LECTURE No. 7. Mycoses

Mycoses are infectious skin diseases caused by fungi. Mushrooms belong to the lower spore chlorophyll-free organisms of plant origin. Some groups of fungi are pathogenic to humans to varying degrees.

All fungi can be divided into two large groups: obligate pathogenic fungi (about 30 species) and conditionally pathogenic (mold fungi: mucor, aspergillus, penecilli). Particularly pathogenic for humans are obligate pathogenic fungi, which play an important role in the development of mycoses (22 species of trichophytons, 16 species of microsporums and 1 species of epidermophyton).

Classification. The classification of human fungal diseases is based on the depth of the lesion and the pathogen. This classification includes four groups of dermatomycosis.

1. Keratomycosis (pityriasis versicolor).

2. Dermatophytosis (microsporia, superficial trichophytosis, chronic trichophytosis, infiltrative-suppurative trichophytosis, favus, mycosis of the feet, mycosis of smooth skin, mycosis of the inguinal folds, onychomycosis).

3. Candidiasis (candidiasis of the superficial mucous membranes, skin, nail folds and nails, chronic generalized candidiasis (granulomatous), visceral candidiasis).

4. Deep mycoses (coccidiosis, histoplasmosis, blastomycosis, sporotrichosis, chromomycosis, cladosporidosis, penicillosis, aspergillosis).

1. Keratomycosis

Keratomycoses are diseases that affect the superficial sections of the stratum corneum of the epidermis, as well as hair. All keratomycosis are characterized by a chronic course and barely noticeable inflammatory phenomena. The group of keratomycosis includes pityriasis (colorful) lichen and trichosporia nodosum.

Multicolored or pityriasis versicolor is a low-contagious chronic disease of mostly young and middle-aged people, which is characterized by damage to the stratum corneum of the epidermis and a mild inflammatory reaction.

Etiology. The disease is caused by a facultatively pathogenic lipophilic yeast-like fungus. The contagiousness of this disease is very low.

Pathogenesis. The occurrence of the disease is facilitated by increased sweating, seborrhea, as well as some endocrine disorders, such as Itsenko-Cushing syndrome, diabetes mellitus, since these disorders cause changes in the physicochemical properties of the water-lipid mantle of the skin and the keratin of the stratum corneum. The disease occurs in all geographical zones, but more often in regions with hot climates and high humidity.

Clinic. The disease manifests itself as perifollicularly located round spots of different sizes, light brown in color ("café au lait") with clear boundaries. Most often, these spots are localized on the skin of the upper body (on the chest, back, scalp), less often - on the skin of the neck, abdomen and limbs. In some patients, lichen versicolor may appear as depigmented or pale brown spots.

Due to peripheral growth, the spots enlarge and merge, forming large lesions with scalloped edges. With a slight scraping, the surface of the foci begins to peel off, and small scales resemble bran. Subjective sensations are most often absent, but sometimes the patient may experience a slight itch.

The disease is characterized by a chronic course, relapses are also characteristic. In summer, under the influence of sunlight, rashes on smooth skin regress and leave behind distinct foci of depigmentation, the so-called post-parasitic leukoderma. Depigmentation of the skin that has been affected by the pathogen fungus is caused by substances that the fungus secretes, which can inhibit the formation of melanin. In people with immunosuppressive conditions of various origins, the prevalence of the process, a tendency to relapse, as well as the appearance of pityrosporum folliculitis - small follicular papules and pustules against the background of typical manifestations of the disease, are noted.

Diagnostics. The diagnosis is made based on the characteristic clinical picture and laboratory data. The main method for identifying pityriasis versicolor is the Balser test, which is considered positive when the lesions are darker in color after smearing the skin suspicious for the lesion with a 5% iodine solution. In the rays of a fluorescent lamp, the lesions glow golden yellow.

The morphology of the pathogen is very characteristic when microscopically examining scales from lesions (short, wide, curved pseudomycelium and single or clustered large spores).

Treatment and prevention. First of all, it is necessary to stop the effects of factors contributing to the disease (excessive sweating, seborrhea, endocrine disorders). Various external fungicidal preparations are recommended for therapy, sometimes in combination with keratolytic agents. Aerosol compounds (clotrimazole, ketoconazole, climbazole) are used in the form of shampoo, cream or solution. The shampoo form is most preferred. During the treatment process, it should be recommended to treat not only smooth skin with antifungal drugs, but also the scalp as the site of predominant colonization of the pityriasis versicolor pathogen.

You can also use the Demyanovich method (the skin is sequentially lubricated with a 60% solution of sodium thiosulfate and 6% hydrochloric acid), you can also rub in 2-5% sulfur-salicylic ointment, 4% boric acid solution or 10% - solution of sodium hyposulfite. When the process spreads, a tendency to relapse, resistance or intolerance to external therapy, the appearance of pityrosporum folliculitis and in people with immunosuppressive conditions, general therapy using one of the aerosol drugs is recommended: itraconazole (200 mg per day for 7 days), fluconazole (50 mg per day for 2-4 weeks) or ketoconazole (200 mg per day for 10 days).

To prevent pityriasis versicolor, in addition to eliminating the factors contributing to this disease, it is important to avoid close contact with the patient (examination of family members), as well as treating underwear and bed linen (boiling) during treatment. At the stage of convalescence, one of the modern antifungal drugs is prescribed once a month (for example, shampoos with azoles) and it is recommended to use water-alcohol shaken mixtures after washing, which contain boric acid (1-1%), resorcinol (3-1%). -nuyu), sulfur (2-5%), salicylic acid (10-1%), sodium hyposulfite (2%). Products for basic skin care for dermatological patients are also indicated, which help maintain a slightly acidic pH of the skin.

2. Dermatomycosis

Dermatomycosis is a group of fungal diseases caused by dermatophytes that parasitize humans and animals. In humans, dermatophytes affect mainly the epidermis (often the stratum corneum), as well as skin appendages - hair (microsporums and trichophytons) and nails (trichophytons and epidermophytons).

The group of dermatomycosis includes diseases such as microsporia, trichophytosis and favus.

Microsporia

It is a highly contagious disease that affects the skin and hair and is caused by various types of fungi.

The incubation period for microsporia in humans is about 2-4 days. The first sign of damage to the scalp is the appearance of foci of hair thinning. The structure of the hair in the affected areas changes: the hair becomes dull, gray, thickened and breaks off at a height of about 4-6 mm. Over time, the areas of broken hair increase peripherally, giving the hair the appearance of being trimmed.

The root part of the affected hair is surrounded by a gray coating, which consists of fungal spores. When such a hair is removed, it will look like a folded umbrella. The skin within the lesions is covered with small asbestos-like scales, which, when removed, reveal a slight erythema. Microsporia of the scalp, caused by a rusty microsporum, is characterized by a large number of foci and a tendency to merge, as well as the spread of the lesion from the scalp to the smooth skin of the face and neck.

Microsporia of smooth skin is characterized by the appearance of pink spots of round or oval shape with a diameter of about 0,5-3 cm. In the peripheral zone of the spots there are bubbles that quickly dry out to crusts. The central part of the spots is covered with scales. Due to the centrifugal growth of foci, individual elements acquire a ring-shaped shape. Along with old outbreaks, new ones arise. In rare cases, new ones appear inside old ring-shaped lesions (iris shape). Microsporia of smooth skin is clinically indistinguishable from skin lesions with superficial trichophytosis. Nail plates are very rarely affected by microsporia.

The clinical diagnosis of microsporia of the scalp is confirmed by positive results of microscopic examination of the hair, obtaining a culture of the pathogen and a distinct green glow of the affected hair during fluorescent examination. The diagnosis of smooth skin microsporia is confirmed based on the detection of mycelium and spores in skin scales from lesions and culture.

Ringworm

It is a contagious disease of humans and animals, which is caused by various types of fungi and affects the skin, hair and nails.

The causative agents of trichophytosis are divided into groups depending on the type of hair damage. There are two main groups: endotriks (fungi that affect the inner part of the hair) and ectotriks (vegetating mainly in the outer layers of the hair).

All trichophytons from the endotrix group are anthropophiles, transmitted only from person to person. They cause superficial lesions of the skin, scalp, and nails.

Ectotriks are zoophiles that parasitize mainly on animals, but can also infect humans. Compared to fungi of the endotriks group, they cause a more pronounced inflammatory reaction of the skin in humans.

According to clinical manifestations, trichophytosis can be divided into three groups: superficial, chronic and infiltrative-suppurative.

With a superficial form of trichophytosis, the lesion occurs at preschool or school age as a result of direct contact with sick children in children's institutions, as well as in a family from adults suffering from a chronic form of trichophytosis. The transmission of the disease can also be carried out indirectly - through objects and things that have been in contact with the patient. There are superficial trichophytosis of the scalp and smooth skin.

When the scalp is affected, the first noticeable sign to others is the discovery, as with microsporia, of round foci of hair thinning as a result of hair breaking off. But with trichophytosis there are more foci, and they are smaller, while one of them stands out for its size - this is the so-called maternal focus. Within the thinning area, the hair appears patchy. Changed in color, dull, gray, thickened hair with trichophytosis, unlike microsporia, breaks off at different levels and not all. Along with short broken hair (2-3 mm), seemingly unchanged, long hair is found in the lesions.

At the mouths of some hair follicles, dark gray hairs broken off low at the base are visible. More often they are localized in the temporal and occipital regions. The boundaries of the lesions are unclear. The surface of the lesion is slightly hyperemic, covered with loose pityriasis scales. When examining the scraped off scales, they reveal short thickened gray hairs, curved in the shape of commas and question marks, altered hairs that were unable to break through the scales and remained “immured” in them. Subjective sensations are usually absent, or mild itching is observed. Without treatment, the lesions gradually increase in size and can occupy large areas.

With superficial trichophytosis of smooth skin, erythematosquamous spots are found, localized mainly in open areas of the skin. In appearance, they are indistinguishable from lesions on smooth skin with microsporia. Further examination of the patient is necessary to clarify the diagnosis.

Nail plates with superficial trichophytosis are extremely rarely affected.

In some patients, untreated trichophytosis can become chronic. A disturbed autonomic nervous system and endocrinopathies play a significant role in its pathogenesis. When examining patients with chronic trichophytosis, you should pay attention to the condition of the scalp, smooth skin and nails. The most common manifestations of chronic trichophytosis of the scalp are single hair broken off at the mouths of the hair follicles at the very surface of the skin in the form of black dots, often in the occipital and temporal regions, small round atrophic scars with a diameter of 1-2 mm and slight fine-plate peeling.

On smooth skin, lesions are more often found in places most exposed to friction (on the extensor surfaces of the elbow and knee joints, on the buttocks, legs, less often on the trunk), where vaguely demarcated erythematosquamous elements of significant size with mild erythema and finely lamellar peeling of the surface are determined.

The third characteristic sign of trichophytosis is damage to the nail plates of the hands and feet (onychomycosis). Damage to the nail begins either from the free edge or from the side, less often from the base. Yellowish-white areas of various shapes appear in the nail plate, and subungual hyperkeratosis develops. The nail becomes thickened, uneven, dull, and brittle. The edge of the nail plate is jagged, the color is dirty gray, brownish, sometimes black. After the crumbly masses fall out, niches form under the nail. The nail folds are usually not changed, the eponychium is preserved.

The chronic form of trichophytosis often lasts for many years and has poor clinical manifestations. They are difficult to detect, and therefore the disease is not diagnosed for a long time.

With infiltrative-suppurative trichophytosis on the scalp, and in men also in the area of ​​\uXNUMXb\uXNUMXbgrowth of the beard and mustache, one or two sharply limited inflammatory nodes appear that protrude above the surface of the skin and are painful on palpation. At first they have a dense texture, and then soften. Their surface is covered with thick purulent-bloody crusts. The hairs that penetrate the scabs appear unchanged, but are easily pulled out when pulled. In some places, more along the periphery of the foci, follicularly located pustules are visible.

After removing the crusts along with the hair, a hemispherical inflamed surface is exposed with many enlarged mouths of hair follicles, from which a drop of pus is released when the focus is squeezed.

At the height of development, mycosis is accompanied by an increase in regional subcutaneous lymph nodes and a disturbance in the general condition - malaise, increased body temperature. Sometimes there are mykids - secondary allergic nodular and spotty rashes on the trunk and limbs. After 2-3 months without treatment, the mycotic process subsides, the infiltrate resolves, scarring alopecia remains and specific immunity is formed. Similar changes develop when the beard and mustache area is affected. This disease is called parasitic sycosis.

After assessing the clinical manifestations, a standard mycological examination (microscopy and cultural diagnostics) is carried out.

General antifungal therapy for microsporia and trichophytosis is prescribed in cases where:

1) a lesion of the scalp and nail plates was revealed;

2) there are widespread foci on smooth skin (with damage to vellus hair);

3) diagnosed with infiltrative suppurative trichophytosis of the scalp;

4) external therapy turned out to be ineffective;

5) individual intolerance to externally applied fungicides was found.

General antifungal drugs for microsporia and trichophytosis include griseofulvin, terbinafine (lamizil, exifin), itraconazole (orungal), fluconazole (diflucan, mycosyst) and ketoconazole (nizoral).

Griseofulvin is recommended to take 1 tablet (0,125 g) 3-8 times a day with meals, washed down with a small amount of vegetable oil. The dosage and duration of treatment depend on the patient’s body weight and drug tolerance. The total duration of treatment for patients with microsporia is on average 6-8 weeks, and for superficial trichophytosis of the scalp 5-6 weeks.

In chronic trichophytosis, the appointment of individual pathogenetic therapy often plays a decisive role, aimed at eliminating those general disorders against which mycosis developed. In addition to long-term systemic and external therapy, vitamins (especially A, C and E), sometimes immunotherapy, are indicated.

With infiltrative-suppurative trichophytosis with allergic rashes, general antifungal and hyposensitizing therapy is prescribed.

External therapy for microsporia and trichophytosis depends on the location of the lesions (on smooth skin, scalp or nail plates), as well as the severity of the inflammatory reaction. External treatment of mycosis foci reduces the time of general treatment and reduces the possibility of infecting others.

With microsporia, superficial and chronic forms of trichophytosis of the scalp, the following groups of drugs are prescribed externally in the form of a cream, ointment, spray:

1) azoles (clotrimazole, ketoconazole, miconazole, bifonazole, econazole, isoconazole);

2) allylamines (terbinafine-lamizil, naftifine-exoderil);

3) morpholine derivatives (amorolfine (loceryl));

4) hydroxypyridone derivatives (cyclopyroxolamine-batrafen).

The hair in the affected area is shaved or cut every 10-12 days. For infiltrative-suppurative trichophytosis, after mechanical cleaning of the lesions from crusts, pus and epilation of hair on them, lotions with a 0,05% solution of chlorhexidine, a 2-3% solution of boric acid or a 0,01% solution of zinc sulfate are prescribed , 0,04% copper sulfate solution.

With the localization of lesions on smooth skin with microsporia, superficial and chronic forms of trichophytosis, the appointment of antifungal drugs in the form of a cream is indicated.

With an infiltrative-suppurative form of trichophytosis of smooth skin, staged external therapy is indicated. At the first stage, the crusts are removed and the pustules are opened. In the future, wet-drying dressings are prescribed with one of the disinfectant solutions.

As acute inflammation subsides, you can switch to gels, creams, ointments containing tar, sulfur, ichthyol, or creams and ointments with antimycotics.

In case of damage to the nail plates, adequate care is recommended, systematic filing of the affected nails. Outwardly, antifungal agents are prescribed in the form of a varnish, patch, ointment, less often - a solution, a cream. To remove nail plates, especially when prescribing general antifungal drugs with a fungistatic effect, Arabian ointment is used, which consists of potassium iodide and anhydrous lanolin, which has a selective effect on the part of the nail plate affected by the fungus and enhances peroxidation processes in the lesion.

Anti-epidemic measures for microsporia include the fight against stray cats, veterinary supervision of domestic cats and dogs, since most infections come from these animals. Given the possibility of infection of children from each other through direct contact, as well as through objects (hats, combs, towels), schoolchildren should be examined at least 2 times a year.

Preventive measures for trichophytosis include:

1) regular examinations of children in children's institutions and persons who serve these groups;

2) identification of sources of infection;

3) isolation and hospitalization of patients;

4) disinfection of things used by the patient;

5) clinical examination of patients;

6) supervision of hairdressing salons;

7) veterinary supervision of animals;

8) preventive examinations of children entering children's institutions and returning from holidays;

9) sanitary and educational work.

Favus

This is a rare chronic fungal disease of the skin and its appendages caused by an anthropophilic fungus.

In the development of the disease, chronic infections, beriberi, endocrinopathy are important. The disease begins in childhood, but since it does not tend to self-heal, it is also found in adults.

The disease is more often localized on the scalp, nails and smooth skin are less often affected.

The disease is divided into scutular (typical), pityroid and impetiginous forms.

With the scutular form, 2 weeks after infection, an itchy red spot appears around the hair, and then a shield (scutula) is formed - the main clinical sign of the favus. The scutula is a round, dry, bright yellow formation with an depression in the center, shaped like a saucer, pierced in the center with hair, consisting of elements of the fungus and cells of the desquamated stratum corneum, ranging in size from a few millimeters to 1 cm.

The lesion can involve the entire scalp, and the hair loses its shine, becomes dull, becomes twisted, becomes ashen-white, and is easily pulled out, but does not break off. Subsequently, cicatricial atrophy of the skin develops, and a border of hair 1-2 cm wide always remains along the edge of the scalp. To the listed signs should be added a specific “barn” smell coming from the patient’s head.

In the pityroid form of the favus, there are no typical scutulae or they are rudimentary. The clinical picture is dominated by abundant pityriasis peeling that occurs on slightly hyperemic skin.

The more rare impetiginous form is characterized by the presence of massive yellow “layered” crusts on the lesions, resembling impetigo crusts. In these forms, characteristic hair changes and atrophy are also observed.

There are the following clinical forms of smooth skin favus: scutular and squamous. With a rare scutular form, typical scutulae appear, which can reach considerable sizes.

The squamous form is presented in the form of limited erythematosquamous foci, resembling foci of trichophytosis. On smooth skin, favus usually does not leave atrophy.

Nail plates with favus are affected mainly in adults, more often on the hands than on the feet. Initially, a grayish-yellowish spot with a diameter of 2-3 mm appears in the thickness of the nail, which gradually increases and acquires a bright yellow color, characteristic of favous scutulae. Subungual hyperkeratosis subsequently develops, the nail plate loses its shine, becomes dull and brittle.

Untreated favus flows for many years. Damage to the internal organs is observed very rarely, mainly in malnourished and people who suffer from tuberculosis infection. Known lesions of the gastrointestinal tract, lungs, favosous lymphadenitis, favosous meningoencephalitis.

The diagnosis of favus is made on the basis of the characteristic clinical picture, the characteristic glow (dim greenish) of the affected hair when illuminated by a fluorescent lamp with a Wood's filter, as well as microscopic examination of the affected hair and obtaining a culture of the pathogen.

Mycosis stop

Mycosis of the feet is understood as a skin lesion caused by some dermatophyte and yeast fungi, which has a common localization and similar clinical manifestations. Mycosis of the feet is one of the first places among skin diseases.

Infection occurs most often in baths, showers, swimming pools, gyms with insufficient observance of sanitary and hygienic rules for their maintenance, as well as on beaches when the skin of the feet comes into contact with contaminated sand scales.

Wearing impersonal shoes without first disinfecting them and sharing towels can also lead to infection.

Pathogens are extremely stable in the environment: they can grow on wood, shoe insoles, and persist for a long time in socks, stockings, gloves, towels, and bath equipment. Mycosis of the feet usually recurs in spring and autumn and can lead to temporary disability.

Mycosis of the feet develops in the presence of predisposing exogenous and endogenous factors that favor the introduction of the fungus.

Exogenous factors include abrasions, increased sweating of the feet, which is aggravated by wearing socks made of synthetic fibers, tight, unseasonably warm shoes and leads to maceration of the stratum corneum on the feet.

Endogenous causes are associated with impaired microcirculation in the lower extremities (with atherosclerosis, obliterating endoarteritis, varicose veins of the lower extremities, autonomic imbalance, Raynaud's symptom), the state of hypovitaminosis, congenital or acquired immunosuppression (for example, with HIV infection, taking glucocorticosteroids, cytostatic, antibacterial , estrogen-progestin drugs, immunosuppressants).

Depending on the inflammatory response and localization of lesions, five clinical forms of foot mycosis are distinguished: erased, intertriginous, dyshidrotic, acute, squamous-hyperkeratotic. Often in one patient you can find a combination of them.

The erased form is usually manifested by weak peeling in the III-IV interdigital transitional folds of the feet and is accompanied by minor inflammatory phenomena. Sometimes a small superficial crack can be found in the depth of the affected interdigital fold. Slight peeling can also be expressed in the soles and lateral surfaces of the feet.

The intertriginous form resembles diaper rash. In the interdigital transitional folds of the feet, in the places of friction of the contacting surfaces of the fingers, maceration of the stratum corneum occurs, masking the hyperemia of the affected skin. There may also be blistering. This leads to detachment of the epidermis with the formation of erosion and cracks in these areas. A whitish swollen epidermis hangs over the edges of erosions in the form of a collar. The lesion is accompanied by severe itching, sometimes pain. This form of the disease can be complicated by a pyogenic infection: swelling and redness of the fingers and rear of the foot, lymphangitis, and regional adenitis appear. Sometimes this form of mycosis of the feet is complicated by erysipelas and bullous streptoderma.

The dyshidrotic form is manifested by a rash of grouped vesicles on the skin of the arches and the lateral surfaces of the feet. On the arch of the feet, they shine through a thinner stratum corneum, resembling boiled grains of rice in their appearance and size. Bubbles occur more often on unchanged or slightly reddened skin, increase in size, merge, forming larger multi-chamber cavity elements. When a secondary infection is attached, the contents of the blisters become purulent. The rash is accompanied by itching and pain. After opening the blisters, erosions are formed with fragments of epidermal covers along the edges.

The disease may be accompanied by vesicular allergic rashes, mainly on the hands, resembling eczematous manifestations. As the process subsides, the rash of fresh vesicles stops, erosions epithelialize, and slight peeling remains in the lesions.

The acute form of mycosis of the feet was identified by Ya. N. Podvysotskaya. This rare form of mycosis occurs as a result of a sharp exacerbation of dyshidrotic or intertrigenous varieties of the disease. A high degree of skin sensitization to fungal allergens occurs most often with irrational therapy of these forms of mycosis of the feet. Excessive fungicidal therapy causes a sharp increase in inflammatory and exudative changes in the foci of mycosis and beyond. The disease begins acutely, with the formation of a large number of blisters and vesicles on the skin of the feet, and then the legs, against the background of edema and diffuse hyperemia. Soon there are vesicular and bullous elements on the skin of the hands and lower third forearms. These rashes are symmetrical.

Elements of the fungus are not found in them, since they have an infectious-allergic genesis. After the opening of the cavity elements, erosions are formed, surrounded by fragments of the macerated stratum corneum. Erosions merge in places, forming extensive diffusely weeping surfaces, often with purulent discharge. The disease is accompanied by an increase in body temperature, a violation of the general condition of the patient, sharp pains in the affected feet and hands. The inguinal and femoral lymph nodes increase in size and become sharply painful.

Squamous-hyperkeratotic form of mycosis of the feet is characterized by focal or diffuse thickening of the stratum corneum of the lateral and plantar surfaces of the feet. The affected areas of the skin usually have a mild inflammatory color and are covered with small pityriasis or flour-like scales.

Peeling is usually clearly visible in the skin furrows. Some patients complain of itching in the lesions. Cracks cause pain when walking. With this form of mycosis of the feet, which is the most characteristic of the red trichophyton, there are usually no mycids.

Clinical manifestations of mycosis of the feet, caused by interdigital trichophyton, differ little from the clinic of mycosis caused by red trichophyton.

The diagnosis is established on the basis of a characteristic clinical picture and the results of a mycological study (detection of mycelium and obtaining a culture of the fungus).

As a treatment, external therapy with substances with fungicidal activity and a wide spectrum of action, such as azoles, allylamines, derivatives of ciclopirox and amorolfine, is recommended.

Pathogenetic therapy should include vasodilators and other agents that improve microcirculation, physiotherapeutic procedures aimed at improving the blood supply to the lower extremities, as well as correcting the underlying disease, against which foot mycosis developed.

Mycosis of the hands

The most common causative agent of mycosis of the feet is red trichophyton, less often - other other dermatophytes.

An important role in the occurrence of mycosis of the hands is played by injuries and impaired microcirculation in the area of ​​the distal upper extremities (with atherosclerosis, Raynaud's syndrome), as well as endocrine disorders and immunosuppressive conditions.

Clinical manifestations of lesions of the palms are similar to those of the squamous-hyperkeratotic form of mycosis of the feet. The lesion may be asymmetrical. Characterized by dryness of the skin of the palms, thickening of the stratum corneum (keratosis), floury peeling in exaggerated skin furrows, ring-shaped peeling.

Lesions can also be observed on the back of the hands in the form of areas of cyanotic erythema with scalloped or oval outlines. The edges of the foci are intermittent and consist of nodules, vesicles, and crusts. The defeat of the palms can be combined with onychomycosis of the hands.

Diagnosis, treatment and prevention are similar to those for athlete's foot.

Mycosis of smooth skin

Trichophyton red is the most common causative agent of mycosis of smooth skin.

The spread of mycosis caused by red trichophyton over smooth skin usually occurs in ascending order. Its generalization is facilitated by hormonal disorders, acquired immunodeficiency states, as well as horn formation disorders that occur with ichthyosis, keratoderma, and hypovitaminosis A.

There are three main forms of mycosis of smooth skin: erythematous-squamous, follicular-nodular and infiltrative-suppurative.

The erythematosquamous form of mycosis is characterized by the appearance of red scaly round or oval spots that tend to grow peripherally, merge and form foci of polycyclic outlines with an edematous, cherry-red color with an intermittent peripheral roller, consisting of follicular papules and pustules. The skin within the foci is poorly infiltrated, may acquire a brownish tint, covered with small scales. Against this background, grouped or single follicular papular or papulo-pustular elements of stagnant red color are located.

The follicular-nodular form of mycosis is distinguished by grouped pustular and papulo-pustular rashes that do not break off and differ little from healthy ones in appearance.

The infiltrative-suppurative form of mycosis is quite rare. According to clinical manifestations, it resembles infiltrative-suppurative trichophytosis caused by zoophilic trichophytons. At the site of the foci after their resolution, atrophy or individual scars remain.

The main means of treatment are systemic antimycotics in combination with external antifungal therapy.

Onychomycosis

This is a fungal infection of the nail plate. About half of patients with ringworm have onychomycosis.

Isolated infection of the nail plate by fungi is rare.

Usually, nail damage occurs a second time when the fungus spreads from the affected skin with mycosis of the feet, hands, chronic trichophytosis. It is also possible hematogenous drift of the fungus into the growth zone of the nail in case of injury to the nail phalanx, as well as in patients with endocrine diseases and immunodeficiency states.

In the pathogenesis of onychomycosis, circulatory disorders in the extremities play an important role. Functional and organic diseases of the nervous system, leading to disruption of tissue trophism, endocrine diseases, immunodeficiency states, some chronic skin diseases, which are characterized by horn formation disorders and nail plate degeneration, are important. Of the exogenous factors, an important role is played by mechanical and chemical injuries of the nail plates and distal extremities, as well as frostbite and chills.

Clinically, onychomycosis is manifested by a change in color, surface and shape of the nail plates. The nail fold is not affected.

In the hypertrophic form, the nail plate thickens due to subungual hyperkeratosis, acquires a yellowish color, crumbles, and its edges become jagged.

In the normotrophic variant, there are yellowish or white stripes in the thickness of the nail, while the nail plate does not change its shape, subungual hyperkeratosis is not pronounced.

The atrophic form of onychomycosis is characterized by significant thinning, detachment of the nail plate from the nail bed, the formation of voids or its partial destruction.

The diagnosis of onychomycosis is made on the basis of a characteristic clinical picture and laboratory data. The latter are obtained by microscopic examination of the affected nail scales and obtaining a culture of the fungus.

For systemic therapy of onychomycosis, one of the modern antifungal drugs is used: itraconazole (orungal), terbinafine (lamizil, exifin) and fluconazole (diflucan, mycosyst).

3. Candidiasis

Candidiasis is a disease of the skin, nails and mucous membranes, sometimes internal organs, caused by yeast-like fungi.

Infants, very old and very sick people are most susceptible to this disease. Endogenous factors predisposing to this mycosis include endocrine diseases, severe general diseases (lymphoma, leukemia, HIV infection), pathological pregnancy. Currently, the most common cause of candidiasis is the use of antibiotics with a wide spectrum of antibacterial action, glucocorticosteroids, cytostatics, hormonal contraception.

A number of exogenous factors also contribute to the development of candidiasis (high temperature, high humidity, chemicals that cause skin damage, microtrauma). Exposure to several predisposing factors at the same time significantly increases the risk of developing candidiasis.

Infection usually occurs in the birth canal, along with this, the possibility of a transplacental route of infection (congenital candidiasis) has also been proven. The occurrence of candidiasis in adults is most often associated with autogenous superinfection, but exogenous infection of the genital, perigenital areas can also occur. Dysbacteriosis and violation of the protective system of the mucous membrane and skin facilitates the attachment (adhesion) of the fungus to epitheliocytes and its penetration through the epithelial barrier.

Distinguish the following varieties of candidiasis:

1) superficial candidiasis (of the mouth, genitals, skin, nail folds and nails);

2) chronic generalized (granulomatous) candidiasis in children and adolescents;

3) chronic mucocutaneous candidiasis;

4) visceral candidiasis (damage to various internal organs and systems: candidiasis of the pharynx, esophagus and intestines, candidiasis of the bronchi and lungs).

Superficial candidiasis is a type of disease that occurs most often.

According to the localization of the lesion, they distinguish:

1) candidiasis of the mucous membranes and skin (candidiasis stomatitis, candidal glossitis, candidiasis of the corners of the mouth, candidal cheilitis, candidal vulvovaginitis, candidal balanoposthitis);

2) candidiasis of the skin and nails (candidiasis of large folds, candidal paronychia and onychia).

The most common clinical form of acute candidiasis is thrush, or pseudomembranous candidiasis. It often occurs in newborns in the first 2-3 weeks of life and in adults with the predisposing factors listed above.

Lesions are usually located on the mucous membrane of the cheeks, palate, gums. In these areas, whitish-cream crumbly plaques appear. Under them, you can find a hyperemic, less often - eroded surface. With a long-term candidal stomatitis, the plaque acquires a brown or cream color and is more firmly held on the affected mucosa.

Acute atrophic candidiasis of the oral mucosa occurs during broad-spectrum antibiotic therapy. The mucous membrane of the mouth becomes inflamed, then becomes atrophic.

These changes are accompanied by sensations of dryness of the mucosa and burning, sometimes severe pain.

Chronic hyperplastic candidiasis of the oral mucosa occurs with prolonged colonization of yeast-like fungi. On the buccal mucosa along the line of teeth closure, along the midline of the tongue and on the hard palate, rounded, thickened white plaques with an uneven, rough surface are formed, which in some places can merge.

Chronic atrophic candidiasis occurs in persons wearing a removable plastic prosthesis of the upper jaw. The mucous membrane of the prosthetic bed is hyperemic, in its central part a loose whitish-gray plaque accumulates, after the removal of which a hyperemic, sometimes eroded mucosa becomes visible.

In patients with lesions of the oral mucosa, mycosis often spreads to the corners of the mouth - candidiasis of the corners of the mouth develops. Limited erosions appear in the corners of the mouth - cracks on a slightly infiltrated base, surrounded by a fringe of slightly raised, whitened epidermis.

Candidal cheilitis is characterized by moderate swelling and cyanosis of the red border of the lips, thin grayish lamellar scales with raised edges, thinning of the skin of the lips, radial grooves, cracks.

Subjectively concerned about dryness, a slight burning sensation, sometimes pain.

Vulvovaginal candidiasis is characterized by the formation of a whitish coating on the hyperemic mucous membrane of the vulva and vagina.

A characteristic crumbly white discharge appears. Patients are disturbed by excruciating itching and burning.

Candida balanoposthitis often occurs against the background of obesity, decompensation of diabetes mellitus, in men with chronic gonorrheal and non-gonorrheal urethritis and narrow foreskin.

Numerous small pustules appear on the head and inner leaf of the foreskin against the background of hyperemia, transforming into erosions of various sizes with whitish blooms. These manifestations are accompanied by itching and burning. In the absence of adequate therapy, they can lead to inflammatory phimosis, there is a danger of joining candidal urethritis.

Candidiasis of large folds usually develops in obese people, in people with diabetes mellitus and receiving glucocorticosteroid hormones. Candidiasis of small folds, on the hands, occurs as a result of prolonged maceration.

Thin-walled, often merging pustules appear in large and small folds on hyperemic skin. In the future, erosions of a dark cherry color with a shiny surface are formed.

Candidal paronychia and onychia are the most common forms of candidiasis. With candidal onychia, there is an initial lesion of the nail fold - the occurrence of inflammatory candidal paronychia.

Subsequently, the eponychium disappears and the hyperemic nail fold hangs over the nail. When pressing on the edematous nail roller, a purulent discharge may appear from under it. Gradually, the lesion spreads to the nail plate, the change of which always begins in the proximal sections. A deformed nail with a changed color grows from under the back roller. It thickens, becomes dull, dirty-gray in color, transverse grooves appear, sometimes punctate impressions.

The presence of yeast-like fungi in patients in the lesions is determined using microscopic and cultural studies. Microscopy of native or aniline-stained preparations for candidiasis reveals a large number of budding cells, pseudomycelium or true mycelium.

To prescribe rational treatment to a patient, it is necessary to take into account the clinical form of candidiasis, its prevalence and identified predisposing factors.

In case of superficial candidiasis of the oral mucosa, genitals and perigenital area, it is necessary to find out the degree of contamination of the gastrointestinal tract with yeast. With massive colonization of the gastrointestinal tract, it is advisable to prescribe drugs to suppress their growth (natamycin, levorin, nystatin).

With local lesions of the skin and mucous membranes, they are limited to the external use of candidal preparations in rational forms. With candidal stomatitis, it is recommended to lubricate the affected mucosa with a solution of sodium tetraborate (borax) in glycerin or with a solution of an aniline dye, polyene antibiotics (nystatin) and azole derivatives in solution forms.

In acute vulvovaginitis, lotions and douching with a solution of chlorhexidine or miramistin have a quick therapeutic effect.

When skin folds are affected, external therapy is carried out depending on the severity of inflammation. First, lotions are prescribed, and then lubrication of the foci with aniline dye.

General anti-candidiasis therapy for patients with superficial candidiasis of the skin and mucous membranes is prescribed for widespread lesions of folds, smooth skin, and mucous membranes.

In case of recurrent vulvovaginal candidiasis or balanoposthitis, it is necessary to identify concomitant factors (diabetes mellitus, abnormal pregnancy), in addition, fluconazole is prescribed.

It is important to prevent candidiasis in persons with a combination of several predisposing factors: immunodeficiency, blood disease, neoplasm, etc. Great importance is attached to the treatment of intestinal dysbacteriosis, the detection and treatment of candidiasis in pregnant women, the treatment of persons with genital candidiasis and their sexual partners.

4. Deep mycoses

Fungi that cause deep mycoses belong to various generic and species groups. Many of them are dimorphic: in the external environment they exist in the form of mycelium, and in the lesions - in the parasitic (tissue) form, which differs sharply from the mycelial form in morphology. In addition to the skin, deep mycoses affect the internal organs.

The most dangerous deep mycoses include coccidioidomycosis and histoplasmosis, which cause severe lesions of the skin, mucous membranes and internal organs, often ending in the death of the patient. Other deep mycoses are caused by opportunistic fungi. The severity of their course depends on the degree of prevalence and the state of reactivity of the patient's body.

Deep mycoses are common in regions with a tropical and subtropical climate.

Deep mycoses, especially with damage to internal organs, require the appointment of a general antifungal therapy (itraconazole, fluconazole, amphotericin B).

5. Pseudomycosis

This group includes superficial (erythrasma) and deep (actinomycosis) diseases of a non-fungal nature.

erythrasma

With erythrasma, skin folds are affected. Given the significant clinical similarity and general localization, the disease must be differentiated from mycosis. Of decisive importance in the diagnosis are the examination of the foci in a lamp with a Wood filter (with a coral-red glow) and the data of microbiological studies. Treatment of erythrasma is similar to the treatment of mycosis of large folds.

Actinomycosis

The disease is caused by several types of actinomycetes. Along with the skin, internal organs can be affected. More than half of the patients have a cervicofacial form of cutaneous actinomycosis, which is manifested by gummy-nodular, tuberculous-compacted, atheromatous, abscessing and ulcerative rashes.

In treatment, high doses of penicillin and actinolysate are used for a long time.

Author: Sitkalieva E.V.

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