particularly chronic because these regions have no sebaceous glands, which normally produce antimicrobial substances. Chronic tinea pedis and tinea mannum can be complicated by tinea unguium 2. Tinea Capitis There are there patterns of in vivo hair invasion: ectothrix, endothrix, and favus Ectothrix infection occurs when hyphae fragment into arthroconidia outside the hair shaft leading to cuticle destruction, In endothrix infection, arthroconid ia are found within the hair shaft without cuticle destruction Favus refers to arthroconidia and air spaces within the hair shaft Ectothrix-producing organisms can be divided into those fungi florescent with woods light examination and those dermatophytes nonfluorescent with wood's light examination In general, organisms resulting in fluorescent ectothrixhair invasion are in the genus microsporum. Geographic variabl ity is frequentlyseen. Microsporum canis is the most common cause of fluorescent ectothrix infection monly causes fluorescent ectothrix in parts of Africa. Although M. audouinii wasformerly common in Europe and both North and South america. this organism is mow seldom cultured 1)Ectothrix tinea capitis Ectothrix tinea capitis usually presents clinically as patches of scalp alopecia with scale The haris may break off at or slightly above the scalp. In general, small patches coalesce to form larger patches, with minimal inflammatory response. This pattern is often referred to as"gray-patch'tinea capitis 2)Endothrix hair infection Endothrix hair infection is nonfluorescent and produced by anthropophilic organisms in the genus Trichophyton. The most common cause of endothrix tinea capitis in North America is T. tonsurans; T. violaceum commonly produces end othrix tinea capitis in Europe leaving a"black-dot"ptients. The clini-calpresentation also includes kerion formaton where boggy purulent patches of alopecia occur as well as presentations simulating seborrhea dermatitis 3 Favus Favus, the third and most serious presentation of tinea capitis, is usually caused by T. schoenleinii. However, both T violaceum and M. gypseum can also produce favuslike crusts. Zoophilic organisms, such as T. equinum, can priduce favus in animals. Favus is characterized clinically by the occurrence of scutula, which are thick, yellow crus composed of hyphae and skin debris. If the cond ition is untreated, chronic infections progressing to scarring alopecia of the entire scalp may occur. A potassium hydroxide examination of hair can differentiate favus fron other causes of scarring alopec ia, and reveals arthroconidia, hyphae, and air spaces within the hair shaft. Using woods light examination, hairs may fluoresce a bluish white to green color. Psoriasis, sebopsoriasis, pityriasis amiantacea, and bacterial pyoderma may simulate features of favus and should be imcluded in the d ifferential diagnosis 3. Tinea cruris Tinea cruris refers to dermatophytosis of the proximal medial thighs, perineum, and buttocks. buttocks. This classic presentation is common in males but seldomoccurs in females. The most common fungal pathogens in males areT rubrum, T. mentagrophyte abd E floccosum; in females cand id iasis caused by candida albicans is more common. Of note is that even in extensive tinea cruris, the scrotum and penis are penis are cliniclly
particularly chronic because these regions have no sebaceous glands, which normally produce antimicrobial substances. Chronic tinea pedis and tinea mannum can be complicated by tinea unguium 2. Tinea Capitis There are there patterns of in vivo hair invasion:ectothrix, endothrix, and favus. Ectothrix infection occurs when hyphae fragment into arthroconidia outside the hair shaft, leading to ccuticle destruction,In endothrix infection, arthroconidia are found within the hair shaft without cuticle destruction .Favus refers to arthroconidia and air spaces within the hair shaft. Ectothrix-producing organisms can be divided into those fungi florescent with wood’s light examination and those dermatophytes nonfluorescent with wood’s light examination, In general, organisms resulting in fluorescent ectothrixhair invasion are in the genus microsporum. Geographic variability is frequentlyseen. Microsporum canis is the most common cause of fluorescent ectothrix infection monly causes fluorescent ectothrix in parts of Africa. Although M. audouinii wasformerly common in Europe and both North and South America, this organism is mow seldom cultured. 1) Ectothrix tinea capitis Ectothrix tinea capitis usually presents clinically as patches of scalp alopecia with scale. The haris may break off at or slightly above the scalp. In general, small patches coalesce to form larger patches, with minimal inflammatory response. This pattern is often referred to as “gray-patch”tinea capitis. 2) Endothrix hair infection Endothrix hair infection is nonfluorescent and produced by anthropophilic organisms in the genus Trichophyton. The most common cause of endothrix tinea capitis in North America is T. tonsurans; T . violaceum commonly produces endothrix tinea capitis in Europe leaving a “black – dot” ptients. The clini-calpresentation also includes kerion formaton where boggy purulent patches of alopecia occur as well as presentations simulating seborrhec dermatitis. 3) Favus Favus, the third and most serious presentation of tinea capitis, is usually caused by T. schoenleinii. However, both T. violaceum and M. gypseum can also produce favuslike crusts. Zoophilic organisms, such as T. equinum, can priduce favus in animals. Favus is characterized clinically by the occurrence of scutula, which are thick, yellow crusts composed of hyphae and skin debris. If the condition is untreated, chronic infections progressing to scarring alopecia of the entire scalp may occur. A potassium hydroxide examination of hair can differentiate favus fron other causes of scarring alopecia, and reveals arthroconidia, hyphae, and air spaces within the hair shaft. Using wood’s light examination, hairs may fluoresce a bluish white to green color. Psoriasis, sebopsoriasis, pityriasis amiantacea, and bacterial pyodermas may simulate features of favus and should be imcluded in the differential diagnosis. 3. Tinea cruris Tinea cruris refers to dermatophytosis of the proximal medial thighs, perineum, and buttocks.buttocks. This classic presentation is common in males but seldomoccurs in females. The most common fungal pathogens in males areT. rubrum , T. mentagrophytes, abd E. floccosum; in fenales candidiasis caused by candida albicans is more common. Of note is that even in extensive tinea cruris, the scrotum and penis are penis are cliniclly
affected. However with cand ida infections. scrotal involvement is common(Differentiating candidiasis from dermatophytosis is important for therapy selection. certain topical antifungals have no significant effect against candida species(ie, tolnaftate), and oral griseofulvin is also not useful Frequently, tinea cruris and tinea pedis occur on the same patient. Other risk factors include contact sports, perspiration, tight clothing, use of gymnasiums, and environmental factors such as high humid ity and tropical temperatures The classic type of tinea cruris is characterized by well-marginated, elevated popular scaly patches of dermatitis vith active, spreading peripheries studded with vesicles vesicopustules. The lesions usually are bilateral but no necessarily sy metrical; the central portions are brownish to red in color snd covered with fine, branny, furfuraceous scales. In acute infections theveis considerable erythena, but the older cases may show cnly lichenified, leathery and plaguelike lesions, The eruption may extened into the pubic areas and as far back as the sacrum, involv ing the scrotum or vulva but particularly the perianal imtertrigimous region In some instances, the lesions may appear as isolated vesicopustules without the typical marg inated appearance. Occasicnally, the axillae may be involed and present a picture similar to that seen in the groin. Sometimes the lesions may be white, soggy and maceraced and. resemble those caused by C albicans Perspiration, irritation from clothing, diabetes, neurodermatitis, leucorrhea and friction resulting from obesity freguently are predisposing factors. there may be moderate to Immense 4. Tinea Corpor Tinea corporis, caused by various species of Trichopyton and Microsporum, is a fung us infection which involves the glabrous skin and produces lesions which vary from those of simple scaling to deep granulomata The commonest manifestation of tinea corpor is the annular erythematous papulosguamous lesion. The central area is scaly, and the advancing active periphery usually is studded with crusting vesicles and pustules. The lesions vary from o, S, to 5 cm in size and may be single or multiple Such lesions may begin on any part of the body and coalesce to form arci form configurations. Children are affected more often than adults, and the disease freguently is acguired from animals Small, circinate, annular lesions may enlarge into erythematous, sguamous lesions which may become solid and plaguelie, or they may be me eczematoid and spread peripherally in circinate fashion but without central clearing. some of the lesions show only dry, superficial scaling ;others appear moist and crusted. In rare instances, the lesions may become granukmatous and produce ulcertion of the skin, most lesions are relatively asymptomatic. although some of them cause itching 5. Tinea Unguium The term tinea unguium refers to dermatophyte infection of either fimgermails or toenails. Onychomycosis is a broader term that includes nail infection by nondermatophyte molds and yeasts. There are four clinical terns of nail involvement (1 )distal subungual invasion; (2)proximal subungual invasion ()white superficial invasion,which can also be referred to as leukonychia trichophytic(mycotica); and (4 )candida onchomycosis or involvement of the entire nail plate as seen in patients with chronic mucocutaneous cand id ias The affected mails are discolored, lusterless, brittle, thickened, friable and may
unaffected. However with candida infections, scrotal involvement is common(Differentiating candidiasis from dermatophytosis is important for therapy selection . certain topical antifungals have no significant effect against candida species (ie, tolnaftate), and oral griseofulvin is also not useful. Frequently, tinea cruris and tinea pedis occur on the same patient. Other risk factors include contact sports, perspiration, tight clothing, use of gymnasiums, and environmental factors such as high humidity and tropical temperatures. The classic type of tinea cruris is characterized by well-marginated, elevated popular, scaly patches of dermatitis vith active, spreading peripheries studded with vesicles or vesicopustules. The lesions usually are bilateral but no necessarily symmetrical; the central portions are brownish to red in color snd covered with fine,branny, furfuraceous scales . In acute infections theveis considerable erythena, but the older cases may show cnly lichenified, leathery and plaguelike lesions, The eruption may extened into the pubic areas and as far back as the sacrum, involving the scrotum or vulva but particularly the periamal imtertrigimous region. In some instances, the lesions may appear as isolated vesicopustules without the typical marhginated appearance . Occasicnally, the axillae may be involed and present a picture similar to that seen in the groin . Sometimes the lesions may be white, soggy and maceraced and . resemble those caused by C. albicons. Perspiration ,irritation from clothing, diabetes, neurodermatitis, leucorrhea and friction resulting from obesity freguently are predisposting factors . there may be moderate to imtense itching. 4. Tinea Corporis Tinea corporis, caused by various species of Trichopyton and Microsporum,is a fung us infection which involves the glabrous skin and produces lesions which vary from those of simple scaling to deep granulomata. The commonest manifestation of tinea corpori is the annular erythematous papulosguamous lesion. The central area is scaly, and the advancing active periphery usually is studded with crusting vesicles and pustules. The lesions vary from o、s、to 5 cm in size and may be single or multiple. Such lesions may begin on any part of the body and coalesce to form arci form configurations. Children are affected more often than adults ,and the disease freguently is acguired from animals. Small, circinate, annular lesions may enlarge into erythematous , sguamous lesions which may become solid and plaguelie, or they may be me eczematoid and spread peripherally in circinate fashion but without central clearing .some of the lesions show only dry, superficial scaling ;others appear moist and crusted. In rare instances, the lesions may become granukmatous and produce ulcertion of the skin, most lesions are relatively asymptomatic . although some of them cause itching. 5. Tinea Unguium The term tinea unguium refers to dermatophyte imfection of either fimgermails or toenails.Onychomycosis is a broader term that includes nail infection by nondermatophyte molds and yeasts . There are four clinical terns of nail involvement (1)distal subungualinvasion;(2)proximal subungual invasion;(3)white superficial imvasion,which can also be referred to as leukonychia trichophytica (mycotica);and (4)candida onchomycosis or imvolvement of the entire nail plate as seen in patients with chronic mucocutaneous candidiasis. The affected mails are discolored, lusterlesss, brittle, thickened, friable and may
become pitted and grooved as a result of paronychia inflannation, Ifection usually begins distally or at the lateral edge of the nail, and beneath the nail there is an accumulation of a cheesy epidermal detritis in which the causative fungus can be demonstrated. such detritis usually dose not occur in C. albicans in fection of the nails. In some instances the top of the nail seperates distally, leav ing it thin, furrowed, ragged and deformed. Trubrm infections usually involve the entire thickness of the nail plate and may eventually destroy the entire nail The patient usually gives a history of previous infection of the toes Feet or hands; toenails are affected more often than fingernails, and one or more nails may be affected. Paronychial involvement is uncommon except in infection due to C albicans. Tinea rmguium is the most resistant of all fung us infections and shows no tendency to spontaneous cure Superficial fungus infections of the face are not uncommon, such lesions are often mistaken for poy morphous light eruptions, discoid lupus erythema to sus, seborrheic dermatitis or contact dermatitis. A suspected infection can be confirmed by microscopic study and by culture 6. Tinea manuum Tinea manuum is frequently caused by the same organisms responsible for both timea pedis and timea cruris T rubrum, T mentagrophytes, and e floccosum. Tinea manuum and timea pedis may coexist; the same dermatophyte usually infects both sites in the same host. Other organisms that cause timea manuum-like presentation are both scytalid ium hyal inum and Hendersonula toruloidea; in add ition, Candida albicans can One or both hands can be infected, and the typical clinicalpresetation is a dry, scaly hyperkeratotic palm does mot sigmificantly benefit from emollients. Unilateral involvement is frequent, and inflammation such as vesicles and bullae are seldom seen In chronic cases, concurrent tinea unguium occurs, which may help in clinicall distinguishing tinea manuum from other hyperkeratotic cond itions. The differential iagnosis includes psoriasis, eczema, drug eruptions, and early pityriasis rubra pilaris potassium hydroxide preparation can exclude nondermatophyte cayses; the diagnosis is comfirmed by culture. Im patients with either tinea manuum or tine pedis, it is important to use culture media without cyclohexmide so as not to eliminate fungal causes unable to grow in the presence of this antibiotic(eg, H. toruloidea, s. hyalinum, and some cand ida 7. Tinea Pedis There are four clinical patterns of tinea pedis: moccasin, inflammatory, interdigital, and ulcerative. The moccasin pattern occurs when one or both plantar surfaces develop erythematous, dry, scaly patches which often extend to the medial or lateral foot or both The differential diagnosis includes psoriasis, eczema, and various keratodermas Inflammatory tinea ped is typically presents on the medial foot as vesicles or bullou lesions. This pattern has been associated with the dermatophytid reaction. The differential amatory tinea pedis includes dyshiddrot blistering conditions. In interdigital tinea ped is, erythema, scale, and maceration occur in the web spaces of one or both feet. Tinea ped is can be differentiated from erythrasma by Woods light examination, as erythrasma, caused by Corynebacterium minutissimum fluoresces coral red. Interd igital tinea ped is may extend beyond the web spaces to the dorsum and plantar surface of the foot. Ulcerative tinea pedis usually is an extension of
become pitted and grooved as a result of paronychial inflannation, Ifection usually begins distally or at the lateral edge of the nail , and beneath the nail there is an accumulation of a cheesy epidermal detritis in which the causative fungus can be demonstrated .such detritis usually dose not occur in C. albicans in fection of the nails. In some imstances the top of the nail seperates distally ,leaving it thin, furrowed , ragged and deformed. T rubrm infections usually involve the entire thickness of the nail plate and may eventually destroy the entire nail The patient usually gives a history of previous infection of the toes. Feet or hands; toenails are affected more often than fingernails,and one or more nails may be affected. Paronychial involvement is uncommon except in infection due to C. albicans .Tinea rmguium is the most resistant of all fung us infections and shows no tendency to spontaneous cure. Superficial fungus infections of the face are not uncommon, such lesions are often mistaken for poymorphous light eruptions, discoid lupus erythema to sus, seborrheic dermatitis or contact dermatitis . A suspected infection can be confirmed by microscopic study and by culture. 6. Tinea Manuum Tinea manuum is frequently caused by the same organisms responsible for both timea pedis and timea cruris:T. rubrum, T .mentagrophytes, and E. floccosum. Tinea manuum and timea pedis may coexist; the same dermatophyte usually infects both sites in the same host. Other organisms that cause timea manuum-like presentation are both scytalidium hyalinum and Hendersonula toruloidea; in addition, Candida albicans can mimic this condition. One or both hands can be infected, and the typical clinicalpresetation is a dry, scaly, hyperkeratotic palm that does mot sigmificantly benefit from emollients. Unilateral involvement is frequent, and inflammation such as vesicles and bullae are seldom seen. In chronic cases, comcurrent tinea unguium occurs, which may help in clinically distinguishing tinea manuum from other hyperkeratotic conditions. The differential diagnosis includes psoriasis, eczema,drug eruptions, and early pityriasis rubra pilaris. A potassium hydroxide preparation can exclude nondermatophyte cayses; the diagnosis is comfirmed by culture. Im patients with either tinea manuum or tine pedis, it is important to use culture media without cyclohexmide so as not to eliminate fungal causes unable to grow in the presence of this antibiotic(eg, H. toruloidea,s. hyalinum, and some candida species). 7. Tinea Pedis There are four clinical patterns of tinea pedis: moccasin, inflammatory, interdigital, and ulcerative. The moccasin pattern occurs when one or both plantar surfaces develop erythematous, dry, scaly patches which often extend to the medial or lateral foot or both. The differential diagnosis includes psoriasis, eczema, and various keratodermas. Inflammatory tinea pedis typically presents on the medial foot as vesicles or bullous lesions. This pattern has been associated with the dermatophytid reaction. The differential diagnosis of inflammatory tinea pedis includes dyshiddrotic eczema and primary blistering conditions. In interdigital tinea pedis, erythema, scale, and maceration occur in the web spaces of one or both feet. Tinea pedis can be differentiated from erythrasma by Wood’s light examination, as erythrasma, caused by Corynebacterium minutissimum, fluoresces coral red. Interdigital tinea pedis may extend beyond the web spaces to the dorsum and plantar surface of the foot. Ulcerative tinea pedis usually is an extension of
interdigital tinea pedis complicated by secondary bacterial infection and may be seen in the immunocompromised host. Occasionally, the ulcerative form may become extensive and require hospitalization The differential diagnosis of tinea pedis includes infection by the yeast Cand ida albicans (and other Candida species), the molds Hendersonula toruloidea and Scytalidium hyalinum, and bacteria in the genera Acinetobacter, Micrococcus, and Pseudomonas, as well as Corynebacterium minutissimum. Culture on agar without cycloheximide is necessary to identify all fungal pathogens correctly. The majority of tinea pedis is caused by T. rubrum. Both T. mentagrophytes and E. floccosum are also commonly isolated Cand ia albicans and dermatophytes are frequently copathogens clinical condition often referred to as "dermatocand id iasis"(dermatocand idosis) 8. Therapy 1)Oral antifungal therapy Oral antifungal theras junct to topical agents when treating tinea corporis,timea is usually necessary when treating tinea capitis, and tinea cruris, and tinea pedis. In general inflannatory tineas such as those resulting from zoophilic dermatophytosis, can also benefit from oral antifungal therapy dermatophy can be treated by the following oral agents griseofulvin, ketoconazole, terbinafine, and itraconazole. Fluconazole also appears to have activity against dermatophytes, although more stud ies are needed regard ing the affectiveness of this costly agent Griseofulvin was introduced in the 1950s and was the only oral agent available for treating dermatophyte infections until ketoconazole first appeared in the 1970s. The activity of griseoulvin is limited to dermatophytes. Ketoconazole is also effective against a variety of yeasts and molds such as pityrosporum and candida, Although griseofulvin is currently the first line therapy for most dermatophytoses, many infections by the common dermatophytes, T, rubrum and T tonsurans, do not always respond to this dru Frepuently the dose of griseofulvin must be doubled in order to see any clinical improvement. In these cirumstances, oral ketoconazole can be quite useful. Ketoconazole can also be used if the patient is allergic to griseofulvin, has a potential drug interaction, or cannot tolerate griseofulv in due to various reactions (e.g, headache, nausea, photosensitivity). The use of both systemic griseofulvin and ketoconazole requires periodic laboratory monitoring The new allylamine, terbinafine, and the mew triazole, itraconazole, both appear to have antifungal activity superior to that of both griseofulvin and ketoconazole. The addition of these new oral agents will certainly improve the treatment and prognosis of dermatophytoses that have been traditionally difficult to manage. In particular, infections with T, rubrum should benefit from both these oral antifungal agents(tinea ped is, tinea unguium) 2)Topical antifungal therapy Topical antifungal agents useful in treating dermatophytoses belong to one of the categories: imidazoles( miconazole, econazole, ketoconazole, etc ) allylamines(naftifine terbinafine); naphthionate (tolnaftate ); and the substituted pyridine ciclopiroxolamine, With the exception of tolnaftate, these agents have activity against dermatophytes, candida, and certain gram positive bacteria, Tolnaftate is effective only against dermatophytes, Although in clinical studies these agents are comparable, they
interdigital tinea pedis complicated by secondary bacterial infection and may be seen in the immunocompromised host. Occasionally, the ulcerative form may become extensive and require hospitalization. The differential diagnosis of tinea pedis includes infection by the yeast Candida albicans (and other Candida species), the molds Hendersonula toruloidea and Scytalidium hyalinum, and bacteria in the genera Acinetobacter, Micrococcus, and Pseudomonas, as well as Corynebacterium minutissimum. Culture on agar without cycloheximide is necessary to identify all fungal pathogens correctly. The majority of tinea pedis is caused by T. rubrum. Both T. mentagrophytes and E. floccosum are also commonly isolated. Candia albicans and dermatophytes are frequently copathogens, a clinical condition often referred to as “dermatocandidiasis” (“dermatocandidosis”). 8. Therapy 1) Oral antifungal therapy Oral antifungal therapy is usually necessary when treating tinea capitis ,and tinea unguium ,and can be an adjunct to topical agents when treating tinea corporis ,timea cruris, and tinea pedis.In general ,inflannatory tineas ,such as those resulting from zoophilic dermatophytosis, can also benefit from oral antifungal therapy. Dermatophytes can be treated by the following oral agents:griseofulvin, ketocomazole, terbimafine, and itraconazole. Flucomazole also appears to have activity against dermatophytes, although more studies are needed regarding the affectiveness of this costly agent. Griseofulvin was introduced in the 1950’s and was the only oral agent available for treating dermatophyte infections until ketoconazole first appeared in the 1970’s . The activity of griseoulvin is limited to dermatophytes. Ketoconazole is also effective against a variety of yeasts and molds such as pityrosporum and candida, Although griseofulvin is currently the first line therapy for most dermatophytoses , many infections by the common dermatophytes , T ,rubrum and T. tonsurans , do not always respond to this drug. Frepuently the dose of griseofulvin must be doubled in order to see any clinical improvement. In these cirumstances, oral ketoconazole can be quite useful. Ketoconazole can also be used if the patient is allergic to griseofulvin, has a potential drug interaction, or cannot tolerate griseofulvin due to various reactions (e.g., headache, nausea, photosensitivity). The use of both systemic griseofulvin and ketocomazole requires periodic laboratory monitoring. The new allylamine, terbinafine, and the mew triazole, itraconazole, both appear to have antifungal activity superior to that of both griseofulvin and ketoconazole . The addition of these new oral agents will certainly improve the treatment and prognosis of dermatophytoses that have been traditionally difficult to manage. In particular, infections with T, rubrum should benefit from both these oral antifungal agents (tinea pedis ,tinea unguium). 2) Topical antifungal therapy Topical antifungal agents useful in treating dermatophytoses belong to one of the following categories:imidazoles(miconazole,econazole,ketoconazole,etc.);allylamines(naftifine, terbinafine); naphthionates (tolnaftate); and the substituted pyridine, ciclopiroxolamine,With the exception of tolnaftate,these agents have activity against dermatophytes,candida,and certain gram positive bacteria, Tolnaftate is effective only against dermatophytes., Although in clinical studies these agents are comparable, they
can be d ifferentiated by cost, base(cream or lotion), vehicle(potential sensitizers )and in ro antifungal activity. For example, among the topic gals, ketoconazole has the best minimum inhibitory concentrations(MIC) against pityrosporum and may be considered the treatment of choice for cutaneous disorders related to the potyrosporum yeast Both H. toruloidea and S hyalinum are recalc itrant to conventional topical and oral antifungal therapy, Griseofulvin and oral ketoconazole are ineffective, Itraconazoin and terbinafine are currently being investigated for their potential contribution to the treatment of these mycoses Regard ing therapy of the superficial mycoses pityrosporum infections are discussed in chapter 3. Tinea migra respocal whitfields ointment, 10%thiabendazole solution, and to topical imidazoles. Griseofulvin is ineffective, Both white and black piedra can easily be treated by cutting the hairs. An alternative therapy could be used of imidazoles in lotion or shampoo form Chromoblastomycosis Chromoblastomycosis a chroic, warty noncontagious disease of the skin and subcutaneous tissues, caused by dematiaceous fungi. It primarily involves agricultural workers, mine workers, and others exposed to the soil in tropical and subtropical areas Predominantly, these are persons who do not use shoes so that trauma may play a role The most frequent cases are in individuals 20 to 60 years of are Its occurrence in animals has been reported, but is rare The term chromoblastomycosis was the original to describe the pathology; the implication was that fungus that, caused the a pigmented form of blastomycosis. Thecurrently accepted terminology is chromoblastomycosis the term chromomycosis was recently rejected because of historical factors and confusion with the term phaeohyphomycosis The first case was described by pedroso in Brazil, in 1911, although he post-poned writing his report until 1920. The first North American case was reported by Medlar and Lane. in Boston. in 1915 The pigmented organisms that cause chromoblastomycosis may also cause, in addition to the tyical clinical picture listed below, fungal cysts and fungal ab-scesses in visceral tissues. In these presentations, the fungus presents as branching, pigmented hyphae rather than as Medlar bodies. These presentations have been segregated by some mycolog ists as phaeohyphomycosis. Numerous other pigmented fungi can produce phaeohyphomycosis 1. Clinical presentation The clinical picture of chromoblastomycosis consists of the presence of warty friable granulomas on the leg. The disease is usually unilateral and begins as a single smooth papule which becomes a verrucoid lesion. It expands and may take on an annular appearance, with clearing and scarring in the center. The warty papules develop pustules within them, simulating North American blastomyces is, hence the name. These pustule may contain Medlar bodies in transepidermal elimination. Other lesions may be subcutaneous modules or tumors. or ulcers with crusts New lesions appear and slowly envelop the foot. Clear skin is often present between The method of spread is unclear. Perhaps they autoinoculated by scratching. The friadility on light touch is evident in some of the
can be differentiated by cost , base (cream or lotion),vehicle (potential sensitizers) and in vitro antifungal activity. For example, among the topical antifungals, ketoconazole has the best minimum inhibitory concentrations (MIC) against pityrosporum and may be considered the treatment of choice for cutaneous disorders related to the potyrosporum yeast. Both H. toruloidea and S hyalinum are recalcitrant to conventional topical and oral antifungal therapy , Griseofulvin and oral ketoconazole are ineffective, Itraconazoin and terbinafine are currently being investigated for their potential contribution to the treatment of these mycoses . Regarding therapy of the superficial mycoses pityrosporum imfections are discussed in chapter 3. Tinea migra respocal whitfield’s ointment,10%thiabendazole solution, and to topical imidazoles. Griseofulvin is ineffective, Both white and black piedra can easily be treated by cutting the hairs .An alternative therapy could be used of imidazoles in lotion or shampoo form. Chromoblastomycosis Chromoblastomycosis a chroic, warty noncontagious disease of the skin and subcutaneous tissues, caused by dematiaceous fungi. It primarily involves agricultural workers, mine workers, and others exposed to the soil in tropical and subtropical areas. Predominantly, these are persons who do not use shoes so that trauma may play a role. The most frequent cases are in individuals 20 to 60 years of are. Its occurrence in animals has been reported, but is rare. The term “chromoblastomycosis’’was the original name used to describe the pathology; the implication was that fungus that, caused the disease was a pigmented form of blastomycosis. Thecurrently accepted terminology is chromoblastomycosis; the term chromomycosis was recently rejected because of historical factors and confusion with the term phaeohyphomycosis. The first case was described by pedroso in Brazil, in 1911, although he post-poned writing his report until 1920. The first North American case was reported by Medlar and Lane, in Boston, in 1915. The pigmented organisms that cause chromoblastomycosis may also cause, in addition to the tyical clinical picture listed below, fungal cysts and fungal ab-scesses in visceral tissues. In these presentations, the fungus presents as branching, pigmented hyphae rather than as Medlar bodies. These presentations have been segregated by some mycologists as phaeohyphomycosis. Numerous other pigmented fungi can produce phaeohyphomycosis. 1.Clinical presentation The clinical picture of chromoblastomycosis consists of the presence of warty friable granulomas on the leg. The disease is usually unilateral and begins as a single smooth papule which becomes a verrucoid lesion. It expands and may take on an annular appearance, with clearing and scarring in the center. The warty papules develop pustules within them, simulating North American blastomycosis, hence the name. These pustules may contain Medlar bodies in transepidermal elimination. Other lesions may be subcutaneous modules or tumors, or ulcers with crusts. New lesions appear and slowly envelop the foot. Clear skin is often present between islands of warty granuloma. The method of spread is unclear. Perhaps they are autoinoculated by scratching. The friadility on light touch is evident in some of the