CUTANEOUS MYCOSES. Introduction

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1 1 CUTANEOUS MYCOSES Dr. Mohamed El-Sakhawy Epidermis Introduction Outermost layer of the skin Its layers are made of Mostly dead cells. Most of the cells of the epidermis undergo rapid cell division (mitosis). As new cells are produced, they push older cells to the surface of the skin. The older cells become flattened, lose their cellular contents and begin making keratin. Keratin:- a tough fibrous protein that forms the 2 basic structure of hair, nails, and skin. 1

2 Layers of Epidermis 3 Hair Follicles 4 2

3 Nails 5 Cutaneous mycoses extend deeper into the epidermis, as well as invasive hair and nail diseases. Infection of the skin, hair or nails caused by a group of keratinophilic fungi, called dermatophytes DERMATOPHYTOSIS (=Tinea = Ringworm) Tinea means "ringworm" or "moth-like". Dermatologists use the term to refer to a variety of lesions of the skin or scalp. 6 3

4 DERMATOPHYTES Digest keratin by their keratinases Resistant to cycloheximide Dermatophyte infections are common diseases of the stratum corneum of the skin, hair and nail Classified into several groups depending on their usual habitat 7 8 4

5 Ecology of Dermatophytes The dermatophytes can be divided into three groups depending on whether their normal habitat or To determine the source of infection Anthropophilic Zoophilic Geophilic 9 Anthropophilic Associated with humans only. Person -to-person transmission through contaminated objects (comb, hat, etc.) Zoophilic Associated with animals. Direct transmission to humans by close contact with animals. Geophilic Usually found in soil. Transmitted to humans by direct exposure. 10 5

6 Zoophilic dermatophytoses 11 Dermatophytes 3 Genera Trichophyton Microsporum Epidermophyton Members of all three groups can cause human infection, but their different natural reservoirs have important epidemiological implications in relation to the acquisition, site and spread of human disease. 12 6

7 Although geophilic dermatophytes occasionally cause infection in both animals and man, their normal habitat is the soil. Members of the anthropophilic and zoophilic groups are thought to have evolved from these and other keratinophilic soil-inhabiting fungi, different species having adapted to different natural hosts. Individual members of the zoophilic group are often associated with a particular animal host, for instance M. canis with cats and dogs and T. verrucosum with cattle. However, these organisms can also spread to man. The anthropophilic species are the most highly specialized group of dermatophytes. They rarely infect other animals and often show a strong preference for a particular body site, only occasionally being found in other regions. 13 Infections are spread by direct or indirect contact with an infected individual or animal. The infective particle is usually a fragment of keratin containing viable fungus. Indirect transfer may occur via the floors of swimming pools and showers or on brushes, towels and animal grooming implements. Dermatophytes can remain viable for long periods of time and the interval between deposition and transfer may be considerable. In addition to exposure to the fungus, some abnormality of the epidermis, such as slight peeling or minor trauma, is probably necessary for the establishment of infection. 14 7

8 Trichophyton (19 species) Hair Skin Nails 15 Trichophyton rubrum An anthropophilic fungus, which has become the most common and widely distributed dermatophyte of humans. It frequently causes chronic infections of skin, nails and rarely scalp. Distribution: World-wide. Key Features: Culture characteristics, microscopic morphology and failure to perforate hair in vitro. 16 8

9 Tinea pedis caused by T. rubrum showing scaling macerated skin between the toes. 17 T. rubrum infection of finger nails 18 9

10 onychomycosis caused by T. rubrum 19 Tinea corporis due to Microsporum canis

11 Tinea corporis caused by T. rubrum showing distinctive 21 erythematous advancing border

12 Tinea barbae caused by T. rubrum. 23 Tinea barbae caused by T. rubrum

13 Trichophyton rubrum surface and reverse on SAB media after 10 days incubation at 30 o C. Most typical strains are downy to cottony in texture with fine white aerial mycelium at the surface. The overall surface is white, sometimes becoming rose on ageing. The reverse is typically wine-red Microscopic morphology of T. rubrum showing the production of scanty to moderate numbers of slender clavate to pyriform microconidia. Macroconidia are absent, however closterosporelike projections may be present in some 26 strains. 13

14 270 Microscopic morphology of T. rubrum showing the production of scanty to moderate numbers of slender clavate to pyriform microconidia. Macroconidia are absent, however closterosporelike projections may be present in some 27 strains. 271 Microscopic morphology of T. rubrum showing closterospore-like projections which may be present in some strains

15 Microsporum (13 species) Skin Hair 29 Microsporum canis A zoophilic dermatophyte, which is a frequent cause of ringworm in humans, especially children. Invades hair, skin and rarely nails. Cats and dogs are the main sources of infection. Distribution: World-wide. Key Features: Distinctive macroconidia and culture characteristics. Abundant growth and sporulation on polished rice grains

16 Young boy showing numerous, circular scaling lesions with distinct erythematous borders following contact with kittens. M. canis was isolated. 31 A five week old baby showing typical M. canis lesions with raised, erythematous 32 advancing borders following contact with several Siamese cats. 16

17 Typical M. canis scalp lesion showing hair loss and scaling. Note small broken off infected hairs in the central part of the lesion. 33 Culture of M. Canis on mycobiotic agar. showing a spreading whitish, cottony surface 34 growth with a golden-yellow reverse pigment. Note non-pigmented strains may occur. 17

18 Culture of M. canis on mycobiotic agar showing a spreading whitish, cottony surface growth with a golden-yellow reverse pigment. Note 35 non-pigmented strains may occur. 173 Slide culture of M. canis showing typical spindle-shaped, verrucose, thick-walled macroconidia (5-15 cells), often with a terminal knob. 36 A few pyriform to clavate microconidia are also present. 18

19 M. canis showing good surface growth and sporulation on polished rice grains. 37 Epidermophyton floccosum Skin Nails 38 19

20 Epidermophyton floccosum An anthropophilic fungus often causing tinea pedis, tinea cruris, tinea corporis and onychomycosis. May become epidemic among personnel using common shower or gym facilities, e.g. athletic teams, troops, ship crews and inmates of institutions. Distribution: World-wide. Key Features: Culture characteristics and microscopic morphology. 39 Severe tinea of the foot (tinea pedis) caused by E. floccosum showing extensive scaling

21 Submammary tinea corporis caused by E. floccosum. 41 E. floccosum on mycobiotic agar. Colonies are usually greenish-brown or khaki coloured, raised and folded in the centre, with a flat periphery and submerged fringe of growth

22 E. floccosum on mycobiotic agar. A deep yellowish-brown reverse pigment is usually present. 43 Microscopic morphology of E. floccosum showing characteristic smooth, thinwalled macroconidia, which are often produced in, clusters growing directly from the hyphae. No microconidia are formed

23 155 Microscopic morphology of E. floccosum showing numerous chlamydoconidia which are formed in older cultures. 45 DERMATOPHYTOSIS Clinical Classification & Manifestations Classified into several groups depending on their usual habitat Infection is named according to the anatomic location involved: 1. Tinea corporis

24 1-Tinea Corporis Tinea corporis is a superficial dermatophyte infection of the glabrous skin, excluding the scalp, beard, face, hands, feet, and groin. Small lesions occurring anywhere on the body, mainly trunk, legs and arms with a dermatophyte especially on glabrous skin. Infection frequently contracted from a household pet. May follow infection of another body site. Person to person transmission may occur in contact sports. 47 M. canis from cats and dogs most frequent

25 Tinea Corporis Tinea Cruris tinea cruris is a dermatophyte infection of the genitalia, pubic area and perianal skin. The scrotum and labia majora are typically not affected. Infection is more common in men than in women. Often transferred from another infected body site. Highly contagious via contaminated towels, floors, etc. Anthropophilic dermatophytes Epidermophyton floccosum and Trichophyton rubrum are most common

26 51 3-Tinea Pedis Tinea pedis - is also called " athlete's foot". Tinea pedis is dermatophytoses of the feet, Infection of toe webs and ringworm of the feet. This infection is most commonly produced by T. rubrum and T. mentagrophytes. Secondary bacterial or yeast infection is also possible

27 53 - Tinea pedis - "athlete's foot"

28 4-Tinea Unguium Tinea unguium, (onychomycosis) a dermatophyte infection of the nail or ring worm of the nails. 19 Risk factors for this infection include aging, diabetes, poorly fitting shoes, and the presence of tinea pedis. Toenails more often infected than fingernails. Infection often follows infection of another body site. Most commonly caused by anthropophilic species T. mentagrophytes and T. rubrum. Affects up to 8% of adult population Tinea unguium (onychomycosis) - nails are Clipped and used for culture 56 28

29 Tinea Unguium 57 5-Tinea Capitis Infection of the scalp involves hyphal proliferation in the stratum corneum that extends into the hair follicle orifice and hair shaft. Inflammatory tinea capitis is associated with zoophilic, Anthropophilic or geophilic species. Mild scaling lesions to widespread alopecia

30 Kerion: highly inflammatory, suppurating lesion caused by black dot appearance seen with ectothrix hair invasion. Favus is a distinctive infection with grey, crusting lesions. Asymptomatic carrier state recognized, may promote spread of infection. Affected hair may appear grey due to coating with arthroconidia. infection is associated with Microsporum and Trichophyton species

31 Tinea capitis (ring worm of the scalp Frequently found in children - Seen as single or multiple patches of hair loss, sometimes with a black dot pattern, which may be accompanied by signs of inflammation such as scaling, pustules and itching. - Tinea capitis is very contagious 61 6-Tinea Barbae - Tinea barbae - ringworm of the bearded areas of the face and neck

32 7-Tinea Faciei Tinea faciei tends to occur in the non bearded area of the face. The patient may complain of itching and burning, which become worse after sunlight exposure. 63 Tinea Faciei 64 32

33 8-Tinea Manuum Tinea manuum is a rare form that primarily affects the palmar areas of the hands, and presents as chronic, dry, scaly, hyperkeratotic skin with minimal erythema. Infections are most frequently caused by T. rubrum. Tinea manuum may accompany tinea pedis or onychomycosis, and a two feet one hand syndrome has been noted to occur

34 67 DERMATOPHYTOSIS Diagnosis I. Clinical Appearance Wood s lamp (UV, 365 nm) II. Laboratory diagnosis Dermatophyte infections may be reliably diagnosed in the laboratory by direct microscopical examination and culture of skin, crusts, hair and nail. A. Direct microscopic examination (10-20% KOH) 68 34

35 DERMATOPHYTOSIS Diagnosis B. Culture Mycobiotic agar Sabouraud dextrose agar 69 Collection of samples 70 35

36 Collection of samples Skin, hair and nail samples are best collected into folded squares of black paper or card, which can be fastened with a paper clip. The use of paper allows the specimen to dry out, which helps reduce bacterial contamination and provides conditions under which specimens can be stored for 12 months or more without appreciable loss in viability of the fungus. Nail samples should be collected by taking clippings from any discoloured, dystrophic or brittle parts of the nail and, importantly, by scraping material from underneath the nail. The sample should be taken from as far back as possible from the free edge of the nail. Scales from skin lesions should be collected by scraping outwards with a blunt scalpel from the edges of the lesions, where most viable fungus is likely to be. Specimens from the scalp should include hair stubs, the contents of plugged follicles and skin scales. Infected hairs are usually easy to pluck from the scalpwith forceps. Cut hairs are unsatisfactory because the 71 focus of infection is usually below or near the surface of the scalp. Wood s lamp This is a source of long-wave ultraviolet light that can be used to detect fluorescence in infected hair. It is especially useful for the detection of inconspicuous scalp lesions, and to select infected hairs for laboratory investigation. Hairbrush sampling Adequate material from minimal lesions may be obtained by brushing the scalp with a sterilized plastic hairbrush or scalp massage pad; this is then used to inoculate an appropriate culture medium by pressing the brush or pad spines into the agar

37 Processing of specimens If there is insufficient material for both microscopy and culture, the sample should be used for culture, since this is generally the more sensitive procedure (except for nails). The specimen should first be examined macroscopically; hair samples are examined under a Wood s lamp. Material from representative parts, and any fluorescent hairs, are divided up into 1 2- mm fragments with a sterile scalpel blade before microscopical examination and culture. 73 Direct microscopy Microscopy of wet mounts of keratinous material in potassium hydroxide is simple and reliable. The preparation is allowed to stand for min to digest and clear the keratin. Dermatophytes are seen in skin and nail as branching hyphae, which often appear slightly greenish in colour and run across the outlines of the colourless host cells. With Calcofluor (see above) the cell outlines fluoresce white

38 Culture Dermatophyte Culture Small fragments of keratinous material are planted or scattered on Sabouraud dextrose or 4% malt extract agar and incubated at C for up to 2 weeks; room temperature is adequate but the dermatophytes grow more slowly. Only T. verrucosum grows well at 37 C. Identification is based on colonial appearance and colour, pigment production, and the micromorphology of any spores produced. Special tests exist for differentiating certain morphologically similar species. Thus, the ability of T. mentagrophytes to produce urease within 2 4 days distinguishes it from T. rubrum, and the ability to grow on rice grains distinguishes M. canis from M. audouinii. 75 Black collection card 38

39 DERMATOPHYTOSIS Treatment Topical Miconazole, clotrimazole, econazole, terbinafine... Oral Griseofulvin Ketaconazole Itraconazole Terbinafine 77 39

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