Adult Cutaneous Fungal

Infections
Medical Student Core Curriculum
in Dermatology

Last updated May 23, 2011

Module Instructions
The following module contains a number
of blue, underlined terms which are
hyperlinked to the dermatology glossary,
an illustrated interactive guide to clinical
dermatology and dermatopathology.
We encourage the learner to read all the
hyperlinked information.
2

Goals and Objectives

The purpose of this module is to help medical students
develop a clinical approach to the evaluation and initial
management of patients presenting with cutaneous fungal
infections.
By completing this module, the learner will be able to:
Identify and describe the morphologies of superficial fungal infections
Describe the correct procedure for performing a KOH examination
and interpreting the results
Recognize the use and limitations of KOH examination and fungal
cultures to diagnose fungal infections
Recommend an initial treatment plan for an adult with tinea pedis,
tinea versicolor, candidal intertrigo, and seborrheic dermatitis
3

Superficial Fungal Infections:

The Basics
Dermatophytoses are estimated to affect 20-25% of people
worldwide, making them one of the most common infections.
Superficial cutaneous fungal infections are limited to the
epidermis, as opposed to systemic fungal infections (e.g.
endemic mycoses and opportunistic infections).
Three groups of cutaneous fungi cause superficial infections:
dermatophytes, Malassezia spp., and Candida spp.
Dermatophytes (which include Trichophyton spp., Microsporum
spp., and Epidermophyton spp.) infect keratinized tissues: the
stratum corneum (outermost epidermal layer), the nail or the hair.
The term tinea is used for dermatophytoses and is modified
according to the anatomic site of infection, e.g. tinea pedis
4

Case One
Mr. Eugene Brown

Case One: History

HPI: Eugene Brown is a 62-year-old healthy man who
presents to his primary care physician with a one-year
history of itching and burning of his feet.
PMH: no chronic illnesses or prior hospitalizations
Medications: none
Allergies: no known allergies
Family history: noncontributory
Social history: lives with wife, works as a banker
Health-related behaviors: reports no alcohol, tobacco or
drug use
ROS: increased nocturia, otherwise negative
6

Case One: Skin Exam

How would you

describe these exam
findings?

Case One: Skin Exam

Erythema and scaling

are present on the
plantar surface and
between the toes

Case One, Question 1

Which of the following is Mr. Browns most
likely diagnosis?
a.
b.
c.
d.
e.

Atopic dermatitis
Candidal intertrigo
Onychomycosis
Psoriasis
Tinea pedis
9

Case One, Question 1

Answer: e
Which of the following is Mr. Browns most likely
diagnosis?
a. Atopic dermatitis (Characterized by red patches and plaques
scale. Lichenification may also result)
b. Candida intertrigo (Erythematous, eroded areas with satellite
papules. Less likely location)
c. Onychomycosis (Fungal infection of the nail)
d. Psoriasis (The interdigital and plantar surfaces of the toes are
unusual locations for psoriasis. Would expect a well-demarcated
plaque with a thick silvery scale)
e. Tinea Pedis

10

Tinea Pedis: The Basics

Tinea pedis (athletes foot) is the most common fungal
infection seen in developed countries, and is most
commonly caused by the fungus Trichophyton rubrum
Shoes provide an ideal environment for fungus to grow
due to moisture
Public showers, gyms, and swimming pools are common
sources of infection
It is difficult to permanently cure and may often recur
There are three clinical patterns of infection: interdigital,
moccasin, and vesiculobullous type
11

Tinea Pedis: Interdigital Type

Most common, presents

with scaling and
redness between the
toes and may have
associated maceration.

12

Tinea Pedis: Moccasin Type

Also known as chronic
hyperkeratotic type.
Sharply marginated scale,
distributed along lateral
borders of feet, heels, and
soles.
At times, vesicles and
erythema are present at the
margins.
Often associated with
onychomycosis (nail fungal
infection).

13

Tinea Pedis: Moccasin Type

Moccasin type may present as
one hand, two feet syndrome.
Affected hand shows unilateral
fine scaling, particularly in the
creases (see below), and nails
are often involved.

14

Tinea Pedis: Vesiculobullous Type

Grouped, 2-3 mm
vesicles or bullae are
seen, often on the arch
or instep. They may be
itchy or painful.
Vesiculobullous type
tinea pedis represents a
delayed hypersensitivity
immune response to a
dermatophyte.
15

Back to Case One

Eugene Brown

16

Case One, Question 2

Which of the following is the most appropriate
next step in diagnosis?
a.
b.
c.
d.

Begin empiric treatment with antifungals.

KOH exam
Skin biopsy
Woods light

17

Case One, Question 2

Answer: b
Which of the following is the most appropriate next
step in diagnosis?
a. Begin empiric treatment with antifungals (First need a
diagnosis. There are many scaly eruptions that can
occur on the foot)
b. KOH exam
c. Skin biopsy (This is too invasive when a simpler test is
available)
d. Woods light (Organisms will not fluoresce on woods
light)
18

Case One: KOH Exam

What are the diagnostic features in this KOH exam?

Magnification 40x
19

Case One: KOH Exam

What are the diagnostic features in this KOH exam?
Parallel walls
throughout the
entire length
Septated and
branching
hyphae
Magnification 40x
20

KOH Exam: Basic Facts

KOH microscopy is the easiest and most cost
effective method used to diagnose fungal
infections of the hair, skin, and nail.
Proper technique requires training.
Sensitivity is dependent on the operators
experience.
KOH dissolves keratinocytes to allow easy viewing
of hyphae.
Heat is used to accelerate this reaction.
21

The KOH Exam Procedure

1. Clean and moisten skin with
alcohol swab
2. Collect scale with #15 scalpel
blade
3. Put scale on center of glass
slide
4. Add drop of KOH and
coverslip; heat slide gently with
flame to adequately dissolve
keratin
5. Microscopy: scan at 10X to
locate hyphae; then study in
detail at 40X if needed

Click here to watch the video

Make sure to turn on your computer volume
(video length 8min 41sec)

22

Case One, Question 3

Which of the following are possible pitfalls
of KOH prep?
a. False negative KOH due to prior partial
treatment with antifungals
b. Misidentification of clothing fibers or lint as
hyphae
c. Possibility of mistaking lipid or cell membranes
for hyphae
d. All of the above are limitations
23

Case One, Question 3

Answer: d
Which of the following are possible pitfalls of KOH prep?
a. False negative KOH due to prior partial treatment with
antifungals
b. Misidentification of clothing fibers or lint as hyphae (clothing
fibers or lint are tapered, while hyphae have parallel walls
throughout)
c. Possibility of mistaking lipid or cell membranes for hyphae
(hyphae have parallel walls throughout and tend to be longer)
d. All of the above are limitations
24

Treatment of Tinea Pedis: Hygiene

For all types of tinea pedis, hygiene and
topical antifungals are effective first-line
therapies
Hygiene:

Dry the area after bathing

Change socks daily and alternate shoes worn
Consider wearing open shoes such as sandals
Use foot powder (available over the counter) to
keep feet dry
25

Topical Antifungals
There are several classes of topical antifungal
medications
Some classes are fungistatic (stop fungi from
growing), others are fungicidal (they kill fungi)
Not all conditions are treatable with topical
antifungals (specifically, hair infections and nail
infections do not respond to topical treatment
and require systemic treatment)
26

Treatment of Tinea Pedis: Topical

Topical antifungals: apply until tinea shows resolution,
then continue treatment for a minimum of two weeks
Imidazoles: Fungistatic
Examples: clotrimazole, miconazole, sulconazole,
oxiconazole, ketoconazole (least activity against
dermatophytes)

Allylamines: Fungicidal
Examples: terbinafine, butenafine, naftifine

Ciclopirox: Fungicidal and fungistatic

Example: Ciclopirox olamine
27

Treatment of Tinea Pedis By Type

Interdigital:
Topical imidazoles, ciclopirox olamine, and allylamines

Plantar Moccasin/Chronic Hyperkeratotic:

Topical allylamines and imidazoles
Keratolytics are also useful: e.g. salicylic acid, benzoic acid
(Whitfields ointment)*, urea, and lactic acid
Vesiculobullous:
Compresses in conjunction with antifungal agents
May require an oral agent such as terbinafine or itraconazole
* Whitfields

ointment is a combination of salicylic and benzoic acid. In US can be

bought through online pharmacies or compounded.
28

Case One, Question 5

Which of the following are common
complications of tinea pedis? You may choose
more than one answer.
a.
b.
c.
d.
e.

Deep vein thrombosis

Furunculosis of the lower leg
Lower leg cellulitis
Peripheral neuropathy
Tinea corporis
29

Case One, Question 5

Answer: c & e
Which of the following are common complications of
tinea pedis?
a. Deep vein thrombosis
b. Furunculosis of the lower leg
c. Lower leg cellulitis (the most common risk factor for
lower leg cellulitis in immunocompetent non-diabetics is
tinea pedis, which creates a portal of entry for bacteria)
d. Peripheral neuropathy
e. Tinea corporis (from autoinoculation)
30

30

Onychomycosis
Another complication of tinea
pedis is onychomycosis, a
chronic fungal infection of the
nailbed that tends to spread to
other nails.
Responds very poorly to topical
antifungals
First line treatments are oral
terbinafine or itraconazole
31

Onychomycosis
Identification of fungus in the affected nail (at
minimum a positive KOH prep or nail biopsy) is
necessary before treatment, for several reasons:
May mimic other conditions (e.g. psoriasis, lichen
planus)
Treatment is expensive, of long duration, and with
potential side effects
Oral antifungals also have drug-drug interactions

32

Case Two
Mr. Daniel Green

33

Case Two: History

HPI: Daniel Green is a healthy 18-year-old who presents
with a lesion on his right leg that has been present for 2
weeks. The lesion is itchy and is growing in size.
PMH: no major illnesses or hospitalizations
Medications: none
Allergies: none
Family history: noncontributory
Social history: Lives with his parents and sister. The family
adopted a puppy 3 months ago. No history of recent travel.
Health-related behaviors: no tobacco, alcohol or drug use.
34

Case Two: Skin Exam

How would you describe

these exam findings?

35

Case Two: Skin Exam

This is a sharply
marginated, erythematous
annular lesion with central
clearing and raised
papulovesicular border with
scaling.

36

Case Two, Question 1

Which of the following is the most
appropriate next step in diagnosis?
a.
b.
c.
d.

Biopsy
KOH exam
Woods light exam
All of the above

37

Case Two, Question 1

Answer: b
Which of the following is the most appropriate
next step in diagnosis?
a.
b.
c.
d.

Biopsy
KOH exam
Woods light exam
All of the above
38

Case Two, Question 2

Which of the following is the most likely
diagnosis?
a.
b.
c.
d.
e.

Atopic dermatitis
Psoriasis
Seborrheic dermatitis
Tinea corporis
Tinea cruris
39

Case Two, Question 2

Answer: d
Which of the following is the most likely diagnosis?
a. Atopic dermatitis (Poorly defined erythematous
patches without central clearing)
b. Psoriasis (Well-demarcated erythematous plaques
with silvery scale)
c. Seborrheic dermatitis (Inflammatory reaction to yeast
typically affecting face, chest, and/or scalp, often with
scaling)
d. Tinea corporis
e. Tinea cruris (Dermatophyte infection in the groin)
40

Tinea Corporis
Tinea corporis, ringworm, refers to dermatophytosis
of the skin, usually affecting the trunk and limbs

Affects all age groups

Most prominent symptom is itching
Asymmetric distribution
The margin of the lesion is the most active; central
area tends to heal
Scrapings should be taken from the red scaly margin
for KOH exam
A variant of this is tinea cruris or jock itch, which has
a similar presentation but appears in the groin

41

Tinea Corporis

Annular lesion
with central
clearing is typical
of tinea corporis

42

Why Perform A Fungal Culture?

Cultures identify the specific species of fungi
causing the infection
As opposed to tinea pedis, tinea corporis is caused
by different fungal species with different
environmental sources
Animals (cats/dogs), tinea capitis, tinea pedis

Using a fungal culture to identify the species will

help identify the source and guide treatment
Even if the KOH prep is negative, a culture may be
positive
43

Tinea Corporis: Treatment

Begin with topical treatment
Topical antifungals are applied until tinea shows
resolution, then continue treatment for a minimum of two
weeks
Imidazoles (fungistatic)
Allylamines (fungicidal)
Ciclopirox (fungicidal and fungistatic)

Oral antifungals are indicated in the following situations:

If there is a poor response to topical agents
If an animal is the source of infection
If eruptions involve a large surface area

44

Case Three
Ms. Anna Jones

45

Case Three: History

HPI: Ms. Jones is a 27-year-old woman who presents with
mild itchiness of her back which began mid summer. She is
also concerned about areas on her back that do not tan.
PMH: asthma
Medications: occasional multivitamin
Allergies: no known drug allergies
Social history: spends her summer months in Florida. Is an
avid runner.
Health-related behaviors: occasional glass of wine 1-2 times
per month, no tobacco or drug use
ROS: negative
46

Case Three: Skin Exam

How would you describe

these exam findings?

47

Case Three: Skin Exam

Well-demarcated, pink
and tan, macules and
patches, across the
back.

48

Case Three, Question 1

Which of the following is the most likely
diagnosis?
a.
b.
c.
d.
e.

Pityriasis alba
Seborrheic dermatitis
Tinea corporis
Tinea versicolor
Vitiligo

49

Case Three, Question 1

Answer: d
Which of the following is the most likely diagnosis?
a. Pityriasis alba (noninfectious, asymptomatic poorlydefined areas of hypopigmentation; self-limited)
b. Seborrheic dermatitis (abnormal immune response to
normal skin yeast causing scaling and crusting)
c. Tinea corporis (fungal skin infection, presents as
erythematous annular lesions with central clearing)
d. Tinea versicolor
e. Vitiligo (autoimmune loss/dysfunction of melanocytes
causing areas of complete depigmentation)
50

Diagnosis: Tinea Versicolor

Tinea versicolor (aka Pityriasis versicolor) is
not a dermatophytosis
It is an infection caused by species of
Malassezia, a lipophilic yeast that is a normal
resident in the keratin of the skin and hair
follicles of individuals at puberty and beyond
Tends to recur annually in the summer months
51

Tinea Versicolor
Characterized by well-demarcated, tan, salmon, or
hypopigmented patches, occurring most commonly
on the trunk (facial involvement is rare)
Macules will grow, coalesce and various shapes and
sizes are attained in an asymmetric distribution
Visible scale is not often present, but when rubbed
with a finger or scalpel blade, scale is readily seen
This is a diagnostic feature of tinea versicolor
Evoked scale will disappear after treatment
52

52

A Closer Look at Tinea Versicolor

53

Case Three, Question 2

Which of the following is the most
appropriate next step in management?
a.
b.
c.
d.

Fungal culture
KOH exam
Skin biopsy
Woods light exam

54

Case Three, Question 2

Answer: b
Which of the following is the most appropriate
next step in management?
a. Fungal culture (Malassezia spp. are easily identified
by a KOH exam but are not easily cultured)
b. KOH exam
c. Skin biopsy
d. Woods light exam
55

Microscopy
Spores (yeast forms)

Short
Hyphae

The KOH exam shows short hyphae and small round spores.
Characteristic spaghetti and meatball pattern.
56

Microscopy with dye added to the

specimen

Magnification 40x

Characteristic spaghetti and meatball pattern corresponding to

hyphae and spores.
57

Tinea Versicolor: Morphology

Its called versicolor because it can be light, dark, or
pink to tan.
In untanned Caucasians, the lesions may be salmoncolored or brown.
In tanned Caucasians, the lesions may appear pale in
comparison to the surrounding skin.
In darker skinned individuals, lesions may appear hyper- or
hypopigmented.

Lets look at some examples of the various colors of

tinea versicolor.
58

Tinea Versicolor: lighter

59

Tinea Versicolor: darker

60

Tinea Versicolor: pink or tan

61

Case Three, Question 3

Which of the following treatments would
you recommend for Ms. Jones?
a.
b.
c.
d.

Antifungal shampoo
Ketoconazole cream
Nystatin cream
Oral terbinafine

62

Case Three, Question 3

Answer: a
Which of the following treatments would you
recommend for Ms. Jones?
a. Antifungal shampoo
b. Ketoconazole cream (effective for limited
areas, but not widespread infections)
c. Nystatin cream (not effective)
d. Oral terbinafine (in contrast to topical
terbinafine, oral terbinafine is not effective)
63

Case Three, Question 4

What is true about treatment of tinea
versicolor?
a. Normal pigmentation should return within a
week of treatment
b. Oral azoles should be used in most cases
c. When using shampoos as body wash, leave
on for ten minutes before rinsing
64

Case Three, Question 4

Answer: c
What is true about treatment of tinea versicolor?
a. Normal pigmentation should return within a week
of treatment (usually takes weeks to months to
return to normal)
b. Oral azoles should be used in most cases (mild
cases can be treated with topicals)
c. When using shampoos as body wash, leave
on for ten minutes before rinsing
65

Tinea Versicolor: Topical Treatment

Shampoos: selenium sulfide 2% shampoo,
ketoconazole shampoo, pyrithione zinc shampoo
Apply daily to affected areas, lather, and rinse
Spreads easily to cover larger areas

Azole creams: ketoconazole, econazole, miconazole,

clotrimazole
Apply daily or bid for 2 weeks
Can be effective for limited areas, but infections tend to be
widespread, so local topical treatment associated with high
relapse rate
More expensive than shampoos
66

Tinea Versicolor: Oral treatment

Oral medication should be used when a large area is
involved.
Oral medications of choice include:
Ketoconazole
Fluconazole
Itraconazole

Ketoconazole can be given as a one-time dose.

Take on an empty stomach, exercise until perspiring
(medication is delivered via sweat), and avoid shower
six hours after taking medication.
67

Tinea Versicolor:
Maintenance Therapy
Many patients relapse
If the patient has had more than one previous
episode then recommend maintenance therapy
Maintenance therapy: topicals are used 1-2x/week

Ketoconazole shampoo
Selenium sulfide (2.5%) lotion or shampoo
Salicylic acid/sulfur bar
Pyrithione zinc (bar or shampoo)

Refer patients who fail maintenance therapy to

dermatology
68

Case Four
Ms. Betty Raskin

69

Case Four: History

HPI: Ms. Raskin is a 62-year-old woman who presents
with a red itchy rash beneath her breasts
PMH: Type 2 diabetes (last hemoglobin A1c 9.2%),
obesity
Medications: Metformin, which she says she often does
not remember to take
Family history: noncontributory
Social history: lives in Texas part-time
Health-related behaviors: no tobacco, alcohol or drug use
ROS: negative
70

Case Four, Question 1

Which of the following best describe these
characteristic exam findings?
a. Well-demarcated red
plaques with overlying
thick silvery scale
b. Grouped vesicles on an
erythematous base
c. Sharply defined red
plaques involving the skin
folds with surrounding
satellite papules
d. Inflammatory nodules

71

Case Four, Question 1

Answer: c
Which of the following best describe these characteristic
exam findings?
a. Well-demarcated red plaques
with overlying thick silvery
scale
b. Grouped vesicles on an
erythematous base
c. Sharply defined red
plaques involving the skin
folds with surrounding
satellite papules
d. Inflammatory nodules
72

72

Case Four, Question 2

Which of the following is the most likely
diagnosis?
a.
b.
c.
d.
e.

Atopic dermatitis
Candidal intertrigo
Psoriasis
Seborrheic dermatitis
Tinea cruris

73

Case Four, Question 2

Answer: b
Which of the following is the most likely diagnosis?
a. Atopic dermatitis (chronic eruption of pruritic, erythematous, oozing
papules and plaques, usually with secondary lichenification and
excoriation)
b. Candidal intertrigo
c. Psoriasis (characterized by well-demarcated, erythematous
papules and plaques with overlying silvery scale)
d. Seborrheic dermatitis (typical skin findings range from fine white
scale to erythematous patches and plaques with greasy, yellowish
scale)
e. Tinea cruris (dermatophytosis of the groin, genitalia, pubic area,
perineal, and perianal skin, usually appears as multiple
erythematous papulovesicles with a well-marginated, raised
74
border)

Candidal Intertrigo: Basic Facts

Candidal intertrigo = candidiasis of large skin folds
May arise in the following areas:

Groin or armpits
Between the buttocks
Under large pendulous breasts
Under overhanging abdominal folds

KOH exam reveals pseudohyphae

Burns more than itches
75

Case Four, Question 3

Which of the following factors predispose to
candidal intertrigo?
a.
b.
c.
d.
e.

Diabetes mellitus
Hot, humid weather
Limited mobility
Obesity
All of the above
76

Case Four, Question 3

Answer: e
Which of the following factors predispose to
candidal intertrigo?
a.
b.
c.
d.
e.

Diabetes mellitus
Hot, humid weather
Limited mobility
Obesity
All of the above
77

77

Case Four, Question 4

Which of the following is the most
appropriate next step in management?
a. Barrier creams or ointments (e.g.
petroleum jelly, zinc oxide paste, etc.)
b. Nystatin ointment
c. Oral antifungal agent
d. Oral glucocorticoid

78

Case Four, Question 4

Answer: b
Which of the following is the most appropriate
next step in management?
a. Barrier creams or ointments (useful as
adjunct/preventive therapy, but does not eradicate
candida)
b. Nystatin ointment (useful for candida, ointment
base prevents maceration in moist areas)
c. Oral antifungal agent (usually can be treated with
topical agent)
d. Oral glucocorticoid (may worsen the infection)
79

79

Candidal Intertrigo: Management

Topical antifungal agents
Polyenes and Imidazoles: nystatin, miconazole,
clotrimazole, or econazole
Allylamines are not used to treat candida

Prevention
Keep intertriginous areas dry, clean, and cool
Encourage weight loss for obese patients
Washing with benzoyl peroxide bar may reduce
Candida colonization
80

Candidal Intertrigo: Management

Topical anti-inflammatory
Low strength glucocorticoid preparations
rapidly improves the itching and burning, but
should be stopped after one week

Systemic antifungal agents (used for

infections resistant to topical treatment)
Oral fluconazole, itraconazole, or ketoconazole

81

Take Home Points

Cutaneous fungal infections are extremely common.
There are three clinical patterns of tinea pedis infection:
interdigital, moccasin, and vesiculobullous type.
If it scales, scrape it! KOH examination is the easiest and
most cost effective method used to diagnose fungal infections
of the hair, skin, and nails.
Fungal culture is important because it may be positive when
KOH prep is negative, and is the only easily available method
to definitively identify the organism.
Culture is especially helpful in tinea corporis when the source
of infection is not obvious (as opposed to tinea pedis).
82

Take Home Points

Tinea versicolor is characterized by well-demarcated, tan,
salmon, or hypopigmented patches, occurring most commonly
on the trunk.
Topical treatment is usually appropriate as a first-line agent for
tinea pedis, tinea corporis, and candidal intertrigo, however
oral medications are called for when involvement is extensive,
when tinea corporis is thought to have been transmitted by an
animal, and in fungal infections of the nails.
Fungal infections have high rates of recurrence after treatment,
but maintaining a dry, clean skin environment is helpful for
prevention.
Monitoring for recurrence and maintenance treatments may be
helpful in patients with recurrent infection.
83

Acknowledgements
This module was developed by the American Academy
of Dermatology Medical Student Core Curriculum
Workgroup from 2008-2012.
Primary authors: Iris Ahronowitz, MD; Ronda Farah,
MD; Sarah D. Cipriano, MD, MPH; Raza Aly, PhD,
MPH; Timothy G. Berger, MD, FAAD.
Peer reviewers: Heather Woodworth Wickless, MD,
MPH; Daniel S. Loo, MD, FAAD.
Revisions and editing: Sarah D. Cipriano, MD, MPH;
John Trinidad. Last revised July, 2011.
84

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management of cases of suspected dermatomycosis in The
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Erbagci Z. Topical therapy for dermatophytoses: should
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