T. Capitis is a worldwide
problem fungal infection of the scalp. It is primarily a disease in young
children where, males are more infected than females. This may be due to
shortness of the hair, which facilitates easy reach of the fungal spores
to the scalp.
Adults are rarely
infected; this is believed to be due to the higher fatty acid of the
scalp, which have dermatophytes inhibiting property.
It was established many
years ago that some saturated fatty acids, from adult human hair (and
derived from sebum) were inhibitory to dermatophytes fungi.
Fungal scalp infection
may be endemic, sporadic or epidemic, where involvement of large number of
school children or in crowded low hygiene refugee camps is not uncommon.
The tendency of scalp
ringworm to clear spontaneously at puberty was believed to be due to the
change in sebum composition at this age.
T. Capitis infections are
common in temperate countries.
Fig. 60a. Tinea capitis (Black
Fig. 60c.Tinea capitis
Fig.60d. After treatment
Contact with infected
persons or their fomites such as combs, brushes, or headgears.
Contact with infected
pets or animals such as cats, dogs or cattle.
Minor trauma is an
important predisposing factor for seeding of the fungi on the scalp to
infection of M. canes infections seems to be low and once treatment is
established children can go back to school.
Fungal strains causing infection
- is the most common strain to cause T. Capitis.
- is often contracted from animals, can cause highly inflammatory lesions.
mentagrophyte - causes highly inflammatory T. Capitis.
- causes an exceedingly chronic infection. The fungal infections often are
T. Violaceum -
causes the clinical lesion called "black dot" ring worm
T. Schoenleini -
causes the clinical type of T. Capitis known as favus.
The clinical picture
usually varies according to the causative dermatophyte.
Some strains such as
Microsporon Canis and T. Mentagrophtes cause highly inflammatory lesions,
while T. Tonsurans lesions have a very chronic course.
The clinical picture may
be sometimes confusing and cannot be easily diagnosed except by detection
of the dermatophyte by potassium hydroxide smears.
Different clinical types
of Tinea Capitis:
Dry Type - lesion may
be dry and scaly simulating dandruff of the scalp, psoriasis and lichen
Black Dot Type -
usually the lesion is dry where the hair is cut short from the stumps,
and the bases of infected hairs are prominent. There is a variable
degree of erythema, itching and scaling. The individual lesion may
persist for a long time or resolve spontaneously.
Kerion - Other lesions
may be highly inflammatory which show swollen, edematous, oozing and
crusting lesion in the form of boggy inflammation of the scalp called
"kerion". This type may be mis-diagnosed and treated as an
abscess of the scalp. Hair loss may be permanent causing cicatricial
Favus - the clinical
picture of favus is characteristic where solid crust is formed on the
infected area, which may spread to cover the whole scalp. The scalp has
special mouse smell. The condition is very chronic and may end with
cicatricial alopecia. The infection may spread to other areas away from
the scalp such as to the abdomen and extremities.
Diagnosis of T. capitis
can be settled by different methods:
The clinical picture
- fungi causing T. capitis characteristically beginn the pathological manifestations in the center feeding on the keratin and
spreading peripherally away from the center. There is central clearing
where the periphery of the lesion shows active edges either papular,
vesicular or papulovesicular edge with scaling surface.
Wood‘s light -
microsporon gives strong green fluorescence.
such as T. Schoenleini give dull green fluorescence under a filtered
ultra violet, Wood‘ light in a dark room. This is very helpful in
rapid screening of large number of school children.
Smear - this is a
simple method and can be done easily in the office. Microscopic
examination of the specimen by potassium hydroxide smears can detect the
hyphae of the causative dermatophyte.
Collection of scrapings
from the infected skin should be taken from the active edge of the
lesion using a blunt scalpel blade or by the edge of a slide. Infected
hairs should be depilated from their roots especially in favus.
The specimen is placed
on a slide and a drop of 30 percent potassium hydroxide is added and
covered by a cover slip . This is heated gently in order to soften and
clear the material . Care should be taken in order not to heat the
specimen too much and not to boil .
The specimen is
examined with low power microscope without staining. This may show the
branched septate hyphae.
Hair invasion by
dermatophyte is ectothrex in Microsporon, T. Mmentagrophyte and T.
Verrucosum, while it is endothrix in T. Tonsurans and T. Violaceum.
Culture - Culture is
on petri dishes or cotton wool - plugged test tubes with Sabouraud‘s
dextrose agar containing antibiotics to inhibit bacterial and saprophyte
contamination. Incubation is kept at 26-30 C for one to two weeks.
Different colonies can be identified morphologically and
Alopecia areata -
the area involved is smooth, free of hair and if there is some hair
growing in the patch it is not short cut at the surface and without
scaling . The exclamation mark sign of some hairs growing on the
periphery of the patches are an aid to diagnose alopecia areata.
Detection of the causative fungi is diagnostic for T. Capitis.
dermatitis - the lesion is more diffuse and with greasy scales, diffuse
hair loss and negative microscopic examination are important criteria
for differential diagnosis .
carbuncles of the scalp may simulate kerion . Bacterial lesions are more
inflammatory , has shorter course , the hair is not loose and cut short.
Dermatophytes can be detected on microscopic examination .
erythematosus : The condition has a chronic course ending with
cicatricial alopecia. The scales are adherent , shows stibbling and
other exposed areas such as the face may be involved. Microscopic examination
for any fungal elements is negative .
Lichen planus: Flat
topped ,violaceous papules may be seen in the lesion, which ends with
cicatricial alopecia . The extremities and the buccal cavity may have
the characteristic lesions of lichen planus.
discovered in the late 1940s and it was used after 1958 for treatment of
fungal lesions in man. This was the first oral antimycotic drug used in
the past till nowadays .
Despite its long history
as a fungastatic preparation, it has the most limited spectrum of activity
of all the available antifungal drugs, meanwhile it has no effect on
Mode of action:
The mode of action of
griseofulvin appears to be in part by inhibition of formation of
microtubules and it is most apparent in the active metabolizing cells near
the hyphal tip.
In man, griseofulvin is
fairly rapidly metabolized and conjugated with glucuronide in the liver,
excreted by the kidney and by the liver in bile.
with certain drugs such as anticoagulants, warfarin, cyclosporin ,
barbiturates and oral contraceptives.
Griseofulvin is available
in the standard microcrystalline form as 125 mg and 500 mg tablets and as
a pediatric oral suspension, 125 mg per 5 ml given after meals preferably
after a fatty meal , which increase drug absorption.
In Tinea capitis a single
dose, 2 g. of griseofulvin especially in young children (in order to be
sure that the effective dose was given), is frequently enough to clear
most of the lesions .
The recommended daily
dose is: A. Infants and children:
and children :
125mg/)day up to the
age of 1 year.(one teaspoonful )
187mg/day from 1 to 5
years (one and a half teaspoonful), and
teaspoonful) from 6 to 12 years divided into two doses or as one dose
after a fatty meal .
In children the daily
dose is 10mg/kg/day given in two divided doses daily. It should be after
meals (after fatty meal as after eating an egg).
The duration of treatment
varies from ten to twenty days according to the type and severity of the
fungal infection .
Adult dose :
0ne to two 500mg tablet
daily or at least 10 mg/ kg /day.
Small adults (55 kg). one
tablet 250 mg. twice daily
Medium-sized adults, one
tablet 250 mg. three times daily.
For large adults (over
100-kg), one tablet 500 mg. twice daily).
The newer oral azoles,
particularly itraconazole, are effective substitutes for griseofulvin but
more expensive .
Special indications of
Widespread Tinea corporis
due to T. rubrum , azoles are the treatment of choice.
Cases that failed to
respond or cannot tolerate griseofulvin
Type of azoles available
Itraconazole - these are
effective new anti-fungal preparations.
Adult: 100-200mg. /day
for few weeks in skin fungal infection and for several months in
Side effects of
This orally active
imidazole is a broad-spectrum anti-fungal agent.
Adult: 200-400 mg/day
with food and is usually well tolerated.
Headache and nausea
are relatively common minor side effects.
Liver enzymes should
be measured at monthly intervals with
courses .Treatment should be stopped if ALT or SGPT rise two- to
The drug interacts with
Terfenadine or astemazole
concurrent use .
Allergy to the drug .
These are antifungal
drugs that act by inhibition of squalene epoxidase formation of the fungal
The two main compounds
are Terbinafine and Naftifine.
Both are active against
Terbinafine such as
Lamasil can be given orally.
Children above 20kg can
be given 62.5 mg daily.
20- 40-kg-body weight :
125 mg can be given daily .
Above 40 kg - 250 mg
The adult dose is 250 mg
daily. Terbinafine is available also as topical preparation (Lamasil
cream). It has produced rapid and long-lasting remissions in both nail
disease and persistent Tinea pedais.
There is some evidence to
suggest that the frequency of relapse is much lower with Terbinafine than
that with other antifungal preparations.
The anti-fungal agent voriconazole is well tolerated,
with only mild to moderate adverse effects, report researchers.
The most common of side effects are headache, rash and abnormal vision.
Visual function tests detected no further abnormalities during treatment,
report Pfizer researchers in Sandwich, Kent, England, and Brussels,
FUNGAL INFECTION OF NAILS
Fungal infection of the
nails has a chronic course , slow and may take few months to manifest .
The severity and effect of infection of the nail is rather much dependent
on the type of infecting dermatophyte .
Different Fungi causing
: Causes chronic infection with little inflammatory reaction.
The course of
the disease is chronic. The lesion manifests with yellowish
discoloration of the nail tip which may spread to involve the
whole nail. The nail color is changed and shows dirty debris
underneath. Later on the nail becomes brittled and breaks off
leaving undermined black remnants .
skin may be invaded by the dermatophyte, leading to characteristically
branny, scaly and erythematous well-defined areas.
and usually localized nail infection .
is usually mild and begins on the nail fold. The adjacent
cuticle is pink, swollen, and tender and characteristically,
beads like pus can be expressed from the lesion. The
affected nail may become dark, ridged and may become separated
from its nail bed.
The nail plate
remains hard and glossy as the normal nail in contrast to infections
caused by dermatophyte, which lead to broken and friable, nails.
Fig. 63. Onychomycosis
Fig. 64. Onychomycosis
Fig. 65. Onychomycosis
T. Corporis is an
inflammatory mycosis of the glabrous skin. Different species as
Trichophyton, Microsporon and Epidermophyton floccosum can cause the
Modes of Infection
Infected pet animals.
The inflammation is transmitted from infected pets such as cat or dogs .
Autoinoculation from a
primary fungal focuses elsewhere on the skin.
From infected fomites
of the patients
Direct infection from
one patient to another
involved are the exposed areas such as face, neck and extremities
especially in children, but any site of the body may be involved.
Body ringworm lesions
present with erythematous papules, which enlarge to the periphery. The
fungus consumes the keratin at the center and retreats away from the
primary inoculation site, forming an oval or circular plaque with elevated
papulo-vesicular active edges more inflamed than the center. The lesions
sometimes form inflamed circles alternating with pale scaly areas.
Fig. 66. Tinea Corporis
Fig. 69. Tinea of the face
Fig. 67. Psoriasis (for differential diagnosis)
Fig.70a. Tinea corporis(Scaly
Fig. 68. Tinea
Manum (Tinea of the hand)
Fig. 70b. Tinea Corporis
( Uncommon site
may be mis-diagnosed as Peri-oral contact dermatitis)
above is a camel-man who used to suck directly the infected
camel breast to get his needs from camel's milk*
Wide spread fungal infection of the scalp&skin
Course of Tinea
T. corporis lesion may
May become a highly
May run a chronic course.
Dissemination may spread
to other parts of the body.
infection may invade the area.
This is a fungal lesion
of the skin that appears as a small papule, which enlarges eccentrically,
where the dermatophyte consumes the keratin in the center and then moves
to the periphery leaving scaly hypopigmented center and raised active
Fig. 71a. Tinea circinata
(Vesiculo-bullous and crusted lesions on the active
periphery with central clearing)
Circinate lesions may
fuse together forming large plaques or gyrate lesions. The symptoms are
minimal apart from mild itching. The condition is mildly contagious.
These lesions form
different clinical varieties:
Mainly T. Rubrum
causes this where large scaly plaques appear on the glabrous
skin by fusing of different lesions causing gyrate and arciform
Crusted lesions covering
wide areas of the skin and scalp with a mousy smell. The characteristics
of this type are Scutula and heavily crusted lesions as that occurring in
Fig. 71. Tinea circinata
Fig. 72. Tinea circinata
This is a boggy
inflammation of the glabrous skin as that of the kerion, which occurs on
the scalp. The condition is caused by dermatophytes transmitted from
animals such as T. verrucosum.
Different clinical types
of Tinea profunda:
The lesions are intensely
inflammatory, sharply circumscribed with follicular pustules that exude
serosanguous or blood tinged secretions.
infection may complicate the condition.
Scarring may be the end
The lesions are round,
scaly erythematous without central clearing. This type is caused by
This is a vesicular form
of body ringworm due to dermatophytes transmitted from animals such as
cats and dogs. Vesicular lesions appear which rupture leaving eroded
This is a rare form of
follicular and perifollicular granulomatous ring worm which has a chronic
The lesion appears on the
glabrous skin mainly on the chins as a circular, raised, circumscribed
boggy-crusted lesion in which the follicles are distended with a viscid
This is a superficial
fungal infection of the glabrous skin. The lesions present with extensive
patches that appear as concentric rings with polycyclic borders and scaly
edges. The course may take a long time where hyperpigmented and residual
hypo-pigmentation appear after healing of the lesions.
Favus is a fungal
infection of the scalp, caused by Trichophyton Schoenleini. Children are
the main age group infected with favus.
The infection rarely
involves the glabrous skin as trunk and neck.
The lesions may present
with thick and crusted patches.
Differential Diagnosis of
|Different skin lesions
may simulate T. Corporis:
Pityriasis Rosea - this
is the most common skin disease that has morphologically some of the
clinical picture as T. Corporis mainly in shape.
Fig. 73. Favus
Tinea Corporis lesion has
an active vesiculo-papular elevated edges while in pityriasis rosea the
edges are smooth. Herald patch (which is a large erythematous plaque
preceded the appearance of the skin eruption) may be detected.
The distribution of
pityriasis rosea lesions is usually along the line of ribs.
When there is a problem
in the differential diagnosis, potassium hydroxide smears can detect the
causative fungal species in T corporis.
Discoid Eczema - the
lesion is more itchy, round erythematous, scaly and there is no elevated
active edge such as in T. corporis and no fungal elements detected on
erythematosus - The sites involved are mainly sun-exposed areas. No papulo
vesicles appear on the edges. The lesion of discoid lupus erythematosus
has adherent scales. Heals with scarring.
Psoriasis - silvery
scales covering the patches with no central clearing.
picture - the fungal lesions have erythematous-raised edges and usually
with a clear center.
examination - examination of a smear of the scrapings from the active
lesion immersed in 20 percent potassium hydroxide and 10 percent sodium
sulfide solution shows the septate hyphae as round or oval in shape
arranged in chains.
Culture: on Sabouraud‘s
medium - can detect the pathogenic fungal species.
Treatment of T. Corporis
Mild solitary lesion: may
need only topical antifungal preparation such as Tolnaftate or imidazole
derivatives as Miconazole, Ecanozole nitrate, Clotrimazole and
Localized tinea corporis,
especially of recent origin, commonly responds usually to topical
antifungal preparations, applied twice daily for about a month.
fungal lesions: are treated by combination of oral and topical antifungal
Care should be taken in
using topical steroids in fungal lesions. Topical steroids may suppress
the inflammation and irritation, but it masks the clinical picture besides
the side effect causing striae and skin atrophy especially the delicate
skin of the intertriginous areas when used for a long time.
Systemic treatment by
griseofulvin or the other new generation antifungal drugs the Azole groups
should be used in wide spread lesions, or cases not responding to topical
preparations or in follicular lesions.
In more widespread
infections of recent onset, griseofulvin will generally be preferred and
may be expected to clear the condition in about 4 weeks.
Where the infection is
long-standing, for example, when caused by T. rubrum, much longer-term
intermittent courses for 3-4-weeks intervals, over a period of several
months may be required.
Ketoconazole appears to
be less satisfactory than griseofulvin in Tinea imbricata, although
preliminary data suggest that itraconazole may work better.
Tinea Cruris is a
superficial fungal inflammation of the intertriginous areas mainly that of
the inguinal, gluteal and the axillary areas. The most common dermatophytes
that can cause T. cruris are Epidermophyton floccosum and Trichophyton rubrum.
lesions are rare and are due to the species T. Mentagrophtes and T.
Tinea Cruris occurs
mainly in adults but infants and young children are rarely infected.
During the last
twenty-five years I have seen a very few cases of Tinea cruris due to
dermatophytes in infants and young children. Tinea cruris due to Candida
are the most common fungal infections in infants and young children.
Occlusion of the crural
area such as by diapers or plastic pants.
Excessive sweating and
Modes of inection
Infection may be
contracted from infected domestic animals such as cats or dogs.
Infected materials such
as towels or others.
Auto inoculation from
fungal focus elsewhere.
Epidemic infection in
school children may occur especially when sharing training suits, swimming
kits or infected clothes
The lesion may begin in
the crural area on the side of one thigh and extends to the other side to
become bilateral. Spread of the lesion may extend to the adjacent areas to
the intergluteal cleft, groin and upper abdomen.
Scrotum is usually not
involved; this may be due to the thin musculature of the area and
continuous movement of the scrotal muscles that may cause difficulty for
the fungus to seed there.
The lesions begin as an
erythematous scaly area spreading to the periphery with an active elevated
edge, where itching is a predominant feature.
The lesions in the early
stages are in the form of erythematous macules or plaques, arciform with
sharp margins extending from the groin down to the thighs. Scaling is
variable and occasionally may mask the inflammatory changes.
Central clearance is
usually incomplete with nodules scattered throughout the affected area.
Satellite lesions if
present are few in number and relatively large.
The course of the lesion
depends on the causative dermatophyte.
The clinical picture usually
varies according to the type of dermatophyte:
infections - are typically acute in onset, rather inflammatory and often
Trichophyton rubrum -
lesions are usually chronic. Extension from the groins to other sites is
common. T. Rubrum lesions extend to the buttocks, the lower back and the
T. interdigitale -
infections may be vesicular and inflammatory.
Fig. 74. Tinea cruris
Fig. 75. Tinea cruris
Fig. 76. Tinea cruris
Fig. 76c. Tinea
Fig.76d. Erythrasma(For differential diagnosis)
Fig. 76d. Tinea versicolor( For D.D.)
Seborrheic dermatitis -
the lesion presents with diffuse erythematous patch free from central
clearing and has no active edges such as the lesions of T. Cruris. Greasy
scales cover the lesion in seborrheic dermatitis. No fungal elements are
detected on microscopic examination.
Pityriasis rosea: the
lesions are oval or rounded discreet patches with few scales on the
center. The edges are not raised and herald patch may be detected
Erythrasma - the lesions
covers the infected area without central clearing. No active edges as in
T. Cruris. Erythrasma gives coral red color with Wood‘s light.
Microscopic examination of the scraping of the lesion shows the causative
Candidiasis - Satellite
lesions appear on the sides of the lesion.
T. pedis is a mycotic
infection of interdigital spaces, sub-digital folds, the soles and other
areas of the skin. Dermatophytes (T. Rubrum, T. Interdigitale and
Epidermophyton floccosum), yeast and moulds are the causative fungi. The
disease is more common in adult males and mainly in temperate zones.
those sharing sport activities in the school or sport clubs may be more
exposed to infection.
Infected fomites such
as stockings, slippers and shoes.
Moist sandy beaches,
swimming pools, common bathrooms and showers used by infected persons
predispose to the spread of T. Pedis.
Fig. 77. Tinea pedis
Fig.77b. T. pedis &
Onychomycosis(due to dermatophytes)
Fig.77c. T. pedis ( due to Candida )
Fig.77c. T. pedis ( due to dermatophytes)
Epidemic cases of T.
Pedis may occur especially in school children and other groups under
certain conditions facilitating spread of fungal infection.
Hot humid climate
may precipitate sweating and maceration of the feet that may act as an
optimum medium for the dermatophytes.
Wearing of nylon
socks or wearing the shoes for a long time may lead to occlusion of the
foot and predispose to infection.
soaps will change the pH of the skin and make the skin more susceptible
to the infection.
circulatory problems or factors causing hyperhidrosis as in certain
endocrine disturbance will lead to more maceration of the interdigital
such as diabetes or chronic debilitating diseases.
antibacterial and steroid preparations used for a long time may
predispose to T. Pedis.
Fig. 78. Tinea pedis
Maceration of the
interdigital area between the third or fourth toe web space or beneath the
interphalangeal crease of the last three toes accompanied by inflammation
The clinical picture
usually depends on the type of the fungus causing the disease.
T. Interdigitale causes
the acute vesicular lesions predisposed by excessive maceration of the
appears in the interdigital area with vesicles on an erythematous base
containing clear yellow liquid.
Secondary infection of
the vesicles may cause more inflammation accompanied by itching and pain.
T. Rubrum causes the
chronic dry and scaly type of T. Pedis. The infection may spread to the
adjacent tissue and nail causing onychomycosis.
Treatment of Tinea Pedis
Correction of the
predisposing factors such as excessive sweating, occlusion of the feet,
and proper hygiene to the feet.
powder dusted in the socks or between the interdigital areas in the
morning before wearing the socks.
preparations alone or in combination with antibacterial when secondary
infections are suspected.
has proven value and the imidazole are equally effective topical
permanganate solution 1: 9000 or aluminium chloride solution 20-30%
applied twice daily has considerable advantages in drying the wet oozing
:If there is any
evidence of bacterial infection, swabs should be taken for culture and
Using griseofulvin in
the treatment of Tinea pedis is sometimes difficult to evaluate. In the
chronic type (usually due to T. rubrum) it is of great value but may
need to be continued for 2 or 3 months.
and Terbinafine are effective medications. There is some evidence that the
speed of recovery is faster and relapsing rates are less with these
Other drugs in this
group, Miconazole, Isoconazole, Tioconazole and Sulconazole are equally
Cases complicated with
onychomycosis may need longer period of treatment.
The dose is:
Children up to age 1
year: 10 mg /kg/day (5 mg/lb./day) or 125 mg/day
From 1 to 5 years: 187
From 6 to 12 years:
Itraconazole is an
effective new antifungal preparation and is given for adults in a dose of
200 mg./day. The drug should always be given after meals. Single daily
dose can be used however twice daily is preferred.
The duration of treatment
varies considerably with the type of infection and the site involved.
Imidazole compounds in
particular have considerable antibacterial properties.
Tinea versicolor is a
superficial fungal infection caused by Malassezia Furfur. The infection is
most prevalent in the tropics predisposed by excessive sweating.
T. Versicolor is unusual
in children and young age. Infection occurs from using infected clothes,
towels and bed sheets.
Autoinfection is also
T. Versicolor has a
chronic course and recurrence is common due to auto- infection or due to
macules and patches appear on the trunk shoulders, upper neck and upper
limbs. Pityriasis versicolor is usually asymptomatic. The condition rarely
forms a distinct problem except for cosmetic. Hyperpigmented patches
intermingled with hypopigmented areas appear on the affected site.
Pruritus is minimal but
may increase with excessive sweating and bathing. The condition may have a
chronic course extending months and even years recurring every summer if
not properly treated.
Fig. 79. Tinea versicolor
Fig. 80. Tinea versicolor (Fresh lesion)
80b Tinea versicolor (Uncommon wide spread lesion)
Fig. 80 Tinea versicolor
Fig. 80b. Tinea
lesion misdiagnosed as vitilligo)
Tinea corporis - the
lesion is more inflammatory with raised active edges and the dermatophytes
can be detected microscopically.
Vitilligo - the
pigmentary loss in vitilligo is complete and the patches are white, smooth
and without the branny scales.
Tuberculoid leprosy - the
clinical picture may sometimes simulate the hypo-pigmented plaques of
tuberculoid leprosy and the diagnosis can be settled by laboratory finding
of the causative bacteria. The neurological signs show anesthesia of the
hypopigmented patches of tuberculoid leprosy.
Pityriasis rosea - the
herald patch, the distinct distribution of the eruption along the line of
the ribs and the negative microscopic examination for any fungal element
will help in the differential diagnosis.
Erythrasma - the two
conditions may co-exit together. Diagnosis can be confirmed by microscopic
detection of the causative organism and the pink fluorescence with Wood‘s
Light in erythrasma.
Seborrheic dermatitis -
the condition is more inflammatory and the sites involved are localized to
certain areas as the intertriginous. The greasy scales covers lesions of
Secondary stage of
syphilis - the history, the clinical features, the color of the lesions
and positive serological tests of syphilis confirm the differential
Preventive measures: are
very important to prevent re-infection.
Certain expensive clothes
can be washed the ordinary way by adding Nizoral shampoos to hot water and
soak the clothes for one hour, then wash and rinse. Towels and bed sheets
should be also boiled and ironed to destroy the fungus.
Selenium sulfide 2.5 per
cent (Selsun shampoo) applied every other day for two weeks clear most of
the lesions. Take care of the genitalia and eyes due to the possibility of
Topical azoles such as
Ecanozole (Pevaryl spray) and other anti- fungal preparations are also
effective, but are more expensive.
Spray or shampoo
preparations are easier to use than creams or ointments. Once or twice
daily application of the medication is usually required for several weeks.
which may improve the condition temporary, are not recommended.
Treatment of Recurrent
Most failures of topical
therapy are either due to inaccurate diagnosis, inadequate treatment,
missing out some lesions or re-infection either auto-infection or from
Treatment with one
percent Ecanozole citrate spray (Pevaryl) is effective and easy to be used
especially on widespread areas.
Oral Itraconazole used in
a single dose of 400 mg and ketoconazole total adult dose 800-1000 is very
effective. Children are given smaller doses depending on their weight.
The value of oral
treatment with 400 mg. of Fluconazole (adult dose) in a single dose proved
to be effective in the treatment of pityriasis versicolor. These
medications are expensive and some patients can not afford the cost. Oral
azoles are better kept as a reserve for reluctant or recurrent cases of T.
medications are not usually recommended as a routine in T. Versicolor
where the lesion may clear with topical preparations such as Ecanozole
cream, spray and shampoo alone.
In recurrent cases,
treatment may take a longer time and it is better to use topical Ecanozole
(Pevaryl sachets). One sachet can be used to rub the skin twice weekly for
one month and later once weekly for three months or for longer periods
Care and precautions to
prevent auto or re-infection from contacts.
This is a fungal
infection confined to the hair shafts and resulting in the formation of
superficial nodules on the infected hair.
Young girls are
Familial outbreaks may
There are two varieties
of Piedra, the black and the white (asteroid), which are caused by Piedra
hortae and Trichosporon beigelii, respectively.
Black Piedra is
characterized by the presence of firmly adherent black, hard, gritty
nodules, which are composed of a mass of fungus cells on the hair shaft,
which causes its disintegration , britling and breaking. These nodules
vary in size from microscopic to 1 mm or more in diameter. This type
occurs in tropical countries and affects monkeys as well as man.
|White Piedra lesions are
soft, white or light-brown nodules on the hair shaft. The fungus grows
both within and outside the hair shaft and like Black Piedra, the hair
shaft may be weakened and break off.
The underlying skin is
not affected and there is no fluorescence under Wood‘s light.
Fig. 81. White piedra
Systemic infections due
to Trichosporon may affect many different sites including the liver,
spleen and heart. Occasionally deep dermal nodules may occur.
arthrospores and budding cells are present.
In culture, the fungus
has slow growth, dark and compact, and usually heaped at the center. In
cultures of T. beigelii the colonies develop rapidly and are creamy and
wrinkled, later becoming deeply furrowed and folded.
The organisms of White
Piedra are surprisingly resistant in vitro to the Azole antifungal drugs.
Shaving or cutting the
hair is an effective method of treatment.
To prevent recurrence,
antifungal preparations such as Benzoic Acid Compound Ointment BPC or a
1:2000 solution of mercury perchloride may be applied to the scalp after