It is based on the detection of biochemical characteristics, proteolytic degradation product which is a result of the activity of mycological infections or noninfectious diseases. These are represented by proteolytic degradation products of native proteins. The peptide patterns of affected samples are identified by comparison with known peptide spectra from skin disorders stored in an already existing database. This procedure is immensely time saving, as it enables simultaneous identification of up to 64 dermatophyte strains, with results coming back within 24 h.
It provides in vivo imaging of the epidermis and superficial dermis at cellular level resolution and can be used to detect cutaneous fungi and parasitic infestations. Advantage of the test being noninvasive and in a retrospective analysis of the test by Friedman et al.
Summarizing it can be safely recommended that a clinical diagnosis of cutaneous dermatophytic infection should always be supplemented by a mycologic confirmation.
While traditional methods like direct demonstration of fungus by KOH offer a reasonably sensitive and inexpensive option, newer noninvasive methods such as dermoscopy have additional advantage of ease of use, ability to detect involvement of vellus hair and thus, influence the choice of treatment topical versus systemic.
Fungal culture and antifungal testing are costlier and more specialized investigations, but such infrastructure needs to build up at most centers, especially in the present scenario of rising prevalence of nonresponsive dermatophytosis. Other methods such as PCR and reflectance confocal microscopy are still used primarily for research purposes. 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. 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. Topical medications have better pharmacokinetics than their systemic counterparts. Hence, combination is expected to have better mycological clearance than systemic and topical alone. Combination should be from different groups for wide coverage and also to prevent emergence of resistance.
Drugs given for shorter duration with higher dose there has a less chance of development of resistance compared to lower dose for longer duration. Drug with keratophilic and lipophilic property, when given in higher doses will have reservoir effect and will lead to better mycological clearance. Tinea involving more than one body region simultaneously, for example, tinea cruris and corporis, or tinea cruris and tinea pedis.
Tinea corporis where the lesions are particularly extensive. However, there is no accepted definition of extensive disease. Tinea pedis when there is extensive involvement of the sole, heel, or dorsum of the foot or when there is recurring and troublesome blistering. Various topical antifungal agents are available for the treatment of localized tinea corporis, tineacruris, tinea faciei, and tinea pedis. It may also be used as an adjunct to oral antifungals for more extensive infection.
Most of the studies in the treatment of tinea corporis and cruris have looked at the efficacy of topical antifungals with very few studies on the use of oral antifungals. A meta-analysis by Rotta et al. Efficacy was evaluated in the form of mycological cure at the end of treatment and sustained cure.
They found no statistically significant differences among the antifungals concerning the outcome of mycologic cure at the end of treatment. For sustained cure, butenafine and terbinafine each was found to be superior to clotrimazole. Pairwise comparison of topical antifungals for the outcome of fungal cure showed butenafine and terbinafine each to be superior to clotrimazole, oxiconazole, and sertaconazole; terbinafine to be superior to ciclopirox, and naftifine to be superior to oxiconazole.
Similarly, Cochrane review[ 6 ] on the topical antifungal treatments for tinea cruris and tinea corporis suggests that the individual treatments with terbinafine and naftifine are effective with few adverse effects. Other topical antifungals like azoles treatments are also effective in terms of clinical and mycological cure rates. Regarding combinations therapy of topical steroids and antifungals though there is no standard guideline. Difference between the different antifungals is mostly regarding fewer application and shorter duration of treatment with some class of topical antifungals compared to others.
Topical antifungal are usually given once or twice daily for 2—4 weeks as illustrated in Table 2. The end point of treatment is clinical resolution in most of the cases. Summary of the use of topical antifungals used in the treatment of tinea corporis, cruris and pedis. Moriarty et al. They also enlist the common reasons of failure of therapy, namely; poor adherence to treatment, reinfection from close contact, drug resistance, misdiagnosis, and infection with uncommon species.
Such patients should be referred to a higher center for appropriate management. They also suggest use of topical hydrocortisone for a short time in inflamed lesions. Studies have also shown that addition of topical steroid also increases the bioavailability of topical antifungals mostly imidazole groups in addition to better symptomatic relief in early inflammatory stage. Steroids may helpful in initial improvement in symptoms but chronic use lead to a complication like atrophy, telangiectasia which is more prominent when lesions are present in flexures.
Topical antifungals with potent anti-inflammatory action such as sertaconazole or luliconazole may be a better option than an antifungal-steroid combination. Tinea pedis is usually treated with a topical antifungal cream for 4 weeks; interdigital tinea pedis may only require 1 week of therapy. Various topical antifungal effective against tinea pedis include azoles, allylamines, butenafine, ciclopirox, tolnaftate, and amorolfine as evidenced by a meta-analysis finding strong evidence of superiority of topical antifungal agents over placebo.
Naftifine hydrochloride gel was also found to be effective both for interdigital and moccasin type of tinea pedis. Luliconazole, an azole antifungal has fungicidal action against Trichophyton species similar to or more than that of terbinafine. Approved by the US Food and Drug Administration for the treatment of interdigital tinea pedis, tinea cruris, and tinea corporis, it has a favorable safety profile.
Finally, use of special carrier system where parent drug attached to carriers such as micelle or use of nanostructured lipid-based carrier, microemulsions, and vesicular systems such as liposomes, niosomes, transfersomes, ethosomes, or penetration enhancer vesicles is promising as it helps in better bioavailability so as to attain better therapeutic response.
Microemulsion formulations of griseofulvin have shown good cure rates in dermatophytosis. Systemic antifungals are indicated in case of extensive involvement and patients who fail topical therapy. Griseofulvin and fluconazole are also effective but require long-term treatment. RCTs support the efficacy of systemic antifungals [ Table 3 ]. Topical therapy is less effective than oral antifungals for the treatment of tinea pedis, and oral treatment is generally given for 4—8 weeks. In a systematic review of efficacy of oral antifungals in, terbinafine was found to be more effective than griseofulvin, whereas the efficacy of terbinafine and itraconazole were similar.
Of various types of tinea pedis, hyperkeratotic variety is more recalcitrant to treatment due to thick scales leading to ineffectiveness of topical antifungals and need for longer duration of systemic antifungals.
Use of keratolytic agents and topical antifungals along with systemic antifungals has been found to be more useful in early achievement of clinical and mycological cure as well as decreasing the duration of oral antifungals leading to better patient compliance. Other adjunctive therapies include use of antifungal powder may help to prevent maceration and avoidance of occlusive footwear.
There is lack of any recent literature regarding systemic antifungals in the treatment of tinea cruris and corporis. Although few newer systemic antifungals have been approved in last two decades but most of them are reserved for more severe life-threatening invasive systemic mycoses with paucity of evidence on efficacy in superficial mycoses.
Recently, posoconazole was found to be effective in a patient with extensive dermatophytic skin and nail infection with underlying CARD9 mutation. Other than the antifungals already mentioned, few plant extract Chinese herbals are also found to be effective against common dermatophytic infection. One of them is macrocarpal C, an active ingredient obtained from the fresh leaves of Eucalyptus globulus Labill with antifungal action against T. It is a deep dermatophytosis that occurs when a long-standing superficial fungal infection causes progressive dissemination into the subcutaneous tissue.
The most common etiological agent is T. Tinea imbricata is a chronic superficial fungal infection of the glabrous skin caused by Trichophyton concentricum. Disease results from close contact with spores and filaments of T. It is postulated that genetic, environmental, and immunologic factors play an important part in the development of this fungal infection.
The mode of inheritance is autosomal recessive pattern with a minority of autosomal dominant cases. The disease is highly recurrent. The treatment should involve a combination of topical and systemic antifungal agents since topical therapy alone is insufficient. Griseofulvin, azole agents, such as ketoconazole and itraconazole, has been used for many years with variable success. A special subgroup of population like with HIV infection usually present with more extensive involvement.
However, characteristic morphology may be missing due to reduced inflammatory component of lesion attributed to suppressed immunity. Terbinafine clearance significantly reduced in patient in renal impairment. So dose should be adjusted accordingly, or drug from different group should be preferred. Similarly, itraconazole should be avoided in patient with hepatic impairment. Terbinafine is a category B drug in pregnancy. However, there is no clear cut guideline available for managing dermatophytic infection and treatment should be individualized and based upon risk-benefit ratio.
It has also been described in literature as T. It is characterized by involvement of at least four body sites such as feet plantar , hands palmar , nails, as well as one other site with exclusion of inguinal area along with identification of T. Chronicity can be considered in terms of duration and recurrences of infection although there is no standard definition for chronicity.
The emergence of such cases could be attributed to various pathogenic agent, host and pharmacologic factors. At present, there are no guidelines on management of chronic dermatophytosis. Although there are few studies to suggest that antifungal resistance is not common in tinea capitis, such data are lacking with respect to tinea cruris and corporis.
This should also be seen with respect to the currently prevailing clinical scenario in India where there is an increasing recognition of a rising trend of nonresponsive cutaneous dermatophytosis. Treatment of cutaneous dermatophytosis has increasingly become difficult, and dermatologists have been forced to think beyond conventional wisdom to counter this menace. Although there is sufficient evidence to demonstrate the efficacy of topical antifungals in limited disease yet, there is scarce data on the frequency of relapse once topical monotherapy is discontinued.
For more extensive disease, the choice is less clear. However, an appropriate dose and duration of administration which can produce mycologic cure and prevent recurrence remains elusive. This review also highlights the huge research gaps in the management of cutaneous dermatophytosis which need to be plugged to provide better and effective care to the patients.
More stringent RCTs are the need of the hour comparing the various oral antifungal therapies to give a clear idea regarding the appropriate dose and duration of therapy. National Center for Biotechnology Information , U.
Indian Dermatol Online J. Alok Kumar Sahoo and Rahul Mahajan 1. Author information Copyright and License information Disclaimer. Address for correspondence: Dr. E-mail: moc. This article has been cited by other articles in PMC. Keywords: Dermatophytosis, superficial fungal infections, tinea corporis, tinea cruris, tinea pedis.
Immunology of dermatophytosis The immune response to infection by dermatophytes ranges from a nonspecific host mechanism to a humoral and cell-mediated immune response. Ashari Zuprin. Kirt Earl Ricardo. Savanna Chambers. Dandy Abdi Cita Gemilang. Sayani Banerjee. Rhadezahara Patrisa. Cindy JA. Lalzio Calmalzio. Christine Jane Rodriguez. San Eli News.
Deomicah Solano. R Hari. Areej Tariq. Kish Dayanara Gonzales. Roel Plmrs. Nooh Din. Elijah Legaspi. Nouval Azkia. Raia The Berserker. More From annisaoktoviani. Current and emerging treatments for uterine myoma. Septian Andy. Popular in Medicine. Andi Susilo. Rudolph Game. Ronald Jacob Picorro. Naresh Teres. Rolando Pinchetti. Rasheena Alaja Jainal. Specimens are wet-mounted in potassium hydroxide and examined under a light microscope for the presence of hyphae and spores.
Fungal culture allows identification of the causative agent, and hence the possible source of infection. However, it is slow, taking up to 4 weeks, and treatment is usually required before the result is available. Endothrix and ectothrix microscopy Ectothrix invasion by fungal hyphae in a hair shaft. Polymerase chain reaction PCR screening may result in faster and more sensitive ways of detecting dermatophyte infection, but is not yet widely available.
Sometimes the diagnosis of tinea capitis is made on skin biopsy when characteristic changes are seen see tinea capitis pathology. The differential diagnosis list is extensive and includes any condition which may present with patchy alopecia, inflammation, or scaling of the scalp.
Examples include:. Tinea capitis always requires at least 4 weeks of systemic medication, as topical agents cannot penetrate the root of the hair follicle. Griseofulvin has previously been the most widely used medication to treat tinea capitis, but it is no longer available in some countries, including New Zealand. Newer antifungal agents such as terbinafine , itraconazole , and fluconazole are at least as effective as griseofulvin for trichophyton infections but less effective for microsporum species.
Topical agents such as povidone-iodine, ketoconazole , and selenium sulfide shampoos can be used to reduce spore transmission.
All members of the household should be screened for tinea capitis and treated simultaneously if found to be affected. Sharing of potential fomites such as hairbrushes, hats, and pillows should be discouraged, and these should be properly cleaned. In cases of zoophilic infection, family pets should be checked by a veterinarian and treated accordingly. Non-inflammatory tinea capitis carries an excellent prognosis with appropriate and early treatment. Severe inflammatory tinea capitis may result in areas of permanent alopecia.
Books about skin diseases Books about the skin Dermatology Made Easy book. DermNet NZ does not provide an online consultation service. If you have any concerns with your skin or its treatment, see a dermatologist for advice.
Tinea capitis — codes and concepts open. Ringworm of the scalp, Dermatophytosis of scalp, Tinea of scalp. Fungal infection, Age site specific, Hair and scalp disorder. Black dot ringworm, M. Systemic antifungal therapy for tinea capitis in children. Cochrane Database Syst Rev. British Association of Dermatologists' guidelines for the management of tinea capitis Br J Dermatol.
Tinea capitis: an updated review.
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