1Adult Cutaneous Fungal InfectionsMedical Student Core Curriculum in DermatologyLast updated May 23, 20112Module Instructions!e follo"ing module contains a num#er of #lue, underlined terms "!ic! are !yperlin$ed to t!e dermatology glossary, an illustrated interacti%e guide to clinical dermatology and dermatopat!ology&'e encourage t!e learner to read all t!e !yperlin$ed information&3Goals and Objectives!e purpose of t!is module is to !elp medical students de%elop a clinical approac! to t!e e%aluation and initial management of patients presenting "it! cutaneous fungal infections&(y completing t!is module, t!e learner "ill #e a#le to)* Identify and descri#e t!e morp!ologies of superficial fungal infections* Descri#e t!e correct procedure for performing a +,- e.amination and interpreting t!e results* /ecogni0e t!e use and limitations of +,- e.amination and fungal cultures to diagnose fungal infections* /ecommend an initial treatment plan for an adult "it! tinea pedis, tinea %ersicolor, candidal intertrigo, and se#orr!eic dermatitis1Superficial Fungal Infections: The BasicsDermatop!ytoses are estimated to affect 202234 of people "orld"ide, ma$ing t!em one of t!e most common infections&Superficial cutaneous fungal infections are limited to t!e epidermis, as opposed to systemic fungal infections 5e&g& endemic mycoses and opportunistic infections6&!ree groups of cutaneous fungi cause superficial infections) dermatop!ytes, Malassezia spp., and Candida spp.Dermatop!ytes 5"!ic! include Trichophyton spp&, Microsporum spp&, and Epidermophyton spp&6 infect $eratini0ed tissues) t!e stratum corneum 5outermost epidermal layer6, t!e nail or t!e !air&!e term tinea is used for dermatop!ytoses and is modified according to t!e anatomic site of infection, e&g& tinea pedis3Case OneMr& 7ugene (ro"n8Case One: Histor-9I) 7ugene (ro"n is a 822year2old !ealt!y man "!o presents to !is primary care p!ysician "it! a one2year !istory of itc!ing and #urning of !is feet&9M-) no c!ronic illnesses or prior !ospitali0ationsMedications) noneAllergies) no $no"n allergiesFamily !istory) noncontri#utorySocial !istory) li%es "it! "ife, "or$s as a #an$er-ealt!2related #e!a%iors) reports no alco!ol, to#acco or drug use/,S) increased nocturia, ot!er"ise negati%e:Case One: S!in "#a$-o" "ould you descri#e t!ese e.am findings;s most li$ely diagnosis;a& Atopic dermatitis#& Candidal intertrigoc& ,nyc!omycosisd& 9soriasise& inea pedis=Case One% &uestion '10(ns)er: e'!ic! of t!e follo"ing is Mr& (ro"n>s most li$ely diagnosis;a& Atopic dermatitis 5C!aracteri0ed #y red patc!es and pla?ues @ scale& Lic!enification may also result6#& Candida intertrigo 57ryt!ematous, eroded areas "it! satellite papules& Less li$ely location6c& ,nyc!omycosis 5Fungal infection of t!e nail6d& 9soriasis 5!e interdigital and plantar surfaces of t!e toes are unusual locations for psoriasis& 'ould e.pect a "ell2demarcated pla?ue "it! a t!ic$ sil%ery scale6e* Tinea +edis 11Tinea +edis: The Basicsinea pedis 5Aat!lete>s footB6 is t!e most common fungal infection seen in de%eloped countries, and is most commonly caused #y t!e fungus Trichophyton rubrumS!oes pro%ide an ideal en%ironment for fungus to gro" due to moisture9u#lic s!o"ers, gyms, and s"imming pools are common sources of infection It is difficult to permanently cure and may often recur!ere are t!ree clinical patterns of infection) interdigital, moccasin, and %esiculo#ullous type Most common, presents "it! scaling and redness #et"eent!e toes and may !a%e associated maceration&12Tinea +edis: Interdigital TpeAlso $no"n as c!ronic !yper$eratotic type&S!arply marginated scale, distri#uted along lateral #orders of feet, !eels, and soles&At times, %esicles and eryt!ema are present at t!e margins& ,ften associated "it! onyc!omycosis 5nail fungal infection6& 13Tinea +edis: Moccasin TpeMoccasin type may present as Aone !and, t"o feetB syndrome& Affected !and s!o"s unilateral fine scaling, particularly in t!e creases 5see #elo"6, and nails are often in%ol%ed&11Tinea +edis: Moccasin TpeCrouped, 223 mm %esicles or #ullae are seen, often on t!e arc! or instep& !ey may #e itc!y or painful& Desiculo#ullous type tinea pedis represents a delayed !ypersensiti%ity immune response to a dermatop!yte&13Tinea +edis: ,esiculobullous TpeBac! to Case One7ugene (ro"n181:Case One% &uestion -'!ic! of t!e follo"ing is t!e most appropriate ne.t step in diagnosis; a& (egin empiric treatment "it! antifungals& +,- e.amc& S$in #iopsyd& 'ood>s lig!t1s lig!t 5,rganisms "ill not fluoresce on "ood>s lig!t61=Case One: .OH "#a$ '!at are t!e diagnostic features in t!is +,- e.am;Magnification 10.20Case One: .OH "#a$ '!at are t!e diagnostic features in t!is +,- e.am;9arallel "alls t!roug!out t!e entire lengt!Septated and #ranc!ing !yp!aeMagnification 10.21.OH "#a$: Basic Facts +,- microscopy is t!e easiest and most cost effecti%e met!od used to diagnose fungal infections of t!e !air, s$in, and nail&9roper tec!ni?ue re?uires training&*Sensiti%ity is dependent on t!e operator>s e.perience&+,- dissol%es $eratinocytes to allo" easy %ie"ing of !yp!ae&-eat is used to accelerate t!is reaction&22The .OH "#a$ +rocedure 1& Clean and moisten s$in "it! alco!ol s"a#2& Collect scale "it! E13 scalpel #lade3& 9ut scale on center of glass slide1& Add drop of +,- and co%erslipF !eat slide gently "it! flame to ade?uately dissol%e $eratin3& Microscopy) scan at 10G to locate !yp!aeF t!en study in detail at 10G if neededClic$ !ere to "atc! t!e %ideoMa$e sure to turn on your computer %olume5%ideo lengt! s lig!t e.amd& All of t!e a#o%e3