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Author: admin | 21.04.2015 | Category: One Ear Ringing

Despite its large surface area and constant exposure to the environment, the skin resists infection well. Cutaneous infections occur when the skin’s protective mechanisms fail, especially when trauma, inflammation, maceration from excessive moisture, or other factors disrupt the stratum corneum.
Anthropophilic dermatophytes are the most common cause of fungal skin infections in humans.
Dermatophyte infections occur more frequently in certain ethnic groups and in people with impaired cell-mediated immunity. The various forms of dermatophytosis, also called ringworm, are named according to the site involved. Tinea capitis occurs primarily in children but may develop in adults—especially the elderly, those who are unkempt, and the impoverished.
Figure 1 Classic annular lesion of tinea corporis shows a raised or vesicular margin with central clearing. Figure 2 A typical kerion presenting as a zoophilic Microsporum canis infection of the scalp (tinea capitis).
Tinea corporis typically appears as a single lesion or multiple circular lesions with scaling, well-delineated margins, and a raised, erythematous edge. Figure 3 (a) The scaling of tinea pedis appears between and under the toes and on the plantar surface. Tinea barbae occurs in adult men and involves the skin and coarse hairs of the beard and mustache area.
Tinea faciei occurs as an infection of the face in women and children and infection of the area outside the mustache and beard in men.
Tinea cruris, infection of the groin, is much more common in men than women and is often associated with infection of the feet.
Clinicians should suspect dermatophyte infection in patients with any scaling, erythematous eruption and in patients whose nails exhibit the characteristics of tinea unguium (see above). The specimen is prepared for microscopic examination by first placing it on a glass slide and treating it with potassium hydroxide (KOH), which digests the keratin of the skin, nails, and hair, and then heating it to hasten the process. Tinea corporis, tinea cruris, tinea pedis, and tinea faciei respond to topical agents applied once or twice daily to the affected area, usually for 2 to 4 weeks. The azoles include ketoconazole, itraconazole, and flucona-zole; like griseofulvin, they are fungistatic. Tinea Pedis, also known as athlete’s foot, is a widespread a fungal infection, but despite this, it is little known and poorly treated.
The patient comes to the doctor because of itching and desquamation of the foot accompanied by bad odor. The disorder can be painful and, if untreated, the skin can evolve into onychomycosis, or in serious bacterial infection. The therapy is based on antifungal agents, particularly fungistatic (the Imadazoline compounds) and fungicidal (such as Terbinafine); the latter works by inhibiting the enzyme squalene epoxidase, which is involved in the synthesis of ergosterol, which is an essential component of fungis’ cell membranes. The accumulation of squalene, which is favored by the drug, causes damage to the vacuole and cell membranes, which becomes irreversible and contributes to eliminating the fungus: this therapy should be continued for at least four weeks, otherwise there is risk that the fungus could reappear. The early symptomatic improvement should not give the impression that the condition is cured: in fact, therapy should be continued until the fungal infection is completely eradicated. In addition to therapy, appropriate hygiene measures, such wiping feet dry right after playing in sport activities, as well as use of personal towels, and not walking barefoot in swimming pools areas and dressing rooms, must be taken. Treatment may also require an extension of the period from four to six weeks, as the normal cycle of skin stratum corneum turnover takes 10-14 days. The most important protective factor is an intact stratum corneum, the tough barrier of protein and lipid formed on the cutaneous surface by the underlying epidermis.1 This barricade impedes invasion by environmental pathogens, and its dryness discourages colonization and growth of the many organisms that require moisture to survive, such as gram-negative bacilli. The organisms causing infection may originate from the victim’s own resident flora, either on the skin or on adjacent mucous membranes, but many come from other people, animals, or the environment. These organisms, which include Trichophyton, Microsporum, and Epidermophyton species, are classified as an-thropophilic, zoophilic, or geophilic, depending on whether their primary source is humans, animals, or the soil, respective-ly.3 Geophilic dermatophyte infections occur sporadically, primarily among gardeners and farm workers.

Transmission of these infections occurs from direct contact between people or from exposure to desquamated skin cells present in the environment— arthrospores can survive for months. Involvement of the feet and groin is most common in adolescents and young adults, especially males, but is unusual in children. These infections include tinea capitis (scalp), tinea corporis (body), tinea barbae (beard area of men), tinea faciei (face), tinea cruris (groin), tinea pedis (feet), tinea unguium (nails), and tinea manuum (hands). Streptococci do not ordinarily survive on normal skin, but the presence of fungal disease apparently permits streptococci of various groups, including A, B, C, and G, to colonize the toe webs.6 From this location, these bacteria may invade the skin damaged by the tinea pedis or migrate to locations higher up the leg and enter the skin through any defects. The organisms typically invade the nail from the distal or lateral borders, and infection spreads proximally. Most cases have accompanying involvement of the feet; inexplicably, usually only one hand is affected (so-called two-feet, one-hand disease). The basic culture medium for isolating dermatophytes is an agar containing Sabouraud medium, often combined with antibiotics to eliminate bacteria and with cycloheximide to inhibit sapro-phytic fungi. Five oral agents are currently available: griseofulvin, ke-toconazole, itraconazole, fluconazole, and terbinafine. Ketoconazole is usually well tolerated, but hepatotoxicity occurs in about 1 in 10,000 patients, typically after several weeks of use.
The most effective agent is terbinafine, administered at a dosage of 250 mg daily for 6 weeks for fingernail infections and for 12 weeks for toenail involvement.9 Because terbinafine persists in the nails for many weeks, it continues to exert anti-fungal effects long after it is discontinued. They may form filamentous projections, which, unlike the hy-phae of molds, do not contain separate cells. Furthermore, the constant shedding of cells of the epidermis impedes most microbes from establishing permanent residence. Direct inoculation of the spores through breaks in the skin can lead to germination and subsequent invasion of the superficial cutaneous layers.
The characteristic skin lesion is an annular scaly patch [see Figure 1], though the clinical appearance varies not only with the site involved but also with the host’s immune status and the type of infecting organism. Because the swollen hairs may fracture a few millimeters from the epidermis in this endothrix infection, the scalp sometimes appears to be marked by small black dots. Hair shedding late in the infection is common because the hair shaft is not damaged until the infection is well advanced. The amount of inflammation varies; when the inflammation is intense, pustules, vesicles, and even bullae may occur. The optimal method of obtaining specimens from the skin is by scraping the scaly lesions; specimens from the nails are best obtained by taking fragments of subungual debris.
Griseo-fulvin, a fungistatic agent, is the oldest oral treatment available and is still useful, primarily in infections not involving the nails. Flucona-zole and itraconazole are very expensive, but they provide protracted levels of antibiotic in the nails, allowing short or intermittent courses of therapy for tinea unguium.
It achieves high levels of drug in the nails, and the drug persists for many weeks after discontinuance.
The terbinafine regimens produce short-term eradication of infection in about 70% to 90% of patients with fingernail infection and in about 50% to 80% of patients with toenail infection. It normally colonizes the skin of adults, especially of the scalp and upper trunk, where the presence of sebum is highest. In general, anthro-pophilic species elicit little inflammation and cause chronic infections.
Like all infections with Trichophyton species, these scalp lesions do not fluoresce under a Wood light. The most severe inflammation, usually from a zoophilic species, results in a kerion, a painful, boggy mass in which follicles may discharge pus and in which sinus tracts form [see Figure 2]. Sometimes, involvement of the hair follicles in the middle of a patch of scaling erythema leads to perifollicular nodules, a condition called Majocchi granuloma. They may crack or crumble, and often, subungual hyperkeratosis lifts the nail plate from the underlying bed (a condition known as onycholysis) [see Figure 4].

Occasionally, vesicles, papules, or follicular nodules form on the dorsal surface of the hands.
Der-matophyte test medium culture can be used in the office and is both accurate and inexpensive.7 When both KOH preparations and cultures are negative, a biopsy may be useful in identifying the infecting organism, usually by special tissue stains such as periodic acid-Schiff or Gomori methenamine-silver stains.
Tinea pedis often recurs after effective therapy, especially in cases of the moccasin form of the disease.
Both fluconazole and itraconazole can cause gastrointestinal disorders, rashes, and, occasionally, hepatotoxicity and can have serious interactions with several medications, including cyclosporine, digox-in, and quinidine.
Candida species are not part of the normal skin flora, but they commonly reside in the orophar-ynx, vagina, and colon. For unknown reasons, these organisms, which are ordinarily commensals, can become pathogenic and cause tinea versicolor (also known as pityriasis versicolor) or folliculitis. Zoophilic and geophilic species, however, often provoke intense inflammation, which sometimes leads to eradication of the organisms and healing without treatment. The hairs then become infected, in one of three microscopic patterns: ectothrix, endothrix, or favus. The victims are generally farm workers, and the infection usually causes erythema, scaling, and follicular pustules. Patients often complain of itching and burning, and symptoms may worsen after exposure to sunlight.
The lesions are usually red, scaling, sharply demarcated areas with raised, erythematous borders. The most common form consists of fissuring, scaling, and maceration in the interdigital spaces, especially between the fourth and fifth toes. When infection reappears, the previous therapy can be resumed without loss of effectiveness. Ketoconazole, itraconazole, and fluconazole can interact with other medications; pharmacologic sources should be consulted for potential interactions.
About 75% of patients who receive one or more courses of terbinafine will have a clinical cure 5 years later. Human infections with zoophilic species have occurred after exposure to dogs, cats, horses, cattle, pigs, rodents, poultry, hedgehogs, and voles. The lesions may be scaly, annular erythematous patches, but often they are indistinct red areas with little or no scaling. The infection, which affects the medial portion of the upper thighs but consistently spares the scrotum, may extend to the buttocks, abdomen, and lower back. A second type involves scaling, hyperkeratosis, and erythema of the soles, heels, and sides of the feet. This therapy is very expensive, and clinicians must decide in each case whether treatment is warranted. Alternatively, with reduction in the other flora or with impaired host defense mechanisms, these yeasts may proliferate in large numbers to produce lesions on the mucosal surfaces of the mouth and vagina. In this kind of tinea pedis, the lesions occur in a so-called moccasin distribution pattern [see Figure 3a].
All these medications are effective in cases of tinea barbae, Majocchi granuloma, extensive tinea corporis, and tinea manuum that are unresponsive to topical agents.
A third form demonstrates an inflammatory pattern characterized by vesicles, pustules, or even bullae, usually on the soles [see Figure 3b].

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