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Disorders caused by fungi are called mycoses. They are usually classified
according to the site where they appear. There is a large group of disorders
which affect the skin. Many fungi, such as the dermatophytes, go no deeper
than the horny layer of the skin: these are the superficial infections. When
fungi are also demonstrated deeper in the tissues, these are referred to as
subcutaneous infections. If organic systems or organs are affected, they are
called systemic infections. It will be obvious that the latter group is the most
life-threatening. In terms of frequency, however, systemic fungal infections
are the rarest.
DERMATOMYCOSES - DEFINITION
AND CHARACTERISTICS
Dermatomycoses are infections of the skin, hair or nails by fungi.
The principal causative agents are dermatophytes, which are
subdivided into three groups (genera): Microsporum spp.,
Trichophyton spp. and Epidermophyton floccosum. The three
genera are distinguished by the form of the spores, or
macroconidia.
Trichophyton: thin-walled, smooth, four to six septa
Microsporum: thick-walled, with projections five to more septa
Epidermophyton: thick-walled, pear to oval shaped four or fewer
septa
Besides the dermatophytes, yeasts are also capable of causing
skin disorders. The most frequent agents in this case are Candida
spp. and Pityrosporum.
Infections are increasingly being caused by species of fungus
which are classified neither as yeasts nor dermatophytes
moulds. An example of this is Scopulariopsis brevicaulis, which can
occur in nails.
DERMATOPHYTES -
CLASSIFICATION
DERMATOPHYTES - DEVELOPMENT
OF A DERMATOPHYTOSIS
As already mentioned in the introduction, fungal
infections do not occur without reason.
As dermatophytes are not commensals, a prerequisite
for the development of an infection is exposure to the
fungus. This is possible, for example, by direct contact
with infected persons or animals, but it is more often a
question of contact with fungal spores. These spores are
contained in epithelial (skin) elements of infected
persons everywhere in our environment. The floors of
communal shower stalls and changing rooms are major
sources of infection. For the development of an infection,
however, more is needed than contact alone.
Dermatophytes prefer warm, moist conditions. This is
why a dry, intact skin constitutes a virtually impenetrable
barrier. But the chance of infection is encouraged by
everything that has an adverse influence on the
situation.
DERMATOPHYTES THEIR HOST
Dermatophytes do not have an exclusive preference for
human beings. Some of the infections in humans even
originate in (domestic) animals.
On the basis of the original host, a distinction is made
between anthropophilic, zoophilic and geophilic
dermatophytes. This distinction is very important, chiefly
because in the event of infection of human beings by
zoophilic dermatophytes, the source of the infection (the
animal) must be co-treated.
In the case of geophilic infections one can try to avoid
further contact with the source.
A point worthy of mention is that zoophilic
dermatophytes in human beings frequently evoke a more
intense inflammatory reaction than an infection by
anthropophilic species. The latter have adapted
themselves better to life in the human epidermis and are
regarded to a lesser degree as invasive organisms which
have to be opposed.
DERMATOPHYTES
THEIR HOST
DERMATOPHYTES - PREFERRED
SITES OF INFECTION
Most dermatophytes have been found to have a
preference for certain situs. A preference for growth in
and around the hair, in the horny layer of skin, in the
moist, warm folds of the skin, or just under the nails.
Trichophyton species have been found to have the
greatest adaptability, or perhaps they are merely the
least fastidious. They are capable of causing tinea
capitis, corporis, barbae, pedis, plantaris and tinea
unguium.
Part of the severity of the symptoms has its origins in the depth
of the mycosis. A number of fundamental characteristics of
dermatomycoses are: erythema, vesicula, scaling, scabs,
pustules, atrophy, dystrophy, hypertrophy and dyschromia. Of
course, these characteristics are exhibited in many other skin
disorders.
The use of Wood's light is limited by the fact that only a few dermatophytes
cause fluorescence. M. canis produces a bright yellowish green
fluorescence. The anthropophilic dermatophytes T. schoenleinii and M.
audouinii also fluoresce. In pityriasis versicolor a yellowish white to yellowish
brown fluorescence can be seen. Erythrasma -- which is not a
dermatomycosis but is certainly important in the differential diagnosis of
tinea cruris -- also produces fluorescence (coral-red) ( see image 3 ). The
other dermatophyte infections, however, do not fluoresce, and this is also
the case with candidoses.
WOOD'S LIGHT
LABORATORY EXAMINATION
To determine whether there is indeed a
dermatophyte or yeast present, a microscopical
examination must be performed.
The most direct and simplest method is to make
a preparation on the basis of potassium
hydroxide (KOH preparation). However, this
examination is insufficient in itself to enable the
causative agent to be identified with absolute
certainty.
To discover the name of the fungus, a culture is
necessary. For the highest possible yield, a
number of key items have to be taken into
account in an examination of this nature.
Scraping the edge of lesion for
microscopic examination
Aspergillus fumigatus: microscopy
Culturing: a) T.rubrum; b) E.floccosum;
c) T.mentagrophytes; d) M.canis
Main systemic antifungals
Poliens:
Amphotericine B (1956)
Nystatine (1951)
Miscellaneous:
Flucytosine (1957)
Grizeofulvine (1958)
Potassium iodide (1811)
Azoles:
Imidazole Myconazole (1969); Ketokonazole (1977)
Triazoles Itraconazole (1980); Fluconazole (1982)
Alilamines:
Terbinafine
Morfolines:
Amorolfine (1989)