255 Postgrad Med J: first published as 10.1136/pgmj.23.259.255 on 1 May 1947. Downloaded from COMMON FUNGUS INFECTIONS 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 favus, 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 hair, 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 endothrix 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 infection of the crural region by copyright. class, but we need refer only to the following (Tinea cruris or Dhobie Itch), between the types:- toes and in the nails. (a) Microspora. 2. Monilia. These are a group of yeast-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 (Tinea 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 erythrasma, within the hair, but the ectothrix group, of and is really of the actinomyces 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 hairs 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 Psoriasis 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 trichophyton 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 abscesses (a) Manual epilation. This is useful for ooze beads of pus. 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 tuberculosis. 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 syphilis and to actinomycosis. 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.