Microsporia ICD 10. Microsporia - symptoms, treatment, folk remedies, causes and prevention. Damage to smooth skin

Microsporia- dermatomycosis, which occurs with damage to the skin, hair, and nail plates are relatively rarely affected.

Code according to the international classification of diseases ICD-10:

Causes

Epidemiology. Fungi of the genus Microsporum are widespread in nature, and infection is possible everywhere. Diseases are more often recorded in countries with hot, humid climates. Mostly children aged 5-10 years are affected, boys are 5 times more likely. The route of transmission is contact (with a sick person or animal) or through various environmental objects. The main condition for infection is skin damage. The following epidemically significant groups of pathogens are distinguished.

Geophilic species (Microsporum gypseum, Microsporum fulvum, Microsporum vanbreuseghemii, Microsporum cookei, Microsporum rasemosum, Microsporum boullardii) live in the soil; infection is possible after contact of a sensitive organism with infected soil.

Pathogenesis. Fungi only affect the skin, which is due to the fungicidal effect of the serum (due to the activity of transferrin, which chelates Fe2+, necessary for fungi) and the unfavorable effect of high temperature (37 ° C). The state of cellular immunity is important. With microsporia, specific immune reactions do not develop. When examining lesions, pathogens are represented by fragments of hyphae and conidia that have entered keratin-containing tissues (the stratum corneum of the skin and hair). The virulence of the pathogens is low (the pathogenicity factor is keratinolytic proteases), and damage to the underlying tissues is not observed in healthy individuals. Predisposing factors are increased skin moisture, low pH of skin secretions, and the composition of the secretions of the sweat and sebaceous glands.

Symptoms (signs)

Clinical picture
. The incubation period for microsporia caused by zoophilic and geophilic species is 1-2 weeks, and by anthropophilic fungi - 1-1.5 months. The clinical picture of the disease depends on the type of fungus: zoophilic and geophilic fungi cause a pronounced inflammatory reaction (infiltrative and suppurative forms), and anthropophilic fungi cause more moderate lesions.

One or more round or oval erythematous-squamous lesions with a diameter of 2-6 cm appear on the scalp. In the lesions, the hair breaks off 2-3 mm from the surface. The hair stumps are surrounded by a whitish or grayish muff consisting of arthrospores. Broken hair can be removed with tweezers without much effort. Microscopically, small spores of the fungus are located inside and outside the hair (growth of the endo- and ectotrix type), mycelial threads and arthrospores are found in the scales.

Foci of microsporia on smooth skin are often located in open areas of the skin. Characteristic are round or oval erythematous-squamous spots 0.5-3 cm in diameter, surrounded by a raised peripheral ridge on which blisters are identified that quickly dry into crusts. Microsporia is characterized by centrifugal growth and subsidence of inflammatory phenomena in the center, due to which the foci of mycosis acquire a ring-shaped character.

In 1-2% of children, damage to the eyebrows, eyelids and eyelashes is observed. In some cases, damage to the nail plates occurs.
Research methods. Microscopy of suspicious hair, identifying small fungal spores (endo- and ectotrix) and mycelium threads. Luminescent method - in the rays of a Wood's lamp, the lesions glow greenish. Isolation of the pathogen is carried out by inoculation on conventional mycological media. Microsporum canis (the main pathogen) grows quickly on Sabouraud's medium and already on the 3rd day forms white colonies with an orange or rusty-red base. Microscopic examination of the culture reveals numerous spindle-shaped macroconidia. Other species grow slowly; macroconidia are thick-walled, multicellular, fusiform (30-160 µm) and covered with spines.

Diagnostics

Differential diagnosis. Dermatophytosis. Favus. Psoriasis. Seborrhea. Alopecia areata.

Treatment

TREATMENT
ABOUT general recommendations. In case of damage to the scalp and disseminated lesions of smooth skin, the patient is isolated. Children who have recovered from microsporia can attend children's groups after three negative results of a microscopic and luminescent examination for fungi and a final disinfection at home.

Drug therapy. Locally (for microsporia of the scalp, external agents are ineffective).. Preparations containing sulfur, selenium, tar, as well as 2-5% iodine solution and sulfur-salicylic ointment are applied alternately in the morning and evening to the lesion.. Ointments with imidazoles (miconazole, clotrimazole, econazole, ketoconazole) or cream with naftifine. Terbinafine, amorolfine, bifonazole, etc. Systemic treatment (in combination with local) - in case of ineffectiveness of local treatment and extensive lesions.. Griseofulvin at a dose of 20 - 22 mg/kg body weight orally in 2-4 doses with fatty foods daily until the first negative test, then at the same dose after day 2 weeks and then 2 times/week for another 2 weeks until a 3-fold negative microscopy result is achieved (with weekly breaks). Side effects: headache (often), gastrointestinal dysfunction, photosensitivity, rashes, leukopenia.. Ketoconazole. Children: 5 mg/kg/day. Adults: 200-400 mg/day. Duration of treatment is 4-6 weeks. Terbinafine. Children: 10 mg/kg/day. Adults 250 mg/day. Duration of treatment is 4-6 weeks.

Prevention. Timely detection and treatment of patients with microsporia. Disinfection in areas of disease. Preventive examinations of children in organized children's groups. Catching stray cats and dogs, systematic examination of domestic animals.

Synonyms. Microsporosis. Ringworm microsporium. Small-spored ringworm. Ringworm Grubi-Saburo

ICD-10. B35 Dermatophytosis

Microsporia is a highly contagious dermatophytosis caused by fungi of the genus Microsporum.

Etiology and epidemiology of microsporia

The most commonly isolated pathogens of microsporia are the fungi Microsporum canis, which are among the zoophilic fungi widespread in the world, causing dermatophytes in cats (especially kittens), dogs, rabbits, guinea pigs, hamsters, and in more rare cases - in monkeys, tigers, lions , wild and domestic pigs, horses, sheep, silver foxes, rabbits, rats, mice, hamsters, guinea pigs and other small rodents, as well as poultry. Infection occurs mainly through contact with sick animals or through objects contaminated with their fur. Infection between humans and humans is extremely rare, occurring on average in 2% of cases.

Microsporum audouinii is a common anthropophilic pathogen that can cause damage to the scalp and, less commonly, smooth skin in humans. Children get sick more often. The pathogen is transmitted only from a sick person to a healthy person directly through contact or indirectly through contaminated care and household items.

Microsporia is characterized by seasonality. Peaks in the detection of microsporia are observed in May-June and September-November. Various endogenous factors can contribute to the occurrence of the disease: sweat chemistry, the state of the endocrine and immune systems. In addition, children have insufficient density and compactness of the keratin of epidermal cells and hair, which also contributes to the introduction and development of fungi of the genus Microsporum.

Microsporia is a disease that is the most highly contagious of the entire group of dermatophytosis. Mostly children, often newborns, are affected. Adults get sick less often, while the disease is often registered in young women. The rarity of microsporia in adults is associated with the presence of fungistatic organic acids (in particular, uncylenic acid) in the skin and its appendages.

In recent years, there has been an increase in the number of patients with chronic mycosis against the background of severe systemic lesions - lupus erythematosus, chronic glomerulonephritis, immunodeficiency states, and intoxications.

Classification of microsporia

microsporia caused by anthropophilic fungi Microsporum audouinii, M. ferrugineum;
microsporia caused by zoophilic fungi canis, M. distortum;
microsporia caused by geophilic fungi gypseum, M. nanum.

According to the depth of the lesion there are:

superficial microsporia of the scalp;
superficial microsporia of smooth skin (with damage to vellus hair, without damage to vellus hair);
deep suppurative microsporia.

Symptoms of microsporia

Microsporum canis affects hair, smooth skin, and very rarely nails; foci of the disease can be located on both open and closed parts of the body. The incubation period of the disease is 5–7 days.
On smooth skin, the lesions look like swollen, raised erythematous spots with clear boundaries, round or oval outlines, covered with grayish scales. Gradually, the spots increase in diameter, and a raised ridge, covered with blisters and serous crusts, forms along their periphery. In 80-85% of patients, vellus hair is involved in the infectious process. The eyebrows, eyelids and eyelashes may be affected. With microsporia of smooth skin, there are no subjective sensations; sometimes patients may be bothered by moderate itching.

With microsporia of the scalp, the lesions are most often located in the occipital, parietal and temporal regions. In the initial period of the disease, a focus of peeling appears at the site of introduction of the pathogenic fungus. Subsequently, the formation of one or two large lesions of round or oval shape with clear boundaries, measuring from 3 to 5 cm in diameter, and several small lesions - screenings, ranging in size from 0.3-1.5 cm are characteristic. Hair in the lesions is broken off and protrudes above the level skin by 4-5 mm.

Along with the typical clinical symptoms of zooanthroponotic microsporia, atypical variants have often been observed in recent years. These include infiltrative, suppurative (deep), exudative, rosacea-like, psoriasiform and seboroid (proceeding like asbestiform lichen), trichophytoid, exudative forms, as well as a “transformed” version of microsporia (with a modification of the clinical picture as a result of the use of topical corticosteroids) .

In the infiltrative form of microsporia, the lesion on the scalp rises somewhat above the surrounding skin, is hyperemic, and the hair is often broken off at a level of 3-4 mm. The sheath of fungal spores is weakly visible at the root of broken hair.

In the infiltrative-suppurative form of microsporia, the lesion usually rises significantly above the surface of the skin due to pronounced infiltration and the formation of pustules. When pressing on the affected area, pus is released through the follicular openings. Discharged hair is glued together with purulent and purulent-hemorrhagic crusts. Crusts and melted hair are easily removed, exposing the gaping mouths of the hair follicles, from which, like a honeycomb, light yellow pus is released. The infiltrative-suppurative form is more common than other atypical forms, sometimes occurring in the form of kerion of Celsus - inflammation of the hair follicles, suppuration and the formation of deep painful nodes.

Due to the absorption of fungal decay products and the associated secondary infection, intoxication of the patient’s body is observed, which is manifested by malaise, headaches, fever, enlargement and soreness of regional lymph nodes.

The formation of infiltrative and suppurative forms of microsporia is facilitated by irrational (usually local) therapy, serious concomitant diseases, as well as late seeking medical help.

The exudative form of microsporia is characterized by severe hyperemia and swelling, with small bubbles located against this background. Due to the constant impregnation of the scales with serous exudate and gluing them together, dense crusts are formed, which, when removed, exposes the moist, eroded surface of the lesion.

microsporia exudative form

With the trichophytoid form of microsporia, the lesion process can cover the entire surface of the scalp. The lesions are numerous, small, with weak pityriasis-like peeling. The boundaries of the lesions are unclear, there are no acute inflammatory phenomena. This form of mycosis can acquire a chronic, sluggish course, lasting from 4-6 months to 2 years. The hair is thin or there are areas of patchy baldness.

trichophytoid form

With the seborrheic form of microsporia of the scalp, sparse hair is mainly noted. The areas of discharge are abundantly covered with yellowish scales, upon removal of which a small amount of broken hair can be found. Inflammatory phenomena in the lesions are minimal, the boundaries of the lesion are unclear.

seborrheic form

Diagnosis of microsporia

The diagnosis of microsporia is based on the clinical picture and the results of laboratory and instrumental studies:

microscopic examination for fungi (at least 5 times);
inspection under a fluorescent filter (Wood's lamp) (at least 5 times);
cultural research to identify the type of pathogen in order to properly carry out anti-epidemic measures;

When prescribing systemic antimycotic drugs, it is necessary to:

general clinical blood test (once every 10 days);
general clinical urine analysis (once every 10 days);
biochemical examination of blood serum (before the start of treatment and after 3-4 weeks) (ALT, AST, total bilirubin).

Differential diagnosis of microsporia

Microsporia is differentiated from trichophytosis, pityriasis rosea, seborrhea, and psoriasis.

The superficial form of trichophytosis of the scalp is characterized by small scaly foci of round or irregular shape with very mild inflammatory phenomena and some hair thinning. The lesions are characterized by the presence of short gray hair broken off 1-3 mm above the skin level. Sometimes the hair breaks off above the skin level and looks like so-called “black dots”. In the differential diagnosis of microsporia, attention is paid to highly broken hair, with muff-like sheaths covering the hair fragments, and asbestos-like peeling. Of decisive importance in diagnosis is emerald fluorescence in the rays of a Wood's lamp of affected hair, detection of elements of a pathogenic fungus and isolation of the pathogen during cultural examination.

Zhiber's pityriasis rosea is characterized by more pronounced inflammation, a pink tint of the lesions, the absence of sharp boundaries, peeling in the form of “crumpled tissue paper”, the absence of the characteristic emerald glow and the absence of detection of elements of a pathogenic fungus during microscopic examination.

Psoriasis is more characterized by clear boundaries, dry lesions, silvery scales, and the absence of muff-like layers of scales on the affected hair.

Treatment of microsporia

Treatment Goals

clinical cure;
negative results of microscopic examination for fungi.

General notes on therapy

For microsporia of smooth skin (less than 3 lesions) without damage to vellus hair, external antimycotic agents are used.

Indications for the use of systemic antimycotic drugs are:

multifocal microsporia of smooth skin (3 or more lesions);
microsporia with damage to vellus hair.

Treatment of these forms is based on a combination of systemic and local antimycotic drugs.

Hair in the affected areas is shaved once every 5-7 days or epilated.

Indications for hospitalization

lack of effect from outpatient treatment;
infiltrative-suppurative form of microsporia;
multiple lesions with damage to vellus hair;
severe concomitant pathology;
according to epidemiological indications: patients from organized groups in the absence of the possibility of isolating them from healthy individuals (for example, in the presence of microsporia in persons living in boarding schools, orphanages, dormitories, children from large and asocial families).

Treatment regimens for microsporia:

Griseofulvin orally with a teaspoon of vegetable oil 12.5 mg per kg body weight per day

Additionally, therapy is carried out with locally active drugs:

ciclopirox, cream
ketoconazole cream, ointment
isoconazole, cream
bifonazole cream
3% salicylic acid and 10% sulfur ointment
sulfur (5%)-tar (10%) ointment

When treating the infiltrative-suppurative form, antiseptics and anti-inflammatory drugs (in the form of lotions and ointments) are initially used:

Ichthyol, ointment 10%
potassium permanganate, solution 1:6000
ethacridine, solution 1: 1000
furatsilin, solution 1:5000

Then treatment is continued with the above antifungal drugs.

Alternative treatment regimens

terbinafine 250 mg
itraconazole 200 mg

Special situations

microsporia - Pregnancy and lactation.

The use of systemic antifungal drugs during pregnancy and lactation is contraindicated.

Treatment of all forms of microsporia during pregnancy is carried out only with locally active drugs.

Treatment of children with microsporia:

Griseofulvin orally with a teaspoon of vegetable oil 21-22 mg per kg body weight per day

Treatment is considered complete when three negative results of the study are carried out at intervals of 5-7 days.

Additionally, therapy is carried out with locally active drugs:

ciclopirox, cream
ketoconazole cream, ointment
isoconazole, cream
bifonazole cream
3% salicylic acid and 10% sulfur ointment, alcohol tincture of iodine
sulfur (5%)-tar (10%) ointment

Alternative treatment regimens

terbinafine: children weighing >40 kg - 250 mg 1 time per day orally after meals, children weighing from 20 to 40 kg - 125 mg 1 time per day orally after meals, children with body weight<20 кг — 62,5 мг 1 раз в сутки
itraconazole: children over 12 years of age - 5 mg per 1 kg of body weight

Requirements for treatment results

resolution of clinical manifestations;
lack of hair glow under a fluorescent filter (Wood's lamp);
three negative control results of a microscopic examination for fungi (microsporia of the scalp - 1 time in 5-7 days; microsporia of smooth skin with damage to vellus hair - 1 time in 5-7 days, microsporia of smooth skin - 1 time in 3-5 days).

Due to the possibility of relapses, after completion of treatment, the patient should be under clinical observation: for microsporia of the scalp and microsporia of smooth skin with damage to vellus hair - 3 months, for microsporia of smooth skin without damage to vellus hair - 1 month.

Control microscopic examinations during dispensary observation must be carried out: for microsporia of the scalp and microsporia of smooth skin involving vellus hair - once a month, for microsporia of smooth skin - once every 10 days.

A conclusion on recovery and admission to an organized team is given by a dermatovenerologist.

Prevention of microsporia

Preventive measures for microsporia include sanitary and hygienic measures, incl. compliance with personal hygiene measures and disinfection measures (preventive and focal disinfection).

Focal (current and final) disinfection is carried out in places where the patient is identified and treated: at home, in children's and medical organizations.

Preventive sanitary-hygienic and disinfection measures are carried out in hairdressing salons, baths, saunas, sanitary checkpoints, swimming pools, sports complexes, hotels, hostels, laundries, etc.

Anti-epidemic measures when microsporia is detected:

For a patient diagnosed with microsporia for the first time, a notification is submitted within 3 days to the department of accounting and registration of infectious diseases of the Federal Budgetary Institution of Health "Center for Hygiene and Epidemiology" and its branches, to territorial dermatovenerological dispensaries.
Each new disease should be considered as newly diagnosed.
When registering a disease in medical organizations, organized groups and other institutions, information about the sick person is entered into the infectious diseases register.
The journal is kept in all medical organizations, medical offices of schools, preschool institutions and other organized groups. Serves for personal registration of patients with infectious diseases and registration of information exchange between medical organizations and state sanitary and epidemiological surveillance organizations.
The patient is isolated.

When a disease is detected in children's institutions, a patient with microsporia is immediately isolated and routine disinfection is carried out before transfer to the hospital or home.
Until a child with microsporia recovers, he is not allowed to enter a preschool educational institution or school; an adult patient is not allowed to work in children's and communal institutions. The patient is prohibited from visiting the bathhouse or swimming pool.
For maximum isolation, the patient is allocated a separate room or part of it, personal items (linen, towel, washcloth, comb, etc.).
In the first 3 days after identifying a patient in preschool educational institutions, schools, higher and secondary specialized educational institutions and other organized groups, medical personnel of these institutions conduct an examination of contact persons. An examination of contact persons in the family is carried out by a dermatovenerologist.

The inspection is carried out before final disinfection.
Further medical observation with mandatory examination of the skin and scalp using a fluorescent lamp is carried out 1-2 times a week for 21 days with a note in the documentation (an observation sheet is kept).
Current disinfection of outbreaks is organized by the medical organization that identified the disease. Routine disinfection before hospitalization and recovery is carried out either by the patient himself or by the person caring for him.
Responsibility for performing routine disinfection in organized teams and medical organizations rests with its medical personnel. Current disinfection is considered timely organized if the population begins to perform it no later than 3 hours from the moment the patient is identified.
Final disinfection is carried out in microsporia foci after the patient leaves the foci for hospitalization or after the recovery of a patient who was treated at home, regardless of the length of hospitalization or recovery.

In some cases, final disinfection is carried out twice (for example, in the case of isolation and treatment of a sick child in the isolation ward of a boarding school: after isolation - in the premises where the patient was and after recovery - in the isolation ward). If a child attending a preschool or school falls ill, final disinfection is carried out at the preschool (or school) and at home. In secondary schools, final disinfection is carried out according to epidemiological indications. The final disinfection in the outbreaks is carried out by a disinfection station. Bedding, outerwear, shoes, hats, carpets, soft toys, books, etc. are subject to chamber disinfection.
An application for final disinfection in households and isolated cases in organized groups is submitted by a medical worker of a medical organization with a dermatovenerological profile.
When 3 or more cases of microsporia are registered in organized groups, as well as for epidemiological indications, the exit of a medical worker from a medical organization with a dermatovenerological profile and an epidemiologist from state sanitary and epidemiological surveillance institutions is organized. As directed by the epidemiologist, final disinfection is prescribed and the scope of disinfection is determined.

The medical worker who has identified the disease is working to identify the source of infection (contact with sick animals). Animals (cats, dogs) are sent to a veterinary hospital for examination and treatment, followed by the submission of a certificate from the place of treatment and observation of the patient with microsporia. If a stray animal is suspected, information is transmitted to the appropriate animal control services.

IF YOU HAVE ANY QUESTIONS ABOUT THIS DISEASE, CONTACT DOCTOR DERMATOVENEROLOGIST KH.M. ADAEV:

EMAIL: [email protected]

INSTAGRAM @DERMATOLOG_95

Manifestations of microsporia in animals are characterized by areas of baldness on the face, the outer surfaces of the ears, as well as on the front, less often the hind, paws. Often, apparently healthy cats can be carriers of the fungus.
Seasonal fluctuations in incidence are associated with litters in cats, as well as more frequent contact of children with animals in the summer. The rise in the incidence of microsporia begins in late summer, the peak occurs in October–November, and the decrease to a minimum occurs in March–April.
The incubation period for zoonotic microsporia is 5–7 days. The nature of the manifestations of microsporia is determined by the location of the lesions and the depth of penetration of the pathogen. There are microsporia of smooth skin and microsporia of the scalp.
Microsporia of smooth skin.
At the site where the fungus has invaded, a swollen, raised red spot with clear boundaries appears. Gradually the spot increases in diameter. A continuous raised ridge is formed along the edge, represented by small nodules, bubbles and crusts. In the central part of the spot, inflammation resolves, as a result of which it acquires a pale pink color, with pityriasis-like peeling on the surface. Thus, the focus has the appearance of a ring. The number of foci with microsporia of smooth skin is usually small (1–3). Their diameter ranges from 0.5 to 3. Most often, lesions are located on the skin of the face, neck, forearms and shoulders. There are no subjective sensations or moderate itching.
In newborns and young children, as well as in young women, severe inflammation and minimal peeling are often observed.
In people prone to allergic reactions (in particular, in patients with atopic dermatitis), the fungus is often masked by manifestations of the underlying process and is not always diagnosed in a timely manner. The use of local hormonal drugs only increases the spread of fungal infection.
A rare type of microsporia includes damage to the skin of the palms, soles and nail plates. Nail lesions are characterized by isolated lesions of the nail, usually its outer edge. Initially, a dull spot is formed, which becomes white over time. The nail in the area of whitening becomes softer and more fragile, and may subsequently collapse.
Microsporia of the scalp.
Damage to the scalp by microsporia occurs mainly in children 5–12 years old. It is generally accepted that the rarity of this form in adults is explained by the presence of organic acids in their hair, which slow down the growth of the fungus. This fact indirectly confirms the independent recovery of children during puberty, when the composition of sebum changes. Interestingly, microsporia of the scalp is practically never found in children with red hair.
Foci of microsporia of the scalp are located mainly on the crown, in the parietal and temporal regions. Usually there are 1-2 large lesions ranging from 2 to 5 cm in size, with round or oval outlines and clear boundaries. Along the edges of large lesions there may be screenings - small lesions with a diameter of 0.5–1.5 At the beginning of the disease, a peeling area forms at the site of infection. In the first days, the fungus is located only at the mouth of the hair follicle. Upon closer inspection, you will notice a whitish ring-shaped scale surrounding the hair like a cuff. On the 6th–7th day, microsporia spreads to the hair itself, which becomes brittle, breaks off above the level of the surrounding skin by 4–6 mm and looks as if it has been trimmed (hence the name “ringworm”). The remaining stumps look dull and are covered with a grayish-white sheath, which is the spores of a fungus. If you “stroke” the stumps, they deviate in one direction and, unlike healthy hair, do not restore their original position. The skin in the affected area is usually slightly reddened, swollen, and its surface is covered with grayish-white small scales.
In the suppurative form of microsporia, against the background of significant inflammation, soft bluish-red nodes form, the surface of which is covered with pustules. When pressed, pus is released through the holes. The formation of a suppurative form of microsporia is facilitated by irrational (usually local) therapy, the presence of serious concomitant diseases, and late consultation with a doctor.

The most commonly isolated pathogens of microsporia are the fungi Microsporum canis, which are among the most widespread zoophilic fungi in the world, causing dermatophytes in cats (especially kittens), dogs, rabbits, guinea pigs, hamsters, and in more rare cases - in monkeys, tigers, lions , wild and domestic pigs, horses, sheep, silver foxes, rabbits, rats, mice, hamsters, guinea pigs and other small rodents, as well as poultry. Infection occurs mainly through contact with sick animals or through objects contaminated with their fur.

Infection between humans and humans is extremely rare, occurring on average in 2% of cases.

microsporia caused by anthropophilic fungi Microsporum audouinii, M. ferrugineum;
microsporia caused by zoophilic fungi M. canis, M. distortum;
microsporia caused by geophilic fungi M. gypseum, M. nanum.

According to the depth of the lesion there are:

superficial microsporia of the scalp;
superficial microsporia of smooth skin (with damage to vellus hair, without damage to vellus hair);
deep suppurative microsporia.

Microsporum canis affects hair, smooth skin, and very rarely nails; foci of the disease can be located on both open and closed parts of the body. The incubation period of the disease is 5-7 days.

Microsporia of smooth skin

On smooth skin, the lesions look like swollen, raised erythematous spots with clear boundaries, round or oval outlines, covered with grayish scales. Gradually, the spots increase in diameter, and a raised ridge, covered with blisters and serous crusts, forms along their periphery.

In the central part of the lesion, inflammatory phenomena resolve over time, as a result of which it acquires a pale pink color with pityriasis-like peeling on the surface, which gives the lesion the appearance of a ring. As a result of autoinoculation of the pathogen and repeated inflammation, iris-like figures “ring in a ring” appear, which are more common in anthroponotic microsporia. The diameter of the lesions is usually from 0.5 to 3 cm, and the number is from 1 to 3; in rare cases, multiple rashes are noted. The location can be any, but most often it is the face, torso and upper limbs.

In 80-85% of patients, vellus hair is involved in the infectious process. The eyebrows, eyelids and eyelashes may be affected. With microsporia of smooth skin, there are no subjective sensations; sometimes patients may be bothered by moderate itching.

Atypical forms of smooth skin microsporia

Erased form form

Hypopigmented form

Erythematous-edematous form

Papular-squamous form

Follicular nodular form

With microsporia of the scalp, the lesions are most often located in the occipital, parietal and temporal regions. In the initial period of the disease, a focus of peeling appears at the site of introduction of the pathogenic fungus. Subsequently, the formation of one or two large lesions of round or oval shape with clear boundaries, measuring from 3 to 5 cm in diameter, and several small lesions - screenings, ranging in size from 0.3-1.5 cm, are characteristic. Hair in the lesions is broken off and protrudes above the level skin by 4-5 mm.

Atypical forms of microsporia of the scalp

Along with the typical clinical symptoms of zooanthroponotic microsporia, atypical variants have often been observed in recent years. These include infiltrative, suppurative (deep), rosacea-like, psoriasiform and seboroid (proceeding like asbestos-like lichen), trichophytoid, exudative forms, as well as a “transformed” version of microsporia (with a modification of the clinical picture as a result of the use of topical corticosteroids).


Infiltrative form	Deep form	Psoriasiform

Seboroid form	Trichophytoid form	Exudative form

At infiltrative form of microsporia the lesion on the scalp rises somewhat above the surrounding skin, is hyperemic, and the hair is often broken off at a level of 3-4 mm. The cap of fungal spores at the root of broken hair is weakly expressed. In the infiltrative-suppurative form of microsporia, the lesion usually rises significantly above the surface of the skin due to pronounced infiltration and the formation of pustules. When pressing on the affected area, pus is released through the follicular openings. sparse hair is glued together with purulent and purulent-hemorrhagic crusts. Crusts and melted hair are easily removed, exposing the gaping mouths of the hair follicles, from which, like a honeycomb, light yellow pus is released. The infiltrative-suppurative form is more common than other atypical forms, sometimes occurs in the form of kerion of Celsus - inflammation of the hair follicles, suppuration and the formation of deep painful nodes. Due to the absorption of fungal decay products and the associated secondary infection, intoxication of the patient’s body is observed, which is manifested by malaise, headaches, feverish state, enlargement and soreness of regional lymph nodes. The formation of infiltrative and suppurative forms of microsporia is facilitated by irrational (usually local) therapy, serious concomitant diseases, as well as late seeking medical help.
Exudative form of microsporia characterized by severe hyperemia and swelling, with small bubbles located against this background. Due to the constant impregnation of the scales with serous exudate and gluing them together, dense crusts are formed, which, when removed, exposes the moist, eroded surface of the lesion.
At trichophytoid form of microsporia the lesion process can cover the entire surface of the scalp. The lesions are numerous, small, with weak pityriasis-like peeling. The boundaries of the lesions are unclear, there are no acute inflammatory phenomena. This form of mycosis can acquire a chronic, sluggish course, lasting from 4-6 months to 2 years. The hair is thin or there are areas of patchy baldness.
At seborrheic form of microsporia The scalp is characterized mainly by sparse hair. The areas of discharge are abundantly covered with yellowish scales, upon removal of which a small amount of broken hair can be found. Inflammatory phenomena in the lesions are minimal, the boundaries of the lesion are unclear.

The diagnosis of microsporia is based on the clinical picture and the results of laboratory and instrumental studies:

microscopic examination for fungi (at least 5 times);
inspection under a fluorescent filter (Wood's lamp) (at least 5 times);
cultural research to identify the type of pathogen in order to properly carry out anti-epidemic measures;

When prescribing systemic antimycotic drugs, it is necessary to:

general clinical blood test (once every 10 days);
general clinical urine analysis (once every 10 days);
biochemical examination of blood serum (before the start of treatment and after 3-4 weeks) (ALT, AST, total bilirubin).

Mycoscopic examination for fungi

Wood's lamp examination

Dermatoscopy

Typical trichoscopic appearance of mycosis of the scalp: comma-shaped hair (blue arrow), corkscrew hair (white arrow), i-shaped hair (green arrow), Morse code hair (gray arrow), and zigzag hair (red arrow).

Mycosis of the scalp - comma-shaped hair
Alopecia areata - exclamation point hair and yellow dots
Trichotillomania - normal hair and blackheads

Cultural examination

The growth of the fungal culture occurs on the 3rd day in the form of a barely noticeable whitish fluff (formation of aerial mycelium); a formed colony is formed on the 23-25th day.

Mature colonies are fluffy, round, opaque, dense in consistency, grayish-white in color with closely spaced radial grooves. The reverse side of the colony becomes orange-yellow-brown in color with age.

Microsporia of smooth skin

the maternal plaque is easily confused with elements of dermatophytosis of the trunk, but unlike them, the edge of the plaque with lichen rosea is not raised
Diagnosis is facilitated by the subsequent appearance of multiple rashes
peeling appears late and is localized in the center of the rash; dermatophytosis, on the contrary, is characterized by peeling along the periphery

papules and nodes merge, forming rings and semirings
elements are often purple rather than red
no peeling

plaques are ring-shaped, but there is no clearing in the center
the edge is not raised
Usually there are crusts on the plaques, there is no peeling
may have a history of diffuse neurodermatitis

red papules or plaques, usually without clearing in the center
the scales are large (with dermatophytosis of the trunk they are smaller)
scraping off the scales results in the appearance of pinpoint drops of blood (Auspitz's sign)

Lipoid necrobiosis differs from mycosis of smooth skin in the absence of obvious signs of inflammation and ruptures in the peripheral ridge. It is necessary to do research on mushrooms
Bowen's disease (torpid course of the disease)

the ring-shaped element in mycosis of smooth skin has a flaky intermittent ridge without a central point at the site of the attached tick

no peeling
often dark color

rapid growth of rashes

Lichen planus (purple polygonal papules or plaques)

seborrheic zones
yellow crusts

night itching
scabies

phenomenon of yellow dust particles during diascopy

Predominant localization on the inner surface of the shoulders and forearms, lateral surfaces of the body, on the chest near the nipples, in the popliteal fossae
when scraping a smooth papule, pityriasis-like peeling is revealed - a symptom of hidden peeling or scale - a symptom of a wafer

Pellagra
Subacute cutaneous lupus erythematosus

the elements are covered with a thick crust, there is no peeling, the skin around them is red and dense to the touch
there is no enlightenment in the center

Microsporia of the scalp

Superficial form of trichophytosis of the pilar part The scalp is characterized by small scaly lesions of round or irregular shape with very mild inflammation and some hair thinning. The lesions are characterized by the presence of short gray hair broken off 1-3 mm above the skin level. Sometimes the hair breaks off above the skin level and looks like so-called “black dots”. In the differential diagnosis of microsporia, attention is paid to highly broken hair, with muff-like sheaths covering the hair fragments, and asbestos-like peeling. Of decisive importance in diagnosis is emerald fluorescence in the rays of a Wood's lamp of affected hair, detection of elements of a pathogenic fungus and isolation of the pathogen during cultural examination.
For Psoriasis of the scalp is more characterized by clear boundaries, dry lesions, silvery scales, and the absence of muff-like layers of scales on the affected hair.

round or oval patches of baldness without peeling, inflammation and blackheads
often there are pinpoint depressions on the nails

patches of baldness without clear boundaries are often observed; within the lesion the hairs have different lengths
Petechiae and bloody crusts may be visible on the scalp where the patient’s hair was pulled out.
no peeling or blackheads
family members can talk about the child’s manipulations with hair (not always)

Bacterial folliculitis

no baldness or flaking
p culture positive for Staphylococcus aureus
in culture of scrapings and hair fragments obtained from a patient with dermatophytosis of the scalp, colonies of Staphylococcus aureus are often found (although the pustules themselves may be sterile)

Bacterial abscess

the likelihood of baldness is lower than with kerion
no peeling
Culture of abscess contents often reveals Staphylococcus aureus or other bacteria

Traction (traumatic) alopecia

strong tension on the hair can lead to its pulling out, leaving areas of baldness in the areas where it grew
There may be signs of folliculitis, but there is no peeling or blackheads
From the anamnesis it often turns out that patients tightly braid their hair or pull it into a ponytail;
hair becomes sparse in peripheral areas

General notes on therapy

For microsporia of smooth skin (less than 3 lesions) without damage to vellus hair, external antimycotic agents are used.

Indications for the use of systemic antimycotic drugs are:

multifocal microsporia of smooth skin (3 or more lesions);
microsporia with damage to vellus hair.

Treatment of these forms is based on a combination of systemic and local antimycotic drugs. Hair in the affected areas is shaved once every 5-7 days or epilated.

Indications for hospitalization

lack of effect from outpatient treatment;
infiltrative-suppurative form of microsporia;
multiple lesions with damage to vellus hair;
severe concomitant pathology;
microsporia of the scalp;
according to epidemiological indications: patients from organized groups in the absence of the possibility of isolating them from healthy individuals (for example, in the presence of microsporia in persons living in boarding schools, orphanages, dormitories, children from large and asocial families).

Requirements for treatment results

resolution of clinical manifestations;
lack of hair glow under a fluorescent filter (Wood's lamp);
three negative control results of a microscopic examination for fungi (microsporia of the scalp - 1 time in 5-7 days; microsporia of smooth skin with damage to vellus hair - 1 time in 5-7 days, microsporia of smooth skin - 1 time in 3-5 days).

A conclusion on recovery and admission to an organized team is given by a dermatovenerologist.

Griseofulvin orally with a teaspoon of vegetable oil 12.5 mg per kg body weight per day in 3 doses (but not more than 1 g per day) daily until the second negative microscopic examination for the presence of fungi (3-4 weeks), then every other day for 2 weeks, then 2 weeks once every 3 days.

Additionally, therapy is carried out with locally active drugs:

3% salicylic acid and 10% sulfur ointment topically in the evening + 3% alcohol tincture of iodine topically in the morning.
sulfur (5%)-tar (10%) ointment externally in the evening

When treating the infiltrative-suppurative form, antiseptics and anti-inflammatory drugs (in the form of lotions and ointments) are initially used:

ichthyol, ointment 10% 2-3 times a day externally for 2-3 days or
potassium permanganate, solution 1:6000 2-3 times externally per day for 1-2 days or
tacridine, solution 1: 1000 2-3 times a day externally for 1-2 days or
furatsilin, solution 1:5000 2-3 times a day externally for 1-2 days.

Then treatment is continued with the above antifungal drugs.

Alternative treatment regimens

terbinafine 250 mg orally 1 time per day after meals (adults and children weighing > 40 kg) daily for 3-4 months or
itraconazole 200 mg once daily orally after meals daily for 4-6 weeks.

Pregnancy and lactation.

The use of systemic antifungal drugs during pregnancy and lactation is contraindicated.
Treatment of all forms of microsporia during pregnancy is carried out only with locally active drugs.

Griseofulvin orally with a teaspoon of vegetable oil 21-22 mg per kg of body weight per day in 3 doses daily until the first negative microscopic examination for the presence of fungi (3-4 weeks), then every other day for 2 weeks, then 2 weeks once a day 3 days.

Treatment is considered complete when three negative results of the study are carried out at intervals of 5-7 days.

Additionally, therapy is carried out with locally active drugs:

ciclopirox cream 2 times a day externally for 4-6 weeks or
ketoconazole cream, ointment 1-2 times a day externally for 4-6 weeks or
isoconazole, topical cream once a day for 4-6 weeks or
bifonazole cream externally once a day for 4-6 weeks or
3% salicylic acid and 10% sulfur ointment topically in the evening + 3% alcohol tincture of iodine topically in the morning
sulfur (5%)-tar (10%) ointment externally in the evening.

Alternative treatment regimens for children

terbinafine: for children weighing >40 kg - 250 mg once daily orally after meals, for children weighing from 20 to 40 kg - 125 mg once daily orally after meals, for children with body weight<20 кг - 62, 5 мг 1 раз в сутки перорально после еды ежедневно в течение 5-6 недель или
itraconazole: for children over 12 years of age - 5 mg per 1 kg of body weight 1 time per day orally after meals every day for 4-6 weeks.

Preventive measures for microsporia include sanitary and hygienic measures, incl. compliance with personal hygiene measures and disinfection measures (preventive and focal disinfection).
Focal (current and final) disinfection is carried out in places where the patient is identified and treated: at home, in children's and medical organizations.
Preventive sanitary-hygienic and disinfection measures are carried out in hairdressing salons, baths, saunas, sanitary checkpoints, swimming pools, sports complexes, hotels, hostels, laundries, etc.

1. For a patient with microsporia identified for the first time, a notification is submitted within 3 days to the department of registration and registration of infectious diseases of the Federal Budgetary Institution of Health "Center for Hygiene and Epidemiology" and its branches, to the territorial dermatovenerological dispensaries. Each new disease should be considered as newly diagnosed .

2. When registering a disease in medical organizations, organized groups and other institutions, information about the sick person is entered into the infectious diseases register.

3. The journal is kept in all medical organizations, medical offices of schools, preschool institutions and other organized groups. Serves for personal registration of patients with infectious diseases and registration of information exchange between medical organizations and state sanitary and epidemiological surveillance organizations.

4. The patient is isolated.

When a disease is detected in children's institutions, a patient with microsporia is immediately isolated and routine disinfection is carried out before transfer to the hospital or home.
Until a child with microsporia recovers, he is not allowed to enter a preschool educational institution or school; an adult patient is not allowed to work in children's and communal institutions. The patient is prohibited from visiting the bathhouse or swimming pool.
For maximum isolation, the patient is allocated a separate room or part of it, personal items (linen, towel, washcloth, comb, etc.).
In the first 3 days after identifying a patient in preschool educational institutions, schools, higher and secondary specialized educational institutions and other organized groups, medical personnel of these institutions conduct an examination of contact persons. An examination of contact persons in the family is carried out by a dermatovenerologist.
The inspection is carried out before final disinfection.
Further medical observation with mandatory examination of the skin and scalp using a fluorescent lamp is carried out 1-2 times a week for 21 days with a note in the documentation (an observation sheet is kept).

5. Current disinfection in outbreaks is organized by the medical organization that has identified the disease. Routine disinfection before hospitalization and recovery is carried out either by the patient himself or by the person caring for him. Responsibility for performing routine disinfection in organized teams and medical organizations rests with his medical staff. Current disinfection is considered timely organized if the population begins to perform it no later than 3 hours from the moment the patient is identified.

6. Final disinfection is carried out in foci of microsporia after the patient leaves the foci for hospitalization or after recovery of a patient who was treated at home, regardless of the length of hospitalization or recovery. In some cases, final disinfection is carried out twice (for example, in the case of isolation and treatment of a sick child in the isolation ward of a boarding school : after isolation - in the premises where the patient was and after recovery - in the isolation ward). If a child attending a preschool or school falls ill, final disinfection is carried out at the preschool (or school) and at home. In secondary schools, final disinfection is carried out according to epidemiological indications. The final disinfection in the outbreaks is carried out by a disinfection station. Bedding, outerwear, shoes, hats, carpets, soft toys, books, etc. are subject to chamber disinfection.

An application for final disinfection in households and isolated cases in organized groups is submitted by a medical worker of a medical organization with a dermatovenerological profile.
When 3 or more cases of microsporia are registered in organized groups, as well as for epidemiological indications, the exit of a medical worker from a medical organization with a dermatovenerological profile and an epidemiologist from state sanitary and epidemiological surveillance institutions is organized. As directed by the epidemiologist, final disinfection is prescribed and the scope of disinfection is determined.
The medical worker who has identified the disease is working to identify the source of infection (contact with sick animals). Animals (cats, dogs) are sent to a veterinary hospital for examination and treatment, followed by the submission of a certificate from the place of treatment and observation of the patient with microsporia. If a stray animal is suspected, information is transmitted to the appropriate animal control services.

Dermatophytosis are infectious diseases caused by dermatophytes. The attention this problem is currently receiving is due to the extreme prevalence of the infection and the continuing challenges of its diagnosis and treatment.

What causes Dermatophytosis:

Dermatophytes are called molds- ascomycetes of the family Arthodermataceae (order Onygenales), belonging to three genera - Epidermophyton, Microsporum and Trichophyton. In total, 43 species of dermatophytes are known, of which 30 are causative agents of dermatophytosis.

The main causative agents of mycoses are, in order of occurrence, T. rubrum, T. mentagrophytes, M. canis.

Dermatophytes are called geophilic, zoophilic or anthropophilic depending on their usual habitat - soil, animal or human. Members of all three groups can cause human diseases, but their different natural reservoirs determine epidemiological features - the source of the pathogen, the prevalence and geography of areas.

Although many geophilic dermatophytes can cause infection in both animals and humans, the most common natural habitat for these fungi is soil. Members of the zoophilic and anthropophilic groups are believed to have descended from these and other soil-inhabiting saprophytes capable of destroying keratin. Zoophilic organisms can be sporadically transmitted to humans if they have an affinity for human keratin. Transmission occurs through direct contact with an infected animal, or through objects that come into contact with the fur and skin scales of these animals. Infections often occur in rural areas, but currently the role of domestic animals is particularly important (especially with M. canis infection). Many members of the zoophilic group are named after their animal hosts. The general epidemiological characteristic of zoonotic and anthroponotic dermatophytosis is high contagiousness. Dermatophytosis is perhaps the only contagious infection among all human mycoses.

The nature of infections caused by anthropophilic dermatophytes is usually epidemic. The main increase in morbidity is due to anthropophilic species. Currently, anthropophilic dermatophytes can be found in 20% of the total population, and the infections they cause are the most common mycoses. According to our epidemiological study, there is an increase in the incidence of dermatophytosis.

Pathogenesis (what happens?) during Dermatophytosis:

All dermatophytes have keratinolytic activity, i.e. capable of decomposing animal and/or human keratin. The activity of keratinases and proteolytic enzymes in general is considered the basis for the pathogenic properties of dermatophytes. Keratinases themselves are capable of decomposing not only keratin, but also other animal proteins, including collagen and elastin. The activity of keratinases varies among different dermatophytes. T. mentagrophytes has the highest activity, T. rubrum has very moderate activity. The ability to decompose different types of keratin generally corresponds to the localization of the dermatophyte infection. Thus, E. floccosum, a species with low keratinolytic activity, does not affect hair.

The introduction of the pathogen colony into the epidermis is ensured by both keratinolytic activity and hyphal growth. Like molds, dermatophytes have a specialized apparatus for directed hyphal growth. It is directed to the points of least resistance, usually at the joints between adjacent cells. Penetrating hyphae of dermatophytes are traditionally considered special perforator organs. It is still unclear whose role in the invasive process is more important - keratinases or directed growth pressure.

The depth of advancement of the fungal colony in the epidermis is limited. In skin infections, dermatophytes rarely penetrate deeper than the granular layer, where they are met by natural and specific protective factors. Thus, dermatophyte infection involves only non-living, keratinized tissue.

The available data on the factors of protection of the macroorganism in dermatophytosis cast doubt on the point of view of some authors that with this infection there is a lymphohematogenous spread of the pathogen or its occurrence in non-keratinizing tissues washed by blood. Deep forms of dermatophytosis have been described in patients with a severe deficiency of one or more resistance factors.

Symptoms of Dermatophytosis:

The basis of foreign classification of mycoses, adopted in ICD-10, is based on the principle of localization. This classification is convenient from a practical point of view, but does not take into account the etiological features of dermatophytosis in some locations. At the same time, etiology options determine epidemiological characteristics and the need for appropriate measures, as well as features of laboratory diagnosis and treatment. In particular, representatives of the genera Microsporum and Trichophyton have unequal sensitivity to certain antimycotics.

For a long time, the generally accepted classification was proposed by N.D. Sheklakov in 1976. In our opinion, a reasonable and acceptable compromise is the use of the ICD classification, clarifying, if necessary, the etiology of the pathogen or its equivalent. For example: dermatophytosis of smooth skin (tinea corporis B35.4), caused by T. rubrum (syn. rubrophytosis of smooth skin). Or: dermatophytosis of the scalp (B35.0 favus/microsporia/trichophytosis).

The term “dermatomycosis,” which is sometimes used to replace the commonly used name for dermatophytosis, is inappropriate and cannot serve as an equivalent to dermatophytosis.

Dermatomycoses are fungal infections of the skin in general, i.e. and candidiasis, and lichen versicolor, and many mold mycoses.

Dermatophytosis of the scalp
Abroad, the following clinical and etiological forms of tinea capitis are distinguished:
1) ectotrix infection. Caused by Microsporum spp. (anthropozoonotic microsporia of the scalp);
2) endothrix infection. Caused by Trichophyton spp. (anthroponotic trichophytosis of the scalp);
3) favus (scab). Caused by T. shoenleinii;
4) kerion (infiltrative-suppurative dermatophytosis).

The most common of these infections is microsporia. The main causative agent of dermatophytosis of the scalp in Eastern Europe is Microsporum canis. The number of registered cases of microsporia in recent years has been up to 100 thousand per year. The occurrence of pathogens of anthroponotic microsporia (M. ferrugineum) and trichophytosis (T. violaceum), common in the Far East and Central Asia, should be considered sporadic.

The classic picture of microsporia is usually represented by one or more rounded lesions with fairly clear boundaries, from 2 to 5 cm in diameter. The hair from the lesions is dull, brittle, light gray in color, and is covered in a white sheath at the base. Hair loss above the surface of the skin explains why the lesions appear trimmed, corresponding to the name “ringworm.” The skin in the lesion is slightly hyperemic and swollen, covered with grayish small scales. This clinical picture corresponds to the name “gray patch lichen”.

For trichophytosis of the scalp characterized by multiple isolated small (up to 2 cm) lesions. Typically, hair breaks off at the skin level, leaving a stump in the form of a black dot peeking out from the mouth of the follicle (“blackhead lichen”).

Classic favus picture characterized by the presence of scutula (lat. shield) - crusts of dirty gray or yellow color. The formed scutula is a dry saucer-shaped crust, from the center of which hair emerges. Each scutula consists of a mass of hyphae glued together with exudate, i.e. is essentially a colony of fungus. In advanced cases, the scutulae merge, covering most of the head. The continuous crust of favus resembles a honeycomb, which is what gives the disease its Latin name. With widespread favus, the crusts give off an unpleasant, “mouse” (barn, cat) smell. Currently, favus is practically not found in Russia.

For infiltrative-suppurative form of microsporia and trichophytosis characterized by severe inflammation with a predominance of pustules and the formation of large formations - kerions. Kerion - a painful dense focus of erythema and infiltration - has a convex shape, looks bright red or bluish, with clear boundaries and a bumpy surface, covered with numerous pustules and erosions, often hidden under purulent-hemorrhagic crusts. Characterized by dilated mouths of the follicles, from which yellow pus is released when pressed. A similar picture is compared to a honeycomb (kerion). Kerion is often accompanied by general symptoms - fever, malaise, headache. Painful regional lymphadenitis develops (usually posterior cervical or postauricular nodes).

Nail dermatophytosis
Onychomycosis affects at least 5-10% of the population, and over the past 10 years the incidence has increased 2.5 times. Onychomycosis on the feet occurs 3-7 times more often than on the hands. Dermatophytes are considered the main causative agents of onychomycosis in general. They account for up to 70-90% of all fungal nail infections. The causative agent of onychomycosis can be any of the dermatophytes, but most often two species: T. rubrum and T. mentagrophytes var. interdigitale. T. rubrum is the main causative agent of onychomycosis in general.

Highlight three main clinical forms of onychomycosis: distal-lateral, proximal and superficial, depending on the location of the pathogen. The most common is the distal form. In this case, elements of the fungus penetrate into the nail from the affected skin in the area of the broken connection of the distal (free) end of the nail and the skin. The infection spreads to the root of the nail, and for its advancement the rate of growth of the fungus must exceed the rate of natural growth of the nail in the opposite direction. Nail growth slows down with age (up to 50% after 65-70 years), and therefore onychomycosis predominates in older people. Clinical manifestations of the distal form are loss of transparency of the nail plate (onycholysis), manifested as whitish or yellow spots in the thickness of the nail, and subungual hyperkeratosis, in which the nail appears thickened. In the rare proximal form, the fungi penetrate through the proximal nail fold. White or yellow spots appear in the thickness of the nail at its root. In the superficial form, onychomycosis is represented by spots on the surface of the nail plate.

The average estimated duration of the disease at present (in the presence of dozens of effective antimycotics) is 20 years, and according to the results of a survey of middle-aged patients, it is about 10 years. Quite a lot for a contagious disease.

Dermatophytosis of the hands and feet
Mycoses of the feet are widespread and occur more often than any other mycoses of the skin. The main causative agent of mycosis of the feet is T. rubrum; much less often, mycosis of the feet is caused by T. mentagrophytes var. interdigitale, and even more rarely - other dermatophytes. Foot mycoses caused by T. rubrum and T. mentagrophytes have epidemiological and clinical features. At the same time, variants of mycosis of the feet are possible, typical for one pathogen, but caused by another.

Infection with mycosis of the feet caused by T. rubrum (rubrophytosis of the feet) most often occurs in the family, through direct contact with the patient, as well as through shoes, clothing or common household items. The infection is characterized by a chronic course, affecting both feet, and often spreading to smooth skin and nail plates. With a long course, the skin of the palms is typically involved, usually the right (working) hand - the “two feet and one hand” syndrome (tinea pedum et manuum). Typically, T. rubrum causes a chronic squamous-hyperkeratotic form of mycosis of the feet, the so-called “moccasin type.” With this form, the plantar surface of the foot is affected. The affected area exhibits mild erythema, moderate to severe peeling, and in some cases a thick layer of hyperkeratosis. Hyperkeratosis is most pronounced in points that bear the greatest load. In cases where the lesion is continuous and covers the entire surface of the sole, the foot becomes as if dressed in a layer of erythema and hyperkeratosis, like a moccasin. The disease, as a rule, is not accompanied by subjective sensations. Sometimes the manifestations of rubrophytosis of the feet are minimal, represented by slight peeling and cracks on the sole - the so-called erased form.

Infection with mycosis of the feet caused by T. mentagrophytes (athlete's foot) most often occurs in public places - gyms, baths, saunas, swimming pools. With athlete's foot, an interdigital form is usually observed. In the 3rd, 4th, and sometimes in the 1st interdigital fold, a crack appears, bordered at the edges by white stripes of macerated epidermis, against the background of surrounding erythema. These phenomena may be accompanied by an unpleasant odor (especially when a secondary bacterial infection is associated) and are usually painful. In some cases, the surrounding skin and nails of the nearest toes (I and V) are affected. T. mentagrophytes is a strong sensitizer and sometimes causes a vesicular form of athlete's foot. In this case, small bubbles form on the toes, in the interdigital folds, on the arch and lateral surfaces of the foot. In rare cases, they merge, forming blisters (bullous form).

Dermatophytosis of smooth skin and large folds
Dermatophytosis of smooth skin is less common than mycosis of the feet or onychomycosis. Lesions on smooth skin can be caused by any dermatophytes. As a rule, in Russia they are caused by T. rubrum (rubrophytosis of smooth skin) or M. canis (microsporia of smooth skin). There are also zoonotic mycoses of smooth skin caused by rarer species of dermatophytes.

Foci of mycosis of smooth skin have characteristic features - ring-shaped eccentric growth and scalloped outlines. Due to the fact that in the infected skin the phases of the introduction of the fungus into new areas, the inflammatory reaction and its resolution gradually change, the growth of lesions from the center to the periphery looks like an expanding ring. The ring is formed by a ridge of erythema and infiltration; peeling is noted in its center. When several ring-shaped lesions merge, one large lesion with polycyclic scalloped outlines is formed. Rubrophytia, which usually affects adults, is characterized by widespread lesions with moderate erythema, while the patient can also have mycosis of the feet or hands, or onychomycosis. Microsporia, which mainly affects children infected from pets, is characterized by small coin-shaped lesions on closed areas of the skin, often by microsporia lesions on the scalp.

In some cases, doctors, without recognizing mycosis of smooth skin, prescribe corticosteroid ointments to the area of erythema and infiltration. In this case, the inflammatory phenomena subside, and the mycosis takes on an erased form (the so-called tinea incognito).

Mycoses of large folds caused by dermatophytes also retain characteristic features: peripheral ridge, central resolution and polycyclic outlines. The most typical localization is the inguinal folds and the inner side of the thigh. The main causative agent of inguinal dermatophytosis is currently T. rubrum (inguinal rubrophytosis). The traditional designation of tinea cruris in the domestic literature was inguinal athlete's foot in accordance with the name of the pathogen - E. floccosum (old name - E. inguinale).

Diagnosis of Dermatophytosis:

The basic principle of laboratory diagnosis of dermatophytosis is the detection of mycelium of the pathogen in pathological material. This is enough to confirm the diagnosis and begin treatment. Pathological material: skin flakes, hair, fragments of the nail plate are subjected to “clarification” before microscopy, i.e. treatment with alkali solution. This allows the horny structures to dissolve and only the masses of the fungus remain in view. The diagnosis is confirmed if filaments of mycelium or chains of conidia are visible in the preparation. In the laboratory diagnosis of dermatophytosis of the scalp, the location of the fungal elements relative to the hair shaft is also taken into account. If the spores are located outside (typical of Microsporum species), this type of lesion is called ectothrix, and if inside, then endothrix (typical of Trichophyton species). Determination of etiology and identification of dermatophytes are carried out based on morphological characteristics after isolation of the culture. If necessary, additional tests are carried out (urease activity, pigment formation on special media, the need for nutritional supplements, etc.). To quickly diagnose microsporia, a Wood's fluorescent lamp is also used, in the rays of which the elements of the fungus in the foci of microsporia give a light green glow.

Treatment of Dermatophytosis:

In the treatment of dermatophytosis, all systemic antifungal agents for oral administration and almost all local antimycotics and antiseptics can be used.

Of the systemic drugs, they act only on dermatophytes or are approved for use only for dermatophytosis: griseofulvin and terbinafine. Drugs with a wider spectrum of action belong to the azole class (imidazoles - ketoconazole, triazoles - fluconazole, itraconazole). The list of local antimycotics includes dozens of different compounds and dosage forms and is constantly updated.

Among modern antimycotics, terbinafine has the highest activity against pathogens of dermatophytosis. The minimum inhibitory concentrations of terbinafine average about 0.005 mg/l, which is orders of magnitude lower than the concentrations of other antimycotics, in particular azoles. Therefore, for many years, terbinafine has been considered the standard and drug of choice in the treatment of dermatophytosis.

Topical treatment of most forms of dermatophytosis of the scalp is ineffective. Therefore, before the advent of oral systemic antimycotics, sick children were isolated so as not to infect the rest of the children's team, and various methods of hair removal were used in treatment. The main treatment method for dermatophytosis of the scalp is systemic therapy. Griseofulvin, terbinafine, itraconazole and fluconazole can be used in treatment. Griseofulvin remains the standard treatment for dermatophytosis of the scalp.

Terbinafine is more effective than griseofulvin overall, but is also less active against M. canis. This is manifested in the discrepancy between domestic and foreign recommendations, since in Western Europe and the USA, tinea capitis more often means trichophytosis, and in Russia - microsporia. In particular, domestic authors noted the need to increase the dose for microsporia by 50% of the recommended one. According to their observations, effective daily doses of terbinafine for microsporia are: in children weighing up to 20 kg - 94 mg/day (3/4 125 mg tablets); up to 40 kg - 187 mg/day (1.5 125 mg tablets); more than 40 kg - 250 mg/day. Adults are prescribed doses of 7 mg/kg, not more than 500 mg/day. Duration of treatment is 6-12 weeks.

In the treatment of dermatophytosis of the nails, local and systemic therapy or a combination of both is also used - combination therapy. Local therapy is applicable mainly only for the superficial form, the initial phenomena of the distal form, or lesions of single nails. In other cases, systemic therapy is more effective. Current topical treatments for onychomycosis include antifungal nail varnishes. Systemic therapy includes terbinafine, itraconazole and fluconazole.

The duration of treatment with any drug depends on the clinical form of onychomycosis, the extent of the lesion, the degree of subungual hyperkeratosis, the affected nail and the age of the patient. To calculate the duration, our proposed special KIOTOS index is currently used. Combination therapy may be prescribed in cases where systemic therapy alone is insufficient or has a long duration. Our experience with combination therapy with terbinafine includes its use in short courses and intermittent regimens, in combination with antifungal nail varnishes.

In the treatment of dermatophytosis of the feet and hands, both local and systemic antifungal agents are used. External therapy is most effective for erased and interdigital forms of mycosis of the feet. Modern antimycotics for topical use include creams, aerosols, and ointments. If these agents are not available, local antiseptics are used. The duration of treatment ranges from two weeks when using modern drugs to four when using traditional drugs. In case of chronic squamous-hyperkeratotic form of mycosis of the feet, involvement of the hands or smooth skin, or damage to the nails, local therapy is often doomed to failure. In these cases, systemic drugs are prescribed - terbinafine - 250 mg per day for at least two weeks, itraconazole - 200 mg twice a day for one week. If nails are affected, the treatment period is extended. Systemic therapy is also indicated for acute inflammatory phenomena and vesiculobullous forms of infection. Externally in these cases, lotions, antiseptic solutions, aerosols, as well as combination products that combine corticosteroid hormones and antimycotics are used. Desensitizing therapy is indicated.

External therapy for lesions of smooth skin is indicated for isolated lesions of smooth skin. For lesions of vellus hair, deep and infiltrative-suppurative dermatophytosis, tinea incognito, systemic therapy is indicated. We also recommend it for localized lesions on the face, and for widespread rubrophytosis (although, as a rule, nails are also affected).

External antifungal drugs are used in the form of creams or ointments; it is possible to use an aerosol. The same drugs are used as for the treatment of mycosis of the feet. The duration of external therapy is 2-4 weeks. or until clinical manifestations disappear and another 1 week. After that. The drugs should be applied to the lesion and another 2-3 cm outward from its edges.

If the scalp or nails are simultaneously affected, systemic therapy is carried out according to appropriate regimens. In other cases, systemic therapy is prescribed terbinafine 250 mg/day for 2-4 weeks. (depending on the pathogen), or itraconazole with 1 cycle of pulse therapy (200 mg twice a day for 1 week). Similar schemes are used for inguinal dermatophytosis.