Fungal skin infections M. Nečas, H. Charvátová I. dermatovenerologická klinika FN u sv. Anny, LF MU Brno http://selectsmarthealth.com/skin-fungus/ Skin infection —Bacterial —Fungal —Viral Fungi imperfecti —Dermatophytes —Yeasts /candida, cryptococcus/ —Dimorphic fungi (deep fungal inf.) —Oportunic fungi (aspergillus aj.) Fungi - mycetes Ø100 thousand of species, ubiquitary ØAerobic organisms ØDo not manufacture chlorophyll classes: Zygomycetes Ascomycetes Basidiomycetes Deuteromycetes (fungi imperfecti) (pathogenic for human) nomenclature —Mycosis = any fungal infection, incl. Yeast, deep mycosis > —Tinea = dermatophytoses > —Trichofytia, epidermophytia, microsporia I. Dermatophytoses —Antropophilic: T.rubrum,T. interdigitale fungi T. tonsurans,T. schoenleinii Microsporon audouinii Epidermphyton floccosum —Zoophilic : T. verrucosum, mentagrophytes, equinum Microsporon canis, persicolor, nanum —Geophilic: T. ajelloi, terrestre Microsporon gypseum Tinea pedis —C. agens: Trichophyton rubrum —clinical variants : interdigital hyperkeratotic dyshidrotic interdigital tinea hyperkeratotic tinea Tinea unguium-onychomycosis —C.agens: T. rubrum T. interdigitale Epidermophyton floccosum Tinea unguium-onychomycosis Tinea unguium-onychomycosis Tinea unguium-onychomycosis Tinea unguium-onychomycosis Tinea inguinalis —C. agens: E. floccosum,T. rubrum,T. interdigitale Tinea inguinalis Tinea manum —etiol: T. rubrum T. interdigitale E. floccosum ---------------------------------- T. verrucosum —forms: hyperkeratotic dyshidrotic erythemosquamous Tinea manum-dyshidrotic form Tinea manum erythemosquamous form Tinea corporis —T. verrucosum —T. mentagrophytes —M. canis ----------------------- —T. rubrum —E.floccosum Tinea corporis -superficial Tinea corporis - erythemosquamous Tinea corporis erythemovesiculous Tinea corporis - deep —T. verrucosum —T. mentagrophytes Tinea faciei —M. canis —T. verrucosum —T. mentagrophytes Ddg: atop. dermatitis seborrhoic dermatitis CDE Tinea capitis —C.agens: Trichophyton (ecto/endothrix ) growth along the hair Microsoporon (ectothrix) invasion of the hair —clinical variants: superficial (non-inflammatory) deep (inflammatory) - Kerion Celsi favus Tinea capitis - superficial Tinea capitis - deep Tinea capitis - deep Tinea capitis - favus —C.agens: Trichophyton Schoenleinii —Most often in children, very rare in W. and C. Europe —Occurence in Middle East region —Scutulum (little shield) – yellowish dish-like crusts —mixture of hyfi and spores, smells like a mouse urine —Rarely trunk and nails affected Tinea capitis - favus Tinea barbae (syccosis barbae parasitaria) —C.agens: T. verrucosum M. canis —Clinical picture: folliculitis, infiltrates, nodules —Ddg: syccosis barbae nonparasitaria (staphylogenes) Pityriasis versicolor uaffecting the epidermis, causative agens – Malassezia furfura (a lipophilic organism) u Factors: warm and humid environment (prevalence of 50% of the tropical area), hyperhidrosis, use of oral contraceptives, corticoids, immunosuppressants, malnutrition u Skin finding: oval to round macules with small (pityriaziform) scales - trunk, neck, upper limbs. Macules - white, pink, red-brown, yellow-brown - wrinkled surface, discreet desquamation u red-brown macules turn white after UV exposure uHistologically: finding spores and hyphae in the stratum corneum (so-called image of meatballs and spaghetti), evident in HE staining uExamination: microscopically (staining with 1% methyl blue, finding spores and hyphae), Wood lamp 365 nm (yellow-orange fluorescence - pteridine present), cultivation (rarely, requires a medium containing lipids) uTh: topical (selenium sulfide, zinc pyrithione, cyclopiroxoamine, tacrolimus, azole and allylamine antifungals), systematic (itraconazole, fluconazole, pamiconazole), photodynamic therapy? uFrequent relapses! Pityriasis versicolor Pityriasis versicolor II. Yeast infections yeasts: reproduce by budding Candidosis: Cryptococcosis —Candida albicans —C.non albicans: glabrata krusei kefyr parapsilosis tropicalis 1) oral candidosis – soor 2) intertrigininous candidosis Candidosis interdigitalis errosiva 3) vaginal candidosis (MOP VI) 4) candidal balanitis 5) paronychium, onychomycosis Deep fungal infections —Blastomycosis: blastomyces dermatitidis skin, pulmonary, and disseminated variant —Histoplasmosis: H. capsulatum (american f.) H.duboisii ( african form) osteoarticular,lymphadenopathy,enteral, skin: nodules, abscessses,ulcers —Lobomycosis: Loboa Loboi tumoriform nodules Deep fungal infections —Coccidiomycosis —Paracoccidiomycosis —Aspergillosis Sporotrichosis —Chromomycosis —Geotrichosis —Maduramycosis Diagnosis of fungal infections 1) Obtaining specimens – disinfection of the lesion with 70% ethanol scraping the scales from the border, or hyperkeratotic material from beneath the nail‘s free end 2) Microscopic investigation: - native preparation (10-30% KOH,30min.-3h) - possible to stain with Parker‘s ink Branched septed fibres (hyphae) Diagnosis of fungal infections 3) fluorescent microscopy with blankophore – binds to chitin of the cell wall of fungi Diagnosis of fungal infections 4) Wood‘s lamp (high pressure flash light lamp emittingd UV A 320-400 nm) UV investigation  fluorescence Pityriasis versicolor: yellow/orange Mikrosporum: green Favus: white/grey Diagnosis of fungal infections 5) culture – on Sabouraud agar evaluation: after 3-5 days - yeasts (at 37 st C) 2w rapidly growing f. - E. floccosum 3w T.rubrum 4w slowly growing - T.verucosum Only after 6 weeks if nt apears, the culture can be concluded as negative Diagnosis of fungal infections —Evaluation of the macromorphology of the colonies —Manufacturing of the microculture —Physiologic tests - ureaze test … - zymograms, auxanograms.. T.rubrum T.mentagrophytes T.tonsurans Epidermophyton floccosum M.audouinii Microsporon canis Microsporon Gypseum Diagnosis of fungal infections —5) histologic excamination with PAS staining (periodic acid Schiff) Antifungal therapy —Antifungals: 1) polyenic 2) azoles 3) alylamines 4) other Antifungal therapy systemic treatment - indications —Deep fungal infections —Deep tinea capitis —Extensive onychomycosis —Recalcitrant superficial tinea Antifungal therapy Parenteral application: 1) Amphotericin B systemic and deep fungal infections intravenous appl., serious AE 2) Voriconazole (VFEND) 3) Posakonazole (Nofaxil, Posatex) 4) Kaspofungine (Candidas) Antifungal therapy Oral application: 1) fluconazole vaginal candidosis 2) ketokonazole yeast infection, dermatopytoses, malassezia 3) itrakonazole yeast infection, dermatophytoses, malassezia onychomycosis: 3m/5m 4) terbinafine onychomycosis: 6t/3m Antifungal therapy topical therapy: ekonazole - Pevaryl crm, pst ketokonazole - Nizoral crm clotrimazole - Canesten crm oxikonazole – Myfungar crm. terbinafin - Lamisil crm cyklopiroxolamine – Batrafen crm, sol.