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Figuring Out
Dermatological Fungal
Infections
Richard M. Haber, MD, FRCPC
Presented at the University of Calgarys Wednesday Evening Course Program, Calgary, Alberta.
uperficial dermatological fungal infections Tinea corporis (affects the trunk, arms, legs)
are caused by dermatophytes. Dermato- Tinea manuum (affects the hands)
phytes are keratophilic superficial fungal infec- Tinea cruris
(affects the groin)
tions that typically involve the skin, nails and Tinea pedis (affects the feet)
d,
hair. Dermatophytes can be classified by:
Tinea unguum (onychomycosis)
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Not fUonauthisoprilsaeyd, view and prin
Distributiond
There are three main sources by which dermatological fungal infections are spread: humanto-human (anthropophilic), animal-to-human
(zoophilic) and soil-to-human (geophilic).
Taxonomy
There are three genera of dermatophytes that
can be differentiated by fungal culture characteristics. These are:
1. Trichophyton (most common)
2. Microsporum
3. Epidermophyton
Tinea capitis
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Fungal Infections
Tinea corporis
Tinea corporis (commonly referred to as ringworm) clinically presents as annular lesions
with scale at the erythematous borders. It characteristically spreads centrifugally, often with
central clearing.
Tinea cruris
Tinea cruris (described as jock itch) is similar
to tinea corporis but occurs in the groin area
and on the buttocks.
Tinea pedis
Tinea pedis (also known as athletes foot) presents with interdigital and subdigital erythema
Tinea unguum
Tinea unguum (called onychomycosis) has a
prevalence in the Canadian population of
6.48% based on a study of 15,000 patients.1
Onychomycosis has a toenail-to-fingernail
involvement of 10:1.
Clinical types of onychomycosis
Approximately 90% of onychomycosis is distal
and lateral subungual in form, often presenting
with yellow or brown discolouration of the nail
and with a thickening of the nail plate.
Onycholysis develops with subungual hyperkeratosis as the dermatophyte enters under the
nail plate, either distally and/or laterally.
Dr. Haber is Head of the Division of
Dermatology, University of Calgary. He practices
out of the Foothills Medical Centre in Calgary,
Alberta.
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Review
Table 1
Allylamines (fungicidal)
Other
Topical
Miconazole
Clotrimazole
Ketoconazole
Oxiconazole
Econazole
Terbinafine
Ciclopirox olamine
(fungicidal)
Tolnaftate
Haloprogin
Systemic
Ketoconazole
Itraconazole
Fluconazole
Terbinafine
Griseofulvin
(fungistatic)
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Investigating dermatophytes
It is most important to establish a definite diagnosis of a dermatophyte. This is done by fungal
scrapings, or in the case of onychomycosis,
clipping back the affected nails and scraping
the subungual hyperkeratosis and debris of the
nail bed as proximally as possible. If tinea capitis is suspected, hair should also be sent, in
addition to scale, for examination.
The scrapings are sent to a mycological lab
where they are viewed after 10% potassium
hydroxide (KOH) is applied to clear the keratin.
Visualization of fungal hyphae is reported as a
positive KOH and the results are usually available in a few days.
The scrapings are also cultured on
Sabourauds agar and when a dermatophyte
grows, the genus and species of the dermatophtye can be identified. This result is usually available in three to four weeks.
Although a positive KOH is very suggestive
of a dermatophyte, a positive fungal culture is
definitive and is the gold standard for diagnosing dermatophyte infections.
Fungal Infections
Tinea capitis
Treating tinea capitis consists of using 250 mg of
oral terbinafine q.d. for two to four weeks in
Take-home message
Always do fungal scrapings of scaly skin
lesions and fungal clippings of dystrophic
nails and send for potassium hydroxide (KOH)
and fungal culture to positively establish a
diagnosis of a dermatophyte infection
Not all ringed lesions are ringworm or
dermatophyte infections. Many annular lesions
occur in dermatology including: nummular
eczema, granuloma annulare and erythema
annulare centrifugum. When in doubt, take
scrapings for KOH and fungal culture
Not all dystrophic finger and toenails are
due to dermatophytes. Skin disease
(e.g., psoriasis and lichen planus in nails) can
simulate onychomycosis. Also saprophytic
fungi can look identical to onychomycosis
but will not respond to the usual therapies.
Again, confirm all suspected cases of
onychomycosis with KOH and fungal culture,
especially as treatment can involve long-term
therapy with oral drugs that can cause sideeffects
Avoid combination therapies containing
antifungal and potent topical corticosteroids.
The immunosuppressive effect of the
corticosteroid can overcome the antifungal
effect, driving the dermatophyte down hair
follicles (Majocchi granuloma) or altering the
clinical appearance of the lesion, losing its
annular appearance (tinea incognito)
67
Review
adults and 5 mg/kg q.d. in children (the easiest
dosing schedule is < 20 kg, 62.5 mg q.d., 20 kg
to 40 kg, 125 mg q.d. and > 40 kg, 250 mg q.d.).
References
1. Gupta AK, Jain HC, Lynde CW, et al: Prevalence and Epidemiology of
Onychomycosis in Patients Visiting Physicians Offices: A Multicenter
Canadian Survey of 15,000 Patients. J Am Acad Dermatol 2000;
43(2 Pt 1):244-8.
2. Gupta AK, Lynde CW, Barber K: Pharmacoeconomic Assessment of
Ciclopirox Topical Solution, 8%, Oral Terbinafine and Oral
Itraconazole for Onychomycosis. J of Cutan Med Surg 2006;
10(Suppl 2):S54-S62.
he mean mycologic
cure rate for toenail
onychomycosis with oral
terbinafine is 75%.
Onychomycosis
Fingernails respond much better than toenails
to treatment and toenail onychomycosis is much
more likely to relapse after therapy.
Oral terbinafine therapy for onychomycosis
is 250 mg q.d. for six weeks for fingernails and
250 mg q.d. for 12 weeks for toenails. The mean
mycologic cure rate for toenails with oral
terbinafine is 75%.2
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