180 Original article

Study of tinea corporis in patients attending the Dermatology

Clinic of Al-Hussein University Hospital, Cairo, Egypt
Fadia A. Sorour, Hamed M. Abdo and Mohamed A. Ebada

Department of Dermatology, Faculty of Medicine, Background

Al Azhar University, Cairo, Egypt
Correspondence to Hamed M. Abdo, MD, Department
of Dermatology, Faculty of Medicine, Al Azhar
University, 11633 Cairo, Egypt
Tel: + 20 106 633 9011; fax: + 20 (2)25104146;
e-mail: hamed392@yahoo.com
Received 16 November 2014
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The etiology of tinea corporis is varied and frequently changing.
Objective
The aim of the study was to detect the current prevailing fungi of tinea corporis among
patients in our locality.
Patients and methods
Skin scrapings were taken from 50 patients with circinate lesion(s) and examined by
direct microscopy and culture. One set of scrapings was mounted in 20% potassium

Accepted 27 March 2015 hydroxide solution and examined for the presence of fungal elements. The second set
Journal of the Egyptian Women’s Dermatologic was inoculated onto Sabouraud’s dextrose agar to identify the causative fungus.
Society 2015, 12:180–185 Results
Out of the 50 patients, 29 were males and 21 were females. Their ages ranged from 1
to 55 years (mean ± SD 19.34 ± 13.1 years). The duration of the disease ranged from
3 to 60 days (mean ± SD 15.96 ± 9.3 days). Direct microscopy was positive in 46
(92%) cases and mycological cultures in 45 (90%) cases. Trichophyton violaceum
was isolated in 17 (34%) patients, followed by Trichophyton rubrum (13 patients;
26%), Microsporum audouinii (five patients; 10%), Microsporum canis (four patients;
8%), Trichophyton verrucosum (four patients; 8%), and Trichophyton tonsurans in two
(4%) patients.
Conclusion
The isolated anthropophilic fungi outnumbered zoophilic ones as an etiological cause of tinea
corporis. T. violaceum and T. rubrum were the most common agents, followed by other fungi.

Keywords:
dermatophytes, Egypt, fungal culture, potassium hydroxide mount, tinea corporis

J Egypt Women Dermatol Soc 12:180–185

& 2015 Egyptian Women’s Dermatologic Society
1687-1537

species, as geoclimatic and social conditions interfere with

Introduction
Fungi are ubiquitous in nature and there is essentially no
part of our earth where fungi are not found. Of the
thousands of fungal species that are free-living in
nature, only a small group is known to be pathogenic
for humans and animals [1]. Superficial fungal infections
are among the world’s most common diseases, and
the prevalence of superficial mycotic infections has risen
to such a level that skin mycoses affect more than
20–25% of the world’s population [2]. Dermatophyte
infections are one of the earliest known fungal infections
of mankind and are very common throughout the
world [3].
The prevalence of dermatomycoses has been studied in
different parts of the world. The relative occurrence of
the etiologic agents of these infections varies from country
to country and from one climatic region to another [4].
Dermatophytosis is common in tropical countries and may
reach epidemic proportions in areas with a high rate of
humidity, overpopulation, and poor hygienic condi-
tions [5]. Generally, dermatophytes exhibit a cosmopoli-
tan problem; that is, they are found in different regions of
the world with variations in the frequency of particular
1687-1537 & 2015 Egyptian Women’s Dermatologic Society
the distribution of dermatophyte species [6].
The ringworm (tinea corporis) is the typical infection of the
exposed glabrous skin and can be caused by all known
dermatophytes, but the prevailing fungi in a particular region
are likely to be the most frequently found infective agents [7].
Mycological diagnosis of tinea corporis consists of a 10–20%
potassium hydroxide (KOH) preparation from skin scrapings,
and fungal culture on Sabouraud’s dextrose agar (SDA).
Examination of the infected scales from the leading edge of
the lesion may reveal septate hyphae coursing through the
squamas [8]. Cultures incubated at room temperature should
grow the causative organism within 2–4 weeks [9].
Knowledge of the zoophilic or anthropophilic origin of the
dermatophyte may allow setting up prophylactic mea-
sures such as treatment of cats, dogs, or pets whose
owners develop skin disease [10]. Also, knowledge of the
predominant causative species provides a clearer under-
standing of risk factors for superficial fungal infections
and future epidemiologic trends [11]. The purpose of
this work was to find out the predominant etiological
agent(s) of tinea corporis to detect and record the current
prevailing fungi of such condition in our area.
DOI: 10.1097/01.EWX.0000464890.25449.5e

Copyright r 2015 Egyptian Women’s Dermatologic Society. Unauthorized reproduction of this article is prohibited.

Patients and methods
Fifty patients with clinical diagnosis of tinea corporis were
randomly chosen to participate in the study after strict
inclusion and exclusion criteria. The study was approved
by the Al Azhar University Medical Ethics Committee,
and prior written informed consent was obtained from
every participant. For junior participants, consent was
taken from their parents/guardians. For every patient,
duplicate sets of skin scrapings were collected from the
lesions. One set of skin scrapings was examined by direct
microscopy and the other by culture. All cultures were
done on Petri dishes.
Direct microscopy
After cleaning the lesion with 70% alcohol, skin scales were
collected by scraping the affected site. The specimen was
placed on a clean glass slide, and a drop of 20% KOH/40%
dimethyl sulfoxide mixture was added (dimethyl sulfoxide
increases the sensitivity of the preparation and softens
keratin more quickly than KOH alone in the absence of
heat) [12]. A coverslip was applied with gentle pressure to
drain away excess solution. The sample was then examined
thoroughly for the presence of filamentous, septate,
branched hyphae with or without arthrospores.
Fungal culture
The second set of scrapings was inoculated onto two
types of SDA culture media: one with cycloheximide (to
suppress the growth of contaminant fungi) and the other
without cycloheximide. Chloramphenicol was added to
both culture media to prevent bacterial overgrowth. The
media were then incubated in a warm, moist environment
at 281C and examined regularly to detect growth of any
fungus. Observation for growth was done periodically up
to 4 weeks, after which the cultures were reported as
positive or negative.
Regarding the identification of dermatophytes, we relied
upon macromorphological and micromorphological char-
acters of the isolates. The fungi were identified by noting
their growth rate, colonial macroscopic morphology, and
microscopic structures. Macroscopic examination in-
cluded color, size, texture, and topography of the colony.
The microscopic structures of fungi usually provide
definitive identification [13]. Using the tease mount
technique, the following microscopic features were
looked for: the type, size, shape, and arrangement of
spores and the size, color, septation, and special shapes of
hyphae.
Results
Demographic and clinical findings
Out of the 50 patients with tinea corporis 29 (58%) were
male and 21 (42%) were female. Their ages ranged from 1
to 55 years (mean ± SD 19.34 ± 13.1 years). The duration
of the disease ranged from 3 to 60 days (mean ± SD
15.96 ± 9.3 days).
Forty-two (84%) cases had no family history of tinea
infection, whereas eight (16%) cases showed positive
Copyright r 2015 Egyptian Women’s Dermatologic Society. Unauthorized reproduction of this article is prohibited.
Study of tinea corporis Sorour et al. 181
history (five tinea circinata and three tinea capitis). Forty-
one (82%) patients did not suffer from any other form of
ringworm infection, whereas nine (18%) patients suffered
from other forms of tinea (four tinea cruris, two tinea
capitis, two tinea pedis, and one onychomycosis). Half of
the patients (50%) had no history of animal contact,
whereas 16 (32%) were in close contact with cats, five
(10%) with dogs, and four (8%) with sheep. Three
patients with Microsporum canis infection and one with
Trichophyton verrucosum had a history of contact with cats,
whereas only one case with M. canis infection was exposed
to a dog.
Regarding the site of the lesion, many patients showed
lesions on the extremities (24 cases; 48%), followed by
the face (12 cases; 24%), with the chest and trunk being
the least affected (six cases; 12% each). Only two (4%)
cases showed disseminated lesions.
The correlation between the mean duration of disease
and the isolated species showed that the longer disease
duration was associated with Trichophyton rubrum infection
(18.69 days), followed by T. verrucosum (17.5 days),
Trichophyton violaceum (16.17 days), Trichophyton tonsurans
(12 days), M. canis (11.25 days), and Microsporum audouinii
(10 days).
Mycological findings
Direct microscopy was positive in 46 of 50 (92%) cases,
whereas mycological culture showed positive result in 45
(90%) cases. Mycological culture has comparable sensi-
tivity to that of KOH mount (90 vs. 92%). All culture-
positive cases were also KOH positive. Only one case was
KOH positive but culture negative.
Microscopically positive KOH results were characterized
by the presence of long tubular branched septated
structures (hyphae) with or without arthroconidia.
Examination of the postculture mounts revealed T.
violaceum (Fig. 1a and b) in 17 (34%) patients followed
by T. rubrum (Fig. 2a and b) (13 patients; 26%), M.
audouinii (Fig. 3a and b) (five patients; 10%), M. canis
(four patients; 8%), T. verrucosum (four patients; 8%), and
T. tonsurans (two patients; 4%) (Table 1).
Although M. audouinii and M. canis may share some
macroscopic characters, the method we used for M.
audouinii identification depends mainly on microscopic
morphology. In all isolated cases, there were no macro-
conidia, but microconidia were occasionally seen. Chla-
mydoconidia were common and presented mostly as
terminal and intercalary. The terminal ones have char-
acteristic pointed appearance at the tip (finger-like
projection) (Fig. 3b). Racquet and pectinate (comb-like)
hyphae were also observed. The above-mentioned
features are consistent with M. audouinii.
Discussion
The epidemiology of most of the dermatophytic infec-
tions has substantially changed over the last years. Some
species are distributed worldwide, such as T. rubrum,
182 Journal of the Egyptian Women’s Dermatologic Society
Figure 1.
(a) Macroscopic morphology of Trichophyton violaceum: colonies are
glabrous, heaped, folded, and deep violet in color. (b) Microscopic
morphology of T. violaceum: hyphae are relatively broad, tortuous, much
branched, and distorted. No conidia are seen. Few chlamydoconidia are
present but these are usually numerous in older cultures. Water,  100.
Trichophyton mentagrophytes var. interdigitale, M. canis, and
Epidermophyton floccosum. Others have partial geographic
restriction, such as Trichophyton schoenleinii (Eurasia,
Africa), Trichophyton soudanense (Africa), T. violaceum (Africa,
Asia, and Europe), and Trichophyton concentricum (Pacific
Islands, Far East, and India) [11]. There are very few data on
superficial mycoses from our region. Therefore, the present
study was conducted to find out the predominant agents of
tinea corporis among 50 patients attending the Dermatology
Clinic, Al-Hussein University Hospital, Cairo, Egypt.
In the present work, although not significantly different,
men were more affected than women (58 vs. 42%).
Similar result was reported by Ibrahim et al. [14]. Also,
other reports showed a nonsignificant difference between
male and female patients as in Kuwait [15] and
Mexico [16]. Other studies showed greater prevalence
of infection in the female population [6,17]. The reason
for these variations is not fully understood, but it may
indicate that sex has an influence on susceptibility to
particular forms of tinea. The acquisition of fungi may be
due to varied forms of outdoor/indoor exposure of male
Copyright r 2015 Egyptian Women’s Dermatologic Society. Unauthorized reproduction of this article is prohibited.
Figure 2.
(a) Macroscopic morphology of Trichophyton rubrum: colonies are flat
to slightly raised, white to cream, suede-like to downy. (b) Microscopic
morphology of T. rubrum: typical smooth thin-walled cigar-shaped
septate macroconidia of T. rubrum (granular type). Water,  100.
and female individuals to pathogenic fungi. Despite a
history of animal exposure in 40% of patients, the
majority of isolated organisms were anthropophilic
species. This may denote that fungal infectivity is diverse
and heterogenous.
Of the studied patients, 41 (82%) did not suffer from any
other type of tinea. The remaining nine had other
associated forms of tinea, including tinea cruris in four
(8%) cases, tinea capitis in two (4%) cases, tinea pedis in
two (4%) cases, and onychomycosis in one (2%) case.
Some similarity is noticeable in the study conducted in
Rome by Panasiti et al. [18], in which tinea corporis, the
prevalent dermatophytosis, was followed in frequency by
tinea cruris and tinea capitis. Corporal tinea may result
from or contribute to other forms of ringworm infections.
In this study, 48% of patients had skin lesions on the
extremities, 24% on the face, 12% on both the neck and
trunk, whereas 4% had disseminated disease. This result is
in accordance with the result obtained by Nejad et al. [19],
who detected that patients had tinea corporis lesions on the
upper limbs (33%), lower limbs (27%), head (13%), face
 Study of tinea corporis Sorour et al. 183

Figure 3. (13%), trunk (9%), groin (9%), neck (3%), and nail (1%) in a
descending manner. The most involved areas affected by
tinea corporis are usually related to the site of maximum
exposure to sources of infection, such as the extremities and
face, whereas the least involved sites such as the neck and
trunk are somewhat more hidden and protected.
Of the 45 isolates, T. violaceum was recovered in 17 cases
followed by T. rubrum in 13 cases. This result is similar to
that of Ellabib et al. [20], who isolated T. violaceum and T.
rubrum as important causes of tinea corporis in Libya.
Epidemiological studies carried out in Egypt reported
high isolation rate of T. violaceum. Zaki et al. [21] reported
that the most frequently isolated dermatophyte species
was T. violaceum (71.1% of all recovered dermatophytes).
Amer et al. [22] demonstrated that T. violaceum was the
most commonly isolated pathogen (44%) in cases of
dermatophytosis in Al Sharkia Governorate. Also agreeing
with this study, Ansari and Siddiqui [23] in their
epidemiological study reported that T. violaceum was the
most prevalent organism, isolated in 41% of cases.
The increasing incidence of T. violaceum as a major cause
of tinea corporis in Egypt is probably because the fungus
is indigenous to North Africa [20]. T. violaceum has been
reported as the most common etiologic agent causing
dermatophytosis in Egypt [24]. Abdo et al. [25] and Azab
et al. [26] reported that T. violaceum was the chief isolate
from scalp infection (eight out of 35 and 21 out of 33,
respectively). Azab et al. [26] also isolated it from tinea
corporis lesions (three out of 33). In Egypt, large family
sizes, close familial contact, and sharing of personal items
such as hairbrushes, hats, and towels are common. This,
in addition to overpopulation, hot humid atmosphere, and
(a) Macroscopic morphology of Microsporum audouinii: colonies are
flat, spreading, grayish-white to light tan-white in color, and have a increased environmental exposure to fungi, may be
dense suede-like surface, which show some radial grooves. (b) responsible for the predominance of certain dermato-
Microscopic morphology of M. audouinii: typical terminal chlamydoco- phytes causing tinea infections. Dispersal of fungi from
nidia are often present, which have short, finger-like projections
showing a pointed appearance at the tip. Most cultures are sterile the patient’s scalp or foot lesions to the trunk and limbs
and macroconidia and microconidia are only rarely produced. Water, or from sharing of nonpersonal objects can also occur.
 200.
In contrast, Bhavsar Hitendra et al. [27] isolated T. rubrum as
the main dermatophyte (55.26%) from tinea corporis and
tinea cruris cases, followed by T. mentagrophytes (27.63%).
Table 1. Results of potassium hydroxide test and fungal culture They failed to isolate any T. violaceum from skin lesions.
n (%) Other studies also revealed that T. rubrum was the main
KOH test (n = 50) dermatophyte isolated from ringworm lesions, particularly
Result tinea corporis [5,28,29]. This difference in dermatophyte
Positive cases 46 (92) isolation could be explained by different samples of the
Negative cases 4 (8)
Total 50 (100) study population and again emphasizes the role of different
Fungal culture (n = 50) environmental conditions and degree of exposure to the
Result pathogens. The predominance of certain dermatophytes
Positive cases 45 (90)
Negative cases 5 (10) varies geographically depending on ethnicity and different
Total 50 (100) environmental factors such as climate, humidity, occupa-
Isolated fungi (n = 45) tion, and different lifestyles.
Isolated dermatophytes
Trichophyton violaceum 17 (34) On comparing the two methods of fungal detection, the
Trichophyton rubrum 13 (26)
Microsporum audouinii 5 (10) KOH test was found to be positive in 46 (92%) cases,
Microsporum canis 4 (8) whereas culture was positive in 45 (90%) cases, showing
Trichophyton verrucosum 4 (8) nearly similar sensitivity. This finding concurred with that
Trichophyton tonsurans 2 (4)
Total positive 45 (90) of Asticcioli et al. [30], who reported that the KOH test
No growth 5 (10) and fungal culture positivity was 96.9 and 100%,
Total 50 (100) respectively. In the literature, KOH versus fungal culture
KOH, potassium hydroxide. sensitivity has conflicting results. Abdelal et al. [31]

Copyright r 2015 Egyptian Women’s Dermatologic Society. Unauthorized reproduction of this article is prohibited.
184 Journal of the Egyptian Women’s Dermatologic Society
reported that KOH preparation has better sensitivity than
culture (67 vs. 46%). Abdo et al. [25], Bhavsar Hitendra
et al. [27], Patel et al. [28], Shenoy et al. [32], Ali et al. [33],
and Nawal et al. [34] also reported higher KOH sensitivity
(85.70 vs. 60.00%, 68.16 vs. 20.15%, 62.12 vs. 29.29%,
53.00 vs. 35.00%, 65.50 vs. 50.00%, and 72.40 vs. 62.80%,
respectively). These results thus document that mycolo-
gical culture is less sensitive than KOH mount; however,
the latter is unable to identify and isolate the causative
dermatophytes. On the other side, high culture positivity
was depicted in studies showing culture as the better
method of detection of fungi from clinical samples. Sen
and Rasul [35] showed that out of 100 samples 49 (49%)
were positive by direct KOH examination, whereas
culture was positive in 51 (51%) cases. Ansari et al. [36]
reported positive KOH mount in 34 (68%) samples,
whereas fungal culture was positive in 37 (74%) of the 50
samples tested.
In this study, only one (2%) case was KOH positive but
culture negative. Conversely, Asticcioli et al. [30] isolated
3.1% of dermatophytes from skin scrapings that were
negative for fungal filaments on KOH examination. They
explained this by the probability that fungal elements
were few and were missed in the observation. In any
study, the high percentage of positivity of either method
depends mainly on strict criteria of patient selection,
good sample collection and processing, and the profes-
sional experience of the investigators.
In our opinion, cultures can be false negative for several
factors: (i) fungi may be present in the specimen but not
viable, or because only a small specimen was taken; (ii) if
the fungi were alive in the tissue, they may have died
during sample transportation, processing, or culturing;
(iii) the patient may have already had some form of
antifungal treatment; and (iv) cycloheximide can some-
times inhibit the growth of some fungi. Therefore, in the
presence of lesions suspected to be mycotic, it is useful to
perform direct microscopic examination besides culture
to aid the diagnosis. In this situation, if there is a positive
direct KOH test and a negative culture, there are two
explanations: (i) the KOH test may be falsely interpreted
as positive (e.g. due to artifacts), whereas culture is true
negative; alternatively (ii) the direct microscopy may be
truly positive and the culture falsely negative.
We were able to isolate both anthropophilic (T. violaceum,
T. rubrum, T. tonsurans, and M. audouinii) and zoophilic
fungi (M. canis and T. verrucosum) from patients living in
an urban area, which could be explained by the process of
immigration and traveling from rural to urban regions and
vice versa. Zoophilic species are pathogens of animals that
known to produce more inflammatory lesions; however;
these species were isolated in this study, unexpectedly,
from less inflammatory lesions. Therefore, one must keep
in mind that zoophilic fungi can produce both types of
lesions. As M. audouinii is usually not identified or is rare
to be isolated from dermatophytosis in Egypt, especially
from tinea corporis, the isolation of M. audouinii in 10% of
cases is very interesting. In line with, but dispropor-
tionate to, our result, it has been claimed by Ibrahim
Copyright r 2015 Egyptian Women’s Dermatologic Society. Unauthorized reproduction of this article is prohibited.
et al. [14] that the isolation rate of M. audouinii was 46.42%
(13 out of 28 isolates from different clinical types of
dermatophytosis). Their result, however, is questionable.
The isolation of M. audouinii in Egypt could be explained
by the fact that, because of its anthropophilic nature, the
fungus is accessible to the general population who was
exposed to it during their routine living conditions. This
is particularly enhanced by the increased national and
international immigration.
Although the dysgonic strains of M. canis are rare,
sometimes it is necessary to differentiate them from M.
audouinii. Dysgonic M. canis colonies are typically heaped
and folded and yellow-brown in color, whereas those of M.
audouinii (on SDA) are flat, spreading, grayish-white to
light tan-white in color, and have a dense suede-like to
downy surface, which may show some radial grooves
(Fig. 3a). Similar to M. audouinii, macroconidia are usually
absent in these strains. However, typical colonies and
macroconidia of M. canis are usually produced by this
variant when subcultured onto polished rice grains [37].
The poor growth of M. audouinii on rice grains serves to
distinguish the species from M. canis. Also, M. audouinii
does not perforate hair, whereas M. canis does [38].
In conclusion, the isolated anthropophilic dermatophytes
outnumbered zoophilic agents as a cause of tinea corporis
in our locality. T. violaceum was the most common
etiological agent responsible for 34% of the cases.
Although this finding matches with many studies, it
differs significantly from others. We recommend further
nation-wide epidemiological research highlighting the
socioeconomic factors attributed to the prevalence of
superficial fungal infections to find out in more detail the
species responsible for such infections.
Acknowledgements
Conflicts of interest
There are no conflicts of interest.
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