Inguinal epidermophytosis microbial. B35 Dermatophytosis. What causes Dermatophytosis

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

What causes Dermatophytosis:

Dermatophytes are called fungi- 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 pathogens 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 body. Members of all three groups can cause human diseases, but their various natural reservoirs determine the epidemiological features - the source of the pathogen, the prevalence and geography of the ranges.

Although many geophilic dermatophytes can cause infection in both animals and humans, the soil is the most common, natural habitat for these fungi. Members of the zoophilic and anthropophilic groups are believed to have descended from these and other soil-dwelling saprophytes capable of degrading keratin. Zoophilic organisms can sporadically be transmitted to humans if they have an affinity for human keratin. Transmission occurs through direct contact with an infected animal, or through objects that fall on the hair and skin scales of these animals. Infections often occur in rural areas, but pets are now especially important (especially in M. canis infections). Many members of the zoophilic group are named after their animal owners. 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, as a rule, epidemic. The main increase in the incidence is provided by anthropophilic species. Currently, anthropophilic dermatophytes can be found in 20% of the general 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 degrading animal and/or human keratin. The activity of keratinases and proteolytic enzymes in general is considered the basis of 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 is not the same in different dermatophytes. T. mentagrophytes is characterized by the highest activity, and T. rubrum is quite moderate. The ability to decompose different types of keratin generally corresponds to the localization of a dermatophyte infection. Thus, E. floccosum, a species with low keratinolytic activity, does not affect hair.

The introduction of the colony of the pathogen into the epidermis is provided by both keratinolytic activity and the growth of hyphae. Like molds, dermatophytes have a specialized apparatus for directed growth of the hyphae. 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 directional growth pressure.

The depth of promotion 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 defense factors. Thus, a dermatophyte infection covers only non-living, keratinized tissues.

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 severe deficiency of one or more resistance factors.

Symptoms of Dermatophytosis:

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

The generally accepted classification for a long time was the one proposed by N.D. Sheklakov in 1976. In our opinion, a reasonable and acceptable compromise is the use of the ICD classification with clarification, if necessary, of 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", with which they sometimes try to replace the common name of dermatophytosis, is inappropriate and cannot serve as an equivalent of dermatophytosis.

Dermatomycoses are fungal infections of the skin in general, i.e. and candidiasis, and multi-colored lichen, and many mold mycoses.

Dermatophytosis of the scalp
Abroad, the following clinical and etiological forms of tinea capitis are distinguished:
1) ectothrix infection. Called Microsporum spp. (anthropozoonotic microsporia of the scalp);
2) endotrix infection. Called Trichophyton spp. (anthroponotic trichophytosis of the scalp);
3) favus (scab). Called 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. The number of registered cases of microsporia in recent years has been up to 100 thousand per year. The occurrence of pathogens of anthroponotic microsporia (M. ferrugineum) and trichophytosis (T. violaceum), common in the Far East and Central Asia, should be recognized as 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 foci is dull, brittle, light gray in color, dressed in a white sheath at the base. Hair loss above the surface of the skin explains why the lesions appear clipped, befitting the name "ringworm". The skin in the focus is slightly hyperemic and edematous, covered with grayish small scales. The specified clinical picture corresponds to the name "lichen gray spots".

For trichophytosis of the scalp multiple isolated small (up to 2 cm) foci are characteristic. Breaking off of hair at the level of the skin is typical, leaving a stump in the form of a black dot peeping out of the mouth of the follicle (“deprive blackheads”).

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

For infiltrative suppurative form of microsporia and trichophytosis characteristically pronounced 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 cyanotic, with clear boundaries and a bumpy surface, covered with numerous pustules and erosions, often hidden under purulent hemorrhagic crusts. Characterized by enlarged mouths of the follicles, from which, when pressed, yellow pus is released. A similar picture is compared with honeycombs (kerion). Kerion is often accompanied by general symptoms - fever, malaise, headache. Painful regional lymphadenitis develops (usually posterior or behind the ear nodes).

Dermatophytosis of the nails
Onychomycosis affects at least 5-10% of the population, and over the past 10 years, the incidence has increased by 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.

Allocate three main clinical forms of onychomycosis: distal-lateral, proximal and superficial, depending on the place of introduction of the pathogen. The most common is the distal form. In this case, the 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 skin. The infection spreads to the root of the nail, and for its advancement, the superiority of the growth rate of the fungus over the rate of natural growth of the nail in the opposite direction is necessary. Nail growth slows down with age (up to 50% after 65-70 years), and therefore onychomycosis prevails in the elderly. Clinical manifestations of the distal form are the loss of transparency of the nail plate (onycholysis), which manifests itself as whitish or yellow spots in the thickness of the nail, and subungual hyperkeratosis, in which the nail looks thickened. With a rare proximal form, fungi penetrate through the proximal nail ridge. 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 the present time (in the presence of dozens of effective antimycotics) is 20 years, and according to the results of a survey of middle-aged patients - about 10 years. Quite a lot for a contagious disease.

Dermatophytosis of the hands and feet
Mycoses of the feet are ubiquitous and occur more frequently than any other skin mycoses. 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, even less often - other dermatophytes. Foot mycoses caused by T. rubrum and T. mentagrophytes have specific epidemiology and clinical features. At the same time, variants of mycosis of the feet are possible, typical for one pathogen, but caused by another.

Infection with foot fungus 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 characterized by a chronic course, damage to both feet, frequent spread to smooth skin and nail plates. With a long course, involvement of the skin of the palms, as a rule, of the right (working) hand is characteristic - the syndrome of "two feet and one hand" (tinea pedum et manuum). Usually 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. In the affected area, there is mild erythema, moderate or severe peeling, and in some cases a thick layer of hyperkeratosis. Hyperkeratosis is most pronounced at the points bearing the greatest load. In cases where the focus 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 (epidermophytosis of the feet) occurs more often in public places - gyms, baths, saunas, swimming pools. With epidermophytosis of the feet, an interdigital form is usually observed. In the 3rd, 4th, sometimes in the 1st interdigital fold, a crack appears, bordered by white stripes of macerated epidermis, against the background of surrounding erythema. These phenomena may be accompanied by an unpleasant odor (especially when a secondary bacterial infection is attached) and, as a rule, are 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 fingers, 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
Smooth skin dermatophytosis is less common than athlete's foot or onychomycosis. Smooth skin lesions can cause any dermatophytes. As a rule, in Russia they are caused by T. rubrum (smooth skin rubrophyton) or M. canis (smooth skin microsporia). There are also zoonotic mycoses of smooth skin caused by rarer types of dermatophytes.

Foci of mycosis of smooth skin have characteristic features - 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, the inflammatory reaction and its resolution gradually change, the growth of foci from the center to the periphery looks like an expanding ring. The ring is formed by a roller of erythema and infiltration, peeling is noted in its center. When several annular foci merge, one large foci with polycyclic scalloped outlines is formed. For rubrophytosis, as a rule, affecting adults, widespread foci with moderate erythema are characteristic, while the patient can also have mycosis of the feet or hands, onychomycosis. Microsporia, which mainly affects children infected from domestic animals, is characterized by small coin-shaped foci on closed areas of the skin, often - foci of microsporia of the scalp.

In some cases, doctors, not recognizing mycosis of smooth skin, prescribe corticosteroid ointments to the focus of erythema and infiltration. In this case, the inflammatory phenomena subside, and mycosis takes an erased form (the so-called tinea incognito).

Mycoses of large folds, caused by dermatophytes, also retain their characteristic features: peripheral ridge, resolution in the center and polycyclic outlines. The most typical localization is the inguinal folds and the inner side of the thigh. The main causative agent of inguinal dermatophytosis is currently T. rubrum (inguinal rubrophytosis). The traditional designation of tinea cruris in the domestic literature was epidermophytosis inguinal in accordance with the name of the pathogen - E. floccosum (the old name is E. inguinale).

Diagnosis of Dermatophytosis:

The basic principle of laboratory diagnosis of dermatophytosis is the detection of the mycelium of the pathogen in the pathological material. This is enough to confirm the diagnosis and start treatment. Pathological material: skin flakes, hair, fragments of the nail plate, are subjected to “enlightenment” before microscopy, i.e. treatment with alkali solution. This makes it possible to dissolve the horn structures and leave only the masses of the fungus in the field of 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 elements of the fungus relative to the hair shaft is also taken into account. If the spores are located outside (typical for Microsporum species), this type of lesion is called ectothrix, and if inside, then endothrix (typical for Trichophyton species). Determination of the etiology and identification of dermatophytes are carried out according to morphological features after the isolation of the culture. If necessary, additional tests are carried out (urease activity, pigment formation on special media, the need for nutritional supplements, etc.). For quick diagnosis of 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 in dermatophytosis griseofulvin and terbinafine. Drugs with a broader spectrum of action 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 updated.

Among modern antimycotics, terbinafine is distinguished by 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 other members of the children's team, and various methods of epilation were used in the treatment. The main treatment for dermatophytosis of the scalp is systemic therapy. Griseofulvin, terbinafine, itraconazole, and fluconazole may be used in treatment. Griseofulvin is still the standard treatment for scalp dermatophytosis.

Terbinafine is more effective than griseofulvin in general, 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 is more often understood as trichophytosis, and in Russia as 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 - 6-12 weeks.

In the treatment of dermatophytosis of the nails, local and systemic therapy or their combination is also used - combination therapy. Topical therapy is mainly applicable only for the superficial form, the initial manifestations of the distal form, or lesions of single nails. In other cases, systemic therapy is more effective. Modern topical treatments for onychomycosis include antifungal nail polishes. Systemic therapies include terbinafine, itraconazole, and fluconazole.

The duration of treatment with any drug depends on the clinical form of onychomycosis, the prevalence of the lesion, the degree of subungual hyperkeratosis, the affected nail, and the age of the patient. The special KIOTOS index we have proposed is currently used to calculate the duration. Combination therapy can be prescribed in cases where systemic therapy alone is not enough or it has a long duration. Our experience with combination therapy with terbinafine includes its use in short courses and in an intermittent regimen, 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 topical antimycotics include creams, aerosols, and ointments. If these funds are not available, local antiseptics are used. The duration of treatment ranges from two weeks with the use of modern drugs to four - with the use of traditional drugs. In chronic squamous-hyperkeratotic form of mycosis of the feet, involvement of the hands or smooth skin, lesions of 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. With damage to the nails, the duration of therapy is extended. Systemic therapy is also indicated for acute inflammation, vesiculo-bullous forms of infection. Outwardly in these cases, lotions, antiseptic solutions, aerosols, as well as combined agents 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. With the defeat of vellus hair, deep and infiltrative-suppurative dermatophytosis, tinea incognito, systemic therapy is indicated. We also recommend it for the localization of lesions on the face, and for widespread rubrophytosis (although nails are usually affected as well).

External antifungals are used in the form of creams or ointments; aerosol may be used. 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 the disappearance of clinical manifestations and another 1 week. After that. The preparations should be applied to the lesion and another 2-3 cm outward from its edges.

With simultaneous damage to the scalp or nails, systemic therapy is carried out according to the appropriate schemes. In other cases, with systemic therapy, terbinafine is prescribed at a dose of 250 mg / day for 2-4 weeks. (depending on the pathogen), or itraconazole 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 (nail damage). Secondary rashes on the skin are possible - eidermophytids (mycids) associated with the allergenic properties of the fungus.

With the squamous form, peeling of the skin of the arch of the feet is noted. The process can spread to the lateral and flexion surfaces of the toes. Sometimes areas of diffuse thickening of the skin are formed according to the type of callosity, with lamellar peeling. Usually patients do not complain about subjective sensations.

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 depth of the fold, surrounded by an exfoliating, whitish, stratum corneum of the epidermis, accompanied by itching, sometimes burning. With prolonged walking, cracks can transform into erosion with a wetting surface. In the case of the addition of pyococcal flora, hyperemia, swelling of the skin develop, itching intensifies, pain appears. The course is chronic, exacerbations are observed in the summer.

With a dyshidrotic form, vesicles appear with a thick horny cover, transparent or opalescent contents (“sago grains”). Bubbles are usually located in groups, prone to merging, the formation of multi-chamber, sometimes large bubbles with a tense tire. They are usually localized on the vaults, inferolateral surface and on the contact surfaces of the toes. After their opening, erosions are formed, surrounded by a peripheral roller of exfoliating epidermis. In the case of a secondary infection, the contents of the vesicles (vesicles) become purulent and lymphangitis and lymphadenitis may occur, accompanied by pain, general malaise, and fever.

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

When the nails are damaged, the nail plates (often V toes) become dull, yellowish, uneven, but retain their configuration for a long time. In the thickness, yellow spots or stripes of ocher-yellow color are noted. Over time, in most patients, subungual hyperkeratosis appears and the destruction of the nail plate occurs, accompanied by the “corrosion” of its free edge. Fingernails are almost not affected.

Dermatomycosis

RCHD (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 Council
RSE on REM "Republican Center
health development"
Ministry of Health
and social development
Republic of Kazakhstan
dated December 12, 2014
Protocol No. 9

I. INTRODUCTION

Protocol name: Dermatophytosis

Protocol code:

Code(s) ICD-10

B35 Dermatophytosis

Abbreviations used in the protocol:

ALT - alanine aminotransferase

ALT - aspartate aminotransferase

Protocol development date: year 2014.

Protocol user: dermatovenereologists, general practitioners / therapists / pediatricians.

Classification

Clinical classification of 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;

Sharp form.

. mycosis of nails:

Distal form;

Surface form;

Proximal shape;

Totally dystrophic form.

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures

The main (mandatory) diagnostic examinations carried out at the outpatient level:

Inspection under a Wood's fluorescent lamp;

Bacteriological examination of scrapings from hair, nails, scales from foci of smooth skin.

Additional diagnostic examinations performed at the outpatient level:

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

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

General blood analysis.

The main (mandatory) diagnostic examinations carried out at the hospital level:

General blood analysis;

General urine analysis;

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

Inspection under a Wood's fluorescent lamp.

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

Diagnostic criteria

Complaints and anamnesis

Complaints:

Rashes on smooth skin, scalp;

Change of nail plates.

Disease history:

Contact with a sick person;

Contact with a sick animal;

Visiting public baths, saunas;

Non-compliance with the rules of personal hygiene (wearing someone else's shoes).

Physical examination

Erythematous rounded lesions with clear contours;

Infiltrated rounded lesions;

scales;

bubbles;

Pustules;

Breaking hair.

Dermatophytosis of smooth skin:

clear boundaries;

peripheral growth;

Ring-shaped form with an inflammatory roller along the periphery;

Resolution of inflammation in the center;

Pityriasis peeling.

Dermatophytosis of the hands and feet:

Erythema;

Pityriasis or floury peeling;

Maceration of the stratum corneum;

erosion;

Superficial or deep cracks;

Bubbles or bubbles;

Damage to the nails.

Dermatophytosis of the nail plate:

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

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

Proximal form - white spots appear in the area of ​​the crescent, 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 foci of smooth skin:

Detection of mycelium filaments, fungal spores.

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

Growth of colonies of pathogenic fungi.

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

Indications for expert advice(in the presence of concomitant pathology)

Consultation therapist/GP/pediatrician (in the presence of concomitant pathology of the digestive system).

Differential Diagnosis

Table 1. Differential diagnosis of dermatophytosis of the scalp

table 2. Differential diagnosis of dermatophytosis of smooth skin

Table 3. Differential diagnosis of dermatophytosis of the nails

Treatment

Treatment goals:

elimination of the pathogen.

Treatment tactics

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

Medical treatment

Etiotropic therapy

Dermatophytosis of the scalp:

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

- children with body weight< 20 кг по 62,5 мг в сутки.

Adults 200 mg;
- children from 12 years of age 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 scheme (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 20 to 40 kg, 125 mg per day;
- children with body weight< 20 кг по 62,5 мг в сутки.

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

Desensitizing therapy(for erythema, weeping, blisters):

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

Adults, 10.0 ml of a 10% solution

Sodium thiosulfate (level of evidence - D), intravenously 1 time per day for 10 days:

Adults, 10.0 ml of a 30% solution.

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

Adults, 0.025 g

Adults, 0.001 g

Adults, 0.1 g.

Dermatophytosis of the nails:

Terbinafine orally (after meals):

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

Itraconazole (adults) orally (after meals) according to the scheme:

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

Fluconazole by mouth (after meals):

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

External Therapy

Dermatophytosis of the scalp:

Shaving hair 1 time in 7-10 days;

With infiltrative-suppurative forms:

10% ichthyol ointment for 8-10 hours

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

Iodine, alcohol tincture 2% 2 times a day.

Dermatophytosis of smooth skin, hands and feet:

Topical combination therapy(1-2 weeks):

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

Isoconazole nitrate + diflucortolone valerate cream, ointment;

- with the addition of a secondary infection:

Betamethasone dipropionate + clotrimazole + gentamicin sulfate cream, ointment;

- with squamous forms:

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

Isoconazole (cream) 1-2 times a day;

Clotrimazole (cream, ointment) 2 times a day;

Naftifin (cream, solution) 2 times a day;

Terbinafine (spray, cream) 2 times a day;

Oxyconazole (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.

Dermatophytosis of the nails:

With the defeat of single nails from the distal or lateral edges on 1/3 - ½ of the plate:

Nail cleanings;

External antifungal drugs:

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

After removal of 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;

Naftifin (cream, solution) 2 times a day;

Terbinafine (cream) 2 times a day;

Oxyconazole (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;

Cyclopirox (cream, solution) 2 times a day.

Medical treatment provided on an outpatient basis

List of essential drugs (having a 100% probability of prescription):

Mebhydrolin tablets 0.1;

Clemastine tablets 10 mg;

Miconazole 2% cream;

Isoconazole 1% cream;

Oxyconazole 1% cream;

Naftifin 1% cream, solution;

Econazole cream 1%;

Sertaconazole cream 2%;

Ichthyol ointment 10%;

Isoconazole nitrate + diflucortolone valerate cream, ointment;

Medical treatment provided at the inpatient level

List of Essential Medicines(having a 100% chance of being assigned):

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;

Oxyconazole 1% cream;

Terbinafine 1% cream, 1% spray;

Naftifin 1% cream, solution;

Econazole cream 1%;

Sertaconazole cream 2%;

Ketoconazole 2% cream; 2% ointment;

Bifonazole 1% cream, solution;

Cyclopirox 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 drugs (less than 100% probability of prescribing): none.

Other treatments: no.

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

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

Surgical intervention: not performed.

Preventive actions:

Compliance with the rules of personal hygiene (wearing someone else's shoes, excessive sweating);

Timely rehabilitation of the mycotic focus (crack of the nail or interdigital space).

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

Microscopic examination of skin scrapings for fungus;

Hospitalization

Indications for hospitalization

Indications for emergency hospitalization: not carried out.

Indications for planned hospitalization:

Treatment failure at the outpatient level;

Mycosis of the scalp (children);

Generalization of mycosis of a different localization with spread to the scalp (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 Dermatovenereologist of the Ministry of Health and Social Development of the Republic of Kazakhstan, JSC "Astana Medical University", 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) Dzhetpisbayeva Z.S. - Candidate of Medical Sciences, JSC "Astana Medical University", Associate Professor of the Department of Dermatovenereology;
4) Baev A.I. - Candidate of Medical Sciences, RSE "KazNIKVI";
5) Ahmadyar N.S. - Doctor of Medical Sciences, JSC "NNTsMD" clinical pharmacologist.

Indication of no conflict of interest: absent.

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

Indication of the conditions for revising the protocol: revision of the protocol after 3 years and / or when new methods of diagnosis and / or treatment with a higher level of evidence appear.

Attached files

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