B35 Dermatophytosis. Dermatophytosis Inguinal epidermophytosis code according to ICD 10

Dermatomycoses

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2014

Dermatophytosis (B35)

Dermatovenereology

general information

Short description

Recommended
Expert advice
RSE at the RVC "Republican Center"
healthcare development"
Ministry of Health
And social development
Republic of Kazakhstan
dated December 12, 2014
protocol No. 9

Dermatophytosis - infectious diseases skin caused by fungi - dermatophytes (Trichophyton, Microsporum, Epidermophyton).

I. INTRODUCTORY PART

Protocol name: Dermatophytosis

Protocol code:

ICD-10 code(s)

B35 Dermatophytosis

Abbreviations used in the protocol:

ALT - alanine aminotransferase

ALT - aspartate aminotransferase

Date of development of the protocol: year 2014.

Protocol user: dermatovenerologists, doctors general practice/ therapists / pediatricians.

Classification

Clinical classification dermatophytosis:

Mycosis of smooth skin;

Mycosis of the scalp;

Mycosis of large folds;

. mycosis of the hands and feet:

Squamous-hyperkeratotic form;

Intertriginous form;

Dyshidrotic form;

Acute form.

. mycosis of nails:

Distal form;

Surface form;

Proximal form;

Total-dystrophic form.

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures

Basic (mandatory) diagnostic examinations performed on an outpatient basis:

Examination under Wood's fluorescent lamp;

Bacteriological research scrapings from hair, nails, scales from areas of smooth skin.

Additional diagnostic examinations performed on an outpatient basis:

Biochemical analysis blood (bilirubin, AST, ALT, alkaline phosphatase).

The minimum list of examinations that must be carried out when referring for planned hospitalization:

General blood analysis.

Basic (mandatory) diagnostic examinations carried out on stationary level:

General blood analysis;

General urine analysis;

Microscopic examination of scrapings from nails, scales from areas of smooth skin;

Examination under Wood's fluorescent lamp.

Diagnostic measures carried out at the emergency stage emergency care: not carried out.

Diagnostic criteria

Complaints and anamnesis

Complaints:

Rashes on smooth skin, scalp;

Changes in nail plates.

History of the disease:

Contact with a sick person;

Contact with a sick animal;

Visiting public baths, saunas;

Failure to comply with personal hygiene rules (wearing someone else's shoes).

Physical examination

Erythematous round lesions with clear contours;

Infiltrated round lesions;

Scales;

Bubbles;

Pustules;

Hair breaking.

Dermatophytosis of smooth skin:

Clear boundaries;

Peripheral growth;

Ring-shaped with an inflammatory ridge along the periphery;

Resolution of inflammatory phenomena in the center;

Pityriasis peeling.

Dermatophytosis of the hands and feet:

Erythema;

Pityriasis or mealy peeling;

Maceration of the stratum corneum;

Erosion;

Superficial or deep cracks;

Bubbles or blisters;

Damage to the nail plates.

Dermatophytosis of the nail plates:

Distal form - the focus is localized in the area of ​​the free edge of the nail, the plate loses transparency, becomes whitish or yellow, and subungual hyperkeratosis is formed;

Superficial form - only the dorsal surface of the nail is affected, spots and stripes appear, then white yellow color, the nail plate becomes rough and loose;

Proximal form - white spots appear in the crescent area, which gradually move towards the free edge, onycholysis is possible;

Totally dystrophic form - the nail plate is yellowish-gray in color, the surface is uneven, pronounced subungual hyperkeratosis.

Laboratory research
Microscopic examination of scrapings from nails, scales from areas of smooth skin:

Detection of mycelium threads and fungal spores.

Bacteriological examination of scrapings from nails, scales from areas of smooth skin:

Growth of colonies of pathogenic fungi.

Instrumental studies
Inspection under a Wood's fluorescent lamp: presence of fluorescent glow.

Indications for consultation with specialists(in the presence of concomitant pathology)

Consultation with a general practitioner/GP/pediatrician (if there is a concomitant pathology of the digestive system).

Differential diagnosis

Table 1. Differential diagnosis dermatophytosis of the scalp

Criteria	Dermatophytosis of the scalp	Psoriasis	Seborrheic dermatitis
Complaints	No complaints. In infiltrative-suppurative forms - malaise, weakness, headache, temperature increase	Itching	Itching
Morphological elements	The plaques are deep red in color, infiltrated, edematous, covered with asbestos-like gray scales in the form of a “muff” at the root of the hair. Single, deep, infiltrative foci of congestive red color, covered with massive layered purulent crusts. When the lesion is compressed, pus is released from the affected follicles.	Psoriatic papules and plaques Pink colour round in shape, with silvery-white peeling, localized at the border of smooth skin and scalp. The defeat is local in nature	Yellowish-red, greasy, scaly, erythematous spots and papules with unclear boundaries, oozing, greasy, sticky yellowish crusts, cracks. The damage is diffuse
Hair change	Hair breaking off different levels(6-8 mm, “black dots” at the hair root)	Not visible	Over a long period of time, thinning of hair in the frontoparietal region is observed.
The lymph nodes	Enlarged cervical lymph nodes	Not enlarged	Not enlarged
Dermatological symptoms	Symptom of "honeycomb" (with infiltrative-suppurative forms)	Psoriatic triad	No
Etiological factor	Dermatophytes	No	Mushrooms of the genus Malassezia
Additional diagnostic methods	Glow under a Wood's fluorescent lamp (greenish glow with microsporia)	No	No
Surrounding skin	Not changed. In infiltrative-suppurative forms there may be allergic rashes	Psoriatic papules and plaques in the area of ​​the elbow and knee joints, skin of the torso	Small punctate follicular nodules, yellowish-pink in color, covered with fatty scales, in “seborrheic zones”, the lesions tend to merge to form ring-shaped figures.
Flow	Permanent		Chronic, prone to relapse

table 2. Differential diagnosis dermatophytosis of smooth skin

Criteria	Dermatophytosis of smooth skin	Eczematide	Psoriasis
Complaints	No	Itching	Itching
Morphological elements	The lesions are round or oval ring-shaped. Along the periphery there is an intermittent ridge formed by erythema infiltration, crusts, vesicles in the center and peeling. When merging, foci with polycyclic scalloped outlines are formed.	Spots of various sizes, round or oval, pinkish-red in color. Peeling reaches the border healthy skin. Along the periphery of the lesion there is a border of exfoliating epidermis.	Papules and plaques are pinkish-red in color with clear boundaries, covered with silvery-white scales.
Peeling	Pityriasis	Pityriasis or finely lamellar	Fine-lamellar
Typical location	Large folds, skin of the torso and limbs	Skin of the trunk and limbs, less often the face	Scalp, elbow and knee joints
Dermatological symptoms	No	A symptom of “hidden peeling” is the appearance of serous exudate after scraping the lesion with a scalpel.	Psoriatic triad: when scraped, the papule acquires a silvery-white color (symptom of “stearin spot”), then a smooth surface is revealed (symptom of “terminal film”) and pinpoint bleeding (symptom of “blood dew”)
Etiological factor	Dermatophytes	No	No
Flow	Permanent	Chronic, prone to relapse	Chronic, prone to relapse

Table 3. Differential diagnosis of dermatophytosis of the nails

Criteria	Nail dermatophytosis	Nail psoriasis	Nail eczema
Clinical form	Distal; Proximal; Superficial; Totally dystrophic	Distal	Proximal
Nail plate color	Yellowish, bright yellow, gray spots and stripes	From yellow to black	Dirty gray
	Changes in the color of the nail plate, changes in the shape of the nail, destruction, crumbling of the nail	Multiple, pinpoint, deep impressions on the nail plate. Separation of the free edge from the nail bed, a translucent pink stripe bordering the affected part of the nail. Compaction of the nail fold at the modified distal edge of the plate	Transverse grooves, small, pinpoint, randomly located surface impressions. The nail separates from the nail bed
Surrounding skin	Not affected, except for candidal onychomycosis	Not affected, except for arthropathic psoriasis	During the period of exacerbation, the periungual ridges are affected in the form of hyperemia, blisters, erosions, scales, crusts
Flow	Perennial permanent, with candidal onychomycosis - wavy		Chronic with periods of relapses and remissions
Etiological factor	Dermatophytes	Absent	Absent

Treatment

Treatment goals:

Elimination of the pathogen.

Treatment tactics

Non-drug treatment
Mode No. 1 (general).
Table No. 15 (shared).

Drug treatment

Etiotropic therapy

Dermatophytosis of the scalp:

Adults and children weighing > 40 kg, 250 mg/day;

- overweight children< 20 кг по 62,5 мг в сутки.

Adults: 200 mg;
- children over 12 years old at the rate of 5 mg per 1 kg of body weight.

Adults: 100-200 mg;
- children 3-5 mg per 1 kg of body weight.

Dermatophytosis of smooth skin, hands and feet:

Itraconazole, orally (after meals) according to the schedule (adults and children over 12 years of age):

200 mg per day for 7 days;
- then 100 mg/day for 1-2 weeks.

Adults: 250 mg;
- children weighing > 40 kg, 250 mg/day;
- children weighing from 20 to 40 kg, 125 mg per day;
- overweight children< 20 кг по 62,5 мг в сутки.

Adults 150 mg;
- children: 5 mg per 1 kg of body weight.

Desensitization therapy(with erythema, weeping, presence of blisters):

Calcium gluconate (level of evidence - D), intravenously, intramuscularly 1 time per day for 10 days:

Adults: 10.0 ml of 10% solution

Sodium thiosulfate (level of evidence - D), intravenously once a day for 10 days:

Adults: 10.0 ml of 30% solution.

Antihistamines (for erythema, itching, weeping, blisters):

Adults 0.025 g.

Adults 0.001 g.

Adults 0.1 g.

Nail dermatophytosis:

Terbinafine orally (after meals):

Adults and children weighing > 40 kg, 250 mg/day;
- children weighing from 20 to 40 kg, 125 mg per day;
- overweight children< 20 кг по 62,5 мг в сутки;
Duration of treatment: for onychomycosis of the hands - 2-3 months; for onychomycosis of the feet - 3-4 months.

Itraconazole (adults) orally (after meals) as follows:

1 pulse: 200 mg 2 times a day for 7 days with a 3-week break.
Pulse frequency: for onychomycosis of the hands, 3-4 pulses; with onychomycosis of the feet - 4-5 pulses;

Fluconazole orally (after meals):

Ketoconazole (adults) orally (after meals), 1 time per day according to the following regimen:

External therapy

Dermatophytosis of the scalp:

Shaving hair once every 7-10 days;

For infiltrative-suppurative forms:

10% ichthyol ointment for 8-10 hours

In the absence of exudation phenomena, the prescription of local antimycotics:

Iodine, alcohol tincture 2% 2 times a day.

Dermatophytosis of smooth skin, hands and feet:

Local therapy with combination drugs(1-2 weeks):

In the presence of weeping, erythema, exudation, vesiculation:

Isoconazole nitrate + diflucortolone valerate cream, ointment;

- when a secondary infection occurs:

Betamethasone dipropionate + clotrimazole + gentamicin sulfate cream, ointment;

- for squamous forms:

Ketoconazole (ointment, cream) 1-2 times a day;

Isoconazole (cream) 1-2 times a day;

Clotrimazole (cream, ointment) 2 times a day;

Naftifine (cream, solution) 2 times a day;

Terbinafine (spray, cream) 2 times a day;

Oxiconazole (cream) 1-2 times a day;

Miconazole (cream) 2 times a day;

Econazole (cream) 2 times a day;

Sertaconazole (cream) 2 times a day;

Bifonazole (cream, solution) 2 times a day.

Iodine, alcohol tincture 2% 2 times a day, 2-4 weeks.

Nail dermatophytosis:

If single nails are affected from the distal or lateral edges of 1/3 - ½ of the plate:

Nail cleaning;

External antifungal drugs:

Bifonazole cream before complete removal infected areas of nails 1 time per day for 10-20 days;

After removing the affected areas of the nail (until the healthy nail grows back):

Ketoconazole (ointment, cream) 1-2 times a day;

Isoconazole (cream) 1-2 times a day;

Clotrimazole (cream, ointment) 2 times a day;

Naftifine (cream, solution) 2 times a day;

Terbinafine (cream) 2 times a day;

Oxiconazole (cream) 1-2 times a day;

Miconazole (cream) 2 times a day;

Econazole (cream) 2 times a day;

Sertaconazole (cream) 2 times a day;

Bifonazole (cream, solution) 2 times a day;

Ciclopirox (cream, solution) 2 times a day.

Drug treatment provided on an outpatient basis

List of essential medicines (having a 100% probability of being prescribed):

Mebhydrolin tablets 0.1;

Clemastine tablets 10 mg;

Miconazole 2% cream;

Isoconazole 1% cream;

Oxiconazole 1% cream;

Naftifine 1% cream, solution;

Econazole cream 1%;

Sertaconazole cream 2%;

Ichthyol ointment 10%;

Isoconazole nitrate + diflucortolone valerate cream, ointment;

Drug treatment provided at the inpatient level

List of essential medicines(having a 100% probability of assignment):

Terbinafine tablets 250 mg;

Itraconazole capsules 100 mg;

Ketoconazole tablets 200 mg;

Fluconazole capsules 50 mg, 100 mg, 150 mg;

Sodium thiosulfate solution 30% 10 ml;

Calcium gluconate solution 10% 10 ml;

Chlorapyramine hydrochloride tablets 25 mg;

Mebhydrolin tablets 0.1;

Clemastine tablets 10 mg;

Clotrimazole 1% cream, 2% ointment;

Miconazole 2% cream;

Isoconazole 1% cream;

Oxiconazole 1% cream;

Terbinafine 1% cream, 1% spray;

Naftifine 1% cream, solution;

Econazole cream 1%;

Sertaconazole cream 2%;

Ketoconazole 2% cream; 2% ointment;

Bifonazole 1% cream, solution;

Ciclopirox 1% cream, 8% solution;

Ichthyol ointment 10%;

Iodine, alcohol tincture 2%;

Isoconazole nitrate + diflucortolone valerate, ointment;

Betamethasone dipropionate + clotrimazole + gentamicin sulfate cream, ointment.

List of additional medications (less than 100% probability of prescription): none.

Other treatments: no.

Other types of treatment provided at the inpatient level: physiotherapeutic treatment methods:

Other types of treatment provided at the emergency stage: not provided.

Surgical intervention: not performed.

Preventive actions:

Compliance with personal hygiene rules (wearing someone else’s shoes, increased sweating);

Timely sanitation of the mycotic focus (cracked nail or interdigital space).

Further management:
In case of damage to the scalp(three times within 3 months after treatment):

Microscopic examination of skin scraping for fungus;

Diflucortolone Isoconazole Itraconazole Ihtammol Iodine Calcium gluconate Ketoconazole Clemastine Clotrimazole Mebhydrolin Miconazole Sodium thiosulfate Naftifine Oxiconazole Sertaconazole Terbinafine Fluconazole Chloropyramine Ciclopirox Econazole

Hospitalization

Indications for hospitalization

Indications for emergency hospitalization: is not carried out.

Indications for planned hospitalization:

Ineffectiveness of treatment at the outpatient level;

Mycosis of the scalp (children);

Generalization of mycosis of a different localization with spread to scalp heads (children).

Information

Information

III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION

List of protocol developers with qualified data:
1) Batpenova G.R. Doctor of Medical Sciences, Professor, Chief Freelance Dermatovenerologist of the Ministry of Health of the Republic of Kazakhstan, JSC Medical University Astana”, Head of the Department of Dermatovenereology;
2) Kotlyarova T.V. - Doctor of Medical Sciences, JSC “Astana Medical University”, Associate Professor of the Department of Dermatovenereology;
3) Dzhetpisbaeva Z.S. - Candidate of Medical Sciences, JSC “Astana Medical University”, Associate Professor of the Department of Dermatovenereology;
4) Baev A.I. - Ph.D., RSE “KazNIKVI”;
5) Akhmadyar N.S. - Doctor of Medical Sciences, JSC NSCMD, clinical pharmacologist.

Disclosure of no conflict of interest: absent.

Reviewer:
Valieva S.A. - Doctor of Medical Sciences, Deputy Director of the branch of KazMUNO JSC in Astana.

Indication of the conditions for reviewing the protocol: revision of the protocol after 3 years and/or when new diagnostic and/or treatment methods with more high level evidence.

Attached files

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

What causes Dermatophytosis:

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

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

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

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

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

Pathogenesis (what happens?) during Dermatophytosis:

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

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

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

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

Symptoms of Dermatophytosis:

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

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

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

Dermatomycosis is fungal infections skin in general, i.e. and candidiasis, and lichen versicolor, and many mold mycoses.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Diagnosis of Dermatophytosis:

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

Treatment of Dermatophytosis:

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

Of the systemic drugs, they act only on dermatophytes or are approved for use only for dermatophytosis: griseofulvin and terbinafine. Preparations with more wide range actions belong to the class of azoles (imidazoles - ketoconazole, triazoles - fluconazole, itraconazole). The list of local antimycotics includes dozens of different compounds and dosage forms and is constantly replenished.

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

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

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

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

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

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

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

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

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

The incubation period has not been precisely established. There are several forms of mycosis: squamous, intertriginous, dyshidrotic, acute and onychomycosis (damage to the nails). Secondary skin rashes are possible - eidermophytids (mykids), associated with the allergenic properties of the fungus.

In the squamous form, peeling of the skin on the arch of the feet is noted. The process can spread to the lateral and flexor surfaces of the toes. Sometimes areas of diffuse thickening of the skin are formed, similar to callus, with lamellar peeling. Usually patients on subjective feelings don't complain.

The intertriginous form begins with subtle peeling of the skin in the III and IV interdigital folds of the feet. Then diaper rash is noted with a crack in the depths of the fold, surrounded by a peeling, whitish, stratum corneum of the epidermis, accompanied by itching and sometimes burning. With prolonged walking, cracks can transform into erosions with a wet surface. In the case of the addition of pyococcal flora, hyperemia and swelling of the skin develop, itching intensifies, and pain appears. The course is chronic, exacerbations are observed in the summer season.

In the dyshidrotic form, vesicles appear with a thick horny cap and transparent or opalescent contents (“sago grains”). Bubbles are usually located in groups, tend to merge, form multi-chambered, sometimes large bubbles with a tense tire. They are usually localized on the arches, inferolateral surface and on the contact surfaces of the toes. After their opening, erosions are formed, surrounded by a peripheral ridge of exfoliating epidermis. If a secondary infection occurs, the contents of the vesicles (blisters) become purulent and lymphangitis and lymphadenitis may occur, accompanied by pain, general malaise, and increased body temperature.

Acute epidermophytosis occurs due to a sharp exacerbation of dyshidrotic and intertriginous forms. It is characterized by the rash of a significant amount of vesicular-bullous elements on the swollen, inflamed skin of the soles and toes. Lymphangitis, lymphadenitis, severe local pain that makes walking difficult, heat bodies. Generalized allergic rashes may appear on the skin of the body. IN clinical practice there is a combination or transition of the above-described forms in the same patient.

When nails are affected, the nail plates (often also the fifth toes) become dull, yellowish, uneven, but retain their configuration for a long time. In the thickness there are spots of yellow color or stripes of ocher-yellow color. Over time, most patients develop subungual hyperkeratosis and destruction of the nail plate occurs, accompanied by “eaten away” of its free edge. The nails on the hands are almost not affected.