Mycoses are divided among three forms: (1) superficial, involving stratum corneum, hair, nails,

(2) subcutaneous, involving dermis and/or subcutaneous tissue, and (3) deep/systemic,
representing hematogenous spread of organisms including opportunistic pathogens in
immunocompromised hosts. The focus of this chapter is the superficial mycoses and their
patterns of integumentary infections (Table 188-1). A glossary of terms used in this chapter is
contained in Table 188-2.
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Table 188-1 Patterns of Integumentary Infections by Superficial Mycoses
Genera Skin Hair Nails
Trichophyton
Microsporum

Epidermophyton


Tinea Nigra

Black Piedra



White Piedra





Pathogenesis
Dermatophytes exhibit a broad armamentarium of enzymes (keratinolytic proteases, lipases etc.)
that act as virulence factors to allow adherence and invasion of skin, hair, and nails, and also to
utilize keratin as a source of nutrients for survival. The initial steps in dermatophyte infections
are adherence to keratin followed by invasion and growth of mycelial elements. As a
consequence of keratin degradation and subsequent release of proinflammatory mediators, the
host develops an inflammatory response of varying degree. The classic ringworm, or annular
morphology of tinea corporis results from an inflammatory host response against a spreading
dermatophyte followed by a reduction or clearance of fungal elements from within the plaque,
and in many cases by spontaneous resolution of the infection.
Adherence
Dermatophytes overcome several lines of host defense before hyphae begin to thrive in
keratinized tissues. The first step is successful adherence of arthroconidia, asexual spores formed
by fragmentation of hyphae, to the surface of keratinized tissues.
12
Early nonspecific lines of host
defense include fungistatic fatty acids in sebum as well competing bacterial colonization.
13,14

Several recent studies have focused on the molecular steps involved in arthroconidial adherence
to keratinized surfaces. Dermatophytes have been shown make selective use of their proteolytic
armamentarium during adherence and invasion.
15,16
The basis for this highly concerted attack
may be explained partially by specific upregulation of multiple genes induced by contact with
keratin, as has been shown by differential gene expression analysis in T. rubrum.
17
Following
several hours of successful adherence, the spores begin to germinate in preparation for the next
step in the infective chain of events, invasion.
Invasion
Trauma and maceration facilitate penetration of dermatophytes through the skin. Invasion of
germinating fungal elements is further accomplished through secretion of specific proteases,
lipases and ceramidases, the digestive products of which also serve as fungal nutrients.
18

Interestingly mannans, which are components of the fungal cell wall, show inhibitory effects on
keratinocyte proliferation and cell-mediated immunity.
19,20

Host Response
Dermatophytes encounter a range of host responses from several lines of nonspecific
mechanisms including fungistatic fatty acids, increased epidermal proliferation, and secretion of
inflammatory mediators to cell mediated-immunity. In the line of defense mechanisms,
keratinocytes represent the first frontier of living cells to encounter invading fungal elements.
The key position of keratinocytes is reflected by their complex response to invasion including
proliferation to increase shedding as well as secretion of antimicrobial peptides including human
defensin-2
21
as well as proinflammatory cytokines (IFN-, TNF, IL-1, 8, 16, and 17) that
further activate the immune system. Once deeper layers of epidermis are involved, new
nonspecific defenses such as competition for iron by unsaturated transferrin emerge. The degree
of host inflammatory reaction depends on the host's immune status as well as the natural habitat
of the dermatophyte species involved. Interestingly, anthropophilic dermatophytes induce
secretion of a limited cytokine profile from keratinocytes in vitro compared to zoophilic
species.
22,23
This difference may reflect the augmented inflammatory response generally
observed with zoophilic species.
The next level of defense is cell-mediated immunity resulting in a specific delayed type
hypersensitivity response against invading fungi. The inflammatory response associated with this
hypersensitivity is associated with clinical resolution, while defective cell-mediated immunity
may result in chronic or recurrent dermatophytoses. The Th2 response does not appear to be
protective, since patients with elevated fungal antigen antibody titers are observed to have
widespread dermatophyte infections.
24
A possible role for the Th17 response to dermatophyte
infections is suggested by the recent discovery of binding of hyphal elements to Dectin-2, a C-
type lectin pattern recognition receptor on dendritic cells, critical for inducing Th17
responses.
25,26
However, the relative importance of the Th17 immune response to
dermatophytosis remains to be elucidated.
Genetics
Despite epidemiological observations suggesting a genetic predisposition to fungal infections,
molecular insight confirming this hypothesis has been lacking. Recently, however, two families
with increased susceptibility to fungal infections and mutations in the C-type lectin fungal
pattern recognition pathway have been described. In addition, mutations in CARD9, an adaptor
molecule downstream of Dectin-1 and Dectin-2, which result in failure of Th17 activation, were
associated with susceptibility to chronic mucocutaneous candidiasis along with chronic
dermatophyte infections.
27



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Table 188-4 Common Laboratory Dermatophyte Identification Methods
Laboratory Test Method Function Findings
Potassium
hydroxide
preparation
Scales from the
advancing
border,
subungual debris,
or affected hair
removed and
placed on a glass
slide. KOH 10%
dropped on
specimen and
covered with a
cover slip. The
undersurface of
the glass slide
may be gently
heated with a
low-lit flame.
KOH solution
and gentle
heating softens
keratin and
highlights the
dermatophyte.
Long narrow septated and branching
hyphae
Culture Sabouraud
medium (4%
peptone,
1%glucose, agar,
water)
Facilitates
growth of
dermatophytes
Microscopic morphology of
microconidia and macroconidia, along
with culture features including surface
topography and pigmentation. The
reader is referred to
http://www.mycology.adelaide.edu.au/
for a comprehensive characterization
of fungal colonies. Common colonies
are characterized in Table 188-5.
Modified
Sabouraud
medium
(addition of
chloramphenicol,
cycloheximide,
and gentamicin)
Facilitates
growth of
dermatophytes
and inhibits
growth of non-
Candida
albicans,
Cryptococcus,
Prototheca
species, P.
werneckii,

Scytalidium
species,
Ochroconis
gallopava
Dermatophyte
test medium
Scales from the
advancing
border,
subungual debris
or affected hair
embedded in the
medium.
Medium
contains the
pH indicator
phenol red.
Dermatophytes
utilize proteins
resulting in
excess
ammonium ion
and an alkaline
environment.
Incubation at room temperature for 5
14 days results in change in color of
medium from yellow to bright red in
the presence of a dermatophyte.
Histolopathology
special stains:
periodic acid-
Schiff and
Grocott's
methenamine
silver
Tissue may be
obtained by skin
or nail biopsy
techniques
Stains fungal
cell wall to
detect fungal
elements in
tissue sections
Pink (PAS) or black (GMS) fungal
elements noted in the stratum corneum


he clinical diagnosis of a dermatophyte infection can be confirmed by microscopic detection of
fungal elements, by identification of the species through culture, or by histologic evidence of the
presence of hyphae in the stratum corneum. In addition, fluorescence patterns under Wood's light
examination may support a clinical suspicion.
Microscopic Examination
Although microscopic evaluation of potassium hydroxide (KOH)-treated samples of scale does
not allow for speciation or characterization of the susceptibility profile, it is used (or underused)
as a quick and inexpensive bedside tool to provide evidence of dermatophytosis. In
dermatophytosis involving the skin, hair or nails, septate and branching hyphae without
constriction (Fig. 188-1) may be visualized under microscopic examination with 10%20% KOH
preparation. All superficial dermatophytes appear identical when visualized in this manner.
Because KOH examination may yield false-negative results in up to 15% of cases,
28
patients
suspected of having dermatophytosis on clinical impression should be treated. Culture
confirmation should be considered whenever systemic treatment is warranted, such as in the case
of tinea capitis.


Microscopic examination of skin scrapings (scales) revealing septate, branching hyphae.

Scale from skin should be collected by scraping the involved area with a dull edge outward from the
advancing margins. Full thickness nail clippings should involve the dystrophic portion, as proximal from
the distal edge as possible without causing injury. Hairs should be plucked (not cut), placed on a glass
slide and prepared with 10%20% KOH and covered with a coverslip. Slightly warming the slide with a
low intensity flame allows better penetration of the KOH solution into keratin. Low-power microscopy
will reveal three possible patterns of infection (Fig. 188-2): (1) Ectothrixsmall or large arthroconidia
forming a sheath around the hair shaft, (2) Endothrixarthroconidia within the hair shaft, or (3) Favus
hyphae and air spaces within the hair shaft.


Graphic demonstration of ectothrix (left) and endothrix hair involvement.


Culture
Speciation of superficial fungi is based on macroscopic, microscopic and metabolic
characteristics of the organism. While some dermatophytes are readily identified on the basis of
their primary isolation cultures, most require further differentiation through subcultures on
specific media (identification culture) or through specific biochemical tests.
Sabouraud's dextrose agar (SDA) is the most commonly used isolation medium for
dermatophytes and it serves as the medium on which most morphologic descriptions are based.
Elimination of contaminant molds, yeast and bacteria is achieved by the addition of
cycloheximide and chloramphenicol (+/gentamicin) to the medium making it highly selective
for the isolation of dermatophytes. The development of colonies can take 57 days in the case of
Epidermophyton floccosum and up to 4 weeks for Trichophyton verrucosum. Cultures are
incubated at room temperature (20C25C) for at least 4 weeks before being finalized as no
growth. Dermatophyte test medium (DTM) is an alternative isolation medium that contains the
pH indicator phenol red. The medium turns red when dermatophyte proteolytic activity increases
the pH to 8 or above, and it remains amber with the growth of most saprophytes.
Nondermatophyte acidic byproducts turn the medium yellow. While DTM serves as a good
alternative for isolation of dermatophytes, it may not allow for their direct identification due to
altered growth and thus morphology of dermatophytes in DTM. Table 188-5 describes general
microscopic features of microconidia and macroconidia of the three genera of dermatophytes,
while Table 188-6 describes colony and microscopic features of the most common dermatophyte
species.




Histopathology
Skin biopsy is not often employed in the workup of typical dermatophytoses. Localized
cutaneous eruptions suspected to represent dermatophytosis with equivocal KOH examination
are often treated despite the lack of confirmation. Biopsy may confirm the diagnosis when a
systemic agent is being considered for treatment of a recalcitrant or more widespread eruption.
Biopsy may be used to aid in the diagnosis of Majocchi's granuloma in which KOH examination
of scale on the surface may more often be negative. Biopsy is also sometimes useful in
confirming the presence of hyphae involving hair shafts on the scalp in tinea capitis, although
culture is necessary to allow speciation of the pathogen. When present, hyphae may be
appreciated in the stratum corneum on hematoxylin and eosin staining. However special stains,
most commonly periodic acid-Schiff (PAS) and methenamine silver stains, highlight hyphae that
may otherwise be subtle in appearance on routine staining. Whereas culture is the most specific
test for onychomycosis, PAS examination of nail clippings is the most sensitive
29
and it obviates
the need to wait weeks for a result.
Wood's Light Fluorescence
Examination of involved hair bearing areas, such as the scalp or beard, with a Wood's lamp (365
nm) may reveal pteridine fluorescence of hair infected with particular fungal pathogens. Hairs
that fluoresce should be selected for further examination, including culture. While ectothrix
organisms M. canis and M. audouinii will fluoresce on Wood's light examination, the endothrix
organism T. tonsurans will not fluoresce. T. tonsurans, which is now the most common cause of
tinea capitis in the United States, thus limits the use of Wood's light examination. Table 188-8
lists common patterns of dermatophyte hair involvement and fluorescence.

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Table 188-8 Pattern of Hair Infection and Fluorescence
Pattern Dermatophyte Fluorescence
Pattern Dermatophyte Fluorescence
Endothrix Trichophyton soudanense None

Trichophyton violaceum None

Trichophyton tonsurans None

Trichophyton gourvilii None

Trichophyton yaoundei None
Ectothrix Mrichophyton canis Yellowgreen

Mrichophyton audouinii Yellowgreen

Mrichophyton distortum Yellowgreen

Mrichophyton ferrugineum Yellowgreen

Mrichophyton fulvum None

Mrichophyton gypseum None

Trichophyton megninii None

Trichophyton interdigitale None

Trichophyton rubrum None

Trichophyton verrucosum None
Favus Trichophyton schoenleinii Bluegray, occasional