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In den letzten Jahren sind therapierefraktare Verlaufe von Dermatophytosen immer mehr in den Fokus getreten. Haufigste Erreger hierbei sind Trichophyton (T.) rubrum und T. mentagrophytes. Die Behandlung umfasst neben lokaltherapeutischen Masnahmen als Erstlinientherapie Terbinafin, ein Allylamin-Antimykotikum, das durch Inhibition der Squalenepoxidase und somit Storung der Ergosterolsynthese wirkt. Bei therapierefraktaren Verlaufen konnte mittlerweile gehauft eine Terbinafin-Resistenz durch Punktmutation im Gen der Squalenepoxidase nachgewiesen werden. Es erfolgen die Darstellung spezieller Aspekte in der Epidemiologie der Dermatophytosen mit Terbinafin-Resistenz sowie Veranschaulichung anhand von 4 Patienten inklusive praxisrelevanter Aspekte bei der Diagnostik. Es wurden eine Aufarbeitung von Handbuchwissen, eine selektive Literaturrecherche sowie eine Aufarbeitung von 4 Patienten mit Dermatophytosen und einer Onychomykose durch Terbinafin-resistente Isolate von T. rubrum vorgenommen. Der Nachweis der Terbinafin-Resistenz erfolgt durch In-vitro-Testung mittels Breakpoint-Methode sowie Sequenzierung des Trichophyton-Isolates und Nachweis der Punktmutation mit Aminosauresubstitution an Position L393F oder F397L des Gens der Squalenepoxidase. Bei therapierefraktaren und rezidivierenden Dermatophytosen sollte vor allem bei T. mentagrophytes und T. rubrum an eine Terbinafin-Resistenz gedacht werden, und eine In-vitro-Resistenztestung des Dermatophyten sowie eine Punktmutationsanalyse der Squalenepoxidase (SQLE) sollten erfolgen. Therapeutisch wird die intermittierende Gabe von Itraconazol in Kombination mit einer antimykotischen Lokaltherapie empfohlen. Dennoch ist mit einem rezidivierenden Verlauf zu rechnen und in der Regel eine Langzeittherapie mit Itraconazol notwendig.

Wir berichten uber eine Terbinafin-resistente Tinea corporis bei einem Reiseruckkehrer aus Asien. Der erstmals in Indien isolierte Genotyp VIII von Trichophyton mentagrophytes hat in den vergangenen Jahren als Erreger der Tinea corporis und Tinea cruris zugenommen und aufgrund seiner haufigen Resistenz gegenuber Terbinafin an Relevanz gewonnen. Insbesondere nach Reisen nach Asien sollte daher bei therapierefraktarer Tinea die systemische Therapie auf Itraconazol umgestellt werden. Mit Itraconazol in veranderter Darreichung kann eine erhohte Bioverfugbarkeit bei niedrigerer Dosierung erreicht werden.

Trichophyton(T.)mentagrophytesnow accounts for an overwhelming majority of clinical cases in India, a new “Indian genotype” (T. mentagrophytes ITS genotype VIII)having been isolated from skin samples obtained from cases across a wide geographical distribution in this country. The conventional diagnostic methods, like fungal culture, are, however, inadequate for diagnosing this agent. Thus, molecular methods of diagnosis are necessary for proper characterization of the causative agent. The shift in the predominant agent of dermatophytosis fromT. rubrumtoT. mentagrophytes, within a relatively short span of time, is without historic parallel. The apparent ease of transmission of a zoophilic fungus among human hosts can also be explained by means of mycological phenomena, like anthropization.

Trichophyton (T.) tonsurans gilt bei Kontakt- und Kampfsportarten weltweit als Haupterreger der Tinea gladiatorum und fuhrt regelmasig zu Ausbruchen. In Leipzig treten im nationalen Ringerkader seit uber 2 Jahren bis heute gehauft und rezidivierend Dermatophytosen bei Kindern und Jugendlichen auf. Die Ringer wurden in der Hautarztpraxis zur klinischen Untersuchung und Probeentnahme vorstellig. Hautschuppen und Haarwurzeln sowie Abstriche wurden entnommen und mykologisch mit fluoreszenzoptischem Praparat, Pilzkultur und Polymerasekettenreaktion (PCR) auf Dermatophyten-DNA (Desoxyribonukleinsaure) untersucht. Die Sequenzierung der r(ribosomale)DNA der Dermatophyten diente als Kulturbestatigungstest. Umgebungsuntersuchungen in der Ringerhalle umfassten Abklatschkulturen und Abstriche von Oberflachen, insbesondere von den Matten. T. tonsurans war bei 21 von 25 Kindern und Jugendlichen sowie 1 Trainer kulturell und/oder mit PCR nachweisbar. In 1 von 10 Abklatschkulturen von Matten und Fusboden wuchs T. tonsurans, eine weitere Kultur wies T. interdigitale nach. Abstriche von den Matten ergaben 2‑mal einen kulturellen T.-tonsurans-Nachweis, 3‑mal war die PCR auf T. tonsurans positiv. Auf den Pilznahrmedien entwickelte T. tonsurans innerhalb von 14 Tagen kleine, flache, ausstrahlende, granulare und weis gefarbte Kolonien mit mahagonibrauner Ruckseite. Die Sequenzierung der Internal-Transcribed-Spacer(ITS)-Region der rDNA sowie des TEF1‑α(„translation elongation factor 1 α“)-Gens bestatigte die Spezies T. tonsurans in allen Fallen. T. interdigitale, isoliert von einer Matte, wurde ebenfalls mit Sequenzierung identifiziert. Acht T.-tonsurans-Stamme wurden einer In-vitro-Empfindlichkeitstestung gegen Terbinafin unterzogen. Alle Isolate waren mit minimalen Hemmkonzentrationen von ≤ 0,1 µg/ml in vitro empfindlich gegen Terbinafin.

A severe outbreak of highly virulent and multi-resistant dermatophytosis by species in the Trichophyton mentagrophytes/T. interdigitale complex is ongoing in India. The correct identity of the etiologic agent is a much-debated issue. In order to define species limits, a taxonomic study was undertaken combining molecular, morphological, and physiological characteristics as evidence of classification. Molecular characteristics show that T. mentagrophytes s. str. and T. interdigitale s. str. can be distinguished with difficulty from each other, but are unambiguously different from the Indian genotype, T. indotineae by sequences of the HMG gene. The entities were confirmed by multilocus analysis using tanglegrams. Phenotypic characters of morphology and physiology are not diagnostic, but statistically significant differences are observed between the molecular siblings. These properties may be drivers of separate evolutionary trends. Trichophyton mentagrophytes represents the ancestral, homothallic cloud of genotypes with a probable geophilic lifestyle, while T. indotineae and T. interdigitale behave as anthropophilic, clonal offshoots. The origin of T. indotineae, which currently causes a significant public health problem, is zoonotic, and its emergence is likely due to widespread misuse of antifungals.

Background The Indian ITS genotype VIII T. mentagrophytes population shows a high amount of different erg1 (ergosterol) mutants encoding for squalene epoxidase, which catalyzes the first step of ergosterol biosynthesis. Objectives Illumination of the implication of point mutations at position Ala448Thr in single and double erg1 T. mentagrophytes mutants because mutants of this type were abundantly found within the Indian fungal population. Methods Growth in fluconazole or terbinafine containing medium was analyzed using a microplate-laser-nephelometry (MLN)-based growth assay. Results Ala 448 Thr erg1 single mutants were terbinafine sensitive but about 50% of isolates showed an increased fluconazole resistance, whereas 95% of the double mutants (Phe 397 Leu, Ala 448Thr) demonstrated combined terbinafine and increased fluconazole resistance. Conclusion The new Indian T. mentagrophytes populations show several point mutations in erg1. Point mutations at position 397 were previously described and cause terbinafine resistance. A large part of the double mutants exhibit resistance to terbinafine and fluconazole, demonstrating a selective advantage of the combination of both mutations.

Eine bullose Manifestation einer Tinea corporis ist selten und wird in der Regel durch zoophile Dermatophyten verursacht. Eine 20-jahrige Patientin stellte sich ambulant mit einer schmerzhaften, juckenden, bullosen Hautveranderung am linken Unterarm vor. Klinisch zeigte sich eine etwa 4 × 3 cm durchmessende, scharf begrenzte symmetrische erythematose Plaque mit peripherer Blaschenbildung und serosen Krusten. Histologisch stellte sich eine ausgepragte spongiotische Dermatitis mit Nachweis von Pilzelementen dar. Mikrobiologisch wurde mittels Kultur, Polymerasekettenreaktion (PCR) und Sequenzierung Trichophyton (T.) tonsurans nachgewiesen. Unseres Wissens nach handelt es sich hier um den ersten publizierten Fall einer bullosen Tinea corporis durch T. tonsurans.

Three boys from the same city, treated by the same dermatologist, developed tinea capitis. Two of them, 4 and 8 years old, underwent mycological diagnostic workup. However, no pathogens familiar in this country, such as Microsporum (M.) canis or Trichophyton (T.) tonsurans, were isolated, but instead that of a dermatophyte that has not been found in Germany for decades. Both dermatophyte isolates showed white-beige-brownish colonies with a flat, radiating edge and a central, verrucous curvature. The sequencing of the internal transcribed spacer (ITS) region of the rDNA confirmed the suspicion of M. ferrugineum already expressed based on the morphological picture. The anthropophilic dermatophyte occurs in the Middle East, Asia, Eastern Europe and Africa and is considered to be the cause of tinea capitis or tinea corporis in children and adolescents. In 2016, M. ferrugineum has again been isolated in Germany, probably as a result of migration movements. The fungus is strikingly isolated to martial arts, especially wrestlers. It mainly affects children and adolescents, some with a Russian-German background. The anthropophilic dermatophyte is transmitted directly from person to person, especially in the case of tinea capitis. An indirect transmission, for example, via mats in martial arts is likely.

Background: During the past decade, a prolonged and serious outbreak of dermatophytosis due to a terbinafine-resistant novel species in the Trichophyton mentagrophytes / T. interdigitale complex is ongoing in India, and it spreads to several European countries.Objective: To investigate the molecular background of the squalene epoxidase (SQLE) gene in order to understand the risk of emergence and spread of multi-resistance in dermatophytes.Methods: Antifungal susceptibility for fluconazole, griseofulvin, itraconazole, ketoconazole, miconazole, naftifine, sertaconazole, and terbinafine was tested in 135 isolates from India, China, Australia, Germany and The Netherlands. Based on the latest taxonomic insights, strains were identified as three species: T. mentagrophytes s. str (n=35), T. indotineae (n=64 representing the Indian clone) and T. interdigitale s. str. (n=36).Results: High minimum inhibitory concentrations (MICs) of terbinafine (>16 mg/L) were found in 34 (53%) T. indotineae isolates. These isolates showed an amino acid substitution in the 397th position of the SQLE gene. Elevated MICs of terbinafine (0.5 mg/L) were noted in 2 (3%) T. indotineae isolates; these isolates lead to Phe415Val and Leu393Ser of the SQLE gene. Stability of the effect of the mutations was proven by serial transfer on drug-free medium. Substitutions of Lys276Asn and Leu419Phe were found in susceptible T. mentagrophytes strains. The double mutant Phe377Leu/Ala448Thr showed higher MIC values for triazoles.Conclusions: High MICs of terbinafine are as yet limited to T. indotineae, and are unlikely to be distributed through the T. mentagrophytes species complex by genetic exchange.

Nadifloxacin (OPC-7251) represents an established antimicrobial agent belonging to the quinolone group and was developed exclusively for topical administration. Nadifloxacin is effective in treating a variety of bacterial skin infections and acne. Here, the in vitro activity of nadifloxacin was assessed and compared with those of erythromycin, clindamycin and tetracycline against Cutibacterium (C.) acnes, formerly Propionibacterium acnes, to gain a picture of the resistance situation in Germany. The study was approved by the Ethics Committee of the Bayerische Landesarztekammer (Munich, Germany; EC-No.17088) and registered at Deutsches Register Klinische Studien (ID:DRKS00014231).

Ein Realtime-PCR(Polymerasekettenreaktion)-Assay sowie ein Microarray zum direkten Nachweis von Dermatophyten wurden hinsichtlich ihrer Spezifitat zur Dermatophytenidentifizierung untersucht. Es handelte sich bei den kommerziell erhaltlichen Testsystemen um ein Microarray-basiertes PCR-Testverfahren (EUROArray Dermatomycosis, Euroimmun, Lubeck, Deutschland) sowie einen Realtime-PCR-Test (DermaGenius® 2.0, PathoNostics BV, Maastricht, Niederlande). Der Microarray erlaubt den Direktnachweis von 50 Dermatophyten mit eindeutiger Identifizierung von 23 Dermatophyten und 6 Hefen/Schimmelpilzen in einem Ansatz. Der Realtime-PCR-Test kann insgesamt 11 Dermatophyten und einen Hefepilz auf Speziesebene identifizieren. Hier wurden 34 Dermatophytenkulturen mit dem EUROArray Dermatomycosis untersucht. Mittels EUROArray wurden 22 von 24 Dermatophytenspezies korrekt identifiziert. Mittels Realtime-PCR liesen sich 9 von 11 im Testsystem vorgesehene verschiedene Dermatophyten richtig identifizieren. Beide molekularen Teste zum Erregernachweis in der Dermatomykologie sind praxistauglich. Der Realtime-PCR-Test hat ein nicht so umfassendes Spektrum und ist weniger spezifisch. Dafur ist der Test sehr schnell in der Durchfuhrung, da kein Post-PCR-Schritt notig ist. Der Test erkennt die haufigsten Dermatophyten wie Trichophyton (T.) rubrum, T. interdigitale, T. benhamiae (inklusive T. erinacei) und Microsporum (M.) canis zuverlassig. Die Durchfuhrung des Microarray ist aufwendiger infolge der Hybridisierung, dafur ist er deutlich spezifischer und das Erregerspektrum wesentlich umfangreicher. Mittels Microarray werden nicht nur die haufigsten, sondern auch seltene humanpathogene Dermatophytenspezies nachgewiesen.

Ein 6 Monate alter weiblicher Saugling aus Bahrain litt an einer ausgepragten Dermatomykose des gesamten Integuments. Die topische Behandlung mit Terbinafin uber 2 Monate fuhrte zu keinerlei Besserung. An der Dermatophytose erkrankte erwachsene Familienmitglieder und Kinder wurden im Heimatland ebenfalls ohne Erfolg topisch und auch systemisch – mit Voriconazol – antimykotisch behandelt. Die mykologische Diagnostik wahrend eines Urlaubsaufenthaltes in Deutschland erbrachte den Nachweis des zoophilen Dermatophyten Trichophyton (T.) mentagrophytes. Mittels Sequenzierung der „internal transcribed spacer“(ITS)-Region der rDNA (ribosomale Desoxyribonukleinsaure) des Pilzes lies sich der neu beschriebene Genotyp VIII innerhalb der Spezies T. mentagrophytes identifizieren. Dieser Genotyp von T. mentagrophytes ist der Haupterreger der aktuellen Epidemie von chronischen therapierefraktaren Dermatophytosen in Indien. Von einer Ubertragung dieses indischen Dermatophytengenotyps in andere Lander im Rahmen der Globalisierung muss ausgegangen werden. Ein wesentlicher Teil dieser indischen T.-mentagrophytes-Stamme ist zudem in vitro und genetisch – Punktmutationen der Squalenepoxidase (SQLE) – resistent gegenuber Terbinafin. Fur das hier untersuchte T.-mentagrophytes-Isolat aus Bahrain bestatigte sich in der SQLE-Mutationsanalyse der Nachweis der Punktmutation TTC/TTA, die fur die F397L-Aminosauresubstitution des Enzyms steht. Der Stamm war zudem in vitro resistent gegen Terbinafin. Diese Punktmutation ist im hohen Mase mit einer In-vitro-Resistenz des Dermatophyten gegenuber Terbinafin assoziiert. Das Madchen wurde erfolgreich rein topisch mit Miconazol, dann auch im Wechsel mit Ciclopiroxolamin behandelt. Es handelt sich hier um die erste Beschreibung einer Infektion durch einen Terbinafin-resistenten T.-mentagrophytes-Stamm vom ITS-Genotyp VIII aus Indien in Deutschland.

Bei der Tinea barbae handelt es sich um eine seltene Dermatomykose, die per definitionem follikular gebunden im Bartbereich erwachsener Manner auftritt. Der Hautbefund beginnt meist mit Erythemen mit Schuppung. Bei Progredienz oder Ausbreitung an Terminalhaaren in die Tiefe kommt es zu Follikulitiden mit Pustel- und Knotenbildung sowie Abszedierungen mit fest anhaftenden gelblichen Krusten, begleitet von einer lokoregionaren Lymphknotenschwellung und gelegentlich vermindertem Allgemeinzustand oder (sub)febrilen Temperaturen. Dies fuhrt haufig zunachst zur Verdachtsdiagnose einer bakteriellen Folliculitis barbae oder Impetigo contagiosa. Die Tinea barbae wird meist durch Spezies der Gattung Trichophyton (T.) ausgelost. Die Erreger sind vielfaltig und gehoren uberwiegend zu den zoophilen, nur gelegentlich zu anthropophilen und selten zu den geophilen Dermatophyten. Mithilfe der gezielten Anamnese und Diagnostik in Form von mykologischen Untersuchungen, Histologie und molekularbiologischem Dermatophytennachweis mittels Polymerasekettenreaktion kann heute schnell die Diagnose einer Tinea barbae, bei unserem Patienten ausgelost durch T. mentagrophytes, gestellt werden. Bei zeitnaher und ausreichend langer Therapie kommt es zur vollstandigen Restitutio ad integrum.

Currently, in Germany, Switzerland, and Austria, a new and until now not known entity of inflammatory and abscessing dermatophyte infection is observed. In particular, these deep infections of the skin and their appendages include Tinea pubogenitalis, Tinea cruris, Tinea barbae, Tinea corporis, and Tinea capitis. Some of the patients came back from a journey to Thailand or South East Asia where transmission occurred. But, independently from a journey to abroad, the dermatophyte might be transferred in Germany, too. In every case, this deep infection is caused by the zoophilic dermatophyte Trichophyton mentagrophytes of the newly described Internal Transcribed Spacer (ITS) genotype VII. From 24 patients with dermatomycoses, altogether 25 isolates of T. mentagrophytes were isolated in the last 6 years. Among them were both male and female patients, the age range was from 1 to 50 years. The infection was affecting the pubogenital area, the capillitium, the face, or the trunk. Most of these infections were acquired in Germany without a stay abroad. A total of 25 dermatophyte isolates—all belonging to T. mentagrophytes—could be characterised. Species identification was confirmed for all isolates by sequencing of the ITS region of rDNA genes. Molecular relationship of the 24 isolates in comparison to already known genotypes within this species was depicted in a phylogenetic tree. The sequences obtained for these isolates are forming their own phylogenetic cluster, corresponding to a new genotype, the ITS genotype VII (“Thai variant”). This genotype is clearly set up from other clusters of T. mentagrophytes, e. g. zoophilic strains isolated from animals and human dermatophytoses, and from T. mentagrophytes genotype VIII “India”. This genotype, as the other zoophilic T. mentagrophytes genotypes, can also be distinguished from the anthropophilic Trichophyton interdigitale.

In Germany, the anthropophilic dermatophyte Microsporum ferrugineum has been rarely isolated for the last 50 years. Currently, started in 2016, M. ferrugineum strains were occasionally identified although this dermatophyte is difficult to differentiate from Microsporum audouinii or Microsporum canis. Furthermore, a small outbreak of infections was observed in Germany. From July 2016 until April 2019, 19 patients with M. ferrugineum infections were diagnosed all over Germany. This included 15 both culture and molecular confirmed cases, and four cases exclusively diagnosed based on sequencing of fungal DNA. Cultural analysis revealed slowly growing colonies with white thallus and peripheral yellow-brownish submerged hyphae bundles. The reverse side of the furrowed colonies showed cream color to yellow staining. Microscopically, big spherical and oval double-walled intercalary-localized chlamydospores, typical “bamboo” hyphae, and acute-angled branched hyphae were observed. Fungal culture material from all isolates was identified by polymerase chain reaction (PCR), Sanger sequencing of the internal transcribed spacer (ITS) region, and/or the translation elongation factor (TEF)-1α gene. Results were referred to the M. ferrugineum CBS 497.48 strain (Centraalbureau voor Schimmelcultures CBS, Utrecht, The Netherlands, www.westerdijkinstitute.nl). Patients were children and adolescents under 18 years, mainly males. Suggested source of infection was martial sports, e.g., wrestling, judo, and boxing. Surprisingly, a significant part of affected patients were Germans of Russian descent. A migrant 3-year-old boy from Afghanistan suffering from Tinea capitis was also among the patients. Another strain was isolated from a 10-year-old wrestler with suspected Tinea corporis. There was no migration background or contact to foreigners, the boy did not stay abroad. The mycological challenge is the cultural identification of M. ferrugineum due to the morphological similarity not only to M. canis, but also to M. audouinii, and Trichophyton verrucosum. Phylogenetic analysis of ITS region of ribosomal DNA and the TEF-1α gene was performed using MEGAX, the statistical maximum likelihood method, and the Tamura-Nei substitution model. Bootstrapping was performed with 1000 replicates. The alignment of the ITS sequences (partial 18.S, ITS1, 5.8S, ITS2, partial 28.S) with known sequences deposited at the Genbank database available at the National Center for Biotechnology Information (NCBI), Bethesda, Maryland, U.S., clearly identified the M. ferrugineum strains after cultural analysis. The phylogenetic analysis of the dermatophytes—the dendrogram of fungal strains—demonstrated the genetic differences between M. ferrugineum strains and M. audouinii or M. canis. The three species could be clearly distinguished from each other. In particular, sequencing of the TEF-1α gene allowed a better differentiation between M. ferrugineum and M. audouinii or M. canis than sequencing of the ITS 2 region.

Background Tinea capitis is a highly contagious infectious disease caused by dermatophytes. In Central Europe, it is mainly caused by zoophilic dermatophytes, as, for example Microsporum (M) canis or Trichophyton (T) mentagrophytes and increasingly by anthropophilic fungi. T tonsurans was commonly related to the Tinea gladiatorum, where transmission occurred between infected persons or via contaminated floors. Objective Reporting the transmission of this highly contagious dermatophyte for the first time via beard shaving and hairdressing in barber shops in Germany. Patients and methods 18 young male patients developed tinea capitis and/or barbae shortly after shavings of the beard and/or hair in a barber shop. Native, cultural and molecular diagnostics as well as tissue biopsies and resistance tests were performed of skin and hair samples. Results In all samples, T tonsurans could be identified. The medical history and the clinical picture suggest a transmission through contaminated hairdressing tools. The patients were treated with terbinafine or itraconazole in combination with or exclusively with topical antimycotics. Conclusion The transmission and a resulting increase in the incidence of infections with T tonsurans may be due to shavings with direct skin contact of insufficiently disinfected hairdressing tools. This path of infection has already been observed in Africa and is now being described for the first time in Germany. Knowledge of the pathogen and its transmission ways are essential to interrupt the chain of infection.

BACKGROUND Dermatophytoses rank among the most frequent communicable diseases in humans, and the zoonotic transmission is increasing. The zoophilic dermatophyte Trichophyton (T.) benhamiae is nowadays one of the main causes of tinea faciei et corporis in children. However, scientific data on molecular pathomechanisms and specific virulence factors enabling this ubiquitous occurrence are scarce. OBJECTIVES To study tissue invasion and the expression of important virulence factors of T. benhamiae, isolates that were recovered from two groups of hosts (humans vs. guinea pigs (GP)) using an ex vivo skin model. METHODS After confirmation of species identity by ITS sequencing, CFU suspensions of dermatophyte isolates (n = 20) were applied to the skin infection model and cultured. Employing specific immunofluorescence staining techniques, the expression of subtilisin 3 and 6 and metallocarboxypeptidase A was analysed. The general mode of invasion was explored. Results were compared with biopsies of naturally infected GP. RESULTS All isolates were successfully recovered and proliferated well after application to the infection model. Progressive invasion of hyphae through all skin structures and destruction of explants were observed with early events being comparable to natural infection. An increasing expression of the examined virulence factors towards the end of culture was noticed but no difference between the two groups of isolates. CONCLUSIONS For the first time, important in vivo markers of dermatophytosis were visualised immunohistochemically in an ex vivo skin infection model and in skin biopsies of GP naturally infected with T. benhamiae. More research on the underlying pathomechanisms of dermatophyte infection is urgently needed.

Background An alarming increase in recalcitrant dermatophytosis has been witnessed in India over the past decade. Drug resistance may play a major role in this scenario. Objectives The aim of the present study was to determine the prevalence of in vitro resistance to terbinafine, itraconazole and voriconazole in dermatophytes, and to identify underlying mutations in the fungal squalene epoxidase (SQLE) gene. Patients/methods We analysed skin samples from 402 patients originating from eight locations in India. Fungi were identified by microbiological and molecular methods, tested for antifungal susceptibility (terbinafine, itraconazole, voriconazole), and investigated for missense mutations in SQLE. Results Trichophyton (T.) mentagrophytes internal transcribed spacer (ITS) Type VIII was found in 314 (78%) samples. Eighteen (5%) samples harboured species identified up to the T interdigitale/mentagrophytes complex, and T rubrum was detected in 19 (5%) samples. 71% of isolates were resistant to terbinafine. The amino acid substitution Phe397Leu in the squalene epoxidase of resistant T mentagrophytes was highly prevalent (91%). Two novel substitutions in resistant Trichophyton strains, Ser395Pro and Ser443Pro, were discovered. The substitution Ala448Thr was found in terbinafine-sensitive and terbinafine-resistant isolates but was associated with increased MICs of itraconazole and voriconazole. Conclusions The high frequencies of terbinafine resistance in dermatophytes are worrisome and demand monitoring and further research. Squalene epoxidase substitutions between Leu393 and Ser443 could serve as markers of resistance in the future.

Patient 1: After contact to a central European hedgehog (Erinaceus europaeus), a 50-year-old female with atopy developed erythrosquamous tinea manus on the thumb and thenar eminence of the right hand. The patient had previously been scalded by hot steam at the affected site. The zoophilic dermatophyte Trichophyton erinacei could be cultured from the hedgehog as well as from scrapings from the woman's skin. Antifungal treatment of the hedgehog was initiated using 2 weekly cycles of itraconazole solution (0.1 ml/kg body weight, BW). In addition, every other day enilconazole solution was used for topical treatment. The patient was treated with ciclopirox olamine cream and oral terbinafine 250 mg daily for 2 weeks, which led to healing of the Tinea manus .Patient 2: An 18-year-old woman presented for emergency consultation with rimmed, papulous, vesicular and erosive crusted skin lesions of the index finger, and an erythematous dry scaling round lesion on the thigh. The patient worked at an animal care facility, specifically caring for hedgehogs. One of the hedgehogs suffered from a substantial loss of spines. Fungal cultures from skin scrapings of both lesions yielded T. erinacei. Treatment with ciclopirox olamine cream and oral terbinafine 250 mg for 14 days was initiated which led to healing of the lesions. Identification of all three T. erinacei isolates from both patients and from the hedgehog was confirmed by sequencing of the internal transcribed spacer (ITS) region of the ribosomal DNA, and of the translation elongation factor (TEF)-1-alpha gene. Using ITS sequencing discrimination between T. erinacei strains from European and from African hedgehogs is possible. T. erinacei should be considered a so-called emerging pathogen. In Germany the zoophilic dermatophyte T. erinacei should be taken into account as causative agent of dermatomycoses in humans after contact to hedgehogs.

Nucleic acid amplification techniques (NATs), such as PCR, are highly sensitive and specific methods that have become valuable supplements to culture and serology in the diagnosis of infectious disorders. However, especially when using formalin-fixed and paraffin-embedded tissue, these techniques are associated with both false-negative and false-positive results, a pitfall that is frequently misjudged. Representatives of the German Society of Hygiene and Microbiology (DGHM) and the German Society of Dermatology (DDG) therefore set out to develop a consensus - in the form of a review article - on the appropriate indications for NATs using paraffin-embedded tissue, its contraindications, and the key points to be considered in the pre- and post-analytical phase. Given that fresh, naive tissue is preferably to be used in the workup of a suspected infection, PCR analysis on paraffin sections represents an exception. The latter may be considered if an infection is suspected at a later point in time and fresh tissue has not been preserved or can no longer be obtained. Potential indications include confirmation of histologically suspected infections with Leishmania spp., Bartonella spp., Rickettsia spp., or in case of ecthyma contagiosum. Infections with, for example, mycobacteria or RNA viruses, on the other hand, are not considered useful indications for NATs using paraffin sections. In order to avoid misinterpretation of test results, it is essential that laboratory reports on NATs using paraffin-embedded tissue contain information on the indication/diagnostic circumstances, the required and chosen pre-analytical steps, the limitations of the method, and on diagnostic alternatives.

Deep trichophytosis is relatively uncommon. The infection of the bearded area is also known as sycosis barbae or tinea barbae and can be caused by various fungal species, most often zoophilic fungi. We report on an 80-year-old male patient with severe sycosis barbae who had no animal contact and was treated with systemic antibiosis without improvement. Microbial and mycological investigations using swabs from oozing lesions revealed Staphylococcus hemolyticus and Candida parapsilosis. Histology demonstrated fungal elements in hair follicles. Paraffin-embedded material was subjected to further mycological analysis. For molecular diagnostics DNA was prepared from paraffin sections for real-time polymerase chain reaction (RT-PCR). For sequencing, DNA was isolated from paraffin-embedded skin tissue and the ITS region of the rDNA was selected. Sequencing of the ITS2 region of rRNA revealed a 100% accordance with Trichophyton (T.) verrucosum. Treatment with oral terbinafine achieved a complete remission. Sycosis barbae is an important differential diagnosis for infections of the bearded area. Nucleic acid amplification techniques (NAAT) are more and more used for direct examination of dermatophytes in clinical samples, e. g. T. verrucosum. NAAT are also used as culture confirmation tests for identification of rare dermatophytes like T. verrucosum. Today, singleplex and multiplex quantitative real-time PCR (qRT-PCR) assays for the detection of the most common dermatophytes including T. verrucosum in clinical specimens are available. Recently, an ITS2 PCR assay has been succefully used for direct detection of T. verrucosum in paraffin-embedded formalin fixed skin tissue. The PCR is fast and highly specific. The sensitivity of direct molecular detection of the dermatophytes both in native clinical material, and in paraffin-embedded skin tissue can been increased. This article is protected by copyright. All rights reserved.

Die Tinea barbae ist eine sehr seltene Dermatophytose. Hier wird eine Tinea barbae profunda als Folge einer Reise nach Sudostasien beschrieben. Ein Geschaftsmann erkrankte nach einer Thailand-Reise an einer foudroyant verlaufenden abszedierenden Infektion im Oberlippen- und Bartbereich. Die anfangliche Therapie mit Aciclovir p. o. und Ciprofloxacin p. o., spater Ampicillin + Sulbactam i. v., war erfolglos. In einer Probeexzision war histologisch mittels Grocott-Gomori-Methenamin-Silber-Farbung Pilzmyzel erkennbar. Daraufhin wurde mit Terbinafin 250 mg uber ca. 4 Wochen behandelt, topisch mit 1 % Ciclopiroxolamin-haltiger Creme. In der Pilzkultur wuchs Trichophyton (T.) mentagrophytes. Zwischenzeitlich erkrankte die deutsche Ehefrau des Patienten an einer Tinea faciei. Aus Hautschuppen von der Wange lies sich ebenfalls T. mentagrophytes anzuchten. Der zoophile Dermatophyt war identisch mit anderen aktuell in Deutschland gefundenen zoophilen Stammen von T. mentagrophytes, die ebenfalls in Thailand erworben wurden. Der Patient hatte in Thailand Kontakt zu Female Sexworkern, die als potenzielle Infektionsquelle der Dermatophytose angesehen werden konnen. Tierkontakt bestand nicht. Die Infektionskette der Dermatophytose aus Thailand reichte wahrscheinlich von der thailandischen Sexworkerin uber den hier vorgestellten Patienten bis zu seiner Ehefrau in Deutschland. Dieser Infektionsweg ist erst seit 1 bis 2 Jahren bekannt, bislang wurden in Deutschland, der Schweiz und Osterreich jedoch ausschlieslich pubogenitale Infektionen (Tinea genitalis profunda) durch T. mentagrophytes nach Sudostasien-Reisen beschrieben. Zur Behandlung mussen oral verabreichte Antimykotika eingesetzt werden, an erster Stelle kommt Terbinafin in Betracht, alternativ Fluconazol oder Itraconazol.

Chlamydia trachomatis is the most common pathogen of sexually transmitted bacterial infections worldwide. Every year in Germany approximately 300,000 new infections are to be expected. Chlamydia infections occur nearly exclusively in the postpubertal period. The peak age group is 15-25 years. The infection usually runs an asymptomatic course and the diagnosis is made by nucleic acid amplification techniques (NAAT) often after chlamydial screening or if complications occur. For treatment of chlamydial infections oral doxycycline 100 mg twice daily over 7 days is initially used or alternatively oral azithromycin 1.5 g as a single dose is recommended. The sexual partner should also be investigated and treated. Genital Mycoplasma infections are caused by Ureaplasma urealyticum (pathogen of urethritis and vaginitis), Ureaplasma parvum (mostly saprophytic and rarely a cause of urethritis) and Mycoplasma hominis (facultative pathogenic). Mycoplasma genitalium represents a relatively new sexually transmitted Mycoplasma species. Doxycycline is effective in Ureaplasma infections or alternatively clarithromycin and azithromycin. Doxycycline can be ineffective in Mycoplasma hominis infections and an alternative is clindamycin. Non-gonococcal and non-chlamydial urethritis due to Mycoplasma genitalium can now be diagnosed by molecular biological techniques using PCR and should be treated by azithromycin.

Dermatophytes are among the most successful fungal pathogens in humans, but their virulence mechanisms have not yet been fully characterized. Dermatophytic fungi secrete proteases in vivo, which are responsible for fungal colonization and degradation of the keratinized tissue during infection. in the present study, we used PCR to investigate the presence of genes encoding fungalysins (MEP) and subtilisins (SUB) in three dermatophyte species whose incidence is increasing in Europe: the anthropophilic Trichophyton rubrum (n = 58), zoophilic Microsporum canis (n = 33), and Trichophyton benhamiae (n = 6). MEP2 and SUB4 genes were significantly correlated with T. rubrum; MEP3 and SUB1 were mostly frequently harbored by M. canis; and MEP1, 2, and 4 and SUB3-7 were most frequently harbored by T. benhamiae isolates (p < 0.05). Furthermore, MEP1-5 and SUB1-3 genes were significantly more prevalent among human clinical isolates of M. canis (n = 17) than among asymptomatic cat isolates of M. canis (n = 16; p < 0.05). Unidentified MEP and/or SUB genes in some isolates in the current study may suggest that other gene repertoires may be involved in the degradation of keratin. the presented analysis of the incidence of MEP and SUB virulence genes in three dermatophyte species of diverse origins provides an insight into the host-fungus interaction and dermatophyte pathogenesis., Mersin Universitesi [2015-AP3-1230] Funding Source: Medline

The disease burden of chronic-relapsing and therapy-refractory superficial dermatophytosis dramatically increased in India within the past 5-6 years. In order to evaluate the prevalence of this trend, 201 skin scrapings were collected from patients from all parts of India and were tested for dermatophytes using both fungal culture and a PCR-ELISA directly performed with native skin scrapings. Fungal culture material was identified by genomic Sanger sequencing of the internal transcribed spacer (ITS) region and the translation elongation factor (TEF)-1α gene. In total, 149 (74.13%) out of the 201 samples showed a dermatophyte-positive culture result. Out of this, 138 (92.62%) samples were identified as Trichophyton (T.) mentagrophytes and 11 (7.38%) as Trichophyton rubrum. The PCR-ELISA revealed similar results: 162 out of 201 (80.56%) samples were dermatophyte-positive showing 151 (93.21%) T mentagrophytes- and 11 (6.79%) T rubrum-positive samples. In this study, we show for the first time a dramatic Indian-wide switch from T rubrum to T mentagrophytes. Additionally, sequencing revealed a solely occurring T mentagrophytes "Indian ITS genotype" that might be disseminated Indian-wide due to the widespread abuse of topical clobetasol and other steroid molecules mixed with antifungal and antibacterial agents.

Die pubogenitale Tinea oder auch Tinea genitalis ist eine zwar insgesamt seltene Form einer Dermatophytose, sie wird jedoch aktuell zunehmend haufiger diagnostiziert. Betroffen sind der Mons pubis, jedoch auch die auseren Genitalorgane bis zum Penisschaft und den Schamlippen sowie die Leisten. Neben einer oberflachlichen erythrosquamosen Form der pubogenitalen Tinea kommen uberwiegend stark entzundlich verlaufende Dermatomykosen des Genitalbereiches im Sinne einer Tinea genitalis profunda bis hin zum Kerion Celsi vor. Insgesamt 30 Patienten im Alter von 14 bis 63 Jahren mit einer pubogenitalen Tinea werden hier beschrieben, darunter 11 Manner und 19 Frauen. Der Hauptteil der Patienten stammte aus Graz in Osterreich, nur 2 Patienten aus Deutschland (Sachsen und Insel Sylt). Erreger waren uberwiegend zoophile Dermatophyten, am haufigsten Microsporum (M.) canis (11), gefolgt von Trichophyton (T.) interdigitale (9), T.-Spezies von Arthroderma benhamiae (2) und T. verrucosum (2). Anthropophile Erreger waren T. rubrum (6) und T. tonsurans (1). Anamnestisch sollte immer nach Haustieren, sportlichen Aktivitaten und Reisen gefragt werden. Genitalrasur und eine gleichzeitig bestehende Tinea pedis und Onychomykose sind disponierende Faktoren. Die Behandlung erfolgte auser bei den 3 schwangeren Patientinnen immer systemisch antimykotisch. Die systemische antimyzetische Therapie erfolgte vorzugsweise mit Itraconazol oder Terbinafin, in einem Einzelfall mit Fluconazol. Griseofulvin wurde nicht verwendet, v. a. auch deshalb, weil dieses klassische systemische Antimykotikum in Osterreich nicht mehr zugelassen ist. Bei fehlendem Ansprechen musste im Einzelfall auch ein Wechsel der antimykotischen Behandlung von Itraconazol auf Terbinafin vorgenommen werden.

Background Tinea capitis is caused by anthropophilic, zoophilic or geophilic dermatophytes of the genera Microsporum or Trichophyton. Objective The aim of this study was to analyze the clinical presentation of tinea capitis among children in western Uganda. Patients and methods From February to June 2012, skin and hair samples were obtained from 115 patients aged from 1 to 16 years presenting at Mbarara Regional Referral Hospital (MUSC) with clinically suspected tinea capitis. Conventional mycological diagnostics comprised Blancophor preparation and cultivation of fungi for species identification. Results Tinea capitis among the children included in the MUSC study was mainly noninflammatory showing mostly a seborrhoeic pattern or "black dot" and "gray patch" form and highly inflammatory kerion celsi. Blancophor preparation identified 82.6 % positive and 17.4 % negative samples. Cultural species differentiation showed Trichophyton (T.) violaceum as the causative agent for tinea capitis in 56.6 % of the patients. In 13 %, Microsporum (M.) audouinii was isolated followed by T. soudanense (2.6 %), and T. rubrum (1.7 %). In addition, moulds (contamination?) such as Scopulariopsis brevicaulis, Aspergillus niger, and Fusarium oxysporum were found as well as mixed infections. Conclusion The anthropophilic dermatophyte T. violaceum represents the most frequent cause of tinea capitis in western Uganda. For successful management oral antifungal therapy is necessary together with supportive topical treatment.

Chronic recalcitrant dermatophytoses, due to Trichophyton (T.) mentagrophytes Type VIII are on the rise in India and are noteworthy for their predominance. It would not be wrong to assume that travel and migration would be responsible for the spread of T. mentagrophytes Type VIII from India, with many strains resistant to terbinafine, to other parts of the world. From September 2016 until March 2020, a total of 29 strains of T. mentagrophytes Type VIII (India) were isolated. All patients were residents of Germany: 12 females, 15 males and the gender of the remaining two was not assignable. Patients originated from India (11), Pakistan (two), Bangladesh (one), Iraq (two), Bahrain (one), Libya (one) and other unspecified countries (10). At least two patients were German-born residents. Most samples (21) were collected in 2019 and 2020. All 29 T. mentagrophytes isolates were sequenced (internal transcribed spacer (ITS) and translation elongation factor 1-&alpha, gene (TEF1-&alpha, )). All were identified as genotype VIII (India) of T. mentagrophytes. In vitro resistance testing revealed 13/29 strains (45%) to be terbinafine-resistant with minimum inhibitory concentration (MIC) breakpoints &ge, 0.2 &micro, g/mL. The remaining 16 strains (55%) were terbinafine-sensitive. Point mutation analysis revealed that 10/13 resistant strains exhibited Phe397Leu amino acid substitution of squalene epoxidase (SQLE), indicative for in vitro resistance to terbinafine. Two resistant strains showed combined Phe397Leu and Ala448Thr amino acid substitutions, and one strain a single Leu393Phe amino acid substitution. Out of 16 terbinafine-sensitive strains, in eight Ala448Thr, and in one Ala448Thr +, new Val444 Ile amino acid substitutions were detected. Resistance to both itraconazole and voriconazole was observed in three out of 13 analyzed strains. Treatment included topical ciclopirox olamine plus topical miconazole or sertaconazole. Oral itraconazole 200 mg twice daily for four to eight weeks was found to be adequate. Terbinafine-resistant T. mentagrophytes Type VIII are being increasingly isolated. In Germany, transmission of T. mentagrophytes Type VIII from the Indian subcontinent to Europe should be viewed as a significant public health issue.

An alarming pan Indian increase in the incidence of superficial dermatophytosis has been noticed over the past 5-6 years. Recent studies have demonstrated emerging predominance of Trichophyton (T.) mentagrophytes as the causative organism in such cases. Interestingly, a distinct Indian genotype of T. mentagrophytes has been identified and recognised with the help of sequencing of the ITS region of the rDNA. That has, however, led to a basic confusion owing to the newly introduced taxonomy of dermatophytes in 2017. According to this most recently suggested classification and new taxonomy of dermatophytes, the former "T. mentagrophytes complex" is differentiated into T. mentagrophytes (zoophilic strains) and T. interdigitale (anthropophilic strains). We have noticed that in some recent studies the causative agent of the chronic, relapsing dermatophytosis outbreak in India has been described as T. interdigitale. In our opinion, it is very likely that these T. interdigitale strains isolated in Delhi and Chennai in India are indeed strains more closely related to the neotype of T. mentagrophytes and not strains of T. interdigitale. We therefore want to underscore the importance of a common nomenclature of species in accordance with the new taxonomy of dermatophytes. This would most likely facilitate better understanding of the issue amongst dermatologists and microbiologists in general. Mistaken identification of Trichophyton isolates not limited to India is very likely to occur due to the lack of appropriate molecular diagnosis which in turn is based on the already published data that presumably wrongly identify one species instead of the other.

Moulds and yeasts, so-called dimorphic fungi, cause a number of cutaneous infections. Transmission takes place via inoculation of the agents as a result of injury, e.g. following barefoot walking in semiarid to arid areas, or through haematogenous spread, mostly from the lung. Examples for inoculation mycoses are mycetomas caused by various fungi and bacteria, chromoblastomycoses due to melanized or brown-pigmented fungi and sporotrichosis due to Sporothrix schenckii, a ubiquitous occurring dimorphic fungus. Secondary cutaneous involvement after haematogenous transmission occurs in blastomycosis, coccidioidomycosis, cryptococcosis and histoplasmosis, frequently in immunosuppressed patients.

BACKGROUND Microsporum (M.) canis, whose source of infection is mostly cats, is still considered as the most frequently occurring zoophilic dermatophyte in Germany and Europe. In distinct areas of Germany, the zoophilic dermatophyte Trichophyton (T.) anamorph of Arthroderma (A.) benhamiae also presents a frequent and emerging causative agent of dermatophytoses. MATERIALS AND METHODS Over a period of 3 years, from March 2010 to March 2013, skin samples from scalp, face, trunk, and limbs were investigated using mycological cultivation and by polymerase chain reaction (PCR) for dermatophytes. Materials originated in particular from the German Free States Saxony and Thuringia, and from the Federal State Saxony-Anhalt, but also included samples submitted from around Germany. The cultural detection of dermatophytes was performed on Sabouraud's 4% glucose agar with and without cycloheximide. For dermatophyte DNA detection, a uniplex PCR-ELISA was used. RESULTS In all, 8464 samples from a total of 7680 patients were investigated. In 114 (1.5%) of 7680 patients, M. canis could be detected both by culture and/or PCR. M. canis was detected culturally in 100 samples, in 107 samples by PCR, in 91 samples both culturally and by PCR. For 12 patients, only cultural detection was done (without PCR). Also detected was tinea corporis due to M. canis in 59 patients, tinea capitis 8, tinea faciei 5, and tinea manus 2 patients. Of the patients, 45% were younger than 20 years, 42% were 20-49 years old, and 13% were 50 years or older. In comparison, T. anamorph of A. benhamiae was detectable by culture and/or PCR in 231 of 7680 patients (2.9%). M. canis was the second most common zoophilic dermatophyte. CONCLUSIONS M. canis is still a frequent zoophilic dermatophyte in Germany. Since a few years ago, a rise of infections due to T. anamorph of A. benhamiae has been observed in Germany and other European countries. At least in distinct regions of Germany, this zoophilic dermatophyte, which is transferred from guinea pigs to human beings, currently seems to be more frequent when compared to M. canis.

Today, tropical and travel-related dermatomycoses must be increasingly anticipated to present in dermatological offices and clinics. Skin infections due to dermatophytes or other fungi may occur after a journey in countries with a high prevalence for the respective causative fungal pathogen, e.g., tinea corporis due to Trichophyton soudanense. Otherwise, more frequently, single infections and even localized outbreaks due to "exotic" or "imported" pathogens of dermatophytoses occur. These epidemics are observed in childcare facilities in Germany and in other European countries. Source of infection are immigrants from Africa and sometimes from Asian countries. Furthermore, African children, and sometimes also adults, are often only asymptomatic carriers of such anthropophilic dermatophytes. Outbreaks of dermatophyte infections with one and more affected children and also adult staff and teachers due to Trichophyton violaceum or Microsporum audouinii in kindergartens and schools are not a rarity these days. Further tropical and travel-associated dermatophytes are Trichophyton tonsurans, Trichophyton schoenleinii, and Trichophyton concentricum. Tinea capitis should be treated in a species-specific manner. Griseofulvin is the treatment of choice for infections due to Microsporum species. In contrast, tinea capitis due to Trichophyton species has to be treated by terbinafine, however, because the agent is not approved for children in Germany, only after receiving written consent of parents. Alternatives are fluconazole and itraconazole. Onset and aggravation of tinea pedis during travel has its origin in a preexisting neglected fungal infection of the feet. In the tropics, exacerbations and secondary bacterial complications of tinea pedis develop under distinctly promoting conditions.

The zoophilic dermatophyte Trichophyton verrucosum is the most important causative agent of bovine dermatophytosis. Additionally, it causes profound and poorly healing skin infections in humans indicating the high zoonotic potential. The objective of this study was to establish differentiation of T. verrucosum from other dermatophytes by mass spectrometry and to identify distinct features of the mass spectra. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) was successful for identification of this pathogen only after extension of the database of the manufacturer with spectra from T. verrucosum strains, which were identified as such by sequencing of the internal transcribed spacer (ITS) region. MALDI-TOF MS analysis was conducted with 46 field isolates from cattle, two live vaccine strains, and 10 isolates from humans identified as T. verrucosum by sequence analysis of the ITS region. The results suggest a very good agreement of both methods. Comparison with the mass spectra of 68 strains of other keratinophilic fungi revealed that most T. verrucosum wild-type isolates showed a characteristic peak at 7950-7954 m/z, which was missing in the spectra of other keratinophilic fungi and the live vaccine strains. The spectra of T. verrucosum were most similar to the spectra of T. benhamiae, an emerging zoophilic dermatophyte. In summary, MALDI-TOF MS is a powerful and reliable tool to identify T. verrucosum.

Most fungal infections of the skin are caused by dermatophytes, both in Germany and globally. Tinea pedis is the most frequent fungal infection in Western industrial countries. Tinea pedis frequently leads to tinea unguium, while in the elderly, both may then spread causing tinea corporis. A variety of body sites may be affected, including tinea glutealis, tinea faciei and tinea capitis. The latter rarely occurs in adults, but is the most frequent fungal infection in childhood. Following antifungal treatment of tinea unguium and also tinea capitis a dermatophytid or hyperergic reaction to dermatophyte antigens may occur. Yeast infections affect the mucous membranes both of the gastro-intestinal system and the genital tract as candidiasis mostly due to Candida albicans. Cutaneous candidiasis affects predominantely the intertriginous regions such as groins and the inframammary area, but also the intertriginous space of fingers and toes. In contrast, pityriasis versicolor is a superficial epidermal fungal infection primarily on the the trunk. Mold infections are rare in dermatology; they play a role nearly exclusively in nondermatophyte-mold (NDM) onychomycosis. The diagnosis of dermatomycoses comprises the microscopic detection of fungi using the potassium hydroxide preparation or alternatively the fluorescence optical Blankophor preparation together with culture. The histological fungal detection with PAS staining possesses a high sensitivity, and it should play a more important role in particular for diagnosis of onychomycosis. Molecular biological methods, based on the amplification of fungal DNA with use of specific primers for the distinct causative agents are on the rise. With PCR, such as dermatophyte-PCR-ELISA, fungi can be detected directly in clinical material in a highly specific and sensitive manner without prior culture. Today, molecular methods, such as Matrix Assisted Laser Desorption/Ionization Time-Of-Flight Mass Spectrometry (MALDI TOF MS) as culture confirmation assay, complete the conventional mycological diagnostics.

In Germany, infections due to the zoophilic dermatophyte Trichophyton (T.) species of Arthroderma benhamiae are being more frequently diagnosed. The source of infection of this emerging pathogen overlaps with that of the zoophilic species T. interdigitale. The most common source are guinea pigs. T. species of Arthroderma benhamiae causes inflammatory dermatophytosis in children and adolescents. In addition to tinea capitis, it may cause both tinea corporis, tinea manus and frequently tinea faciei. In Germany, T. species of Arthroderma benhamiae is a frequent zoophilic dermatophyte, which in regions is probably more frequent than Microsporum canis. The mycological identification of the isolates with their yellow stained colonies is based on their macroscopic and microscopic features. However, some exhibit colony features consistent with those of T. interdigitale. These strains only can be identified unambiguously by means of molecular techniques. Using detection methods such as PCR-ELISA or real-time PCR, the dermatophyte can be identified directly from clinical material. Sequencing of the internal transcribed spacer region (ITS) of the ribosomal DNA has been approved as culture confirmation test for T. species of Arthroderma benhamiae. In addition, matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI TOF MS) is useful. Widespread dermatophytosis due to T. species of Arthroderma benhamiae, in particular of tinea capitis, requires oral antifungal agents. Terbinafine is most effective, alternatives are fluconazole and itraconazole.

Summary Dermatomycoses are caused most commonly by dermatophytes. The anthropophilic dermatophyte Trichophyton rubrum is still the most frequent causative agent worldwide. Keratinolytic enzymes, e.g. hydrolases and keratinases, are important virulence factors of T. rubrum. Recently, the cysteine dioxygenase was found as new virulence factor. Predisposing host factors play a similarly important role for the development of dermatophytosis of the skin and nails. Chronic venous insufficiency, diabetes mellitus, disorders of cellular immunity, and genetic predisposition should be considered as risk factors for onychomycosis. A new alarming trend is the increasing number of cases of onychomycosis – mostly due to T. rubrum – in infancy. In Germany, tinea capitis is mostly caused by zoophilic dermatophytes, in particular Microsporum canis. New zoophilic fungi, primarily Trichophyton species of Arthroderma benhamiae, should be taken into differential diagnostic considerations of tinea capitis, tinea faciei, and tinea corporis. Source of infection are small household pets, particularly rodents, like guinea pigs. Anthropophilic dermatophytes may be introduced by families which immigrate from Africa or Asia to Europe. The anthropophilic dermatophytes T. violaceum, T. tonsurans (infections occurring in fighting sports clubs as “tinea gladiatorum capitis et corporis”) and M. audouinii are causing outbreaks of small epidemics of tinea corporis and tinea capitis in kindergartens and schools. Superficial infections of the skin and mucous membranes due to yeasts are caused by Candida species. Also common are infections due to the lipophilic yeast fungus Malassezia. Today, within the genus Malassezia more than 10 different species are known. Malassezia globosa seems to play the crucial role in pityriasis versicolor. Molds (also designated non-dermatophyte molds, NDM) are increasingly found as causative agents in onychomycosis. Besides Scopulariopsis brevicaulis, several species of Fusarium and Aspergillus are found.

Summary Miconazole is a broad-spectrum antifungal used in topical preparations. In the present investigation the minimal inhibitory concentration (MIC) of miconazole for eighty wild type strains of gram-positive and gram-negative bacteria isolated from infected skin lesions was assessed using a modified agar dilution test (adapted to CLSI, Clinical Laboratory Standards Institute). 14 ATCC reference strains served as controls. Miconazole was found efficacious against gram-positive aerobic bacteria (n=62 species), the MICs against Staphylococcus (S.) aureus, S. spp., Streptococcus spp. und Enterococcus spp. ranged between 0.78 and 6.25 μg/mL. Interestingly, there were no differences in susceptibility between methicillin-susceptible (MSSA, 3) methicillin-resistant (MRSA, 6) and fusidic acid-resistant (FRSA, 2) S. aureus isolates. Strains of Streptococcus pyogenes (A-streptococci) (8) were found to be slightly more sensitive (0.78-1.563 μg/mL), while for gram-negative bacteria, no efficacy was found within the concentrations tested (MIC >200 μg/mL). In conclusion, for the gram-positive aerobic bacteria the MICs of miconazole were found within a range which is much lower than the concentration of miconazole used in topical preparations (2%). Thus topically applied miconazole might be a therapeutic option in skin infections especially caused by gram-positive bacteria even by those strains which are resistant to antibiotics.

Trichophyton (T.) species of Arthroderma (A.) benhamiae is a new emerging pathogen of dermatomycoses in children and adolescents. This zoophilic fungus seems to be more common than other zoophilic dermatophytes, e. g. Microsporum canis transmitted from cats to humans, zoophilic strains of T. interdigitale, and T. verrucosum as cause of ringworm of cattle. Trichophyton species of A. benhamiae is transmitted from guinea pigs (Cavia porcellus form. domestica) to human beings and causes highly inflammatory dermatomycoses both of the face and the scalp. When this dermatophyte produces purulent abscess-forming deep cutaneous infections of the scalp known as kerions, they are both a diagnostic and in particular a therapeutic challenge.

Approximately 2-13% of the world population suffers from onychomycosis. Recently, lasers have been introduced for treatment. However, no effect was found with in vitro laser irradiation of pathogens on agar plates. This study aimed to investigate the efficacy of laser irradiation against fungi using an alternative in vitro approach.Lasers of 808, 980 and 1064 nm were used to heat cell culture media and a nail clipping. Trichophyton rubrum. T. interdigitale. Microsporum gypseum. Candida albicans. C. parapsilosis, and C. guilliermondii species were subcultured and subjected to laser treatments (808/980 nm: 9-27 J/cm(2), 6 ms, 12 × 12 or 12 × 50 mm and 1064 nm: 50-240 J/cm(2), 90 ms, 5-10 mm). After irradiation, the fungal elements were transferred onto agar plates using conventional and Drigalski spatulas and were incubated for 6 days.The highest increase in temperature was found using a 980-nm laser with a pulse duration of 6 ms and a fluence of 27 J/cm(2). The histology work-up revealed a dissection of the nail plate from the nail bed tissue after laser irradiation. Growth inhibition was only found for C. guilliermondii and T. interdigitale. All other pathogens presented only reduced growth, and C. albicans growth was unaffected.This study demonstrates a clear thermal effect for linear scanning 980-nm and long-pulsed 1064-nm laser systems on either nail clippings or cell culture media. Complete pathogen growth impairment was achieved if temperatures were measured above 50 °C. The results for the 1064-nm system were almost comparable to 980 nm results.

Summary Background The prevalence of onychomycosis has increased steadily in the past decade. An accurate diagnosis at the outset is important for successful and cost-effective treatment of patients. However, current diagnostic tests for onychomycosis are not rapid, sensitive or specific. Objectives To develop a microsatellite-based polymerase chain reaction (PCR)-enzyme-linked immunosorbent assay (MS-ELISA) for the detection of Trichophyton rubrum, which is the most common aetiological agent of onychomycosis. Methods An archival set of 434 nail and skin specimens from 217 patients was included as the test sample in this study. We also compared MS-ELISA with an earlier published topoisomerase PCR-ELISA (TI-ELISA) using template DNA extracted by another method. Results The MS-ELISA detected the highest number of positive samples (69%) followed by direct microscopy (56%), TI-ELISA (44%) and fungal culture (30%). When an identical DNA extraction method was applied to 120 specimens, the MS-ELISA proved to be twice as sensitive as the TI-ELISA. Conclusions We have optimized a target gene and DNA extraction method for rapid detection of T. rubrum onychomycosis.

Onychomykosen sind weltweit im Anstieg begriffen. Vor einer antimykotischen Therapie steht die exakte Diagnostik, die derzeit mit den Routineverfahren Mikroskopie und mit kulturellem Erregernachweis erfolgt. Diese konventionellen mykologischen Methoden weisen jedoch Nachteile auf. Das mikroskopische Praparat ermoglicht keine Gattungs- oder Speziesidentifizierung, es werden lediglich avitale Pilzelemente nachgewiesen. Der Zeitaufwand fur die Pilzkultur ist hoch, beim kulturellen Nachweis besteht zudem eine betrachtliche subjektive Fehlermoglichkeit bei der Bestimmung der Pilzspezies. Uber einen Zeitraum von 3 Monaten wurden in einer chirurgischen Praxisklinik insgesamt 218 Patienten – alle wiesen disponierende Faktoren fur eine Nagel- und Fuspilzinfektion auf – mit Verdacht auf Tinea pedis und/oder Onychomykose in die prospektive Studie aufgenommen. Zusatzlich zur konventionellen Diagnostik der Nagelspane und Hautschuppen mittels Nativpraparat mit Blancophor® und Pilzkulturen wurde ein PCR (Polymerasekettenreaktion)-ELISA-Test zum Direktnachweis von Dermatophyten-DNS durchgefuhrt. Letzterer erlaubt aufgrund von spezifischen Primern, die gegen das Topoisomerase-II-Gen gerichtet sind, die Identifizierung von Trichophyton (T.) rubrum, T. interdigitale und Epidermophyton floccosum im klinischen Material. Kulturell waren bei 23,9 % der Patienten Dermatophyten nachweisbar (T. rubrum oder T. interdigitale). Mittels PCR-ELISA-Test konnte dagegen bei 29,9 % der Patienten Dermatophyten-DNS von entweder T. rubrum oder T. interdigitale nachgewiesen werden. Epidermophyton floccosum wurde weder kulturell noch mit PCR gefunden. Die PCR-ELISA-Technik zum Nachweis von Dermatophyten-DNS wies im Vergleich zur Kultur eine hohere diagnostische Sensitivitat (79,0 %) und diagnostische Spezifitat (85,5 %) auf. Der PCR-ELISA-Test ermoglicht eine schnelle und sehr spezifische sowie empfindliche Diagnostik einer Dermatophytose der Nagel und der Haut innerhalb von 24 (bis maximal 48) Stunden mit Identifizierung des Erregers bis zur Speziesebene.

Altogether 285 dermatophyte isolates of 21 different species - including both Trichophyton rubrum and T. interdigitale, but also eight additional Trichophyton species, Microsporum canis and seven other Microsporum species, as well as Epidermophyton floccosum and Arthroderma spp. - were analyzed using Matrix Assisted Laser Desorption Ionization Time-of-Flight Mass Spectrometry (MALDI-TOF MS) and the AnagnosTec 'SARAMIS' (Spectral Archiving and Microbial Identification System) software. In addition, sequence analysis of the internal transcribed spacer (ITS) of the ribosomal DNA was performed for a high number of the tested strains. Sufficient agreement was found between the results obtained with standard identification methods and those with the MALDI-TOF MS for species identification of dermatophytes. A mass spectra database was constructed which contained the species identifications of all 285 isolates. The results were confirmed for 164 of the isolates by sequence analysis of the internal transcribed spacer (ITS) of the ribosomal DNA. Statistical analysis of all 285 dermatophyte strains showed that conventional identification matched the results of MALDI-TOF MS for 78.2% of the isolates tested. In the case of the 164 isolates for which the identifications were confirmed by PCR, the results of their conventional diagnosis and MALDI-TOF MS were in agreement for only 68.9 % (113 of 164 strains) of the test isolates. In contrast, there was agreement of 99.3 % or 98.8 % in the identifications obtained with PCR and MALDI-TOF MS techniques (283/285 or 162/164). The two exceptions were isolates that proved to be T. violaceum which could not be identified by the MALDI-TOF MS technique. In conclusion, the MALDI-TOF mass spectroscopy represents a fast and very specific method for species differentiation of dermatophytes grown in culture.

Tinea capitis is a dermatophyte infection common among prepubertal children in sub-Saharan Africa and mainly caused by Trichophyton and Microsporum species. Accurate identification is challenging as conventional methods like culture and microscopy are slow and mostly based on morphological characteristics, which make them less sensitive and specific. Modern molecular methods, like polymerase chain reaction (PCR) assays, are gaining acceptance and are quick as well as accurate. The aim of this study was to investigate the clinical patterns of tinea capitis and to accurately identify the most common causative dermatophytes affecting the scalps of children aged 1 to 16 years attending the Skin Clinic at Mbarara University of Science and Technology (MUST), Mbarara, Uganda, East Africa, using both conventional mycological methods and PCR-ELISA for detection of dermatophyte DNA. One hundred fifteen clinical samples from children from Western Uganda attending the MUST Skin Clinic with a clinical diagnosis of tinea capitis were analyzed. T. violaceum was identified as the most common causative agent, followed by M. audouinii, T. soudanense, and T. rubrum. The early identification of the causative agent of tinea capitis is a prerequisite for the effective management of the disease, the identification of probable source and the prevention of spreading. Children with tinea capitis in Western Uganda should be treated by systemic therapy rather than topical preparations to ensure high cure rates as the most common causative dermatophytes T. violaceum exhibits an endothrix rather than ectothrix invasion of the hair follicle.

The medical term onychomycosis should be understood as chronic infection of the nails caused by a fungus. The most common causative agents are the dermatophytes and Candida species. The less common are certain types of moulds (nondermatophyte moulds or NDMs). In approximately 60-80 % of the cases, onychomycosis is due to dermatophytes. Among dermatophytes, the most often isolated causative pathogen is Trichophyton (T.) rubrum. Other common species are T. interdigitale (formerly T. mentagrophytes), Epidermophyton floccosum, and T. tonsurans. The most significant yeasts causing onychomycosis are Candida albicans and Candida parapsilosis. Predisposing factors for onychomycosis include mainly diseases such as diabetes mellitus, peripheral vascular arterial disease, chronic venous insufficiency, polyneuropathies of diverse etiologies, and immunosuppression, e.g., myeloproliferative diseases (such as lymphoma and paraproteinemia), HIV/AIDS, etc. Other factors facilitating the fungal infection are frequent trauma in professional sportsmen, often accompanied by excessive perspiration. The diagnostic methods that are often applied in different dermatologic departments and ambulatory units are also different. This precludes the creation of a unified diagnostic algorithm that could be used everywhere as a possible standard. In most of the cases, the method of choice depends on the specialist's individual experience. The therapeutic approach depends mostly on the fungal organism identified by the dermatologist or mycologist. This review hereby includes the conventional as well as the newest and most reliable and modern methods used for the identification of the pathogens causing onychomycosis. Moreover, detailed information is suggested, about the choice of therapeutic scheme in case whether dermatophytes, moulds, or yeasts have been identified as causative agents. A thorough discussion of the schemes and duration of the antifungal therapy in certain groups of patients have been included.

Mycobacterium marinum gehort zu den nichttuberkulosen oder „atypischen“ Mykobakterien. Das Reservoir dieser ubiquitar vorkommenden und langsam wachsenden Bakterien ist das Salz- und auch Suswasser. Insbesondere Aquarien bilden eine wesentliche Infektionsquelle fur diese „Freizeit- oder Hobby-Infektion“ der Haut vorzugsweise an Fingern, Handen und Unterarmen. Betroffen sind nicht nur Immunsupprimierte, sondern auch Personen mit intaktem Immunsystem. Charakteristisch sind erythematose Plaques und Knoten mit Neigung zur Hyperkeratose, Verkrustung und oberflachlichen Ulzeration, manchmal auch sporotrichoid fortgeleitete Infektionen. Diagnostisch wegweisend ist die Histologie mit nicht verkasenden Granulomen mit Epitheloidzellen und Langhans-Riesenzellen. In der Ziehl-Neelsen-Farbung stellen sich nicht immer die typischen saurefeste Stabchen dar. Der molekularbiologische Nachweis von Mykobakterien-DNS mittels Polymerasekettenreaktion stellt heute eine diagnostische Standardmethode dar. Zur oft langwierigen Behandlung kommen nach der meist zunachst praktizierten Kryotherapie die Tuberkulostatika bzw. Antibiotika Rifampicin, Ethambutol und Clarithromycin einzeln oder in Kombination zum Einsatz.

During the last years an increasing number of patients suffering from therapy refractory chronic wounds which are frequently infected by multi-resistant bacteria have led to an increased interest in the treatment using larvae or mads (maggots) of the fly species LUCILIA SERICATA. A 62-year-old woman suffered from post-traumatic ulcerations of both legs covered by slough and necrotic tissue. Marked signs of infection were found, conventional wound treatment using topical agents and systemic antibiotics was not successful. That's why larval treatment was initiated using both bagged larvae in Biobags (a live wound-dressing containing maggots) and loose larvae. Maggot treatment duration was 11 days. Both the maggot debridement treatment (MDT) and wound ground granulation were successful. In addition, before and after the larval therapy topical antiseptic treatment using polihexanide-containing solution and application of oral antibiotics was performed, followed by wet wound dressing with alginates. Both ulcers improved and healed following the maggots therapy. It is concluded that MDT using larvae of the species LUCILIA SERICATA in badly healing chronic ulcers of the legs successfully leads to cleaning, debridement, reduced bacterial load, and improved wound granulation, as it was shown for the woman here described.

Ectoparasites or epidermal parasites include a very heterogenous group of infections of the outer layers of the skin. Worldwide the most common are scabies, lice, tungiasis, and hookworm-induced cutaneous larva migrans. In recent years, bed bug infestations in hotels or vacation homes seem to have become more frequent. Demodex folliculorum and Demodex brevis are found in the facial and scalp hair follicles in 95% of individuals. Classic Demodex folliculitis is often overlooked in differential diagnostic considerations. This inflammatory sebaceous gland disease as well as Demodex blepharitis both provide a diagnostic and therapeutic challenge. Permethrin can be used topically against demodicosis. Vacationers who go barefoot on beaches in tropical Africa, South America and subtropical Asia risk infestations from female sand fleas. The lesions can be curetted or removed with a punch biopsy, then treated with antiseptics or even systemic antibiotics if a secondary infection develops. Cutaneous larva migrans is one of the most common imported ectoparasite infections from the tropics. Topical treatment measures include thiabendazole or cryotherapy. If the infestation is severe, systemic antihelminthics or ivermectin can be employed.