Skin fungal infections

1. DEFINITION:
Fungal skin infections are commonly affect the outer layer of the skin, nails and hair.
Most of the fungi causing infections are usually dermatophytes (tinea), yeast (candida)
and molds. The sign and symptoms depends on the type of the organisms that cause
the infections. Most of the time, fungal skin infections may appear red, scaly and itchy.
The rashes present have a well-defined border and sometimes it appear like a dry skin.
Type:
1. Tinea Corporis/Ringworm
 Fungal infections that occur at skin, buttocks, other than groin, scalp,
soles and palm area.
 Causative organism: dermatophytes
2. Tinea Pedis
 Most commonly known: athlete’s foot, kulat air
 Occur at the area between toes and around the foot below ankle level
 Causative organism: dermatophytes
3. Tinea Cruris
 Most commonly known: jock’s itch
 Occur at the area around the groin and adjacent skin to the groin
 Causative organism: dermatophytes
4. Tinea Versicolor
 In Malay: panau
 Skin appear to have a different colour of patches and spots, usually paler
than usual skin colour
 Causative organism: yeast
CAUSES
TINEA CORPORIS (ringworm)
Tinea corporis is a skin infection caused by a fungi.

2. Tinea corporis is caused by mold-like fungi called dermatophytes.
Fungi are germs that can live on the dead tissue of the hair, nails, and outer skin layers.
Tinea corporis is caused by mold-like fungi called dermatophytes.
Tinea corporis is common in children, but can occur in people of all ages.
Fungi thrive in warm, moist areas. A tinea infection is more likely if you:
 Have wet skin for a long time (such as from sweating)
 Have minor skin and nail injuries
 Do not bathe or wash your hair often
 Have close contact with other people (such as in sports like wrestling)
Tinea corporis can spread easily. You can catch it if you come into direct contact with
an area of ringworm on someone's body. You can also get it by touching items that
have the fungi on them, such as:
 Clothing
 Combs
 Pool surfaces
 Shower floors and walls
Ringworm can also be spread by pets. (Cats are common carriers.)

3. TINEA PEDIS (athlete’s foot)
Tinea pedis is a foot infection due to a dermatophyte fungus. Tinea pedis thrives in
warm humid conditions and is most common in young adult men.
Tinea pedis is most frequently due to:
 Trichophyton (T.) rubrum
 T. interdigitale, previously called T. mentagrophytes var. interdigitale
 Epidermophyton floccosum
TINEA VERSICOLOUR(pityriasis versicolor)
The fungus Pityrosporum ovale is a type of yeast that’s found on the surface of the skin.
It normally doesn’t cause any health problems. However, sometimes this yeast begins
to grow out of control, affecting the natural color, or pigmentation, of your skin.

4. Tinea versicolor occurs when Pityrosporum ovale grows rapidly on the surface of the
skin.
 Hot, humid weather
 Oily skin
 Hormonal changes
 Weakened immune system
TINEA CRURIS (jock itch)
 Jock itch is most commonly contracted by coming into contact with clothing or
towels contaminated with the fungus. It can also spread from an athete's foot
outbreak.
 Jock itch may also be caused by the spread of athlete's foot fungus to the groin.
 The groin provides a warm and humid environment, which encourages fungus
growth
 Excessive perspiration can also encourage fungus growth
EPIDEMIOLOGY:
A total of 18 prevalence studies of the general population in developing countries (10 in
sub-Saharan Africa) can be considered representative of large geographical areas; of
these, 13 provided data specific to children, 17 to rural areas, and 4 to urban areas. All
reported high prevalence figures for skin diseases (21-87%), the following disorders
being the commonest in children: pyoderma (prevalence range 0.2-35%, 6.9-35% in
sub-Saharan Africa), tinea capitis (1-19.7%), scabies (0.2-24%, 1.3-17% in sub-
Saharan Africa), viral skin disorders (0.4-9%, mainly molluscum contagiosum),

5. pediculosis capitis (0-57%), dermatitis (0-5%), and reactions due to insect bites (0-
7.2%).
Children present a higher prevalence rate than adults for pyoderma (especially those
under 5 years), certain mycoses (tinea capitis), and, to a lesser extent, scabies. In
addition, there have been reports of a particularly high prevalence of pyoderma and/or
scabies in more limited settings, or in particular communities (e.g., Aboriginal
communities from Pacific).
Incidence data in the general population are scarce, those that are available varying
considerably from one place to another for pyoderma (e.g. 10.7% by year to 1.57 per
100 person-weeks in children), and for scabies. Data from five areas suggest that skin
disorders commonly represent one of the main organ-specific reasons for visiting a
primary healthcare centre, the ratio of visits due to skin problems being in the range 6-
23.7% (the highest rates in children); in such centres, the main disorders appear to be
pyoderma and scabies, while diseases lacking a specific diagnosis are also common.
The cost of skin diseases has been estimated on few occasions only, but was found
significant in the two areas where evaluated. Community-based data from three areas
indicated that certain disorders (mainly scabies and pyoderma) were more likely to
result in a request for treatment than other skin diseases (tinea capitis, viral disorders,
pediculosis capitis).
Data from 18 available bacteriological studies suggest that group A streptococci remain
the main etiological agent of pyoderma (either primary or secondary to scabies) in many
tropical developing countries, followed by Staphylococcus aureus. The prognosis of
pyoderma appears overall to be good, with a global risk for poststreptococcal
glomerulonephritis estimated to be largely under 1% in many areas. Lethality related to
pyoderma appears very low, except possibly in children aged less than 3 months in
whom it has been reported on occasions. to be a significant source of severe
bacteraemic sepsis.
The severity of scabies appears to be related to superinfection, which occurs in 16-67%
of cases and bears the same risks as primary pyoderma, and to epidemics whose
frequency over the world appears largely underestimated. Overall, tinea capitis appears
to be a benign disorder, rarely presenting with superinfection, and with spontaneous
healing around puberty. The other very common skin disorders (molluscum
contagiosum, pediculosis capitis) are also almost constantly benign. Where HIV
infection is common, its contribution to the epidemiology of common skin diseases is
unknown.
Despite the relative paucity of objective data and some methodological restrictions, it
can be assumed that the main etiological factors whose role is probably significant in
developing countries are a hot and humid climate (pyoderma), low hygiene and poor
access to water (pyoderma), high interpersonal contact and household overcrowding

6. (scabies and pyoderma), and certain other skin conditions like reactions to insects bites
and scabies (pyoderma).
There have also been several reports on the frequency of skin diseases (mainly
pyoderma and/or ectoparasitoses/ scabies) in specific population groups: street-children
in Kenya (prevalence of skin diseases, 50.9%) [33], child workers in Nigeria (skin
infection, 12%) [34], refugee camp in Sierra Leone (scabies, 77-86% in children) [35],
remote Amerindian villages in Amazonia (pyoderma, 11%) [36], jungle villages in
Panama (pyoderma, 11-20% according to age) [37], an orphanage community in India
(pyoderma, 10%) [38], slums in Brazil (scabies 8.8%, p. capitis 43%) [39], and remote
aboriginal communities in Oceania, mainly Australia [40-43], and Malaysia [44].
Aboriginal communities from Australia and the Pacific islands exhibited particularly high
prevalence figures in children, and often adults, for scabies, beta-haemolytic group A
streptococcal pyoderma, and dermatophytoses (scabies: 25% (adults) to 50%
(children); pyoderma: 10-70%).
Reference:
http://apps.who.int/iris/bitstream/10665/69229/1/WHO_FCH_CAH_05.12_eng.pdf
The increasing population of immunocompromised individuals is a major factor in the
emergence of opportunistic fungal infections. The human immunodeficiency virus (HIV)
disease epidemic has been shown to be responsible for dramatic increases in
cryptococcosis, penicilliosis and histoplasmosis. As HIV patients are at increased risks
for fungal infections, the concentration of this group of patients in a single centre may
result in a different fungal epidemiological profile as compared with a general hospital,
non-infectious disease reference centre.

7. The distribution of races was significantly associated with HIV status. Among the
HIVnegative individuals, the Malays comprised more than half (55.6%) of patients,
followed by Chinese and Indians. However, among HIV-positive individuals, only one-
third were Malays. Chinese, Myanmar, Indonesian and other races formed the other
two-thirds of patients (Figure 1). Other races included Vietnamese, Bangladeshi,
Pakistani, Caucasians and other East Asians. The most common groups of fungi
isolated were yeasts (80.5%), followed by thermally dimorphic fungi (16.9%) and
moulds (2.6%). Among isolates, Candida albicans was the most commonly isolated.
All age groups were affected. The most commonly affected age groups in this study
were adults aged 18 years and above. A high male-to-female ratio (2.9:1) was noted in
our patient population. Almost half of male patients were infected with HIV (43.9%)
compared to (20.0%) in female patients. The distributions of mycoses among all
patients were highest in Malays, followed by Chinese and Indians; however, this may
reflect normal ethnic distribution in Malaysia. The distribution of race between HIV-
positive group and HIV-negative group differed significantly (p<0.001). Malay
predominance in HIV-negative group was significantly diminished by increases in
Chinese, Myanmar and Indonesian proportions.
Almost two-thirds (62.6%) of positive fungal cultures came from the infectious disease
(ID) and general medical wards. This finding may be attributed to the patient population
in those wards with serious underlying medical conditions, including HIV as compared
with other wards.
Reference :
http://iiumedic.net/imjm/v1/download/Volume%2012%20No%201/Vol12No1%20p39-
42.pdf
RISK FACTOR:
General:
Warm, moist environment such as shoes, socks,swimming pools, locker rooms, and the
floors of public showers. Spread from person to person through direct contact or
indirectly from objects carrying the fungus. Direct contact with infected people or
animals. It also may be spread on clothing or furniture. Heat and humidity may help to
spread the infection.
Specific:
1. Weak immune systems:
a. organ transplant patients
b. people living with hiv/aids
c. cancer patients

8. d. hospitalized patients
e. stem cell tranplants patients
f. people taking medications that weaken the immune systems
2. How did I get a fungal infection?You can get a fungal infection by touching a
person who has one. Some kinds of fungi live on damp surfaces, like the floors in
public showers or locker rooms. You can easily pick up a fungus there. You can
even catch a fungal infection from your pets. Dogs, cats and farm animals can be
infected with a fungus. Often this infection looks like a patch of skin where fur is
missing.
3. Antibiotic Use & Fungal Infections:Antibiotics are medicines designed to kill
harmful bacteria that are causing infection or illness. Sometimes these drugs can
also reduce the helpful bacteria that live in the body. When these populations are
reduced, fungi may take the opportunity to colonize.
4. Corticosteroid Use & Fungal Infections:Corticosteroids are a group of drugs that
reduce inflammation. They effectively treat many skin disorders. Unfortunately,
these drugs also can reduce our immune response and improve conditions for
fungus growth.
5. Medical Conditions & Fungal Infections:Individuals with diabetes and some
cancers, such as leukemia, are more susceptible to fungal infections than the
general population.
6. Compromised Immune System & Fungal Infections:The immune system is a set
of chemical and cellular responses that attack disease-causing organisms and
help prevent their growth. A number of factors can depress this system. These
include chemotherapy (cancer-killing drugs) and acquired immune deficiency
syndrome (AIDS).A depressed immune system less effectively fights off all types
of infection. Thus a fungus that normally would be controlled by the immune
system may begin to grow.
7. Environmental Factors & Fungal Infections:Fungi require moisture to grow and
reproduce. Fungal infections are more prevalent in warm, moist areas of the
body, such as the mouth and vagina. Also, sweaty clothes and shoes can
enhance fungus growth on the skin. Exposure to fungi is more frequent in
communal areas with moisture, such as locker rooms and showers.
8. Hereditary Factors & Fungal Infections:Some people seem to have a genetic
predisposition toward fungal infections. They may contract infections more easily
than others exposed to the same conditions. Whether this is due to differences in
immune response, skin chemistry, or other factors is not known.

9. 9. Transmission of Fungal Infections:Fungal infections can be passed from person
to person or from objects and surfaces to a person. Also, an individual can
transfer infection to other parts of the body by touching.
SIGNS & SYMPTOMS
a) Ringworm (tinea corporis)
 Known as “kurap”
 Red, itchy flat scaly area on arms, legs, or body
 Patch’s border expand, forms almost a circular ring
 Irregular, wavy outlined ring
b) Athlete’s foot (tinea pedis)
 Known as “kaki makan air”
 Ulceration between toes
 Soft, pale, and white skin when it’s wet
 Itching
 Stinging and burning
c) Jock’s itch (tinea cruris)
 Reddish patches spread out from the fold near the groin towards the upper thighs
(for poster, hajar x reti nk shorten ayat ni..nk buat “reddish patches at groin area”,
takut trlalu sama dgn snior’s)
 Itching
 Burning
d) Tinea versicolor
 Known as “panau”
 Discoloured patches on torso and shoulders

10.  Scaling
 May accompanied by itching
REFERENCES
http://www.mayoclinic.org
Rutter, P. (2009) Community Pharmacy: Symptoms, Diagnosis and Treatment, 2nd
Edition. Elsevier Limited.
COMPLICATION FOR FUNGAL INFECTION
- Spread to another part of body such as to, legs and toenails, hands fingernails
and any essentially body area.
- Such as fungal nail infection(onychomycosis) for tinea pedis.
- With a patient with lack of immune response like diabetic patient cause ulceration
neuropathy (loss of pain) and gangrene.
- Prone to bacterial infection causes inflammation on the skin (cellulitis) if left
untreated.
- Tinea versicolor reinfection in high rate thus must wait for a few months for
disappearance of white spots after skin regenerate.
DIAGNOSED AND TEST
1. Tinea corporis (ringworm)
2. Tinea pedis ( athlete’s foot)
3. Tinea versicolor
4. Jocks itch (tinea cruris)
 By performing a physical examination :-
 Vital sign
 Inspection on infected skin
 By taking history before get the infection :-
 Sexual history
 HIV status

11.  Gym or sports activity
 Use of communal pool or whirlpool
 Pets
 Travel history
 Skin scrappings :-
 Infected skin will be tested with potassium hydroxide.
 Small area of infected skin will be scrapes off.
 Then, it will be placed in potassium hydroxide.
 The potassium hydroxide will kills all normal cells.
 So the fungal cells will be easily seen under microscope.
 Fungal cultures.
ANTIFUNGAL TREATMENT
1. Topicals
 Clotrimazole
 Econazole
 Ketoconazole sometimes combined with mild
steroid
 Miconazole (hydrocortisone) to reduce
inflammation
 Tioconazole
 Terbinafine
How to use cream? Apply cream to the affected area two times a day for 2 weeks and
continue for 5 to 7days until it heals.
2. Shampoo which contain ketoconazole help to treat scalp fungal infections and
certain skin conditions.
3. Pessaries are tablets which are designed to be put into the vagina.
4. Intravenous (severe) –injected into the bloodstream
5. Oral- swallowed in capsule, pill or liquid form

12. PREVENTION/ALTERNATIVES/SUPPLEMENT
Types of infection Prevention Alternatives/supplement
Tinea corporis/
Ringworm on body
Ringworm is contagious. It spreads when
you have skin-to-skin contact with a
person or animal that has it.
To prevent the infection from spreading:
a. Avoid infected animals
b. Don't share personal items
c. Keep clean
Topical application of :
a. Tea tree oil- may kill
fungus, and reduce
allergic skin reactions.
b. Garlic oil- can inhibit
unwanted fungi
Each of these is effective at
reducing the symptoms of
itching and burning.Tinea pedis/
athlete's foot
Prevent athlete's foot by keeping your feet
clean and dry.
Example:
- Take time to dry your feet, including
each toe, thoroughly
-Wear cotton socks to absorb sweat
- Wear sandals to prevent bare feet from
touching floors contaminated with fungi.
Tinea Cruris/
Jock itch (Groin)
Reduce your risk of jock itch by:
- Keep your groin area dry.
- Wear clean underwear.
- Don't share personal items
- Avoid tightfitting clothes/underwear
Tinea versicolor Tinea Versicolor can be caused by
malnutrition and vitamin deficiencies. To
prevent or improve the condition is eat a
healthy balanced diet or take vitamin
supplements
Vitamins that can help
regulate melanin production
so that the hypo-pigmented
spots typical of Tinea
Versicolor disappear faster.
a. Vitamin B12
regulates melanin
production
b. Vitamin C is
important for collagen
production
c. Vitamin A can treat
skin that is blotchy in
colour; it can even out
your skin tone
d. Vitamin E is an anti-
oxidant that protects
and repairs skin