DERMATOPHYTOSIS

INTRODUCTION
• Dermatophytosis or cutaneous mycoses are most
common superficial mycoses affecting skin, hair and nail
• Generally called ringworm infections
• These infections are caused by a homogenous group of
closely related keratinophilic fungi known as
Dermatophytes
• These Dermatophytes infect only superficial keratinised
structures such as skin, hair and nail but not deeper
tissues
• The diseases caused by non-dermatophytic fungi infecting
skin are called dermatomycoses whereas that of hair and
nail are known as piedra and onychomycosis.
• It is a group of about 40 related fungi that belong to
three genera :
1. Microsporum : infects skin and hair not nails
2. Trichophyton : skin, hair, nail
3. Epidermophyton : skin and nail not hair
• Depending on the usual habitat (humans,
animals, or soil), dermatophytes are classified
as follows
1. Anthropophilic: These are the fungal species
exclusively infecting humans
2.Zoophilic: They infect animals as well as birds
3.Geophilic: These fungal species are frequently
isolated from soil
• They are highly contagious and frequently
transmitted by exposure to shed skin scale, nails,
hairs containing hyphae and conidia.
• The infection primarily depends on the personal
habits and living conditions of people.
• They remain viable for long periods on fomites.
• They are restricted to non-viable skin because most
are unable to grow at 37˚C or in the presence of
serum
• Many species have particular keratinase, elastase and
other enzymes which make them host specific.
• Several are capable of sexual reproduction – produce
ascospore. Thus belongs to genus Arthroderma
• In skin, they produce hyaline, septate, branching
hyphae, or chains of arthoconidia.
 CLASSIFICATION
• According to shape and site of
infection:
1. Microsporum : spindle shaped;
infect skin and hair.
- M. canis
- M. gypseum
- M. gallinae
- M. nanum.
2. Trichophyton : pencil shaped;
infect skin, nail, hair.
- T. rubrum
- T. tonsurans
- T. mentagrophytes.
• 3. Epidermophyton : club shaped; infect skin and nail.
- E. floccosum.
• According to habitat :
1. Antropophilic : habitat in human body.
- some Trichophyton species
- E. floccosum.
- T.rubrum, T. mentagrophytes, T.violaceum
2. Geophilic : usually habitat in soil.
- M. gypseum, M.amazonicum
3. Zoophilic : usually habitat in animal.
- M. canis (dogs and cats)
- M. gallinae (fowl)
- M. nanum (pigs)
- T. equinum (horses)
- T. verrucosum (cattle).
 PATHOGENESIS
Dermatophyte infection is acquired by direct contact
with soil, animals or humans infected with fungal spores.
Then the spores are carried to different areas due to
scratching of the inoculated site. Predisposing factors
include moist humid skin and tight fitting underclothing.
Skin: Dermatophytes grow in a centrifugal pattern in
the stratum corneum; leading to formation of
characteristic well-demarcated annular- or ring-shaped
pruritic scaly skin lesions with central clearing and
raised edges. Scaling, erythema, and rarely blister
formation may occur
 Nails: They invade the nails through the lateral or
superficial nail plates and then spread throughout the
nails
 Hair shafts: Dermatophytes can invade within the hair
shaft or may be found surrounding it. Hairs become
brittle and areas of alopecia may appear.
 A deep and persistent suppurative folliculitis may be
produced; called as Majocchi granuloma
 Lesions are not produced by the tissue invasion by the
fungi ; but in response to the host's inflammatory
reaction elicited by fungal antigens
Pathogenesis :
Hyphal invasion of the skin of scalp

Subsequent spread down the keratinized wall of hair follicle

Infection begins just above hair follicle, grow downwards on

non involving area as the hair grows upwards.

Production of dull grey, circular patches of alopecia with

black dots of broken hair ,scaling and itching.
Males are more commonly infected than
females as progesterone is inhibitory to
dermatophyte growth.
Severity depends on the infecting fungi,
immune status of the host and the site of lesion
• Anthropophilic dermatophytes are the most
common dermatophytes affecting humans.
They cause relatively mild and chronic lesions but
respond to treatments
• In contrast, geophilic and zoophilic species,
being less adapted to human hosts, produce
more acute inflammatory response and severe
infections; but they tend to resolve more
quickly
 CLINICAL FEATURES

• The skin infections caused by Dermatophytes are chronic

infections of the skin often found in the warm humid
areas of the body
• Typical ringworm lesions are circular , dry, erythematous,
scaly and itchy which have an inflamed border containing
papules and vesicles surrounding a clear area of
relatively normal skin
• These lesions are associated with variable degrees of
scaling and inflammation
• Nails are thickened, deformed, friable, discolored,
subungual debris accumulation
Dermatophytid or Id Reaction
Occasionally, hypersensitivity to dermatophyte
antigens may occurs secondary eruption in
sensitized patients because of circulation of
allergenic products. However, these lesions are
distinct from the primary ringworm lesions as
they occur distal to primary site and fungal
culture often turns negative.
 Dermatophytes; Clinical classification

• Dermatophytosis is classified according to site of

involvement :
1. Tinea capitis : infection in scalp and hair.
2. Tinea barbae : infection in beard area.
3. Tinea corporis : infection in the trunk.
4. Tinea cruris (jock itch): infection in groin/ inguinal
region.
5. Tinea manum : infection in hand.
6. Tinea unguium (onychomycosis): infection in nail.
7. Tinea pedis (athlete’s foot) : infection in foot.
 Tinea Capitis
• Dermatophytosis or ringworm of the scalp and hair is
called Tinea capitis.
• Caused by Trichophyton or Microsporum.
• This infection presents as the following clinical types
a)Inflammatory – Kerion, favus
b)Non-inflammatory – Black dot, Ectothrix and Endothrix
• Zoophilic species : induce combined inflammatory
and hypersensitivity reaction – kerion.

• Trochophyton schoenleinii : acute inflammatory

reation of hair follicle leading to formation of scutula
(crust)- favus.
 Ectothrix
• The arthrospores appear as mosaic sheath
around hair or as chains on surface of hair
shaft
• The cuticle of hair remains intact
• Hyphae invade hair shafts at mid follicle
and as hair grows out of follicle, hyphae
burst out of shaft and cover hair surface
with mass of small arthrospores
• Caused by T. mentagrophytes, M. canis,
M. audouinii, M.
gypseum and T.
verrucosum
 Endothrix
• Hyphae form arthrospores within
hair shaft, which is severely
weakened
• Cuticle of hair is usually destroyed
• The arthrospores are 3-4 µm in
diameter and are observed in chains
filling inside shortened hair stubs
• Caused by T. schoenleinii, T.
tonsurans and T. violaceum
• T. rubrum cause both ectothrix as
well as endothrix infections
 Tinea corporis

• This is disease of non-hairy skin of body and may

result from extension of infection from scalp, groin or
beard

• Characterised by erythematous scaly lesions, annular,

sharply marginated plaques with raised border which
may be single, multiple or confluent
 Tinea Pedis
• This is the infection of plantar aspect of foot, toes
and interdigital web spaces
• It is frequently seen among individuals wearing shoes
for long hours and popularly known as Athlete’s Foot
• In toe webs, scaling, fissuring, maceration and
erythema may be associated with an itching or
burning sensation
• Due to maceration and peeling, cracks appear which
are prone to secondary bacterial infections
• When infection becomes chronic, sole becomes
hyperkeratotic and is often covered with fine scales
 Tinea Barbae

• Infection of beard and moustache areas of face with

invasion of coarse hairs
• Also called as barber’s itch
• There are erythematous patches on face which show
scaling
 Tinea Faciei

• Dermatophytic infection of skin that occurs on non-

bearded regions of face
 Tinea Cruris

• Dermatophytic infection of groin

• Involves perineum, scrotum and perianal area and
may spread to inner third of buttock and occasionally
to thigh
• The appearance of Tinea Cruris can be seen in other
intertriginous areas such as axilla and around
umblicus of obese patients
 Tinea Manuum

• Dermatophyte infection of skin of palmar aspect of

hands
• The most common clinical manifestation is diffuse
hyperkeratosis of palms and fingers
 Tinea Unguium

• Dermatophyte infection of nail plates and is largely a

disease of adults
• It begins under leading free edge of nail plate or
along lateral nail fold and may continue until entire
nail plate and nail bed are infected
• There is accumulation of subungual debris in an
opaque, chalky or yellowish thickened nail
 LABORATORY DIAGNOSIS
SPECIMENS
• Scrapings of the skin and nail as well as short length
of hair plucked from the basal root portion not by
clipping. Scrapings are taken from the active margin
of cutaneous lesion. If any small vesicle or blisters
present, epithelium forming roof is an ideal sample.
• Disinfect the affected site with alcohol before
collecting the specimens
• Specimens should be sent to the lab by folding in a
thick black paper
Direct microscopic examination
1.KOH wet mount
The specimen is mounted in KOH (10% for skin
scrapings or hair, 20-40% for nail clippings)
Branching hyaline septate (non-pigmented) hyphae is
considered positive for fungi; spores may also be seen
• Ectothrix and Endothrix can be distinguished from
wet mount and arrangements of arthrospores can
be made out
KOH
• The demonstration of fungus in nails may be
difficult and may be possible only after
keeping clippings overnight in higher
concentration of KOH (20%)
2.Calcofluor white stain is often more useful in
visualizing fungal hyphae or arthrospores
3.Histopathological examination of the skin
biopsy may be stained with PAS to demonstrate
hyphae
 Wood’s lamp Exmaination

 Wood’s glass/filter consist of barium silicate with

9% nickel oxide.
 This wood’s filter is opaque to all light expect for a
band between 320 and 400 nm with a peak at 365
nm
 Fluorescence of tissue occurs when light of shorter
wavelength, in this case 340-400nm, initially
emitted by wood’s light, is absorbed and radiation
of longer wavelengths, usually visible light, is
emitted.
Hence it transmits long-wave ultraviolet light
with peak of 365 nm that shows characteristic
fluorescence produced by some microbial
agents.
The chemical substance responsible for the
fluorescence is pteridine.
 Bright green: M.canis, M.audouinii
 Dull green: T.schoenleinii
 No fluorescence: All other dermatophytes
 Golden yellow : M.furfur
FUNGAL CULTURE
• Species identification is possible only by culture
examination
• Sabouraud’s dextrose agar containing
chloramphenicol and cycloheximide
• The plates incubated aerobically at 25-30°C for up to
10 days up to 4 weeks
• Identification of dermatophytes in the laboratory is
by examining the macroscopic and microscopic
characteristics of the fungal colonies.
• Macroscopic appearance of the colonies
such as-rate of growth, texture, pigmentation, colony
topography
• Microscopic appearance
The colonies are teased and LPCB mount is made to
demonstrate the hyphae and spores (or conidia)
• Conidia: Two types of spores or conidia are observed
such as small unicellular microconidia, and large
septate macroconidia; both are used for identification
of species
• Special hyphae: Dermatophytes possess thin
septate hyaline hyphae; some species have
specialized hyphae such as spiral hyphae,
racquet hyphae and favic chandeliers etc.
MACROSCOPIC EXAMINATION
 MICROSCOPIC EXAMINATION
MACROCONIDIA MICROCONIDIA

TRICHOPHYTON Rare, thin walled, smooth, pencil Abundant

shaped

MICROSPORUM Numerous, thick walled, rough, Rare

spindle shaped

EPIDERMOPHYTON Numerous, thick walled, rough, Absent

spindle shaped
• The Dermatophyte test medium (DTM) is
used for presumptive identification of
dermatophytes from fungal or bacterial
contaminants found prevalent in cutaneous
lesions. On incubation at 25°C, the
dermatophytes turn medium red due to
change in colour of indicator phenol red by
increased PH through their metabolic activity
while other fungi and bacteria do not.
Dermatophyte test medium
• Dermatophyte identification medium (DIM) is
also used for presumptive identification of
dermatophytes and to avoid false positive
results associated with use of DTM.
HAIR PERFORATION TEST
To differentiate b/w T.mentagrophytes and
T.rubrum and M.canis and M.equinum
Positive: Shows Wedge shaped perforation
PROCEEDURE
Place a sterile filter paper strip in to bottom of sterile petri
dish and cover surface of strip with sterile distilled water

Add small portion of sterilized prepubertal or infant hair in

to water

Add 5-6 drops of 10% yeast extract to speed up the action

Inoculate the colony directly on hair and
incubate at 25°C for four weeks

Observe hair by making wet smear or LPCB

mount for the presence of conical perforations
of hair shaft
Positive: T.mentagrophytes and M.canis
Negative: T.rubrum and M.equinum
• Hairbrush sampling technique: Adequate material
from minimal lesions may be obtained by brushing
scalp with stere plastic hairbrush or massage pad,
which is then inoculated in to an appropriate fungal
culture medium by pressing brush or pad spines in
to agar
• Urease Test: Is done on Christensen’s urease
medium.
Positive: T.mentagrophytes
Negative: T.rubrum
• Molecular methods: PCR can be used to
detect species specific genes (e.g. chitin
synthase gene)
• Skin test: It is done for detecting
hypersensitivity to dermatophyte antigen
(trichophytin)
TRICHOPHYTON
MICROSPORUM
Epidermophyton floccosum
 TREATMENT
 Oral terbinafine or itraconazole are the drugs of
choice for treatment of dermatophytosis. Duration of
treatment depends on the affected site (1-2 weeks
for skin lesions, 6 weeks for hair infection, 3 months
for onychomycosis). They can be given as pulse
therapy
 Alternate: Oral griseofulvin and ketoconazole may be
given
 Topical lotion such as whitefield ointment or
tolnaftate can be applied