ORAL REVALIDA e-REVIEW: DERMATOLOGY

DERMATOPHYTE INFECTIONS
Patricia Duque-Ang, MD
May 23, 2020

I. TINEAS
TINEA CORPORIS/ CIRCINATA TINEA OF MANUUM & TINEA
TINEA CAPITIS TINEA BARBAE, FACIAL
ET CRURIS PEDIS

Toe webs

Kerion
PHOTO
Tinea faciei

Plantar arch

Black dot ringworm Tinea barbae

Tinea manuum with associated tinea

unguium

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BENIN • BERNARDINO | BAÑEZ • BAUTISTA, J. • BAUTISTA, T. •BELMONTE • BERBA • BIGLETE • BONGCO • BORLONGAN • BRIONES • BUIZA
 DERMATOPHYTE INFECTIONS
• Pruritus • Facial pruritus • Pruritus
CHIEF • Pruritus
• Pruritic, scaling areas of hair loss • Erythematous lesions on facial area • Pruritic scaly lesions on hands and
COMPLAINT • Pruritic lesions over the body
or around facial hair feet
Ask for:
Ask for: Ask for: • Type of footwear used – occlusive
or just barefoot
• Duration Ask for: • Exposure to a pet with M. canis
• Direct contact with someone with
• Exposure to animals (zoonotic • Onset of the appearance of lesions • Participating in contact sports (e.g.
HISTORY the same lesions
fungi account for a significant • Where the lesions started appearing wrestling)
• Taking a shower in a public
portion of cases) |& • Exposure to animals | U • May be a presenting sign of AIDS (wide
bathroom or if there’s any
• Contacts with same lesion spread distribution)
previous swimming in a public
pool.
• Scaly, erythematous papular
eruptions with loose and broken TINEA FACIEI
hairs
• Primary lesion- single or multiple
• Visualization of characteristic erythematous patches, arcuate
“black dots" that can occur in
shape
endothrix tinea capitis or the
• Secondary lesion- scales, crust due • Erythematous patch with scaling
classic scutula of favus strongly
to chronic scratching • One or more circular, sharply spreading peripherally with partial
PHYSICAL suggest tinea capitis
circumscribed, slightly erythematous, central clearing
EXAM • Favus- severe form of tinea capitis TINEA BARBAE dry, scaly hypopigmented patches • Vesicles/Bullae may be
(Description of appearing as yellow-shaped crust
lesion) • Primary lesion- superficial lesions: • Annular plaque with advancing scaling unruptured or ruptured with
or scutula that grouped together in
similar to Tinea faciei; deeper border and central clearing | U scaling
patches like honeycomb | !
lesions: erythematous plaques • May have macerations
• Kerion- severe form of tinea
around areas with facial hair
capitis, characterized as deep,
boggy plaque with pustule • Secondary lesion- scales and crusts
formation | !
* Examine also rest of the skin
surface and nail
• Nummular eczema: pruritic papules
and vesicles; coin shaped weepy
• Bacterial folliculitis- in general,
plaques with oozing; sometimes with
lesions appear pustular, without
satellite papules and vesicles | !
• Seborrheic dermatitis- presents crust and ulceration | !
• Contact dermatitis: localized on area Subtypes:
with diffuse scaling, associated • Acne vulgaris- main lesion is
exposed to allergen/ irritants | !
with erythema and pruritus, comedone, not present in tinea | ! • Interdigital type – erythema and
alopecia typically absent • Erythema multiforme: targetoid desquamation between the toes
• Impetigo- check for evolution of
lesion with central purpura, pale
• Psoriasis- well demarcated, lesion (macule-vesicle-erosion), • Hyperkeratotic/ moccasin type –
DIFFERENTIALS edematous halo, macular erythema | !
erythematous plaques with coarse honey-colored crust dry scaly erythematous type, non-
scale • Intertrigo: well delineated, circular, inflammatory type
(pathognomonic), and sites of
moist patch in flexural areas like groin;
• Alopecia areata- discrete, often predilection such as centrofacial • Vesiculobullous – inflammatory
caused by friction + heat + moisture |
circular patches of alopecia. Scale and exposed extremities to trauma, type mostly at skin of plantar arch
!
is absent not present in tinea | !
• Tuberculoid leprosy- Well-defined
• Contact dermatitis- resolution of
erythematous, annular plaque with
lesions after removal of irritant | !
central clearing, anesthetic/hyposthetic
|!
• AKA scalp ringworm TINEA FACIEI TINEA PEDIS
• Fungal infection of the scalp that • Ringworm of the face • Dermatophytosis of the feet
most often presents with pruritic, • Fungal infection of the face Superficial dermatophyte/ fungal infection • “Athlete’s foot”
DEFINITION
scaling areas of hair loss of the skin
• Caused by all pathogenic TINEA BARBAE TINEA MANUUM
dermatophytes EXCEPT • Ringworm of the facial hair • Dermatophytosis of the hands

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BENIN • BERNARDINO | BAÑEZ • BAUTISTA, J. • BAUTISTA, T. •BELMONTE • BERBA • BIGLETE • BONGCO • BORLONGAN • BRIONES • BUIZA
 DERMATOPHYTE INFECTIONS
Epidermophyton floccosum and • Fungal infection of facial hair
Trichophyton concentrcum | G
• Endothrix infections:arthroconidia
(fungal spores) are found within
the hair shaft on direct microscopic
examination. (e.g. T. tonsurans, T.
violaceum, and T. soudanense)
• Ectothrix infections: arthroconidia
primarily surround the outside of
the hair shaft (e.g. T. verrucosum,
M. canis, M. audouinii, M. nanum,
and M. gypseum)
TINEA PEDIS
• Most common tinea infection
• Affects adults & adolescents
• Distribution: usually bilateral
• Common in tropical, humid areas
• Occurs mainly in children TINEA MANUUM
EPIDEMIOLOGY • M=F May occur in adults and children
• M>F
• Usually adults who shave • Commonly occurs in association
with tinea pedis/ tinea cruris
• Distribution: often unilateral
• Often associated with Tinea
unguium of fingernails
• Trichophyton & Microsporum
genera- most common cause TINEA FACIEI • RF: hyperhidrosis, hot humid
• Epidermophyton- rare cause weather, occlusive footwear
• T. mentagrophytes / T. verrucosum -
• Trichophyton tonsurans - black dot deep, nodular, suppurative lesion • T. rubrum - most common;
ringworm, subtle, seborrheic-like • Trichophyton rubrum - most common produces dry scaly erythematous
• T. viaolaceum / T. rubrum -
scaling, and inflammatory kerion cause type (non-inflammatory type)
superficial, crusted, partially bald
• Trichophyton violaceum - also patches with folliculitis • Microsporum canis (from pet dogs) • Moccasin/Sandal appearance –
ETIOLOGY produces black dot tinea • T. mentagrophytes involvement of entire sole and
• T. tonsurans and T. violaceum - TINEA BARBAE • Mode of transmission: contact with sides of feet
chains of large spores within the infected humans, household pets, farm • T. mentagrophtyes- produces
• T. rubrum
hair shaft (large-spore endothrix) animals inflammatory/vesicular type or
• T. mentagrophytes interdigital type
• Microsporum canis complex-
• M. canis | U
produce small spores visible on the • Usually in interdigit – erythema,
outside of the hair shaft (small- • M. nanum - hog farmers scaling, maceration
spore ectothrix)
PATHOGENESIS • Dermatophytes attach to the skin, hair, and nail which is attractive for its warm, moist environment conducive to fungal proliferation
& RISK • Fungi may release keratinases & other enzymes to invade deeper into the stratum corneum
FACTORS • But generally, do not invade deeply due to nonspecific host defense mechanism. Hence, SUPERFICIAL

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BENIN • BERNARDINO | BAÑEZ • BAUTISTA, J. • BAUTISTA, T. •BELMONTE • BERBA • BIGLETE • BONGCO • BORLONGAN • BRIONES • BUIZA
 DERMATOPHYTE INFECTIONS

T. RUBRUM
• “Moccasin or sandal” appearance -
infection involves the entire sole
and sides of the foot.
• “Two feet, one hand syndrome” -
• Face
both feet and one hand (usually
• Neck
dominant hand due to scratching)
SITES OF
Scalp, glabrous skin, eyelids, lashes • Moustache, beards, sideburns, for Occurring in sites other than the scalp,
PREDILECTION Tinea barbae beard, face, hands, feet, and groin
T. MENTAGROPHYTES
• Submaxillary region or chin for
• Multilocular bullae (inflammatory
Tinea barbae |&
type) involving the skin of the
plantar arch and sides of the feet
and heel
• Erythema and desquamation
between the toes (interdigital type)
• Wood’s light- uses UV light which
demonstrate fungal fluorescence; Clinical diagnosis confirmed by:
2-3 loose hairs obtained • Microscopic mounts of extracted hair
*Fluorescent-positive infections - • Biopsy specimen • KOH exam of skin scrapings (from border- highest yield of fungal elements):
M. audouinii, M. canis, M. • Culture can be performed on hyaline septate branching hyphae
DIAGNOSTICS
ferrugineum, M. distortum, and T. extracted hair or tissue
schoenleinii homogenates of biopsy specimen
*Fluorescent-negative infections -
T. tonsurans, T. violaceum and T.
verrucosum

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BENIN • BERNARDINO | BAÑEZ • BAUTISTA, J. • BAUTISTA, T. •BELMONTE • BERBA • BIGLETE • BONGCO • BORLONGAN • BRIONES • BUIZA
 DERMATOPHYTE INFECTIONS
• KOH exam- long septated or For Tinea faciei:
branched hyphae • KOH exam- best location:
• Culture- not routinely done since erythematous, slightly scaling,
fungal pathogens have long growth indistinct borders present at the
period, for exact identification if periphery of the lesions
diagnosis is uncertain; specimen
collected by rubbing lesion with
moistened cotton swab or gauze
pad
• Dermoscopy/Trichoscopy- may
show broken hairs, dystrophic
hairs, corkscrew hairs, comma
hairs, and black dot

• Fungal culture may be done - results after 1 week or 2 weeks

• Skin biopsy: septate branching hyphae at stratum corneum

Dermoscopy of tinea capitis. Comma

hairs (arrow), corkscrew hairs
(arrowhead), and broken hairs (thick
arrow) in a child with tinea capitis
SYSTEMIC SYSTEMIC
*Topical treatment does not penetrate Terbinafine
the hair shaft • 3-6mg/kg/day for 1-4 weeks
Pediatric patients: • 250 mg/tab OD for patients over
Griseofulvin as first line 40kg
• Ultramicronized form: • 125 mg/tab OD for patients 20-40kg
10mg/kg/day • 62.5 mg/tab OD for those under SYSTEMIC- for extensive disease or presence of fungal folliculitis
• Griseofulvin V oral suspension- 20kg • Terbinafine 250mg OD for 1 to 2 weeks
20mg/kg.day • Itraconazole 100mg/cap 2 caps OD for 1 week or 1 cap OD for 15 days
• Given for 2-4 months or 2 weeks Itraconazole • Fluconazole 150-200mg once weekly for 2 to 4 weeks
after negative laboratory • 5mg/kg/day for 2-3 weeks • Griseofulvin microsize 0.5 to 1g per day or ultramicrosize 375 to 500mg per day
examination for 2 to 4 weeks
• Absorbed effectively with fatty food Fluconazole
MANAGEMENT • Check for AST/ALT or CBC if • 6mg/kg/day for 2-3 weeks TOPICAL- for localized disease without fungal folliculitis
prolonged course • Miconazole, sulconazole, Itraconazole – BID for 2-4 weeks
TOPICAL • Ketoconazole, Terbinafine – apply OD for 1 week (may shorten course of
Trichophyton infections: Terbinafine • Miconazole disease by 1 week)
• 3-6 mg/kg/day for 1–4 weeks • Ketoconazole
• 250-mg tablet for patients over 40 • Terbinafine *AVOID use of Corticosteroids – may cause widespread tinea due to
kg immunosuppression; may cause flares
• 125 mg (1/2 tablet) for those 20–40
kg ** for Tinea faciei:
• 62.5 mg (1/4 tablet) for those under • If fungal folliculitis is present, oral
20 kg medication is required
• If there is no folliculitis, the infection
Microsporum infections: generally responds well to topical
• Higher doses of Terbinafine medication.

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BENIN • BERNARDINO | BAÑEZ • BAUTISTA, J. • BAUTISTA, T. •BELMONTE • BERBA • BIGLETE • BONGCO • BORLONGAN • BRIONES • BUIZA
 DERMATOPHYTE INFECTIONS
• Fluconazole 6 mg/kg/day for 2–3 • Oral agents are appropriate for
weeks widespread infections

Adult patients:
• Terbinafine 250 mg per day
• Itraconazole 5 mg/kg per day
(maximum 400 mg per day)
• Fluconazole 6 mg/kg per day
• Griseofulvin ultramicronized 10 to
15 mg/kg per day (maximum 750
mg per day)
• Given for 2-4 months or 2 weeks
after negative laboratory
examination

ADJUNCT
• Selenium sulfide shampoo or
ketoconazole shampoo left on the
scalp for 5 min 3 times a week to
reduce the shedding of fungal
spores
TINEA FACIEI
• Prognosis usually is good
• Recurrence is uncommon with • Lesions respond to topical and oral
adequate treatment antifungal treatment within 4-6
• Exposure to infected persons, weeks
asymptomatic carriers, or
contaminated fomites increase the TINEA BARBAE
• Localized tinea corporis – excellent
relapse rate • Prognosis usually is good • Good prognosis provided
prognosis; 70-100% cure rates after
• Without medication, there is • Inflammatory lesions undergo preventive precautions be taken
treatment with topical azoles or
PROGNOSIS
spontaneous clearing at about age spontaneous remission within a few allylamines or short-term or pulse • Complications are more likely to
15 years, except with T. tonsurans, months; however, if untreated, they occur in patients who are
systemic antifungals
which often persists into adult life leave scarring alopecia immunocompromised or are non-
• Widespread tinea may be a presenting
• Complete hair regrowth occurs in • Noninflammatory tinea barbae ambulatory
sign of AIDS
most children with hair loss lesions are more likely to be chronic
• Patients with prolonged or severe and may not tend to resolve
infections (e.g., kerion, favus) have spontaneously
the greatest risk for permanent • In superficial chronic tinea barbae,
alopecia, but mostly still regrows alopecia may occur in the center of
the lesions; however, this is not
common
TINEA FACIEI
• Combs, brushes, and hats should • Isolation and treatment of infected
be cleaned mechanically and pets is of great importance • Keep your skin clean dry
disinfected with household bleach • Dry hands and foot thoroughly
• Don’t share clothing, towels, sheets or after bathing
and natural bristle brushes must be TINEA BARBAE other personal items with someone
PREVENTION discarded • Avoid wearing occlusive footwear
• Eliminating the source of tinea who has tinea for long periods
• Household members should use barbae infection is of great
antifungal shampoo for 2-4 weeks importance. If farm workers become
to reduce risk for reinfection from infected, examine all animals for the
continued contact with presence of fungal skin lesions
asymptomatic carriers

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BENIN • BERNARDINO | BAÑEZ • BAUTISTA, J. • BAUTISTA, T. •BELMONTE • BERBA • BIGLETE • BONGCO • BORLONGAN • BRIONES • BUIZA
 DERMATOPHYTE INFECTIONS
• Beddings, furniture covers, and
towels should be washed
• Cats and dogs may be reservoirs,
consult veterinarian

II. ONYCHOMYCOSIS/ TINEA UNGUIUM

DISTAL SUBUNGUAL PROXIMAL SUNUNGUAL WHITE SUPERFICIAL

PHOTO

• Discolored (white, gray, yellow) nails

CHIEF COMPLAINT
• Dry, brittle nails
• Ask for history of frequent exposure of hands to moisture
• PMH: other Tinea infections, psoriasis, DM, immunosuppression, trauma
HISTORY
• Exposure to poor nail grooming, sports, fitness activities, occupation, occlusive shoes
• History of contact with household member with similar presentation
• Dry, brittle, lusterless nails with yellow brown
discoloration near the hyponychium
PHYSICAL EXAM • Powder like debris present under nail bed
• Proximal white discoloration of nail fold • Small chalky white spots on the surface of the nail
(Description of • Starts at distal corner of nail involving the
plate
lesion) junction of nail and its bed.
• Yellowish discoloration, spreading proximally
as a streak.
• Candidal onychomycosis: whole nail plate involved, almost all fingers are dark, ridged, and separated from bed; non tender swelling of proximal and lateral
nail folds with destruction of nail bed (paronychia) | !
DIFFERENTIALS • Psoriasis: onycholysis (separation from nail bed), multiple nail pits, beau’s lines, onychodystrophy, oil spots/ salmon patches (pathognomonic) | !
*Dermatophytes always starts from outside the nail vs Psoriasis which usually starts at the middle | !
• Lichen planus of nails: thinning and distal splitting of nail plates, longitudinal ridging, rough nail texture | !
DEFINITION Fungal infection of the nail plate
• Adults > Children
EPIDEMIOLOGY • M=F
• 30% of diagnosed are superficial infections
• T. mentagrophytes, Cephalosporium, Aspergillus,
ETIOLOGY & RISK • T. rubrum and Trichophyton megninii
• T. rubrum usually and Fusarium oxysporum fungi
FACTORS • Maybe an indication of HIV infection
• In HIV population: T. rubrum
ONYCHOMYCHOSIS CAUSED BY T. RUBRUM
• Usually starts at the distal corner of the nail (involves the junction of the nail and its bed)
PATHOGENESIS • A yellowish discoloration occurs, which spreads proximally as a streak in the nail
• Subungual hyperkeratosis becomes prominent and spreads until entire nail is affected
• Gradually, entire nail becomes brittle and separated from its bed (d/t piling up of subungual keratin)

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BENIN • BERNARDINO | BAÑEZ • BAUTISTA, J. • BAUTISTA, T. •BELMONTE • BERBA • BIGLETE • BONGCO • BORLONGAN • BRIONES • BUIZA
 DERMATOPHYTE INFECTIONS
• Skin of soles: granny scaling and erythema

ONYCHOMYCHOSIS CAUSED BY T. MENTAGROPHYTES

• Usually superficial
• No paronychial inflammation
• Generally begins with scaling of the nail under the overhanging cuticle (remains localized to a portion of the nail)
• In time, entire nail plate may be involved
• Primarily involves distal nailbed and hyponychium • Invasion of the toenail plate on the surface of the
SITES OF • Involves the nail plate mainly from proximal
PREDILECTION • With secondary involvement of the underside of nail
nailfold
the nail plate of fingernails and toenails
Culture:
• Not usually done due to long waiting time
• On Sabouraud agar with chloramphenicol and cycloheximide (Mycosel) agar (32% sensitive) |&

KOH smear
• Performed rapidly in office |&
DIAGNOSTICS • Scrape off the brittle nail
• Dermatophyte: long septated hyphae
• Candida: pseudo hyphae

Periodic Acid-Schiff (PAS) stain |&

• 41-93% sensitivity
• More sensitive than KOH or culture
TOPICAL
• If nail involvement is mild
• Diffusion into highly keratinized nail plate is poor
• Preferred for children

SYSTEMIC
• Indications: DM, soaking cannot be avoided, immunocompromised

MANAGEMENT Itraconazole
• Pulsed dosing
• 200 mg twice daily for 1 week of each month
• Fingernails: for 2 months
• Toenails: for 3-4 months

Fluconazole
• 150-300 mg once weekly for 6-12 months

• Recurrence (relapse or reinfection of onychomycosis is not uncommon (10-53%)

PROGNOSIS
• Fingernail fungal infections: more favorable prognosis than toenail infections
PREVENTION Avoid water immersion, use gloves if can’t be avoided

REFERENCES
• Andrews’ Diseases of the Skin
• Doc Ang’s lecture
• Batch 2020 Derma trances
• Amboss
• Medscape

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BENIN • BERNARDINO | BAÑEZ • BAUTISTA, J. • BAUTISTA, T. •BELMONTE • BERBA • BIGLETE • BONGCO • BORLONGAN • BRIONES • BUIZA
 DERMATOPHYTE INFECTIONS
III. APPENDIX/GALLERY
TINEA PEDIS TINEA CORPORIS TINEA CAPITIS ONYCHOMYCOSIS TINE FACIEI/BARBAE

Diagnosis: Tinea corporis caused by Diagnosis: Distal subungual

Dry scaling erythema of the the dermatophyte Trichophyton Reddened, papular, and pustular Diagnosis: Tinea barbae
onychomycosis
toes and the lateral foot, mentagrophytes round nodule located on the scalp.
which extends to the lower Crusts, scaling, and alopecia are There is an inflamed region with
leg. Fingernail showing yellow
Round, erythematous lesion with seen in the area of the lesion. discoloration starting at the distal follicular papules above the mouth;
central scaling. The border is raised edge, longitudinal striations, and additional papules on the chin
and lined with pustules. separation from the nail bed.

There is pronounced
Diagnosis: Superficial white
erythema in the region of
onychomycosis
the interdigital space in the
middle of the image with a
The nail of the big toe shows white
healing blister.
patches of fungus on its surface.

There is an erythematous, There is a round, almost hairless

marginated lesion that has a map- plaque with coarse scaling located Diagnosis: Tinea faciei
like appearance and central pallor in the middle of the scalp of a child.
without scaling

Diagnosis: Proximal subungual

onychomycosis

There is white discoloration from the

proximal edge and transverse ridges
Diagnosis: Tinea pedis on the whole nail plate.

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BENIN • BERNARDINO | BAÑEZ • BAUTISTA, J. • BAUTISTA, T. •BELMONTE • BERBA • BIGLETE • BONGCO • BORLONGAN • BRIONES • BUIZA