Dermatomycosis is an infectious disease of the skin and its appendages, which is caused by various pathogenic, conditionally pathogenic fungi. Typical pathogens include Trichophyton, Microsporum, Epidermophyton. According to the clinic, dermatomycoses are divided into mycoses of smooth skin, skin folds, scalp, hands and feet. Onychomycosis (fungal infections of nails) also belong to this category. To diagnose the disease, microscopy is required, backcutting of the scraping of the pathological focus. Treatment includes local and systemic antimycotics, keratolytics, antihistamines, according to indications, physiotherapy, surgical intervention is prescribed.
ICD 10
B35 B37.2
General information
The prevalence of dermatomycosis in the population, according to various estimates, is 20-30%, and the frequency of the disease increases with age — among people over 70 years of age, fungal infections occur in every second. Most often, the lesion proceeds according to the type of mycosis of the feet with the addition of onychomycosis. In recent years, there has been a tendency to increase the number of mycoses not only among adults, but also in children. Given the complexity of the selection of treatment, the late treatment of patients, these diseases are among the most relevant in practical dermatology.
Causes
The pathogens are dermatophyte fungi, which include representatives of the genera Trichophyton, Microsporum, Epidermophyton. The most common pathogens are T. rubrum, T. mentagrophytes, Epidermophyton floccosum. Occasionally, the cause of mycotic infection is filamentous non-dermatomycetes (Aspergillus spp., Fusarium spp., Scopulariopsis spp.), fungi of the genus Candida. The following factors contribute to the development of the disease:
- Dermatoses. Fungal infections occur in 20-30% of patients with eczema, neurodermatitis, psoriasis, which is facilitated by constant traumatization of the skin, violation of local immunity, treatment with topical corticosteroids. The risk of infection increases in the presence of hyperhidrosis, diaper rash, and callosities.
- Professional factors. Dermatomycosis is widespread among miners, military personnel, athletes. The development of the disease is facilitated by wearing special clothes and shoes, the presence of shared locker rooms, the isolation of production areas.
- Chronic diseases. Up to 50% of patients with diabetes mellitus, chronic lower limb ischemia, venous insufficiency and other somatic pathologies suffer from dermatomycosis. The infection usually worsens against the background of a decrease in the overall reactivity of the body.
- Non-compliance with hygiene. This applies both to neglect of personal hygiene, which includes proper cleansing, moisturizing and nourishing the skin, and non—compliance with cleanliness in public areas – baths, saunas, swimming pools. Infection often occurs when visiting non-professional masters of the beauty sphere who do not adhere to the rules of sterilization of instruments.
Pathogenesis
Dermatophytes are transmitted through close contact with an infected person, sharing household items, visiting public places. Infection is facilitated by small wounds, cracks, diaper rash, through which the pathogen quickly penetrates into the thickness of the epidermis. The probability of developing an infectious process depends on the virulence and pathogenicity of the fungus, as well as on the activity of specific immune factors.
Representatives of dermatophytes have aggression factors — several types of proteases that can destroy protein molecules in the skin. Due to this, they damage keratin substances, multiply freely in the primary focus of infection. In response to infection with the pathogen, local and general immune reactions are activated, which leads to local inflammation, allergization, intoxication of the body.
Classification
In dermatology, there are several approaches to the systematization of dermatomycoses. According to the national classification of Sheklakov N.D. and Kashkin P.N., nosological forms are distinguished according to the etiological principle — epidermophytia, rubromycosis, trichophytia, etc. Today, the clinical classification according to ICD-10 is more often used, in which the following forms of dermatomycosis are indicated:
- Mycosis of the scalp. This group includes trichophytia, microsporia, favus. The lesions are localized in the area of hair growth on the head, in the beard, mustache.
- Mycosis of large skin folds. Inguinal rubrophytia or epidermophytia is most often observed, however, lesions of other skin folds are possible, especially in overweight patients.
- Mycosis of the hands and feet. According to the morphological features of skin damage in this type of dermatomycosis, squamous-hyperkeratotic, intertriginous, and dyshydrotic forms are distinguished.
- Nail mycosis (onychomycosis). According to the degree of damage to the nail plate, onychomycosis can be distal, proximal, superficial, total-dystrophic.
- Mycosis of smooth skin. All cases of dermatophytosis that are not included in any of the above groups belong to this category.
Symptoms
Mycoses of the scalp
They are manifested by bright red infiltrated plaques, which are covered with gray scales on top. The elements are mainly formed around the hair in the form of a muff. Occasionally, deep inflammatory foci are possible, which are large in size, covered with massive grayish-yellow crusts. In the focus of fungal infection, hair breaking is observed at a height of 5-8 mm or at the root itself. A person complains of severe itching, rapid contamination of hair after washing.
Mycoses of skin folds
The main representative of this group is inguinal dermatophytia. The disease affects the inguinal folds, adjacent areas of the skin: the inner surface of the thighs, the perianal zone, the perineum. Due to self—infection, it is possible to spread the process to the area of the armpits, elbow bends, popliteal pits, and in severe cases – to any area of smooth skin. The frequency of inguinal dermatophytosis in the structure of all dermatomycoses is up to 10%.
At the initial stage, the pathology is represented by pink edematous spots that have a rounded shape, clear contours and a smooth surface. If treatment is not carried out, the foci merge to form large polygonal spots, the marginal zone of which is covered with polymorphic elements: bubbles, erosions, crusts. Most of all, patients are concerned about excruciating itching, which interferes with sleep and daily activity, forcing them to comb the affected area until it bleeds.
Mycoses of the feet
The clinical picture of epidermophytia of the distal extremities depends on the form of the lesion. As a rule, pathology begins with an erased form, in which there is a slight peeling in the interdigital spaces, which does not cause the patient any concern. Sometimes, against the background of peeling, surface cracks of the skin form, which do not inflame, do not bleed.
In the squamous-hyperkeratotic form, abundant peeling is accompanied by plaques of a reddish-bluish color, yellowish-gray callosities that occur due to excessive keratinization of the skin. With a dyshydrotic form, multiple bubbles with a thick tire appear, when opened, bright pink wet erosions are formed. Secondary allergic rashes, called dermatophytides, are typical for mycoses of the feet.
Onychomycosis
Fungal infection of nails has different symptoms, which depends on the shape and depth of the lesion. Pathology is mainly manifested by grayish-yellow stripes on the nail plate, its increased fragility, tendency to deformation, transverse striation and cracks. At the advanced stage of the disease, without treatment, there is a significant destruction of the nail, in addition to a cosmetic defect, itching and painful sensations occur.
The normotrophic form is characterized by a decrease in the transparency of the nail, thickening of its edges due to subcutaneous hyperkeratosis. In the hypertrophic variant, the thickening of the nail plate is more pronounced, in severe cases, the nail acquires a curved beak-shaped shape (onychogryphosis), a dirty gray shade. For atrophic onychomycosis, total destruction and detachment of the nail plates is typical, and onycholysis is considered the extreme degree of such a process.
Mycoses of smooth skin
Classical dermatomycosis is characterized by the appearance of flat flaky spots of pink or red color with a raised border. There may be inflammatory papules or vesicles along the edges of the foci. Over time, the central part of the elements turns brown due to hyperpigmentation, and the edges continue to grow, so that the foci merge into large polygonal spots. Subjectively, patients experience itching, burning, soreness of the affected area.
Complications
Erosions and cracks of the skin that occur in the focus of dermatomycosis are the entrance gate for bacterial infection. Purulent skin inflammations in such patients occur 3 times more often than in healthy people, and up to 40% of cases of bacterial lesions are accompanied by lymphostasis, intoxication, elephantiasis. Treatment of secondary infection is difficult because fungi produce antibiotic substances that cause increased resistance of the macroorganism to drugs.
With mycoses of the feet, the probability of the formation of plantar warts increases 4 times, which is facilitated by hyperkeratosis, aflatoxin-like substances of fungi, increased reproduction of papillomaviruses against the background of mycotic infection. With superinfections and relapses of dermatomycosis, the risk of developing or exacerbating seborrheic dermatitis, atopic dermatitis, eczema, psoriasis increases.
Dermatomycosis of the feet, especially in the absence of treatment, can be complicated by acute dermatophytia or rubrophytia, which are a sign of high sensitization to fungi. The symptoms of the disease are rapidly progressing, the process captures the surface of the feet and shins. Against the background of bright hyperemic skin, multiple blisters, erosions, cracks are formed. It is characterized by the addition of inguinal lymphadenitis and lymphangitis, an increase in body temperature, a general intoxication syndrome.
If a patient with dermatomycosis tries to carry out treatment on his own, there is a risk of transformation of the disease into an unrecognized dermatophytia. In this case, the external manifestations of mycosis change against the background of uncontrolled treatment with corticosteroid ointments. The disease is characterized by alternating phases of imaginary well—being – temporary relief of inflammation under the action of corticosteroids, and exacerbation caused by secondary immunosuppression.
Diagnostics
Examination of the patient by a dermatologist begins with a thorough examination of the skin, including with the use of a Wood fluorescent lamp, a dermatoscope. To find out the possible cause of the disease, its predisposing factors, a thorough collection of anamnesis is necessary. Diagnosis involves an extended examination, for which the following methods are recommended:
Analysis of scrapings. The material from the affected nails, areas of smooth skin or scalp is used for the study. A microscopic method is shown for the rapid detection of mycelium or fungal spores. In order to accurately determine the type of pathogen and choose the right drug for treatment, a bacteriological study is performed, the results of which assess the growth of colonies of pathogenic fungi.
Other analyses. To assess the general condition of the body, to identify concomitant pathologies of internal organs, patients are prescribed a general blood test, a general urine test. If necessary, a biochemical blood test is performed, with chronic or often recurrent mycoses, it is advisable to look at the results of the immunogram.
Consultations of narrow specialists. Since dermatomycoses often develop against the background of chronic somatic diseases, a dermatologist may need the help of an allergist-immunologist, gastroenterologist, endocrinologist.
Treatment
Conservative therapy
Treatment of a fungal lesion requires the removal of a pathogenic fungus from the focus of inflammation. For this purpose, various variants of antimycotics are used, among which there are up to 20 dosage forms, more than 100 different names of active substances. When choosing an effective etiotropic treatment, the type of dermatomycosis, the depth of the lesion, the presence of complications, and the general condition of the patient are taken into account. Etiotropic therapy includes the following types of drugs:
- Antifungal ointments. Treatment can be carried out with drugs from groups of imidazole, triazole, and allylamines derivatives. The drugs are applied 1-2 times a day to the affected area, prescribed for long courses until the complete disappearance of clinical manifestations.
- Antifungal varnishes. In case of nail lesions, it is more convenient to apply special therapeutic varnishes, which are characterized by ease of use, good therapeutic effect. As an alternative treatment, special patches are used, which additionally protect against the spread of infection.
- Fungicidal solutions. An alcohol solution of iodine and potassium iodide have an antifungal effect, so they are also used in the process of antiseptic treatment of foci of mycotic infection.
- Systemic antimycotics. In case of moderate / severe course, local treatment is combined with taking antifungal drugs inside. The specific medicine and the scheme of its use are selected by the doctor according to the results of the diagnosis.
Pathogenetic treatment of dermatomycosis includes desensitizing therapy, which is carried out with infusion solutions of calcium gluconate, sodium thiosulfate. Antihistamines are prescribed to reduce itching, swelling, and wetness. In case of circulatory disorders against the background of concomitant diseases, drugs that improve microcirculation are recommended, which contribute to the delivery of antimycotics to the focus of fungal lesions.
Since fungal infection often reflects a general decrease in the body’s resistance, vitamin and mineral complexes, adaptogens, phytopreparations are prescribed in complex therapy. If the patient is diagnosed with pathologies of the gastrointestinal tract, immune system or other organs, treatment is selected with the participation of a specialized specialist. According to indications, synthetic and natural immunomodulators are used.
Of the hardware procedures for fungal infection of the hands or feet, medical manicure (pedicure) is popular. The procedure includes antiseptic treatment of nails and skin, application of keratolytics, removal of hyperkeratosis areas with special cutters. This contributes to a better penetration of local antimycotics to the source of infection, and also gives a good aesthetic result. Of the physiotherapy procedures, UVI, diathermy, amplipulse therapy are effective.
Surgical treatment
Minimally invasive surgical methods are mainly used for onychomycosis. A total lesion of the nail plate requires its removal using a laser, a radiofrequency scalpel or a classical surgical technique. The help of surgeons is also required for complications of dermatomycosis by the bacterial process (abscesses, phlegmon) — in this case, an autopsy and drainage of the focus is carried out.
Prognosis and prevention
The prognosis for dermatomycosis is determined by the type of pathogen, the depth of the lesion, and the timeliness of the start of therapy. Complex treatment with systemic and local remedies gives a good effect in most patients, allows to achieve complete elimination of the pathogen, regression of clinical symptoms. Less optimistic prognosis for patients with immunosuppression, chronic somatic pathology.
The basis for the prevention of mycotic infection is the observance of personal hygiene, correction of excessive sweating, diaper rash, excessive dryness of the skin. Putting on someone else’s shoes, using someone else’s combs, walking barefoot in public pools and on beaches is unacceptable. If cracks or other skin lesions appear, you should not self-medicate, it is necessary to consult a doctor as soon as possible.
