What are the common types of superficial yeast infections. How can you identify them visually. What are the most effective treatment options for superficial fungal skin infections. How long does it typically take to treat tinea infections.

Understanding Superficial Fungal Infections: Types and Causes

Superficial fungal infections, also known as dermatomycoses, are among the most prevalent skin conditions worldwide. These infections are primarily caused by three genera of fungi collectively referred to as dermatophytes: Trichophyton, Microsporum, and Epidermophyton. These fungi have a predilection for keratinized tissues, such as the skin, hair, and nails.

The nomenclature of these infections typically reflects the area of the body affected:

• Tinea corporis: Infection of the body surface
• Tinea cruris: Infection of the groin area
• Tinea pedis: Infection of the feet
• Tinea capitis: Infection of the scalp
• Tinea barbae: Infection of the beard area
• Tinea manuum: Infection of the hands
• Tinea unguium: Infection of the nails

It’s important to note that while these infections are commonly referred to as “tinea,” not all superficial fungal infections are caused by dermatophytes. For instance, tinea versicolor is caused by Malassezia furfur, which is not a true dermatophyte.

Prevalence and Epidemiology

Superficial fungal infections are incredibly common, with an estimated lifetime risk of acquiring a dermatophyte infection between 10% and 20%. In the United States, dermatophytosis ranks second only to acne as the most frequently reported skin condition. Among the various types of tinea infections, tinea pedis, tinea corporis, and tinea cruris are the most prevalent.

Trichophyton rubrum is the most common causative agent in these infections, accounting for over 76% of all superficial fungal diseases in a representative sample of the U.S. population. The exception to this is tinea capitis, where Trichophyton tonsurans is the most likely etiologic agent.

Identifying Superficial Yeast Infections: Visual Characteristics and Symptoms

Recognizing the visual characteristics and symptoms of superficial yeast infections is crucial for accurate diagnosis and prompt treatment. While the specific appearance can vary depending on the type of infection and its location on the body, there are some general features to look out for:

Common Visual Characteristics

• Redness or discoloration of the affected area
• Scaling or flaking of the skin
• Circular or ring-like patches with raised, scaly borders
• Blistering or pustules in some cases
• Cracking or fissuring of the skin, especially in moist areas

Symptoms Associated with Superficial Yeast Infections

In addition to the visual signs, patients with superficial yeast infections may experience:

• Itching or burning sensation in the affected area
• Mild to moderate pain or discomfort
• Increased sensitivity of the skin
• In some cases, a foul odor (particularly with tinea pedis)

Are these symptoms always indicative of a yeast infection? While these signs and symptoms are common in superficial fungal infections, they can also be present in other skin conditions. Therefore, a proper diagnosis by a healthcare professional is essential for appropriate treatment.

Diagnostic Approaches for Superficial Fungal Infections

Accurate diagnosis of superficial fungal infections is crucial for effective treatment. While clinical presentation is often the most important clue, additional diagnostic methods can confirm the presence of fungi and identify the specific species involved.

Clinical Examination

The first step in diagnosis is a thorough clinical examination. A healthcare provider will assess the appearance of the affected area, considering factors such as:

• The location and distribution of the lesions
• The presence of scaling, redness, or other characteristic features
• Any associated symptoms reported by the patient

Microscopic Examination

Direct microscopy of a potassium hydroxide (KOH) preparation is a common and rapid diagnostic technique. This involves:

1. Scraping a sample from the affected area
2. Treating the sample with KOH to dissolve keratin
3. Examining the sample under a microscope for the presence of fungal hyphae

How accurate is KOH microscopy in diagnosing fungal infections? While KOH microscopy is a quick and simple method, it has limitations in terms of sensitivity and specificity. It can confirm the presence of fungi but cannot identify the specific species.

Fungal Culture

In cases where microscopy results are inconclusive or identification of the specific fungal species is necessary, a fungal culture may be performed. This involves:

1. Collecting a sample from the affected area
2. Inoculating the sample onto a specialized culture medium
3. Incubating the culture for several days to weeks
4. Identifying the fungal species based on growth characteristics and microscopic features

Wood’s Lamp Examination

For certain types of fungal infections, particularly those caused by some Microsporum species, a Wood’s lamp examination can be helpful. This involves exposing the affected area to ultraviolet light, which may cause certain fungi to fluoresce.

Treatment Strategies for Superficial Yeast Infections

Once a superficial yeast infection has been diagnosed, the next step is to implement an effective treatment strategy. The choice of treatment depends on various factors, including the type and extent of the infection, the patient’s overall health, and any previous treatments attempted.

Topical Antifungal Medications

For most superficial fungal infections, topical antifungal medications are the first-line treatment. These medications come in various forms, including:

• Creams
• Lotions
• Gels
• Sprays
• Powders

Some commonly prescribed topical antifungal agents include:

• Azoles (e.g., clotrimazole, miconazole, ketoconazole)
• Allylamines (e.g., terbinafine, naftifine)
• Ciclopirox
• Tolnaftate

How long should topical treatments be used? The duration of treatment varies depending on the specific infection and medication used. Generally, treatment should continue for at least one week after the clinical clearing of the infection. For tinea corporis and tinea cruris, treatment typically lasts two weeks, while tinea pedis may require four weeks of treatment with an azole or one to two weeks with an allylamine medication.

Systemic Antifungal Medications

In cases where the infection covers an extensive area or is resistant to topical therapy, systemic (oral) antifungal medications may be necessary. Common oral antifungals include:

• Terbinafine
• Itraconazole
• Fluconazole

Systemic treatments are typically reserved for more severe or recalcitrant cases, as they can have more significant side effects and drug interactions compared to topical treatments.

Combination Therapy

In some cases, a combination of antifungal and anti-inflammatory agents may be prescribed. This approach can be particularly useful when there is significant inflammation associated with the fungal infection. However, combination products containing corticosteroids should be used with caution due to the potential for side effects such as skin atrophy.

Preventive Measures and Lifestyle Modifications

While treating an active superficial yeast infection is crucial, preventing recurrence and spread is equally important. Here are some preventive measures and lifestyle modifications that can help:

Maintain Good Hygiene

• Keep skin clean and dry, especially in areas prone to fungal infections
• Change out of damp or sweaty clothing promptly
• Use antifungal powders in shoes and on feet if prone to tinea pedis
• Avoid sharing personal items like towels, combs, or shoes

Choose Appropriate Clothing

• Wear breathable, moisture-wicking fabrics
• Avoid tight-fitting clothes in warm, humid weather
• Wear sandals or open-toed shoes when possible to keep feet dry

Protect Feet in Public Areas

• Wear shower shoes or sandals in public showers, locker rooms, and pool areas
• Keep feet dry and change socks regularly, especially if prone to excessive sweating

Maintain a Healthy Immune System

• Eat a balanced diet rich in vitamins and minerals
• Get adequate sleep and manage stress
• Exercise regularly to promote overall health

How effective are these preventive measures? While these strategies can significantly reduce the risk of fungal infections, they may not completely eliminate the possibility of recurrence. Consistent application of these measures, along with prompt treatment of any new infections, is key to long-term management.

Challenges in Managing Superficial Yeast Infections

Despite the availability of effective treatments, managing superficial yeast infections can present several challenges. Understanding these challenges can help healthcare providers and patients develop more effective treatment strategies.

Recurrence and Chronic Infections

One of the primary challenges in managing superficial yeast infections is the high rate of recurrence. Factors contributing to recurrence include:

• Incomplete eradication of the initial infection
• Reinfection from environmental sources or close contacts
• Underlying medical conditions that increase susceptibility (e.g., diabetes, immunosuppression)
• Genetic predisposition to fungal infections

How can recurrent infections be managed? For patients with frequent recurrences, long-term suppressive therapy or prophylactic treatment may be necessary. This could involve regular use of topical antifungal agents or periodic oral antifungal treatment.

Antifungal Resistance

The development of antifungal resistance is an emerging concern in the management of superficial yeast infections. Factors contributing to resistance include:

• Overuse or misuse of antifungal medications
• Incomplete treatment courses
• Use of suboptimal drug concentrations

To address this challenge, healthcare providers may need to consider alternative antifungal agents or combination therapies for resistant cases.

Patient Adherence to Treatment

Successful treatment of superficial yeast infections often requires prolonged application of topical medications or completion of oral medication courses. Patient adherence can be challenging due to:

• The need for frequent application of topical medications
• Potential side effects of medications
• Improvement of symptoms before the infection is fully eradicated

Improving patient education about the importance of completing the full treatment course and using medications as prescribed is crucial for overcoming this challenge.

Emerging Treatments and Future Directions

As our understanding of superficial yeast infections continues to evolve, new treatment approaches and technologies are emerging. These advancements hold promise for improving the management of these common skin conditions.

Novel Antifungal Agents

Research is ongoing to develop new antifungal agents with improved efficacy and safety profiles. Some areas of focus include:

• New azole derivatives with broader spectrum activity
• Antifungal peptides derived from natural sources
• Nanoparticle-based delivery systems for improved drug penetration

How might these novel agents impact treatment? These new medications could potentially offer shorter treatment durations, reduced side effects, and improved efficacy against resistant strains.

Immunomodulatory Approaches

There is growing interest in the role of the immune system in susceptibility to and clearance of fungal infections. Potential immunomodulatory approaches include:

• Topical immune response modifiers
• Vaccines targeting specific fungal antigens
• Probiotics to enhance local immune responses

Personalized Treatment Strategies

Advances in genetic and molecular diagnostics may lead to more personalized treatment approaches. This could involve:

• Genetic testing to identify individuals at higher risk for recurrent infections
• Molecular typing of fungal strains to guide treatment selection
• Tailored prevention strategies based on individual risk factors

As research in these areas progresses, it is likely that our approach to managing superficial yeast infections will become more sophisticated and tailored to individual patient needs. This may lead to improved outcomes and reduced recurrence rates in the future.

In conclusion, superficial yeast infections remain a common and challenging condition in dermatology. While current treatments are generally effective, ongoing research and emerging technologies offer hope for even better management strategies in the future. As always, early diagnosis, appropriate treatment, and consistent preventive measures remain key to successfully managing these infections.

Topical Treatment of Common Superficial Tinea Infections

ANDREW WEINSTEIN, M.D., M.P.H., AND BRIAN BERMAN, M.D., PH.D.

Tinea infections are superficial fungal infections caused by three species of fungi collectively known as dermatophytes. Commonly these infections are named for the body part affected, including tinea corporis (general skin), tinea cruris (groin), and tinea pedis (feet). Accurate diagnosis is necessary for effective treatment. Diagnosis is usually based on history and clinical appearance plus direct microscopy of a potassium hydroxide preparation. Culture or histologic examination is rarely required for diagnosis. Treatment requires attention to exacerbating factors such as skin moisture and choosing an appropriate antifungal agent. Topical therapy is generally successful unless the infection covers an extensive area or is resistant to initial therapy. In these cases, systemic therapy may be required. Tinea corporis and cruris infections are usually treated for two weeks, while tinea pedis is treated for four weeks with an azole or for one to two weeks with allylamine medication. Treatment should continue for at least one week after clinical clearing of infection. Newer medications require fewer applications and a shorter duration of use. The presence of inflammation may necessitate the use of an agent with inherent anti-inflammatory properties or the use of a combination antifungal/steroid agent. The latter agents should be used with caution because of their potential for causing atrophy and other steroid-associated complications.

Tinea infections are superficial fungal infections caused by the three genera of dermatophytes, Trichophyton, Microsporum and Epidermophyton. ¹ Commonly, the infections caused by these organisms are named for the sites involved. Tinea capitis refers to a dermatophyte infection of the head, tinea barbae affects the beard area, tinea corporis occurs on the body surface, tinea manuum is limited to the hands, tinea pedis to the feet, and tinea unguium infects the toenails. These names do not distinguish between species (for example, tinea capitis may be caused by Trichophyton or Microsporum genera).

With some pertinent exceptions, dermatomycosis is typically confined to the superficial keratinized tissue² and, thus, can often be treated with topical antifungal medications.³ Because these agents do not penetrate hair or nails, tinea capitis, tinea barbae, and tinea unguium usually require systemic therapy. This article focuses on the diagnosis and treatment of tinea infections with topical medications. Because tinea capitis and tinea unguium are not typically amenable to topical therapy, they will not be discussed in this article.

It is important to note that nondermatophytes and yeasts may infect the sites mentioned above. For example, tinea unguium is only a subset of the onychomycoses, which include other types of fungal infections of the nails. Similarly, tinea corporis refers only to dermatophyte infection of the skin and not other superficial fungal infections such as candidiasis. Although tinea versicolor is commonly called a tinea, it is caused by the non-dermatophyte Malassezia furfur (also referred to as Pityrosporum orbiculare and Pityrosporum ovale) and is not a true tinea infection.⁴

Epidemiology

Because tinea infections are highly common, it is likely that the primary care physician will frequently treat affected patients. The estimated lifetime risk of acquiring dermatophytosis (tinea infection) is between 10 and 20 percent.⁵ In the United States, dermatophytosis is second only to acne as the most frequently reported skin disease.⁶ The majority of superficial fungal infections are tineas and, of those, the most common are tinea pedis, tinea corporis, and tinea cruris. ⁷Trichophyton rubrum is the most likely agent in these dermatomycoses. T. rubrum accounted for 76.2 percent of all superficial fungal diseases in a representative sample of the U.S. population.⁸ With the exception of tinea capitis (in which Trichophyton tonsurans was the most likely etiologic agent), T. rubrum was the most common dermatophyte isolated in all superficial fungal diseases studied.⁸

Clinical Manifestations

Clinical presentation is the most important clue to accurate diagnosis and treatment. The anthrophilic dermatophytes (commonly isolated from human infection) are the most common source of human dermatomycoses. These tend to evoke a limited host response and are less likely to be accompanied by severe inflammation or to clear spontaneously.⁹ Occasionally, severe inflammation is a component of dermatophytosis. This is particularly true in the case of tinea infections caused by zoophilic species (commonly isolated from animal infection). The most common of these is Microsporum canis.

TINEA CORPORIS

Tinea corporis refers to tinea anywhere on the body except the scalp, beard, feet, or hands. This lesion presents as an annular plaque with a slightly raised and often scaly, advancing border and is commonly known as ringworm. Each lesion may have one or several concentric rings with red papules or plaques in the center. As the lesion progresses, the center may clear, leaving post-inflammatory hypopigmentation or hyperpigmentation.

TINEA CRURIS

Because it affects the groin area, tinea cruris is also known as “jock itch.” It is characterized by red scaling plaques on the medial thighs and inguinal folds (Figure 1). The plaques are typically bilateral but usually spare the penis and scrotum, in contrast to candidiasis.¹⁰ Many people with tinea cruris have coincident tinea pedis, and it has been postulated that the tinea cruris is spread by hand from the tinea pedis.¹¹

TINEA PEDIS

Tinea pedis, or athlete’s foot, is the most common dermatophyte infection (Figure 2). Its etiology is closely tied to the use of occlusive footwear.¹² Most commonly, tinea pedis presents with toe-web maceration.¹³ This fairly subtle presentation is contrasted with the moccasin distribution affecting the soles and lateral feet that is often seen in patients with T. rubrum infection (Figure 3). In the latter cases, the feet tend to be hyperkeratotic with scale and some erythema (Figure 4). In some cases of tinea pedis, a dermatophytid (also known as “id”) reaction may occur in which small vesicles or pustules appear at distant sites. The id reaction may be the only manifestation of an otherwise asymptomatic webspace maceration and usually resolves with treatment of the primary fungal infection.

Diagnosis

The clinical suspicion of dermatophytosis can be confirmed with diagnostic tests. Because other entities may mimic tinea infection, treatment should not be initiated on the basis of clinical presentation alone. In most cases, a simple potassium hydroxide (KOH) preparation with mycologic examination under a light microscope can confirm the presence of dermatophytes. Occasionally, culture media (including indicator media) or histologic examination may be useful in making the diagnosis. A Wood’s light is not helpful in diagnosing tinea infections of the skin and is mainly used to identify fungal elements in hairs infected with Microsporum, which is a less common dermatophyte. The latter fluoresce green under Wood’s light. This light may also be helpful in diagnosing erythrasma by its coral-red fluorescence when this condition is part of the differential diagnosis of a tinea skin condition.¹⁴

KOH Preparation for Direct Microscopy

The KOH preparation, a relatively simple diagnostic method with excellent positive predictive value, is used to visualize the hyphae that characterize dermatophytes. Additional confirmatory tests are rarely needed for the diagnosis of tinea.¹⁵ The KOH helps dissolve the epithelial tissue, allowing the hyphae to be seen on microscopy.

Because the organisms live in the superficial keratinized tissue, a sample of scale should be visualized under low or medium power. Scale is collected from the active border of a lesion. This is done by scraping the lesion with the edge of a rounded scalpel blade or the edge of a glass slide. The debris is collected on another slide and concentrated in the middle. If a vesicle is being examined, it may be unroofed, and that material can be examined.

The slide should be covered with a cover slip, and KOH (5 to 20 percent) should be added to the side of the cover slip, allowing capillary action to draw the KOH to the scaly sample. The preparation may be heated gently over a flame to highlight the fungal elements. If dimethyl sulfoxide has been added to the KOH, heating is not required.

During examination of the sample, the condenser of the microscope should be in the down position. The presence of septate hyphae confirms the diagnosis of tinea. The examiner should make sure that hyphae are being seen rather than the edge of an epithelial cell. It is helpful to visualize the hyphae crossing the path of more than one cell.

If clinical decisions are to be made based on microscopic examination, practitioners must comply with Clinical Laboratory Improvement Amendments (CLIA) regulations. Performing KOH examinations requires a Provider–Performed Microscopy (PPM) certificate. Obtaining the latter requires completion of paperwork and does not require a site inspection. The American Academy of Dermatology publishes a handbook with directions for compliance with the PPM regulation.¹⁶

Culture

Mycologic culture is rarely indicated in the diagnosis of tineas other than tinea unguium and tinea capitis. In some cases, even though clinical suspicion is high, diagnosis may be a challenge. Culture, while relatively simple to perform, requires one to four weeks to grow and clinical expertise to interpret the result. The most common medium used for isolating dermatophytes is Sabouraud’s peptone-glucose agar.¹ Various formulations of this medium are commercially available; some have additives that inhibit bacterial and nondermatophyte growth. ¹⁷ A dermatophyte test medium (DTM) indicator can also be used. The latter has the added advantage of a phenol indicator that turns red in the alkaline environment produced by dermatophytes.¹⁸ Although DTM has the advantage of simplicity, it has a high rate of false-positive and false-negative results.¹

All media require collection of an adequate sample of infected material. Scale may be collected in a manner similar to that used for the KOH preparation or with a cotton swab. The swab must first be moistened with sterile water and then rubbed vigorously over the active border of the lesion. This method is best used when the lesion is not scaly or when the use of a blade or slide is impractical.¹⁹ The physician performing the culture must comply with stricter CLIA regulations. Performing cultures requires a level of certification that necessitates a laboratory inspection.

HISTOPATHOLOGIC EVALUATION

When the diagnosis of a dermatophyte infection remains in question after office testing or failure to respond to treatment, biopsy specimens may be submitted to a pathologist for evaluation. Fungal staining with periodic acid–Schiff highlights fungal elements.¹⁷

Treatment

Most tinea corporis, cruris, and pedis infections can be treated with topical agents. Consideration should be given to systemic treatment when lesions covering a large body-surface area fail to clear with repeated treatment using different topical agents.³ In treating dermatophytosis, the physician must also address environmental factors that lead to or exacerbate tinea infection and select an appropriate topical therapy for the infection.

NONPHARMACOLOGIC MEASURES

Because fungi thrive in moist warm environments, patients should be encouraged to wear loose-fitting garments made of cotton or synthetic materials designed to wick moisture away from the surface. Socks should have similar properties. Areas likely to become infected should be dried completely before being covered with clothes. Patients should also be advised to avoid walking barefoot and sharing garments.

NONSPECIFIC AGENTS

A variety of traditional agents without specific antimicrobial function are still in use, including Whitfield’s ointment and Castellani’s (carbol fuchsin solution) paint. The efficacy of these preparations has not been well quantified.

ANTIFUNGAL AGENTS

The antifungal agents can be grouped by structure and mechanism of action. The two principal pharmacologic groups are the azoles and the allylamines. Polyenes (amphotericin B [Fungizone] and nystatin [Mycostatin]) are not discussed in this article because this group of compounds is not effective in the treatment of dermatophyte infections. Other agents that do not fit into the two main groupings are tolnaftate (Tinactin), haloprogin (Halotex), ciclopirox (Loprox) and butenafine (Mentax).³

Because there are few direct comparisons of individual topical agents, it can be difficult to justify the choice of one preparation over another. This choice is made less clear because several genera and species may produce the same clinical condition. When treating a dermatophyte infection, it is unlikely that the physician will know the infecting species. In general, tinea corporis and tinea cruris require once- to twice-daily treatment for two weeks. Tinea pedis may require treatment for four weeks.³ Treatment should continue for at least one week after symptoms have resolved.¹⁷ Some of the newer agents require only once-daily application and shorter courses of treatment, and are associated with lower relapse rates.

The application area should include normal skin about 2 cm beyond the affected area. Guidelines regarding the optimal vehicle of treatment (e.g., cream, ointment, gel, or lotion) are given in Table 1.²⁰ Ideally, an agent will provide clinical and mycologic cure, symptomatic relief, and low relapse rate, along with ease of use. In addition to specific anti-fungal properties, some preparations have antibacterial and anti-inflammatory properties that may influence their efficacy. Combination therapy (antifungal plus steroid) can be considered when inflammation is an issue. Combination agents should not be used when the diagnosis is in question because that may lead to their overuse or to adverse effects.

The mechanism of action may have an effect on efficacy. The newer agents have fungicidal activity, which may translate into higher cure rates and lower relapse rates. Clinical judgment with regard to prior treatments and complicating conditions (bacterial growth or intense inflammation), along with knowledge of the agent’s properties, will help guide the choice of therapy. When inflammation is a salient clinical feature, it must be considered in the selection of a treatment option.

Tolnaftate

This narrow-spectrum antifungal has no antibacterial or anticandidal activity.²¹ It is effective in most dermatophytoses and for treatment of tinea versicolor.²² It is available as an over-the-counter medication and requires twice-daily application.

Haloprogin

Introduced after tolnaftate, haloprogin combines equivalent efficacy with a broadened fungal spectrum (including yeasts).²³ It is associated with higher rates of irritant dermatitis.²⁴ It is applied twice daily.

Ciclopirox

This broad-spectrum agent is effective against dermatophytes, yeasts, and some bacteria. ³ It has in vitro antibacterial activity against gram-negative and gram-positive bacteria. It has been shown to be more effective than the nonprescription agent clotrimazole (Lotrimin) in the treatment of tinea pedis.²⁵ It requires twice-daily application.

Ciclopirox 8 percent lacquer (Penlac), which was approved for treatment of onychomycosis in late 1999, has limited efficacy. In two trials of daily application to infected toenails for 48 weeks, complete cure was achieved in 5.5 and 8.5 percent of patients. Only the latter was statistically significant compared with placebo. Partial clearance was also low (12 percent in the more successful trial). Penlac requires daily application for up to 48 weeks and monthly follow-up for nail debridement.²⁶

Butenafine

This agent is similar in structure to that of the allylamines. Butenafine is fungicidal for dermatophytes in vitro.²⁷ It is applied once daily and, after four weeks of use, is associated with high cure rates and a long disease-free interval. ²⁸

Azoles

This class includes many over-the-counter and prescription preparations. Members of this class include clotrimazole, econazole (Spectazole), ketoconazole (Nizoral), miconazole (Micatin), oxiconazole (Oxistat), and sulconazole (Exelderm). These agents have broad-spectrum activity, including activity against some gram-positive bacteria. Ketoconazole,²⁹ sulconazole and oxiconazole³⁰ require only once-daily application because of their long durability in the superficial layers of the skin. Clotrimazole, miconazole, and econazole require twice-daily application.

Allylamines

Naftifine (Naftin) and terbinafine (Lamisil) are applied once-daily and remain active in the skin for up to one week after application.^31,32 Both agents have fungicidal activity in vitro, but the clinical significance of this point is uncertain.^33,34 Terbinafine has been compared with ketoconazole and miconazole. Terbinafine was more efficacious after one week than ketoconazole was after two weeks. ³⁵ In addition, one week of terbinafine was found to be as effective as four weeks of miconazole.³⁶ Evidence also suggests that terbinafine may be effective in curing tinea pedis in as few as three applications.³⁷ Naftifine has intrinsic anti-inflammatory properties equivalent to members of the azole class plus 1 percent hydrocortisone.³⁸ Evidence suggests that the fungicidal activity of naftifine and its duration of activity result in higher cure rates and a lower relapse rate.³⁹

COMBINED STEROID/ANTIFUNGAL AGENTS

In the United States, the only combination steroid/antifungal agent indicated for the treatment of dermatophytosis is clotrimazole-betamethasone (Lotrisone). This formulation combines an effective antifungal agent with a potent steroid. Patients who have symptomatic inflammatory dermatophytosis with erythema, pruritus, and burning are optimally treated twice daily with this combination. The steroid component provides rapid symptomatic relief while the slower-acting antifungal agent eradicates the causative organism. Inflammation typically occurs in tineas caused by zoophilic dermatophytes.

The efficacy of this combination treatment has been demonstrated in two randomized controlled studies,^40,41 the first treating tinea cruris and the second treating tinea cruris and corporis. In each study, the combination was better than either of the components alone in clearing the tinea infection. Because of these results, it is inferred that the steroid may enhance the antifungal activity of the clotrimazole.⁴⁰

A steroid/antifungal preparation should be used only when a diagnosis of fungal infection has been confirmed, not when it is in question. An analysis of the use of this product found that nondermatologists are more likely to use combination therapy.⁴² In the absence of fungi or inflammation, the added expense of this preparation is not justified.

Because of the potent steroid component, this medication provides rapid relief, but it must be used judiciously. ⁴³ Potential complications associated with long-term steroid use are atrophy, steroid-induced acne, rosacea, and striae. Caution must be used when treating areas of thin skin and naturally occluded body areas, such as the groin, axillae, breast, and face. Treatment of these areas should be avoided whenever possible. When the groin is affected by dermatophytosis, the cream should be used sparingly and only for two weeks. The recommended duration of treatment for tinea pedis is four weeks. This combination should not be used in children younger than 12 years.

Identifying and Treating Superficial Fungal Infections in the Urgent Care Setting

Urgent message: Rashes often lead patients to seek relief in the urgent care center. The ability to differentiate among common, superficial fungal infections and to select the most appropriate treatment or refer is an important skill to master.

Kosta G. Skandamis, MD and George Skandamis, MD
Introduction
Superficial fungal infections are among the most common skin conditions seen in the urgent care setting. Dermatophytes are the most common type of fungi that infect and survive on dead keratin (i.e., skin, hair follicles, nails), but certainly not the only type the clinician is likely to be presented with. Candidiasis, primarily due to Candida albicans, affects not only mucous membranes, but also skin (skin folds and moist areas). Finally, tinea versicolor (also known as pityriasis versicolor or, more colloquially, as yeast infection(is caused by the lipophilic yeast Pityrosporum, also known as Malassezia furfur.

In this article, we will review common causative organisms and discuss presenting characteristics, differential diagnosis, and available treatments.

Overview: Dermatophyte (Tinea) Infections
Three types of dermatophytes account for the majority of superficial fungal infections:

• Trichophyton
• Epidermophyton
• Microsporum

Dermatophytes can be classified according to the place of origin (anthropophilic, zoophilic, or geophilic), according to the tissue mainly involved (epidermomycosis, trichomycosis, or onychomycosis), or by body region affected (tinea faciale, corporis, cruris, manus, pedis).

It is not uncommon for dermatophyte infections to affect healthy individuals, but immunocompromised patients are particularly susceptible.

Dermatophytes tend to present in children as scalp infections, while young adults are likely to have intertriginous infections. Gupta, et al, reported in the Journal of the American Academy of Dermatology that the prevalence of fungal nail infections is 0.7% in patients < 19 years of age, compared with 18% in patients 60 to 79 years of age.

The single most important test for diagnosis of dermatophytosis is the hyphae under the microscope. (See Table 1.) Cultures are usually unnecessary, since most species respond to many of the same agents.

Table 1. Summary of Diagnostic Methods
Infection	Methods
Tinea capitis	Black dot type Visualization of hyphae under the microscope or by fungal cultures.Gray patch type Direct visualization of hyphae under the microscope or by Wood’s lamp. Hairs infected with Microsporum spp fluoresce.
Tinea cruris	Direct visualization of hyphae under the microscope or by cultures (on Sabouraud’s medium).
Tinea pedis	Direct microscopy or fungal cultures.
Cutaneous candidiasis	Clinical diagnosis can be confirmed by potassium hydroxide (KOH) preparation or culture of scrapings.
Tinea versicolor	Identify round yeast and elongated hyphae “spaghetti and meatballs” on direct microscope examination of scales prepared with KOH or by the blue-green fluorescence of the scales under the Wood’s lamp.

Tinea Capitis
Tinea capitis affects children almost exclusively, and is much more common in African-Americans than in Caucasians. In adults, seborrheic dermatitis can mimic tinea capitis. Clinically, tinea capitis presents as two distinctly different forms:

Without treatment, BDTC progresses, leaving permanent scars. A secondary infection and transition to kerion may occur.

Diagnosis is only by visualization of hyphae under the microscope or by fungal cultures. A Wood’s lamp is not helpful.Gray patch tinea capitis (GPTC), caused by Microsporum canis, is usually contracted from dogs or cats and, rarely, from another person.

The infection starts as an erythematous, scaling, pruritic, well-demarcated circular patch, showing numerous broken-off hairs, that keeps spreading centrifugally. Many patches coalesce to form larger patches. Many patches may be present for weeks to months. (See Figure 2.)

Figure 2. Gray patch tinea capitis.

Diagnosis is by direct visualization of hyphae under the microscope or by Wood’s lamp. Hairs infected with Microsporum spp fluoresce.

Occasionally, the lesion becomes boggy, waxy, purulent, and extremely tender and is associated with lymphadenopathy (kerion; see Figure 3).

Treatment
BDTC and GPTC both respond to the same medications (Table 2). Topical agents are ineffective.
Treatment of kerion is a subject of minor controversy. While some practitioners advocate treating with antibiotics active against Group A Strep and S aureus in addition to Griseofulvin 250 mg BID for four to six weeks plus hot compresses, others maintain that kerion can be treated successfully without antibiotics.

Figure 3. Gray patch tinea capitis with associated kerion.

	Dose*	Side effects	Noteworthy
Griseofulvin	Adults For GPTC: 250 mg BID, 1-2 months; microsize 15 mg/kg/day up to 500 mg/dayFor BDTC: 250 mg TID, 6-12 weeks; ultramicrosize 10/mg/dayChildren 30-50-pound child: 125 mg- 250mg/day > 50-pound child: 250 mg – 500 mg/day	Headache, nausea/vomiting, photosensitivity	CBC, LFTs if treatment lasts > 3 months
Terbinafine	Adults 10-20 kg: 62.5 mg/day, 4 weeks 20-40 kg: 125 mg/day, 4 weeks > 40 kg: 250 mg/day, 4 weeksChildren Not recommended	Rarely, nausea, abdominal pain, aplastic anemia
Itraconazole	Adults 200 mg/day, 4-8 weeksChildren 3-5 mg/kg/day, 4-6 weeks Or 5 mg/kg/day, 1 week each month for 2-3 months	Needs acid gastric pH, raises levels of digoxin and cyclosporine
Fluconazole	Adults and children 6 mg/kg/day, 2 weeks Repeat at four weeks if needed		Only oral agent approved for children < 2 years
CBC, complete blood count; LFT, liver function test *Variations on doing regimens exist in the literature.

Prevention
Examine school and home contacts to identify asymptomatic carriers. Carriers should be treated with selenium sulfide shampoo or with an oral antifungal agent. Children under treatment can return to school.

Tinea Corporis
Tinea corporis (TC, also referred to as ring worm) refers to dermatophyte infections of the trunk, legs, arms, and neck (excluding feet, hands, or groin), most commonly due to Trubrum. It affects all ages and can be transmitted by autoinoculation form other parts of the body, but also from close contact with animals or contaminated soil.

TC is more common in tropical and subtropical regions. It appears clinically as multiple, bright, mildly pruritic or asymptomatic sharply marginated, scaly plaques, with or without vesicles at the margin (Figure 4). These plaques enlarge peripherally with central clearing and production of concentric rings.
Allergic contact dermatitis, psoriasis, seborrheic dermatitis, and granuloma annulare all can mimic TC.
Tinea contact gladiatorum affects athletes who have skin-to-skin contact, and is caused primarily by Ttonsurans. In such case, the athlete should abstain from contact sports for 10 to 15 days.

Figure 4. Tinea corporis.

Treatment
Tinea corporis usually responds well to topical antifungals, particularly the azoles. Systemic treatment is reserved for immunocompromised individuals, patients who failed topical treatment, and for TC gladiatorum.

Tinea Cruris
Tinea cruris (jock itch) refers to dermatophytosis of the groin, pubic area, and inner thighs. Primarily, it affects obese males who wear tight occlusive clothing in a humid, warm environment. Usually, it is associated with tinea pedis, often with a history of tinea cruris.

Clinically, tinea cruris presents as an erythematous patch on the inner aspect of one or both thighs. It spreads outward with central clearing and sharp, slightly elevated border which may or may not contain tiny vesicles. Scrotum and penis are rarely involved.

Differential diagnosis involves intertrigo, erythrasma, pityriasis versicolor, and psoriasis.
Diagnosis is achieved by direct visualization of hyphae under the microscope or by cultures (on Sabouraud’s medium).

Treatment
Tinea cruris responds well to topical antifungals, including azole and allylamine products, as well as ciclopirox and haloprogin. Failure to treat concomitant tinea pedis results in recurrence.

Prevention
Prevention is achieved by wearing shower shoes when using public baths, using antifungal powders to keep the groin dry, and avoiding hot baths and opting for boxer shorts instead of briefs. Wearing loose clothing may also be helpful. Also, avoid sharing fomites, like hats, clothing, and towels.

Tinea Pedis
Tinea pedis (athlete’s foot; see Figure 5) is the most common dermatophytic infection seen in practice. It involves the feet and is characterized by erythema, scaling, maceration, and/or bulla formation. The infection can, in time, spread to the groin, trunk, hands, and nails. Bacteria can invade through the cracks and cause cellulitis or lymphangitis.

Tinea pedis tends to be chronic, with exacerbations.

Males are more prone to tinea pedis than females. Hot, humid weather, occlusive shoes, and excessive sweating are other predisposing factors. Typically, tinea pedis is transmitted by walking barefoot on contaminated floors.

Skin lesions can be:

• interdigital type (dry scaling or macerated, peeling, fissuring of tow webs)
• mocasin type, which is the most difficult to treat (well=demarcated erythema with tiny papules and scales and being confined to heels, soles, and lateral borders of feet)
• inflammatory/bullous type (vesicles or bullae filled with clear fluid on soles, instep, web spaces)
• ulcerative type (extension of interdigital tinea infection onto dorsal and plantar foot, usually complicated by bacterial infections).

Differential diagnosis includes erythrasma, impetigo, Candida intertrigo, bullous impetigo, and dyshidorisis.
Diagnosis is established by direct microscopy or fungal cultures.

Treatment
Most topical agents (azoles, pyridines, allylamines, or benzylamines) applied BID for four weeks are effective against tinea pedis. Some prescription agents have a broader spectrum and can be applied once daily. A meta-analysis of 11 randomized trials concluded that treatment with terbinafine or naftifine. HCI produces a higher cure rate than treatments with itraconazole.

It should be noted that topical agents may be unable to penetrate keratinized plantar skin. In such cases, the oral form of these agents may be preferable.

Apply Burow’s wet dressings to macerated, interdigital lesions. Apply cool compresses and, if severe, add systemic steroids to acutely inflamed feet.

Prevention
Instruct patients to wear shower shoes in public baths and locker rooms. Wash feet with benzoyl peroxide after shower.

Tinea Manuum
Tinea manuum refers to a chronic dematophytosis of the hands that does not resolve spontaneously. Even after treatment, recurrences are common. Usually, the dominant hand is involved. tinea manuum can last for years.
On examination, hands look red with white scales confined to palmar creases (Figure 6). Borders are well demarcated with central clearing and pruritus is present.

Tinea manuum is usually associated with tinea pedis and/or tinea cruris and/or tinea unguium of fingernails.

Figure 6. Tinea manuum.

Treatment
Because of the thickness of the palmar skin, topical agents are not effective. Use:

• terbinafine 250 mg QD for two weeks, or
• itraconazole 200 mg QD for one week, or
• fluconazole 200 mg QD for two to four weeks.

Cutaneous Candidiasis
Cutaneous candidiasis is a superficial skin infection affecting moist, macerated, chafed skin. Intertrigo refers to Candida infection on intertriginous areas (two closely opposed skin surfaces; see Figure 7). Factors that increase skin friction, moisture, warmth, or maceration and decrease immune response typically increase risk.

Clinically, the initial picture is one of an erythematous, pruritic plaque of the groin, perianal area, axilla, abdominal pannus, web space of toes and fingers, or under the breasts, with fine peripheral scaling and satellite pustules. Later, the plaques coalesce to form large eroded areas.

Diagnosis is clinical but can be confirmed by potassium hydroxide (KOH) preparation or culture of scrapings.

Treatment
The treatment is tailored toward the actual fungal infection, the underlying predisposing factors, and keeping the intertriginous areas as dry as possible.

Initial treatment for the majority of patients is a topical antifungal cream, typically miconazole or clotrimazole, applied for seven to 14 days. Oral antifungal agents (ketoconazole 22 mg/day or fluconazole 100 mg/day for four to six weeks) are reserved for resistant cases.

Various drying agents (e.g., corn starch, Domeboro’s solution, talcum powder, antifungal powders) can minimize skin fold moisture. Drying agents are used after adequate antifungal treatment has been completed. High-risk patients should use drying agents indefinitely, as well as antifungal cream once or twice a week.

Tinea Versicolor
Tinea versicolor is a chronic asymptomatic scaling dermatosis due to overgrowth of a yeast (Pityrosporum ovale) that resides normally in the keratin of skin and hair follicles. The term “tinea” should be reserved for dermatophytosis, and the present condition should be termed “pityriasis versicolor” (PV). Predisposing factors include humidity, high rate of sebum production, application of grease to skin, or high levels of cortisol.
PV presents as multiple, sharply demarcated hypopigmented macules with fine scales on the upper back, trunk, neck, arms, and abdomen (see Figure 8). The small macules are asymptomatic or may produce mild itching and can enlarge to form extensive patches.

Differential diagnosis includes vitiligo, pityriasis alba, psoriasis, and tinea corporis.
Diagnosis is achieved by identifying round yeast and elongated hyphae, so-called “spaghetti and meatballs,” on direct microscopic examination of scales prepared with KOH or by the blue-green fluorescence of the scales under the Wood’s lamp.

Figure 7. Intertrigo infection (cutaneous candidiasis).

Patients should be informed that PV is not considered contagious, does not leave permanent scars, and that skin color alteration resolves within months.

Treatment
Selenium sulfide lotion applied to affected areas daily for two weeks is the mainstay of treatment.
Topical azole antifungal agents can be used once daily for two weeks.
Recurrence can usually be prevented by using any topical agent once weekly for the following few months.

Oral therapy is also effective (and sometimes preferred for its convenience), using:

• ketoconazole 200 mg/day for 10 days, or
• fluconazole 150 mg to 300 mg single dose/week for two to four weeks, or
• itranconazole 200 mg/day for seven days.

Oral therapy does not prevent recurrences.

Figure 8. Pityriasis versicolor.

Conclusion
Acute discomfort is often viewed as an urgent matter for which some may be disinclined to wait for a primary care appointment. Urgent care’s growth has been fueled by its ability to fill such gaps. Being prepared to provide relief with an accurate diagnosis and informed treatment choice for common, superficial fungal infections will help further establish the practitioners as an invaluable member of the healthcare “team.”

Identifying and Treating Superficial Fungal Infections in the Urgent Care Setting

Tagged on: Clinical    Cutaneous Candidiasis    Dermatophyte (Tinea) Infections    Rashes    Superficial Fungal Infections    Tinea Capitis    Tinea Corporis    Tinea Cruris    Tinea Manuum    Tinea Pedis    Tinea Versicolor

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Aspergillosis: causes, symptoms, diagnosis and treatment.

Definition

Aspergillosis is a fungal disease of humans, animals and birds caused by Aspergillus, a fungus of the genus Aspergillus. In humans, aspergillus was first discovered by J. H. Bennett in 1844, and the first aspergillosis disease was described by R. Virchow in 1856.

Sporadic human aspergillosis occurs in all countries of the world.

Causes of aspergillosis

Aspergillus are widespread in nature – they can be found in the air, soil, plants, skin of humans and animals. Infection of humans occurs by inhalation or ingestion of Aspergillus spores, less often as a result of their penetration through damaged skin or mucous membranes.

The disease is not transmitted from person to person.

In addition, doctors talk about the so-called occupational hazards – we are talking about industries where there is a possibility of processing raw materials contaminated with aspergillus: breweries and flour mills, silicate factories, weaving, twine and rope factories, etc.

An additional danger of aspergillosis is that it complicates the course of such pathological processes of the respiratory system as allergies, rhinitis, bronchitis, cavernous tuberculosis, and lung cancer.

Immunity after an illness is unstable.

Classification of the disease

According to ICD 10:

• Aspergillosis.
• Invasive pulmonary aspergillosis.
• Other forms of pulmonary aspergillosis.
• Tonsillar aspergillosis.
• Disseminated aspergillosis.
• Other types of aspergillosis.
• Aspergillosis, unspecified.

According to clinical manifestations, there are:

• visceral aspergillosis;
• skin and mucous membrane lesions;
• aspergillosis of the organs of hearing and vision;
• allergic manifestations.

Aspergillosis symptoms

Aspergillus most often affects the lungs, where aspergilloma forms – tumor-like formations consisting of dense plexuses of the fungus. On the radiograph, the tumor-like body is sharply outlined and surrounded by a light, narrow crescent-shaped air cushion resembling a mushroom.

Aspergillosis of the respiratory tract (Aspergillus pneumonia) causes the following symptoms: first there is a persistent sensation of bitterness in the mouth and a scratchy throat.

The temperature can rise to high values ​​in the morning and decrease to normal or subfebrile values ​​(up to 37.5) in the evening.

The feverish state is accompanied by aching bones and chills. The disease proceeds rapidly – at first, a painful dry cough is paroxysmal in nature, later it becomes productive – the sputum discharge is gray-green, streaks of blood may be present. The patient complains of shortness of breath even with a slight load, intense pain in the chest, aggravated by breathing and changing the position of the body.

With the generalization (massive spread) of the process, septicopyemic forms develop (along with the general intoxication of the body, the formation of metastatic abscesses in various tissues and organs occurs).

There are aspergillus pleurisy (inflammation of the pleura), meningoencephalitis, endocarditis (inflammation of the inner lining of the heart and valves).

Aspergillus splenomegaly (enlargement of the spleen) is chronic, the spleen tissue is literally riddled with threads of the fungus.

Aspergillus is known as one of the causative agents of mycetoma (Madura foot) – a syndrome characterized by unilateral painless dense infiltrate limited to the foot or hand, edema, granuloma formation and fistulas. Bone tissue may be involved in the process, which leads to limb deformity.

Aspergillus otitis is described, which manifests itself as mild hyperemia (redness), peeling and itching of the skin of the external auditory canal. Later, there is a thinning of the epithelium and a gradual filling of the external auditory canal with a loose grayish or yellowish, cotton-like mass, in which fungal spores are present. The spread of mycosis to the eardrum is manifested by pronounced stabbing pains in the ear. Damage to the ethmoid bone, maxillary and sphenoid sinuses is possible with the transition of the process to the orbits. Ulcerative conjunctivitis and other eye lesions are observed.

In the development of skin aspergillosis, in addition to factors common to mold mycoses, trauma (burns, wounds), skin maceration, and previous inflammatory processes play a role. Eczema-like aspergillosis of the skin, similar to seborrheic eczema, has been described. The disease is chronic and is manifested by rashes, vesicles, multiple dense, painless nodes, localized mainly on the upper limbs. Gradually, the nodes soften, open with the formation of ulcers and scars.

Aspergillosis of the nails is often associated with infection with dermatophytes, molds that require keratin for nutrition and live on the stratum corneum of the skin, hair or nails, causing superficial mycoses. Such a mixed infection is characterized by the appearance of gray, yellow, less often greenish spots or stripes in the thickness of the nail, the development of subungual hyperkeratosis (thickening). In the future, the nail is deformed and crumbles.

Diagnosis of aspergillosis

In the process of diagnosing aspergillosis, great attention is paid to the anamnesis. The definition of chronic pulmonary pathology and immunodeficiency states is important.

• For pulmonary aspergillosis, x-rays are taken. If it is not informative enough, then a CT scan of the lungs is performed.

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Sputum examination

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Histological examination of tissue taken from the lesion: skin epithelial cells, lung granulomas.

Biopsy diagnosis of dermatosis – morphological study of biopsy specimens for the diagnosis of skin diseases (except neoplasms) (Pathology of skin biopsies)

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Fungus identification in lower respiratory specimen by culture

Synonyms: Sowing on yeast and mold fungi.

Sowing on yeast and mold fungi.

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Fungus identification in lower respiratory specimen by culture

Synonyms: Sowing on yeast and mold fungi.

Sowing on yeast and mold fungi.

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The presence of the fungus in the organ of vision is determined by culture of discharge from the eye.

Fungus identification in lower respiratory specimen by culture

Synonyms: Sowing on yeast and mold fungi.

Sowing on yeast and mold fungi.

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Differential diagnosis of pulmonary aspergillosis is carried out with inflammatory diseases of the respiratory tract of viral or bacterial etiology, sarcoidosis, candidiasis, pulmonary tuberculosis, cystic fibrosis, lung tumors, etc. Aspergillosis of the skin and nails is similar to epidermophytosis, syphilis, actinomycosis.

Which doctors to contact

Aspergillosis is diagnosed and treated by general practitioners,
therapists, pulmonologists, phthisiatricians, infectious disease specialists,
otolaryngologists, dermatologists.

Treatment of aspergillosis

The duration of therapy and the amount of therapeutic measures depend on the form of the disease and the state of the patient’s immunity. The severity of the patient’s condition and the form of aspergillosis determine whether treatment is carried out on an outpatient basis or in an appropriate hospital.

Antifungals are always the drugs of choice.

In case of damage to the skin, nails, mucous membranes, local therapy with antifungal drugs and antiseptics is carried out. The duration of treatment ranges from several weeks to 3 months or more.

At the same time, drug therapy is carried out for the background process – the one against which aspergillosis arose: allergies, bronchitis, lung cancer, tuberculosis. Antibacterial drugs and corticosteroids are used.

If aspergilloma bleeds, surgery is performed to remove it.

Complications

Aspergillus is associated with the occurrence of bronchial asthma, pulmonary bleeding, the formation of bronchiectasis (bronchial deformities with the development of a chronic suppurative process in them.), cor pulmonale.

With the spread of aspergillus with blood flow from the primary focus, there is a risk of aspergillus endocarditis, encephalitis, abscess of the brain, kidneys, liver, myocardium, damage to bones, gastrointestinal tract, ENT organs; aspergillus sepsis.

Prevention of aspergillosis

There is no specific prevention of aspergillosis.

People working in flour mills, granaries, vegetable stores, weaving factories should use respirators.

Early recognition and treatment of the underlying disease is important to prevent secondary (pulmonary) aspergillosis.

Sources:

1. Moskvitina E. N. Atlas of pathogens of fungal infections. – M.: GEOTAR-Media, 2017. – 208 p.
2. Seidulaeva L.B., Egemberdieva R.A., Sadykova A.M., Tukhanova N.B., Ismailova B.S. Aspergillosis (case report) // Bulletin of KazNMU. – 2017. – No. 1. – S. 124-126.
3. Morozova L.V., Ermilov O.V., Ovsyannikova M.N. Pulmonary aspergillosis: two forms – two clinical cases // Actual problems of medicine. – 2017. – No. 12. – P. 174-179.
4. Diagnosis and treatment of chronic pulmonary aspergillosis: clinical guidelines of the European Respiratory Society and the European Society for Clinical Microbiology and Infectious Diseases // Eur. Respir. J. 2016; 47:45–68. DOI: 10.1183/13993003.00583;2015

IMPORTANT!

The information in this section should not be used for self-diagnosis or self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.
For a correct assessment of the results of your analyzes in dynamics, it is preferable to do studies in the same laboratory, since different laboratories may use different research methods and units of measurement to perform the same analyzes.

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Malassezia or “what kind of mushroom”?

Yeast fungi of the genus Malassezia normally live on the skin of cats, dogs and humans. When viewed under a microscope at a magnification of X 1000, they resemble a nesting doll in appearance, as they reproduce by budding. The main species, Malassezia pachydermatis, inhabits the superficial layers of the skin (external auditory canal, interdigital space, chin, skin folds) and mucous membranes (mouth, rectum, vagina, paraanal glands). As a habitat, it prefers places with increased secretion of the sebaceous glands.

Pathogenesis

Malassezia itself does not cause any skin lesions, but under certain conditions, it can play a role in the development of the pathological process. There are a number of predisposing factors that contribute to the occurrence of Malassezia dermatitis:

• increased environmental humidity (frequent bathing), as well as humidity associated with the anatomical features of the body (skin folds, hanging ears) and hypersecretion of the sebaceous glands
• increase in ambient temperature (summer, spring)
• Skin pH 4. 0 to 8.0
• some diseases: atopic dermatitis, food allergies, endocrine diseases; viral leukemia and immunodeficiency in cats
• increased reproduction of staphylococci (this fungus is in a symbiotic relationship with skin staphylococci)

An allergic reaction (type I hypersensitivity) can also develop on Malassezia.

It is important to remember that Malassezia dermatitis is not contagious.

There is no age and gender predisposition in animals, however, there are breeds that are genetically predisposed to the appearance of Malassezia dermatitis: German Shepherds, Bassets, West Highland White Terriers, Shih Tzu, Dachshunds, Boxers, Poodles. In some cat breeds (Sphynx, Devon Rex), this problem occurs more often than others.

Clinical signs:

Clinical signs are varied, but most often Malassezia dermatitis is accompanied by itching (although this may be a manifestation of the underlying disease). The skin acquires a specific sweet smell. Claws and nail beds become brown. Brown coloration is characteristic of discharge from the external auditory canals, skin and / or wool. The skin becomes “greasy”, thickened.

Lesions can be localized and generalized. The folds on the lips, interdigital spaces and claw beds, ears, armpits and groin are most often affected.

Diagnostics

Diagnosis of Malassezia dermatitis is based on the presence of clinical signs in the animal, cytological examination (finding more than one Malassezia in the field of view when examining the material under a microscope), and response to antifungal therapy.

Cytological examination includes:

taking material from the surface of the skin with adhesive tape or pressing the glass to the skin, staining the preparation with special dyes (Leukodif, Diff-Quik), examination under a microscope at a magnification of X1000.

It is important to remember that this disease is almost always a secondary problem.