Superficial and Cutaneous Mycoses

Outline of presentation
Objective General information about mycoses Superficial mycoses
Black piedra White piedra Tinea nigra Pityriasis

Cutaneous mycoses

Objective
At the end of this chapter, the student will be able to: List commonly known superficial and cutaneous mycoses
List the etiological agents, epidemiology, pathogenesis and clinical picture, and laboratory diagnostic techniques applied for these fungal infections.

Describe the laboratory diagnostic features to differentiate the etiological agent which causes superficial and cutaneous mycoses.

Mycoses
Dermatomycoses
Superficial mycoses Cutaneous mycoses Subcutaneous mycoses

Systemic mycoses
Primer systemic mycoses
Opportunistic mycoses
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Superficial mycoses
Development of fungal infection on epithelial tissue skin, hair nail without noticeable invasion of living tissue

Growth on human body may be coincidental

Mammalian body may be the natural habitat of fungus

Superficial infection
Black piedra White piedra Tinea nigra Pityriasis

Black piedra
Affecting hair primarily scalp
Etiology Piedraia hortae Dematiaceous filamentous fungus found in soil Particularly at humid tropical areas Classified in Ascomycetes

Characterized by formation of brown to black nodules that are very firmly attached to the hair shaft
Nodules can not be pulled out of the hair shaft

It is though to be a condition of poor hygiene

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Black piedra Contd

Microscopically
Septate hyphae, ascostromata, ascospores are visualized asci, and

Hyphae darkly pigmented

Cultures on routine mycology media

Colonies slow growing, small, folded, velvety and dark brown to black in color
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Black piedra Contd

Treatment
Hair cut and proper regular washing Topical salycylic acid, azole creams
Oral ketoconazole or terbinafine may also be used

Relapses may occur even after appropriate management of the infection with antifungal agents
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White piedra
Localized to the hair of groin and axillae or scalp
But may also be seen on facial hairs and sometimes
pubic hair Fungus surround the hair shaft and form a white to brown swelling along the hair Etiology Trichosporon spp (T. inkin, T. ashii, T.beigelii, T.mucoides)

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Etiology contd
Have multilamelar dolopores cell wall; develop

Hyphae elements have arthroconidia Classified in basidiomycetes

Form cubic or rectangular arthroconidia

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White piedra Contd

As an opportunistic fungal pathogen
Immunocompromised hosts

Frequent in tropical and temperate zone Common in young adults Clinical presentation
Asymptomatic fungal growth on the outside of the hair shaft
Soft, white to yellow nodules, loosely attached to the hair
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White piedra Contd

Macroscopic Features
Culture SDA (without cycloheximide)
Colonies yeast-like
Rapid growing, smooth,

Wrinkled, raised, folded,, waxy, white, or yellowish white to cream color

Microscopic Features
Abundant and well-developed pseudohyphae and hyphae Blastoconidia are unicellular and variable in shape Typical microscopic feature production of arthroconidia
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White piedra Contd

Treatment Shaving the hairs is the simplest method of treatment
Topical application of an imidazole agent may be used to prevent re-infection

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Tinea nigra
A superficial chronic infection of Stratum corneum
Usually occur on the palmar aspects of hands and occasionally the plantar and other surfaces of the skin

Etiology
Hortaea (Exophiala, phaeoannellomyces) werneckii Ascomycetes
A common saprophytic fungus believed to occur : In soil, compost, Humus and on wood in humid tropical and sub-tropical regions Dematiaceous fungi frequently branched septate .
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Tinea nigra contd

Distribution World-wide
More common in tropical regions of Central and South America, Africa, South-East Asia and Australia

Clinical manifestations

Skin lesions characterized by brown to black macules

Usually occur on the palmar aspects of hands and occasionally the plantar and other surfaces of the skin Lesions are non-inflammatory and non-scaling

Familial spread of infection has also been reported

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Tinea nigra contd

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Tinea nigra contd

Laboratory diagnosis Clinical Material: Skin scrapings Culture oatmeal agar: growth restricted smooth and slimy with an oily glistening black color On SDA colonies
Initially mucoid yeast like and shiny black
With age develop abundant aerial mycelia and become dark olivaceous in color
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Tinea nigra contd

Direct Microscopy
Skin scrapings should be examined using 10% KOH and Parker ink or calcofluor white mounts Dematiceous multibracnhed septate hyhae and budding yeast cells
Typical 2-celled, pale brown yeast cells, with prominent darkly pigmented septa, which act as annellided
Annelids may also arise from the hyphae Annelloconidia are 1to 2 celled cylinderical to spindle shaped hyaline To pale brown and usually occur in aggregate masses
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Calcofluor white Stain of skin scrapping

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Tinea nigra contd

Treatment
Topical therapy Whitefields ointment

Azole creams
Terbinafine

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Malassezia infections
Malassezia furfur
A dimorphic, lipophilic yeast Normally resident on human skin in the sebum-rich areas of the upper trunk and head

Pityriasis versicolor
A chronic, superficial fungal disease of the skin characterized by well-demarcated white, pink, fawn, or brownish Discrete serpentine hyper or hypo pigmented maculae
occur on the skin usually on chest, upper back, arm or abdomen
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Pityriasis versicolor Contd

Lesions, often coalescing, and covered with thin furfuraceous scales
The colour varies according to
The normal pigmentation of the patient Exposure of the area to sunlight, and the severity of the disease

Lesions occur on the trunk, shoulders and arms, rarely on the neck and face
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Pityriasis versicolor hyphopigmented

showing

hyperpigmented

and

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Pityriasis folliculitis Pityriasis folliculitis

Characterized by follicular papules and pustules Localized to the back, chest and upper arms, sometimes the neck, and more seldom the face

Itchy and often appear after sun exposure

Scrapings or biopsy specimens show numerous yeasts occluding the mouths of the infected follicules

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Malassezia infections contd

Seborrhoeic dermatitis and dandruff
Dandruff being the mildest manifestation Seborrhoeic dermatitis characterized by Rash consisting of yellow brown greasy scales, with a distinctive distribution over
The scalp, face, Interscapular and presternal areas

Clinical manifestations
Erythema and scaling in areas with a rich supply of sebaceous glands, the scalp, face, eyebrows
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Malassezia infections contd

Multifactorial host factors seborrhoeic dermatitis
Genetic predisposition

predispose

to

Emotional component (possible neurologically mediated factors)

endocrine

or

Changes in quantity and composition of sebum

Increase in alkalinity of skin (due to sweating)

External local factors such as occlusion
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Malassezia infections contd

Fungaemia
Causing catheter acquired in neonate and adult patients undergoing lipid replacement therapy Patients may also develop small embolic lesions in the lungs or other organs

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Malassezia infections contd

Diagnosis
Direct microscopic examination of scrapping of infected skin treated with 10-20% KOH Stain with Calcofluor white
Hematoxtline and Eosine (H&E) Period Acid Schiff (PAS)
PAS of skin scraping

Short unbranched hyphae and spherical cells are observed

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Malassezia yeasts microscopic examination

Growth of Malussezia yeast after 7 days of incubation at 32oC.

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Malassezia infections contd

Treatment
Topical azoles and selenium sulfide shampoo For widespread itraconazole infection oral Ketoconazole or

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Cutaneous mycoses

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Cutaneous mycoses
Affect superficial keratinized tissue (skin hair and nail) Dermatophytes important etiologic agent The disease referred deramatophytosis
A complex of disease caused by any of several species of taxonomically related filamentous fungus
Trichophyton,

Epidemophyton
Microsporum

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Cutaneous mycoses contd

Dermatophytes

Geophilic

Zoophilic
Anthrophilic

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Cutaneous mycoses contd

Disease process in dermatophytosis unique
Invaded the keratinised tissue (stratum corneum)

Ketatinophilic and ketatinolytic

Metabolic products usually induces an allergic and inflammatory eczematous response in the host Various forms of dermatophytes referred as tinea or ringworm

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Cutaneous mycoses contd

Tinea
Tinea capitis of scalp eyebrows and eyelashes

Tinea barbae of beard

Tinea corporis of the smooth or glabrous skin Tinea cruis of groin

Tinea pedis of the foot

Tinea unguium of the nails
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Ecology of Common Human Dermatophyte Species

Species Epidermophyton floccosum Trichophyton rubrum Natural habitat Humans Humans Incidence Common Very Common

Trichophyton interdigitale
Trichophyton tonsurans Trichophyton violaceum Trichophyton concentricum Trichophyton schoenleinii Trichophyton soudanense Microsporum audouinii Microsporum ferrugineum Trichophyton mentagrophytes Trichophyton equinum Trichophyton erinacei Trichophyton verrucosum Microsporum canis Microsporum gypseum Microsporum nanum Microsporum cookei

Humans
Humans Humans Humans Humans Humans Humans Humans Mice, rodents Horses Hedgehogs Cattle Cats Soil Soil/Pigs Soil

Very Common
Common Less Common Rare* Rare* Rare* Less Common* Less Common* Common Rare Rare* Rare Common Common Rare Rare

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Cutaneous mycoses contd

Dermatophytes infection begins in the skin after trauma and contact Susceptibility may be enhanced by moisture warmth

Factors

Chemistry of skin, Compostion of sebum Perspiration Heavy exposure Genetic predisposition

Higher in hot humid climate

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Cutaneous mycoses contd

Clinical manifestations

Affected by factors such as

The species of dermatophytes

The inoculum size

The size of infection The immune status

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Cutaneous mycoses contd

Tinea pedis (Athlelets Foot) Infection of the toe webs Vesicular ulcerative and moccasin types, with hypherkeratosis of the sole Infections by anthropophilic dermatophytes
Trichophyton rubrum, Trichophyton mentagrophytes, and Epidermophyton floccosum.

Caused by the shedding of skin scales containing viable infectious hyphal elements [arthroconidia] Transmission may take place by indirect contact
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Tinea pedis in toe foot pad

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Cutaneous mycoses contd

Tinea Manuum

Infection of the hands

Causative agent T. rubrum less common than tinea pedis Like tinea pedis
Presents with the classic pattern of erythema and mild scaling on the dorsal aspect of the hands or as a chronic, dry, scaly hyperkeratosis of the palms When the palms are infected, the feet are also commonly infected A typical pattern of involvement is either one hand and both feet or both hands and one foot.

Cutaneous mycoses contd

Tinea cruris
E. floccosum and T. rubrum

Dermatophytosis of
The proximal medial thighs, preum and buttocks Occurs more commonly in males

Due to spread of the fungus from the feet

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Cutaneous mycoses contd

Tinea unguium (dermatophyte onychomycosis) Etiology Trichophyton rubrum and T. interdigitale superficial white onychomycosis Invasive, subungual

Distal subungual onychomycosis the most common

Yellowish-white spots which slowly invade the ungula and then the nail plate

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Tinea of the nails caused by T. rubrum

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Cutaneous mycoses contd

Tinea barbae Trichophyton verrucosum
Rare infection Infection exclusively in males

Limited to the bearded

Develop without characteristic lesions Always with pruritus

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Cutaneous mycoses contd

Tinea corporis
Affect glabrous skin Anthrophophilic species

T. rubrum

T. tonsurans
T. verrucosum
Geophilic M. gypseum zoophilic species M. canis
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Cutaneous mycoses contd

Tinea capitis

Trichophyton and Microsporum

Most common in pediatric Dermatophytosis of the scalp Ectothrix Endothrix Favus hyphae without spores throughout hair length

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Cutaneous mycoses contd

Laboratory diagnosis
Microscopy
Direct mount,10% potassium hydroxide (10% KOH)

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Cutaneous mycoses contd Isolation and identification

Sabourauds dextrose agar containing cycloheximide (actidione) and antibiotics

incubated at 26-28oC 2-4 weeks

Identification of the species primarily on the conidia that produced

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Cutaneous mycoses contd

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Isolation and identification

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Cutaneous mycoses contd

Treatment and Management
Dependent on the clinical setting
Topical or systemic antifungal Agent Removal of infected and dead epithelial structure Surgical removal of the nail

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