Fungal Infection of the Skin

November 24th , 2003

Michael Hohnadel D.O.

Duncanville Dermatology
Clinic
Dermatology Residency
KCOM Dermatology
Department

Topics Covered

Basic diagnostic techniques

KOH
Culture
Woods light

Tinea infections with special attention to scalp, feet and

nails
Tinea Versicolor
Candidiasis
Differentials to consider.
Basic Treatment

Questions
1. What is a Woods light useful for ?
2. If I think it might be a fungus but it is KOH negative,
what can be done to prove it ?
3. How do you know the endpoint of therapy when
treating tinea capitis ?
4. How do you know the endpoint of therapy when
treating tinea versicolor ?
5. If a patient has thick ugly nails, what is the chance
that it is classic onychomycosis ?

Diagnostic Tests
KOH Preparations

Skin

Two slides or slide and #15 blade.

Scrape border of lesion.
Apply 1-2 drops of KOH and heat gently
Examine at 10x and 40x

Focus back and forth through depth of field.

Look for hyphae

Clear, Green
Cross cell interfaces
Branch, constant diameter.

Chlorazol black, Parkers ink can help.

Diagnostic Tests
KOH Preparations

Nails

Hair

Thin clipping, shaving or scraping

Let dissolve in KOH for 6-24 hours.
Can be difficult to visualize.
Culture often required.
Directly examined without KOH.
Apply KOH and heat hair until macerated
Look for spores.

Be Persistent !

Tinea Versicolor

Trichophyton
Tonsurans

Tinea Versicolor

Parkers Ink Stain

Watch out for Mosaic Fungus

Mosaic Fungus
Lipid droplets in
interepithelial
spaces and cell
membrane
overlap simulate
fungal hyphae.

Diagnostic Tests

Fungal Cultures
DTM

(Dermatophyte Test Medium)

Yellow to red is (+).

Nickersons

Media

Yeast
Black growth is (+)

Sabourauds

Molds

Media

Diagnostic Test: Fungal Culture

Example of DTM

Diagostic Test Fungal Culture

Diagnostic Tests
Fungal Culture
Sample Collection
Scrape

with blade or rub with cotton Q-tip. Nail

clipping or curette.
Implant in media.
Cap Loosely, Fungi are aerobic
Read at 2 weeks and 4 weeks.

Tinea Capitis

Diagnostic Tests
Woods

Light

Tinea Capitis
Blue

green florescent with M. Canis.

Not useful for Trichophyton (Most Common)

Other Areas:
Useful

to diagnose as erythrasma (coral red/pink).

Tinea versicolor may be pale white yellow.
Less helpful if patient recently bathed.

PAS

stain of skin or nail clipping.

Woods Light M. Canis

Woods Light - Erythrasma

Different Types of Infection

Dermatophyte Fungal Infection

Tinea Capitis
Tinea Pedis
Tinea Unguium (Onychomycosis)

Tinea Corporis
Tinea Faciales
Tinea Cruris
Tinea Manuum

Tinea Vesicolor
Candidiasis

Tinea Capitis

Tinea Capitis
Children most common cases.
Most Common Organisms:
T. Tonsurans - acounts for 90% in U.S.
M. Canis - seen in children with infected animals.
Adults not infected.

M. Audouinii - grey, broken shaft tinea

Tinea Capitis
Presentations of Tinea Capitis
1. Non-inflammatory black dot type
2. Seborrheic type
3. Pustular
4. Inflammatory (Kerion)

Tinea Capitis
Black

Dot Type

Large

Areas of Alopecia without

inflammation
Mild scaling
Occipital adenopathy
Black dot hairs.
At first glance may look like Alopecia areata

Tinea Capitis

Tinea Capitis
Seborrheic type
Common

resembles dandruff
Close exam for broken hairs, black dots
Adenopathy
Frequently negative KOH (70%)
Culture often necessary for DX

Tinea Capitis
Kerion
Inflamed,

Boggy and tender.

M. Canis common etiology
Systemic symptoms: Fever, Adenopathy.
Scaring alopecia may occur
KOH often negative
May look bacterial

Tinea Capitis - Kerion

Tinea Capitis
Pustular
Discrete pustules and crusted areas
No significant hair loss or scale
Often KOH negative
Frequently treated as bacterial at first

Tinea Capitis Diagnosis

History

Close contacts, pets, duration.

Morphology

Broken hairs, black dots, localized.

Woods

Lamp

Blue green.

Hair

of lesion

Shaft Exam

Endo/Exothrix

Culture

Plucked Hair shafts, Q-tip or tooth brush.

Normal Hair

Tinea Capitis - Endothrix

Tinea Capitis - Exothrix

KOH and Quick Ink

M. Canis

Tinea Capitis Treatment

Must treat hair follicle
Topical not effective
Systemic agents

Griseofulvin for children liquid with good taste.

Imidazoles, terbinafine.
Steroids for inflamed lesions like Kerion.
Treat until no visual evidence, culture (-) plus 2 weeks
Average of 6-12 weeks of treatment.

Examine / treat family in recurrent cases.

Tinea Pedis and

Manuum.
T. Rubrum most common etiology
Dull erythema with pronounced scale.
Leading edge of scale not as common.
Two feet one hand involvement.

T. Mentagrophytes causes inflammatory

tinea pedis
Vesicles and bullae.

General Morphology
Tinea Pedis

Tinea Pedis

General Morphology
Tinea Manuum

Two feet one hand

Tinea Pedis
Groups: M > F. Young and middle aged.
Patient is susceptible to reoccurrence
Onychomycosis and tinea pedis associated.
Differential:
Eczema, contact dermatitis
Psoriasis.
Erythrasma and Candida (esp in web spaces.)
Pitted keratolysis

Tinea Pedis Diagnosis

PE/History onychomycosis, contacts, med cond.
KOH exam Thick scale, no leading edge
Woods Light - Helps to differentiate from erythrasma
Culture
Remember: hand eczema may be a
dermatophyte infection of hands or id reaction
from tinea at another location.

Tinea Pedis: Treatment

Dry Feet
Alternate shoes, Absorbent powders, Change socks
Scale my be reduced with keratolytic
SAL acid, Lactic acid, Carmol

Topicals and/or Systemics.

Topical: naftine, lamisil, mentax may be more effective than
azoles. Steroids if inflamed.
Systemic allyamines or azoles
Treat secondary bacterial infections.
Steroids for severe inflammation and ID.

General Morphology
Onychomycosis

15-20% of those between 40-60 yrs. infected.

No Spontaneous remissions
General Appearance:

Typically begins at distal nail corner

Thickening and opacification of the nail plate
Nail bed hyperkeratosis
Onycholysis
Discoloration: white, yellow, brown
Edge of the nail itself becomes severely eroded.

Some or all nails may be infected

Often accompanying tinea pedis

Onychomycosis
4 Types:
1.
2.

Distal Subungal
White superficial

3.

Proximal Subungal

4.

T. Mentagrophytes and molds

Chalky white patches
May indicate HIV infection

Candidaonychomycosis

Normally hands with accompanying paronychia

Onychomycosis

Onychomycosis with Onycholysis

White Onychomycosis

Candidaisis of nail

Paronychia

Onychomycosis
Differential Diagnosis: (50% of thick nails not classic fungus.)

Allergic contact (nail polish, food items)

Psoriasis
Lichen Planus
Molds
Nail dystrophies (ex nephrogenic)
Drugs

Onycholysis from Contact

Dermatitis to Artificial Nails

Psoriasis

Middle of nail, oils spots, pitting.

Psoriasis

Lichen Planus

Onycholysis from wet - dry

Pseudomonas of nail

Terry nails half and half

Molds

Bowens disease of the Nail

Onychogryphosis

Diagnosis of Onychomycosis
Try to identify fungi before oral therapy
1. KOH of nail clipping

May need some time to dissolve nail.

2. Culture

DTM - dermatophytes

Sauborauds Molds

Nickerson Yeast

3. Nail clipping for histology and PAS staining if above is

negative and clinical suspicion is high.

Curettes for Specimen Collection.

Treatment of Onychomycosis.
Debridement of infected area helps penetration / comfort.

Mechanical

Urea products (ex carmol)

Topical Treatment:

Can be effective for limited involvement and for

prevention.

Agents

Penlac (every day for one year)

Mycocide Nail solution

Treatment of Onychomycosis
Oral therapy
Effective. Relapse rate 15-20 % in one year.
Lamisil 250mg. 6 weeks/12 weeks.
Baseline labs and one month.
CBC (neutropenia), Liver function.

Itraconazole 200 mg /day. 6 weeks/12 weeks

Baseline labs and one month. Similar to lamisil.
Pulse dosing fingernails - (200 mg bid 1 wk q mo.) x 2
No lab monitoring needed

Treatment of Onychomycosis
Notes on Therapy
Other Azoles require longer therapy.
Nails will not appear clear at end of
therapy
Measurements and digital photography
verify effectiveness.

For you and for patient

General Morphology
Tinea Corporis
Papulosquamous
Erythematous
Annular
Scaling
Crusting
Ringworm

General Morphology
Tinea Faciales

General Morphology
Tinea Cruris

General Morphology
Tinea Versicolor

Numerous, well-marginated, oval-to-round

macules with a fine white scale when scraped.
Pigmentary alteration uniform in each
individual.

Scattered over the trunk and neck. Seldom the

face.
Pityrosporum orbicularis, M. furfur

Red
Hypo pigmented
Hyperpigmented

Normal flora of skin

Asymptomatic.

Tinea Versicolor

More
apparent
in the
summer.

Tinea
Vesicolor
Hyperpigmented
Variety
Looks Like: intertrigo,
erythrasma .

Tinea Versicolor - Differential

Vitiligo
Pityriasis Alba
Pityriasis Rosea
Nummular Eczema
Psoriasis
Idiopathic guttate hypomelanosis

Vitiligo
White
without
scale.

Pityriasis Alba
Frequently on face,
KOH neg. Few
lesions.
May have fine white
scale.

Pityriasis Rosea
Papules or
plaques with
Collarette of
scale, KOH (-),
Woods light
neg. HX.

Guttate Psoriasis

Idiopathic guttate hypomelanosis

White,
small, no
scaly, age.

Tinea Versicolor

Diagnosis:
Scrape lightly fine white scale
KOH Positive for short hyphae and spores
(Spaghetti and meatballs)
Woods Light pale yellow white fluoresce.
Culture rarely done.

Tinea Versicolor

Tinea Vesicolor Woods Light

Yellow White

Tinea Versicolor Microscope

Tinea Versicolor-Treatment
Topicals for limited involvement.
Selenium Sulfide Shampoos: lather 10
minutes wash off x 7 days.
Ketoconazole 2% shampoo: 5 minutes 1-3
days.
Imidazoles topicals to body qd-bid for 2-4
wks.
Terbinafine spray.

Tinea Versicolor-Treatment
Oral for extensive
Itraconazole, fluconazole,
ketoconazole.
Dosing varies: single dose to 5-10 days of
therapy.
Likes gastric ph for absorption.
Avoid bathing with 12 hours of ingestion.

Tinea Versicolor-Treatment
Notes
Hypopigmentation resolves slowly
No scale when scraped indicates cure.
Sunlight helps restore pigment
Prophylaxis before summer in some patients.
Selenium shampoos
Q month orals

Candidiasis
Candida Albicans
Normal Flora
Occurs in moist areas especially where skin touches.
Presentation: primary lesion is a red pustule.
Most Common: pustules dissect horizontally through the
stratum corneum leaving a red, glistening denuded
surface with long continuous border with satellite lesions.
May also present as an eruption of multiple pustules
which become erythematous papules between skin folds.

Candidiasis
Immunosuppression of any type (disease,
steroids), D.M., Antibiotics or receptive
environments predispose.
Diagnosis: History of predisposing factors
and/or classic appearance of lesions at typical
locations.
Red and glistening in intertriginous area esp in
predisposed individual think candida.

Candidiasis

Candidiasis

Difficult to be sure in Web spaces.

Candidiasis
Differential:
1. Erythrasma likes skin creases
2. Eczema may look like pustular candida
3. Bacterial folliculitis as above
4. Psoriasis gluteal cleft
5. Tinea same locations

Candidiasis
KOH for pseudohyphae and spores
May be impossible to tell visually from tinea.

Woods Light
Culture. Nickersons (+)
Remember yeast part of normal flora.

Add up the evidence

Candidiasis

Treatment of Candidiasis

Keep dry Z-sorb powder, cotton ball between

toes.

Topical azoles.

Occasionally co-administration of a weak topical

steroid may be helpful.

Diaper rash

Angular chelitis.

Treat co-existent bacterial infection if present.

THE END