SKIN AND SOFT TISSUE INFECTIONS

Superficial fungal Key points

infections C Superficial fungal infection is the fourth most common cause
of human disease
Roderick Hay
C Dermatophyte or ringworm infections respond to antifungals,
but only oral agents are effective in scalp infection (tinea
Abstract capitis)
Superficial fungal infections or mycoses are common treatable condi-
tions seen in everyday clinical practice, although they can present C Fluconazole-resistant Candida species are increasingly found
differently in immunosuppressed patients. Dermatophyte or ringworm in vaginal candidiasis
infections, superficial candidiasis of the mouth, skin or genital tract
and infections caused by Malassezia, such as pityriasis versicolor, C The yeast Malassezia is implicated in causing dandruff and
are the main conditions. Although they present with typical clinical seborrhoeic dermatitis
changes, diagnosis can generally be confirmed by direct microscopy
or culture of suitable samples. Treatment largely depends on the use C Laboratory confirmation of infection is still dependent on mi-
of azole (imidazole/triazole) or allylamine antifungals, applied in short croscopy and culture
courses topically or for longer periods orally, depending on the site
and severity of the infection.
Keywords Dermatophytosis; fungal infections; Malassezia infection;  Dermatophyte lesions can scale and itch. In tinea corporis,
MRCP; superficial candidiasis; superficial mycoses the lesion can be annular.
 In tinea pedis, skin erosions or blisters develop in the web
spaces, and the soles can be covered with dry scales.2
 Lesions of tinea cruris in the groin have a prominent rim.
 Tinea capitis (scalp ringworm; Figures 1 and 2) is a disease
of childhood presenting with alopecia and scaling on the
Introduction scalp. Its incidence has increased in the UK, Europe and
Superficial fungal infections include common skin diseases as the USA because of the spread of anthropophilic species,3
well as rare infections confined to specific geographical areas or particularly Trichophyton tonsurans.
groups of patients.1 Together, however, they are the fourth most  In untreated or severely immunosuppressed individuals
common cause of human disease and the most common infection with AIDS, dermatophytosis can lead to widespread or
globally. The principal diseases are: atypical infections, as well as rapidly spreading white
 dermatophytosis (ringworm e tinea capitis, tinea pedis) onychomycosis involving the whole nail plate.
 superficial candidiasis (cutaneous, oropharyngeal, vaginal) Dermatophytosis is often confused with other common skin
 disease caused by Malassezia spp. (pityriasis versicolor, conditions forming rings (e.g. eczema, annular erythemas,
seborrhoeic dermatitis). granuloma annulare). Tinea capitis can also be difficult to
recognize because the hair loss is often patchy and confined to
Dermatophytosis small areas or single hairs. The diagnosis of dermatophytosis
Dermatophyte fungi are organisms that digest keratin. They should be confirmed in the laboratory.
belong to three principal genera e Trichophyton, Microsporum
and Epidermophyton. They are also grouped according to their Superficial candidiasis
sources of infection: geophilic (soil), zoophilic (animals) and Superficial Candida infections are usually caused by Candida
anthropophilic (humans). Transmission is indirect through albicans. This organism is a common commensal in the mouth,
desquamated epidermis or hairs, or direct through bodily contact. vagina and gastrointestinal tract in healthy individuals. The
Dermatophytosis (tinea) is an infection of skin and the kera- prevalence of carriage is greater in hospitalized patients and
tinized structures (hair, nails) arising from it. In the skin, the those who are immunocompromised.
archetypal lesion is annular with central healing (ringworm).
Clinical descriptions are based on the site of infection. Tinea Oropharyngeal candidiasis (oral thrush): has typical symptoms
pedis is estimated to affect up to 15% of the healthy population, and signs of soreness and white patches on an erythematous
and fungal nail disease (onychomycosis, see MEDICINE 2017; 45: background (plaque type). An erythematous variety exists; this
390e395) >15% depending on age. does not have plaques, but sore areas of erythema are typical.
Acute or chronic infection can occur in immunocompromised
individuals. Other predisposing factors include antibiotic therapy
and dentures.
Roderick Hay DM FRCP FRCPath FMedSci is Emeritus Professor of
Cutaneous Infection at King’s College London, UK. Research
interests: dermatological epidemiology and fungal disease. Vaginal candidiasis (vaginal thrush): is a common infection,
Competing interests: Professor Hay has been a Consultant for Mayne with clinical appearances similar to those of oropharyngeal dis-
Pharma. ease, plus discharge. Pruritus can also occur, and recurrent

MEDICINE --:- 1 Ó 2017 Published by Elsevier Ltd.

Please cite this article in press as: Hay R, Superficial fungal infections, Medicine (2017), http://dx.doi.org/10.1016/j.mpmed.2017.08.006
 SKIN AND SOFT TISSUE INFECTIONS

Figure 1 Inflammatory tinea capitis caused by Microsporum canis

acquired from a cat. Figure 3 Chronic Candida paronychia. In this patient, the infection is
centred on the nail fold.

Figure 2 Tinea capitis caused by an anthropophilic fungus (Tricho-

phyton tonsurans). Signs such as scaling can be minimal.

Figure 4 Pityriasis versicolor caused by Malassezia. Scaling can be

episodes are common. Women with vaginal thrush seldom have difficult to see in such cases.
underlying predisposing factors.
particularly common in patients with AIDS or chronic neuro-
Candidiasis of the skin: is often confined to body folds, logical conditions such as Parkinson’s disease.
including the interdigital spaces of the hands or feet. Typically,
small satellite pustules lie distal to the periphery of the rim of the Malassezia folliculitis: is an itchy, follicular rash on the upper
rash. Chronic paronychia (nail fold infections) can be caused by back and shoulders that can resemble acne.
Candida (Figure 3).
Laboratory diagnosis
Malassezia infection The key to diagnosis is the demonstration of the organisms in
Malassezia spp. are common surface commensals of greasy skin skin scales, hair or nails. Scrapings are taken with a scalpel or
(e.g. scalp, chest). They are associated with pityriasis versicolor, nail clippers. They are examined in potassium hydroxide or a
seborrhoeic dermatitis and folliculitis.4 Malassezia infection can fluorescent stain such as Calcofluor, and can be cultured on
complicate chronic central venous cannulation, mainly in neo- Sabouraud’s medium. Skin scales, hair and nails can be sent to a
nates, manifesting as pulmonary infiltrates on chest imaging. laboratory folded in a card (transport packs are available). Ma-
terial from mucosal surfaces is best sent on a moistened swab.
Pityriasis versicolor: is a scaly, hypo- or hyperpigmented rash Routine molecular diagnostic measures are not available.
on the trunk (Figure 4). It is common in tropical regions and in
patients who have recently taken a holiday in a sunny climate. Management
The patches can resemble vitiligo, but the presence of scaling is Topical antifungals (e.g. terbinafine, imidazoles such as clotri-
typical. mazole; Table 1) are necessary for most circumscribed in-
fections. Treatment lasts 1e4 weeks. Nail infections require
Seborrhoeic dermatitis: is a common scaly condition affecting systemic treatment with terbinafine 250 mg daily for 6 weeks to 3
the face (including the nasolabial folds), the front of the chest months, or itraconazole 200 mg twice daily for 1 week every
and the scalp (dandruff). Severe seborrhoeic dermatitis is month for 3 months (pulsed therapy).

MEDICINE --:- 2 Ó 2017 Published by Elsevier Ltd.

Please cite this article in press as: Hay R, Superficial fungal infections, Medicine (2017), http://dx.doi.org/10.1016/j.mpmed.2017.08.006
 SKIN AND SOFT TISSUE INFECTIONS

nystatin, amphotericin). Oral fluconazole or itraconazole

Antifungal therapy may be necessary in more severe infections and in
Antifungal Site of action immunocompromised patients; however, there are
important interactions with other drugs, such as ciclo-
Topical treatments for all sporin and rifampicin. Resistance to fluconazole is a
superficial mycosesa recognized problem, particularly in infections caused by
CImidazoles (cream, ointment, Cell membrane e Candida krusei or Candida glabrata (increasingly seen in
powder) (e.g. clotrimazole, 14a-demethylase vulvovaginal candidiasis), and long-term suppressive
miconazole, econazole, treatment with this drug should be avoided.5
ketoconazole)  The usual treatment for pityriasis versicolor is a topical
CAllylamine antifungals Cell membrane e azole or terbinafine. In extensive infections, itraconazole,
(e.g. terbinafine) squalene epoxidase 200 mg/day for 5 days, can be used. A
Oral treatments
CTriazoles (itraconazole, Cell membrane e
KEY REFERENCES
fluconazole) e all superficial 14a-demethylase
1 Hay RJ, Ashby HR. Fungal infections. In: Griffiths CE, Barker J,
mycoses
CTerbinafine e
Bleiker T, Chalmers R, Creamer D, eds. Rook’s textbook of
Cell membrane e
dermatology. Chichester: Wiley Blackwell, 2016: 32.1e329643.
dermatophytosis squalene epoxidase
CGriseofulvin e
2 Canavan TN, Elewski BE. Identifying signs of tinea pedis: a key to
Inhibition of mitotic
understanding clinical variables. J Drugs Dermatol 2015; 14(suppl
dermatophytosis spindle formation
10): S42e7.
(tinea capitis)
3 Fuller LC, Barton RC, Mohd Mustapa MF, et al. British Association
a
Topical polyenes (e.g. nystatin, amphotericin) are sometimes used for oral of Dermatologists’ guidelines for the management of tinea capitis.
or vaginal infections in non-immunocompromised patients. Br J Dermatol 2014; 171: 454e63.
4 Velegraki A, Cafarchia C, Gaitanis G, Iatta R, Boekhout T. Malas-
Table 1
sezia infections in humans and animals: pathophysiology, detec-
tion, and treatment. PLoS Pathog 2015; 11: e1004523.
 Tinea capitis is treated with griseofulvin, terbinafine or 5 Sobel JD. Recurrent vulvovaginal candidiasis. Am J Obstet Gyne-
itraconazole. Terbinafine, at conventional dosage, is more col 2016; 214: 15e21.
effective in Trichophyton infections, and griseofulvin or
itraconazole in Microsporum infections.
 Treatment of Candida infections in immunocompetent
patients involves topical azoles or polyene antifungals (e.g.

TEST YOURSELF
To test your knowledge based on the article you have just read, please complete the questions below. The answers can be found at the
end of the issue or online here.

Question 1 Question 2
A 4-year-old girl presented with three areas of hair loss on the A 46-year-old man presented with discoloured toenails. He had a
scalp. These were mildly itchy. She was of African origin. On long history of recurrent athlete’s foot.
clinical examination, there were areas on her scalp where the On clinical examination, he had has dystrophic toenails on six
hair was sparse, and there were broken hairs with erythema and toes, which were thickened and pale yellow to white in colour.
scaling. The nail folds were not swollen. He also had scaling on the soles
of the feet. There was no other skin abnormality.
What is the most appropriate next step?
A. Advise an antidandruff shampoo What is the most likely diagnosis?
B. Advise an oral antifungal agent A. Fungal nail infection
C. Send hair and skin scrapings to the microbiology B. Psoriasis
laboratory C. Eczema
D. Advise betamethasone cream to apply to the scalp D. Trauma
E. Advise local application of terbinafine cream E. Paronychia caused by Candida

MEDICINE --:- 3 Ó 2017 Published by Elsevier Ltd.

Please cite this article in press as: Hay R, Superficial fungal infections, Medicine (2017), http://dx.doi.org/10.1016/j.mpmed.2017.08.006
 SKIN AND SOFT TISSUE INFECTIONS

Question 3 On clinical examination, she had a white vaginal discharge and

erythema and inflammation of the vaginal mucosa.
A 30-year-old woman presented with recurrent vaginal
discharge. She had had six episodes of vulvovaginal candidiasis
What is the most appropriate next step?
over the previous year, each treated with fluconazole, but the
A. Advise another course of fluconazole
time between each episode of infection had been decreasing. On
B. Change the antifungal treatment to oral terbinafine
the last occasion, she had been treated there was little response.
C. Perform an HIV test
She had no history of other illnesses and was not taking any
D. Investigate for a primary immunodeficiency.
other medicines.
E. Take a vaginal swab to identify any yeast isolated

MEDICINE --:- 4 Ó 2017 Published by Elsevier Ltd.

Please cite this article in press as: Hay R, Superficial fungal infections, Medicine (2017), http://dx.doi.org/10.1016/j.mpmed.2017.08.006