YEAST:

Blastospore; hyphae;
pseudohyphae

MOULD:
Mycelium; hyphae
If they do this to food…..
 Superficial fungal infections
10

• Prevalence: ~ 29.4 million cases

• Annual economic burden
– USD$1,953,000,000 in expenses
– USD$450,000,000 in indirect costs
• Ranked 4th among 22 skin disease groups evaluated in terms of direct costs
– USD$1.7 billion with 74% of costs attributable to prescription drugs
• an estimated average of 4,124,038 ± 202,977 annual visits during the study period
– (N.B. 2010: 308 million)
oDermatomycosis - more general name for any
skin disease caused by a fungus.
oDermatophytosis - "ringworm" disease of the
nails, hair, and/or stratum corneum of the skin
caused by fungi called dermatophytes.
oDermatomycosis - more general name for any
skin disease caused by a fungus.
THE SKIN PLANTS
• Etiological agents are called dermatophytes - "skin
plants". Three important anamorphic genera, (i.e.,
Microsporum, Trichophyton, and Epidermophyton),
are involved in ringworm.
• Dermatophytes are keratinophilic - "keratin
loving". Keratin is a major protein found in horns,
hooves, nails, hair, and skin.
• Ringworm - disease called by the Romans ‘tinea'
(which means small insect larvae).
Species found in different anamorphic genera are the cause
of different clinical manifestations of ring worm
• Microsporum - infections on skin and hair
• Epidermophyton - infections on skin and nails
• Trichophyton - infections on skin, hair, and nails.
 Clinical manifestations of ringworm infections are
called different names on basis of location of
infection sites
• tinea capitis - ringworm infection of the head, scalp,
eyebrows, eyelashes
• tinea favosa - ringworm infection of the scalp (crusty hair)
• tinea corporis - ringworm infection of the body (smooth
skin)
• tinea cruris - ringworm infection of the groin (jock itch)
• tinea unguium - ringworm infection of the nails
• tinea barbae - ringworm infection of the beard
• tinea manuum - ringworm infection of the hand
• tinea pedis - ringworm infection of the foot (athlete's
foot)
 Ringworm of the Body (Tinea
Corporis)
There are several types of ringworm (tinea) that can affect different parts of the body.
When fungus affects the skin of the body, it often produces itchy, red, raised, scaly
patches that may blister and ooze. The patches often have sharply defined edges. They
are often redder around the outside with normal skin tone in the center, creating the
appearance of a ring. Your skin may also appear unusually dark or light.

http://www.webmd.com/skin-problems-and-treatments/ringworm/ss/slideshow-ringworm-overview
TYPICAL TINEA CORPORIS
TINEA CORPORIS
TINEA CORPORIS
TINEA CORPORIS
TINEA CORPORIS
 Ringworm of the Scalp (Tinea
Capitis)
Ringworm of the scalp commonly affects children in late childhood or adolescence. This
condition may spread in schools. Tinea capitis often appears as patchy, scaling bald spots
on the scalp. (Other scalp conditions, such as seborrhea or dandruff, do not cause hair
loss).
TINEA CAPITIS
BLACK DOT TINEA CAPITIS
 Tinea Capitis - Exothrix

KOH and ‘Quick Ink’

M. Canis
 Ringworm of the Foot (Tinea
Pedis)
Tinea pedis is an extremely common skin disorder, also known as athlete's foot. This
fungal infection may cause scaling and inflammation in the toe webs, especially the
one between the fourth and fifth toes. Other symptoms include itching, burning,
redness, and stinging on the soles of the feet

http://www.webmd.com/skin-problems-and-treatments/ringworm/ss/slideshow-ringworm-overview
TINEA PEDIS
TINEA PEDIS
TINEA PEDIS
TINEA PEDIS
TINEA PEDIS
 Ringworm of the Beard (Tinea
Barbae)
Ringworm of the bearded area of the face and neck, with swellings and
marked crusting, sometimes causes the hair to break off. In the days when
men went to the barber daily for a shave, tinea barbae was called barber's
itch.

http://www.webmd.com/skin-problems-and-treatments/ringworm/ss/slideshow-ringworm-overview
TINEA BARBAE
 Ringworm of the Hand (Tinea
Manus)
Ringworm may involve the hands, particularly the palms and the spaces between the
fingers. It typically causes thickening (hyperkeratosis) of these areas, often on only one
hand. Tinea manus is a common companion of tinea pedis (ringworm of the feet). It is also
called tinea manuum.

http://www.webmd.com/skin-problems-and-treatments/ringworm/ss/slideshow-ringworm-overview
Tinea Manuum
TINEA MANUM
 Ringworm of the Nails (Tinea
Unguium)
Ringworm is the most common fungal infection of the nails, also called
onychomycosis. It can make fingernails look white, thick, opaque, and brittle, but
more often toenails look yellow, thick, and brittle. Artificial nails increase the risk for
tinea unguium as emery boards can carry infection, and water can collect under the
artificial nail, creating a moist area for fungal growth

http://www.webmd.com/skin-problems-and-treatments/ringworm/ss/slideshow-ringworm-overview
TINEA UNGUIUM
TINEA CRURIS
TINEA CRURIS
TINEA CRURIS
TINEA CRURIS
TINEA CRURIS
MAJOR FUNGAL INFECTION: Summary
Tinea Pedis
• Tinea Pedis, more commonly
known as athlete's foot is an
infection of the skin and feet
that can be caused by a variety
of different fungi
• Transmitted by spores present in
infected skin scales, which are
continually shed.
• It is often due to Trichophyton
species.
• Although tinea pedis can affect
any portion of the foot, the
infection most often affects the
space between the toes.
• Athlete’s foot is typically
characterized by skin fissures or
scales that can be red and itchy.
Tinea Corporis
 A dermatophytes infection of
the trunk and limbs. Common
specially in warm climates
 Affects all age groups
 Transmitted by direct
contact with infected
animals, humans of soil
 The condition might be seen
in infants in parts of the body
covered by nappies and may
confused with cutaneous
cadidiasis ( and hence
incorrectly treated )
 T. Corporis presents most
commonly as characteristic
ring-shaped erythematous
lesions that spread out from
their centers ( and which gave
rise to the older name
“ringworm”). These may
appear in inflammatory or
non-inflammatory forms
Tinea Cruris
 Localized form of
T.corporis, affecting the
groin. Most often seen in
men
 Occurs worldwide but is
specially common in hot,
humid countries
 Appears in skin folds,
around genitalia and in
the perianal region
 May be associated with
poor personal hygiene
 The lesions are itchy, red,
ring-shaped, scaly
patches with an
exaggerated edge. The
edges of the lesions may
have pustules or papules
 Direct examination
• microscopy of skin, nail and hair specimens with 10% KOH
– simplest
– cheapest
– immediate identification of spores and hyphae
• e.g. confirms the dx of tinea capitis
– Differentiates btw endothrix or ectothrix infection

– Drawbacks of KOH microscopy

• Sensitivity:
– tinea capitis: 67 to 91%
– tinea pedis 73.3% (95% CI: 66.3 to 79.5%)
– Onychomycosis: 80%
• Low specificity: 42.5% (36.6 to 48.6%); 72% (onychomycosis)
• Unable to differentiate between dermatophytic /
Nondermatophytic infections
 How Is Ringworm Diagnosed?

Sometimes, the diagnosis of ringworm is obvious from its location and appearance.
Otherwise, doctors can test skin scrapings for tinea fungus

http://www.webmd.com/skin-problems-and-treatments/ringworm/ss/slideshow-ringworm-overview
 Diagnosis
• Note the symptoms.
• Microscopic examination of slides of skin scrapings,
nail scrapings, and hair. Often tissue suspended in 10
% KOH solution to help clear tissue. Slides prepared
this way are not permanent. These degrade rapidly
due to presence of base.
• Isolation of the fungus from infected tissue.
• Proper treatment is dependent on diagnosis and
prognosis.
 Major sources of ringworm infection
• Schools, military camps, prisons.
• Warm damp areas (e.g., tropics, moisture
accumulation in clothing and
shoes). Historical note: More people were
shipped out of the Pacific Theater in WWII
back to U.S. because of ringworm infection
then through injury.
• Animals (e.g., dogs, cats, cattle, poultry, etc.).
 Tips for Preventing Ringworm

Ringworm is difficult to prevent, but here are tips to reduce your risk:

 Don't share clothing, sports gear, towels, or sheets.

 Wear slippers in locker rooms and public pool & bathing areas.
 Shower after any sport that includes skin-to-skin contact.
 Wear loose-fitting cotton clothing. Change your socks and underwear at least once
a day.
 Keep skin clean and dry. Dry yourself completely after showering.
 If you have athlete's foot, put your socks on before your underwear to prevent
spreading to other parts of your body.
 Take your pet to the vet if it has patches of missing hair, which could be a sign of a
fungal infection.

http://www.webmd.com/skin-problems-and-treatments/ringworm/ss/slideshow-ringworm-overview
 Pityriasis versicolor (formerly
tinea versicolor
• Commensal yeast: Malassezia species
• occurs most frequently in hot and humid
tropical climates
– also prevalent in temperate climates
• Malassezia has an oil requirement for
growth
– increased incidence in adolescents
– predilection for sebum-rich areas of the skin
– use of bath oils and skin lubricants may
enhance disease development
• Pityriasis versicolor occurs
– when the budding yeast form transforms to
the mycelial form
– Various factors implicated:
• e.g. hot and humid environment, oily skin and
excessive sweating.
 Candidiasis
 Cutaneous candidosis less common than
dermatophytosis
 Candida species
 capable of producing skin and mucous membrane infections
 ~200 species
 ~20 of them associated with human or animal infections
 e.g. C. albicans, C. tropicalis, C. glabrata, C. parapsilosis, C. krusei, C.
guilliermondii
 C. albicans accounting for most of the infections

 found among the commensal flora of the

diseased skin, mouth, vaginal tract, and
gastrointestinal tract
Cutaneous candidosis
 Antifungal Agents
1. Polyene Antifungal Drugs
These drugs interact with ergosterol in the fungal cell
membrane and form pores
•Amphotericin
•Nystatin
•Pimaricin

2. Azole Antifungal Drugs

These drugs inhibit cytochrome P450’s (C14-demethylase)
involved in ergosterol biosynthesis.
•Fluconazole
•Itraconazole
•Ketoconazole
 Antifungal Agents
3. Allylamine Antifungal Drugs
Allylamine drugs inhibit squalene epoxidase, a critical
enzyme in the ergosterol biosynthetic pathway.
• Terbinafine
• Naftifine
4. Morpholine Antifungal Drugs
Inhibit the ergosterol biosynthetic pathway at a later step
•Amorolfine

5. Antimetabolite Antifungal Drugs

•Flucytosine (5-fluorocytosine) is converted to
5-fluorouracil in fungal cells, which inhibits DNA, RNA
and protein synthesis
Mechanisms
 Terbinafine
• Inhibition of
squalene epoxidase
enzyme which is
essential for
ergosterol
synthesis of cell
membrane →
accumulation of
toxic squalene.
Results
Terbinafine was the most powerful antimycotic and T.
rubrum had the highest ( minimal inhibitory
concentration) MIC values for the four antifungal agents.
 T. capitis T. corporis T. pedis
Species of T. unguium T. cruris T. mannum Total No
Dermatophytes No (%) No (%) No (%) No (%) No (%) No (%) (%)

T. rubrum 0 5 (35.7%) 8 (66.7%) 2 (100.0%) 1(100.0%) 1 (100.0%) 17 (32.1%)

T.
mentagrophytes 7 (30.4%) 2 (14.3%) 2 (16.7%) 0 0 0 11 (20.8%)

T. violaceum 6 (26.1%) 3 (21.4%) 1 (8.3%) 0 0 0 10 (18.9%)

T. verrucosum 1 (4.3%) 0 0 0 0 0 1 (1.9%)

T. schoenleinii 2 (8.8%) 0 0 0 0 0 2 (3.8%)

T. soudanense 1 (4.3%) 0 0 0 0 0 1 (1.9%)

T. tonsurans 0 1 (7.1%) 0 0 0 0 1 (1.9%)

M. canis 2 (8.8%) 1 (7.1%) 0 0 0 0 3 (5.6%)

M. ferrugineum 1 (4.3%) 1 (7.1%) 0 0 0 0 2 (3.8%)

M. audouinii 3 (13.0%) 0 0 0 0 0 3 (5.6%)

E. floccosum 0 1 (7.1%) 1 (8.3%) 0 0 0 2 (3.8%)

23 14 12 1 53
Rubrum had MIC endpoints
the
Dermatophytes Terbinafine Itraconazole Griseofulvin Ketoconazole
Species
T. mentagrophytes 0.06 - 0.25 0.125 -2 1-4 0.25 -2

T.ment,var erinacei 0.06 - 0.125 0.25 – 0.5 0.5 - 2 0.06 - 0.25

T. rubrum 0.06 - 0.5 0.125 - 4 1-8 0.06 – 4
T. violaceum 0.06 - 0.125 0.06 – 0.5 0.5 - 2 0.06 - 0.5

T. verrucosum 0.06 0.125 2 1

T. schoenleinii 0.06 0.125 - 0.5 0.5 - 1 0.125

T. soudanense 0.06 0.5 2 1

T. tonsurans 0.5 2 1 4
M. canis 0.06 -0.5 0.125 – 2. 2-4 0.25 – 1
M. ferrugineum 0.06 - 0.125 0.06 - 0.125 0.5 0.125

M. audouinii 0.06 - 0.125 0.06 - 0.125 1-2 0.125 - 2

E. floccosum 0.06 0.125 4 2
FUNGAL INFECTION: Comparative Studies- For Research Touch
Terbinafine vs Clotrimazole
• Studies show that Terbinafine has a much higher
rate of cure after week 1 as opposed to
Clotrimazole
• The proportion of patients effectively treated by
terbinafine was higher at each visit compared
with clotrimazole.
• At four weeks 90% (96) of patients were
effectively treated by terbinafine compared with
only 59% (61) by clotrimazole (p=0.0001).
• At week 6 the proportion of patients effectively
treated by terbinafine remained unchanged but
was still significantly higher than the 73% (76) of
patients effectively treated by clotrimazole (p=0
002)

Results of a double blind study comparing twice daily application for one week of terbinafine 1% cream with twice daily
application for four weeks of clotrimazole
E G V Evans, B Dodman, D MWilliamson, GJ Brown, R G Bowen. BMJ VOLUME 307 1 1 SEPTEMBER 1993
FUNGAL INFECTION: Treatment
Terbinafine vs Ketoconazole
• Studies show that rates of mycological cure 100% 94%
90%
were 94% for terbinafine and 69% for
80%
ketoconazole (p = 0.027). 69%
70%
• A clinical and mycological overall 60%
evaluation was obtained for 72% of 50%

patients receiving terbinafine and 31% of 40%

patients receiving ketoconazole cream (p = 30%

0.002) 20%
10%
• As per the study, a 1-week course of 0%
terbinafine 1% is significantly more Terbinafine Ketoconazole

effective than ketoconazole 2% cream in

the treatment of tinea corporis and tinea
cruris as regards clinical and mycological
cure and treatment safety.

Comparative study between terbinafine 1% emulsion-gel versus ketoconazole 2% cream in tinea cruris and tinea
corporis.
Eur J Dermatol. 2000 Mar;10(2):107-9
FUNGAL INFECTION: Treatment
Terbinafine vs Miconazole
• Studies have been conducted to compare the
efficacy of terbinafine during 1 week with the 5
efficacy of miconazole during 4 weeks in the
treatment of tinea pedis
• A similar patient profile with an equal 4

distribution as to age, sex, race, duration and

Effective cure (weeks)

seriousness of the fungal infection and previous
3
treatment was kept
• Patients were treated with terbinafine for 1
week and placebo for 3 weeks, or with 2
miconazole for 4 weeks. Evaluation was done 1,
2, 3, 4 and 10 weeks after the start of the
treatment. 1

• In the treatment of tinea pedis local application

of terbinafine cream during 1 week is as good as 0
treatment with miconazole cream during 4 Terbinafine Miconazole
weeks.

Double-blind study of the efficacy of 1 week topical terbinafine cream compared to 4 weeks miconazole cream in
patients with tinea pedis..
Vermeer BJ, Staats CC, van Houwelingen JC. J Med Assoc Thai. 1999 Oct;82(10):1006-10.
 Tinea pedis: treatment 102

– all efficacious relative to placebo in the treatment of tinea pedis

• Allylamines
– greater effectiveness when used for longer
• The effectiveness of azoles improved over time
– No difference in treatment failure rates between any of the individual azoles
• allylamines more efficacious than azoles
– The meta analysis of 8 trials and outcomes from 962 participants supports the finding that allylamines are more
effective than azoles when applied for between 4 to 6 weeks
 103

• Terbinafine and itraconazole

– more effective than no treatment (placebo)
• Terbinafine (two weeks treatment)
– more effective than itraconazole (two weeks treatment)
• Terbinafine
– more effective than griseofulvin
• No significant difference in effectiveness found between:
– two weeks of terbinafine vs four weeks of itraconazole
– fluconazole vs either itraconazole or ketoconazole
– griseofulvin and ketoconazole
– different doses of fluconazole

Recommendation:
• to treat initially with topical azoles and use topical allylamines for azole treatment failures
 Rubbing alcohol,
Direct application of rubbing alcohol and/or hydrogen peroxide after bathing can aid in
killing the fungus at the surface level of the skin and will help prevent a secondary
(bacterial) infection from occurring. In addition, soaking the feet in a bath of 70% rubbing
alcohol will help dry the skin out, and likewise kill the invading fungus The alcohol is not,
however, effective against spore
 LE Sales
2014 2015.00 2016.00

D01A1 TOPICAL DERMAT

ANTIFUNGAL 63510269.00 69861295.90 76847425.49

LAMISIL 12500648.00 13750712.80 15125784.08

SPRAY 1 % 1 30 ML 3581040.00 3939144.00 4333058.40

TERBIN 1452116.00 1597327.60 1757060.36

SOLUT.TOPIC 1 % 1 15
ML 556013.00 611614.30 672775.73

TERBINAFINE 1182195.00 1300414.50 1430455.95

SPRAY 1 % 1 120 ML 1182195.00 1300414.50 1430455.95

 Proj. RX
Proj. RX
LAMISIL 69.44
PITYRIASIS VERSICOLOR B36-0 22.24 LAMISIL 151.19
TINEA PEDIS B35-3 13.20 1% 133.12
TINEA BARBAE T.CAPITIS B35-0 12.32 ALEXANDRIA 42.22
TINEA CORPORIS B35-4 4.36 DERM. 37.97
TINEA CRURIS B35-6 3.58 G.P. 2.42
TINEA UNGUIUM B35-1 2.79 SURG. 1.26
ERYTHEMA INTERTRIGO L30-4 1.45
CARD. 0.56
TERBIN 24.61
DELTA/CANAL 35.20
PITYRIASIS VERSICOLOR B36-0 6.47
DERM. 35.20
TINEA BARBAE T.CAPITIS B35-0 5.49
U. EGYPT 34.47
TINEA CRURIS B35-6 3.68
DERM. 27.05
TINEA PEDIS B35-3 2.28
TINEA UNGUIUM B35-1 2.21
G.P. 7.42
DIAPER DERMATITIS L22-0 1.45 CAIRO - GIZA 21.24
DERMATOPHYTOSIS UNSP B35-9 0.86 DERM. 18.34
CANDIDIASIS UNSPECIFIED B37-9 0.74 SURG. 1.41
DERMATITIS UNSPECIFIED L30-9 0.73 G.P. 1.25
TINEA CORPORIS B35-4 0.73 CARD. 0.24
 unit 2016

TERBIN global nappi

SOLUT.TOPIC 1 % 1 15 ML

TERBINAFINE ecap 26000.00

SPRAY 1 % 1 120 ML
price 2017
TERBECOMASIL eccopharm 63000.00
terbinafine 120ml 48.60
SPRAY 1 % 1 30 ML terbecomasil 19.80
LAMISIL 35/152 112000.00 lamisil 43.00
SPRAY 1 % 1 30 ML 27.00
Mycopedis Target unit

Launch 3 month( 5-6-7) 6000

Delta/month 2017 2500

Alex/month 2017 3000

Cai / month 2017 2500