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Home , Actinomycosis, Erythrasma, Kerion

255 Postgrad Med J: first published as 10.1136/pgmj.23.259.255 on 1 May 1947. Downloaded from

COMMON FUNGUS OF THE SKIN By I. R. MARRE, M.R.C.S., L.R.C.P. Skin Physician to the Acton, Evelina and Metropolitan Hospitals.

The common superficial mycoses of the skin produce a vigorous reaction, frequently going are caused by a number of different organisms, on to pustulation. and I -propose to give a short general descrip- The Achoria are responsible for the produc- tion of the types of fungi usually responsible tion of , characterized by the occurrence for these infections, before proceeding to the of yellowish, cup-shaped scutula. It com- question of diagnosis and treatment. monly affects the scalp, but may affect the , There are three groups to be considered:- glabrous skin or nails. The usual organism is I. Ringworm fungi. A. Schonleini, but the group is nowadays 2. Monilia. usually placed in the trichophyta.' The epidermophyta never affect the hair. 3. Other fungi. They are commonly responsible (especially the I. Ringworm fungi. This is a very large E. inguinale) for of the crural region by copyright. class, but we need refer only to the following ( or Dhobie Itch), between the types:- toes and in the nails. (a) Microspora. 2. Monilia. These are a group of -like (b) Trichophyta. fungi, of which the usual one is M. albicans. (c) Achoria. Unlike the ringworm fungi, the manifestations (d) Epidermophyta. of which are usually fairly localized, monilia are capable of serious generalized and systemic http://pmj.bmj.com/ The microspora have small spores in mosaic infections. Monilia have a predilection for arrangement, and are found in profusion on the folds and flexures, and the infection is often hair surface. They are responsible for most of characterized by moist whitish patches. the scalp ringworm in this country, and are ,either conveyed by human infection (M. au- 3. Otherfungi. We need only concern our- douini-the largest group), or from animals (M. selves here with two: lanosum). Infection with M. audouini tends to (a) Microsporon furfur. on September 29, 2021 by guest. Protected -die out at puberty, and only occasionally (It) Microsporon minutissimum.. attacks the glabrous skin. Infection with M. (a) Microsporon furfur is the cause of Pity- lanosum generally shows more reaction, and on riasis Versicolor (). It is a the glabrous skin cause well-marked rings. yeast-like fungus. The trichophyta are large-spored ringworm, and are divided into two groups, the endothrix (b) Mierosporon minutissimum. This exceed- and the ectothrix. The endothrix group are of ingly minute organism, only seen with I/12 in. human origin and grow in large-spored chains oil immersion lens, is the cause of , within the hair, but the ectothrix group, of and is really of the group. animal origin, grow on the hair surface and In discussing the superficial fungus infec- within the hair as well. The trichophyta also tions, it is most convenient to divide the body attack the glabrous skin, beard and nails, and into regions, and to describe the common in- 256 POST-GRADUATE MEDICAL JOURNAL MaY I947 Postgrad Med J: first published as 10.1136/pgmj.23.259.255 on 1 May 1947. Downloaded from fections in each area. We shall consider the every case by examination of affected in following regions:- 30 per cent. potassium hydroxide solution, when spores or mycelial threads will be seen i. The scalp. under i in. objective. Gentle warming after 2. The beard. immersion of the hair in the KOH solution 3. The glabrous skin.. facilitates examination. 4. The flexures. Infection with Microsporon shows fluores- 5. The feet. cence under Woods' light (filtered ultra-violet 6. The nails. light), but other types of scalp ringworm are difficult to recognize by this means. 1. The Scalp Other conditions may resemble tinea super- ficially, but reveal no fungus on examination. In this country the most common type is the Alopecia areata is a non-scaly completely bald small spored infection with M. audouini, and it patch, with upright " exclamation mark " hairs does not, unfortunately, respond to local treat- at the periphery. Seborrhoeic dermatitis has ment. It usually starts as a small whitish-grey yellow greasy scales with no patchy hair loss: scaly patch, which spreads and forms a mildly has a red inflamed base, covered with inflamed circular lesion, covered with short, typical silvery scales, and no loss of hair. broken, twisted and bent stumps about in. Pediculosis capitis is a common .cause of scalp long. There may be several such small patches, in children. and after a time large areas are affected by sepsis coalescence. If untreated the condition per- Treatment. Local measures should be tried sists until puberty, when it tends to die out. with M. lanosum and ectothrix Its be altered infection, as these are often successful, appearance may by scratching (Kerion) by copyright. and infection. and avoid epilation. The patches may be painted twice daily with Pigmentum Castellani Endothrix trichophyton is a common cause (Fuchsin paint), or rubbed with Whitfield's of " black-dot " ringworm, the stumps break- ointment (Ung. Ac. Benzoic. B.P.C.). The ing off at scalp level. They should be elevated formation of a Kerion may be encouraged by with a comedo-expressor for removal and rubbing in a 33 per cent. soldium chloride examination. ointment. Ectothrix trichophyton is characterized by a With the other and more resistant types of http://pmj.bmj.com/ violent inflammatory reaction, usually with the scalp ringworm, epilation must be carried out, development of a Kerion. This is a well- and three methods be used. defined boggy swelling, with a red inflamed may surface, from which small follicular (a) Manual epilation. This is useful for ooze beads of . There is a tendency to self- small single patches, and epilation with cure here, as the infected hairs become loose forceps is carried out every three or four and tend to fall out, so that a days. The rest of the scalp is kept covered

eventually on September 29, 2021 by guest. Protected smooth, bald patch is left. If there has been with an antiseptic ointment, such as Ung. scarring the baldness may be permanent, but Hydrarg. Ammon. usually hair grows again. (b) X-ray epilation. Is most successful Favus starts as a scalyspot with minute yellow and efficient in capable hands. After the spots at the hair follicles. These spread and epilating dose a mild mercury ointment is become yellow, cup-shaped crusts or scutula, applied to the scalp, and frequent shampoos with concave side upwards. The hair is brittle to assist hair fall. X-ray is difficult to use in and lustreless, but does not show much ten- children under the age of 4 or 5, as they do dency to break into stumps. The disease not keep still. spreads slowly if untreated, with an end result (c) Thallium acetate epilation. The method of permanently bald scarred patches. consists in the administration by mouth of 8 Diagnosis. This should be confirmed in. mgm. of thallium acetate per kilogram of COMMON FUNGUS INFECTIONS OF THE May 1947 SKIN 257 Postgrad Med J: first published as 10.1136/pgmj.23.259.255 on 1 May 1947. Downloaded from body weight. The drug is dangerous, as a fine branny scaling, affecting usually the trunk, mistake in the dose may lead to the death of axillae and neck. It begins as irregurar fawnish the patient, and it is used only for children macules, which coalesce to form diffuse sheets, as it is highly toxic to adults. and are separated by paler areas of normal skin. It is said to occur particularly in cachectic 2. The Beard patients who perspire freely, and therefore is common in . This is an uncommon infection, and usually there are other foci on the body. There are Diagnosis. This is simple in the circinate two types:- variety of ringworm, but may be much more (a) Kerion or inflammatory type due to difficult in the eczematous or plaque types. animal ectothrix trichophyton. Demonstration of the fungus in Io per cent. potassium hydroxide is certain. Pityriasis (b) Dry scaly type, usually an endothrix versicolor shows abundant fungus in scrapings of human origin, which may spread peri- of the scales. pherally, or form a follicular sycosis. Pityriasis rosea can be differentiated by the Diagnosis. Rests on demonstration of fun- herald patch, together with the sudden secon- gus. The condition must be differentiated dary eruption Qn the body and upper parts of from coccal sycosis barbae, in which there are the arms and legs, and no fungus can be no stumps with fungus, and also from granu- demonstrated. lomatous eruptions due to iodides and bro- Contact dermatitis is differentiated by the mides, to and to . history and lack of circinate outline. The Treatment. Initial sepsis and pustulation plaque type must be recognized from psoriasis be dealt with saline com- with its silvery scales and bleeding points, and may by hypertonic from neurodermatitis where thereis presses, or boric acid lotion. When this has no evidence by copyright. subsided, manual epilation may be undertaken, of fungus disease elsewhere. together with a twice daily application of a Final and certain diagnosis lies in recog- fungicide such as Whitfield's ointment or Cas- nition of the fungus microscopically. tellani's paint. Epilation by X-ray has been Treatment. Tinea ofthe glabrous skin usually used in this area but is usually unnecessary. responds well to treatment. Castellani's pig- ment painted on twice daily for a week suffices, 3. The Glabrous Skin or Whitfield's ointment may be used. Tincture The appearance of the infection here varies of iodine (weak tincture) may be used in the http://pmj.bmj.com/ considerably with the infecting fungus. There same way. is a macular scaly eruption which may be due Pityriasis versicolor responds to an ointment to M. audouini or an endothrix trichophyton. of 2 per cent. sulphur and salicylic acid, to- The classical eruption ofcircinate ringed lesions gether with frequent bathing and changing of is caused by M. lanosum. This is a ringed scaly underclothes. Treatment must be persisted lesion, with vesiculation, which in- with for at least two weeks after peripheral apparent cure, on September 29, 2021 by guest. Protected creases in diameter, clearing in the centre, and as the condition is resistant. often joining up with other patches to form gyrate figures. An eczematous type is formed After cure a course of general ultra violet by the ectothrix trichophyton, at first vesi- light is useful in preventing a recurrence. cular and later pustular. A solid plaque type resembling psoriasis is also found on the body, 4. The Flexures as well as a granulomatous type, both due to Here we are concerned mainly with the trichophyta. Favus caiases a crusted type of groins, internatal cleft, submammary region in lesion, with the tendency to formation of the female, and the axillae. scutula. yellowish Tinea cruris, or Dhobie Itch, is a common Pityriasis versicolor (due to M. furfur) is a type of ringworm, usually confined to the cafe-au-lait coloured macular eruption, with a upper and inner parts of the thighs. It may 258 POST-GRADUATE MEDICAL JOURNAL May I947 Postgrad Med J: first published as 10.1136/pgmj.23.259.255 on 1 May 1947. Downloaded from spread to he genitals and the internatal cleft, tion will confirm the diagnosis. The picture and is also found in the submammary and in moniliasis is usually distinctive with its red axillary areas. If specifically sought, there is centre and thin detached edge, and the yeast- nearly always a primary focus between the toes, like fungus will be found in the free edge of the and this must be treated simultaneously. The lesion. Acute coccal is much more condition is usually due to Epidermophyton In- painful and acute than the chronic monilial guinale, and is a well-marginated scaly rash type. spreading peripherally from the flexures. Treatment. The epidermophyton (tinea cru- Erythrasma is caused by a tiny fungus (M. ris) usually responds well to simple fungicides minutissimum), and gives rise to well-defined such as Whitfield's ointment or Pigmentum reddish-yellow or reddish-brown patches es- Castellani. pecially in the crural regions and the axillae. Erythrasmna responds well to the twice daily There is a faintly scaly surface, and the fungus inunction of a 2 per cent. sulphur and salicylic is found in the scales (with 1/12 in. oil im- ointment. mersion lens). Monilia is best treated with a i per cent. Monilia grow best in warm, moist places, aqueous solution of gentian violet, or for small and, therefore, favour the intertriginous areas, areas a i per cent. solution in 25 per cent. especially in fat people, and in diabetics. The spirit. Monilial paronychia may be treated in eruption starts as small macules or vesicles, the same way with a 2 per cent. solution of which coalesce to form irregular red patches, gentian violet in 25 per cent. spirit introduced bounded by an edge of detached skin. Mac- into the nail fold twice daily with an orange erated patches of whitish epithelium may be stick. found in association with the condition, es-

pecially in the internatal cleft. Moniliasis has 5. The Feet by copyright. special names (a) in the webs of the fingers, and in the of the mouth. Here, too, different types of lesions are pro- (b) angles duced by different organisms. E. inguinae (a) Erosio interdigitalis blastomycetica. A produces scaly patches between the toes and on tender infection of the web of the fingers, the soles, with the usual sharply marginated with a moist, red base, surrounded by de- border. Trichophyta produce vesicular erup- tached skin. tions on the soles and sides of the feet, whereas (b) Perleche. An affecting the monilia produce macerated cracks between the angle of the mouth. In infants infection of toes. The feet are often secondarily infected, http://pmj.bmj.com/ the buccal mucosa with monilia is known as and this must be attended to first. Hyper- thrush, and may affect the whole gastro- keratotic patches on the feet may be impreg- intestinal tract; in adults a and nated with fungus and must be treated. has been described. Monilia is a Diagnosis. If all the webs of the toes are common cause ofpruritus vulvae and pruritus and is the in- ani. affected, the epithelium macerated, fection is monilia, whereas if the fourth space on September 29, 2021 by guest. Protected A chronic form of paronychia is due to in- shows a scaly eruption, it is likely to be E. fection of the nail fold with monilia, with red inguinale. Contact dermatitis from shoes and and moderately tender swelling of the parony- from medicaments is common, and may be chial tissues. This condition is found particu- distinguished from fungus by the site, history larly among people who keep their hands in and lack of microscopical evidence. Psoriasi- water, such as housewives and barmaids, and form fungus infections are seen and are differ- it is probable that continual maceration of the entiated from true psoriasis by the lack of skin is a factor. psoriasis elsewhere, by more intense itching Diagnosis. Tinea cruris and erythrasma may and by demonstration of the fungus. be confused, but the former has a festooned Treatment. Infection usually responds well marginated border, tends to central clearing to footbaths twice daily with i : 5000 potassium andspreads more rapidly. Microscopic examina- permanganate. The affected areas are allowed May 1947 COMMON FUNGUS INFECTIONS OF THE SKIN 259 Postgrad Med J: first published as 10.1136/pgmj.23.259.255 on 1 May 1947. Downloaded from to rest in the lukewarm bath for 2o minutes and no fungus can be demonstrated. Syphilis and to dry in the air. Later both epider- of the nails is usually associated with signs mophyta and trichophyta respond well to elsewhere. Whitfield's ointment or Castellani's paint, and Treatment. Fungus infection of the nails is the monilia to i per cent. gentian violet. The difficult to cure and demands unremitting greatest care to prevent re-infection must be attention on the part of the patient. In early taken. Cotton socks should be worn beneath infection, with only part of the nail affected, ordinary socks or stockings, and boiled and this part should be scraped away with a piece changed daily. Hyperkeratotic areas may be of broken glass or sharp knife until there is no treated with 6 per cent. salicylic acid ointment, obvious infection. This should be done daily, until they are flat, and later with the usual and Whitfield's ointment is applied under fungicides. strapping each night. Persistence with this Footwear may be sterilized by shutting in treatment, for months if necessary, will result an air-tight box with formaldehyde, so that the in a cure. vapour is allowed to act for four or five days. If much of the nail is affected, surgical evul- sion should be performed, and the thickened 6. The Nails nail bed scraped. After a few days, continuous Ringworm of the nails, or , application of Whitfield's ointment should be may begin independently, but often occurs insisted on until the nail is fully grown. with fungus infection elsewheie on the body. Ringworm fungi of the body, and particu- Infection usually takes place at the free edge of larly of the feet, are capable of sensitizing a the nail, when the nail bed is attacked, and a patient, with the production of an allergic or dirty grey scaly thickening raises the nail from sensitization eruption, which is itself free froft its bed. It spreads down the nail and grows up fungus. A lichenified dermatophytide (or my- by copyright. into the nail plate, which becomes discoloured cide) has been described on the trunk due to and thickened, and finally crumbles. Infection , but more characteristic in ring- may, however, pass under the lateral border of worm infection is the 'pompholyx' type of the nail, first attacking one side with ridging of eruption on the hands. This consists of tiny the nail, but gradually passing across and vesicles along the sides of the hand, on the affecting the whole nail. The infection is due palms and between the fingers, and these to trichophyta or epidermophyta. vesicles contain no fungus. Treatment of the

Diagnosis. Psoriasis of the nails may re- primary focus results in the spontaneous clear- http://pmj.bmj.com/ semble fungus closely, but is not so irregular, ing up of the secondary sensitization eruption.

CORRECTION on September 29, 2021 by guest. Protected Vol. XXIII, No. 257. March 1947, page I65. SEBORRHOEIC DERMATITIS:- Treatment. The first formula given should be corrected to read:- R Acidi Salicylici ...... gr. 20 Hydrargyri Perchloridi ...... gr. Liq. Carbonis deterg...... m. 15 Olei ricini ...... Io Spirit vini rect. or spirit meth. indust...... ad.