, grows gradually and spreads over the whole plate. The nail plates are
usually not affected with mic-rosporosis. In psoriasis of the nails the plate is covered with pricks like a thimble.
Eczema and pyoderma of the nails are attended with characteristic foci of affection around the nail plate. The
typical lesions of lichen planus are pinkish, yellowish, and whitish longitudinal bands on the nail plate. Yeast
onychia is marked by its combination with paronychia, in which the skin fold around the nail swells, becomes
hyperaemic and a drop of pus may be expressed from under it; the eponychium disappears. A symmetrical
affection with involvement of all the nail plates in the process and dys-trophic changes of the nails are
characteristic of dystrophia unguium.
The diseases of the nail plates listed above are, naturally, attended with the corresponding changes on
other skin areas and the mucous membranes, which makes the diagnosis of onychia much easier.
The final decision concerning the disease may be made on the basis of cultural diagnosis, i.e. growth of
the culture of the fungus, the causative agent of the disease, on nutrient media (usually Sa-bouraud's medium).
For microscopical diagnosis it is best to collect the scrapings from the skin folds at the free margin of the
nail where the threads of the fungal mycelium are found in great amounts. The furfuraeeous scales may also be
collected from the skin furrows for examination. The keratotic masses of the nail plates are removed from the
free margin of the nail (cut off with scissors) or from the middle and deep layers of the plate (with a drill or a
scalpel). Detection of the threads of the fungal mycelium in the preparations verifies the fungal origin of the
disease but does not allow the species of the causative agent to be judged. This can be done by means of
cultures.

Generalized Rubromycosis
In most patients, generalized rubromycosis develops after a more or less long existence of a localized
affection of the skin on the feet (sometimes on the hands too) and of the nail plates. Abnormalities of the
internal organs and the endocrine and nervous systems, trophic changes of the skin, and long-term medication
with antibiotics, steroid and cytostatic agents predispose to dissemination of the process. The lympho- and
haematogenous routes of spreading of the process with accumulation of the fungal components in the lymph
nodes cannot be ruled out in such cases.
Clinical picture and course. The clinical picture of the disease is diverse and can be conditionally
subdivided into several varieties: erythemo-squamous (superficial), folliculan-papular (deep), and exudative
forms, and affections of the type of erythroderma.
Erythemo-squamous foci of rubromycosis may be found on any skin areas, are attended with severe
itching, and resemble neuroder-mitis, parapsoriasis, granuloma annulare, some forms of eczema, psoriasis, etc.
From the standpoint of clinical diagnosis, the tendency of the foci to gather in groups, to form rings, arches,
semi-arches and garlands, the hyperpigmentation and mild scaling in the centre help in suspecting mycosis.
Particular importance in the diagnosis is attributed to the scalloped contours of the foci and the interrupted
swollen ridge on the periphery. The process takes a chronic course with a tendency to become exacerbated in
the warm season. Microscopy of the scales and downy hair (the latter are unaltered clinically but may contain
the components of the fungus) is of decisive importance. Erythemo-squamous rubromycosis is differentiated
from superficial and infiltrative-suppurative trichophytosis by cultural diagnosis.
The follicular-papular (deep) form of rubromycosis usually attacks the legs, buttocks, and forearms. The
lesions tend to form figures and clinically may resemble erythema.nodosum, Bazin's erythema induratum,
nodular vasculitis, and papulonecrotic tuberculosis (small scars remain often at the site of the foci). When this
form is localized on the face, a differential diagnosis has to be made with erythematosis and lupus vulgaris.
 The touching skin in the inguinal and intergluteal areas and under the mammary glands are rather frequent
sites of the disease. The surface of the foci is yellowish-red or brown. They are slightly infiltrated and there is
scaling. The edges are elevated and have an interrupted scalloped swelling on which small papules and crusts
are seen. Such foci of rubromycosis are differentiated with candi-diasis of the large folds and microbial eczema,
in which many daughter lesions (seedlings) are found on the edges of the main focus. In candidiasis, the focus is
more macerated and weeps, whereas microbial eczema is marked by pleomorphism of the primary lesions with
prevalence of microvesicles, pustules, and 'serous wells' and at places with stratified formation of yellowish
purulent crusts.
In rubromycotic erythroderma, the foci of affection have a deep-red colour with a bluish tinge. They
merge and extend over large skin areas. Exudative manifestations of mycosis are relatively rare and may occur
in the skin folds and on the limbs.
The lesions of the smooth skin in rubromycosis described above may be combined, which makes the
clinical diagnosis easier, particularly if the skin on the feet and palms and the nail plates are involved at the
same time.
Treatment. In lesions on the smooth skin of only the palms and soles, treatment is begun with the
application of Whitfield's or Arievich's keratolytic ointment (see Epidermophytosis, Treatment) or varnishes
(e.g. Ac. salicylici, Ac. lactici aa 10.0, Collodii elastici 80.0). The keratolytic ointment is applied to the focus
under a compress dressing for 48 hours after which 5 per cent salicylic petrolatum is applied under the
compress for another 48 hours. As a result of this the horny layer is macerated as a rule and is easily separated
(removed with a scalpel or a pair of scissors) in the form of a 'glove' or 'sock'. The keratolytic varnish is applied
to the skin on the soles and palms daily for three to five days and no dressing is needed. After that, hot hand or
foot baths with potassium permanganate or sodium hydrocarbonate are taken and the remnants of the varnish
and the separated horny layer are removed. The procedure is repeated until the hyperkeratotic masses are
removed (two or three procedures are sometimes carried out one after the other). Next, the skin is painted with 2
per cent iodine tincture in the morning and with 10-15 per cent sulphur ointment and 2-3 per cent tar or
Wilkinson's ointment (for three weeks). In treating children the doses of all these agents are reduced by half.
Acid powders (e.g. boric acid and tannin acid powders, 3.0 g of each and zinc oxide and talc, 15 g of each) are
prescribed for the interdigital folds.
Lesions on the large skin folds and the foci of affection in other forms of generalized rubromycosis are
painted with Castellani's paint, nitrofungin, 2 per cent iodine tincture, fungicidal ointments. In such cases
external treatment is combined with oral medication with the antifungal antibiotic griseofulvin-forte; the daily
dose is four to six tablets (one tablet contains 0.125 g). For the first 15 to 20 days (till the first negative results
of tests for the fungi) adults are given griseofulvin daily and then for the next 15 to 20 days every other day in a
dose of 15 mg/kg. Children are treated according to a different schedule: the daily dose of 21-22 mg/kg is given
in three portions during a meal and is washed down with vegetable oil. For the first two weeks it is given daily,
for the next two weeks every other day, and for the last two weeks the drug is given twice a week. It is
advisable to prescribe vitamin A concentrate (5 to 10 drops for children, 20 to 40 drops for adults three times a
day), vitamin E (10 to 30 drops twice a day) or cod-liver oil enriched with vitamins (one tea-, dessert- or
tablespoonfull daily) together with griseofulvin. It is believed that griseofulvin is concentrated in the horny
layer of the skin, hair, and nails as the result of which the fungus cannot penetrate these parts. That is why the
'recovery' of the hair, for instance, begins at the proximal part of the hair (or the nail), while the distal part still
contains components of the fungus. In view of this, in medication with griseofulvin it is advisable to shave the
new-grown hair every seven or ten days and remove the nail plates (see below), which makes the process of
recovery easier.
In the generalized forms of rubromycosis and sometimes in cases with localized foci, it is important to
reveal the pathogenic mechanisms of the disease and undertake the appropriate treatment Cases have been
described, in which treatment for Itsenko-Cushing's disease or hypothyroidism led to resolution of the foci of
rubromycosis without medication with oral griseofulvin or external treatment. All forms of rubromycosis
following a torpid course are managed by non-specific stimulation therapy: injection of pyrogenic agents
(pyrogenal, prodigiosan), aloe, autohaemotherapy.
The nail plates are attacked by rubromycosis more often than by any other fungus disease. The treatment
applied for rubroonycho-mycosis may also be used in the management of affection of the nails in
trichophytosis, favus, and epidermophytosis if the physician finds removal of the affected nail plates expedient.
Only treatment of onychia of candidiasis origin has specific features: it is discussed in the respective section.
The treatment of fungus-infected nails is difficult. Its success is determined to a great measure by careful
and scrupulous fulfilment by the nurses of all the physician's prescriptions. Much patience and persistence are
required of the patient himself. Even when all these conditions are met, however, recurrences and reinfections
are frequent unfortunately, which is linked with various causes (persistence of the fungus on one nail plate or
nail bed leads to the spreading of the process to the 'prepared soil', high prevalence of Epidermophyton and
Trichophyton rubrum in nature in high susceptibility to the disease of a person who has recovered from it, etc.).
Combination of oral griseofulvin with external therapy is most effective. In some cases, griseofulvin is
prescribed at the same time that the nail plates are removed, but usually it is given after all the affected nails and
the subunguinal keratotic masses have been removed.
The nail plates are removed by means of keratolytic plasters, (ureaplast, a plaster containing 20 per cent
urea; a plaster containing 10 per cent trichloroacetic acid, etc.1), keratolytic ointments (equal parts of potassium
iodide and lanolin) or surgically with subsequent treatment of the nail bed with fungicidal agents. A thick layer
of plaster is applied to the nail plate and covered with adhesive plaster. This dressing is left for 48 hours. The
procedure is repeated two to four times until the nail plate becomes soft, after which it is removed with a scalpel
or nippers. In removing the nail plate by means of potassium iodide ointment (Araviisky's method), the nail is
covered with a thick layer of the ointment over which compress paper and cotton are applied and fastened with
a bandage. The dressing is changed several times every four or five days until the nail plate becomes soft and
can be removed painlessly with forceps or a scalpel.
With the nail plate removed, treatment of the nail bed with fungicidal agents (nitrofungin, 5 per cent
iodine tincture, sulphur-tar ointments, Castellani's paint, etc.) is begun and oral griseofulvin is given at the same
time. The adult doses of griseofulvin are as follows: one tablet taken four times a day in body weight less than
60 kg, five times a day in body weight of 60 to 70 kg, six times a day in body weight of 70 to 80 kg, seven
times a day in body weight of 80 to 90 kg and eight times a day in body weight over 90 kg. Griseofulvin is
taken daily for the first month of treatment and every other day for the next two or three months. It may cause
side effects and complications (headache, dizziness, gastro-intestinal disorders, skin eruptions of various
character, etc.). Urinalysis and differential blood count must be regularly made during the treatment.
After removal of the nail plates treatment may also be continued by Andriasyan's method comprising
application of 15 per cent re-sorcin-lactic-salicylic ointment for 48 hours three times running. The ointment is
covered with compress paper, cotton and bandage. Next 5 per cent salicylic ointment is applied in the same
manner for 48 hours after which the remaining nail plate (the 'root' of the nail) and the keratotic masses are
removed. The nail bed is then treated with the fungicidal agents listed above or with fungicidal plasters (phenol
or thymol). Whenever necessary, application of keratolytic plasters and dressings with 15 per cent resorcin-
lactic-salicylic ointment is repeated.

Prevention and Measures for Control of Epidermophytosis and Rubromycosis

The wide spread of tinea pedis and rubromycosis, especially among the urban population, explains the
need for applying both collective and individual measures of prevention of these diseases. The principal
conditions for the organization of effective preventive measures are recording of the morbidity (among the
various population groups, at various enterprises, etc.), its analysis, and active detection and timely treatment of
all sick individuals, including those with the subclinical form of the disease. The staff of public baths, showers,
and swimming pools as well as athletes participating in water sports are subject to particularly careful control.
The measures of collective prevention at an enterprise are determined by the type of the works. In coal-
mining and mining industries, for instance, measures are applied to reduce dust and the increased humidity, in
metallurgical and textile industries overheating of the body is controlled, etc. All wooden gratings at public
baths and showers (the most common places of infection) should be covered with oil-paints or replaced by
rubber mats (without seams). Wash-basins, wash-tubs, floors, benches, and floorings in public baths, showers,
and swimming pools should be disinfected daily with 3 per cent clarified calcium hypochlorite solution, 5 per
cent chloramine or lysol solution. Bathing sandals, individual rubber footwear or bathing shoes are
recommended for wearing when taking showers at industrial enterprises. Bathing shoes may also be worn in
public baths, showers, and swimming pools. For the prevention of foot mycosis some authors recommended
formaldehyde foot baths (taken under the control of medical personnel) or 'water mats' for use on coming out of
the public bath or shower room. The footwear of sick individuals as well as sports shoes and sports boots shared
in common are disinfected in a formalin-vapour chamber. Sponges and wash-cloths are disinfected by boiling
for 10 minutes.
Individual prevention is very important in the control of foot mycoses. The population should know the
routes of infection, the measures of prevention, and the main symptoms of the disease. Such knowledge is
provided through health education (lectures, talks), publication of booklets, leaflets, posters, and other means of
visual propaganda. Predisposing factors should be removed: increased perspiration of the feet is treated
(especially in the spring-summer season), special orthopaedic footwear is worn to correct flat-foot, sores on the
skin and intertrigo are prevented, acrocyanosis is treated. Concurrent (from the moment that the disease was
detected and for the whole period of treatment) and terminal (after hospitaliza-tion of the patient or after he has
been cured) disinfection is conducted in the family where mycoses of the feet are found.
Preventive measures are also carried out in medical establishments in which patients with mycoses of the
feet are treated. All bandages, cotton, and tampons that had been used are burnt or au-toclaved at 1.5 atm for 30
minutes or soaked in 10 per cent clarified calcium hypochlorite solution for two hours. Instruments are boiled
for 10 minutes or kept in 10 per cent formaldehyde solution, 4 per cent solution of 1-chlorbetanaphthol
emulsion or twice-diluted ly-soform solution for 15 minutes.

Trichophytoses
The group of trichophytoses includes three forms of the disease: superficial, chronic, and infiltrative-
suppurative, or zoophilic tri-chophytosis. In each of these forms only the scalp, or the smooth skin, or (less
frequently) the nail plates may be involved. Some patients have combined lesions, e.g. affection of the scalp and
smooth skin, affection of the scalp, the smooth skin, and the nail plates, etc.
Aetiology. Superficial and chronic forms of trichophytosis are caused by the same causative agents, which
are called anthropophilic fungi. They are characterized by the fact that they parasitize only on human skin and
its appendages, in involvement of the hairs they are localized within the hair shaft (Trichophyton endotkrix), and
cause mild inflammatory changes of the skin. This group of fungi includes T* violaceum and T. tonsurans
(crateriforme). Infiltrative-suppurative, or zoophilic, trichophytosis is caused by zooantb.ro-pophilic fungi.
They are characterized by the possible occurrence both in animals (mice, rats, rabbits, guinea pigs, cows,
calves, horses, etc.) and in humans. In affection of the hairs, these fungi are found on the surface of the hair
shaft (T. ectotkrix) and produce an inflammatory reaction on the skin, ranging in intensity from mild to violent
with involvement of the subcutaneous fat in the process. This group of fungi includes T. mentagrophytes (a
variant of T. gyp-seum) and T. verrucosum (f aviforme). Two varieties are distinguished among them, namely T.
ectotkrix microides (small-spored) and T. ectotkrix megasporon (large-spored). The small-spored variety is
formed by T. gypseum whose main host are house and field mice and guinea pigs. The large-spored variety is
produced in the hair by T. verrucosum; domestic cattle (calves, less frequently cows and horses) are its main
host1. When the species of the causative agent in the given patient is known, adequate therapy will be applied
and the epidemiological measures will be scientifically substantiated.
Epidemiology. Infection with anthropophilic fungi occurs from direct contact with a sick individual or
through articles of everyday use (combs, hats, scarfs, hair-clippers, etc.) and objects (toys, pillow-cases, etc.)
contaminated with fungi. Children acquire superficial trichophytosis from other children who have this form of
the disease or from adults (mother, grandmother, and others) with chronic trichophytosis of adults. Infection
with zooanthropophilic fungi is transmitted by persons sick with the corresponding disease, through
contaminated articles or from animals suffering from trichophytosis (calves, horses, etc.), and through scales
and hairs left by animals, e.g. on hay, straw, and other objects.

Superficial Trichophytosis
Superficial trichophytosis is most common among schoolchildren but may be encountered at any age. It
has been established that approximately 40 to 50 per cent of children acquire the disease from adults. It is not
only a 'school' infection, as it was thought to be previously, but a 'family' infection. That is why preventive
measures in this mycosis are conducted both in children's establishments (nurseries, kindergartens, schools) and
in the family (home) of the sick child.
Clinical picture and course. Superficial triehophytoses of the scalp, smooth skin, and nails are
distinguished.
Superficial trichophytosis of the scalp (Trichophytosis ca-pitis) occurs as microfocal and macrofocal
varieties differing from each other only in the size of the foci. There is no acute inflamma tion, the foci have
irregular, unclear boundaries, a spherical shape, and are covered with whitish furfuraceous scales. Vesicles,
pustules, and crusts may sometimes be found on the periphery of the foci. Not all the hairs in the focus are
involved in the process, it is as if there is thinning of the hair (they become rare). Some are broken off very
short (1-2 mm from the skin surface) and have the appearance of commas, hooks, question marks and are called
stubs. Several foci are usually found on the skin (Fig. 7), though in some cases there may only be one small or
large focus. The patients have no subjective complaints. If no treatment is applied, the disease may persist years
and develop into chronic trichophytosis (in females) or spontaneous recovery may occur (most frequently in
males). Adult males may have superficial trichophytosis of the beard and moustache areas (trichophytosis
barbae) the clinical manifestations of which are similar to those of trichophytosis of the scalp.
Superficial trichophytosis of the smooth skin mostly occurs on the face, neck, forearms, and trunk,
though it may develop on any other skin areas. The foci are clearly circumscribed and are rather elevated above
the skin surface. They are round or oval with a small ridge of a macular or papular character on the periphery
on which small vesicles and crusts may form. The centre of the focus is marked by resolution of the
pathological process and because of that it is paler in colour and peels. The foci merge and form a quaint
pattern (Fig. 8). Mild itching may sometimes be felt. The downy hair may be involved in the process, which
delays recovery. Trichophytosis of the smooth skin is mostly encountered among children.
Trichophytosis of the nails (trichophytosis unguium). The nail plates (usually the finger-nails) are
involved in the process in 2-3 per cent of patients with superficial trichophytosis. The lesion first appears on the
free margin of the nail (less frequently on the lunula) and spreads over the whole nail within a few months. The
nail plate thickens, becomes loose and crumbles, and acquires a dirty-greyish colour. Subunguinal
hyperkeratosis develops. Several nail plates are usually involved. If not treated, the process persists for years.

Chronic Trichophytosis
Aetiology. The disease is caused by the same anthropophilic fungi which are responsible for superficial
trichophytosis.
Pathogenesis. The disease sets in in childhood at first as the superficial form which later acquires the
features of chronic (black-dot) trichophytosis in girls; most boys recover spontaneously by the time of puberty.
In some cases, the disease takes the black-dot form already in childhood, that is why the word 'adult' is now de -
leted from the previous name of the disease (chronic trichophytosis of adults). Endocrine disorders (diseases of
the gonads, Itsenko-Cushing's disease), disorders of the vegetative nervous system (ac-rocyanosis),
hypovitaminosis (vitamin A lack) etc. are important in the pathogenesis of the disease. Females account for 80
per cent of all cases. Adults with chronic trichophytosis account for at least 30 per cent of patients with
trichophytosis capitis.
Clinical picture and course. Chronic trichophytosis of the scalp, the smooth skin, and the nails are
distinguished.
Chronic trichophytosis of the scalp is mostly localized in the occipital and temporal areas where small
pale-reddish lesions with a bluish tinge, diffuse or microfocal scaling, and atrophic bald spots are found. A very
characteristic feature is involvement of the hairs, which are broken off on a level with the smooth skin and
resemble comedones (blackheads). They are so characteristic of chronic tricho-phytosis of the scalp that the
disease itself is often called black-dot trichophytosis. In some cases the only manifestation of the disease are a
few black dots, which are detected with great difficulty, especially in women with thick hair, and thoroughness
and experience are required of the physician or nurse who is conducting the examination. Black-dot
trichophytosis may remain unrecognized for many years and even decades, in which case the sick person is a
great epi-demiological hazard because children are infected and develop the superficial form of trichophytosis.
In view of this, it is necessary to examine the mother, grandmother, nurse, and neighbours in each case to rule
out chronic trichophytosis (mainly trichophytosis ca-pitis) among them.
Chronic trichophytosis of smooth skin differs markedly from the superficial form of the disease in clinical
picture, localization, and course. Localization of the foci on the skin of the legs, buttocks, knees and forearms is
most typical; less frequently they are found on the face and trunk. The foci have no clear-cut boundaries and are
continuous with normal skin. They have a cyanotic bluish colour and are covered with scales on various areas,
thus resembling foci of chronic eczema. The persistent and torpid course of chronic trichophytosis of the
smooth skin is explained by the aner-gic immunological state of the body and the simultaneous involvement of
the downy hairs in the foci, the scalp and the nails (disseminated affection). Subjective disorders are either
absent or are manifested by mild itching. Chronic trichophytosis of the skin on the palms and soles is marked
by lamellar scaling of the type of dry dyshi-drosis, occurring against the background of hyperkeratosis, with
frequent involvement of the nail plates and mild inflammation.
Involvement of the nails is encountered in one third of pa-tiens with chronic trichophytosis and is
characterized by thickening of the nail plates. They become dirty-greyish and uneven and crumble and break
easily. The free nail margin separates from the nail bed.

Infiltrative-Suppurative, or Zoophilic, Trichophytosis

This form, which is caused by zooanthropophilic fungi, was previously called deep trichophytosis
(trichophytia profunda) because the formation of deep suppurative pustules was thought to be its characteristic
feature. It has now been established that zooanthropophilic fungi are capable of inducing in humans a clinical
picture with various degree of inflammation. In making the diagnosis of the superficial form of trichophytosis, it
is advisable to perform not only microscopy (for confirming the fungal origin of the disease) but also
bacteriological (cultural) examination so as to identify the specie, of the causative agent, which is of high
epidemiological impor tance.
An increase in the infiltrative-suppurative trichophytosis morbidity has been registered recently in many
countries (FRG and GDR, USA, Rumania, Poland, Czechoslovakia, etc.). In some regions of the USSR,
patients with this form of trichophytosis account for more than 50 per cent of the total number of patients with
superficial trichophytosis, microsporosis, and favus. Moreover, the role of T. gypseum is outgrowing that of T.
faviforme. From the epidemiological standpoint, attention is focused on insects (the grasshopper in particular),
besides the animals listed above as well as on the possible development of zooanthropophilic fungi in straw
and the stalk of Indian corn. The role of the soil in the developmental cycle, storage (reservoir), and
transmission of zoophilic dermato-phytes and the question concerning carriage of zoophilic trichophy-tons by
animals are now the subjects of intensive study.
Clinical picture and course. Several clinical forms of infiltrative-suppurative trichophytosis are
distinguished.
Infiltrative-suppurative trichophytosis of the scalp. In a disease that takes a characteristic course, large
solitary foci of affection form. They are sharply circumscribed, hyperaemic, considerably infiltrated, and
covered with many purulent, succulent crusts. When these crusts are removed, it may often be seen that the pus
is discharged from each follicle separately, though at first glance it seems that the patient has a single large and
deep-seated abscess; as a result there is another name for the disease, 'follicular abscess'. The pus discharged
from each follicle separately resembles honey secreted from the honeycomb. Hence the third frequently
encountered name of the disease, kerion Celci (Celsus' honeycomb). In infiltrative-suppurative
trichophytosis of the beard and moustache areas (sycosis parasitaria), multiple foci of affection form, which
are smaller than those on the scalp but in other clinical symptoms are similar to them.
In zoophilic trichophytosis of the deep form, the infiltrate is very tender to palpation. General symptoms
(indisposition, a temperature reaction, headache) and enlargement and tenderness of the regional lymph nodes
are frequently encountered. With no treatment applied, the disease resolves in a few months leaving scars or,
more often, cicatricial atrophy. The described symptoms and course, however, are far from being encountered in
all patients with suppurative (zoophilic) trichophytosis. The disease may be marked by hyperaemia of the foci
and infiltration but there may be no follicular suppuration (in approximately one fifth of the patients) or it may
take (in about one third of the patients) the course of the superficial form (hyperaemic, slightly infiltrated foci
with a moderate ridge of swelling on the periphery and lamellar scaling).
In infUtrative-suppurative trichophytosis of the smooth skin
the characteristic lesion is a hyperaemic patch, which is strictly demarcated from the surrounding healthy
skin, has rounded contours, and is infiltrated and covered with furfuraceous or lamellar scales, there are many
follicular pustules and purulent crusts on its surface. The infiltrated patch grows along the periphery to a large
size (to a diameter of 5 cm and more) and resolves spontaneously in a few weeks, leaving hyperpigmentation
and sometimes cica-tricial atrophy. The inflammation and infiltration in zoophilic trichophytosis of the smooth
skin, however, just as those in affection of the scalp, may vary in intensity from sharply pronounced (the deep
form) to a hardly noticeable superficial form.
Diagnosis. Superficial trichophytosis of the scalp has to be differentiated first of all with microsporosis
and favus of the scalp. The decisive factors in the diagnosis of trichophytosis are hairs that have broken off at a
low level ('stubs'), a considerable amount of hairs preserved in the foci, no tendency of the foci to merge, and
the characteristic localization of the fungal spores inside the hair shaft (endothrix). Seborrhoeic eczema and
seborrhoea of the scalp are distinguished by the absence of circumscribed foci, no involvement of the hair (in
distinction from trichophytosis), itching, and more conspicuous inflammatory phenomena. It should be noted
that superficial trichophytosis and microsporosis of the smooth skin share clinical symptoms and microscopic
picture in common. The character of the involvement of the hairs (if they are also involved), the medical history
(e.g. a sick cat in the family or house), studying the epidemiological situation at the children's establishment, the
results of cultural diagnosis, etc. make the diagnosis easier. In some cases the lesions on the smooth skin have
to be differentiated from pityriasis rosea, seborrhoeic eczema, and psoriasis annula-ris. In trichophytosis the
foci are demarcated more sharply and there are an oedematous hyperaemic swelling on the periphery covered
with vesicles and crusts, and threads of the fungal mycelium.
The diagnosis of chronic trichophytosis of the scalp is based on the presence of 'dark dots' and atrophic
bald areas in the occipital and temporal regions, and the characteristic affection of the nail plates. Foci on the
smooth skin are differentiated from erythemo-squamous dermatoses (rubromycosis, parapsoriasis guttata, pso-
riasis, etc.).
Trichophytosis unguium is differentiated with rubromycosis, favus, and other diseases of the nails (see
Rubromycosis of the Nail Plates).
Infiltrative-suppurative trichophytosis is differentiated with the infiltrative-suppurative form of
microsporosis. The latter is caused by Microsporum lanosum and is relatively rare. In localization of the lesions
on the face of men, the disease is differentiated with sycosis vulgaris (staphylococcal), which is usually of a
long duration and with no rapidly developing inflammatory phenomena. The follicular character of the lesion
and the acute course of the process allow zoophilic trichophytosis to be differentiated from chronic pyo-derma
and deep mycoses (sporotrichosis, deep blastomycosis, etc.).

Microsporosis
Aetiology. The causative agents of microsporosis, like the causative agents of trichophytosis, are
subdivided into two groups, the anthropophilic and zooanthropophilic fungi. Microsporum ferrugineum and M.
audouini are anthropophilic fungi which parasitize only on the human skin and its appendages. M. audouini is
prevalent in European countries, in the USSR it is encountered only in individuals arriving from abroad. M.
lanosum ('furry or cat' microsporum, syn. M. canis, or 'dog' microsporum) is the only zooanthropophilic
microsporum found in the USSR. The difference in the terminology is explained by the fact that the main
source of zooanthropophilic microsporosis in the USSR are kittens and cats, whereas in European countries it is
mostly transmitted by dogs.
Epidemiology. Infection with anthropophilic microsporum occurs during direct contact with a sick person
or through clothes and articles used in everyday life, which are contaminated with the fungi. M. ferrugineum is
the most contagious among all known pathogenic fungi. With the appearance of a sick child in the collective,
many children become infected and an outbreak of the disease occurs, which calls for intensive organizational
and anti-epidemic measures. The zooanthropophilic microsporum (lanosum) is acquired from a person sick
with the disease' (a rare occurrence) or directly from sick kittens, cats, and dogs.
Infection may also occur through clothes and articles (toys, pillow-cases, scarfs, hats, etc.) contaminated
with the fungus. It has recently been established that cats may be myco-carriers.
Microsporosis mainly attacks children. By puberty the disease may be cured spontaneously. In adults,
only the smooth skin is involved. Microsporon does not affect the nail plate as a rule.

Clinical Picture and Course of Microsporosis Caused by Anthropophilic M.

Verrtigineum
Affection of the scalp is marked by the appearance of very many small foci with irregular outlines and
unclear boundaries, which resemble the lesions in superficial trichophytosis. Unlike the latter, however, in
anthropophilic microsporosis the foci tend to coalesce and form one large focus of affection with polycyclic
edges, moderate scaling, and a cyanotic-pink colour. This form of microsporosis is characterized by the
localization of the foci in marginal zones: some are on the smooth skin and others on the scalp. Often foci are
arranged in the form of iris, i.e. one of the rings (the hyperaemic ridge of swelling) seems to be arranged within
another, sometimes forming quaint patterns. The regularly found well pronounced follicular hyperkeratosis in
the foci of affection on the scalp is a clinical symptom distinguishing the disease from superficial trichophytosis
and zoophilic microsporosis of the scalp. A characteristic feature of all forms of microsporosis is that the affect -
ed hairs break off long (5-8 mm from the skin surface) and that there is a whitish muff at the base of the hair
shaft. All the hairs are affected in the focus.
The foci on the smooth skin are well outlined and often produce quaint figures and iris forms. M.
fetrugineum often causes isolated affection of the smooth skin without involvement of the scalp in the process
but with affection of the downy hair, as a result of which it is difficult to cure a patient.

Clinical Picture and Course of Microsporosis Caused by Zooanthropopbilic M.

Lanosum
Affection of the scalp is characterized by the formation of solitary large foci with strictly rounded or oval
outlines and well contoured boundaries (the foci seem to be stamped) covered with grey asbestos-like scales
(Fig. 9). All the hairs are affected in the focus, they seem to be cut at one level (they break off at a length of 5-8
mm from the skin surface). A small white muff may sometimes be seen at the base of the diseased hair shaft,
these are fungal spores surrounding it. Inflammation in the foci is mild and the skin is therefore pink. In some
cases, however, hyperaemia and infiltration in the foci are very pronounced and sometimes the process follows
the course of deep microsporosis (microsporia profunda), develops acutely with the formation of pustules and
purulent crusts in the foci, general disorders (elevated body temperature, indisposition), involvement of regional
lymph nodes, and often with the appearance of secondary allergic eruptions, microsporids.
Erythematous foci with rounded or oval contours and greyish scales on their surface form on the smooth
skin. They have slightly elevated edges on which solitary vesicles or serous crusts and scales may be seen. The
downy hairs are involved in the process in almost all patients. The foci occur mostly on the open parts of the
body (the skin on the face, neck, the upper part of the chest, upper limbs). The number of foci sometimes
reaches several dozens, which is characteristic of microsporosis of the smooth skin caused by M. lanosum.
Diagnosis. Microsporosis of the scalp is distinguished from superficial trichophytosis both by the clinical
picture (hairs that break off long, inflammation of the skin, copious asbestous scaling) and by the ability of
hairs infected with microsporum to produce greenish-yellow or silver-green (emerald coloured) luminescence
in the dark when irradiated with short ultraviolet rays passed through Wood's glass. M. ferrugineum produces
bright-green luminescence of the hairs, M. lanosum pale-green, whitish luminescence, which makes it possible
to differentiate anthropophilic and zooanthro-pophilic microsporosis of the scalp. Luminescence of
microsporosis is used not only in differentiating it from other fungus disease of the scalp but in mass
examination in children's collectiveswhere a case with microsporosis had been registered, in the examination of
cats and dogs in whom microsporosis is suspected, and as a criterion of curability. It should be borne in mind
that iodine and ointments extinguish the luminescence. In such cases it is advisable to wash the patient's hair
thoroughly and repeat the examination in three or four days.

Favus
Favus has been known since ancient times and was highly prevalent in pre-revolutionary Russia. In the
years of Soviet power, the number of afflicted persons has fallen sharply and favus as a mass disease has been
eradicated in the USSR.
Raising of the standard of life of the population, wiping out of illiteracy, dispensary methods of
dermatomycosis control, free-of-charge and skilled medical service, widely conducted health education, and
other measures contributed to the success in favus control in the USSR.
Aetiology. The causative agent of the disease, the anthropophi-lic fungus Trichophyton (Achorion)
shoenleinii is found inside the hair shaft and is therefore an endothrix.
Epidemiology. Favus is marked by low contagiosity. The incubation period is two or three weeks. The
disease takes a chronic course. Infection takes place from direct contact with sick persons or, most frequently,
through articles contaminated with the fungus (bed-linen, clothes, toys, etc.). Favus develops in childhood as a
rule, but may be recognized for the first time in an adult because spontaneous cure is not typical of this disease.
The lesions mostly occur on the scalp, the nail plates are involved in one fifth of the patients, involvement of
the skin is a much rarer occurrence.
Pathogenesis. The disease prevails among hypotrophic, feeble children suffering from endocrine
disorders, gastro-intestinal diseases, and those with a history of various infections. Poor care and inobservance
of the rules of hygiene provide favourable conditions for the disease.
Clinical picture and course. Favus of the scalp, favus of the smooth skin, favus of the nails and visceral
favus are distinguished.
Favus of the scalp. Scutular, squamous (pityroid), and impe-tiginous forms of the disease are encountered.
The first form is typical of favus, the other two are atypical. The scutular form of favus has an extremely
characteristic clinical picture. Ochre-yellow cup-shaped crusts with a depression in the centre (scutula, favus
shields) appear on slightly hyperaemic spots. These crusts are formed of a pure culture of the fungus and a small
amount of keratotic masses. Sometimes scars but more often cicatricial atrophy are ex-posedon removal of the
crusts. It is extremely characteristic that in involvement of the whole scalp, a band of healthy hairs remains on
the periphery. The hairs do not break but become thin, lustreless, grey, as if dusty and have the appearance of a
wig or tow. A specific mouse-like or barn-like odour is present. The squamous (pityroid) form of favus of the
scalp is marked by the appearance of congestive-hy-peraemic skin areas with copious microlamellar scaling, the
picture resembling that of severe seborrhoea. The impetiginous form is manifested by pustules forming in the
orifices of the hair follicles. These pustules dry up with the formation of crusts, which have the appearance of
the crusts in impetigo. In these two atypical forms, however, the diagnosis of the disease is suggested by the
character of the affection of the hairs which have the same appearance as those in the typical, scutular form. If
not treated, favus may persist for a lengthy period of time and terminate in cicatricial atrophy of the skin on the
scalp (with a narrow band of hair left on the borderline with the smooth skin).
Favus of the smooth skin is of a secondary character as a rule, developing after affection of the scalp. In
very rare cases it occurs as an independent disease. The scutular form of favus of the skin is characterized by
the formation of typical, though much larger, scutula, which grow and may coalesce. Limited skin areas arc in-
volved, but sometimes the process may be of a diffuse character. The atypical varieties of the disease are
marked by the formation of ery-thematous scaling foci which tend to grow along the periphery and coalesce
(pityroid form) or by the formation of superficial follicular pustules producing a picture resembling that of
ostial folliculitis (impetiginous form). The favus lesions leave no cicatricial atrophy on the smooth skin.
Slow involvement of the nail plate in the process is typical of favus of the nails. A brown or dirty-grey
spot or yellow bands form first in the centre of the nail. These remain for a long time and spread gradually over
the whole nail plate. The destructive changes of the nails are much less pronounced than those in the other ony-
chomycoses. The finger-nails are mostly affected.
Visceral favus. Affection of the internal organs has been described in weakened, emaciated patients, in
those suffering from tuberculosis. Cases with favus of the lungs, gastro-intestinal tract, meninges and the brain
matter (meningoencephalitis) are known. The neck, occipital, and parotid lymph nodes are sometimes involved
in the process in favus of the scalp (favus lymphadenitis) . The sputum, faeces, cerebrospinal fluid and the
aspirate of the lymph nodes are examined for the causative agent in visceral favus.
Diagnosis. In the typical, scutular form of favus the diagnosis is made easily and is based on the
appearance of the scutula and the character of the affection of the hairs. The diagnosis of the atypical forms of
the disease is much more difficult. In such cases favus is suggested by the appearance of the hair (lustreless, as
if dusty, thinned but not broken). In distinction from the squamous form of favus, seborrhoeic eczema is
marked by a bright colour of the foci which are conspicuously oedematous and by the presence of serous
crusts. As distinct from the impetiginous form of favus, in impetigo vulgaris and ostial folliculitis, the foci are
surrounded by an acute inflammatory, oedematous corona and the disease does not take the chronic protracted
course typical of favus. The final diagnosis is based on the results of microscopy, and whenever necessary, on
the findings of cultural examination.

Dermatophytids (Dermatomycids)
Dermatophytids are secondary allergic eruptions appearing in irritation of the primary foci of mycosis by
irrational stimulating therapy or in hyper-reactivity of the body to the entry of the fungi. Dermatophytids occur
most frequently in trichophytosis and mi-crosporosis, when the disease is caused by zooanthropophilic fungi.
They may be superficial (lichenoid, erythematous, erythemo-squa-mous, vesicular) or deep-seated (pustular)
and appear near to the focus of mycosis or far from it. No fungal components are found in the secondary
eruption. Only in some cases may fungus cultures be isolated from the patient's blood at the peak of the allergic
eruption. Clinically and morphologically dermatophytids may resemble scarlatinal- or measles-like rash,
parapsoriasis, pityriasis rosea, etc. The eruption of dermatophytids may be attended with general symptoms:
headache, indisposition, malaise, elevated body temperature, etc. Dermatophytids are called trichophytids,
microsporids, favids depending on the character of the main fungus disease in which they form.

Microscopic Diagnosis of Trichophytosis, Microsporosis, and Favus

Fungi are examined in unstained, native preparations. A 10-30 per cent solution of caustic alkalis (KOH or
NaOH) is used to clarify the preparation, i.e. dissolve the keratotic masses. It is best. to work with a 20 per cent
solution. The preparations may also be clarified in ammonium hydroxide.
Heating the hair in making the microscopic preparation is not recommended because this may disturb the
interrelationship of the fungus and the hair and it will thus be difficult to make the diagnosis. The hair, freed
from the scales and crusts, is clarified in a 20 per cent caustic alkalis solution for 5 to 10 minutes (in favus a
little longer). The scales and crusts may be heated but not to the boiling point of the alkali, The enrichment
method suggested by Chernogubov is recommended in the examination of coarse keratotic masses, especially
those taken from the palms, soles, and nail plates. The pathological material is collected into Widal's (or a
centrifuge) test tube, a 20 per cent alkali solution is poured into the test tube to a level of 1-2 mm above the
pathological material, and the contents are heated at boiling point until a homogeneous mass forms. The
material is then centrifuged or left to settle for 24 hours. The sediment which forms is examined by the routine
techniques. A simpler modification of the method may be used: instead of heating the material with a 10-20 per
cent KOH or NaOH solution to boiling point, the test tube is left for 24 hours at room temperature. The
sediment is taken with a Pasteur's pipette, put on a glass slide, and examined with the microscope.
Collection of the pathological material. The success of microscopical diagnosis depends to a great
measure on proper collection of the material for the examination. The suspected material collected in an out-
patient clinic is quite often sent for examination by post, in which case it must be chosen more thorougly.
In involvement of only the smooth skin, on which there are rounded foci with a hyperaemic swollen ridge
on the periphery, sometimes with vesicles and crusts on the ridge, and resolution of the process consisting of
various types of scaling in the centre of the focus, the scrapings are collected (with a scalpel or scissor blades)
from the periphery of the focus where it is easier to detect the mycelial threads or the spores of the fungus.
When the nails are affected the keratotic masses are cut off with a pair of scissors (in affection of the free nail
margin ) or taken from the middle and deep layers of the plate with a scalpel or a drill. In involvement of the
smooth skin or nail plates, the mycelial threads or the fungal spores are detected, but the fungus that caused the
disease cannot be identified. In affection of the hair on the scalp, the causative agent can often, though not
always, be identified from its relationship with the hair shaft and the treatment and anti-epidemic measures may
be planned. It is therefore very important to know which material should be collected for examination in a
fungus disease of the scalp. In superficial trichophytosis, for instance, it is necessary to look for hairs that have
broken off short (1-2 mm above the skin surface) and have the appearance of commas, hooks, and question
marks (stubs). Sometimes they are hidden under the crusts and are exposed when these are removed. In chronic
trichophytosis the occipital and temporal areas are inspected for hairs broken off on a level with the skin (black
dots). When found they are removed from the follicle with a histological needle or the tip of a scalpel. In
infiltrative-sup-purative trichophytosis of the scalp, the hairs are taken from the periphery of the focus because
in the centre of the focus the pus lyses the fungi. Some of the hairs on the periphery, however, may be healthy.
The final diagnosis is made after many preparations are examined. In microsporosis caused by M. lanosum or
M. furru-gineum, hairs that have broken off high (5-8 mm from the skin surface) are collected for examination;
a whitish muff of fungal spores is often found at their base. Long, unbroken but thinned hairs lacking their
natural lustre and resembling a wig are removed for examination in the scutular, squamous, and impetiginous
forms of favus. Hair shafts which are near to the scutula or far from it but not those which pierce it in the centre
should be taken.
Treatment of the preparation. The object of the examination (hairs, scales, crusts, keratotic masses of the
nail plates, etc.) is placed on a slide. The skin and nail scales are ground on it, the long hairs (in favus) are
divided into several short segments (by touching them with the heated edge of a scalpel). Three or four
suspicious hairs or a sufficient amount of scales are then placed in the centre of the glass slide and one or two
drops of caustic alkali are applied. The material, with the exception of the hairs, is heated slightly over the
flame of a burner until a white ring of alkali crystals appears on the periphery. A cover glass is placed on top
and microscopy is carried out, first at low and then at high magnification.
Microscopic picture. Mycelial threads of various length and thickness, sometimes branching and septate,
are discovered in the scales removed from the affected smooth skin and in the scrapings of the keratotic masses
of the nail plates. Round, square, oval or irregularly shaped spores arranged in a chain (arthrospores) or lying
freely are often found. The laboratory's report (e.g. 'threads of mycelium and spores of a fungus are found in the
scales sent for examination') allows the fungal nature of the disease to be established but the question
concerning the species of the causative agent remains unsolved. In examination of hair shafts contaminated with
T. endothrix (studs, black dots), they are seen to be filled entirely with parallel chains of round or quadrate
spores. The shaft has clear-cut boundaries and the chains of spores should be searched for on its edge. Such a
picture is produced by two fungal cultures: T. vio-laceum and T. tonsurans (crateriforme). Clinically this may be
superficial or chronic trichophytosis of the scalp. In infection with T. ectothrix, the surface of the hair shaft is
covered with parallel chains of spores. In some cases the spores are small, resembling the microsporum spores
in size; this applies to T. ectothrix microides (T. gypseum culture). In others they are larger and resemble in size
the spores of the T. endothrix; this applies to T. ectothrix megaspo-ron (T. verrucosum, seu faviforme, culture).
Hairs contaminated with microsporum fungi are seen on microscopy to be covered with very small round spores
arranged chaotically (mosaically) and not in chains as in affection with the trichophyton fungi. When the cover
glass is pressed, the spores 'slip off' the hair and form groups along its sides. A small amount of septate mycelial
threads stretching along the length of the hair and small clusters of spores are seen inside the hair shaft.
T. schoenleinii produces a rather characteristic pattern inside the hair under the microscope. The fungus is
an endothrix, i.e. it is located inside the hair shaft. The hair shaft is not involved entirely in breadth; healthy
parts of the hair alternate with diseased parts, that is why the hairs do not break in favus. The mycelial threads
of various length and thickness are separated by septa at different distances one from another. The size of the
spores varies; there are round or polygonal, large and small spores (this is called pleomorphism of the
components).
Attention is also drawn to the large amount of drops of fat and air in the preparation, though they may
also be encountered in contamination with other fungi.

Treatment of Trichophytosis, Microsporosis, and Favus

A patient with an isolated affection of the smooth skin (superficial trichophytosis, microsporosis, favus)
may be cured by external treatment alone: a 2-5 per cent iodine tincture is applied in the morning, and ointment
with 10 per cent sulphur and 3 per cent salicylic acid or a 10-15 per cent sulphur-tar ointment in the evening.
This treatment is continued for two or three weeks, after which the skin is painted with 2 per cent iodine
tincture for three or four weeks.
In superficial or chronic trichophytosis, microsporosis and favus of the scalp, multiple or solitary foci on
the smooth skin but with involvement of the downy hair in the process, the antibiotic griseofulvin is of high
therapeutic value. It is dispensed in 0.125 g tablets as a highly dispersed preparation (forte); it is less toxic and
better absorbed in the intestine. It penetrates the blood and tissues well and is adsorbed by the horny layer of
the epidermis, hair, and nails. It is prescribed in a daily dose of 21-22 mg/kg. The daily dose is divided into
three portions taken during a meal. The drug is washed down with a teaspoonful of vegetable or cod-liver oil
for better absorption in the intestine. Griseofulvin is given daily until two tests for fungi are negative, then it is
given every other day until three tests made at intervals of two or three days yield negative results after which it
is taken twice a week for two weeks.
Griseofulvin pauses side effects more often in children than in adults. These are allergic eruptions
(micropapular, macular, and urticarial rash), headache, pain in the heart and abdomen, nausea, vomiting, a loose
stool, changes in the blood (leucopenia or leucocytosis, eosinophilia, lymphopenia), diminished non-specific
immu-nogenesis, disturbed porphyrin metabolism, and unpaired metabolism of the vitamin B complex with the
appearance of symptoms of hypovitaminosis. If the allergic eruption is sparse and the itching mild, the
antibiotic is not discontinued and hyposensitizing and antihistaminic agents (calcium gluconate, suprastin, etc.)
are prescribed. In cases with copious allergic eruption and severe itching, griseofulvin is temporarily
discontinued and hyposensitizing treatment is applied. As soon as the allergic rash disappears, griseofulvin is
given again but in half the daily dose for the first few days. Griseofulvin therapy is discontinued and not
renewed if the eruption reappears. Headache, nausea and pain in the heart and abdomen are sometimes relieved
by not giving the antibiotic for two or three days, after which the patients are quite tolerant to it. Poly-vitamins
of the B complex are given for the whole period of griseofulvin therapy to prevent hypovitaminosis.
Griseofulvin is more effective in trichophytosis and favus than in microsporosis.
Griseofulvin is contraindicated in diseases of the blood, liver, and kidneys, porphyrin disease, and
malignant new growths.
External treatment is applied together with griseofulvin therapy. The lesions on the scalp are painted with
a 2 per cent iodine tincture in the morning and a 10-15 per cent sulphur-tar or Wilkinson 's ointment is applied
to them in the evening (the hairs are shaved once in seven to ten days to remove the viable spores). The hair
may be washed two or three times a week. Similar external therapy is applied in multiple foci on the smooth
skin. In involvement of the downy hair, Arievich's peeling ointment (salicylic acid 12 g, lactic acid 6 g,
petroleum jelly 82 g) or collodium film (salicylic acid 10 g, lactic acid 10 g, collodium 80 ml) is used to remove
it. The'collodium film is applied for a few days, then it is covered with an ointment containing 2-5 per cent
salicylic acid. Wax paper and cotton are fastened over it. After this the film is easily removed with the downy
hairs. Whenever necessary, the procedure is repeated and only after that an iodine tincture and a sulphur-tar
ointment are prescribed.
Involved nail plates are treated by the method described in detail in the section dealing with rubromycosis
of the nails.
When griseofulvin therapy is contraindicated, the affected hair is removed from the scalp with 4 per cent
epilin plaster (epilin 4 g, distilled water 15 ml, anhydrous lanolin 22 g, beeswax 5 g, lead plaster 54 g). Its dose
depends on the patient's body mass and is determined from the following scheme: body mass 10 kg2 g; 11
kg-2.5 g; 12 kg-3 g; 13-14 kg-3.5 g; 15 kg-3.5-4 g; 16-17 kg -4 g; 18 kg-4.5 g; 19-25 kg-5 g; 26-30 kg-5.5 g;
31-35 kg-6 g; 36-40 kg7-8 g; 41-50 kg9-10 g; 50 kg12 g. Hairs on the area to which the plaster mass
will be applied are shaved off, the rest are cut short. Epilin plaster is applied in a thin layer (preferably only to
the foci of the mycosis) and fastened with strips of adhesive tape placed tile-like.
In children under 6 years of age the plaster is applied once for 15 to 18 days, in older children and adults it
is applied twice, changing the dressing in 8 to 10 days. In easily excitable and asthenic children, epilation with a
plaster is accomplished by the interrupted method. In the case of children under 6 years of age, the plaster mass
is applied for 3 days and after an interval of 7 days for another 7 to 10 days. Children over 6 years of age and
adults are treated with the epilin plaster for one week, then an interval of 7 days is made after which the plaster
is again applied for 10 to 14 days. Shedding of the hairs usually begins on the 12-14th day after the plaster is
applied and ends approximately by the 20-25th day. If by the 20th-22nd day it does not occur or is negligible, a
new portion of the plaster is applied in the same dose (in young children for the second time and in older
children and adults for the third). A good epilatory effect usually occurs in four to six days in such cases.
Medicinal treatment (iodine tincture in the morning and sulphur salicylic acid or sulphur-tar ointment in the
evening; one or two manipulations for peeling the horny layer) is carried out in the period of baldness until the
hairs grow again (30 to 45 days).
Side effects may occur, though rarely, with the use of the epilin plaster: conjunctivitis, blepharitis,
headache, restless sleep, night fears, acneform and follicular eruptions on the face, follicular hy-perkeratosis on
the scalp. If such develop, the plaster mass is removed and abundant intake of fluid, ascorbic acid, vitamin B lf
and an-tihistaminics are prescribed. In five to seven days the plaster may be applied again as a rule. Treatment
with epilin plaster is contraindicated in diseases of the liver, kidneys, nervous system, and joints. Children are
treated with it only under in-patient conditions (it is not used for infants under 12 months of age). Blood and
urine tests are made prior to application of the plaster and every 10 days during its use.
If griseofulvin and epilin plaster are not available or are contraindicated, the scalp may be exposed to X-
rays which besides causing an epilatory effect (shedding of the hair) is a therapeutic procedure which stimulates
the body's defence forces. In X-ray epilation, the scalp is divided into four fields (frontoparietal, two temporal,
and occipital) and each field is irradiated separately once in a dose of 400 to 500-550 r (depending on the age).
Fractional irradiation in doses of 100-150 r is now usually carried out (until each field is exposed to the total
dose). The hairs begin to fall out on the 14-16th day; hair washing with warm water and soap and manual
epilation help in removing the hairs in a shorter period. Growth of new hairs begins in two months on the
average. In the period of baldness, the diseased areas are treated just as after removal of the hairs with epilin
plaster.
Di-iodolein (Jodi 37.5, Kalii jodati 25.0, Ac. oleinici 350.0, Spi-riti aethylici 96% 87.5) is prescribed for
children with microspo-rosis of the scalp for whom griseofulvin, epilin plaster, and X-ray irradiation are
contraindicated. Painting the affected areas with it twice daily and cutting and washing of the hair every week
for six to eight weeks may have a favourable effect.
When treatment is completed hairs taken mostly from the affected areas are examined with the
microscope three times at intervals of seven to ten days. The examination is repeated during the second and
third months. A child is allowed to attend children's collective if three successive tests prove negative and on
condition that a cap is worn and terminal disinfection has been conducted at home. A follow-up period of three
months (beginning with first control microscopy) provides grounds for considering the patient to be cured.
Infiltrative-suppurative trichophytosis of the scalp and smooth skin is managed by different methods
because it is marked by a tendency to spontaneous cure. In an acute course (the deep form), wet dressings (10
per cent ichthammol solution, 2 per cent boric acid solution, 0.1 per cent ethoxydiaminoacridine lactate, 1:5000
nitrofurazone solution, Goulard's water) and manual removal of the hairs with eyelid forceps are resorted to
first. When the acute symptoms abate, a 10-15 per cent sulphur-tar Wilkinson's ointment is prescribed. The
infiltrative and superficial forms of zooanthropo-philic trichophytosis are treated from the onset with ointments
without the preliminary application of wet dressings. In such cases an attempt may be made first to cause an
exacerbation of the process which would enhance the therapeutic effect of iodine and ointments applied later.
This is achieved by covering the foci with adhesive tape placed tile-like for 24-48-72 hours or by fractional X-
ray epi-lation which is discontinued when the process is exacerbated (in this case the pus lyses the fungi in the
hair; moreover, the hair shaft surrounded by the purulent muff is removed rather easily by manual epilation).

Prevention and Organization of Control of Trichophytosis, Microsporosis, and Favus

Microsporosis is most contagious (especially that produced by M. ferrugineum) and often causes
outbreaks of epidemics in children's establishments, day schools and boarding schools. Trichophytosis rates
next in contagiosity. Favus is least contagious. The control of these three diseases should be conducted both
among the urban and the rural population. The control of these mycoses in the USSR is based on the elaborated
dispensary method, which had demonstrated its value. It includes the following measures: (1) obligatory
registration of all sick individuals and notification (in accordance with the accepted form) of the higher medical
establishment which treats skin and venereal diseases, where a concrete plan of measures is drawn up (with due
account for the epidemiological situation) and the sanitary epidemiological station, which conducts the
appropriate measures of disinfection and, if necessary, notifies the veterinary service. The last catches all sick
and stray cats and dogs, applies measures for the extermination of rats (in epizootics among rodents), and treats
sick domestic cattle; (2) regular examination of children and the staff of children's establishments. It is
advisable to have for this purpose portable luminescence lamp for the early detection among child contacts
those afflicted with microsporosis; (3) early, effective, and free-of-charge treatment of all persons found to be
infected with trichophytosis, microsporosis or favus. This is an important achievement of the Soviet dispensary
system. Temporary in-patient hospitals are organized for persons with fungus diseases during epidemics, and
expeditions and detachments of medical and sanitary workers are sent to these regions, which allows the
outbreak of the disease to be rapidly arrested; (4) detection of the source of infection as quickly as possible,
though in some cases when contamination occurs by the mediated route (through various articles) it is very
difficult and sometimes impossible to find its source. 'House-to-house' examination of the population is often
resorted to in such cases; (5) examination of all members of the sick person's family; (6) dissemination of health
education, especially among schoolchildren and their parents and among the staff of children's establishments,
improves the sanitary literacy of the population as the result of which they come for medical advice earlier; (7)
strict control over the work of barber's shops and hairdressing salons (decontamination of hair clippers over the
flame of a burner, of scissors, razors, and combs in a 3 per cent formaldehyde solution, and of other articles by
means of which the infection may be transmitted to healthy persons). Barbers and hairdressers are not allowed
to serve individuals who have on the skin of the face and scalp lesions which give reason to suspect a fungus
disease. After giving each child a hair cut, the clippers and scissors are disinfected by boiling in a 2 per cent
sodium hydrocar-bonate solution or submerged in ethyl alcohol and then held over a flame. Children with any
signs of a fungus infection of the scalp are attended to after the others. After the hair of each such child is cut,
the clippers are boiled in a 2 per cent sodium hydrocarbonate solution for 15 minutes. The same procedure is
carried out after attending to a child with obvious symptoms of mycosis of the scalp; (8) if a child in a children's
collective is found to have superficial trichophytosis or favus, all the children are examined twice (after the last
case is revealed) at an interval of one week. During this period new children are not accepted into the
groups and no hair cuts are given. All bed clothes and other articles belonging to children in the group, in
which the sick child was detected, are washed separately. If microsporosis is found, the same measures are
conducted but for a period of six weeks. The children are examined once in four or five days (because
microsporosis is more contagious and has a longer incubation period) using a luminescence lamp without
fail; (9) coordination of the therapeutic and preventive measures applied by dermatologists and
paediatricians with the work of the sanitary epidemiological stations and veterinary establishments; (10)
disinfection measures in the infection foci are carried out with the use of a steam formaldehyde or steam-
air chamber; hats which are not valuable are burnt (destroyed).

CANDIDIASIS

Candidiasis is a disease of the skin, mucous membranes, nail plates, and viscera, which is caused by
yeast-like fungi of the genus Candida.
Aetiology and pathogenesis. Yeast-like fungi are widely spread in nature as saprophytes, which
become pathogenic under definite conditions. Most frequently the disease is caused by yeast and yeast-like
fungi of the type of Candida albicans or Monilia, which form no spores (anascosporular), possess a
pseudomycelium, and reproduce by budding. The yeast-like fungi vegetate on fruit and vegetables (there
are especially very many of them in spoiled apples and pears which are beginning to rot). In production,
yeasts may be found in fruit masses used in the manufacture of candies, marmalade, and jam, and in
finished products (sweets, syrups). Under normal conditions these fungi are also saprophytes found in the
gastrointestinal tract; they may occur on healthy human skin and mucous membranes.
Exogenic and endogenic favouring factors are distinguished in the pathogenesis of candidiasis.
The exogenic factors are as follows: injury to the skin and mucous membranes (e.g. yeast aifections
of the nipples of nursing mothers, which are injured by the child when it sucks, yeast stomatitis and
perleche in persons with faulty dentures, candidiasis onychia and paronychia following injury inflicted
during a manicure, etc.); increased humidity leading to the dissemination of candidiasis in geographical
latitudes which are distinguished by a damp and warm climate; exposure of the skin to acids and alkalis
which facilitate maceration of the skin; pathogenicity and virulence of the fungus itself. The exogenic
factors promote the development of candidiasis in a certain condition of the macro-organism and when it is
susceptible to yeast fungi.
 The endogenous factors which contribute to weakening of the body's defence forces and in this way
enhance to the development of candidiasis are: diminished activity of blood serum fungistase which
inhibits the vital activity of the yeast flora; hypovitamino-sis (lack of riboflavine, or vitamin B 2, in
particular); symptoms of vegetoneurosis (increased sweating, circulatory disorders in the limbs);
metabolic diseases (diabetes, obesity); gastro-intestinal disorders which are conducive to dysbacteriosis,
endocrinopathies which lead to obesity, hypo-hyperthyroidism, and Itsenko-Cush-ing's syndrome; age
(insufficiency of salivation and reduced lyso-zyme activity of a physiological character in the newborn and
because of weakened defence forces of the body in old individuals); general infectious diseases (scarlet
fever, typhoid, etc.); diseases leading to cachexia (tuberculosis, carcinoma, lymphogranulomatosis,
leukoses, malignant anaemia).
Treatment with antibiotics, especially with broad-spectrum antibiotics, promotes the development of
intestinal dysbacteriosis, which may cause severe forms of systemic candidiasis. Similar results may be
produced with the use of oral contraceptives, cortico-steroid hormones, cytostatic (immunosuppression)
agents which induce hormonal shifts and reduce body resistance.
Epidemiology. The listed exogenic factors, which are conducive to the development of candidiasis,
determine the contingent of individuals who often have a yeast disease. Confectioners and persons
engaged in the canning industry whose skin is macerated by sugar substances and fruit juices or is
exposed to the effect of oxalic, malic, citric and lactic acids, alkalis and fruit essences, which damage the
skin and lead to its maceration, are among these contingents. Workers of public baths, bath houses, and
swimming pools, dishwashers at catering establishments often acquire the disease because the yeasts
themselves become virulent when they are on good nutrient medium. The disease also prevails among
housewives whose hands are* macerated, in bartenders with the skin macerated by syrups, etc. In
distinction from the exogenic factors which create favourable conditions for the development of the
disease among whole groups and categories of the population, the endogenic factors contribute to the
development of candidiasis in some persons. Dysbacteriosis from medication with antibiotics,
corticosteroids, and cytostatics, may develop, however, in many persons irrespective of their occupation.
Classification. The clinical forms of candidiasis are subdivided into superficial (candidiasis of the
skin and mucous membranes, onychia, paronychia) and systemic, or visceral. Besides these, chronic
generalized (granulomatous) candidiasis of children (which some authors believe to be intermediate
disease between the superficial and visceral forms of candidiasis) and candidids (moniliids, or levurids),
secondary allergic eruptions, are distinguished.

Superficial Candidiasis. Cutaneous Candidiasis

Candidiasis of the large skin folds, or intertriginous candidiasis, or yeast intertrigo. Lesions occur in
the femoroingui-nal folds and the folds between the buttocks (often in infants), in the axillae, under the
mammary glands in females, and in the skin folds on the abdomen in obese persons. Large dark-red eroded foci
with sharply pronounced boundaries and moderate dampness form here. A border of separating whitish
macerated epidermis is seen on their periphery. The presence of small foci around the main focus of a similar
character ('daughter' foci, or siftings) is a characteristic feature.
Interdigital yeast erosions on the hands are a common occurrence. It is mostly encountered in women
working at confectioneries, canneries, and fruit and vegetable processing enterprises, barmaids, laundrywomen,
and housewives. The lesions are usually found in the folds between the third and fourth fingers and the sides of
these fingers; the corneal layer here is macerated, slightly swollen, mother-of-pearl in colour or it is separated,
exposing an eroded, moist, and shining red surface. Fragments of macerated epidermis with a mother-of-pearl
hue are seen on the boundaries of the erosions. These erosions are marked by a persistent character and a
tendency to recur. There is a sensation of burning and itching. The yeast erosions attack the feet less frequently,
but many of the interdigital folds are involved (sometimes all of them).
Among the other yeast of the smooth skin encountered much less frequently than candidiasis of the large
and interdigital skin folds, mention should be made of yeast lesions of the small folds (behind the ears, in the
region of the umbilicus, anus, prepuce), which differ from affections of the large folds only in size. Candidal
dermatitis of the palms and soles is characterized by hyperkeratosis, conspicuous pattern of the skin furrows,
and a dirty-brown colour of the skin. Candidal dermatitis of infants and adults may be localized or diffuse,
and erythemo-squamous or dyshidrotic in character. The whitish macerated epidermis on the periphery and the
presence of yeast lesions on other skin areas suggest the true character of the disease. Candidal
balanoposthitis occurs mostly in diabetics or as the result of contamination from a female suffering from
vulvovaginitis. It is marked by the appearance of localized foci of hyperaemia, erosions, a whitish epidermis on
the skin of the inner surface of the prepuce and the glans penis and severe itching.
The diagnosis of cutaneous candidiasis presents no difficulties in most cases and is based on the
peculiarity of the above-described clinical symptoms and is verified by laboratory diagnosis. Candidiasis of the
large folds is differentiated with epidermophytosis of the large folds, in which daughter foci do not form, and
with micro-bial eczema, which is accompanied with more or less pronounced pyogenic symptoms. In common
intertrigo, the boundaries of the lesion are less marked and there is neither a separating band of epidermis on the
periphery nor daughter foci. .In seborrhoeic eczema of the skin folds of children, maceration is also encountered
but the weeping is pronounced more sharply than in candidiasis of the large folds and, besides, there are marked
oedema and bright hyperaemia of the foci. Psoriasis of the folds is characterized by marked infiltration and
papular lesions on the periphery. Intertriginous candidiasis differs from Ritter's disease (exfoliative dermatitis)
by the absence of serous bullae, a satisfactory general condition, and the absence of dyspeptic and gastro-
intestinal disorders as a rule. Moreover, exfoliative dermatitis sets in with the appearance around the mouth of
red spots and their dissemination over the entire surface; bullae and vesicles with a serous content form against
this background. Leiner's disease (erythroderma desquamativum) begins with the appearance of red oedematous
spots on the buttocks and the femorogluteal and inguinal folds, which later coalesce and spread to the abdomen
and back. The process becomes generalized with even involvement of the whole surface of the smooth skin and
the folds, which is a rare occurrence in candidiasis. Moreover, erythroderma usually develops at the age of four
to six weeks and is accompanied with severe gastro-intestinal disorders, anaemia, and elevated body
temperature. The main lesions in syphilis-like papular impetigo are papules and there is no maceration or loose
gruel-like masses in the folds.

Candidiasis of the Mucous Membranes

Yeast fungi may affect any mucous membranes (in the mouth, conjunctiva, vulva, urethra, urinary bladder,
etc.). Below is a description of the most common affections.
Candidiasis of the oral mucosa (thrush) is mostly encountered in the newborn and in infants in the first
weeks of life. Among adults it is less frequent. At first, dots of white film resembling semolina grains appear
against a hyperaemic background on the mucous membranes of the cheeks, tongue, gums, and soft palate. They
coalesce and form an entire film, which is easily removed at first, but then it thickens, turns a dirty colour, and
is seated more firmly on the mucous membrane. Involvement of the mucosa tongue may be a manifestation of
yeast stomatitis, but sometimes it occurs as independent disease (yeast glossitis). In such cases, the usual thrush
films are seen on the back of the tongue or deep furrows stretching in different directions (scrotal tongue) on the
floor and edges of which whitish films may be seen. With the appearance of whitish plugs lending the
appearance of follicular tonsillitis, the condition is called mycotic (yeast) tonsillitis; swallowing is painless and
there is neither any visible inflammatory nor temperature reaction.
Candidiasis of the mouth angles (mycotic perleche) and can-didal-induced cheilitis may accompany
each other or may occur separately. They usually develop against the background of vitamin B 2 deficiency (lack
of riboflavine). A low bite may play a role in the pathogenesis of perleche. Macerated areas with greyish-white
crumbs or films form against a hyperaemic background, usually in both angles of the mouth. When the films are
removed, cracks or pin-point erosions are exposed in the angles. The vermilion border is somewhat thickened
and dry.
Gandidal vulvovaginitis is marked by oedema and hyperaemia of mucosal areas with clear-cut
microscalloped contours, whitish or greyish films, and characteristic secretion which has the appearance of
crumbs. There are severe itching and, at times, a sensation of burning.
The diagnosis of candidiasis of the mucous membranes is based on the clinical picture (the presence of
whitish or greyish films) and the results of microscopy. Thrush may resemble leucoplakia, lichen planus,
syphilitic papules of the mouth, aphthae and aphthous stomatitis. The first two diseases are rarely encountered
among children. Moreover, some lichen planus lesions may also be found on other skin areas and mucous
membranes and there are no easily removable membranes or films. Syphilitic papules are surrounded by a
clearly pronounced inflammatory border and are sharply demarcated, and other symptpms of syphilis are
present. Aphthae are characterized by tenderness and enlargement of the submandi-bular lymph nodes. In
aphthous stomatitis there are very many small erosions with a bright inflammatory band on the periphery and a
saucer-like floor with a yellow coating.
Mycotic perleche has to be differentiated from streptococcal perleche which is prevalent among children
and is usually unilateral (mycotic perleche is mostly encountered in adults and is usually bilateral). Maceration
is more typical of the yeast infection, whereas exudation with impetiginization is characteristic of the
streptococcal form.
Affections of mucous membranes of non-yeast origin (geographical tongue, rhomboid glossitis,
vulvovaginitis) are distinguished by the absence of macerated areas or whitish or greyish films on the mucous
membrane and the absence of caseous crumb-like deposits.

Candidiasis of the Nail Folds and Nails

Candidiasis of the nail folds (paronychia) and the nail plates (ony-chia) are the most common forms of
yeast diseases and prevail among females. They are often accompanied by interdigital erosions. The process
begins in the proximal part of the nail fold which becomes hyperaemic and swollen, and a small drop of pus
may be pressed out from under it; the cuticle (eponychium) disappears. Then the side folds are involved. There
is sharp pain in the acute stage of the disease. After .the inflammation subsides, the process usually spreads to
the nail plate whose sides and the region of the lunula turn brownish-red-grey. The nail becomes thin, crumbles,
and is covered across with stripes (a characteristic sign). In some cases it is easily separated. The disease usually
occurs only on the fingernails, mostly on the third and fourth fingers.
Diagnosis. Candidiasis is distinguished from onychomycoses of other aetiology by the combination of
paronychia and onychia and the positive results of laboratory tests.
Candidids (monilids) are secondary allergic eruptions occurring in candidiasis. They are also called
levurids (Fr. levure yeast). Candidids appear in hyperergy of the body caused by processes of its sensitization.
They are characterized by the sudden appearance of erythemo-squamous foci which disseminate rapidly, and in
many cases by the development of general phenomena, which distinguishes eczema-like dermatophytids from a
true yeast affection of an eczematous character. Moreover, microscopy reveals yeast and yeast-like fungi in the
last cases but not in those with levurids, while skin tests with the corresponding antigens produce a sharply
positive result. Rational therapy leads to rapid disappearance of levurids. If treatment is inadequate, however,
they may remain for a lengthy period of time and even transform into eczema.
Levurids occur most frequently in acute disseminated candidiasis of the mucous membranes, large folds,
and smooth skin. In areas free of the erythemo-squamous foci, levurids in rare cases are of an urticarial or
bullous character.

Chronic Generalized (Granulomatous) Candidiasis of Children

This is a peculiar variety of candidiasis whose scrupulous study was begun at the end of the fifties and
sixties. In most of the cases described, the disease developed in early childhood and was first manifested by
thrush. Later, with the use of antibiotics (usually their combination) for various infectious diseases or colds
generalization of the process was noted. The lesions in the oral cavity occur on the buccal mucosa, on the
mucous membrane of the hard and soft palate and the gums. A persistent perleche forms. Macrocheilia develops
due to yeast cheilitis. A scrotal (furrowed and corrugated) tongue is found in most cases. The appearance on the
skin of the face (usually the nose, cheeks, and middle of the forehead), scalp, trunk, and limbs of hyperaemic,
infiltrated, and peeling spots, which gradually transform to granulomatous foci with scalloped outlines, is
characteristic. Most of the lesions are covered with crusts on removal of which vegetations and hyperkeratosis
are revealed. The nail folds of all the children are infiltrated and oedematous, while the nail plates are very
thick, distorted, and dirty-grey in colour. The cuticle is preserved (as distinct from yeast paronychia in adults).
After resolution of the lesions, cicatricial atrophy remains on the smooth skin and permanent baldness on
the scalp.
Most of these children have recurrent pneumonia, bronchitis, diarrhoea; X-ray demonstrates an
abnormally pronounced broncho-vascular pattern, a denser shadow of the pulmonary tissue in the vicinity of the
roots, etc. There are regular bouts of elevation of body temperature (to 38-39C) with a rapid fall.
The complement fixation reaction with yeast antigens is usually sharply positive (4-J-) in patients
suffering from generalized granulomatous candidiasis and the agglutination reaction is positive in high dilutions
(a titre of 1:160 to 1:2560).
The disease follows a very long course with regular exacerbations, despite the use of modern methods of
treatment.
The prognosis is grave in most cases. Cachexia develops even if the child is given a high-calorie diet; the
body's defence forces are weak. Intercurrent diseases developing in this condition can cause a fatal outcome.

Visceral (Systemic) Candidiasis

 With the extensive use of antibiotics in the treatment of various diseases, cases of disseminated combined
forms of candidiasis with involvement of the internal organs and the development of yeast sepsis began to be
registered in all countries. The opinion has been advanced that dysbacteriosis is important in the pathogenesis of
visceral candidiasis. Dysbacteriosis is characterized by inhibition by antibiotics of the vital activity of Gram-
negative bacilli and cocci. These bacteria are presented in the body of a healthy human as antagonists of the
yeast-like fungi of the Candida genus and delay their development. Highest importance in the- development of
dysbacteriosis is attributed to broad-spectrum antibiotics (penicillin, streptomycin, chlortetracycline,
terramycin, etc.), and especially to their combinations. Antibiotics disturb the vitamin balance in the patient's
body (e.g. suppress the vital activity of Escherichia coli which contributes actively to the synthesis and supply
of various vitamins), with the result that vitamin deficiency occurs facilitating the development of candidiasis. It
is believed that antibiotics directly stimulate the development of yeast-like fungi. A definite role in the
pathogenesis of visceral candidiasis is now attributed also to corticosteroids and cytostatics, though the
mechanism of their action leading to candidiasis is insufficiently studied. Various factors are evidently
important in the pathogenesis of this form of candidiasis, in some cases dysbacteriosis is the predominant cause,
in others vitamin deficiency, etc.
Clinical picture and course. Involvement of the mucous membranes of the respiratory and gastro-
intestinal tracts and urogenital organs is most frequent in visceral candidiasis. Cases with yeast diseases of the
cardiovascular and nervous systems, kidneys, liver, spleen, bronchi and lungs (pneumonia), brain matter, heart
muscle, blood vessels, and other organs have been described. Visceral candidiasis may result in a septic state
which sometimes occurs without a preceding lesion of the internal organs. Affection of the viscera occurs as a
rule in weak and emaciated patients suffering from severe chronic infections or severe systemic diseases and
when such patients are treated with antibiotics, corticosteroids or cytostatics. There are no, or hardly any
specific clinical symptoms of visceral candidiasis. A yeast lesion of an internal organ should be suspected when
a disease takes a protracted, torpid course (pneumonia, enteritis, colitis, myocarditis, etc.) with subfebrile
temperature and does not respond to the commonly applied methods of treatment, and when the process
deteriorates if antibiotics are given. Yeast lesions of the visible mucous membranes (especially in the mouth),
nail folds and nail plates, which often accompany affections of the internal organs help in suspecting visceral
candidiasis. Various skin areas are rarely involved in such cases. The final decision is made on the basis of
laboratory findings.

Laboratory Diagnosis of Candidiasis

Microscopy of native preparations is mostly used in the laboratory diagnosis of candidiasis. In
involvement of the internal organs, microscopy of stained specimens (sputum, faeces, urinary sediment),
serological tests, and skin allergic tests are conducted in addition. Cultural diagnosis is resorted to when yeast
sepsis or affection of the spinal cord or brain is suspected (centrifuged blood or cerebro-spinal fluid is
inoculated into nutrient medium). Depending on the character and localization of the process, the skin scales,
scrapings from the mucous membranes and nails, pus, mucous clots of sputum and faeces, and the urinary
sediment are examined with the microscope for Candida fungi.
In examination of native preparations, the pathological material is placed on a glass slide and 10 per cent
alkali (KOH or NaOH) solution is poured over it, a cover slide is then put on top and the preparation examined
with a microscope first at low and then at nigh magnification. Fine mycelial threads (particularly abundant in
thrush) and yeast cells characteristically in the stage of division (budding) are seen. Several smaller daughter
cells are found next to the maternal (large) cell. The budding yeast cells in the preparation may form clusters
resembling bunches of grapes. It should be borne in mind that when yeast are present as saprophytes, only
occasional yeast cells are found in the preparation, and not always, while in candidiasis yeast cells and
mycelium are a constant finding. This is true both in examination of material in superficial forms of candidiasis
and in examination of the corresponding specimens (sputum, faeces, urine, etc.) in candidiasis of the internal
organs.
The preparations are stained when there is doubt concerning the origin of the occasional yeast cells. A
small clump of the material to be examined is placed into a drop of tap water on a glass slide, blended with a
loop or small spatula, spread in a thin layer on the glass, and fixed over the flame of a burner. The Gram, Ziehl-
Neelsen or Romanovsky-Giemsa stain is used.
The agglutination reaction (with the yeast antigen) testifies to the presence of candidiasis only if the result
is sharply positive in a dilution of 1:160 and higher. A lower titre of the reaction may be produced in individuals
who do not have candidiasis but are simply carriers of saprophytic yeast. The results of intracutaneous allergic
tests should be considered carefully because they may be of a group character and be found in individuals with
a history of the disease.
The diagnosis of visceral candidiasis is often considered by comparing the clinical findings with the
results of laboratory studies.

Treatment of Candidiasis Patients

Some forms of superficial candidiasis (e.g. interdigital yeast erosion of the hands, 'bath' dermatitis, etc.)
are cured after the removal of factors which favour their development (maceration of the epidermis with water,
exposure to the effect of acids, alkalis, syrup, etc.) and the prescription of external agents. The most beneficial
among them are 1-2 per cent aqueous or alcohol solutions of aniline dyes: gentian violet (crystal violet),
methylene blue. The formula for aniline dyes prepared on alcohol is as follows:
Rp: Gentian violet, seu Methylenum coeruleum 0.4 Spiritus vini rectif. 40% 20.0 MDS.
For external application
Paints such as a 5-10-20 per cent solution of sodium borate in glycerin, silver nitrate solutions,
Castellani's paint are also used.
Ointments and pastes containing salicylic acid, sulphur, tar, ben-zoic acid, etc. are prescribed.
In disseminated and protracted forms of candidiasis of the skin and visible mucous membranes, the
identified unfavourable external and internal factors are removed whenever possible or reduced (see
'Pathogenesis of candidiasis') and oral anti-yeast antibiotics are prescribed. These are nystatin and levorin the
daily dose of which (2 000 000-3 000 000 U) is divided into three or four portions. They are given for 14 to 17
days (depending on the character of the process). Treatment with nystatin and levorin is combined with the
prescription of vitamins of the B complex, ascorbic acid, rutin; children are given a vitamin A concentrate in
addition. Mycohep-tinum (daily dose 1 000 000-2 000 000 U) and amphoglucaminum (daily dose up to 450
000-600 000 U) are new anti-yeast agents given orally. Besides the drugs listed above, a 0.5-1 per cent dequali-
nium ointment, 0.05-1 per cent nitrofurilenum ointment, ointments containing nystatin or levorin (3 000 000-5
000 000 U of antibiotic per 1 g of ointment base), mycoheptinum or amphottfcicin ointment are used for
external treatment. Specific hyposensitization by means of intracutaneous injections of Candida vaccine or
Candida filtrate is conducted.
Treatment of children suffering from chronic generalized (gran-ulomatous) candidiasis is rather difficult.
Long-term courses of nystatin therapy are prescribed in such cases (of 18 to 20 days with intervals of two or
three weeks). Non-specific stimulating agents (gamma globulin, blood transfusion, transfusion of native or dry
plasma, aloe, iron or phosphorus preparations) and vitamins, particularly those of the B complex (riboflavine,
pyridoxine, folic acid) are given at the same time. Amphotericin B is infused intravenously. Applications of 20
per cent pyrogallol plaster to the foci of granulation tissue are prescribed; some of the foci are destroyed by dia-
thermocoagulation or liquid nitrogen. After removal of the hyper-keratotic layers and granulations, anti-yeast
ointments and solutions of aniline dyes are used. The patient is given a high-calorie diet rich in vitamins.
Yeast onychia is treated by means of dressings with a 50 per cent pyrogallol ointment, zinc sulphate
electrophoresis, and fungicidal plasters.
The treatment of visceral candidiasis is especially difficult. The daily dose of nystatin is raised to 6 000
000-8 000 000 U. A high-calorie diet and vitamins are prescribed. Antibiotics and cortico-steroids are
discontinued whenever possible. Diabetes, achylia, and other diseases are treated. Sodium iodide or potassium
iodide (3 to 5 g daily) or intravenous infusions of a 10 per cent sodium iodide solution in combination with
infusions of a 40 per cent methenamine solution (2 to 10 ml) are extensively used. Six to eight blood
transfusions (5.0 to 10.0 ml), injections of polyvalent vaccine or autovac-cine are given. Dequalinium in
dragee, amphoglucaminum, myco-heptinum are prescribed. Amphotericin B is given by intravenous drip.
The contents of the flask (50 000 U of amphotericin B) are dissolved under strict sterile conditions in 10
ml of distilled water immediately before giving the infusion. The solution is then taken from the flask with
a syringe and poured into another flask containing 450 ml of a sterile 5 per cent glucose solution. The dose
is 250 U/kg on the average, but is sometimes increased to 1000 TJ/kg. The intravenous drip is given two or
three times a week. The total dose of the drug ranges from 1 500 000 to 2 000 000 U. Treatment with this
drug may cause side effects and complications: a chill, elevated body temperature, persistent headache,
nausea, vomiting, a neph-rotoxic effect, hypokalaemia, anaemia. Diseases of the kidneys, liver, blood,
diabetes and individual intolerance to the preparation are contraindications for treatment with
amphotericin B.

Canfldiasis Prevention
 The timely detection and treatment of yeast diseases (particularly those of the oral mucosa) in
children and the staff of children's establishments prevent mass candidiasis (thrush, perleche, yeast
dermatitis of the newborn) in these collectives. The prevention of thrush in the newborn is linked with the
application of measures for treating the expectant and nursing mothers, and not allowing individuals with
yeast lesions to take care of the infants. Sick children are isolated from healthy ones. Much importance in
the prevention of candidiasis among children is attributed to a rational diet, hygienic care, and disinfection
of articles used in the care of children, bedclothes and clothes. The exogenic and endogenic factors
conducive to the development of candidiasis should be borne in mind and attempts made to remove them.
Antibiotics and cortico-steroids, for instance, should be prescribed against the background of saturation of
the patient's body with vitamins. The patient's mouth should be examined carefully and regularly because
the appearance of white films is often the first sign of the development of visceral candidiasis.
Control over production technology is a measure for preventing interdigital erosions on the hands of
persons working at canneries and fruit and vegetable processing enterprises, where everything should be
done to prevent maceration of the epidermis with water, acids, and fruit syrups. Measures for the control
of traumas should be undertaken.
The treatment of diabetes and obesity in patients with metabolic disorders, treatment of gastro-
intestinal diseases, vegetoneurosis, general invigorating therapy for weakened patients and persons who
had suffered from severe infections, correction of vitamin-balance disordersall this prevents the
development of superficial and systemic forms of candidiasis. Vitamins, especially those of the B
complex, are recommended as a preventive measure for these patients, whereas those treated with large
doses of antibiotics and corticosteroids are prescribed preventive nystatin therapy.

* DEEP MYCOSES
Fungus diseases with involvement of the skin, mucous membranes and internal organs form the
group of deep (systemic) mycoses. They are characterized by a protracted course and torpidity in response
to treatment.-Some of them (actinomycosis, chromato-blastomycosis, mould mycosis) are relatively rare
in the USSR, others (histoplasmosis, coccidioidomycosis) are encountered very rarely, though in some
countries a considerable number of cases with these diseases are registered. Actinomycosis is now
considered a bacterial disease and related to pseudomycoses.

Actinomycosis
Actinomycosis is an infectious disease caused by various species of actinomycetes.
Aetiology and pathogenesis. As it is said above, a large group of actinomycetes is now recognized as
bacteria, while the disease itself as a pseudomycosis. Aerobic (mostly found in the soil, atmosphere, water,
and on cereals) and anaerobic actinomycetes (found as saprophytes usually on the mucous membranes of
animals and humans) are distinguished. Both the anaerobic and the aerobic species may be pathogenic for
humans, though the anaerobic actinomycetes Actinomyces israelii and Actinomyces bovis are most com-
monly responsible for the disease.
Actinomycetes occurring as saprophytes in the oral cavity and intestine of man may lead to the
development of the disease through auto-inoculation, which is promoted by weakening of the body's
defence immunological properties and by activation of the agent's pathogenicity and virulence. In other
cases the actinomycetes, which are disseminated in nature, enter the human body through the mouth,
respiratory tract, and intestinal mucosa. The causative agent may also gain entrance by way of injured skin
and mucous membranes when the wound is contaminated with soil, dust, and plant particles.
Exogenic infection of the skin, however, is less frequent; the process on the skin is usually of a
secondary character spreading from the deeper lying tissues and organs per continuitatem or by meta-
stasis.
Clinical picture. The duration of the incubation period is not known. Suteev, for instance, believes it to
range from one to three weeks. According to Kashkin, the process may sometimes develop very slowly with the
pathological changes appearing two to three years after the injury.
Actinomycosis of the neck and face is encountered most frequently, lesions of the thoracic (in affection of
the lungs) and abdominal (with changes in the liver, spleen, kidneys, and intestine) cavities are rarer. As it is
mentioned above, primary affection of the skin is rare. The cutaneous process is usually of a secondary
character, developing as the result of spread of the infection from foci present in the abdominal and thoracic
cavities, the mouth and nose (carious teeth, tonsils, paranasal sinuses).
 Three forms of cutaneous actinomycosis are distinguished: gum-mato-nodular, tuberculo-pustular, and
ulcerative.
Cutaneous actinomycosis is manifested commonly in the form of gummatous lesions. Subcutaneous
ligneous infiltrated patches and tumour-like nodular lesions of a livid colour with a grooved and lobular surface
develop. The lesions soften in places and fistulas form. Greyish-yellow, purulent crumb-like masses with an
unpleasant odour and containing small granular particles (driisens, or colonies of actinomycetes) are discharged
from the fistulas. The destructive processes may involve the deeper lying tissues as a result of which ulcers
form. The edges of the ulcers are undermined while the floor is covered with granulations and papillomatous
growths.
The ulcerative form of actinomycosis is rare and results from the disintegration of large nodes. The edges
of the ulcers are soft, loose, and undermined. The floor is covered with vegetations, necrotic masses, and a
copious purulent secretion containing driisens in the form of yellowish granules. On healing, the ulcer leaves
irregular, bridge-shaped scars which adhere to the underlying tissues.
The tuberculo-pustular form of actinomycosis is marked by tubercles which rapidly undergo necrosis and
ulcerate. As the result of fusion of the tubercles, infiltrated surfaces form, which are also characterized by a
ligneous hardness and the presence of fistulas with copious purulent discharge and occasional ulcers.
Actinomycosis morbidity among females is half that among males. Contagiosity is negligible. There is no
reliable information of transmission of the disease from a sick to a healthy person.
The histological picture is marked by the presence of granulation tissue with foci of abscess formation,
which contain actinomycetes.
The differential diagnosis is made with scrofuloderma, lupus tuberculosis (lesser depth and hardness of
the ulcers), gummatous syphilids, malignant tumour, and with other deep mycoses.
Diagnosis. The characteristic ligneous infiltrations, fistulas, and ulcers are significant in making the
diagnosis. The detection of the driisens of actinomycetes (a cluster of fine threads surrounded by radial threads,
that have club-like thickenings) on microscopy of the purulent discharge and histological examination of
biopsic tissues is important. The allergic skin tests and serological tests with actinolysate are also carried out.
Treatment. Combined treatment with actinolysate (the filtrate of a culture of pathogenic aerobic
actinomycetes) and antibiotics produces the best results. Actinolysate is given by subcutaneous or intramuscular
injections; 3-4 ml is injected twice a week to a total of 15 to 20 injections. The treatment is repeated two to five
times at intervals of one or two months. It may also be administered intradermally, 0.05-0.1 ml is injected the
first time and then the dose is gradually increased by 0.1-0.2 ml with each injection. The intervals between the
injections are determined by the local, general, and focal reaction (their duration usually ranges from two to
four days). Penicillin is given by injections in a daily dose of 1 000 000-1 500 000 U (total dose 25 000 000-30
000 000 U). If no effect is produced, streptomycin, erythromycin, morphocycline, etc. are prescribed.
Transfusion of blood of the same group (100-150 ml once a week), medication with iodine preparations, a diet
rich in proteins, and general invigorating therapy are recommended in severe cases. Surgical methods of
treatment and X-ray therapy have not lost their value.
The prognosis is quite favourable if the process is not neglected. It becomes grave in the generalized and
especially in the visceral forms.
Prevention consists in the treatment of all morbid conditions in the oral cavity and the control of mild
injuries, particularly among the rural population.

Deep Blastomycosis (Blastomycosis Profunda)

Gilchrist's disease (syn. North American Blastomycosis) is a non-contagious chronic infection caused by
Blastomyces derma-titidis fungus. The skin, lungs, and bones are mostly involved, as well as the liver, spleen,
and kidneys. The infection enters through the skin or respiratory tract. The disease is manifested in two forms,
primary-cutaneous and systemic (visceral).
The primary skin affections are characterized by red papular eruptions on the face, limbs, and buttocks.
The papules merge, and pustules form on their surface, which become covered with purulent crusts and ulcerate.
They grow gradually to form large ulcerating patches covered with granulating verrucous growths with a
cicatrizing centre. The lesions have serpiginous, cyanotic-red edges with characteristic focal miliary pustules.
The skin manifestations may be of a secondary character occurring as the result of dissemination from
diseased internal organs. These are large subcutaneous or intradermal nodes which may ulcerate and form
fistulas and extensive ulcers that leave thick retracted scars.
Histological examination reveals pleomorphic granular infiltration of the dermis and small intradermal
abscesses. Very many Blas-tomyces dermatitidis yeast cells (8-15 urn and larger in diameter and with a double-
contour light-refracting wall) are found in the pus, urine, and removed pieces of tissue.
The disease has to be differentiated from syphilitic gummata (regularly rounded ulcers with dense-elastic
swollen egdes), leish-maniasis, tuberculosis verrucosa, chronic pyodermavegetans, and the other deep
mycoses.
The skin test with the blastomycetes vaccine and the complement fixation test are also valuable, in
addition to microscopy and cultural studies. The results of the agglutination test are less specific.
Busse-Buschke disease (syn. blastomycosis purulenta profun-da, European blastomycosis, cryptococcosis,
ascomycosis, torulo-sis). This is a systemic torpid fungus disease with predominant involvement of the
meninges. Cases with affection of the lungs, spleen, liver, kidneys, skin, subcutaneous fat, and mucous
membranes have also been described. The disease is caused by the fungus Cryp-tococcus neoformans
(Saccharomyces neoformans).
Lesions on the skin are quite rare. They occur as multiple acnei-form papules and subcutaneous
gummatous nodes merging to form infiltrated surfaces and subcutaneous abscesses. Foci of ulcerations form
with deep crateriform granulating ulcers marked by serrated, mildly infiltrated, undermined edges. The floor of
the ulcers is covered with flabby granulations and a muco-purulent secretions, which dry to form thick crusts.
Retracted scars form in place of the ulcers. Hyperkeratosis of the palms and soles and onychia are encountered
in rare cases. Metastasis to the lungs, bones, lymph nodes, and bone marrow is frequent. Affection of the
nervous system (meningitis, meningoencephalitis), pneumonia, and sepsis may cause death.
Histological examination reveals caseous necrosis of the dermis surrounded by a zone of reactive
inflammatory proliferation and granulation tissue.
It is difficult to distinguish the causative agent of European blastomycosis from Blastomyces dermatitidis
morphologically, though in contrast to the latter it does not form mycelium in the cultures. Serological reactions
(agglutination, precipitation, complement fixation) and allergic tests for cryptococcosis have no independent
diagnostic value.
The diagnosis of deep blastomycosis is based on the detection of the elements of the fungus in the foci
histologically, the isolation of the fungal culture and the corresponding clinical picture of the disease. The
serological reactions and skin tests are of auxiliary significance. Fever and pain in the bones and muscles may
aid in the diagnosis of deep blastomycosis of the type of Busse-Buschke disease.
The manifestations of Busse-Buschke disease are differentiated first of all with gummatous syphilids,
from which they are distinguished by the deeper-seated ulcers with soft, livid, dentate and undermined edges
and a granulating bleeding floor.
Differential diagnosis most frequently has to be made with chronic pyoderma vegetans whose clinical
picture may be very similar to that of deep blastomycoses. Iodine preparations have sometimes to be prescribed
in such cases; they cause exacerbation of a pyoder-mic process but have a favourable effect on the foci of deep
blastomycosis. Tuberculosis verrucosa is distinguished from American blastomycosis by the absence of multiple
foci, especially at the onset of the disease; it is rarely localized on the face and, besides, the vegetation is denser
and there is a characteristic dark-violet border on the periphery of the lesion. Sporotrichosis is characterized by
multiple foci of affection, their frequent localization on the upper limbs along the course of the lymphatics, a
lesser tendency to cicatrization and when the scars form, they are of an irregular shape and with a dentate and
pigmented periphery. In differential diagnosis with syphilitic gumma, the signs taken into consideration are the
deeper-seated infiltrate in the latter, the difference in the firmness of the edges and floor of the ulcer, the
presence of a gummatous necrotic core, the formation of a stellate retracted scar, positive blood Wassermann
reaction in some patients, and the Treponema pallidum immobilization test (TPIT) that is positive as a rule.
Treatment. Deep blastomycoses are treated with nystatin (5 000 000-7 000 000 U daily for three to four
weeks) or levorin (500 000 U tablets given four to six times a day). Long-term medication with large doses of
iodine preparations is indicated. Intravenous infusion of amphoiericin B (50 000 U in a 5 per cent glucose
solution two or three times a week, a total dose of 1 500 000-2 000 000 U) is effective. Broad-spectrum
antibiotics, sulphadimidine (4-6 g daily), specific vaccine therapy, phthivazid, diethylstilbestrol, hae-motherapy,
autohaemotherapy, vitamins, and pyretotherapy are also applied.
The indicated external agents are 1-2 per cent aqueous and alcohol solutions of aniline dyes, Lugol's
solution, Castellani's paint, levorin ointment, etc. Surgical treatment is sometimes undertaken.