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11 NOVEMBER 2010
Medical Bulletin
Common Superficial Fungal Infections
a Short Review
Dr. King-man HO
MBBS (HK), MRCP (UK), FHKCP, FHKAM (Medicine), FRCP (Glasgow, Edin),
Dip Derm (London), Dip GUM (LAS)
Consultant Dermatologist, Social Hygiene Service, CHP
Specialist in Dermatology and Venereology
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Medical Bulletin
fissures are found in the web spaces, in particular, the distal onycholysis start at the hyponychium spreading
web space between the 4th and 5th toes. This type is proximally. 2) proximal subungual onychomycosis
usually associated with T. rubrum or T. mentagrophytes. (PSO): the dermatophytes invade the nail unit under
the proximal nail fold and spread distally. It is usually
Diffuse scaling on the soles extending to the sides of the caused by T. rubrum and is usually associated with
feet is found in the moccasin type, usually caused by T. immunosuppressed conditions, e.g. HIV infection. 3)
rubrum. Genetic predisposition is proposed to explain superficial white onychomycosis (SWO): the fungi,
the strong family history and recalcitrant nature of this mainly T. mentagrophytes, directly invade the superficial
type of tinea pedis. layers of the nail plate but do not penetrate it leading
to a white, crumbly nail surface. 4) total dystrophic
The ulcerative type, usually caused by T. mentagrophytes onychomycosis.
var. interdigitale, typically begins in the two lateral
interdigital spaces and extends to the lateral dorsum
and the plantar surface of the arch. The lesions of the toe Tinea Capitis
webs are usually macerated and have scaling borders. Tinea capitis usually occurs predominantly in
Secondary bacterial infection is not uncommon which prepubertal children. It can be acquired from infected
may be referred to as mixed toe web infection. puppies and kittens and by close contact with infected
children. The three most common dermatophytes
In the vesiculobullous type, usually caused by T. causing tinea capitis are Trichophyton tonsurans,
mentagrophytes var. interdigitale, vesicular eruptions on Microsporum canis and Microsporum audouinii. The
the arch or side of the feet are found. This type may causative agent varies in different geographical areas.
give rise to the dermatophytid reaction which is an In the USA and in some cities in the UK, T. tonsurans is
inflammatory reaction at sites distant from the site of the most common cause. In Hong Kong, tinea capitis is
the associated dermatophyte infection. Pompholyx usually caused by M. canis. Pet exposure is associated
like lesions on the hands are the classic dermatophytid with infections caused by M. canis.
reaction.
The dermatophytes can invade hair in three patterns:
ectothrix, endothrix and favus. Arthroconidia are found
Tinea Manuum around the hair shaft in ectothrix infections and within
Tinea manuum may present as diffuse hyperkeratosis the hair shaft in endothrix infections. Hyphae and air
with predilection to the palmar creases of the palms and spaces are found within the hair shafts in favus. Many
digits. White powdery scales along the palmar creases fungi producing a small spore ectothrix pattern and
are typically seen. It may also present as annular lesions T. schoenleinii, which causes endothrix infection, will
like the typical tinea corporis but on the dorsum of show fluorescence under Woods light because of the
the hands or as pompholyx like lesions on the palmar presence of pteridine.
aspect. Infection of only one hand is common and
usually occurs in a patient with concomitant tinea pedis. Tinea capitis can present in the following patterns:
The term two feet and one hand syndrome is coined to seborrhoeic pattern, black-dot pattern, kerion and favus.
describe this interesting condition. Tinea unguium of In the seborrhoeic pattern, dandruff-like scaling is found
the involved hand might be observed. The typical fungi on the scalp. Prepubertal children presenting with
responsible for tinea manuum are the same as those for suspected seborrhoeic dermatitis on the scalp should be
tinea pedis and tinea cruris. presumed to have tinea capitis until proven otherwise.
In the black dot pattern, patchy alopecia with black
stumps of broken hair shaft due to breakage of hair near
the scalp are found. In kerion, boggy masses covered
Tinea Cruris with pustular folliculitis are found and scarring may
Flexural tinea usually only occurs in the groins and
does not involve the axillae or submammary folds. The ensue afterwards. In favus, most frequently caused by T.
infection occurs more in males. It begins in the crural schoenleinii, yellow saucer-shaped adherent crusts made
folds and may extend to the thighs, buttocks and gluteal up of hyphae and spores occur around the hairs.
cleft area. Scrotal infection alone is rare. Infection is
nearly always from the patients own feet and is caused Fungal culture and species identification provide
by the same organisms as those causing tinea pedis. additional information for patient management.
Zoophilic dermatophytes, M. canis, may have an animal
source and therefore the pets should be examined
by veterinary surgeons for the presence of similar
Tinea Unguium infections. Anthropophilic dermatophytes, T. tonsurans,
Both dermatophytes and non-dermatophytes can
cause onychomycosis. Less than 10% of cases of should prompt the attending physician to look for
onychomycosis are due to yeasts or non-dermatophyte infections of the household or institutional contacts
moulds, while dermatophytes account for approximately or even institutional outbreaks. Mild infections and
90% of cases. Toenail infections are more common asymptomatic carriers with positive fungal culture but
than fingernail infections and are usually found along no clinical signs can be found in tinea capitis, especially
with tinea pedis. The main causative dermatophytes in T. tonsurans infections. The carriers are considered
are T. rubrum, T. mentagrophytes and E. floccosum. The infectious as they shed the fungus. Institutional
clinical presentations of onychomycosis are as follows: outbreaks are however very uncommon in Hong Kong.
1) distal and lateral subungual onychomycosis (DLSO):
it is the most common type, usually caused by T.
rubrum. Discolouration, subungual hyperkeratosis and
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Medical Bulletin
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Medical Bulletin
antibiotic treatment e.g. tetracyclines, corticosteroids possible in those cases of clinical distal lateral subungual
and immunosuppression associated with organ onychomycosis. Simple nail clipping of the distal
transplantation. Scrapings or biopsy specimens show diseased nails may not give the maximum yield.
abundant Malassezia yeasts occluding the opening of the Repeated sampling is sometimes required to isolate the
infected follicles. However, as the colonisation of hair causative fungi. Two types of media, one with and the
follicles by Malassezia is not abnormal, the diagnosis of other without cycloheximide, are ideally used to culture
Malassezia folliculitis has to be confirmed by the response nail samples.4 The one with cycloheximide suppresses
to antifungal therapy: topical treatment is effective in the growth of the non-dermatophyte filamentous fungi
most cases, whereas others need systemic therapy with and hence enhances the growth of the dermatophytes.
azole or triazole. Whereas the one without allows the growth of the non-
dermatophyte filamentous fungi, some of which may
sometimes cause skin diseases. Therefore a positive
Mould Infections culture for non-dermatophyte filamentous fungi should
be interpreted with care and correlated with the clinical
Mould is ubiquitous in the environment, but pure mould features of the patient.
infection of the skin is very uncommon. Superficial
skin infection may mimic moccasin tinea pedis, tinea Laboratory diagnosis of Candida infection can also be
manuum, and tinea unguium. made with the help of Gram staining of relevant clinical
samples. Demonstration of yeasts with pseudohyphae
formation is regarded as pathognomic of tissue invasion
and hence genuine clinical disease. Fungal cultures
Principles of Laboratory Diagnosis of can be performed but results have to be interpreted in
Superficial Fungal Infections clinical context.
Clinical diagnosis is usually good enough for the routine As Malassezia species can be detected in many
management of patients. If laboratory confirmation is asymptomatic individuals and only cause disease
deemed required, the following principles should be when these yeasts are in certain phases of growth or
borne in mind. As cutaneous diseases associated with metabolism, the best way to establish the diagnosis is by
these fungi may or may not have genuine tissue invasion, clinical examination (which can be assisted by Woods
and skin surface is the habitat of some of these fungi and light). Diagnosis can also be made with the help of
the skin surface is liable to environmental contamination, KOH wet mount examination of the scales. The classic
mere isolation of some of these fungi from clinical spaghetti and meat ball pattern can be demonstrated
specimens taken from the skin surface is not a sine qua non by microscopic examination of the wet mount. Fungal
of their role in disease causation. The laboratory approach culture is not indicated for the diagnosis of superficial
to these cutaneous conditions may involve answering infections caused by this yeast.
the following 3 questions: 1) what is the purpose of
performing the laboratory tests under consideration? 2) Commercial kits with colour indication for positivity have
which is the most appropriate laboratory test? 3) how to been developed recently to make fungal cultures possible
interpret the laboratory results in the concerned clinical in the physicians office. Molecular diagnostics are also
context? To better inform the laboratory microbiologists, developed to increase the sensitivity of laboratory tests
it is prudent to provide the essential clinical information for tinea unguium.5 These technological advances will
and specify the organisms of interest on the request certainly facilitate the clinical management of cutaneous
form. The laboratory diagnostic approach will involve fungal infections in the community based clinical settings.
1) wet mount KOH examination that can be performed
rapidly at the bed-side with or without staining (e.g. by
Parkers blue black ink, chlorazole black), 2) culture for
proper species identification. Treatment
Pharmacological treatments for superficial fungal
The scales from active lesions produced by skin scraping
infections can be grouped into topical and systemic.
can be collected and wrapped in colour paper (and put in
Generally speaking, imidazoles (isoconazole, tioconazole,
a properly sealed container) and sent to the supporting
clotrimazole) and the triazoles (itraconazole, fluconazole)
laboratory by mail. Cleansing of the site may be required
are active against yeast and dermatophytes, topical
in those grossly contaminated sites such as from a dirty
allylamines (terbinafine, naftifine) and amorolfine
foot before performing skin scraping.
may be fungicidal, polyenes (nystatin, amphotericin B)
are active against Candida sp but not dermatophytes;
Diseased hairs should be plucked (not cut) in those cases
systemic terbinafine albeit thought to be fungicidal to
of suspected tinea capitis. Scraping of diseased scalp
dermatophytes does not work for yeast infections. With
skin for fungal study is the recommended approach of
the exception of tinea captitis and tinea unguium which
the British Association of Dermatologists.2 Specimen
(except for those cases with only mild distal disease)
collection by cytobrush or toothbrush are alternative
requires systemic treatment, topical treatment may be
methods of sample collection especially in the context
tried in most other superficial fungal infections. Systemic
of outbreak investigation.2, 3 As aforementioned, species
treatment may also be considered in those cases with
identification in tinea capitis is preferred.
extensive disease or significant hyperkeratosis. The
treatment course for topical treatment spans from as
Subungual hyperkeratotic material should be collected
short as 1 week to 4-6 weeks. In the real life situation,
with a curette in those cases of suspected onychomycosis.
a longer course is not uncommonly required. Systemic
Sampling should also be collected as proximal as
regimes are summarised in the following table.
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Medical Bulletin
References
1. Segal E. Candida, still number one what do we know and where are
we going from there? Mycoses 2005;48:311.
2. Higgins EM, Fuller LC, Smith CH. Guidelines for the management of
tinea capitis. Br J Dermatol 2000;143:53-8.
3. Bonifaz A, Isa-Isa R, Araiza J, et al. Cytobrush-culture method to
diagnose tinea capitis. Mycopathologia 2007;163:30913.
4. Sobera JO, Elewski BE. Onychomycosis. In: Richard K Scher, C
Ralph Daniel III. Nails: Diagnosis, Therapy, Surgery. 3rd ed. 2005.
Philadelphia. Elsevier Saunders, pp126-8
5. Robert R, Pihet M. Conventional Methods for the Diagnosis of
Dermatophytosis. Mycopathologia 2008;166:295306.
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