Download Tinea capitis

Fungal Infection of the Skin
Dr. Ahmed A. Kawen
Dermatology & Venereology
Dermatophytosis
“Ringworm" disease of the nails, hair, and/or stratum
corneum of the skin caused by fungi called
dermatophytes.
●Dermatophytes, have the ability to infect and survive on
keratin only (skin, hair, and nail).
●They caused by three genera: Microsporum,
Trichophyton, and Epidermophyton.
●Dermatopyte classified according to their origin into:
Anthropophilic (human source), Zoophilic (animal
source), Geophilic (soil source).
 Zoophilic infections usually elicit a brisk inflammatory
response.

Dermatophytosis

Trichophyton
–

Microsporum
–

T.rubrum, T.mentagrophytes, T.violaseum,
T.schoenleinii, T.verrucosum
M.canis, M.gypseum
Epidermophyton
–
E.floccosum
Dermatophytosis

Geophilic
–

Zoophilic
–

M.gypseum
M.canis, T.verrucosum
Anthropophilic
–
T.rubrum, T.violaseum, T.schoenleinii ,E.floccosum
Epidmiology

Trichophyton rubrum is
dermatophyte worldwide
the
most
common

Occur most frequently in postpubertal hosts
except tinea capitis which occurs mainly in
prepubertal children

Men tend to more frequently have tinea cruris and
tinea pedis than women
Etiological agents



Microsporum - infections on skin and hair (not
the cause of TINEA UNGUIUM)
Epidermophyton - infections on skin and nails
(not the cause of TINEA CAPITIS)
Trichophyton - infections on skin, hair and
nails.
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Clinical Significance
Dermatophyte
Skin
Hair
Microsporum
X
X
Trichophyton
X
X
Epidermophyton
X
Nails
X
X
Clinical manifestations of ringworm

Infections with dermatophytes are usually
called Tinea (ringworm); for further
description, the anatomical site is added,
including:







Tinea capitis; ringworm infection of the scalp.
Tinea corporis; ringworm infection of the body
(smooth skin)
Tinea cruris; ringworm infection of the groin.
Tinea unguium; ringworm infection of the nails.
Tinea barbae; ringworm infection of the beard.
Tinea manuum; ringworm infection of the hand.
Tinea pedis; ringworm infection of the foot (athlete's
foot).
1- Tinea of the trunk and limbs (Tinea
corporis or T. circinata):

It can occur at any age. The clinical
infection usually starts from an inoculation
site and spreads peripherally, where the
lesion becomes more pronounced (active
border).

The active border: is a very characteristic pattern of
dermatophyte infection, typically the active border is scaly,
red, and slightly elevated, a few small vesicles and pustules
may be seen within them. The lesions expand slowly and
healing in the centre leaves a typical
ring-like pattern, this
characteristic annular appearance results from the
immunological elimination of the fungus from the centre of the
lesion, and the subsequent resolution of the inflammatory
host response at that site.
Tinea corporis - body ringworm



Skin lesion pink-red, scaly, annular patch with
expanding border (active border).
Any dermatophyte can cause it but the
T. rubrum is the most common pathogen
Tinea imbricata
T.concentricum Anthropophilic
– begin as small, brown, pruritic macules and
papules and progress to concentric rings of scales.
The infection usually begins in childhood, and
progresses slowly over time. The lesions are quite
pruritic, and itching aggravated by heat.
. Females are more commonly affected in the adult
population; this sex ratio is reversed in children
– . A T-cell defect caused by an autosomal recessive
trait has been suggested
–
Tinea imbricata
Tinea imbricata
2-Tinea cruris - ringworm of the groin



is common and affects men more often than women.
The children are rarely affected.
The upper inner thigh is involved and lesions expand
slowly to form sharply demarcated plaques with active
border. The scrotum is usually spared.
DDX: intertrigo, contact dermatitis (irritant or allergic),
candidiasis, erythrasma (bacterial infection), psoriasis,
and seborrhoeic dermatitis


Caused by E. floccosum, T. rubrum and T.
mentagrophytes
The inflicted are more likely to have tinea
pedis and onychomycosis as a source of
dermatophytes
Tinea cruris - ringworm of the groin
3- Tinea of the face (Tinea faciei):


It is limited to the glabrous skin of the face in
adult males. In pediatric and female patients,
the infection may appear on any surface of the
face, including the upper lip and chin.
The lesions have annular shape with active
border
4- Tinea of the beard (Tinea barbae):
It is a superficial dermatophyte infection that is limited to the
beard areas of the face and neck and occurs almost exclusively
in adult males .
Like tinea capitis, the hairs are infected and easily removed
(easily epilation).
Two types:
(1) The deep type: develops slowly and produces nodules
and kerion-like swellings: acquired from animal, caused by
T. mentagrophytes var. mentagrophytes and T.
verrucosum.
(2)Superficial
type:
less
inflammatory,
characterized by pustular folliculitis , caused by T.
rubrum. Aquired from contaminated razors in
barber- shops. In both types: the hairs are either
easily plucked or lost.
5- Tinea of the foot (Tinea pedis,
Athlete’s foot):
-----Tinea pedis,
It is a common type of dermatophyte infection. The forth web
space is most commonly involved. A warm moist environment
of the of the toe webs predispose for this infection. The
involved area is usually white, macerated, and soggy, with
itching.
Lack of sebaceous glands and moist environment
due to occlusive shoes are predisposing factors
Caused by T. rubrum, T. mentagrophytes, E. floccosum
Types:
(1)Moccasin:
erythema
diffuse
hyperkeratosis,
scaling
and
(2)Interdigital :Most common type; erythema,
maceration, fissures and ,ulceration between toes
(3)Inflammatory : we see vesicles and bulla
6- Tinea of the hands (Tinea manum):
It appears dry diffuse and keratotic, at the palmar surface.
It is different from that of back of hands due to lack of
sebaceous glands on the palms
Caused by T. rubrum, T. mentagrophytes and E. floccosum.
-----Tinea manum
Usually non-inflammatory and often unilateral there is
diffuse hyperkeratosis of the palms and digits with
accentuation of scales on creases that fails to respond
to emollients
An important clinical clue is tinea unguium
Is often present in patients with tinea pedis(two feet
and one hand syndrome)
7- Tinea of the nails (Tinea ungium,
onychomycosis):
The initial changes occur at the free edge of the nail, which
becomes yellow and crumbly. Subungual hyperkeratosis,
onycholysis, and thickening may then follow. Usually only few
nails are infected but rarely all are.
infection of the nail unit
Three types : based upon the point of fungal entry into the
nail unit
Distal/lateral subungual: with invasion via the
hyponychium (most common)
Superficial white: with direct penetration into the dorsal
surface of the nail plate
Proximal subungual: with invasion under the proximal nail
fold ( seen frequently in immunocompromised hosts).
Multiple nails on one or both hands or feet are usually
affected
Frequently associated with chronic tinea pedis
Caused by T. rubrum, T. mentagrophytes and E. floccosum
Onychomycosis
Types:
1.
2.
Distal Subungal
White superficial

3.
Proximal Subungal

4.
Chalky white patches
May indicate HIV infection
Total dystrophic
Onychomycosis
Onychomycosis with Onycholysis
White Onychomycosis
Leukonychia mycotica
Candidaisis of nail
Paronychia
Psoriasis
Middle of nail, oils spots, pitting.



Variants:
Tinea incognito: tinea lesion modified by topical
steroids, may lack a raised scaly border.
Majocchi’s granuloma: is characterized by
follicular papulopustules or nodules, commonly
seen in women who have tinea pedis or
onychomycosis and shave their legs. Topical
steroids and immunosuppression are predisposing
factors.
8- Tinea incognito (steroid modified tinea):
Fungal infections treated with topical steroids, appear as diffuse
erythema and scales with scattered papules and pustules, and usually
lose their characteristic features (annular shape with active border).
9-Tinea capitis - ringworm of the scalp
● Tinea capitis is a dermatophytosis of the scalp and associated hair (which lost and
become easily epilated).
● It occurs mainly in children (boys more than girls),and it is very rare in adults
(because fatty acids from sebaceous glands inhibit dermatophyte growth).
● Tinea capitis transmited usually by direct contact (with infected human or infected
animal) or from contaminated fomites. Transmission is higher with: decreased
personal hygiene, overcrowding, and low socioeconomic status.
●The most important differential diagnosis of tinea capitis is alopecia areata in which
the skin is smooth without any signs of inflammation or scaling
T. tonsurans is currently the most common cause of tinea capitis in the US while
T.verrucosum in iraq
Types and clinical presentation:
A- Noninflammatory Type (Gray Patch):
It is the most common type in Iraq. Hairs in the affected area turn gray and lusterless and
break off above the level of the scalp with minimal Inflammation. It is usually result from
anthropophilic dermatophyte
B- Inflammatory Type (Kerion):
A sever inflammatory reaction with a boggy tumor like mass that exudes pus. It is usually
result from zoophilic dermatophyte (cats, dogs and cattles). Inflammatory lesions are
usually pruritic, and may be associated with pain, posterior cervical lymphadenopathy,
and fever. If not treated properly; it is often results in scarring alopecia.
C- “Black Dot” Tinea capitis:
Hairs broken at the level of the scalp leave behind black dots in the areas of alopecia .
D- Favus (honeycomb):
Characterized by thick yellow crusts (scutula), which may lead to scarring alopecia.
Tinea capitis - ringworm of the scalp

Types:
1.
Scally.
Black dot.
Favus.
Kerion.
2.
3.
4.
Scally type;
Kerion;
Black dot type;
Favus;

caused by T. schoenleinii.
The most important DDx of tinea capitis is Alopecia Areata
ENDOTHRIX FUNGUS
ECTOTHRIX FUNGUS
100X
TINEA CAPITIS
ECTOTHRIX
ENDOTHRIX
YELLOW- GREEN
FLUORESCENCE
DULL GRAY-GREEN
FLUORESCENCE
M.AUDOUINII
M.CANIS
M.FERRUGINEUM
T.SCHOENLEINII
NO FLUORESCENCE
NO FLUORESCENCE
M.GYPSEUM
T.MENTAGROPHYTES
T. RUBRUM
T.TONSRANS
T. VIOLACEUM



Dermatophytid “id” Reaction:
A non infective cutaneous eruption (usually
papulovesicular) representing an allergic
response to a distinct focus of a dermatophyte
infection. The condition disappears
spontaneously when the primary infection is
improved.
Tinea Capitis Treatment
•Must treat hair follicle
•Topical not effective
•Systemic agents
•Griseofulvin for children ;12.5 mg/kg.
•Imidazoles, terbinafine.
•Steroids for inflamed lesions like Kerion.
•Treat until no visual evidence, culture (-)… plus 2 weeks
•Average of 6-8 weeks of treatment.
Other oral anti-fungal for patients who do not
tolerate or respond to Griseofulvin.



Terbinafine (Lamisil) 3 to 6mg/kg once a day
for 2 to 4 weeks.
Fluconazol: 6mg/kg/day once daily for 6wk
Itraconazole: 5mg/kg/day,once daily or divided
into two doses,for 2 to 4 weeks
Tinea Pedis: Treatment
•Dry Feet
•Alternate shoes, Absorbent powders, Change socks
•Scale my be reduced with keratolytic
•Topicals and/or Systemics.
•Topical: terbinafine may be more effective than azoles.
Steroids if inflamed.
•Systemic allyamines or azoles
Treatment of Onychomycosis.
Topical Treatment:
•
Can be effective for limited involvement and for
prevention.
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.
•Pulse dosing fingernails - (200 mg bid 1 wk q mo.) x 2
Indication of systemic antifungal in dermatophyte infections:
1- Tinea capitis.
2- Onychomycosis.
3- Tinea incognito.
4- Widespread infection.
5- Immunocompromised patient.
6- Recurrent or persistent infection
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