Why Is Ringworm Restricted to Superficial Skin Layers Peer Review
Tinea capitis (ringworm of the scalp), kerion, tinea faciei (face up), tinea barbae (barber's itch, tinea sycosis, ringworm of the beard), tinea corporis (ringworm of the body, tinea circinata, tinea glabrosa), Majocchi granuloma, tinea imbricata, tinea cruris (ringworm of the groin, jock itch), tinea pedis (athlete'southward foot), tinea manuum (hands), and tinea unguium (onychomycosis, dermatophyte infection involving nails).
Fungal pare infections are categorized into superficial and deep, with superficial infections defined as those limited to the stratum corneum of the epidermis, or to the hair and nails. The three near mutual types of superficial mycoses are dermatophytosis, diseases caused by Malassezia and superficial candidiasis, while the least common are tinea nigra, black and white piedra, and the infections caused by nondermatophytic molds. This chapter will focus on the superficial dermatophytoses.
Superficial fungal infections are some of the about common dermatologic diseases seen worldwide. It is estimated that between xiii.eight and 20% of the population has had a dermatophyte infection and approximately 12-13% accept onychomycosis.
Dermatophytosis is an infection caused by fungi from three genera, namely Microsporum, Trichophyton, and Epidermophyton. Infections acquired by these organisms are referred to as tinea which precedes the Latin proper name for the site which they involve, i.e. tinea capitis is a dermatophyte infection involving the scalp. The most common arrangement to classify these organisms is based upon mode of manual; geophilic (found in soil and infect both animals and humans), zoophilic (found on animals, merely can exist transmitted to humans), and anthropophilic (constitute on humans). The most common dermatophytes that upshot in illness in humans are summarized in Table I.
Table I.
| Species | Incidence | Natural habitat | Special features | Associated condition |
|---|---|---|---|---|
| Epidermophyton floccosum | Common | Humans | Tertiary most common organism | Tinea cruris, pedis, manuum, and onychomycosis |
| Microsporum audouinii | Less common* | Humans | Ectothrix, Wood lamp green fluorescence | Tinea capitis—more than common in Europe |
| Microsporum canis | Mutual | Cats | Ectothrix, Wood lamp dark-green fluorescence, associated with pet exposure | Tinea capitis—second almost common. 10% tin result in kerionTinea barbae |
| Microsporum ferrugineum | Common | Humans | Tinea capitis | |
| Microsporum gypseum | Common | Soil | Outdoor or occupational exposure | Inflammatory lesions |
| Trichophyton rubrum | Very common | Humans | Well-nigh mutual organism worldwide, 58% | Tinea corporis, cruris, pedis, manuum, and onychomycosis and Majocchi granuloma |
| Trichophyton tonsurans | Mutual | Humans | Endothrix, three% | Tinea capitis—majority of cases in United States. Common cause of tinea corporis worldwide |
| Trichophyton violaceum | Less mutual | Humans | Endothrix | Tinea capitis—endothrix |
| Trichophyton mentagrophytes var interdigitale | Mutual | Humans | Second most common organism causing tinea corporis and pedis, 27% | Tinea corporis, cruris, pedis (interdigital), manuum, and onychomycosis |
| Trichophyton mentagrophytes var mentagrophytes | Common | Mice, rodents | Inflammatory tinea pedis and barbae, dermatophytid reaction | |
| Trichophyton verrucosum | Common | Cattle | 7% | Tinea barbae, capitis, and kerion |
| Trichophyton nanum | Less common | Pigs | Tinea capitis, corporis, and cruris | |
| Trichophyton simii | Less common* | Monkeys | Asia | Tinea capitis |
| Trichophyton equinum | Less common | Horse | Tinea corporis | |
| Trichophyton concentricum | Rare* | Humans | Genetic and immunologic susceptibility, geographic brake | Tinea imbricata |
| Trichophyton schoenleinii | Rare* | Humans | Endothrix, blue-white fluorescence with Wood lamp | Favus |
| Trichophyton soudanense | Rare* | Humans | Africa | Tinea capitis |
What is the best treatment, and methods to prevent spread?
The best treatment and methods to prevent spread
The most common antifungal agents are summarized in Tabular array Two. Treatment options are summarized in Table 3.
Key concepts regarding the most common antifungal agents.
Suggested systemic treatment regimens for various dermatophytoses.
It is of import to reduce fomite load past disinfecting pilus brushes, cleaning towels, clothing and linen, getting rid of old shoes, vacuuming, and washing the floors. Wearing loose aerated wearable can too be beneficial.
Topical therapy is platonic for patients with limited involvement by tinea corporis, cruris, and pedis. Medications should be applied to the lesion and at least 1-2cm across this area once or twice a 24-hour interval for at least 1 to 4 weeks, depending on which agent is used. Topical azoles and allylamines testify high rates of clinical efficacy. For tinea capitis, antifungal shampoos containing 2% ketoconazole or 2.5 selenium sulfide shold be used in conjunction with oral antifungals and all household contacts should similarly utilise the shampoo daily. The side outcome profile is express to principal contact dermatitis.
Other topical agents that specifically accost onychomycosis include ciclopirox olamine eight% and amorolfine 5% nail lacquers (the latter is approved in Europe but not in the USA).
Ciclopirox olamine (Penlac, Loprox) is a hydroxypyridone derivative that works differently than other antifungals agents in that it does not affect sterol biosynthesis, instead it chelates polyvalent cations in metal-dependent enzymes that are involved in fungal cell metabolism and growth and upshot in membrane instability. Ciclopirox has antifungal action against dermatophytes, yeast and molds. Ciclopirox olamine is applied to affected nails daily and then removed with alcohol weekly for 48 weeks. Although ciclopirox olamine has but approximately a 5.7-8.5% complete cure rate when used lonely, when used in conjunction with systemic medication it may improve efficacy and reduce the recurrence rate.
Amorolfine is a morpholine topical antifungal that inhibits D14 reductase and D7-D8 isomerase resulting in depletion of ergosterol and ignosterol accumulation in the fungal cytoplasmic cell membranes. Its spectrum of activeness includes dermatophytes, and some filamentous fungi and yeasts. Amorolfine is practical once or twice weekly for vi months and has a slightly greater efficacy with a 12–46% complete cure charge per unit.
In the summer of 2014 two new topical anti-fungal agents were approved for the treatment of onychomycosis, both of which do not require nail debridement or weekly removal and accept shown greater efficacy as compared to Ciclopirox nail lacquer. These include:
Efinaconazole (Jublia) x% smash solution is a wide spectrum (effective against dermatophytes, not-dermatophytes and yeasts) triazole specifically adult to treat onychomycosis due to is expert nail penetration. Similar other azole antifungals it inhibits lanosterol 14α-demethylase in the ergosterol biosynthetic pathway. When used alone this has an judge 15.2-17.8 complete cure rate.
Tavaborole (Kerydin) 5% is classified as a Oxaborole (a novel, boron-based pharmaceutical amanuensis). Information technology is a broad spectrum anti-fungal which inhibits fungal protein synthesis via forming boron-based bonds at the enzyme-editing site to prevent catalytic turnover of leucyl-tRNA synthetase and block fungal poly peptide synthesis. It has a vi.5-nine.ane% complete cure rate.
Nonprescription agents (Vicks VapoRub, tea tree oil and snakeroot extract) have all also been evaluated in small nonblinded trials, past applying these agents once, and twice daily or every third 24-hour interval respectively for 48 weeks achieving results on par with ciclopirox.
More recently diverse lasers take been used with some success in clinical clearance.
Luliconazole (Luzu) 1% cream is another newly canonical (November 2013) topical antifungal medication that belongs to the azole class. It inhibits ergosterol synthesis by inhibiting lanosterol demethylase. It was canonical for the treatment of interdigital tinea pedis, tinea cruris and tinea corporis acquired by Trichophyton rubrum and Epidermophyton floccosum. It is to be applied to the affected area and approximately 1-inch of the immediately surrounding area in one case a day for 1-2 weeks.
Several factors must be considered before starting systemic medications such as the patient'south comorbidities, interactions with nutrition and other medications, medication adverse side-effects, compliance, and cost. Information technology is important to remember that systemic medications for onychomycosis typically consist of several months of therapy and relapse is not uncommon. The dosage and dosing schedule varies depending upon the report. Although griseofulvin has been used in the past for onychomycosis, it shows express efficacy and is no longer a recommended therapy. All systemic antifungal agents, except fluconazole, are extensively metabolized in the liver and tin can accept significant drug interactions. Although minimally metabolized, fluconazole is an inhibitor of several cytochrome P450 enzymes, leading to drug interactions. The verbal interactions are beyond the scope of this article and accept been extensively reviewed. Although fluconazole has meliorate oral bioavailability (90%), as compared to terbinafine (twoscore%) and itraconazole (55%), it is non canonical by the US Nutrient and Drug Administration for treatment of dermatophytes and is but used off label. Since terbinafine has a higher cure charge per unit (70% verses 54%), equally compared to itraconazole for the handling of onychomycosis, and has less safety concerns (less drug interactions, and no blackness box warning pertaining to risk of cardiovascular issues) currently it is the preferred FDA approved oral therapy for onychomycosis; even so, it too has risks and can be associated with serious skin hypersensitivity reactions.
Lastly, due to the take chances of fatal liver injury and adrenal gland insufficiency the FDA changed its boxed warning for oral ketoconazole and recommends it only be used in certain life-threating systemic mycoses when alternative therapy has failed, is unavailable or not tolerated. Although information technology has been used in the by as a one-fourth dimension dose to treat tinea versicolor, this is no longer recommended.
Systemic therapy may be indicated for all-encompassing tinea corporis, patients who have shown resistance to topical antifungal agents, infections that arise in association with immunosuppression, or for patients who accept tinea capitis, Majocchi granuloma, or tinea unguium. Apply of oral agents requires attention to potential drug interactions and monitoring for adverse furnishings.
Depression dominance topical corticosteroid tin be added to the topical antifungal regimen to provide rapid relief from the inflammatory component of the infection, but the steroid should only be applied for the first few days of treatment. Utilise of combined corticosteroid and antifungal agents is non advised, since patients tend to continue this medication for the entire course of handling and prolonged employ of steroids can atomic number 82 to persistent and recurrent infections (tinea incognito), longer duration of treatment regimens, and adverse side effects such equally skin atrophy, striae, and telangiectasias.
How do patients contract this infection, and how do I prevent spread to other patients?
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Epidemiology
The incidence of infection tends to change with age, geographic location, and climate. Dermatophytes grow best in warm and humid environments, and are more than mutual in tropical and subtropical regions.
Some dermatophytes are geographically restricted: for example T. concentricum is merely seen in indigenous populations of certain islands in the S Pacific and in some areas of Due south America; whereas T. mentagrophytes var. erinacei is limited to French republic, Britain, Italy, and New Zealand; and M. audouinii is found primarily in Europe. On the other hand, M. canis, M. nanum, T. mentagrophytes, T. verrucosum, and T. equinum occur worldwide.
Infections are well-nigh common in postpubertal hosts, except for tinea capitis which is more common in children with an incubation menstruum of typically 1 to 3 weeks. Although both genders are affected in that location is a slight male predilection. Predisposing factors include household exposure to an infected family unit member, immunosuppression, genetic susceptibility, diabetes mellitus, palmoplantar keratoderma, ichthyosis, and atopy. Human immunodeficiency virus (HIV) infection in and of itself has not been found to increase the susceptibility to dermatophyte infection, simply at that place may be a greater likelihood for recurrence and chronicity, likewise as atypical presentation or more extensive infection.
Dermatophytes invade keratinized tissue via their ability to produce keratinases. Mannans in the cell wall of the fungi inhibit the host'south immune response, which explains why most anthropophilic fungi elicit very niggling inflammation. Furthermore, mannans are taken up by the keratinocytes, resulting in decreased prison cell turnover, which decreases the likelihood of the fungus being sloughed off. This could explain why some people have chronic infections.
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Infection control problems
Infection occurs by direct contact with arthrospores (asexual spores formed in the hyphae) on infected hosts or from indirect contact with conidia (sexual or asexual spores) found in the surround or on fomites (infected exfoliated skin in habiliment, brushes, towels, rugs, shoes, etc). Infective elements can remain feasible in the surround for months to years depending on the species.
What host factors protect confronting this infection?
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The host has innate defenses against dermatophytes including activation of complement via the alternative pathway which results in inhibition of fungal growth. Additionally polymorphonuclear leukocytes can damage or kill fungi. The evolution of prison cell-mediated immunity correlates with delayed hypersensitivity, and the inflammatory response results in clinical cure. In contrast, the lack of or a defective cell-mediated immunity predisposes the host to chronic or recurrent dermatophyte infection.
What are the clinical manifestations of infection with this organism?
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The clinical presentation is variable depending upon several factors, including the site of infection, the species of the fungus, the host's response and the immunological status of the patient. If a patient is treated erroneously with topical steroids or immunomodulators, such as tacrolimus, the clinical presentation is modified. This variant is referred to tinea incognito. The lesions become less erythematous and annular and are usually without scale. The plaques tend to be more extensive; less divers and often contain pustules and papules.
Tinea capitis
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This is about common in children afterwards the showtime year of life, but tin can be seen in adults (Effigy ane). Primary culprits in the by were Yard. canis and K. audouini, both of which colonize and destroy the exterior of the hair shaft (ectothrix) and could be identified by their fluorescence under a Wood lamp. Clinically they presented as dry out scaly patches of baldness with broken hairs and referred to as "grayness patch" tinea capitis. In Europe, Thou. audouini is reappearing. Currently the almost common organisms in the United States are T. tonsurans and T. violaceum which are found inside the hair shaft (endothrix) and do not fluoresce. Since hairs ofttimes suspension shut to the scalp these are referred to as "black dot" tinea capitis. Tinea capitis is often associated with posterior cervical and auricular lymphadenopathy. The differential diagnosis includes seborrheic dermatitis and bacterial infections.
Figure 1:
Tinea capitis, gray patch
Favus
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This is the most severe form of tinea capitis and is caused past T. schoenleinii (Figure 2). It is a chronic scalp infection typically seen in children in developing countries. It presents as thick yellow crust (scutula) on an erythematous base of operations associated with scarring alopecia. Organisms and air spaces tin can be seen within the hair shaft, and with Wood lamp the pilus has blueish-white fluorescence.
Figure 2:
Tinea capitus, favus
Tinea faciei
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This is a regional form of tinea corporis that involves the face, only non the bearded area (Effigy 3). The chief lesions resemble those on the body presenting as plaques that take an annular configuration with calibration or pustules at the border. Notwithstanding, steroids are often used and therefore the lesions can appear less defined and can contain papules and pustules presenting as tinea incognito. The differential diagnosis includes seborrheic dermatitis, contact dermatitis, acne vulgaris, perioral dermatitis, and rosacea.
Figure 3:
Tinea faciei
Tinea barbae
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This is typically seen in postpubertal males and involves the bearded region of the face and neck (Effigy 4). Tinea barbae is well-nigh oft acquired past zoophilic dermatophytes: T. verrucosum or T. mentagrophytes var. mentagrophytes, and lesions are more inflammatory. The condition is usually acquired through contact with infected animals and can be spread through use of contaminated razors. The patient typically presents with erythematous plaques studded with pustules pierced by terminal hairs. Abscesses, sinus tracks and bacterial superinfection are non uncommon and the patient may take malaise, fever, and lymphadenopathy. When the infection is caused by T. rubrum the lesions tend to be more superficial and less inflammatory. The patient may experience alopecia which can be permanent in the more inflammatory forms of the condition.
Figure four:
Tinea barbae
Tinea corporis
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This is a dermatophyte infection that occurs on the exposed glabrous pare of the torso and extremities (Figure v). The most common organisms that crusade tinea corporis worldwide are T. rubrum, followed by T. mentagrophytes. Although anyone can go infected, those who have close contact with other people (military housing, contact sports, locker rooms) and those who are immunosuppressed are more predisposed. Domestic animals are an important source of manual. Infections also can be transmitted from human being to human being, especially from those who accept tinea capitis or pedis, or from the soil. Classically, the lesions appear as erythematous, annular to serpiginous, centrifugally growing plaques that have peripheral scale and central clearing. Sometimes the lesions, peculiarly those caused by zoophilic dermatophytes, can have a pustular or vesicular active border.
Figure v:
Tinea corporis
Tinea cruris
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This is a dermatophyte infection that involves the inguinal region and often spreads to buttocks, waist, and thighs, but spares the scrotum (Effigy 6). The most common organisms are T. rubrum, T. mentagrophytes, and Eastward. floccosum. This status is well-nigh oftentimes seen in men since the scrotum encourages a moist warm surround which allows for fungal growth. Lesions tin be unilateral or bilateral and are characterized by sharply demarked erythematous plaques with a scaling advancing border, but tin can sometimes contain pustules. If the scrotum is involved or if at that place are satellite lesions, cutaneous candidiasis should be considered. The differential diagnosis besides includes intertrigo, erythrasma and contact dermatitis.
Figure 6:
Tinea cruri
Tinea imbricata
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This is a variant of tinea corporis that is geographically restricted to the ethnic people of some S Pacific islands and some areas of South America (Figure vii). The condition is caused by T. concentricum and is characterized by all-encompassing concentric rings of calibration.
Figure 7:
Tinea imbricata
Tinea pedis and manuum
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In the United states of america this is the most common superficial fungal infection in adults and is often chronic (Figure 8). Infections are almost often caused past T. rubrum, only can also be caused by T. mentagrophytes, East. floccosum, and T. Tonsurans (children). When the feet are involved it typically presents as either a diminished interdigital infection (most common) or equally diffuse scaly thicken plaques on the plantar surface of the foot in which instance it is referred to as "moccasin sandal." This latter infection is oft chronic and difficult to cure. Variable erythema or even vesicles tin can likewise be seen.
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Tinea manuum typically presents similar to the diffuse grade on the foot; yet, lesions are most often simply on i hand and are associated with bilateral foot involvement, resulting in the "two anxiety-one hand syndrome." The nails may also be involved. Bacterial superinfection and cellulitis tin complicate the infection. The differential diagnosis includes dyshidrotic dermatitis, contact dermatitis, psoriasis, and bacterial infections.
Figure eight:
Tinea pedis and manuum
Onychomycosis
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This is the near common affliction of the nails seen in dermatology (Figure ix). Onychomycosis of the toenails occurs significantly more frequently than infections of the fingernails. One, several or all nails can exist afflicted. Predisposing factors include occlusive footwear; humidity and moist feet; repeated smash trauma; a genetic predisposition; and concurrent diseases such equally diabetes, peripheral vascular illness, and immunosuppression. The incidence ranges from 3 to 13% depending on the population studied and increases with age. In that location are 4 subtypes of onychomycosis depending upon which office of the smash is infected. Approximately 60% of cases of onychomycoses are caused past T. rubrum, xx% past T. mentagrophytes, and 10% past Eastward. floccosum. In cases of superficial white onychomycosis, T. mentagrophytes can exist cultured in the majority of cases. Onychomycosis tin can also be caused by yeasts and nondermatophyte molds such as Scopulariopsis and Scytalidium, also as Aspergillus, Acremonium, and Fusarium; however, this is seen in less than x% of infections.
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Distal subungual onychomycosis affects the boom bed, plate, and hyponychium. The nail is often thickened, yellowish-brownish, and associated with subungual debris.
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Distal lateral onychomycosis is similar to distal subungual, just occurs as a upshot of extension of tinea pedis onto the lateral cuticle.
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Proximal subungual onychomycosis occurs when the fungus invaded through the proximal cuticle. Clinically the nail has a whitish appearance and is more unremarkably seen in people who take HIV or other types of immunosuppression.
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Superficial white onychomycosis is an uncommon class of onychomycosis and presents equally a white chalky smash.
Figure 9:
Onychomycosis
What common complications are associated with infection with this pathogen?
Do other diseases mimic its manifestations?
Differential diagnosis of tinea corporis includes: other dermatologic weather condition that can assume an annular appearance such a nummular eczema, urticaria, pityriasis rosea, erythema chronicum migrans, erythema multiforme, erythema annulare centrifugum, polymorphous light eruption, subacute cutaneous lupus erythematosus, granuloma annulare, sarcoidosis, and Hansen illness.
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Nummular eczema presents as one to several pruritic erythematous coin shaped plaques. It is about often seen on the distal extremities of males and tin can be associated with xerosis. Over time the lesions may centrally articulate or become scaly. Lesions can also get lichenified or incorporate pustules.
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Urticaria is a common status that presents every bit evanescent annular to serpiginous plaques that have an erythematous raised border and blanched center and are without scale. Onset of lesions is typically associated with new drug exposure, foods, or recent illness.
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Pityriasis rosea is characterized by small fawn-colored lesions distributed along the carve lines in a Christmas tree distribution. The condition is self-express and believed to have a viral etiology.
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Erythema chronicum migrans represents the hallmark lesion of Lyme disease and presents as a centrifugally expanding erythematous plaque with central clearing. One or several lesions can be nowadays.
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Erythema multiforme is a cell-mediated response, most often to canker simplex. It presents equally multiple targetoid lesions frequently with an acral distribution.
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Erythema annulare centrifugum is believed to stand for a hypersensitivity status and presents every bit annular erythematous plaques with a abaft scale. Lesions are most commonly located on the torso, buttocks, and thighs.
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Polymorphous light eruption is a common acquired idiopathic photodermatosis characterized by recurrent erythematous papules, papulovesicles, and plaques located on sun-exposed surfaces in off-white-skinned females.
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Subacute cutaneous lupus erythematosus presents every bit annular, arcuate, or papular lesions most commonly in lord's day-exposed areas. Approximately fifty% of patients will see the criteria for systemic lupus erythematosus and present with arthralgias, low grade fever, malaise, or myalgias.
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Granuloma annulare is an idiopathic granulomatous condition that typically presents as nonscaly, annular plaques with indurated borders on the distal extremities.
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Sarcoidosis is some other idiopathic granulomatous status that present equally annular, indurated plaques. The lesions tin can be associated with lung disease or asymptomatic hilar lymphadenopathy.
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Hansen illness (leprosy) is an uncommon status in the U.s. outside of endemic regions. The disease is acquired past Mycobacterium leprae. Information technology has a varied clinical presentation depending upon the host's immune response. In patients with a practiced allowed response lesions are often few and present as annular, sharply demarcated, and erythematous to hypopigmented plaques. The lesions are often associated with scaling, baldness, and anesthesia. Patients who have lacking cellular amnesty have more numerous lesions that are less well defined and can be macular or papular.
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The differential diagnosis of onychomycosis includes psoriasis, lichen planus, chronic nail injury, and certain genodermatoses.
What mutual complications are associated with infection with this pathogen?
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Kerion
An inflammatory class of tinea capitis which occurs as a result of advanced disease coupled with an exaggerated inflammatory response. Lesions present every bit indurated boggy plaques containing perifollicular abscesses associated with localized alopecia. Posterior cervical and auricular lymphadenopathy and fifty-fifty systemic illness can occur in conjunction with this infection.
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Majocchi granuloma
Deep variant of tinea corporis where there is follicular involvement. Clinically presents every bit boggy, indurated papules and plaques that may bleed purulent fabric. The lesions are characterized histologically by a suppurative granulomatous folliculitis.
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Tinea profunda
This is a variant of tinea corporis associated with an excessive inflammatory response which tin can take a granulomatous or verrucous advent.
How should I identify the organism?
What laboratory studies should you order and what should you expect to detect?
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Rapid in-office testing can be done by scraping the peel or obtaining a nail or hair sample. Potassium hydroxide (KOH) will show hyphae interspersed among the epithelial cells, or inside or on the hair shaft. Trichophyton tonsurans, the virtually common agent of tinea capitis, can be seen as solidly packed arthrospores within the cleaved hair shafts scraped from the plugged blackness dots of the scalp. The use of dimethyl sulfoxide (DMSO) with KOH accelerates dissolution of the keratin and improver of Parker blueish ink or chlorazol blackness makes identification of the hyphae easier.
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Fungal culture is used for positive identification of the species. Usually fungal growth is noted in 5 to xiv days, simply usually takes 4 to 5 weeks for species identification. Dermatophyte Test Medium (DTM) is an culling to traditional cultures. It allows identification of the presence of dermatophytes, via a simple color change from yellow to bright carmine due to product of element of group i metabolites, without having to look at the colony, the hyphae, or macroconidia. Notwithstanding, this medium does non permit identification of the species of dermatophyte. The color change should occur in 3 to 7 days; afterward that fourth dimension, a color alter is nigh likely due to a contaminant.
Results that confirm the diagnosis
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If direct microscopic examination with KOH and cultures are negative, a biopsy can be performed. Organisms are all-time visualized in the stratum corneum, smash, or hair utilizing the periodic acrid Schiff (PAS) or Gomori methenamine silver (GMS) stain; only the species of the fungus cannot exist determined. Histopathology provides a quick and reliable method for identification of a dermatophyte infection with a sensitivity of approximately 81% compared with culture, which is approximately 53%. A PAS stain is considered more sensitive than fungal cultures for the diagnosis of onychomycosis. One written report showed that GMS is superior to PAS staining, just other studies refuted this and concluded that PAS is significantly cheaper and should exist the preferred stain.
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Although new techniques take been developed using molecular genetics tools specifically brake fragment length polymorphisms and more recently polymerase chain reaction assays to diagnose dermatophyte infections they are not widely available and can exist cumbersome.
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The emergence of resistant fungal strains has highlighted the need for in vitro susceptibility-resistance testing. The E test® (AB Biodisk, Solna, Sweden) is a patented commercial method that quantitatively determines antimicrobial drug minimal inhibitory concentration by providing a quicker, less labor intensive test every bit compared with the traditional agar dilution method. The examination is set upwards similar to an agar disc diffusion test, only the disc is replaced with a calibrated plastic strip that is impregnated with a continuous concentration gradient of drug.
WHAT'S THE EVIDENCE for specific direction and treatment recommendations?
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