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Fungal Skin Infections (Mycology)

  • Asja ProhicEmail author
  • Nejib Doss
  • Roderick J. Hay
  • Moussa Diallo
  • Aditya K. Gupta
Living reference work entry

Abstract

Fungal infections or mycoses can cause a wide range of diseases in humans and animals. Common fungal skin infections are caused by dermatophytes (dermatophytoses) or yeasts (candidiasis or candidosis).

Dermatophyte infections are common worldwide, and dermatophytes are the prevailing causes of fungal infection of the skin, hair, and nails. These infections lead to a variety of clinical manifestations, such as tinea pedis, tinea corporis, tinea cruris, tinea capitis, and tinea unguium (dermatophyte onychomycosis).

Candidiasis is caused by infection with species of the genus Candida, predominantly with Candida albicans. Candida species produce a wide spectrum of diseases, ranging from superficial mucocutaneous disease to systemic candidiasis.

Other fungal infections include tinea nigra, black piedra, and infections caused by Malassezia yeasts.

Keywords

Fungal infection Mycosis Superficial fungal infection Cutaneous fungal infection Dermatophytosis Tinea Ringworm Athlete’s foot Trichophyton Microsporum Epidermophyton Tinea unguium Endothrix Ectothrix Sabouraud dextrose agar Hair perforation test Onychomycosis Deep mycosis Tinea capitis Dermatophyte infections of the scalp Black dot tinea capitis Kerion Favus Scutulae M. canis T. tonsurans T. schoenleinii Tinea corporis Dermatophyte fungal infection of the glabrous skin T. rubrum Tinea faciei Dermatophyte infection of the face Ringworm of the face Tinea incognita Tinea barbae Ringworm of the beard Tinea sycosis Barbers’ itch T. verrucosum Tinea cruris Dermatophyte infection of the groin and adjacent areas E. floccosum T. mentagrophytes Tinea pedis Dermatophyte infection of the foot T. interdigitale Interdigital tinea pedis Hyperkeratotic tinea pedis Moccasin-type tinea pedis Vesiculobullous tinea pedis Inflammatory tinea pedis Tinea manuum Dermatophyte infection of the hand Two feet-one hand syndrome Distal lateral subungual onychomycosis White superficial onychomycosis Proximal subungual onychomycosis Endonyx onychomycosis Mixed onychomycosis Total dystrophic onychomycosis Nodular perifolliculitis Majocchi’s granuloma Dermatophytid reaction Id reaction Tinea nigra Hortaea werneckii Piedra Trichomycosis nodularis Black piedra Piedraia hortae White piedra Trichosporon asahii Candidiasis Candidosis Moniliasis C. albicans C. glabrata C. tropicalis C. krusei C. dubliniensis Cutaneous candidiasis Mucosal candidiasis Candidal intertrigo Erosio interdigitalis blastomycetica Candidal napkin dermatitis Perianal candidiasis Angular cheilitis Angular stomatitis Perleche Generalized cutaneous candidiasis Candidal paronychia Candidal onychomycosis Chronic mucocutaneous candidiasis STAT1 gene mutation AIRE gene mutation Oral candidiasis Oral candidosis Vulvovaginal candidiasis Vulvovaginal candidosis Genital candidiasis Candidal balanitis Malassezia Pityrosporum M. furfur M. pachydermatis M. sympodialis M. slooffiae M. globosa M. obtusa M. restricta M. dermatis M. japonica M. yamotoensis Pityriasis versicolor Tinea versicolor Mold infection Non-dermatophyte mold onychomycosis Deep fungal infection Subcutaneous mycosis Systemic mycosis Chromoblastomycosis Sporotrichosis Mycetoma Lobomycosis Zygomycosis Verrucous dermatitis Pedroso’s disease Cladophialophora carrionii Fonsecaea pedrosoi Eumycetoma Actinomycetoma Nocardia Streptomyces Actinomadura Sporothrix schenckii Lymphangitic sporotrichosis Fixed sporotrichosis Histoplasmosis Coccidioidomycosis Cryptococcosis Cryptococcus neoformans Blastomycosis Blastomyces dermatitidis Histoplasma capsulatum Coccidioides immitis Coccidioides posadasii 

1 Introduction

Fungal infections or mycoses are disorders caused by fungi, which are saprophytic or parasitic organisms found in every continent and environment (Nenoff et al. 2014a; White et al. 2014).

Fungal infections of the skin, hair, and nails are a common public health problem worldwide.

The prevalence differs by social, geographic, and economical status and life environment and is expected to involve 20–25% of the world’s population (Ameen 2010). In superficial mycoses, fungi invade keratinized tissue such as the horny cell layer, hair and nails. In deep fungal infections, fungi tend to parasitize the dermis and deeper layers.

2 Classification

The clinical nomenclatures used for the mycoses are based on (1) site of the infection, (2) route of acquisition of the pathogen, and (3) the type of virulence exhibited by the fungus (Table 1) (Walsh and Dixon 1996).
Table 1

Classification of mycoses

Site of the infection

Superficial fungal infections

Superficial mycoses are limited to the stratum corneum and essentially elicit no inflammation. Cutaneous infections can involve the integument and its appendages, including hair and nails

Deep fungal infections

Deep fungal infections have the capacity for deep invasion of the skin or production of skin lesions secondary to systemic visceral infection. They comprise two distinct groups of conditions, the subcutaneous and systemic mycoses

Route of acquisition

Exogenous

Routes of entry include airborne, cutaneous, or percutaneous

Endogenous

Endogenous infection involves colonization by a member of the normal flora or reactivation of a previous infection

Virulence

Mycoses due to primary pathogens

These mycoses originate primarily in the lungs and may spread to many organ systems. Organisms that cause systemic mycoses are inherently virulent. In general, primary pathogens that cause systemic mycoses are dimorphic

Mycoses due to opportunistic pathogens

Systemic mycoses due to opportunistic pathogens are infections of patients with compromised host defense mechanisms

3 Superficial and Cutaneous Fungal Infection

3.1 Dermatophytosis

Dermatophyte infection (dermatophytosis), known as tinea or ringworm, is common superficial fungal infection caused by fungi known as dermatophytes. Dermatophytes occur worldwide, but some species have geographically limited distribution. These fungi are responsible for millions of superficial mycoses per year, including common diseases such as athlete’s foot, ringworm, and nail infections (Achterman and White 2012). They are a unique group of fungi that invade and multiply within keratinized cutaneous tissues causing infection. There are three genera of dermatophytes, recognized by the nature of their macroconidae (asexual spores), including Trichophyton (T.), Microsporum (M.), and Epidermophyton (E.). There are about 40 species in these 3 genera.

Dermatophytes are classified as anthropophilic, zoophilic, or geophilic according to their normal habitat (Table 2) (Kwon-Chung and Bennett 1992).
Table 2

Ecology of common human dermatophyte species

Geophilic

Zoophilic

Anthropophilic

M. amazonicum

M. cookei

M. gypseum

M. nanum

M. praecox

M. racemosum

M. vanbreuseghemii

T. ajelloi

T. gloriae

T. simii

M. canis (cats, dogs)

M. equinum (horses)

M. gallinae (chickens)

T. equinum (horses)

T. mentagrophytes

(rodents, rabbits, hedgehogs)

T. verrucosum (calves, cows)

E. floccosum

M. audouinii

M. ferrugineum

T. concentricum

T. gourvilli

T. megninii

T. interdigitale

(formerly T. mentagrophytes var. interdigitale)

T. kanei

T. rubrum

T. schoenleinii

T. soudanense

T. tonsurans

T. violaceum

3.1.1 Diagnosis

In many cases, the diagnosis of dermatophyte infections is not clinically obvious, and mycological analysis is required. For specimen collection, the advancing edge of the scaly lesion with the highest numbers of hyphae is carefully scraped with a clean scalpel. Nail clippings and subungual debris from the involved portion of the nail can be collected from patients with suspected tinea unguium (Westerberg and Voyack 2013). Infected hairs appearing as broken stubs are best for examination. They can be removed with forceps without undue trauma or collected by gentle rubbing with a moist gauze pad. However, the brush method is a reliable, painless, and more expedient way to obtain cultures from children with suspected tinea capitis (Hubbard and Triquet 1992) (Fig. 1). The presence of a dermatophyte infection is confirmed by direct microscopy and culture of skin scrapings (Nenoff et al. 2014b).
Fig. 1

Tinea capitis; diagnosis using toothbrush technique. (Taken by Prof. Roderick J Hay, International Foundation for Dermatology, Willan House, 4 Fitzroy Square, London W1T 5HQ, UK)

3.1.1.1 Direct Microscopy
Identification of fungal elements is better achieved by the addition of potassium hydroxide solution (KOH) (Fig. 2). Adding calcofluor-white stain to the slide causes the fungi to become fluorescent, making them easier to be identified under a fluorescent microscope (Fig. 3). Microscopy can identify a dermatophyte by the presence of fungal hyphae (branched filaments) making up a mycelium, arthrospores (broken-off spores), arthroconidia (specialized external spores), and pores inside the hair (endothrix) (Fig. 4) or outside the hair (ectothrix) (Fig. 5) (Hay and Ashbee 2010).
Fig. 2

KOH mount of infected skin scales showing typical dermatophyte hyphae breaking up into arthroconidia. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)ungal growth is usu

Fig. 3

Dermatopyhte arthrospores; calcofluor-white stain. (Taken by Prof. Roderick J Hay, International Foundation for Dermatology, Willan House, 4 Fitzroy Square, London W1T 5HQ, UK)

Fig. 4

Infected hair; endothrix invasion caused by T. tonsurans (below healthy hair). (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Fig. 5

Infected hair; ectothrix invasion by T. tonsurans. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

3.1.1.2 Culture

For culture, the specimen is inoculated into a medium such as Sabouraud dextrose agar containing cycloheximide and chloramphenicol. The cultures are incubated at 30 °C and examined frequently for 4 weeks. Fungal growth is usually noted in 5–14 days (Robert and Pihet 2008).

The dermatophyte test medium represents an alternative for the isolation. Due to alkaline by-products generated during growth of dermatophytes, the color of this medium changes to deep red (Li et al. 2009). The species of fungus can be identified by morphology on the culture plate (Figs. 6 and 7), biochemical characteristics, and microscopic morphology (Figs. 8, 9, 10, and 11).
Fig. 6

T. mentagrophytes; colonies morphology on Sabouraud agar. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Fig. 7

M. canis; colonies morphology on Sabouraud agar. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Fig. 8

M. canis; macroconidia. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Fig. 9

M. gypseum; macroconidia. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Fig. 10

T. mentagrophytes; macroconidia and a few microconidia. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Fig. 11

T. violaceum; macroconidia. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

3.1.1.3 Biochemical and Physiological Test

In case of atypical isolates, some tests may be performed, such as the search for urease activity or the in vitro hair perforation test (Ghannoum and Isham 2009).

3.1.1.4 Wood’s Light
Wood’s light (UV long-wave light), also known as “black light,” is valuable in the diagnosis of certain skin and hair diseases that show particular patterns of fluorescence in UV radiation. It is a useful diagnostic tool for diagnosing tinea capitis due to Microsporum species (fluoresces a light, bright green, while tinea capitis caused by Trichophyton species does not fluoresce) (Fig. 12) (Gupta and Summerbell 2000).
Fig. 12

Wood’s lamp examination of tinea capitis; scalp hairs emitting a diagnostic brilliant green fluorescence in M. canis infection. (Taken by Prof. Roderick J Hay, International Foundation for Dermatology, Willan House, 4 Fitzroy Square, London W1T 5HQ, UK)

3.1.1.5 Histopathology
Histopathological examination of skin using periodic acid-Schiff (PAS) stains can reveal fungal elements (Fig. 13). It may also be useful for diagnosis of onychomycosis (Fig. 14) and deep mycosis (Ghannoum and Isham 2009).
Fig. 13

Dermatophyte infection; hyphae (PAS positive) present in the stratum corneum. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Fig. 14

PAS stain showing dermatophyte hyphae (melanizing strain of T. rubrum) in the nail plate. (Taken by Prof. Roderick J Hay, International Foundation for Dermatology, Willan House, 4 Fitzroy Square, London W1T 5HQ, UK)

3.1.1.6 Dermoscopy

The comma hairs, which are slightly curved, fractured hair shafts, and corkscrew hairs, have been described as the dermoscopic marker of tinea capitis. Broken and dystrophic hairs are also seen. However, in tinea corporis, the involvement of vellus hair as seen on dermoscopy is an indicator of systemic therapy (Errichetti and Stinco 2016).

3.1.1.7 Molecular Method

Molecular biological methods, based on the amplification of fungal DNA with use of specific primers for the distinct causative agents, are on the rise. With polymerase chain reaction (PCR), such as dermatophyte-PCR-enzyme-linked immunosorbent assay (ELISA), fungi can be detected directly in clinical material in a highly specific and sensitive manner without prior culture. Larger laboratories have established matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) mass spectrometry as culture confirmation test in the differentiation of dermatophytes (Nenoff et al. 2013).

3.1.2 Different Types of Dermatophytosis

3.1.2.1 Clinical Feature

The incubation period of fungal infections in humans is usually between 1 and 2 weeks. Because dermatophytes require keratin for growth, they are restricted to hair, nail, and superficial skin. Thus, fungi do not infect mucosal surfaces.

In humans, dermatophytoses are referred to as “tinea” or “ringworm” infections due to the characteristic ringed lesions and are named according to the area of the body involved (Degreef 2008).

3.1.2.2 Tinea Capitis
  • Definition: Tinea capitis is a dermatophyte infection of the scalp and one of the most common dermatophyte infections seen in children. The major organisms involved in this condition vary with the geographic area. M. canis, a zoophilic species, is often isolated from tinea capitis cases in continental Europe; however, the anthropophilic dermatophyte T. tonsurans is currently responsible for most cases in the USA and the UK (Hay 2017).

  • Clinical feature: It is characterized by spreading, scaly, irregular, or well-demarcated areas of erythema and alopecia (Fig. 15). Follicular papules or pustules may be found on the borders, especially when the lesion is caused by zoophilic organisms (Fig. 16). Black dot tinea capitis refers to an infection with fracture of the hair, leaving the infected dark stubs visible in the follicular orifices (Fig. 17). Zoophilic dermatophytes are more likely to cause inflammatory and in some cases suppurative lesions, including inflammatory masses called kerion (Fig. 18). An anthropophilic species, T. schoenleinii, causes favus, a chronic infection characterized by yellow, cup-shaped crusts (scutulae) around the hairs. Severe long-lasting disease can cause irreversible scarring alopecia (Fig. 19).

  • Pathological manifestation: Hyphae observed in the horny layers of the stratum corneum and within the hair follicle (Fig. 2).

  • Prognosis and treatment: Its untreated cases can last for a month to several years, depending on host factors and the species of dermatophyte involved (Nenoff et al. 2014b). The mainstay of therapy is the use of oral agents such as griseofulvin, terbinafine, itraconazole, and fluconazole.

  • Differential diagnosis: Psoriasis, seborrhoeic dermatitis, folliculitis, and trichotillomania

Fig. 15

Tinea capitis; scaly plaque with hair loss in a child. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 16

Tinea capitis; pustules along the border. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 17

Black dot tinea capitis. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 18

Kerion; inflammatory type of tinea capitis. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 19

Favus of the scalp showing extensive lesions with scarring alopecia. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

3.1.2.3 Tinea Corporis
  • Definition: Tinea corporis is a cutaneous dermatophyte infection occurring in sites other than the feet, groin, face, or hand. Common causes are T. rubrum, T. tonsurans, and M. canis.

  • Clinical feature: Typically, the lesion begins as an erythematous, scaly plaque with a slightly elevated edge that may rapidly worsen and enlarge (Fig. 20). The central area becomes brown or hypopigmented and less scaly as the active border progresses outward (Fig. 21) (Pires et al. 2014; Seyfarth et al. 2007).

  • Pathological manifestation: Hyphae observed in the horny layers of the stratum corneum (Fig. 2).

  • Prognosis and treatment: Untreated tinea corporis may resolve within a few months, particularly if it is caused by a zoophilic or geophilic organism, but infections caused by anthropophilic organisms may be more persistent. Tinea corporis is normally treated by topical agents such as allylamines, ciclopirox, and amorolfine (Hay and Ashbee 2010).

  • Differential diagnosis: Subacute cutaneous lupus erythematosus (SCLE), seborrheic dermatitis, granuloma annulare, nummular eczema, psoriasis, and pityriasis rosea

Fig. 20

Tinea corporis; annular lesion with a raised inflammatory edge and central clearing. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Fig. 21

Disseminated multiple lesions of tinea corporis. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

3.1.2.4 Tinea Faciei
  • Definition: Tinea faciei is a dermatophyte infection limited to the glabrous skin of the face. Zoophilic species M. canis, from cats and dogs, is the most common agent (Nenoff et al. 2014a).

  • Clinical feature: While some lesions may resemble those of tinea corporis, others have little or no scaling or lack raised edges (Fig. 22). Due to these atypical presentations, tinea faciei is usually misdiagnosed and treated with corticosteroids which can lead to a clinical presentation called tinea incognita (Fig. 23) (Celić et al. 2005).

  • Pathological manifestation: Hyphae observed in the horny layers of the stratum corneum (Fig. 2).

  • Prognosis and treatment: Prognosis is good in recognized cases. Usually topical antifungal agents are sufficient. In tinea incognita or following the failure of topical therapy, oral antifungal agents (itraconazole, tebinafine, fluconazole) are required.

  • Differential diagnosis: Seborrhoeic dermatitis, discoid lupus erythematosus (DLE), folliculitis, atopic dermatitis, and rosacea

Fig. 22

Large annular scaly erythematous plaques typical of tinea faciei. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 23

Tinea incognita misdiagnosed as seborrheic dermatitis. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

3.1.2.5 Tinea Barbae
  • Definition: Tinea barbae is a dermatophyte infection of the beard and moustache area in men.

  • Clinical feature: The lesions of tinea barbae may be superficial patches resembling tinea corporis, usually caused by anthropophilic species like T. rubrum (Fig. 24), or deep, kerion-like plaques due to infection with zoophilic species, such as T. verrucosum or M. canis (Degreef 2008) (Fig. 25).

  • Pathological manifestation: The pathology of tinea barbae is similar to that in tinea capitis (Fig. 2).

  • Prognosis and treatment: Kerions undergo spontaneous remission within a few months; however, if untreated, they leave scarring alopecia. Therapy includes local and systemic antimycotics. In a case of severe inflammation, oral corticosteroids may be a consideration (Gupta and Cooper 2008).

  • Differential diagnosis: Sycosis barbae, acne vulgaris, and perioral dermatitis

Fig. 24

Superficial form of tinea barbae. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 25

Deep, kerion form of tinea barbae. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

3.1.2.6 Tinea Cruris
  • Definition: Tinea cruris is an acute to chronic infection of the groin and adjacent areas, usually caused by anthropophilic dermatophytes. The most common agents are T. rubrum, E. floccosum, and T. mentagrophytes.

  • Clinical feature: The symptoms include burning, pruritus, and erythematous lesions with scales and raised, sharply demarcated borders that may have tiny vesicles (Fig. 26). Infection may spread to the perineum and perianal areas, into the gluteal cleft, or onto the buttocks (Nenoff et al. 2014b) (Fig. 27). In males, the scrotum is typically spared. The same fungi can cause tinea cruris and tinea pedis, and the two conditions may be present concurrently (Sahoo and Mahajan 2016).

  • Pathological manifestation: Hyphae observed in the horny layers of the stratum corneum (Fig. 2).

  • Prognosis and treatment: The prognosis of tinea cruris is excellent with appropriate treatment. Topical antifungal therapy is generally sufficient. In a case of widespread or recalcitrant tinea cruris, oral antifungal drugs should be considered.

  • Differential diagnosis: Inverse psoriasis, erythrasma, seborrheic dermatitis, and candidal intertrigo

Fig. 26

Tinea cruris; prominent border with small vesicles and pustules. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 27

Tinea cruris; well-demarcated, irregular bordered, annular plaques on groin and buttocks. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

3.1.2.7 Tinea Pedis
  • Definition: Tinea pedis is a fungal infection of the foot. It usually occurs in adults and adolescents (particularly young men) and is rare prior to puberty. Common causes are T. rubrum, T. interdigitale, and E. floccosum. Infection is usually acquired by means of direct contact with the causative organism, as may occur by walking barefoot in locker rooms or swimming pool facilities (Nenoff et al. 2014b).

  • Clinical feature: The three major clinical types of tinea pedis are (1) interdigital tinea pedis which manifests as pruritic, erythematous erosions or scales between the toes, especially in the third and fourth digital interspaces (Fig. 28); (2) hyperkeratotic (moccasin-type) tinea pedis which appears as scaling of the soles and lateral surfaces of the feet, with variable degrees of inflammation and dryness (Fig. 29); and (3) vesiculobullous (inflammatory) tinea pedis which is characterized by a pruritic, sometimes painful, vesicular or bullous eruption with underlying erythema between the toes or on the soles (Fig. 30). Tinea pedis frequently is accompanied by tinea unguium (Fig. 31), tinea cruris, or tinea manuum (Sahoo and Mahajan 2016).

  • Pathological manifestation: Hyphae observed in the horny layers of the stratum corneum (Fig. 2).

  • Prognosis and treatment: Uncomplicated tinea pedis usually responds to topical (allylamines, imidazoles, and ciclopirox olamine) and systemic therapy (Gupta and Cooper 2008).

  • Differential diagnosis: Erythrasma and interdigital Candida infection for interdigital type; palmoplantar psoriasis, chronic contact dermatitis, and keratoderma for hyperkeratotic type; and palmoplantar pustulosis and acute palmoplantar (dyshidrotic) eczema for vesiculobullous type

Fig. 28

Interdigital tinea pedis; the toe web space contains wet macerated scale. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Fig. 29

Hyperkeratotic type tinea pedis; the entire plantar surface thickened and covered with scales. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 30

Vesiculobullous tinea pedis; a few vesicles on the sole. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 31

Tinea pedis accompanied by tinea unguium. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

3.1.2.8 Tinea Manuum
  • Definition: Tinea manuum is a dermatophyte infection of the hands.

  • Clinical feature: Patients present with a hyperkeratotic eruption on the palm or annular plaques similar to tinea corporis on the dorsal hand (Figs. 32 and 33). Nearby nails may also be infected (tinea unguium) (Fig. 34). Tinea manuum commonly occurs in association with tinea pedis and is often unilateral (two feet-one hand syndrome) (Singri and Brodell 1999) (Fig. 35).

  • Pathological manifestation: Hyphae observed in the horny layers of the stratum corneum (Fig. 2).

  • Prognosis and treatment: Uncomplicated tinea manuum usually responds to topical (allylamines, imidazoles, and ciclopirox olamine) and systemic therapy (Gupta and Cooper 2008).

  • Differential diagnosis: Hand dermatitis (usually if both hands are affected)

Fig. 32

Tinea manuum; hyperkeratotic eruption on the palm. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 33

Tinea manuum; annular plaques on the dorsal hand. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 34

Tinea manuum and tinea unguium. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 35

Two feet-one hand syndrome. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

3.1.2.9 Tinea Unguium (Onychomycosis)
  • Definition: Tinea unguium or onychomycosis is an infection of the nail by fungi. It is most often due to T. rubrum and T. interdigitale, rarely to candida and non-dermatophytic molds (Ghannoum and Isham 2009). Risk factors include family history, prior trauma, warm climate, participation in fitness activities, immunosuppression (such as human immunodeficiency virus (HIV) and drug-induced), communal bathing, and occlusive footwear (Hay and Baran 2011; Hay 2005).

  • Clinical feature: It can present as different patterns including:
    1. 1.

      Distal lateral subungual onychomycosis which is the most common pattern characterized by fungal infections of the nail bed resulting in subungual hyperkeratosis and onycholysis (Fig. 36).

       
    2. 2.

      White superficial onychomycosis which is generally restricted to the upper layer of the nail plate. Small, white, speckled, or powdery patches or linear bands appear on the surface of the nail plate (Fig. 37).

       
    3. 3.

      Proximal subungual onychomycosis which is the most common form of onychomycosis among patients infected with HIV and those with immunocompromised conditions. Fungi target the area under the cuticle, leading to leukonychia in the proximal nail plate that moves distally with nail growth (Fig. 38).

       
    4. 4.

      Endonyx onychomycosis which is clinically characterized by a diffuse milky-white discoloration of the affected nail, in the absence of nail bed hyperkeratosis or onycholysis (Hay 2005) (Fig. 39).

       
    5. 5.

      Mixed onychomycosis, where different patterns are present in the same nail (Fig. 40).

       
    6. 6.

      Total dystrophic onychomycosis which is the most advanced form of any subtype, presents as a thickened, opaque, and yellow-brown nail (Nenoff et al. 2014b; Hay and Baran 2011) (Fig. 41).

       
  • Pathological manifestation: Nail scrapings showing hyaline septate hyphae are diagnostic for a dermatophyte (Fig. 42).

  • Prognosis and treatment: If left untreated, tinea unguium could result in poor nail formation, nail plate distortion, ingrown nails, and secondary infections (Shemer 2012). Treatment options include topical and systemic antifungal drugs, laser treatment, photodynamic therapy, and surgery (Piraccini and Gianni 2013; Gupta and Simpson 2014).

  • Differential diagnosis: Nail psoriasis, trauma, candidal onychomycosis, pachyonychia congenita, viral wart, and subungual hematoma

Fig. 36

Distal lateral subungual onychomycosis. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 37

White superficial onychomycosis. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 38

Proximal subungual onychomycosis. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 39

Endonyx onychomycosis. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 40

Mixed onychomycosis. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 41

Total dystrophic onychomycosis. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia

Fig. 42

KOH slide preparation of the nail scraping showing long septated hyphae and numerous arthrospores. (Taken by Prof. Roderick J Hay, International Foundation for Dermatology, Willan House, 4 Fitzroy Square, London W1T 5HQ, UK)

3.1.2.10 Nodular Perifolliculitis (Majocchi’s Granuloma)
  • Definition: Nodular perifolliculitis or Majocchi’s granuloma is an uncommon condition in which the dermatophyte invades the dermis or subcutaneous tissue. T. rubrum is the most frequent etiologic agent. It may occur after localized trauma that alters the hair follicle and enables the entrance of the microorganism.

  • Clinical feature: The clinical findings are typically characterized by a localized area with erythematous, perifollicular papules or small nodules (Kanaan et al. 2015) (Fig. 43).

  • Pathological manifestation: Perifollicular granulomatous inflammation is found by histologic examination. (Fig. 44). PAS-positive spores may be noted with great magnification.

  • Prognosis and treatment: Topical antifungal agents may not be effective due to deep invasion of fungus into the hair follicle. Treatment with an oral antifungal is recommended.

  • Differential diagnosis: Furunculosis, folliculitis, insect bite, and cutaneous leishmaniasis

Fig. 43

Nodular perifolliculitis on the buttocks presenting with follicular papules, pustules, and nodules. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 44

Nodular perifolliculitis; the histopathology reveals perifollicular, granulomatous inflammation (arrows) (H&E X10). (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

3.1.2.11 Dermatophytid Reaction (Id Reaction)
  • Definition: Dermatophytid reaction or Id reaction is a non-infective cutaneous eruption representing an allergic response to a distant focus of dermatophyte infection.

  • Clinical features: Inflammatory perifollicular papules, small nodules, or pustules are typically seen (Fig. 45). With foot infections, vesicles on the hands and feet are often seen as an Id reaction (Ghannoum and Isham 2009).

  • Pathological manifestation: Superficial perivascular lymphohistiocytic infiltrate with a spongiotic epidermis, often with vesiculation, and the eosinophils in the dermal infiltrate are characteristic features (Fig. 13).

  • Prognosis and treatment: Topical corticosteroids and emollients are main therapeutic options for this condition. Occasionally systemic corticosteroids are required for a few weeks.

  • Differential diagnosis: Allergic contact dermatitis, drug eruption, and insect bite

Fig. 45

Dermatophytid reactions in a child with tinea capitis. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

3.2 Unclassified Fungal Infection

3.2.1 Tinea Nigra

  • Definition: Tinea nigra is an uncommon superficial fungal infection caused by Hortaea werneckii. It typically affects young individuals as an asymptomatic unilateral macule, from light brown to black on the palms and soles, mainly in tropical and subtropical region (Falcão et al. 2015). Typically, the incubation period is 2–7 weeks.

  • Clinical feature: The typical clinical picture is characterized by single, unilateral, and asymptomatic macules, light brown to black, with sharp borders. It affects the palmoplantar region, particularly the palms and palmar aspect of the fingers, and is more prevalent in women under 20 years (Fig. 46). Other areas of the body, such as the neck and chest wall, are more rarely affected (Rossetto et al. 2014). A pigmentary change in the skin results in a dark-colored macule due to the accumulation of a melanin-like substance in the fungus (Sarangi et al. 2014).

  • Pathological manifestation: The fungus is exclusively found in the stratum corneum and does not extend into the stratum lucidum (Fig. 47).

  • Prognosis and treatment: With treatment, it usually resolves in a few weeks. Keratolytic agents alone and topical antifungal agents, such as azole derivatives, terbinafine or ciclopirox, whether or not associated with keratolytic agents, can be used (Falcão et al. 2015).

  • Differential diagnosis: Nevi (melanocytic and atypical), melanoma, post-inflammatory hyperpigmentation, melanosis of syphilis and pinta, and chemical stain

Fig. 46

Tinea nigra; brown macules on the palm. (Taken by Dr. Otto de Azevedo Bastos, Médico Clínico, Médico Dermatologista, Cabo Frio, Brazil)

Fig. 47

Tinea nigra; positive septate hyphae in the stratum corneum in PAS stain. (Taken by Prof. Cliff Rosendahl, Faculty of Medicine, the University of Queensland, Australia)

3.2.2 Piedra (Trichomycosis Nodularis)

  • Definition: Piedra or trichomycosis nodularis is an asymptomatic fungal infection of the hair shaft, resulting in the formation of nodules of different hardness on the infected hair. Two varieties of piedra may be seen; one called black piedra caused by Piedraia hortae and one called white piedra caused by several species of fungi in the genus Trichosporon, most commonly by Trichosporon asahii (Khatu et al. 2013).

  • Clinical feature: Black piedra consists of darkly pigmented, firmly attached nodules that vary in size to as large as a few millimeters in diameter. The most commonly affected area of the body is the scalp hair. White piedra shows irregular, white, cream-colored, or brown soft nodules or gelatinous sheaths along the hair shaft (Fig. 48). The most commonly affected areas of the body are beards, moustaches, pubic and axillary hair, eyelashes, and eyebrows (Viswanath et al. 2011).

  • Pathological manifestation: Microscopic examination reveals septate hyphae, chlamydospores, and irregularly shaped hyphal elements.

  • Prognosis and treatment: Shaving or cutting the hair is the treatment of choice. White piedra can be treated by using topical antifungals; black piedra may be treated with oral terbinafine.

  • Differential diagnosis: Pediculosis, crab lice infestation, trichorrhexis nodosa, and trichomycosis axillaris

Fig. 48

White piedra; whitish to cream-colored easily detachable nodules of the axillary hairs. (Taken by Prof. Aldo Morrone, San Gallicano Dermatological Institute, Rome, Italy)

3.3 Yeast Infection

3.3.1 Candidiasis (Candidosis or Moniliasis)

Candidiasis, also named candidosis or moniliasis, is a fungal infection caused by yeasts from the genus Candida (C.). Candida species are members of the normal human flora colonizing the mucous membranes and digestive tract. C. albicans is the species most commonly isolated, responsible for about 70–80% of all candidal infections. Other significant species include C. glabrata, C. tropicalis, C. krusei, and C. dubliniensis. Its risk factors include hot weather; restrictive clothing; poor hygiene; infrequent diaper or undergarment changes in children and elderly patients; altered flora resulting from antibiotic therapy; inflammatory diseases involving skinfolds such as psoriasis; immunosuppression resulting from corticosteroids and immunosuppressive drugs; pregnancy; diabetes; other endocrinopathies such as Cushing disease, hypoadrenalism, and hypothyroidism; blood dyscrasias; and T-cell defects (Hawkins and Smidt 2014; Casqueiro et al. 2012).

3.3.1.1 Diagnosis

The diagnosis of candidiasis is dependent on clinical and laboratory findings including:

3.3.1.1.1 Clinical Feature

Candida infections produce very diverse cutaneous and mucosal manifestations depending on the area involved, the extent of disease, and host immunity. Candidiasis is classified according to location and clinical features into two subtypes including cutaneous candidiasis and mucosal candidiasis (Hay and Ashbee 2010).

3.3.1.1.2 Direct Microscopy
For diagnosing candidiasis in laboratory, scrapings or smears obtained from skin, nails, or oral or vaginal mucosa for a wet mount are examined under the microscope. Potassium hydroxide (KOH), Gram stain, and methylene blue are useful for direct demonstration of fungal cells (Fig. 49).
Fig. 49

C. albicans blastospores (methylene blue stain). (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

3.3.1.2 Different Types of Candidiasis
3.3.1.2.1 Cutaneous Candidiasis

Candidal Intertrigo

  • Definition: Intertrigo is the most common clinical presentation of candidiasis, commonly involving the armpits, groins, and intergluteal, interdigital, and submammary regions. The condition is particularly common in obese patients with diabetes who show high heat and humidity at involved sites, but it can occur in anyone (Casqueiro et al. 2012).

  • Clinical feature: It is characterized by initial mild erythema that may progress to a more intense inflammation with erosions, oozing, exudation, maceration, and crusting (Figs. 50, 51, and 52). Satellite lesions are commonly found and may coalesce and extend into larger lesions (Casqueiro et al. 2012). Babies frequently develop candidal napkin dermatitis especially if treated with broad-spectrum antibiotics (Hawkins and Smidt 2014) (Fig. 53). Perianal candidiasis produces white maceration and pruritus ani.

  • Pathological manifestation: PAS stain reveals nonseptated hyphae (Figs. 49, and 54).

  • Prognosis and treatment: The topical polyene compound nystatin and midazoles including clotrimazole, miconazole, and econazole are safe and effective against most of the Candida species (Rosen 2016).

  • Differential diagnosis: Tinea cruris, erythrasma, seborrhoeic dermatitis, contact dermatitis, atopic dermatitis, psoriasis vulgaris inversa, and Hailey-Hailey disease

Fig. 50

Submammary intertrigo. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Fig. 51

Candida infection of the groins. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Fig. 52

Interdigital candidiasis of the finger web (erosio interdigitalis blastomycetica). (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Fig. 53

Candida napkin dermatitis. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Fig. 54

Skin candidiasis; PAS stain showing numerous nonseptated hyphae (arrows). (Taken by Prof. Aldo Morrone, San Gallicano Dermatological Institute, Rome, Italy)

Angular Cheilitis (Angular Stomatitis or Perleche)

  • Definition: Angular cheilitis, also known as angular stomatitis or perleche, is an acute or chronic inflammation of the skin and contiguous labial mucosa located at the lateral commissures of the mouth. It can be caused by Candida albicans alone, mixed infection of Candida and Staphylococcus aureus, and Staphylococcus aureus alone (Usatine 2013).

  • Clinical features: Perleche presents as erythema, maceration, and fissuring at the oral commissures. Lesions are most often bilateral and may be painful (Fig. 55).

  • Pathological manifestations: PAS stain reveals nonseptated hyphae (Figs. 49 and 54).

  • Prognosis and treatment: Angular cheilitis typically resolves promptly with therapy. However, recurrence is common. The treatment includes the control of local predisposing factors and topical antifungal therapy with azole ointment.

  • Differential diagnosis: Bacterial stomatitis, impetigo, and herpes simplex infection

Fig. 55

Angular cheilitis; erythematous and eroded skinfolds at the angles of the mouth. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Generalized Cutaneous Candidiasis

  • Definition: Generalized cutaneous candidiasis is an unusual form of cutaneous candidiasis that manifests as a diffuse eruption over the trunk, thorax, and extremities.

  • Clinical feature: Physical examination reveals a widespread rash that begins as individual vesicles that spread into large confluent areas (Fig. 56). The patient has a history of generalized pruritus, with increased severity in the genitocrural folds, anal region, axillae, hands, and feet (El Ahmed et al. 2012).

  • Pathological manifestation: PAS stain reveals nonseptated hyphae (Figs. 49 and 54).

  • Prognosis and treatment: It is not acutely life-threatening condition but often requires prolonged therapy to produce a cure. Intravenous liposomal amphotericin B and fluconazole can be used for disseminated candidiasis.

  • Differential diagnosis: Tinea corporis, pustular psoriasis, pityriasis rubra pilaris, and acute generalized exanthematous pustulosis

Fig. 56

Generalized cutaneous candidiasis in a patient with diabetes mellitus. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Candidal Paronychia and Onychomycosis

  • Definition: Candidal paronychia and onychomycosis are inflammation of the nail fold and nail apparatus produced by Candida species.

  • Clinical feature: Candidal infection manifests as painful red periungual swelling. It is associated with secondary nail thickening, ridging, discoloration, and occasional nail loss (Figs. 57 and 58) (Hay 2005).

  • Pathological manifestation: PAS stain reveals nonseptated hyphae (Figs. 49 and 54).

  • Prognosis and treatment: Topical treatment including miconazole is required, until a new cuticle has formed. Systemic therapy includes ketoconazole, fluconazole, and itraconazole, which have significant anticandidal action (Hay and Ashbee 2010).

  • Differential diagnosis: Tinea unguium, contact dermatitis, herpetic whitlow, and psoriasis

Fig. 57

Acute candidal paronychia; erythema and swelling of the proximal and lateral nail folds and nail discoloration. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 58

Chronic candidal paronychia; slightly tender, edematous nail fold with onycholysis and nail discoloration. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Chronic Mucocutaneous Candidiasis

  • Definition: Chronic mucocutaneous candidiasis is a heterogeneous group of syndromes with common features of chronic, non-invasive candidal infections of the skin, nails, and mucous membranes and associated autoimmune manifestations (most commonly endocrinopathies) (Chambô Filho et al. 2014; Coleman and Hay 1997). It may be inherited with hypothyroidism (STAT1 gene mutation) and with hypoparathyroidism or hypoadrenalism (AIRE gene mutation) (Coleman and Hay 1997).

  • Clinical feature: The characteristic lesions are whitish plaques, with crusts and ulcers typically found in Candida carriers. Oral (Fig. 59), pharyngeal, and gastrointestinal and vagina mucosae are most frequently affected (Okada et al. 2016; Hay and Ashbee 2010). Skin lesions more frequently are acral and characterized by erythematous, hyperkeratotic, serpiginous plaques (Fig. 60) (Chambô Filho et al. 2014). Nails may be markedly thickened, fragmented, and discolored, with significant edema and erythema of the surrounding periungual tissue, simulating clubbing (Fig. 61).

  • Pathological manifestation: A PAS stain can confirm the presence of pseudohyphae (Fig. 54).

  • Prognosis and treatment: The prognosis is good; however, the risk of mycotic aneurysms, while low, remains a real possibility. Management includes antifungal therapy and treatment of associated endocrine and autoimmune abnormalities (Chambô Filho et al. 2014).

  • Differential diagnosis: Primary and secondary immunodeficiencies affecting T-cell functions including combined immunedeficiencies, such as CD25 deficiency, and severe combined immunodeficiency

Fig. 59

Chronic mucocutaneous candidiasis; whitish plaques on tongue. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Fig. 60

Chronic mucocutaneous candidiasis; hyperkeratotic plantar plaques. (Taken by Prof. Roderick J Hay, International Foundation for Dermatology, Willan House, 4 Fitzroy Square, London W1T 5HQ, UK)

Fig. 61

Onychogryphosis and gross thickening of the nails in a patient with chronic mucocutaneous candidiasis. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

3.3.1.2.2 Mucosal Candidiasis

Oral Candidiasis (Oral Candidosis)

  • Definition: Oral candidiasis or oral candidosis is one of the common fungal infections, affecting the oral mucosa. It is caused by an overgrowth of Candida species, the commonest being C. albicans.

  • Clinical feature: The characteristic sign of an acute infection is a sharply defined patch of creamy, crumbly, curd-like white pseudomembrane, which, when removed, leaves an underlying erythematous base. The buccal epithelium on the cheeks, the gums, or the palate may be affected (Sharon and Fazel 2010) (Fig. 62). In immunocompromised patients, the tongue may be affected as well (Fig. 63). In severe cases, extension to the pharynx or the esophagus may occur, and erosion and ulceration are occasional complications (Millsop and Fazel 2016).

  • Pathological manifestation: PAS stain reveals nonseptated hyphae (Figs. 49 and 64).

  • Prognosis and treatment: Fluconazole was found to be the drug of choice as a systemic treatment of oral candidiasis. Although nystatin and amphotericin B were the most drugs used locally, fluconazole oral suspension is proving to be a very effective drug in the treatment of oral candidiasis (Garcia-Cuesta et al. 2014).

  • Differential diagnosis: Oral leukoplakia, lichen planus, and herpetic infection

Fig. 62

Oral candidiasis (thrush) of the tongue and palate. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Fig. 63

Oral candidiasis of the tongue in an immunocompromised patient. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 64

Mucosal candidiasis; PAS stain showing nonseptated hyphae. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Vulvovaginal Candidiasis (Vulvovaginal Candidosis)

  • Definition: Vulvovaginal candidiasis or vulvovaginal candidosis is one of the most common causes of vulvovaginal itching and discharge. The disorder is characterized by inflammation in the setting of Candida species.

  • Clinical feature: Symptoms suggestive of episodic vulvovaginal candidiasis include external dysuria, vulval pruritus, swelling, and redness. Signs include vulval edema, fissures, excoriation, or thick curdy discharge (Fig. 65). Powell and Nyirjesy 2014, Casqueiro et al. 2012). Genital candidiasis may occur as a symptom of a sexually transmitted disease (Dovnik et al. 2015).

  • Pathological manifestation: PAS stain reveals nonseptated hyphae (Fig. 64).

  • Prognosis and treatment: Approximately 10–20% of women will have complicated vulvovaginal candidiasis. Antifungals such as fluconazole may be taken orally as a single dose or can be applied intravaginally in a single day or 3-day regimens.

  • Differential diagnosis: Bacterial vaginosis, irritant dermatitis, physiologic discharge, and psoriasis

Fig. 65

Vulvovaginal candidiasis. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Candidal Balanitis

  • Definition: Candidal balanitis is inflammation of the glans penis by Candida species. The most common cause is C. albicans.

  • Clinical feature: In the mildest cases, transient tiny papules or pustules develop on the glans penis a few hours after intercourse, and rupture, leaving a peeling edge. In more severe and chronic cases, the inflammatory changes become persistent over the glans and the prepuce (Fig. 66).

  • Pathological manifestation: PAS stain reveals nonseptated hyphae (Fig. 64).

  • Prognosis and treatment: The eruption responds quickly to miconazole and clotrimazole. The prognosis is generally favorable, and, though uncommon, a complication of balanitis may occur in recurrent cases and include phimosis and cellulitis (Lisboa et al. 2010).

  • Differential diagnosis: Herpes simplex, psoriasis, and lichen planus

Fig. 66

Candidal balanitis and candidal intertrigo. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

3.3.2 Malassezia Infection

Lipophilic yeasts of the genus Malassezia (M.), former Pityrosporum, are part of the normal cutaneous microflora of humans and other warm-blooded animals. However, under the influence of predisposing factors, these yeasts can become pathogenic and associated with several skin diseases and even systemic infections. In general, because of their dependence on lipids for survival, Malassezia yeasts are most often found in sebum-rich areas of the skin such as the scalp, face, and trunk (Nenoff et al. 2015). Currently, they are classified into at least 14 species, 8 of which have been isolated from the human skin including M. furfur, M. pachydermatis, M. sympodialis, M. slooffiae, M. globosa, M. obtusa, M. restricta, M. dermatis, M. japonica, and M. yamotoensis (Prohic et al. 2016a).

3.3.2.1 Direct Microscopy
Microscopically, the appearance is classically of clusters of budding yeasts with short hyphae that may be branched (“spaghetti and meatballs”) (Fig. 67). Sabouraud dextrose agar and modified Dixon’s agar are used for colony identification (Fig. 68). The presence of Malassezia yeasts in the culture can be identified by their micromorphology (Fig. 69).
Fig. 67

Direct microscopy of pityriasis versicolor scales; clusters of budding yeasts with short hyphae (“spaghetti and meatballs”). (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Fig. 68

Culture of M. furfur on modified Dixon agar. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Fig. 69

PAS stain of M. furfur from culture. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

3.3.2.2 Pityriasis Versicolor (Tinea Versicolor)
  • Definition: Pityriasis versicolor or tinea versicolor is a mild, chronic, superficial fungal infection of the stratum corneum, characterized by scaly, dyspigmented irregular macules most often occurring on the trunk and extremities. The most common cultured species is M. globosa (Prohic et al. 2016b; Hay and Ashbee 2010).

  • Clinical feature: Its skin lesions are characterized by well-defined macules, with slight desquamation and color ranging from white to brownish and brown (Kallini et al. 2014; Santana et al. 2013). The involved skin regions are usually trunk, back, abdomen, and proximal extremities.

    Hypopigmented lesions often arise in patients with a dark skin phototype after exposure to the sun (Fig. 70) (Prohic et al. 2016a). Hyperpigmented skin patches give the affected region a darker-than-normal skin color (Santana et al. 2013) (Fig. 71). The scalp and genitalia are less commonly involved (Fig. 72). In children, it is characterized by depigmented lesions that usually affect the face and specifically the forehead, in contrast to adult presentations, in which this site is rarely affected (Hawkins and Smidt 2014) (Fig. 73).

  • Pathological manifestation: Cutaneous biopsy may reveal the presence of many Malassezia yeasts on the epidermis (Fig. 74).

  • Prognosis and treatment: Topical antifungals including selenium sulfide shampoo and azoles such as ketoconazole are used for treatment. Oral antifungals including ketoconazole, itraconazole, and fluconazole are administered in extensive disease. Although tinea versicolor is recurrent and preventive measures should be taken, the prognosis is excellent (Prohic et al. 2016a; Rosen 2016).

  • Differential diagnosis: Vitiligo, pityriasis alba, pityriasis rosea, pityriasis alba, secondary syphilis, and indeterminate leprosy for hypopigmented lesions and erythrasma, melasma, and confluent and reticulated papillomatosis for hyperpigmented lesions

Fig. 70

Hypopigmented pityriasis versicolor. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Fig. 71

Hyperpigmented pityriasis versicolor. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 72

Hyperpigmented pityriasis versicolor affecting the scalp. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Fig. 73

Childhood pityriasis versicolor; hypopigmented macules with fine scales located on the forehead. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 74

Skin biopsy showing Malassezia yeasts in the stratum corneum (PAS stain). (Taken by Prof. Roderick J Hay, International Foundation for Dermatology, Willan House, 4 Fitzroy Square, London W1T 5HQ, UK)

3.3.3 Mold Infection

Molds are fungi that are commonly found as soil saprophytes or plant pathogens. Mold infections cause indolent infections in healthy or immunocompromised individuals. They are more common in elderly than in children and young adults (Hwang et al. 2012). The nails are involved in the majority of cases (Motamedi et al. 2016; Chabasse and Pihet 2014).

3.3.3.1 Non-dermatophyte Mold Onychomycosis
  • Definition: Non-dermatophyte mold onychomycosis is infection of nail apparatus due to non-dermatophytic molds. The most common causative agents include Scopulariopsis brevicaulis, Aspergillus species, Fusarium species, Neoscytalidium species, and Onychocola canadiensis (Gupta et al. 2012).

  • Clinical feature: Molds produce a deep variety of white superficial onychomycosis characterized by a larger and deeper nail plate invasion (Chabasse and Pihet 2014). Leukonychia and melanonychia can also be clinical manifestations. The surrounding skin is often dry and may itch (Figs. 75 and 76). One or more toenails may be infected, or the mold may simply be a contaminant.

  • Pathological manifestation: Fungal filaments within the nail plate are indicative of onychomycosis (Fig. 77).

  • Prognosis and treatment: Mold nail infections are difficult to treat, as there is today no consensus. The treatment is usually a combination of topical (ciclopirox nail lacquer and amorolfine nail lacquer) and oral antifungal therapy (itraconazole and/or terbinafine) with surgical or chemical (urea) removal of the infected nail.

  • Differential diagnosis: Tinea unguium, nail changes in psoriasis, and Darier disease

Fig. 75

Nail affected by onychomycosis caused Aspergillus species. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 76

Nail affected by onychomycosis caused by Scopulariopsis brevicaulis. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 77

Direct microscopy (15% KOH) showing conidia and Neoscytalidium. (Taken by Prof. Roderick J Hay, International Foundation for Dermatology, Willan House, 4 Fitzroy Square, London W1T 5HQ, UK)

3.4 Deep Fungal Infection

Deep fungal infections comprise two distinct groups of conditions, the subcutaneous and systemic mycoses. Neither are common, and the subcutaneous mycoses, with some exceptions, are largely confined to the tropics and subtropics.

3.4.1 Subcutaneous Mycosis

Subcutaneous mycoses include a heterogeneous group of fungal infections that develop at the site of traumatic inoculation. An inflammatory response develops in the subcutaneous tissue frequently with extension into the epidermis. The fungi that cause subcutaneous mycoses normally reside in soil or on vegetation.

The most common subcutaneous mycoses are chromoblastomycosis, sporotrichosis, and mycetoma. Rarer infections include lobomycosis and subcutaneous zygomycosis (Bordoloi et al. 2015; Elgart 2014).

3.4.1.1 Different Types of Subcutaneous Mycosis
3.4.1.1.1 Chromoblastomycosis (Verrucous Dermatitis and Pedroso’s Disease)
  • Definition: Chromoblastomycosis, also called verrucous dermatitis and Pedroso’s disease, is a group of chronic cutaneous and subcutaneous mycoses caused by dematiaceous pigmented fungi in tropical and subtropical climates. The most common of the etiologic agents are Cladophialophora carrionii and Fonsecaea pedrosoi (Carolina Rojas et al. 2015). Its main risk factors include lack of protective shoes, gloves or garments, poor nutrition, and hygienic habits.

  • Clinical feature: Most infections begin on the foot or leg, but other exposed body parts may be infected. A primary lesion is represented by an erythematous papule or a warty growth, which gradually enlarges from the site of infection. The disease can present clinically in different forms including nodular, tumoral, verrucous, plaque, and cicatricial lesions (Bhat et al. 2016; Queiroz-Telles 2015; Samaila and Abdullahi 2011) (Figs. 78 and 79).

  • Pathological manifestation: The hallmark histopathologic finding is the muriform cell, which may be observed alone or in clusters. Additional pathologic features include hyperkeratosis, pseudoepitheliomatous hyperplasia, irregular acanthosis, and pyogranulomatous inflammation (Fig. 80).

  • Prognosis and treatment: Its lesions are recalcitrant and very difficult to treat. Systemic therapy includes itraconazole, terbinafine, and 5-fluocytosine.

  • Differential diagnosis: Cutaneous tuberculosis, sporotrichosis, cutaneous leishmaniasis, and blastomycosis

Fig. 78

Chromoblastomycosis; papular and verrucous lesions with edema of the feet. (Taken by Prof. Aldo Morrone, San Gallicano Dermatological Institute, Rome, Italy)

Fig. 79

Chromoblastomycosis; nodular and verrucous lesions at the back of the foot. (Taken by Prof. Roderick J Hay, International Foundation for Dermatology, Willan House, 4 Fitzroy Square, London W1T 5HQ, UK)

Fig. 80

Chromoblastomycosis; skin biopsy showing a typical muriform cell in a microabscess (PAS stain and original magnification x 1500). (Taken by Prof. Moussa Diallo, Department of Dermatology, University Gaston Berger of Saint-Louis, Saint-Louis, Senegal)

3.4.1.1.2 Mycetoma
  • Definition: Mycetoma is a chronic granulomatous infection of the skin and subcutaneous tissues characterized by induration and abscess formation with draining sinuses. It is caused by both fungi (eumycetoma) and filamentous bacteria (actinomycetoma). Three genera including Nocardia, Streptomyces, and Actinomadura comprise the most frequent causative agents of actinomycetoma.

  • Clinical feature: The foot is a common site of involvement, but all parts of the body can be affected (Omer et al. 2016). Multiple nodules develop which may suppurate and drain through sinuses, discharging grains during the active phase of the disease (Figs. 81 and 82). The infection tends to penetrate deeper, reaching muscles, tendons, ligaments, and underlying bony structures (Zijlstra et al. 2016) (Fig. 83).

  • Pathological manifestation: The finding of grains inside more or less exuberant productive lesions clinically compatible with the diagnosis of mycetoma is the main diagnosis criterion of the condition (Fig. 84). The responsible species can be partially identified by the color of the grains.

  • Prognosis and treatment: Both forms of mycetoma present as a progressive, cutaneous, and subcutaneous swelling, although actinomycetoma has a more rapid course (Omer et al. 2016). For actinomycetes, antibiotics such as streptomycin, co-trimoxazole, dapsone, rifampicin, and oxazolidinones used in combination show a discrete efficiency. In infections caused by fungi, amphotericin B, itraconazole, or ketoconazole may be effective (Develoux 2016).

  • Differential diagnosis: Kaposi sarcoma, hidradenitis, angiosarcoma, tuberculosis, and chronic osteomyelitis

Fig. 81

Mycetoma; nodular lesion of the foot. (Taken by Prof. Aldo Morrone, San Gallicano Dermatological Institute, Rome, Italy)

Fig. 82

Foot eumycetoma with multiple sinuses and discharge with black grains. (Taken by Dr. Shehu Yusuf, Dermatology Unit, Department of Medicine, Aminu Kano Teaching Kano, Nigeria)

Fig. 83

Radiographs of left foot demonstrating soft tissue swelling and bony destruction involving metatarsals. (Taken by Prof. Aldo Morrone, San Gallicano Dermatological Institute, Rome, Italy)

Fig. 84

Mycetoma; typical appearance of histopathological examination showing grains of mycetoma (H&E stain). (Taken by Prof. Moussa Diallo, Department of Dermatology, University Gaston Berger of Saint-Louis, Saint-Louis, Senegal)

3.4.1.1.3 Sporotrichosis
  • Definition: Sporotrichosis is a chronic disease caused by the dimorphic fungus Sporothrix schenckii. The disease results from the inoculation of the fungus into subcutaneous tissue through minor trauma, even if a zoonotic transmission was reported. The incubation period ranges from a few days to a few months, the average being 3 weeks (Gandhi et al. 2016).

  • Clinical feature: In lymphangitic sporotrichosis which is by far the most common manifestation, a nearly painless red papule forms at the site of inoculation (Fig. 85). Over the next several weeks, similar nodules form along proximal lymphatic channels (Fulghum et al. 2015). In the fixed sporotrichosis, the infection remains largely confined to the area of penetration of the fungus producing infiltrating plaque or nodules with ulcerative evolution with sometimes an epitheliomatous aspect (Fig. 86).

  • Pathological manifestation: The usual histopathologic picture is that of a mixed granulomatous and pyogenic process. Rarely, asteroid bodies consisting of a central basophilic yeast surrounded by eosinophilic material radiating outward like spokes on a wheel can be seen (Fig. 87). This reaction is thought to represent either antigen-antibody complexes or disintegrating neutrophils and is not specific for sporotrichosis.

  • Prognosis and treatment: Saturated potassium iodide solution, itraconazole, and terbinafine are administered for its treatment (Mahajan 2014). Surgical procedures (excision/debridement) in combination with appropriate drug therapy are used for recalcitrant cases. Prognosis is good, although fibrous scars can lead to functional or unesthetic sequelae (Orofino-Costa et al. 2017).

  • Differential diagnosis: Cutaneous mycobacterial infection due to M. marinum and cutaneous leishmaniasis

Fig. 85

Lymphangitic form of sporotrichosis; papules and nodules at the site of inoculation. (Taken by Prof. Dlova Ncoza, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa)

Fig. 86

Fixed form of sporotrichosis; ulcerated papulo-nodule along lymphatic channels. (Taken by Prof. Moussa Diallo, Department of Dermatology, University Gaston Berger of Saint-Louis, Saint-Louis, Senegal)

Fig. 87

Sporotrichosis; asteroid body in the dermis due to Sporothrix schenckii (H&E stain). (Taken by Prof. Roderick J Hay, International Foundation for Dermatology, Willan House, 4 Fitzroy Square, London W1T 5HQ, UK)

3.4.1.2 Different Types of Systemic Mycosis

Systemic mycoses are fungal infections affecting internal organs. The most common portals of entry are the respiratory tract, gastrointestinal tract, and blood vessels. In recent years, they have become important opportunistic infectious complications in immunocompromised patients, including those with acquired immunodeficiency syndrome (AIDS) and patients receiving treatment for malignancies. They also include a group of primary respiratory infections, such as histoplasmosis and coccidioidomycosis, which may affect otherwise healthy individuals and those with underlying illness. A variety of skin changes may be seen in association with the systemic mycoses. The skin lesions depend partly on which fungus is the causative agent.

3.4.1.2.1 Cryptococcosis
  • Definition: Cryptococcosis is an infection caused by the encapsulated yeast, Cryptococcus neoformans, a dimorphic fungus recovered from pigeon excreta, soil, dust, and human skin. The most common clinical manifestation is disseminated meningoencephalitis in patients with AIDS.

  • Clinical feature: Skin and soft tissue involvement is relatively rare (10–20%) but is almost always considered a marker for disseminated disease. Cutaneous clinical presentation is varied; there can be papules, pustules, nodules, abscesses, edema, panniculitis, ulcers, and cellulitis-like and molluscum contagiosum-like lesions (Christianson et al. 2003) (Fig. 88).

  • Pathological manifestation: Direct preparations are performed on a drop of serum or exudate placed on a slide. The cells seen are large, budding cells with capsules. Stains with PAS (Fig. 89) or mucicarmine (Fig. 90) are used for demonstrating this microorganism.

  • Prognosis and treatment: Control of host immunity, the site of infection, management of antifungal drug toxicity, and the status of underlying disease are the most important factors for management of cryptococcosis. Disseminated, non-central nervous system (CNS) cryptococcus infection can be treated with oral fluconazole or itraconazole. CNS involvement is treated with intravenous amphotericin B combined with flucytosine, followed by oral fluconazole (Perfect et al. 2010).

  • Differential diagnosis: Acne vulgaris, giant molluscum contagiosum, cutaneous histoplasmosis, and cellulitis

Fig. 88

Disseminated cutaneous cryptococcosis. (Taken by Prof. Roderick J Hay, International Foundation for Dermatology, Willan House, 4 Fitzroy Square, London W1T 5HQ, UK)

Fig. 89

Cryptococcus neoformans; presence of innumerable encapsulated cells (PAS stain). (Taken by Prof. Roderick J Hay, International Foundation for Dermatology, Willan House, 4 Fitzroy Square, London W1T 5HQ, UK)

Fig. 90

Cryptococcus neoformans; presence of innumerable encapsulated cells (mucicarmine stain). (Taken by Prof. Roderick J Hay, International Foundation for Dermatology, Willan House, 4 Fitzroy Square, London W1T 5HQ, UK)

3.4.1.2.2 Blastomycosis
  • Definition: Blastomycosis is a rare fungal infection caused by the fungus Blastomyces dermatitidis, which grows in wood and soil. Fungus affects primarily the lungs, skin, and other viscera.

  • Clinical feature: Skin involvement has been reported in 40–80% of cases. Its cutaneous manifestation comes in two forms, verrucous and ulcerative. Verrucous skin lesions, which lie above subcutaneous abscesses, are raised and crusted with an irregular shape and sharp border and may extend with progression of the disease over the years (Fig. 91) (Saccente and Woods 2010).

  • Pathological manifestation: Histopathologic examination of tissue with a special stain, such as Grocott-Gomori methenamine silver nitrate, reveals a round multinucleate yeast with a double refractile cell wall (Fig. 92) (Saccente and Woods 2010).

  • Prognosis and treatment: When the infection spreads and skin becomes involved, treatment is necessary. Itraconazole is now considered the agent of choice for non-life-threatening blastomycosis with fluconazole, voriconazole, and posaconazole having a role in selected patients. Amphotericin B is used in severe and life-threatening disease (Bradhser 2008).

  • Differential diagnosis: Basal cell carcinoma, squamous cell carcinoma, giant keratoacanthoma, scrofuloderma, lupus vulgaris, atypical mycobacterial infection, syphilis, leishmaniasis, granuloma inguinale, lymphoma, and pyoderma gangrenosum

Fig. 91

Cutaneous blastomycosis; verrucous skin lesions. (Taken by Prof. Roderick J Hay, International Foundation for Dermatology, Willan House, 4 Fitzroy Square, London W1T 5HQ, UK)

Fig. 92

Cutaneous blastomycosis; budding cells of blastomycosis (Grocott’s methenamine silver stain). (Taken by Prof. Roderick J Hay, International Foundation for Dermatology, Willan House, 4 Fitzroy Square, London W1T 5HQ, UK)

3.4.1.2.3 Histoplasmosis
  • Definition: Histoplasmosis is an opportunistic fungal infection caused by inhalation of dimorphic fungus Histoplasma capsulatum. The causative agent is found globally in soil, especially in soil containing high concentrations of bird and bat droppings (Cano and Hajjeh 2001). Pulmonary involvement is the most common clinical presentation.

  • Clinical feature: Primary cutaneous histoplasmosis is very rare and can present with nodules, ulcers, abscesses, or molluscum contagiosum-like lesions (Nair et al. 2000). Cutaneous manifestations are reported to occur in 10–25% of AIDS patients with disseminated histoplasmosis and can manifest as papules, pustules, plaques, ulcers, molluscum or wartlike lesions, and, rarely, erythema nodosum (Chang and Rodas 2012) (Fig. 93).

  • Pathological manifestation: In histopathology, its diagnostic feature is the presence of tiny 2–4 μm spores within the cytoplasm of macrophages and variably within giant cells (Fig. 94).

  • Prognosis and treatment: Itraconazole is the drug of choice, except in severe systemic involvement, where amphotericin is preferred. Patients with disseminated histoplasmosis, even those with advanced AIDS, usually respond promptly to antifungal therapy (Kauffman 2009).

  • Differential diagnosis: Molluscum contagiosum, herpes simplex, and acneiform eruptions.

Fig. 93

Histoplasmosis in the immunosuppressed patient. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

Fig. 94

Histoplasmosis; histopathological examination showing multiple Histoplasma capsulatum yeasts (Grocott’s methenamine silver stain). (Taken by Prof. Roderick J Hay, International Foundation for Dermatology, Willan House, 4 Fitzroy Square, London W1T 5HQ, UK)

3.4.1.2.4 Coccidioidomycosis
  • Definition: Coccidioidomycosis is caused by the dimorphic, soil-borne ascomycete fungi Coccidioides immitis and Coccidioides posadasii. Dissemination can affect any organ, with the skin, CNS, and musculoskeletal system being reported as the most prevalent.

  • Clinical feature: Cutaneous manifestation is variable and may consist of papular lesions, plaques, abscesses, sinuses, ulceration, or toxic erythema (Fig. 95). Hypersensitivity reactions may result in erythema multiforme (Fig. 96) (Garcia Garcia et al. 2015).

  • Pathological manifestation: Culture, microscopy, and serology have been the mainstay for diagnosis of coccidioidomycosis. In skin biopsy, spores may be evident, although hyphae are less likely to be present (Fig. 97).

  • Prognosis and treatment: Cutaneous forms of coccidioidomycosis should be treated with fluconazole or itraconazole, with the alternative of using amphotericin B in severe or rapidly progressing cases.

  • Differential diagnosis: Erythema nodosum, lipomas, cutaneous lymphoma, and pseudolymphoma

Fig. 95

Cutaneous coccidioidomycosis. (Taken by Prof. Roderick J Hay, International Foundation for Dermatology, Willan House, 4 Fitzroy Square, London W1T 5HQ, UK)

Fig. 96

Erythema multiforme in acute coccidioidomycosis. (Taken by Prof. Roderick J Hay, International Foundation for Dermatology, Willan House, 4 Fitzroy Square, London W1T 5HQ, UK)

Fig. 97

Cutaneous coccidioidomycosis; Coccidioides immitis spherules containing endospores (Grocott’s methenamine silver stain). (Taken by Prof. Roderick J Hay, International Foundation for Dermatology, Willan House, 4 Fitzroy Square, London W1T 5HQ, UK)

3.5 Fungal Infection in HIV-Positive Patient

A multitude of fungal infections are exceedingly common in patients infected with HIV, many of which have cutaneous manifestations. Among these infections, the most important ones include:
  • Candidiasis: Recurrent and persistent mucocutaneous candidiasis is one of the most common manifestations of HIV-positive patients (Fig. 98).

  • Pityriasis versicolor: It may be persistent and recurrent in patients with HIV infection (Fig. 99).

  • Dermatophytosis: Infection by dermatophytes occurs with an increased frequency and aggressiveness in HIV-infected patients. Tinea corporis, tinea capitis, and tinea faciale are particularly common (Fig. 100). T. rubrum and T. mentagrophytes are the most common causes of dermatophytosis in these patients. Dermatophytic infections are particularly resistant to topical agents, and recurrences after topical and systemic therapy are common (da Silva et al. 2014).

  • Deep fungal infection: The most common presentation of deep or locally invasive fungal infection is the eruption of nodules near the initial site of infection, but abscesses, mycetomas, and atypical lesions are also possible (Fig. 101).

  • Nail fungal infection: It is one of the early manifestations of HIV infection with a prevalence of 15–40% (Surjushe et al. 2007). Onychomycosis in HIV/AIDS patients is characterized by being clinically more aggressive, with a higher frequency of unusual presentations and multiple nail involvement (Cambuim et al. 2011) (Fig. 102).

Fig. 98

Mycetoma of the foot in HIV-positive patient. (Taken by Prof. Aldo Morrone, San Gallicano Dermatological Institute, Rome, Italy)

Fig. 99

Pityriasis versicolor in a HIV-positive patient. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Fig. 100

Tinea corporis in HIV-positive patient. (Taken by Prof. Aldo Morrone, San Gallicano Dermatological Institute, Rome, Italy)

Fig. 101

Mucosal candidiasis in HIV-positive patient. (Taken by Prof. Asja Prohic, Department of Dermatovenerology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina)

Fig. 102

Onychomycosis in HIV-positive patient. (Taken by Prof. Nejib Doss, Department of Dermatology, Military Hospital of Tunis, Tunis, Tunisia)

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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Asja Prohic
    • 1
    Email author
  • Nejib Doss
    • 2
  • Roderick J. Hay
    • 3
  • Moussa Diallo
    • 4
  • Aditya K. Gupta
    • 5
    • 6
  1. 1.Department of DermatovenerologyUniversity Clinical Center of SarajevoSarajevoBosnia and Herzegovina
  2. 2.Department of Dermatology and VenerologyMilitary Hospital of TunisTunisTunisia
  3. 3.International Foundation for DermatologyLondonUK
  4. 4.Department of Dermatology and VenerologyUniversity Gaston Berger of Saint-LouisSaint-LouisSenegal
  5. 5.Department of MedicineUniversity of Toronto School of MedicineTorontoCanada
  6. 6.Mediprobe Research IncLondonCanada

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