Diagnosis and Treatment of Cutaneous Mycoses 
Continuing medica] education 
STATE OF THE ART 
IN DIAGNOSIS AND TREATMENT 
OF CUTANEOUS MYCOSES 
G. Ginter and E. Rieger 
ABSTRACT 
The constant increase in the number and spectrum of fungal infections in dermatolo gy is due to improved recognition as well 
as to an increasing population of susceptible patients. This rise in prevalence calls for improved methods of diagnosis and 
management. As with other micro bial infections, the diagnosis of fungal disease is based on a combination of clinical observation 
and laboratory investigations. Laboratory methods for the diagnosis of fungal infection continue to be updated, but depend 
mostly on microscopic examination and cultivation of the fungus. The classification and identification of fungi is based on 
their morphology rather than on the nutritional and biochemical differences that are of such importance in the classification of 
bacteria. The development of new antifungal drugs such as the triazoles and allylamines bas improved the treatment of many 
forrns of fungal infections although problerns remain. This paper reviews current laboratory diagnosis and management of 
fungal infections found in Europe. 
KEYWORDS 
dermatomycoses, diagnostic procedures, management 
l. FUNDAMENTALS 
1.1 . THE NATURE OF FUNGI 
Among the 50.000 to 250.000 known species of fungi 
fewer than 200 have been associated with human disease. 
Fungi are eukaryotic organisrns that have definite cell walls 
and are devoid of chlorophyll. Fungi may reproduce sexually 
or asexually; most species are capable of both. Their 
nutritional requirements are simple and readily available in 
the dead organic material of their usual habitats. 
Anatomy of Fungi: Fungi appear in two basic forms, yeasts 
and molds. Yeasts are typically single, small, oval cells that 
reproduce by simple budding. Mold colonies are made up of 
acta dermatovenerologica A.P.A. Vol 5, 96, No 1 
filamentous strands called hyphae. A mass of hyphae is 
called a mycelium. Vegetative hyphae make up the body of 
the mold colony or thallus. Fertile hyphae are directed 
upward to form aerial hyphae (support the reproductive 
structures that produce sexual spores or asexual conidia). 
Fungi pathogenic to humans are Fungi imperfecti (Deu-
teromyceta; sexual reproduction is unknown) . 
Mycosis is any injury to an organism by the growth of 
fungi into its tissue (prerequisite: predisposing factors, 
impairrnent of bost defense mechanisms). 
Law of specificity is invalid with respect to fungi (i.e. 
one type of fungus may cause various clinical pictures and 
vice versa) ! 
3 
Diagnosis and Treatment of C11taneo11s Mycoses 
1.2. DYM (DHS) 
DYM (DHS) System (Categorization by Rieth, early 1960s) 
is a clinically useful scheme: 
D = Dermatophytes 
Y =Yeasts 
M=Molds 
1.2.1. Dermatophytes ("Ringworm Fungi'') 
Infections of the skin, hair and nails. 
Classification: 3 anamorphic (asexual) genera of dermato-
phytes: (Table 1) 
The diseases caused by these fungi are grouped under the 
general term dermatophytosis = tinea. 
1.2.2. Yeasts 
These are "opportunistic" or "facultative" pathogens , 
which convert from saprophytic to parasitic form in a 
predisposed bost. 
Table 1. Classijication of dermatophytes. 
I Trichophyton (worldwide approx. 30 species) 
II Epidermophyton (1 species) 
III Microsporum (worldwide approx. 15 species) 
Table 2. Clinically important yeasts 
4 
I Candida 
(approx. 8 out of 100 species are facultative 
human pathogens) 
II. Trichosporon 
III. Cryptococcus 
AXIO:M: No form of yeast is physiological on or in 
humans. However, saprophytic forms may be present on 
mucous membranes, especially those of the gastrointestinal 
tract, without pathological significance (commensals). 
(Perhaps significant in developing immunity?) 
Clinical Presentation: 
Cutaneous Candidosis 
Mucosal Candidosis 
Systernic Candidosis 
Complication 
(especially intertriginous 
areas; hair follicles; nail 
matrix, nail fold, nail plate) 
(oral cavity, esophagus, 
gastrointestinal tract, vagina) 
(interna! organs) 
of pre-existing dermatoses 
Classification: >60 genera (>500 species). 
Clinically most important yeasts: (Table 2) 
Diagnostic procedure: Biochernical differentiation [ 1] 
(Exception: Candida albicans - on rice agar) 
rubrum (most common agent) 
mentagrophytes (2nd most common agent) 
verrucosum 
jloccosum 
canis 
gypseum 
Species 
albicans (most common) 
tropicalis 
pseudotropicalis 
stellatoidea 
krusei 
parapsilosis 
guilliermondii 
glabrata 
cutaneum 
neoformans 
acta dermatovenerologica A.P.A. Vol 5, 96, No 1 
Diagnosis and Treatment of Cutaneous Mycoses 
Definition: 
- Moniliasis: 
- Candidosis: 
- Candidiasis: 
- Thrush: 
consigned to medical history 
infection due to organisms belonging 
to the genus Candida 
= candidosis 
oral candidosis 
1.2.3. Molds or NDF (non dermatophytic filamentous 
fungi) 
"Facultative" pathogens causing "opportunistic" infections 
in predisposed or compromised patients (convert from a 
saprophyte to a parasite). 
Affected sites: predominantly internat organs (especially the 
lungs), furthermore the paranasal sinuses, rarely the skin (for 
example alternariosis). 
Sporadic occurrence in our geographic region [Central 
Europe] (for example complicating a pre-existing eczema 
[eczema of the auditory canal] oran old burn) . 
May act as a potent allergen (inhalatory, alimentary). 
Habitat: Common soil inhabitants, dust, decomposing 
organic matter; outside air ("airborne fungi"); traumatic 
implantation of spores; nosocomial outbreaks in hospital 
wards (contarninated ventilation system). 
Medically important molds: 
-Aspergillus (A. fumigatus) 
(A. flavus) 
(A. niger) 
- Penicillium (P. marneffei) 
-Mucor 
-Absidia 
-Rhizopus 
1.3. LABORATORY DIAGNOSIS OF FUNGAL 
INFECTION 
1.3.1. Collection of Specimens: 
- skin scales (outwards from the margin of the lesion) 
- hair roots, contents of plugged follicles 
- nail specimens (discoloured, dystrophic or brittle parts) 
- smears: sputum, oral cavity, vagina, cervix, urethra, etc. 
Techniques for collection of specimens: 
- Clean cutaneous and scalp lesions and nails with 70% 
alcohol prior to sampling. 
- Collecting specimens: 
Skin scales: use sterile instruments (autoclaved) : curette, 
blunt scalpel, forceps, edge of a glass microscope slide. 
acta dermatov ene rologica A .P.A . Vol 5, 96, No 1 
Nail specimens: use a raspatory (bone scraper), a scalpel or 
scissors ( deep scrapings from under the leading edge of the 
nail) 
Hair roots: use epilation forceps; hairbrush sampling: scalp 
is brushed with a plastic hairbrush or scalp massage pad 
which is then pressed into the surface of an agar plate 
(sterilize in 1 % chlorhexidine for 1 h, rinse in sterile water 
and dry before reuse). 
Smears (oral cavity, vagina): prepare a slide smear using a 
sterile cotton swab or platin um wire loop or by scraping with 
a wooden spatula. 
Transport of specimens: 
Skin scales, nails, hair roots: in sterile glass or plastic 
containers; folded squares of black paper. 
Smear swabs: in tubes containing liquid culture medium, 
inoculation onto solid culture medium. 
Biopsy specimens: culture (without fixation in formal-
dehyde). 
1.3.2. Direct Examination 
Technique for immediate identification of fungal elements 
in skin scales, nail and hair specimens. 
Processing: 
- Immerse the specimen in a drop of 10% to 15% potassium 
hydroxide (KOH) solution (or 10% tetramethylammonium 
hydroxide) on a glass microscope slide for a few minutes 
(keratin and debris more or less dissolve, while the fungal 
elements remain intact and stand out from the background) . 
- Place a coverslip over the preparation. 
- Gentle heating over an open flame reduces the tirne needed 
for the specimen to clear. 
- Microscopic exarnination with 100-400x magnification: 
hyphae, mycelium, spores. Adding a drop oflactophenol with 
cotton blue to the preparation heightens contrast and is 
helpful in instructing the inexperienced. 
- Stain dried slide smears and aspirations using Gram stain 
or methylene blue stain [l]. 
NOTE: 
- Determination of genus and species of filamentous and 
yeast like fungi is impossible or not possible with certainty. 
- Negative results with this technique do not rule out fungal 
infection! 
1.3.3. Culture 
Culture methods are required to determine genus and 
species of the fungal agent. 
5 
Diagnosis and Treatment of Cutaneous Mycoses 
Processing: 
- Skin, nail and hair samples can be minced to increase the 
surface area of the specimen. The inoculum should be spread 
over the surface of a tu bed or bottled agar slant or streaked 
far isolation on plated media. 
Using only gentle pressure, inoculate specimen onto 
culture medium in a petri dish or test tube in approximately 
15 to 20 places. Use only sterile wire loops, mycological 
hooks, or cotton swabs. Avoid air drafts, and never 
completely uncover plates. 
If plates are used, the lids must be sealed with either air-
permeable tape or commercially available products to prevent 
accidental exposure to mold spores and conidia and cross-
contarnination. 
Media in common use [2]: 
- Kimmig agar 
- Sabouraud's dextrose agar (SAB): contains no added 
antibiotics (will support the growth of aerobic actinomycetes 
as well as fungi). 
- Sabouraud-BHI (SABHI) agar: contains no added anti-
biotics, is more nutritional than regular SAB 
- Sabouraud 's agar with antibiotics: contains various 
combinations of chloramphenicol, cycloheximide, genta-
micin, penicillin, or streptomycin to discourage or prevent 
bacterial growth 
Time considerations: 
D: at least 2-3 weeks (up to 7 weeks) 
Y: l-2days 
M : days to weeks 
Cultures should be incubated far at least faur weeks befare 
being reported as negative. 
Temperature considerations: 
D: standard incubation temperature is 25° to 30°C 
Y: room temperature or 37°C incubation 
M: isolation is usually challenged at 37° and 42°C 
Techniques far Exarnining Cultures: macroscopically and 
microscopically 
Tease preparation culture examination: 
Dig out a small portion of the mold colony with a teasing 
needle, taking as little agar as possible. Place the portion in 
a drop of lactophenol (with orwithout cotton blue) ona clean 
glass slide. Using two teasing needles, break up the mycelial 
mat. Place a coverslip over the preparation and exarnine it 
under the microscope far conidia, conidiogenous structures, 
septation, pigment, and unique morphologic features. 
Disposal of examined cultures according to regulations 
(infectious waste). 
6 
1.3.4. Wood's Light 
Wood's light is particularly useful far detection of 
inconspicuous scalp lesions, pityriasis versicolor, and 
erythrasma. This portable source is a quartz lamp emitting 
low frequency UV light at a wavelength of 365 nm. 
Fluorescence of hair in different colors is a feature of: 
- Microsporum tinea capitis: light bright green 
- Erythrasma: coral red (brick red) 
- Pityriasis versicolor: yellow to golden 
1.3.5. Calcofluor White 
Calcofluor is a fluorochrome with an affinity far chitin 
and cellulose. When added to KOH preparations, it is taken 
up by fungal elements, which in turo fluoresce blue-white 
or green when viewed with a fluorescent microscope. Yeast 
cells, pseudohyphae, and hyphae display a chalk-white or 
brilliant apple-green fluorescence, depending on the filters 
used [3]. 
Advantage: False negative diagnoses, which may result from 
a paucity of fungal elements in the specimen, are ruled out. 
1.3.6. Histopathology 
Histopathology provides the most valuable infarmation 
when it reveals the presence of the organism itself. Some 
fungi can be identified in sections stained routinely with 
hematoxylin and eosin, others can only be seen when special 
stains are used [ 1,4,5]: 
Reagents to demonstrate fungal elements in tissue: 
- Periodic acid-Schijf's stain (PAS): fungal elements appear 
pink 
- Methenamine-silver stain according to Grocott-Gomori: 
fungal elements appear brown or black [6] 
2. DIAGNOSIS AND MANAGEMENT 
2.1.DERMATOPHYTOSIS (Tinea, Ringworm, 
Dermatomycosis) 
The term dermatophytosis is used to describe infections 
of the skin, hair and nails due to a group ofrelated filamentou s 
fungi, the dermatophytes, which are also known as the 
ringworm fungi. The clinical presen tati on of these infections 
depends on severa! factors including: the site of infection, 
the immunological response of the bost and the species of 
infecting fungus. In most farms of dermatophytosis, the 
fung us is confined to the superficial stratum corneum, nails 
and hair. However, deeper infection involving the dermis can 
occur, as in kerion, and this can result in the farmation of 
suppurative lesions. 
acta dennatovenerologica A.PA. Vol 5, 96, No I 
Diagnosis and Treatment of Cutaneous Mycoses 
It is useful, for epidemiologic reaso ns, to classify 
dermatophytes according to their natural habitats: Anthro-
pophilic species parasitize humans almost exclusively, while 
zoophilic species prefer lower anirnals, and geophilic species 
are soil-dwelling saprophytes. Member of all three groups 
are capable of producing human disease. 
Diagnosis: 
Direct examination: 
- branching, septated filaments (mesh of hyphae = mycelium) 
- the recognition of fungal hyphae and/or arthrospores during 
microscopic examination of clinical material gives no 
indication as to the species of dermatophyte involved. 
- differentiation of dermatophytes from yeasts or molds is 
not possible by microscopic examination of the native 
specimen alone; culture is necessary. 
Culture: 
Colony morphology: The surface is a light color (whitish-
yellow or beige), never gray, green, black, or dark brown. 
The color is more intense on the reverse (possibly pigment 
diffusion out from the colony). Development of downy-to-
fluffy colonies or ofheaped, glabrous, button-like colonies; 
never development of creamy colonies. 
Technique for exarnining cultures bas been described (see 
13.3.). 
2.1.1. Tinea corporis 
Detinition: Dermatophyte infections of the trunk, legs and 
arrns, but excluding the groin, hands and feet. 
General considerations and incidence: 
Frequency: 
Age: 
Gender: 
Source: 
approximately 7% 
children and adults 
male and female 
humans and animals. Infection with anthro-
pophilic species (T. rubrum, E. floccosum) often follows 
autoinoculation from another infected body site, such as the 
feet. Tinea corporis due to zoophilic species (M. canis, T. 
verrucosum) commonly occurs following contact with 
infected household pets or farm animals. Human-to-human 
spread of infection with geophilic or zoophilic species is 
unusual. 
Course: 
Duration: 
Diagnosis: 
Laboratory: 
subacute-chronic 
weeks-months-years ! 
Native specimen: Material should be collected from the 
raised border of the lesion; in case of vesicles: the en tire top 
should be subrnitted. Branching hyphae 
acta dermatovenero logica A.P.A. Vol 5, 96, No 1 
Culture: Species of fungus (source of infection, appropriate 
treatment) 
Causative agents: 
- Trichophyton rubrum (anthropophilic) 
- Trichophyton mentagrophytes (anthropophilic or zoophilic) 
- Trichophyton verrucosum (zoophilic) 
- Epidermophyton floccosum (anthropophilic) 
- Microsporum canis (zoophilic) 
Differential diagnosis: 
- Nummular eczema 
- Seborrheic dermatitis 
- Erythema multiforme 
- Lupus erythematosus 
- Pityriasis rosea 
- Pityriasis versicolor 
- Psoriasis 
Management: 
a) adjuvant measures: thoroughly boi! or disinfect laundry 
b) topical antifungal agents: treatment of choice for localized 
lesions 
- imidazoles 
- naftifine ar terbinafine l %-creamonce daily for 1 (-2) weeks 
[1,2] 
- amorolfine cream once daily for 3 (-6) weeks [3] 
NOTE: Treatment should be continued for at least 1 week 
after the lesions have cleared, medication should be applied 
at least 3 cm beyond the advancing margin of the lesion. 
c) systemic antifungal agents: 
In the case of multilocular or extensive spread, chronicity, 
recurrence or lack of compliance. 
- itraconazole: 100 mg daily for 15 days [ 4,9] 
- terbinafine: 250 mg daily for 2 (to 4) weeks [5 ,6] 
- jluconazole: 150 mg once a week for 1-2 weeks [7], or 50 
mg daily for 2-4 weeks [8] 
- griseofulvin: 500 mg daily for 10 days or longer [9] 
NOTE: Spontaneous recovery possible! Extensive lesions 
or non-response are possible in immunodeficient patients 
(e.g. HIV infection). 
2.1.2. Tinea inguinalis 
Definition: Dermatophyte infections of the groin and pubic 
region. Tinea of the groin is a highly contagious condition 
(rninor epidernics in schools and other communities. The 
infec tion is usually transmitted via contarninated towels' or 
the floors of bath-rooms, showers, or hotel bedrooms etc. 
(occurs usually between the ages of 18 and 60). 
7 
Diagnosis and Treatment of Cutaneous Mycoses 
Epidemiology: 
Prevalence: approx. 5% 
Age: adolescents, adults, old age 
Gender: more prevalent in men (males:females = 3: 1) 
Source: humans (commonly acquired from another 
Course: 
Duration: 
Diagnosis: 
infected area of the same individual = 
autoinoculation) 
(subacute) - chronic (seasonal improvement) 
weeks - months - years 
Laboratory: Native specimen: scales fromlesion 
periphery. Branching hyphae 
Culture: species of fungus 
Etiology: 
- Trichophyton rubrum (most often) 
- Epidermophyton floccosum (often) 
- Trichophyton mentagrophytes 
- Trichophyton verrucosum 
Differential diagnosis: 
- Erythrasma 
- Bacterial and candidal intertrigo 
- Psoriasis 
- Seborrheic dermatitis 
- Benign farnilial chronic pemphigus 
Management: 
a) adjuvant measures: boil underwear 
b) topical antifungal agents: 
- imidazoles 
NOTE: To prevent relapse, treatment should be continued 
for at least 2 weeks after disappearance of all symptorns and 
signs of infection. 
- naftijine or terbinafine l % cream (in D-infections!) 1 (-2) 
weeks (1,2) 
- amorolfine cream once daily for 3 weeks (3) 
c) systemic antifungal agents: if compliance is lacking or in 
case of extensive infection (involving the buttocks or anterior 
or posterior aspects of the thighs) or folliculitis. 
- itraconazole 100 mg daily for 15 days [ 4,9] 
- terbinafine 250 mg daily for 2 weeks (5,6) 
- fluconazole 150 mg once a week for 1-2 weeks [7], or 
50 mg daily for 2-4 weeks (8) 
To prevent reinfection following treatment the patient 
should be advised to dry the groin thoroughly after bathing 
and to use separate towels to dry the groin and the rest of the 
body. The feet should be exarnined and treated if tinea pedis 
is presen t. Occlusive or synthetic garments should be avoided. 
8 
If the patient is obese, weight loss may be of benefit by 
reducing chafing and sweating. 
2.1.3. Tinea capitis 
Definition: Dermatophyte infections of the scalp and hair. 
Worldwide in distribution (most prevalent in Africa, Asia 
and Southern and Eastern Europe). Improved standards of 
hygiene and prompt eradication of sporadic infection have 
led to a marked decline in the incidence of tinea capitis in 
Western Europe and North America. 
Clinical manifestations of tinea capitis are varied: 
- mild scaling lesions: similar to seborrheic dermatitis 
- widespread alopecia 
- highly inflammatory suppurating lesion: kerion (infection 
with a zoophilic dermatophyte) 
Epidemiology: 
Age: children > adults 
Gender: anthropophilic Microsporum species: 
males > females ( 6-10 years of age) 
anthropophilic Trichophyton species: male 
children (under the age of 12) 
Source: 
Course: 
Duration: 
Diagnosis: 
Laboratory: 
cattle 
mild to highly intlammatory 
weeks to months (spontaneous remission 
possible after months) 
Native specimen: 
skin scales (hyphae and arthrospores), contents of plugged 
follicles 
hair roots: - ectothrix, endothrix, or mixed infection (except 
for favus, the distal portion of infected hair seldom contains 
any fungus; clipped hairs without roots are unsuitable for 
mycological investigation). 
- endothrix (infected hairs are filled with arthro 
spores): T. tonsurans, T. violaceum (not tluorescent) 
- ectothrix (the hair surface is covered with a dense 
mass of small (2-3 mm diameter) arthrospores): M. 
canis, M. audouinii, M. ferrugineum (brilliant green 
fluorescence), T. schoenleinii (pale dull green 
fluorescence) 
Culture: species of fungus (NOTE: Trichophyton verru-
cosum: slow growth!) 
Etiology: in Western Europe predominantly zoophilic 
dermatophytes! 
- Trichophyton verrucosum (zoophilic; cattle, less often 
horses; 60%) 
acta dermatovenerologica A.P.A. Vol 5, 96, No 1 
Diagnosis and Treatment of Cutaneous Mycoses 
- Trichophyton mentagrophytes (var. granulosa) (zoophilic; 
guinea pigs, mice, hamsters; 30%) 
- Trichophyton rubrum (anthropophilic; rare) 
- Epidermophyton floccosum (anthropophilic) 
- Microsporum canis (zoophilic; Western Europe) 
- Trichophyton violaceum (anthropophilic; eastern and 
southern Europe, North Africa) 
- Trichophyton tonsurans (anthropophilic; North America) 
- Trichophyton schoenleinii (anthropophilic; sole etiological 
agent of favus) 
Differential Diagnosis: 
- Seborrheic dermatitis 
- Pyoderma 
- Furunculosis 
- Bacterial falliculitis 
- Hair loss: alopecia areata, discoid lupus erythematosus 
- "dissecting cellulitis" 
- Candida infection (heroin addicts) 
NOTE the importance of native specimen exarnination to 
rule out a mycotic infection! 
Management: 
a) adjuvant measures: 
- cut hair short! 
- antiseptic pretreatment is recommended! 
- systemic antibacterial antibiotics are usually not necessary! 
- a protective dressing is recommended initially! 
NOTE: 
Trichophyton infection in children: no physical exercise; 
patients should be kept away from school and kindergarten 
as long as the native specimen findings remain positive. 
Anthropophilic agent: Screen ali family members; 
ketoconazol shampoo is recommended for ali family 
members far 1 week. 
Zoophilic agent: Provide information as to the source of 
the infection, treat infected animals. 
b) topical antifungal agents: 
- wash hair with ketoconazole shampoo 
- initially: polyvinylpyrolidone-iodine complex gel 
- later: naftifine gel and Sofratiill (TM) or Bactigras (TM) 
and protective dressing 
c) systemic antifungal agents: 
Mycological confirmation of the clinical diagnosis is 
essential befare treatmentis commenced. Mycological tests 
should be repeated 1 month after starting treatrnent and again 
before discontinuing the drug. 
Children: 
- griseofulvin 10-20 mg/kg body weight daily far severa! 
weeks (given after meal until the native specimen findings 
become negative; 2-3 months duration of treatrnentis usually 
acta dermatov enerologica A.P.A. Vol 5, 96, No J 
required) 
- terbinafine 250 mg. daily far 4 weeks 
Children: dosage according to body weight (BW): 
10-20 kg BW: 62,5 mg/day 
20-40 kg BW: 125 mg/day 
over 40 kg BW: 250 mg/day 
(employ only in case of griseofulvin resistance, or if 
griseofulvin is not available) 
- itraconazole 100 mg daily far 2-4 weeks (given after meal) 
[ 10, 11) 
Children: itraconazole suspension 5 mg/kg BW daily -
currently (1995) in process of approval. Employ only in case 
of griseofulvin resistance, or if griseofulvin is not available. 
- fluconazole (no dosage recommended 1995) 
Microsporum (Gray Patch) Tinea capitis 
Definition: The zoophilic Microsporum canis is seldom 
responsible far more than minor outbreaks of human 
infection. Household pets, such as dogs and cats, are a 
common source of infection, but feral cats are another prolific 
source of M. canis. Tinea capitis due to anthropophilic 
Microsporum audouinii is a contagious disease endemic in 
many countries. It is primarily a disease of children females, 
and most prevalent between 6 and 10 years of age. The 
disease seldom persists beyond the age of 16. Large outbreaks 
often occur in schools or other places where children are 
congregated. 
Epidemiology: 
Prevalence: epidemic and endemic by anthropophilic M . 
audouinii, endemic by M . canis 
Age: 
Gender: 
Source: 
Course: 
Duration: 
Diagnosis: 
Laboratory: 
children (up to age 14) 
in males more common than in females 
cats (especially young and stray cats) 
su binflammatory 
weeks - months - years (spontaneous 
remission in puberty at latest) 
Native specimen: see Tinea capitis 
Culture: species of fungus (M. canis: rapid growth in a few 
days!) 
Etiology: 
- Microsporum canis (zoophilic) 
- Microsporum gypseum (geophilic; infrequent) 
- Microsporum audouinii (anthropophilic; rare; endemic in 
parts of Africa) 
9 
Diagnosis and Treatment oj Cutaneous Mycoses 
Management: 
As in tinea capitis 
NOTE: 
-highly infectious in children - patients should be kept away 
from kindergarten and school until the direct rnicroscopic 
examination becomes negative! 
- protective dressing (cap) is recommended 
- higher griseofulvin dosage in Microsporum tinea capitis 
than in Trichophyton tinea capitis 
children: 15-25 mg/kg BW daily griseofulvin (given after 
meal) 
duration of treatment: weeks to 2 months (until native 
specimen rnicroscopy from severa! sites becomes negative) 
- veterinary examination of cats and possibly other pets 
- therapeutic resistance to griseofulvin is a possible, but rare 
pitfall - oral treatment with fluconazole or itraconazole is 
recommended [10,11]! 
2.1.4. Tinea barbae (Kerion celsi) 
Definition: Dermatophyte infections of the beard. 
Epidemiology: 
Age: 
Gender: 
Source: 
Course: 
Duration: 
Diagnosis: 
adults (especially agricultural and slaughter-
house workers, butchers, veterinarians) 
males 
farm, laboratory and zoo animals; hay, chaff 
(straw) (usually contaminated by infected 
rnice) 
inflarnmatory 
weeks - months 
Laboratory: as in Tinea capitis! 
Etiology: 
- Trichophyton verrucosum 
- 7'richophyton mentagrophytes var. mentagrophytes sive 
granulosa 
- Trichophyton rubrum (rare) 
Management: as in Tinea capitis 
2.1.5. Tinea manuum 
Definition: predominantly chronic dermatophyte infection, 
usually unilateral, or of both hands. 
Differentiate between infections of the (hairless) palm and 
interdigital spaces, and those ofthe (pilose) back ofthe hand. 
Palmar infection: two clinical forn s: 
- the dyshidrotic or eczematoid form 
JO 
- the hyperkeratotic form 
Hand infection may be acquired as a result of contact with 
another person, with an animal, or with soil, either through 
direct contact, or via a contaminated object such as a towel 
or gardening tool. Autoinoculation from another site of 
infection can also occur. Manual work, profuse sweating and 
existing inflammatory conditions (such as contact eczema) 
are predisposing factors. 
Epidemiology: 
Prevalence: 
Age: 
Gender: 
Source: 
Course: 
Duration: 
Diagnosis: 
Laboratory: 
approx. 11 %; worldwide 
adults 
male and female 
hurnans 
acute (dyshidrotic from), subacute or chronic 
(hyperkeratotic form) 
months - years (lifelong) 
Native specimen: skin scales, vesicle tops and contents. 
Branching hyphae 
Culture: species of fungus 
Histopathology (PAS stain) may be necessary 
NOTE:- a false negative result is possible if treatment has 
already been initiated: repeat direct microscopic exarnination 
after discontinuation ! 
- concurrent onychomycosis may be a constant source of 
reinfection, therefore treatrnent of tinea unguium should be 
considered1 
Etiology: 
- Trichophyton rubrum (80-90%) 
- Trichophyton mentagrophytes var. interdigitale 
- Epidermophyton floccosum 
- Microsporum canis 
- Microsporum gypseum 
- Trichophyton verrucosum 
Differential Diagnosis: 
- Candidosis 
- Inverse psoriasis (palmaris) (usually bilateral) 
- Eczema (usually bilateral) 
- Isolated atopic dermatitis of the hands 
- Dyshidrotic eruptions (is usually bilateral or even 
symmetrical) 
Management: 
a) topical antifungal agents: Treatment for severa! weeks is 
usually recommended and should be continued for 3-4 weeks 
once the clinical signs and symptoms have cleared. 
acta dennatovenerologica A.P.A. Vol 5, 96, No 1 
Diagnosis and Treatment of Cutaneous Mycoses 
- imidazales 
- naftifine ar terbinafine 1 o/o cream l-2x daily for severa! 
weeks 
- amarolfine cream once daily for 3 (to 6) weeks 
- calarless Castellani solutian if necessary 
b) systemic antifungal agents: 
- itraconazole 100 mg daily for 4 weeks [ 4,9] 
- terbinafine 250 mg daily for 2 (to 6) weeks [ 12] 
- fluconazole 150 mg once a week for 1 or 2 weeks; or 50 
mg/day for 2-4 weeks 
- griseafulvin, if necessary 
2.1.6. Tinea pedis (Tinea of the soles, "athlete's foot", 
epidermomycosis of the "moccasin type") 
Definition: Dermatophyte infections of the feet (interdigital 
spaces often involved, chronic ditluse desquamation can 
affect the en tire so le). 
Three clinical forms may be distinguished: 
- acute or chronic interdigital infection 
- chronic hyperkeratotic (moccasin or dry type) infection 
- vesicular (int1ammatory) infection 
Tinea pedis is a very widespread condition that appears 
to be increasing in prevalence. It often begins in late child-
hood or young adult life and is most common between the 
ages of 20 and 50. Men are more frequently affected than 
women. 
The infection is usually acquired by walking barefoot on 
contaminated t1oors. Hyphae and arthrospores of the causal 
dermatophytes can survive for long periods (> 12 months) in 
human skin scales. Excessive sweating and occlusive 
footwear are factors that favour the development of tinea 
pedis. 
Epidemiology: 
Prevalence: 
Age: 
Gender: 
Source: 
Course: 
Duratian: 
15-30% of the population in our geographic 
region (Central Europe), most common 
infectious disease of humanity worldwide. It 
does not occur in aborigina! people wearing 
no occlusive footwear! 
adults 
more prevalent in men 
humans 
chronic 
weeks - months - years - decades 
Often recurrence! 
Concomitant mold, candidal and/or bacterial infection is 
relatively common in patients with tinea pedis = secondary 
infection - inflammation and further maceration). 
acta dermatovenerologica A.P.A. Vol 5, 96, No 1 
Diagnosis: 
Laboratory: 
Native specimen: skin scales from lesion periphery. 
Branching hyphae, arthrospores (sometimes appearance of 
characteristic yeast cells: C. albicans) 
Culture: species of fungus 
Etiology: 
- Trichophyton rubrum (approx. 70%; chronic tinea pedis) 
- Trichophyton mentagrophytes var. interdigitale (approx. 
28%; more int1ammatory lesions) 
- Epidermophyton t1occosum (approx. 2%) 
Differential Diagnosis: 
- Candida albicans infection (mild interdigital erosion and 
maceration; diabetes mellitus/hot climates) 
- Gram-negative foot infection: bacterial infection (more 
int1ammation, erosion of the skin) 
- Erythrasma (Corynebacterium minutissimum) 
- Inverse psoriasis 
- Andrew's bacterid 
- Keratosis palmoplantaris 
- Eczema, contact dermatitis 
Management: 
a) adjuvant measures: 
- daily bathing of the feet followed by careful drying of the 
toes and interdigital spaces 
- boil socks and stockings or wash with "myco-ex" 
- wear air permeable (leather) footwear (open-toed shoes 
and sandals) and soft absorbent socks 
- change shoes and socks frequently 
- disinfect shoes 
- use antifungal foot powder on the feet and inside footwear 
b) topical antifungal agents: 
- imidazales 
- naftifine ar terbinafine 1 o/o cream, once daily for at least 1 
to 2 weeks [13,14,15,1] 
- amarolfine cream once daily for 3 (-6) weeks [3] 
c) systemic antifungal agents: If the disease is extensive, 
involving the sole and dorsum of the foot, or there is acute 
int1arnmation: 
- itracanazale 100 mg daily 
Tinea pedis / interdigital infection: for 2 weeks [9, 16] 
Tinea pedis / chronic hyperkeratotic infection (moccasin or 
dry type): for 4 weeks [17,4] (or 400 mg daily for 1 week) 
- terbinafine 250 mg daily for 2 (-6) weeks (both interdigital 
and sole) [17,16,12] · 
- jluconazale 150 mg once a week up to 6 weeks [7], or 50 
mg daily for 2-6 weeks [8] 
11 
Diagnosis and Treatment of Cutaneous Mycoses 
NOTE: 
- laboratory tests should be performed in any patient with 
foot lesions of undeterrnined origin 
- high recurrence rate! 
- concomitant onychomycosis is a constant source of 
reinfection - consider curative treatment to help prevent the 
infection from spreading ! 
REFERENCES 
General reading: 
- Thorne Crissey J, Lang H, Parish LC. Manual ofMedical 
Mycology. London, Edinburgh, Boston, Melbourne, Paris, 
Berlin, Vienna: Blackwell Scientific Publications, 1995 
- Kwon-Chung KJ, Bernett JE. Medica! Mycology. Phila-
delphia, London: Lea & Febiger, 1992 
- Richardson MD, Warnock DW. Fungal Infection. Diagno-
sis and Management. London, Edinburgh, Boston, Mel-
bourne, Paris, Berlin, Vienna: Blackwell Scientific Publ-
ications, 1993 
- Rippon JW, Fromtling RA. CutaneousAntifunga!Agents. 
Selected Compounds in Clinical Practice and Development. 
New York, Basel, Hong Kong: Marcel Dekker, 1993 
- International Sumrnit on Cutaneous Antifungal Therapy. 
October 21 -24, 1993. San Francisco. Abstract book 
- International Sumrnit on Cutaneous Antifungal Therapy. 
November 10-13, 1994. Boston. Abstract book 
1. Fundamentals: 
1. Clark G. Staining Procedures. 3rd ed. Baltimore, Williams 
& Wilkins 1973. 
2. Kwon-Chung KJ, Bennett JE. Medical Mycology. Lea & 
Febiger, Philadelphia, London 1992; Appendix B: 816-826. 
3. Hageage GH Jr., Harrington BJ. Use of calcofluor white 
in clinical mycology. Lab Med 1984; 15: 109-112. 
4. Gridley MF. A stain far fungi in tissue sections. Am J 
Clin Pathol 1953; 23: 303-307. 
5. Luna LG. Manual ofHistologic Staining Methods of the 
Armed Forces Institute of Pathology. 3rd ed. New York, 
McGraw-Hill, 1968. 
6. Grocott RG. A stain for fungi in tissue sections and smears 
using Gomori's methenarnine-silver nitrate technique. Am J 
Clin Pathol 1995; 25: 975-979. 
2. Diagnosis and Management: 
2.1. Dermatophytosis (Tinea) 
1. Kagawa S. Clinical efficacy ofterbinafine in 629 Japanese 
patients with dermatomycosis. Clin Exp Dermatol 1989; 14: 
114-115. 
12 
2. Zaias N, Berman B, Cordero CN, HernandezA, Jacobson 
C, Millikan L, Rojas R, De la Rosa J, Villars V, Birnbaum 
JE. Efficacy of a 1- week, once-daily regimen of terbinafine 
1 % cream in the treatment of tinea cruris and tinea corporis . 
J AmAcad Dermatol 1993; 29 : 646-648. 
3. Nolting S, Sernig G, Friedrich HK, Dietz M, Reckers-
CzaschkaR, Bergstrasser M , Zaug M. Vergleich von Amorol-
fin und Bifonazol bei der Behandlung der Dermatomykosen. 
ZHautkr 1993 ; 68 (Suppl 1): 61-65. 
4. SaulA, BonifazA. Itraconazole in common dermatophyte 
infections ofthe skin : Fixed treatrnent schedules. J AmAcad 
Dermatol 1990; 23 : 554-558. 
5. Del Palacio Hernanz A, Lopez Gomez S, Iglesias Diez 
L, Gonzalez Lastra F. Clinical evaluation of terbinafine 
(Larnisil) in dermatophytosis. J Dermatol Treatrnent 1990; 
1 (Suppl 2): 39-40. 
6. Tuezuen Y, Kotogyan A, Oguz O. Terbinafine: efficacy 
and safety in the treatment of dermatophytosis. Int J Dermatol 
1992; 31: 720-721. 
7. Montero-Gei F, Perera A. Fungal infections in normal 
hosts. Therapy with Fluconazole for Tinea corporis, cruris 
andpedis . Ciin InfectDis 1992; 14 (Suppl 1): 77-8 1. 
8. De CuyperC,AmblardP,AustadJ, etal. Noncomparative 
study of Fluconazole in the treatment of patients with 
common fungal infections of the skin. Int J Dermatol 1992; 
31 (Suppl 2): 17-20. 
9. Finzi A, Cilli P. Italian multicentre trial comparing 
itraconazole with griseofulvin in the treatment of dermato-
mycoses. Prelirninary results. J Eur AcadDermatol Venereol 
1992; 1 (Suppl 1): 15-18. 
10. Legendre R, Esola-Macre J. Itraconazole in the treatrnent 
of tinea capitis. J AmAcad Dermatol 1990; 23 : 559-560. 
11 . Dhondt A, Cauwenbergh G, De Doncker P. Short oral 
therapy in difficult- to - treat tinea infections. J Eur Acad 
Dermatol Venereol 1992; 1 (Suppl 1): 11-14. 
12. White JE, Perkins PJ, Evans EGV. Successful 2-week 
treatment with terbinafine (Larnisil) for moccasin tinea pedis 
and tinea manuum. Br J Dermatol 1991 ; 125: 260-262. 
13. Evans EGV., Dodman B, Williamson DM, et al. Com-
parison of terbinafine and clotrimazole in treating tinea pedis. 
BrMedJ 1993; 307: 645-647 . 
acta dennatovenerologica A.P.A. Vol 5, 96, No 1 
Diagnosis and Treatment oj Cutaneous Mycoses 
14. Berman B, Ellis C, Leyden J, et al. Efficacy ofa 1-week, 
twice-dail y regimen of terbinafine 1 % cream in the treatment 
of interdigital tinea pedis: Result of placebo-controlled, 
double-blind, multicenter trials . J AmAcad Dermatol 1992; 
26: 956-960. 
15. Evans EGV. A double-blind comparison of 1, 3, 5 and 7 
day topical therapy with 1 % terbinafine (Lamisil) cream in 
tinea pedis. Br J Dermatol 1992; 127 (Suppl 40): 21. 
16. De Keyser P, De Backer M, Massart DL, Westelinck 
KJ. Two-week oral treatment of tinea pedis, comparing 
terbinafine (250 mg/day) with itraconazole (100 mg/day): a 
double-blind, multicentre study. Br J Dermatol 1994; 130 
(Suppl 43): 22-25. 
17. Hay RJ, McGregor JM, Wuite J, Ryatt KS, Ziegler C, 
Clayton YM. A comparison of 2 weeks of terbinafine 250 
mg/day with 4 weeks of itraconazol 100 mg/day in plantar-
type tinea pedis . Br J Dermatol 1995; 132: 604-608. 
AUTHORS' ADDRESSES 
Gabriele Ginter MD, Consultant Dermatologist, Dept. of Dermatology, University of Graz 
Auenbruggerplatz 8, A-8036 Graz, Austria 
Edgar Rieger MD, Dermatologist, same address 
acta dermatovene rologica A.P.A. Vol 5, 96, No 1 13