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Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is caused by mutations in the Autoimmune Regulator (AIRE) gene, which impair the thymic negative selection of self-reactive T-cells and underlie the development of autoimmunity that targets multiple endocrine and non-endocrine tissues. Beyond autoimmunity, APECED features heightened susceptibility to certain specific infections, which is mediated by anti-cytokine autoantibodies and/or T-cell driven autoimmune tissue injury. These include the 'signature' APECED infection chronic mucocutaneous candidiasis (CMC), but also life-threatening coronavirus disease 2019 (COVID-19) pneumonia, bronchiectasis-associated bacterial pneumonia, and sepsis by encapsulated bacteria. Here we discuss the expanding understanding of the immunological mechanisms that contribute to infection susceptibility in this prototypic syndrome of impaired central tolerance, which provide the foundation for devising improved diagnostic and therapeutic strategies for affected patients., (Published by Elsevier Ltd.)

Angioinvasive fungal infections cause significant morbidity and mortality because of their propensity to invade blood vessel walls, resulting in catastrophic tissue ischemia, infarct, and necrosis. While occasionally seen in immunocompetent hosts, opportunistic fungi are emerging in immunosuppressed hosts, including patients with hematologic malignancy, AIDS, organ transplant, and poorly controlled diabetes mellitus. The widespread use of antifungal prophylaxis has led to an "arms race" of emerging fungal resistance patterns. As the at-risk population expands and new antifungal resistance patterns develop, it is critical for dermatologists to understand and recognize angioinvasive fungal pathogens, because they are often the first to encounter the cutaneous manifestations of these diseases. Rapid clinical recognition, histopathologic, and culture confirmation can help render a timely, accurate diagnosis to ensure immediate medical and surgical intervention. Superficial dermatophyte infections and deep fungal infections, such as blastomycosis and histoplasmosis, have been well characterized within the dermatologic literature, and therefore this article will focus on the severe infections acquired by angioinvasive fungal species, including an update on new and emerging pathogens. In the first article in this continuing medical education series, we review the epidemiology and cutaneous manifestations. The second article in the series focuses on diagnosis, treatment, and complications of these infections., (Copyright © 2018 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Erosio interdigitalis blastomycetica (EIB) is a Candida infection affecting the third web space, between the third and fourth fingers. In 1915, Gougerot and Goncea first described saccharomycetic organisms isolated from the hands and feet. Johannes Fabry later named it in 1917, well before the genus Candida was introduced in 1923. EIB is most common among those who work with their hands frequently in water, such as dishwashers, launderers, bartenders, and homemakers. Clinical presentation most commonly consists of a central erythematous erosion surrounded by a rim of white macerated skin involving at least one interdigital web space. The differential diagnosis is narrow, consisting of irritant contact dermatitis (ICD), erythrasma, inverse psoriasis, and bacterial infection (i.e. impetigo). The diagnosis is made by clinical examination in addition to fungal culture and KOH testing. The prognosis is good and treatment options include avoidance of frequent water immersion and topical or oral antifungal agents. Suspicion for secondary infections such as erysipelas and cellulitis should remain high until lesions have resolved. This review aims to address the history, epidemiology, pathophysiology, histopathology, clinical presentation, differential diagnoses, diagnosis, prognosis, and management of EIB. It also suggests an alternative name in place of the current misnomer.

Cutaneous infections and infestations are common among children and adolescents. Ectoparasitic infestations affect individuals across the globe. Head lice, body lice, scabies, and infestations with bed bugs are seen in individuals who reside in both resource poor areas and in developed countries. Superficial cutaneous and mucosal candida infections occur throughout the life cycle. Dermatophyte infections of keratin-containing skin and skin structures result in tinea capitis (scalp), tinea corporis (body), tinea pedis (foot), and tinea unguium (nails). Less frequent endemic fungal infections such as blastomycosis, coccidiodomycosis, and histoplasmosis may present with skin findings. This article will describe the epidemiology and transmission of these conditions as well as their clinical manifestations. The approach to diagnosis will be addressed as well as primary prevention and current therapies., (Copyright © 2018 Mosby, Inc. All rights reserved.)

The objective of the present randomized, double-blind trial was to evaluate the efficacy and safety of daily washing with miconazole nitrate-containing soap for candidiasis at diaper-covered sites in elderly subjects under long-term inpatient care. To confirm the onset and disappearance of candidiasis, we microscopically evaluated the existence of the pseudohyphae and/or blastoconidia of Candida spp. We enrolled 75 elderly patients who wore diapers all day in the hospital or nursing home. Patients were randomly assigned to receive treatment with either miconazole soap or miconazole-free placebo soap, and 28 patients in the miconazole group and 27 patients in the placebo group were followed for 4 weeks. Although washing with miconazole soap did not affect the frequency of pseudohyphae/blastoconidia-positive patients, it significantly inhibited the positive conversion of pseudohyphae/blastoconidia compared with the placebo group. As a result, the frequency of patients positive for pseudohyphae/blastoconidia was significantly lower in the miconazole group than in the control group at 4 weeks (17.9% vs 44.4%). Clinically apparent diaper candidiasis did not develop in either group. Washing with miconazole soap was a significant independent factor for reducing the cases positive for pseudohyphae/blastoconidia, while diarrhea and heart failure were significant factors associated with an increase in the positive rate at the end-point. Severe adverse effects were not found in any patients. Thus, washing with miconazole soap is well-tolerated and can inhibit the positive conversion of Candida in patients wearing diapers. Therefore, maintenance of genital hygiene using this soap may prophylactically decrease the overall prevalence of patients with diaper candidiasis., (© 2017 Japanese Dermatological Association.)

The yeasts of the genus Candida infect skin, nails, and mucous membranes of the gastrointestinal and the genitourinary tract. The aim of this study was to determine the prevalence of dermatomycoses caused by Candida spp., and their etiological aspects in the metropolitan area of Porto Alegre, Brazil. A retrospective study with data obtained from tertiary hospital patients, from 1996 to 2011, was performed. The analyzed parameters were date, age, gender, ethnicity, anatomical region of lesions, and the direct examination results. For all the statistical analyses, a = 0.05 was considered. Among positive results in the direct mycological examination, 12.5% of the total of 4,815 cases were positive for Candida spp. The angular coefficient (B) was -0.7%/ year, showing a decrease over the years. The genus Candida was more prevalent in women (15.9% of women versus 5.84% of men), and in addition, women were older than men (54 versus 47 years old, respectively). There was no difference between ethnic groups. The nails were more affected than the skin, with 80.37% of the infections in the nails (72.9% in fingernails and 7.47% in toenails). Our study corroborates the literature regarding the preference for gender, age, and place of injury. Moreover, we found a decrease in infection over the studied period.

Several primary immunodeficiencies (PIDs) have recently been described that confer an elevated risk of fungal infections and noninfectious cutaneous manifestations. In addition, immunologic advances have provided new insights into our understanding of the pathophysiology of fungal infections in established PIDs. We reviewed PIDs that present with an eczematous dermatitis in part I. In part II of this continuing medical education article we discuss updates on PIDs associated with fungal infections, their biologic basis in PIDs, and noninfectious cutaneous manifestations., (Published by Elsevier Inc.)

An epidemiological survey of dermatomycoses and their causative fungus flora in Japan for 2011 was conducted in accordance with methods and criteria of the past four surveys. The survey covered a total number of 36,052 outpatients who visited 12 dermatological clinics throughout Japan. The results were as follows. 1）Dermatophytosis was the most prevalent cutaneous fungal infection (2,980 cases) seen in these clinics, followed by candidiasis (378 cases) and then Malassezia infections (152 cases). 2）Among dermatophytoses, tinea pedis was the most frequent (1,930 cases : male, 980 ; female, 950), then in decreasing order, tinea unguium (780 cases : male, 409 ; female, 371), tinea corporis (203 cases : male, 132 ; female, 71), tinea cruris (112 cases : male, 86 ; female, 26), tinea manuum (43 cases : male, 25 ; female, 18), and tinea capitis including kerion (16 cases : male, 13 ; female, 3). 3）Tinea pedis and tinea unguium were seen to increase in the summer season and occur mostly among the aged population. Compared to the last survey, by clinical form, there was a marked decrease in dermatophytosis patients. 4）As the causative dermatophyte species, Trichophyton rubrum was the most frequently isolated at about 80 % among all dermatophyte infections excluding tinea capitis. T. mentagrophytes was about 10 %. Microsporum canis was isolated in five cases. M. gypseum was isolated in three cases, and Epidermophyton floccosum was isolated in only one case. T. tonsurans was isolated in 13 cases. 5）Cutaneous candidiasis was seen in 378 cases (305, male ; 537, female). Intertrigo (298 cases) was the most frequent clinical form, followed by diaporcandidiasis (79 cases), erosion interdigitalis (62 cases), genital candidiasis (46 cases). 6）Tinea versicolor was seen in 97 cases. Malassezia folliculitis was isolated in 55 cases.

Superficial fungal diseases that affect the skin and its appendages are frequently seen in basic triage and in dermatology services. These diseases are distributed in Venezuela with an incidence of 92.9%. The aim of this study was to determine the genera and species that cause dermatomycoses in residents of Anzoátegui state, Venezuela, during the period 2002-2012. A total of 4257 patients with a presumptive diagnosis of superficial mycoses were studied, with ages from 7 months to 79 years. The overall prevalence was 30.9%. The most frequent were dermatophytosis (44.7%). M. canis produced 148 cases of tinea capitis. Three dermatophytic agents represented 95% of all cases, with a significant predominance of T. mentagrophytes with 50%. Candidosis occurred in 28.4%. C. albicans, and the C. parapsilosis complex, were responsible for 80% of the cases. The other species identified were C. tropicalis (n = 41, 11.0%), C. glabrata (n = 10, 2.7%), C. guilliermondii (n = 6, 1.6%), C. krusei (n = 4, 1.1%). Pityriasis versicolor occurred in 22.4% of the cases studied, and less frequently were present onychomycosis produced by a non dermatophytic mold: Fusarium oxysporum (n = 34, 65.4%), Aspergillus terreus (n=16, 30.8%) and Scytalidium dimidiatum (n=2; 3.8%). Rare cases of Trichosporon onychomycosis (0.5%) and one case of black tinea were also found. Health education in the population is recommended to promote measures to prevent transmission of these fungi and prevent the spread of this silent public health problem.

Mucocutaneous and cutaneous candidiasis, though common in children, is often under-reported. The prevalence of Candida dubliniensis in causing these infections in this age group is also largely unknown. A prospective epidemiological cross-sectional study for candidiasis was performed in paediatric patients clinically suspected of candidiasis with oropharyngeal lesions (75 patients), cutaneous lesions (18 patients) and lesions at both sites (2 patients). Candida species were identified by conventional tests. For C. dubliniensis, chlamydospore production, growth on tobacco agar and growth at 45 °C were performed. Nine isolates were confirmed at a reference centre. The rates of candidiasis were 77.3 % (58 out of 75 patients clinically suspected of candidiasis) and 83.3 % (15/18) in oropharyngeal and cutaneous lesions respectively, and 1 of the 2 children with lesions at both sites was diagnosed as having chronic mucocutaneous candidiasis due to C. dubliniensis. The commonest species isolated was Candida albicans, in 41 (70.7 %) patients with oropharyngeal candidiasis and 11 (73.3 %) with cutaneous lesions; C. dubliniensis was isolated from 11 and 3 children respectively. In the paediatric population, C. albicans predominates in mucocutaneous and cutaneous candidiasis, with C. dubliniensis also contributing substantially.

Background: Diabetic patients are particularly susceptible to fungal infections due to modifications that occur in their immunological system. These modifications compromise natural defences, such as skin and nails, especially from lower limbs., Aims: Assessing the presence of dermatomycosis in lower limbs of Portuguese diabetic patients followed on Podiatry consultation. Determination of possible predisposing factors and the most frequent fungal species associated with the cases are included in the study., Methods: A six-month prospective study was carried out in 163 diabetic patients with signs and symptoms of dermatomycosis followed by Podiatry at the Portuguese Diabetes Association in Lisbon. Samples from the skin and/or nails of the lower limbs were collected and demographic and clinical data of those patients were recorded., Results: Trichophyton rubrum was the most frequently isolated dermatophyte (12.1%), followed by Trichophyton mentagrophytes (7.7%) and Trichophyton tonsurans (4.4%). Our study showed positive associations between type 2 diabetes and the presence of dermatomycosis in the studied population (p=0.013); this association was also shown between the occurrence of dermatomycosis and the localization of the body lesion (p=0.000). No other predisposing factor tested was positively associated with infection (p>0.05)., Conclusions: Data on superficial fungal infections in diabetic patients are scarce in Portugal. This study provides information on the characterization of dermatomycosis in lower limbs of diabetic patients., (Copyright © 2012 Revista Iberoamericana de Micología. Published by Elsevier Espana. All rights reserved.)

Unlabelled: Onychomycosis is the most common nail disease and its prevalence in the literature is estimated between 18 and 50%. The main objective of this study is to describe the epidemiology of onychomycosis and specify the most frequently fungal agents isolated at the University Hospital of Casablanca., Material and Methods: [corrected] In a retrospective study, performed at the laboratory of Parasitology and Mycology, University Hospital Center of Casablanca (Morocco), over a period of 5 years (2006-2010), mycological results (microscopic study and culture) of 2070 nail samples made during this period were analysed. All onychomycosis cases included in this study had positive microscopy and culture., Results: Totally, during this period, mycological aetiology was confirmed in 64.5% of cases. Dermatophytes were isolated in 65% of cases (n = 858), yeasts in 30% (n = 405) and molds from 72 nails. Candida albicans is the predominant yeast species in this study (49%), essentially in the fingernails. Onyxis in toenails is essentially dermatophytic, and Trichophyton rubrum is isolated in 75% of onychomycosis of foot., Conclusion: Onychomycosis is a frequent disease in our context, due to diversified fungal agents: dermatophytis in toenail and Candida at the fingernails., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Background: Tinea pedis and onychomycosis are among the commonest fungal diseases in the world. Recently, there has been an increase in the numbers of fungal agents implicated in these conditions., Objective: To analyze the epidemiology of fungal foot diseases and to identify associated etiological factors in outpatients attending the Department of Dermatology of Charles Nicolle Hospital in Tunis, Tunisia., Patients and Methods: One hundred and forty eight patients were assessed for the presence of fungal foot diseases during the period between January and April 2009. The mean age was 41.5 years (range: 2-87 years) and sex ratio was 0.8. A complete dermatological examination was performed on all subjects, and specimens of the feet were taken from patients presenting signs of tinea pedis or onychomycosis for microscopy and fungal culture., Results: Fungal foot infection was suspected in 71 subjects, and the diagnosis was confirmed in 67 cases (45.3%) by positive microscopy or culture. Older age and family history of mycosis were predisposing factors for foot fungal infection. The condition was caused by dermatophytes in 57.1% of cases and Candida species in 35.7%. Trichophyton rubrum and Candida parapsilosis were the predominant dermatophyte and yeast species, respectively., (Copyright © 2011 Elsevier España, S.L. and AEDV. All rights reserved.)

Since March 2007 to March 2011, 414 patients with onychopathies were prospectively analyzed. Prevalence of the toenail and fingernail mycoses was 78 % and 58 %, respectively. The major etiological agents were Trichophyton rubrum, Candida spp. and Trichophyton mentagrophytes. Dermatophytes were more frequently cultured from toenails, whereas Candida spp. from fingernails (both, p < 0.05). In candidal onychomycosis, species different from C. albicans were prevalent. A higher prevalence of toenail and fingernail mycoses, a predominance of T. rubrum in toenails (p < 0.05), and greater positivity in the direct examination (DE) and in culture (both, p < 0.05) were more frequently observed in men than in women. The correlation between DE and culture was 68 %. DE and culture yields were associated with a greater size lesion. DE was more effective in onycodystrophies with duration of more than 5 years. Culture positivity was independent of nail affection chronicity.

Background: Evidence suggests that Candida can be sexually transmitted; however, the contribution of sexual transmission to the pathogenesis of genital candidosis needs further elucidation., Objective: The aim was to evaluate genital candidosis and its transmissibility in heterosexual couples., Methods: Heterosexual couples were recruited among attendees of an Sexually Transmitted Diseases clinic. Specimens for yeast culture were collected from the glans penis and inner preputial layer using direct impression on CHROMagar Candida medium; vaginal exudates were collected using a cotton swab with subsequent inoculation on CHROMagar Candida medium. Mitochondrial DNA restriction analysis was performed to compare Candida isolates from both partners., Results: A total of 64 couples were enrolled in the study. Frequency of sexual intercourse was significantly higher in couples where both partners yielded positive cultures and with at least one having genital candidosis (Odds ratios: 6.844; 95% CI 1.408-33.266). The same Candida species was found in both partners in 25% (16/64) of all couples but only 17.2% (11/64) were genetically similar. In total 12 of the 34 women suffering from vulvovaginal candidosis (VVC) had recurrent VVC (RVVC); two sexual partners of RVVC women (16.7%) had candida positive cultures, compared with 15 (68.2%) sexual partners of non RVVC women (Odds ratios: 0.093; 95% CI 0.016-0.544)., Conclusions: Only in a few heterosexual couples a genetic similarity of Candida species recovered from both partners was found. RVVC women were more likely to have an asymptomatic candida negative sexual partner. This study suggests that male genitalia do not represent a relevant reservoir for RVVC; thus, the relevance of sexual transmission should not be emphasized., (© 2010 The Authors. Journal of the European Academy of Dermatology and Venereology © 2010 European Academy of Dermatology and Venereology.)

Background: Yeasts represent the second cause of nail fungal infection in the world, and Candida albicans and Candida parapsilosis are the two most common species., Objectives: To determine the yeast species frequency and their in vitro antifungal susceptibility, obtained from patients with clinical features suggestive of onychomycosis., Methods: A prospective study was carried out in four dermatological care centers in Mexico from 2004 to 2007. Clinical diagnosis was corroborated by direct examination and culture. The yeast species was determined by morphological and biochemical tests. An antifungal susceptibility test to ketoconazole, itraconazole and fluconazole by the broth microdilution method was performed on each isolate (document M27-A2)., Results: One hundred sixty-six yeast isolates were obtained; the most frequently found species were C. parapsilosis (31.9%), C. albicans (22.4%) and Candida guilliermondii (12.7%). Of all isolates, 51 showed resistance to one or several of the azole compounds: 33 to itraconazole, 12 to ketoconazole and 6 to fluconazole. It was remarkable that the four Candida glabrata isolates were resistant to the three azole compounds; C. guilliermondii and Candida famata were resistant to itraconazole in 42.9% and 54.5%, respectively., Conclusion: The results obtained show the importance of identifying the aetiological agent and antifungal susceptibility testing in order to avoid therapeutic failures in onychomycosis., (Copyright © 2010 Revista Iberoamericana de Micología. Published by Elsevier Espana. All rights reserved.)

Data in the literature regarding the prevalence of Candida in psoriatic and atopic dermatitis patients are controversial. We conducted a prospective study to determine the prevalence of Candida on the tongue, axillae and groin of psoriatic patients when compared with atopic dermatitis patients and normal controls. During the period 2003-2005, data were collected from 100 psoriatic patients, 100 patients with atopic dermatitis and 100 normal controls. Fungal test specimens for Candida were collected from the axillae, groin and tongue of each patient. There was no increase in the prevalence of Candida in intertriginous area of either psoriatic or atopic dermatitis patients. However, the prevalence of Candida on the tongue was significantly higher in psoriatic patients (32%) compared with atopic dermatitis (18%) (P = 0.024) and higher, although not significantly, than in normal controls (21%) (P = 0.08). Our study did not reveal higher prevalence of Candida in the axillae and groin of either psoriatic or atopic dermatitis patients. There was a higher prevalence of Candida on the tongue of psoriatic patients. The Candida of the tongue was asymptomatic and did not correlate with age, gender, type of psoriasis or severity of the disease, therefore we conclude that this is clinically irrelevant.

Onychomycosis is a common disorder in adults. Its prevalence increases also in diabetics. The objective of the study was: 1) evaluation of finger and toe nail susceptibility to Candida albicans and Trichophyton mentagrophytes infection in patients with type 1 and type 2 diabetes with long term glycaemia under poor control as compared with healthy persons, and 2) checking whether or not various aetiology of type 1 and type 2 diabetes may influence the intensity of fungal nail infection. The materials comprised finger and toe nails sampled from 26 patients with type 1 diabetes (20 females and 6 males at average age 51 +/- 10 years), 25 patients with type 2 diabetes (17 females and 8 males at average age 58 +/- 4 years). Twenty two healthy volunteers (18 females and 4 males at average age 47 +/- 14 years) served as controls. All of the diabetics (except one with type 1 diabetes and four with type 2 diabetes) had increased fasting glycaemia; moreover, all of them had poor controlled long term glycaemia because the concentration of glycated haemoglobin HbAlc exceeded 7.5%. The patients with type 1 diabetes were treated with insulin while those with type 2 diabetes with diet only (one person), with gliclazide (sixteen persons), with glimepirid (five persons), and with metformin (four persons). Enhanced fingernail susceptibility to Candida albicans infection was detected in 38.5% of the patients with type 1 diabetes, in 28% of those with type 2 diabetes, and in 22.7% of the controls. Intensive toenail infection was found in 34.6%, 20%, and 22.7% respectively. Enhanced fingernail susceptibility to Trichophyton mentagrophytes infection was found in 30.8% of the patients with type 1 diabetes, in 48% of those with type 2 diabetes, and in 4.54% of the controls while intensive toenail infection in 15.4%, 20%, and 18,2% respectively. Statistical analysis gave evidence of statistically significant higher susceptibility to infection of finger and toe nails with T. mentagrophytes but not with C. albicans in both type 1 and type 2 diabetics, as compared with the controls. In the diabetics, no significant correlation was found between the susceptibility to C. albicans and T. mentagrophytes infection and the age of the patients, metabolic diabetes control (evaluated on the basis of serum glucose level and blood HbAlc concentration), as well as the duration of diabetes.

There have been few studies on fungal infection of the foot in military personnel. The aim of this study was to determine the prevalence and aetiological factors of superficial mycoses of the foot in military personnel attending the Department of Dermatology of the Army Central Hospital in Algiers, Algeria. A complete dermatological examination was performed in 650 male military personnel. Cultures of skin and nail specimens of the feet were performed for each participant. Fungal infection of the foot (including tinea pedis and Candida interdigital infection) was clinically diagnosed in 147, and confirmed in 119 by positive cultures, resulting in a total prevalence of 18.3%. When subjects were grouped according to military rank, fungal infection of the foot was prevalent in troop soldiers; when grouped according to years of service to the army, the infection was frequent in military recruits. The dermatophyte species Trichophyton rubrum (20.9%) and the yeast species Candida parapsilosis (18.7%) were shown to be the major causal agents isolated. Tinea pedis and Candida interdigital infection are the most prevalent (68%) superficial fungal infections among Algerian military personnel.

Superficial mycoses are limited to skin, hair, nails and mucous membranes. The most common etiological agents are dermatophytes and yeasts of Candida genus. The aim of this work was to know the etiological agents of dermatomycoses and their clinical presentation. Were analized 2073 samples of skin, hair, nails, and oral mucous membranes obtained from 1817 patients who attended the Microbiology Branch of the Central Laboratory at Dr. J. M. Cullen Hospital, since September 1999 to September 2003. The samples were examined and identified according to the localization and type of lesion. Out of the total samples 55.67% were positive; 63% were recovered from females, and 37% from males. The most common localization was the skin. Trichophyton rubrum was the most frequent dermatophyte, and among yeasts, Candida albicans was the prevalent species. Fourteen non-dermatophytic fungi (Fusarium spp. and Aspergillus spp.) were isolated, and considered emergent pathogens from superficial mycoses.

This study was conducted to evaluate the occurrence of mycoses affecting the feet of soccer players and to compare this results with those in non-athlete individuals of the same age and sex. Initial evaluation consisted of a dermatological examination of the foot in 22 Chinese athletes, 83 Brazilian athletes and 24 Brazilian non-athletes. Scales of plantar skin, interdigital and subungual areas of the foot were collected for mycological examination (direct and culture). Nail clippings were obtained for histopathologic analysis. Tinea pedis was diagnosed more frequently among the non-athlete individuals. None of the Chinese athletes had tinea pedis alone. However, in this group onychomycosis was frequently higher when compared to the other groups. The fungal microbiota comprised Trichophyton rubrum (40%), Trichophyton mentagrophytes (36.4%) and Candida spp (20%). Candida spp was isolated only from Brazilian athletes. Results obtained with KOH wet mounts agreed with the results obtained in culture and with histopathologic examinations (50.5% vs 40.9%). The frequency of tinea pedis among soccer players was lower than the other groups in this study, possibly due to health education and professional feet care.

Eruptions in the diaper area are the most common dermatologic problem in infancy. Such eruptions can be subdivided into primary diaper dermatitis, an acute inflammation of the skin in the diaper area with an ill-defined and multifactorial etiology, and secondary diaper dermatitis, a term which encompasses eruptions in the diaper area with defined etiologies. The most important factors in the development of primary diaper dermatitis are: (i) water/moisture, (ii) friction, (iii) urine, (iv) feces, and (v) microorganisms (sometimes). Possible treatments include minimizing diaper use and using disposable diapers, barrier creams, mild topical cortisones, and antifungal agents. A variety of other inflammatory and infectious processes can occur in the diaper area and an awareness of these secondary types of diaper dermatitis aids in the accurate diagnosis and treatment of patients.

Unlabelled: Cutaneous fungal infections are common in Singapore. The National Skin Centre is a tertiary referral centre for dermatological diseases in the country, and sees more than 2,500 cases of superficial fungal infections annually., Aim: This study analyses data collated from the centre's medical record office as well as fungal culture results from the mycology laboratory., Results: From 1999 to 2003, there were a total of 12,903 cases of superficial fungal infections seen at the centre. The majority of patients (n=9335) (72.3%) were males. The most common infection was tinea pedis (n=3516) (27.3%), followed by pityriasis versicolor (n=3249) (25.2%) and tinea cruris (n=1745) (13.5%). Candidal infections were also common (n=1430), the majority of which were cases of candidal intertrigo. There were very few cases of tinea capitis, which is uncommon in Singapore. The number of cases of onychomycosis has shown a rising trend over the past 5 years. Trichophyton rubrum was the most prevalent fungal pathogen isolated from all cases of superficial fungal infections of the skin, except for tinea pedis, where Trichophyton interdigitale was the most frequently isolated organism. Dermatophytes remain the most commonly isolated fungal pathogens isolated in toenail onychomycosis, whilst Candida species accounted for the majority of isolates in fingernail onychomycosis., Conclusion: Current epidemiologic trends of superficial fungal infections in Singapore show some similarities to recent studies from the United Kingdom and United States.

Introduction: Tinea cruris is almost exclusively a male dermatophytosis. This infection is also sexually transmitted, and may cause epidemics in public areas such as common bathing facilities, dormitories and among military recruits. It has been aimed to investigate the prevalence and the causative agents of tinea cruris and tinea pedis in patients who were admitted to the Department of Urology with various pathologies., Materials and Methods: Direct microscopy and cultures of the epithelial scrapings were performed to identify the causative agent in patients who were admitted to the Department of Urology., Results: Out of a total of 155 cases examined, 39 (25.1%) were mycologically proven cases of dermatomycosis. In 11 (28.2%) of the patients tinea pedis, in 3 (7.7%) tinea cruris and in 10 (25.6%) Candida intertrigo were detected. In the remaining 15 (38.5%) cases, only direct microscopic examinations were found positive. The most common causative agent was Candida albicans (33.4%) followed by Trichophyton rubrum (29.1%), Trichophyton mentagrophytes var. interdigitale (29.1%), Candida glabrata (4.2%) and Candida tropicalis (4.2%)., Conclusion: The investigation of genital dermatomycosis should be a part of routine urological examination and the clinical diagnosis should be confirmed by mycological methods., (Copyright 2005 S. Karger AG, Basel)

Background: We have previously reported a PCR-based identification system for pathogenic fungi by targeting the DNA topoisomerase II gene, in which primer mixes specific for this gene were used for the PCR amplifications., Objective: To test the potential of the PCR using primer mix that is specific for the DNA topoisomerase II gene and are designated as PsVIc, for rapid identification of Candida species involved in cutaneous candidiasis, and to define the relation between Candida species and the infection lesion., Methods: Scales from 48 patients with cutaneous candidiasis were cultured on GYEP agar plates, and the genomic DNAs were purified from the colonies and used as DNA templates for PCR amplifications. Candida was identified as individual species based on the sizes of the PCR products generated in the PCR amplifications using PsVlc., Results: Four Candida species (five genotypes; Candida albicans, Candida glabrata, Candida parapsilosis I, Candida parapsilosis II and Candida tropicalis II) were identified in the patients' scales. In 19 of the patients (39.6%), multiple PCR products (two or three bands) were amplified in a DNA sample, especially derived from scales at the groin of bed-ridden older patients using napkins., Conclusion: The PCR-based identification using the primer mix was useful for an epidemiological study of Candida species in cutaneous candidiasis.

Objective: The objective of this study was to assess new ostomy patients for the presence of peristomal complications when they returned for their 2-month postoperative follow-up at a major university hospital., Design: A prospective descriptive design was used., Setting and Subjects: For 1 year, new ostomy patients were seen at a 540-bed university-based hospital. Subjects included 220 patients with ostomies who underwent a fecal or urinary diversion at a university-based hospital., Instruments and Methods: For 12 months, each patient who returned for a 2-month follow-up visit was assessed by 1 of 3 WOC nurses for the presence or absence of peristomal complications using a tool developed by the investigators. The study was conducted from August 2001 to August 2002. Descriptive statistics were used to summarize the data., Results: A total of 220 new ostomy patients were examined, 35 of whom had peristomal complications for a frequency of 16%. Sixteen of the 35 patients had ileostomies, 10 patients had colostomies, and 9 patients had ileal conduits. Of the 35 patients with peristomal complications, 24 had irritant dermatitis, 7 had mechanical injury, and 3 had Candida infections. The WOC nurses determined the causes of the peristomal complications to be related to flush stomas, peristomal hernias, inappropriate opening in the skin barrier, and mechanical injury from the pouching systems. Nine of 35 patients had flush stomas; 5 patients developed peristomal hernias. For 7 patients, the skin barrier in the pouching system was larger than the stoma, allowing the effluent to contact the peristomal skin, resulting in denuded peristomal skin; and 7 patients had pressure areas on the peristomal skin and were wearing convex pouching systems., Conclusions: With more laparoscopic ostomy surgeries resulting in decreased hospital stays, there is less opportunity for the patient to learn pouching techniques and problem solving regarding peristomal complications. Patients require more education regarding peristomal issues and follow-up after discharge to ensure the maintenance of a secure pouching system. Decreased hospital stays and decreased reimbursement for outpatient and home health services will continue to be a challenge for the WOC nurse. There is also a need for universal definitions of complications and the need for continued studies examining the frequency of these complications, as well as the role of stoma site marking in reducing these complications.

Superficial mycosis, including dermatophytic infections, tinea versicolor, and cutaneous candidiasis is mostly limited to the outer layers of the skin, nails, and mucous membranes. In this study, Apolipoprotein E (ApoE) polymorphism and lipoprotein cholesterol concentrations were compared between 42 patients with superficial fungal disease and 27 control subjects. Both the patients and controls were found to be normolipemic. The patients with superficial fungal disease had significantly higher concentrations of high-density cholesterol (HDL) compared to the control group (p=0.0462). However, there was no difference in the serum triglyceride, low-density lipoprotein (LDL) and very low-density lipoprotein (VLDL) cholesterol concentrations. A significantly higher incidence of heterozygosity E2/3 was found in the patients (p=0.0228), and significantly lower incidence of homozygosity E3/3 in all patients, and those with candidiasis and dermatophytosis (p=0.0139, 0.0194 and 0.0337, respectively) compared to the control group. The E3/4 genotype differences between patients and controls were not statistically significant. There were slight differences in the allele frequencies between the two groups, but these did not reach statistically significant levels. It was concluded that the presence of apoE2/3 genotype, high HDL-cholesterol levels and the absence of apoE3/3 genotype can be regarded as risk factors for superficial fungal disease, especially dermatophytosis.

Objectives: The prevalence of mycotic infection seems to be higher among diabetic patients than in the non-diabetic population. The aims of this study were to determine the frequency of mycosis and to compare clinical and fungal results., Patients and Methods: This transversal study included 307 type 1 and 2 diabetic patients admitted between January 1998 and January 2000. A dermatologist examined all patients. The mean age was 44 +/- 17 years and the duration of diabetes 8 +/- 6 years. Patients with suspected lesions underwent mycological examination., Results: Clinical signs of presumed fungal infection were found in 61% of patients, but mycosis was confirmed only in 30%. Fungal foot infection accounted 38% of the patients, mostly due to dermatophytes (94%). The commonest localizations of dermatophytes were interdigital (60%) followed by onychomycosis (30%). The main fungal agent was Trichophyton rubrum. The main risk factors for fungal infections were the age of patients (P = 0.0003) and duration of diabetes (P < 0.05). Interdigital foot localization of dermatophytes was correlated to age (P < 0.0001) and to the male gender (P < 0.01). The frequency of dermatophytes in nails was higher in type 2 diabetic patients (P < 0.01). Vulvovaginal candidosis and interdigital dermatophytes were more frequent in obese than in non-obese patients. The accuracy and specificity of direct examination were respectively 85% and 79%., Conclusion: The high frequency of mycosis in diabetic patients at hospital is demonstrated. The main risk factors were age, male gender and obesity.

Background: Ultraviolet radiation (UVR) is an important risk factor for skin cancer in transplant recipients. In view of the potential suppressive effect of UVR on host resistance it was examined whether exposure to UVR was also associated with the occurrence of various skin infections., Methods: In a cohort of renal transplant recipients (n = 137), lifetime exposure was assessed by means of a retrospective questionnaire on cumulative sunlight exposure. Diagnosed skin infections since renal transplantation were extracted from the patient's medical charts. Season of diagnosis was regarded as indicative of short-term exposure., Results: In comparison with winter a high rate of herpes simplex infections was found in spring [rate ratio (RR) = 4.09, 95% confidence interval (CI) 1.2-14.5], and high rates of herpes zoster infections (RR = 1.6, 95% CI: 0.8-3.5) and fungal/yeast infections in summer (RR = 2.1, 95% CI: 1.3-3.4). A higher lifetime exposure (RR = 2.31, 95% CI: 1.04-5.1) and a greater cumulative number of reported sunburns (RR = 2.3, 95% CI: 1.1-5.1) were independently associated with a higher risk of bacterial infections., Conclusions: The seasonal association with the occurrence of clinical herpes infections indicates an effect of short-term UVR. Our data suggest that the number of sunburn episodes in the past is also relevant for the susceptibility to certain skin infections.

Background: Renal transplant recipients are predisposed to superficial fungal infections caused by graft-preserving immunosuppressive therapy. Reports have documented a wide range of prevalence rates for superficial fungal infections in this patient group., Objective: The aim of this study was to determine the prevalence and clinical and mycological features of superficial fungal infections in renal transplant recipients at our center., Methods: One hundred two consecutively registered renal transplant recipients (34 women, 68 men) and 88 healthy age- and sex-matched persons acting as controls (30 women, 58 men) underwent screening for the presence of superficial fungal infection. Skin scrapings and swabs were obtained from the dorsum of the tongue, upper part of the back, toe webs, and any suspicious lesions. Nail clippings were also collected. All samples were examined by direct microscopy and were stained with calcofluor white. The samples were cultured in Sabouraud dextrose agar, mycobiotic agar, and dermatophyte test medium. Candida species were identified on the basis of germ-tube production, spore formation in cornmeal agar, and results of biochemical testing. Dermatophytes were identified on the basis of colonial and microscopic morphologic features in conjunction with results of physiologic evaluation (in vitro hair perforation test, urease activity, temperature tolerance test, and nutritional test)., Results: Sixty-five (63.7%) of the 102 renal transplant recipients had cutaneous-oral candidiasis, dermatophytosis, or pityriasis versicolor, whereas only 27 (30.7%) of controls had fungal infection. Pityriasis versicolor was the most common fungal infection in the patient group (36.3%), followed by cutaneous-oral candidiasis (25.5%), onychomycosis (12.7%), and fungal toe-web infection (11.8%). Pityriasis versicolor and oral candidiasis were significantly more common among the renal transplant recipients, whereas the frequency of dermatophytosis in patients and controls was similar. Candida albicans was the main agent responsible for oral candidiasis, and Trichophyton rubrum was the most common dermatophyte isolated. Analysis showed that age, sex, and duration of immunosuppression did not significantly affect the prevalence of superficial fungal infection. Cyclosporine treatment and azathioprine therapy were identified as independent risk factors for superficial fungal disease., Conclusions: The prevalence of opportunistic infections with Pityrosporum ovale and C albicans is increased among renal transplant recipients, probably owing to the immunosuppressed state of this patient population. However, renal transplant recipients are not at increased risk of dermatophytosis.

Subject of the study was spreading of mycoses in the troops based on the Kola Peninsula. Examined were the military serving on atomic submarines, maintenance crews of deactivated atomic submarines awaiting disposal, and coastal units. Spreading of skin lesions among the submariners was not same as among the coastal military. Signs of clinical mycoses were observed in 41.2% of submariners of the active unit, in 66.9% of the maintenance crews, and in 38.1% of the coastal military. Infection agents were fungi g. Candida (albicans, guilliermondii, krusei, pseudotropicalis), Epidermophytia plicarum, Ptyriasis versicolor, Trichophyton interdigitale. Among the fighters on active submarines, 53.8% of the clinical observations were accounted for onychomycosis and foot skin lesions and 38.5%--for erythema, maceration and suppuration. Among the maintenance crews 51.8% of the observations were accounted for onychomycosis and foot skin lesions and maceration; hyperkeratosis and fissures prevailed in the coastal military (31.1%). For submariners most common were Candida albicans (80.7%) and guilliermondii (11.6%), and Trichophyton interdigitale (7.7%). In the maintenance crew those were Candida albicans (84.1%) and guilliermondii (11.6%) and in the coastal military, Candida albicans (70.6%), guilliermondii (11.8%) and krusei (14.7%).

Onychomycosis epidemiology is a combination of various factors which include, among others, clinical presentation, etiologic agents of the infection and the patient's history background. Out of a total of 672 nail samples examined, 460 (68.4%) were microscopy positive for fungi and 306 (66.5%) of these were culture positive, including Candida (82%), dermatophytes (13.4%), Trichosporon spp (3.6%) and nondermatophyte molds (1%). Onychomycosis was more frequent in females (79.7%) than in males (20.3%). These were more common in fingernails (96.1%) than in toenails (60%) and yeasts were the most isolated etiologic agents. Among the clinical presentations, paronychia (CP) (57.2%) and onycholysis (CO) (24.8%) were the most common, caused frequently by C. albicans in 52.6% and 60.5% of the cases, respectively. T. rubrum (44.4%) and Trichosporon spp (22.2%) were the most frequent species in the case of distal lateral subungual onychomycosis (DLSO). Fusarium spp was the agent responsible for 33.3% of the cases of proximal subungual onychomycosis (PSO) and for 14.3% of white superficial onychomycosis (WSO), whereas Acremonium spp was responsible for 14.3% of the cases of WSO.

To our knowledge, visits in the ambulatory setting due to cutaneous fungal infections have not been recently characterized. To provide descriptive epidemiology on ambulatory cutaneous fungal infection visits, we analyzed office-based physician visits for cutaneous fungal infections recorded in the National Ambulatory Medical Care Survey (NAMCS) from 1990 to 1994. The International Classification of Diseases (ICD-9) was used to define the cutaneous fungal infections. Sampling weights were applied to achieve the nationally representative estimates. From 1990 to 1994, an estimated 21.6 million physician office visits at an estimated cost of $216 million/y (office visit plus medication costs) were made for cutaneous fungal infection diagnoses. The total cost of office visits (without medication costs) was approximately $116 million/y. The total cost of the top 5 medications was approximately $68 million/y. According to an analysis of visits per physician specialist, dermatologists had the largest proportion of visits for cutaneous fungal infections. The cost associated with the diagnosis and management of cutaneous fungal infections is significant. Of all the physician specialists, dermatologists treated the most cutaneous fungal infections.

Practicing wound ostomy continence (WOC) nurses see peristomal complications in their ostomy patient population. The exact frequency and cause of these complications are unknown. Research into problems arising from prolonged use of ostomy appliances is lacking. To ascertain the frequency of peristomal complications, two WOC nurses at a major medical center prospectively assessed the peristomal skin of all new ostomy patients returning for their 2-month postoperative check-up using a peristomal complications tool. The study was conducted from August 1999 to August 2000. Descriptive statistics were used to summarize the data. In the course of the study, 161 new ostomy patients were seen, 10 with peristomal complications, for a frequency of 6%. The frequency of peristomal complications was the highest in people with ileal conduits (five of 34, 15%) and ileostomies (four of 46, 9%). Only one of the 81 people with a colostomy developed peristomal complications. All 10 patients had a retracted stoma. Eight had chemical damage (six with irritant dermatitis, two with pseudoverrucous lesions) and two had Candida infections. Although the study sample size is small, the results suggest that patients with ileal conduits and patients with retracted stomas may require more frequent follow-up visits to monitor skin conditions and pouching modifications.

Cutaneous mycoses are third among diseases after parasitic and infectious ones that pose problems for persons returning from the tropics. The paper presents semiotics of the following tropical superficial mycoses: tinea imbricata, infections with Scytalidium, tinea nigra, zakazenia grzybami Scytalidium, lupieZ czarny, black piedra, white piedra. Treatment, diagnostics and prophylaxis are discussed.

Distribution of Candida species was investigated by examining 245 samples from skin lesions and nails. The isolates were identified using standard laboratory methods including germ tube test, micromorphology of colonies on rice agar, the commercial kit, saccharide assimilation and fermentation tests. Eight species of Candida were identified: C. albicans accounted for 56.4% of the isolates, C. parapsilosis 29.1, C. tropicalis 7.8, C. pulcherrima 2.9, C. guilliermondii 1.5, C. krusei and C. zeylanoides for 0.9% each, and C. robusta for 0.5%. The factors significantly associated with colonization were prolonged antibiotic therapy, parenteral nutrition, low birth body mass of infants, intubation, duration of stay in hospital, indwelling intravenous catheter, malignancies, diabetes, surgery, and obesity.

In the period between December 1992 and September 1993 a total of 1060 clinically suspected cases of dermatomycoses were examined for causative fungi. Of these 330 (31%) were suspected as cutaneous candidosis. A higher incidence was observed in adults (62.9%) than in children (36.2%) and infants (19.5%). The infected patients that were adults were divided into four categories: diabetics; those receiving steroid; those receiving antibiotic therapy; and a non-risk control group. Analysis of the data revealed that the incidence rate appears to be approximately doubled in diabetes (49.3%), steroid therapy (33.8%) and antibiotic therapy (27.4%) than in the control group (15.7%). Candida albicans was the most frequent isolate (57.6%) followed by Candida tropicalis (16.5%).

Congenital candidiasis, especially the disseminated disease, is very uncommon but has been reported in very low birth weight infants. Five cases of congenital candidiasis, two with cutaneous type and three with systemic type, are described. All cases were symptomatic within the first 24 hours of life and none of them had significant risk factors such as the presence of foreign body in the maternal genital tract. Cutaneous candidiasis presented as extensive erythematous rash with infiltrative plaques in one and as bullous lesions in the other. Three infants who had disseminated candidiasis presented with extreme leukemoid reaction, severe hyperglycemia, and skin mottling with some patchy areas resembling first-degree burns, respectively. One infant had meningitis and the autopsy of another who died revealed several microabscesses containing Candida spores in the liver and lungs. The urine microscopy obtained by suprapubic bladder aspiration was found to be a good diagnostic marker of systemic invasion. The purpose of this report is to highlight the importance of recognizing candida as a possible pathogen in a critically ill neonate even though the clinical presentation may be nonspecific and varied. The presence of characteristic skin lesions of Candida species within 24 hours of life is an important clue to the possible diagnosis of congenital candidal infection. Even though very high mortality has been reported in congenital disseminated candidiasis, early recognition and treatment could give a favorable outcome.

Background: To evaluate the diagnostic value of Gram stain of pericatheter skin swabs and the intravascular device hub in detecting catheter-related bacteremia (CRB) in critically-ill patients., Methods: Over a 12-month period, 170 intravascular catheters (> 7 days in place) suspected as being the primary source of CRB were prospectively examined in adult patients admitted to 10 intensive care units of different hospitals in Spain. Blood cultures, Gram staining and culture of swabs obtained from skin entry side and catheter hub were performed before catheter removal. A semiquantitative culture of the catheter tip was carried out. Catheter-associated bacteremia was considered to be present if the same organism was isolated from the catheter tip, skin and/or hub, and blood cultures., Results: The incidence rate of CRB was 15%. Staphylococcus epidermidis was the most frequently isolated microorganism. Considered together, the sensitivity, specificity, positive predictive value and negative predictive value for Gram staining of the skin and hub were 80, 81.9, 35.3 and 97.1%, respectively., Conclusions: The Gram stain of skin and hub swabs has a great utility in predicting CRB, specially in the absence of microorganisms. Gram stains of the above mentioned sites could be recommended as an easy and fast method to rule out the presence of CRB.

Background: Candidal infections of the skin/nails and vagina are very common worldwide. Various in vitro test systems are available to help to determine the antifungal activity of drugs. The minimum inhibitory concentration (MIC) is a standard measure of the in vitro potency of drugs against yeasts., Methods: Vaginal smears and skin/nail scrapings of 50 consecutive patients with candidal vaginitis and 46 consecutive patients (28 women, 18 men) with cutaneous/nail candidosis were used in the study. Direct microscopy and culture from vaginal smears and skin scrapings were performed on all patients. The MICs were determined using the broth dilution method., Results: For vaginal candidosis, the mean age of the patients was 28.2 years (range, 9-49 years). Candida albicans accounted for 58% of the isolates, C. glabrata for 32%, C. tropicalis for 6%, and C. parasilosis for 4%. At the MIC of < or = 4 mg/L, 65-95% of C. albicans, 66-94% of C. glabrata, 33-100% of C. tropicalis, and 0-50% of C. parasilosis were susceptible to the drugs tested (ketoconazole, itraconazole, nystatin, amorolfine, clotrimazole, and miconazole). For cutaneous/nail candidosis, the mean age of the patients was 45 years (range, 19-82 years). C. albicans made up 59% of the isolates, C. parasilosis 20%, C. krusei 13%, C. glabrata 4%, and C. tropicalis 4%. At the MIC of < or = 4 mg/L, 59-96% of C. albicans, 100% of C. glabrata, 83-100% of C. krusei, 89-100% of C. parasilosis, and 100% of C. tropicalis were susceptible to the drugs tested (ketoconazole, itraconazole, nystatin, amorolfine, clotrimazole, and miconazole)., Conclusions: C. albicans is the most common Candida species causing cutaneous/nail and vaginal candidosis in Singapore. The in vitro antifungal activities of ketoconazole, itraconazole, nystatin, amorolfine, clotrimazole, and miconazole are similar against the various Candida species. C. parasilosis in vaginal candidosis appears to be less susceptible. Here, itraconazole and amorolfine may be more effective.

The results of a 20-year microbiological monitoring of full-term newborns with infectious inflammatory diseases hospitalized from maternity homes of Moscow are presented. The incidence of candidiasis within that period was shown to increase 7 times at the account of the events of cutaneous and mucocutaneous candidiasis, gastrointestinal candidiasis and candidiasis of the central nervous system. One of the sources of the endogenic contamination of the newborns and infants was their intestinal microflora. In 4.6 per cent of the patients the meconium contamination by Candida was stated during the first days after the birth.

Background: Questionnaire studies have been used to determine the prevalence of onychomycosis in the United Kingdom and Europe. One disadvantage of this methodology is that the patient self-diagnoses the onychomycosis. There have been very few large studies involving clinical examination of the nails of subjects, followed by mycological confirmation of the onychomycosis. We therefore determined the prevalence of onychomycosis in patients visiting dermatologists' offices in Ontario, Canada., Methods: In a prospective, multicenter study, the finger- and toenails of all new patients presenting to dermatologists' offices were examined by a board-certified dermatologist. If there was clinical suspicion of onychomycosis, then nail samples were obtained for mycological examination at a central laboratory. Patients referred specifically for the management of onychomycosis were excluded., Results: Toenails appeared abnormal in 455 (22.7%) of 2001 patients. Mycologically-confirmed pedal onychomycosis was present in 182 (9.1%) of the 2001 patients. The estimated value of the prevalence of onychomycosis in Ontario is 6.86% (95% confidence interval (CI): 5.8-8.0%), when corrected for age and sex of the general population using census data. Onychomycosis increased with age (P < 0.0001). The odds of males having onychomycosis was 84.3% greater than females of the same age (P = 0.0003). The distribution of organisms in the 141 patients with pedal onychomycosis who were culture positive was: dermatophytes 131 (92.9%), Candida species 4 (2.8%) and non-dermatophyte molds 6 (4.3%)., Conclusions: The prevalence of mycologically-confirmed toenail onychomycosis was 9.1%, with the estimated prevalence in Ontario being 6.86%. The majority of patients with abnormal-appearing nails were unaware they might have onychomycosis, that it is infectious and potentially treatable, suggesting that there is potential for increased public awareness and education.

Both, psoriasis and atopic dermatitis are multifactorial diseases with an unknown pathogenesis. To elucidate the influence of fungal infections in the onset or recurrence of those inflammatory skin disease we determined the frequencies of Candida and dermatophyte infections of the skin and orointestinal tract concomitantly seen in patients with psoriasis or atopic dermatitis. We analyzed the files of more than 40,000 in-patients of the Department of Dermatology, Kiel. Sex- and age-adjusted relative risk were calculated. The results demonstrate that patients with psoriasis (N = 3006) presented with a decreased rate of tinea. This was significant for tinea corporis (RR = 0.13, p < 0.01). Candida infections of the skin were seen more often in psoriasis patients compared to controls. Differentiating between Type I (early onset) and Type II (late onset) psoriasis only Type I psoriasis patients presented with decreased dermatophyte infections and increased Candida colonization of the intestinum. However, patients with Type II psoriasis demonstrated an increased rate of candidosis cutis and candidosis oris as compared to controls. Patients with atopic dermatitis (N = 1808) displayed a decreased overall incidence of tinea and Candida infections. Furthermore, in patients with atopic dermatitis a Candida colonization of the orointestinal tract was found elevated (RR = 1.51, p < 0.01), whereas tinea corporis (RR = 0.24, p < 0.01) and candidosis cutis (RR = 0.30, p < 0.001) was found decreased compared to controls. Our results show that the influence of fungal infections on the two skin diseases investigated is not as strong as often considered. The increased relative risk in patients with atopic dermatitis to present with Candida colonization in the digestive tract or vice versa may contribute to the pathogenesis of atopic dermatitis.

Background: Large-scale studies performed outside the United States have demonstrated that most cases of onychomycosis and tinea pedis are caused by dermatophytes, primarily Trichophyton rubrum. However, other studies have suggested that yeasts and nondermatophytic molds may play a role, particularly in onychomycosis., Objective: This study was undertaken to determine the epidemiology of superficial fungal infections in a U.S. population., Methods: Fungal cultures were performed on patients with clinically suspected tinea cruris, tinea corporis, tinea capitis, tinea pedis, and onychomycosis., Results: Dermatophytes were the most commonly isolated fungi in each type of superficial fungal disease studied. T. rubrum was the most commonly isolated dermatophyte species, although Trichophyton tonsurans was more common in tinea capitis and equally common in tinea corporis/tinea cruris. In tinea pedis and onychomycosis, dermatophytes appeared in approximately 95% and 82% of isolates, respectively. Candida albicans and nondermatophyte molds played only a minor role in onychomycosis; C. albicans was isolated in 7% of nail cultures and nondermatophytic molds were isolated in 11%., Conclusion: These results are in general agreement with other major epidemiologic studies performed outside the United States. Dermatophyte fungi cause most superficial fungal infections.

A 1-year study was conducted on 151 patients with finger- or toenail disease attending a dermatology clinic in Al Ain, United Arab Emirates. Nail scrapings and or clippings were collected and investigated with a KOH preparation for direct microscopy and cultured for fungi. Eighty-nine (59%) patients were females. Most females (62%) presented with fingernail disease while in men the toenails were involved in 76%. Fungi were isolated in 78 (52%) of all cases and the fingernails were more commonly positive than toenails. Of the 78 isolates, 49 (63%) were yeasts, including eight Candida species, dermatophytes accounted for 22 (28%) and seven (9%) were other moulds. Non-dermatophyte moulds constituted 20% of male isolates but only 4% of female isolates. Eighty-one per cent of Candida species were from fingernails, while 87% of all the dermatophytes were from toenails.

We investigated skin diseases associated with mucocutaneous Candida infection by analyzing the clinical records of 44695 in-patients of the department of dermatology of Kiel. For more than eighty skin diseases the relative risk (RR) was calculated by age-and sex-adjusting methods. 1996 patients demonstrated a mucocutaneous candidosis, 14.8% of them being hospitalized because of extensive Candida infection. In patients with dermatomyositis, bullous pemphigus, tinea inguinalis, and condylomata acuminata a Candida infection was observed more than threefold than expected. Furthermore, patients with urticaria, folliculitis, and bullous pemphigoid demonstrated candidosis more than twice as often as control patients. In addition, patients with erysipelas, acne, psoriasis, and atopic dermatitis showed a candidosis significantly more often (RR between 1.3 and 1.6). Some internistic maladies were investigated, too. In patients presenting with diabetes mellitus, heart-insufficiency, hypertension, chronic tonsillitis, and urinary tract infection a mucocutaneous Candida infection was significantly increased.

Cases of onychomycosis represent up to 30% of diagnosed superficial fungal infections and are caused by three groups of fungi: dermatophytes, yeasts, and nondermatophytic molds. The majority of toenail infections are caused by dermatophytes; Trichophyton rubrum is isolated with the greatest frequency. In infections of fingernails, Candida species can be isolated as frequently as the dermatophytes. Of the molds, Scytalidium species can infect both fingernails and toenails, as well as adjacent skin, and represent 3% of the nail infections in a temperate country such as the United Kingdom but a much higher proportion in tropical countries. Other molds such as Scopulariopsis, Acremonium, and Aspergillus species can infect damaged nails. The isolation of a dermatophyte is always considered indicative of infection, but the presence of other molds, which may be aerial contaminants, must be interpreted with care.