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Tinea capitis describes a dermatophyte infection of scalp and hair that predominately occurs in children. The diagnostic workup includes microscopic examination, culture and/or molecular tests. Treatment is guided by the specific organism involved and should consist of systemic agents as well as adjuvant topical treatment. The aim of the present update of the interdisciplinary German S1 guidelines is to provide dermatologists, pediatricians and general practitioners with a decision tool for selecting and implementing appropriate diagnostic and therapeutic measures in patients with tinea capitis. The guidelines were developed based on current international guidelines, in particular the 2010 European Society for Pediatric Dermatology guidelines and the 2014 British Association of Dermatologists guidelines, as well as on a review of the literature conducted by the guideline committee. This multidisciplinary committee consists of representatives from the German Society of Dermatology (DDG), the German-Speaking Mycological Society (DMykG), the German Society for Hygiene and Microbiology (DGHM), the German Society of Pediatric and Adolescent Medicine (DGKJ) and the German Society for Pediatric Infectious Diseases (DGPI). The Division of Evidence-based Medicine (dEBM) provided methodological assistance. The guidelines were approved by the participating medical societies following a comprehensive internal and external review., Die Tinea capitis ist eine durch Dermatophyten hervorgerufene, vor allem im Kindesalter auftretende Mykose der behaarten Kopfhaut. Die Diagnostik erfolgt mittels mikroskopischer, kultureller und/oder molekularer Methoden. Die Therapie sollte systemisch und begleitend topisch erfolgen und ist abhängig von dem jeweiligen Erreger. Das Ziel des Updates dieser interdisziplinären deutschen S1-Leitlinie ist es, vor allem Dermatologen, Kinderärzten und Allgemeinmedizinern eine Entscheidungshilfe für die Auswahl sowie Durchführung einer geeigneten und suffizienten Diagnostik und Therapie für Patienten mit Tinea capitis zur Verfügung zu stellen. Die Leitlinie wurde unter Berücksichtigung aktueller internationaler Leitlinien, insbesondere der Leitlinien der European Society for Pediatric Dermatology 2010 sowie der British Association of Dermatologists 2014 und den Ergebnissen einer Literaturrecherche durch die Leitlinienkommission erstellt. Diese Kommission ist multidisziplinär und besteht aus Vertretern der Deutschen Dermatologischen Gesellschaft (DDG), der Deutschsprachigen Mykologischen Gesellschaft (DMykG), der Deutschen Gesellschaft für Hygiene und Mikrobiologie (DGHM), der Deutschen Gesellschaft für Kinder- und Jugendmedizin e.V. (DGKJ) und der deutschen Gesellschaft für Pädiatrische Infektiologie (DGPI). Methodisch wurde die Leitliniengruppe durch die Division of Evidence-based Medicine (dEBM) begleitet. Die Leitlinie wurde nach einem umfangreichen internen und externen Review durch die beteiligten Fachgesellschaften freigegeben.

Currently, in Germany, Switzerland, and Austria, a new and until now not known entity of inflammatory and abscessing dermatophyte infection is observed. In particular, these deep infections of the skin and their appendages include Tinea pubogenitalis, Tinea cruris, Tinea barbae, Tinea corporis, and Tinea capitis. Some of the patients came back from a journey to Thailand or South East Asia where transmission occurred. But, independently from a journey to abroad, the dermatophyte might be transferred in Germany, too. In every case, this deep infection is caused by the zoophilic dermatophyte Trichophyton mentagrophytes of the newly described Internal Transcribed Spacer (ITS) genotype VII. From 24 patients with dermatomycoses, altogether 25 isolates of T. mentagrophytes were isolated in the last 6 years. Among them were both male and female patients, the age range was from 1 to 50 years. The infection was affecting the pubogenital area, the capillitium, the face, or the trunk. Most of these infections were acquired in Germany without a stay abroad. A total of 25 dermatophyte isolates—all belonging to T. mentagrophytes—could be characterised. Species identification was confirmed for all isolates by sequencing of the ITS region of rDNA genes. Molecular relationship of the 24 isolates in comparison to already known genotypes within this species was depicted in a phylogenetic tree. The sequences obtained for these isolates are forming their own phylogenetic cluster, corresponding to a new genotype, the ITS genotype VII (“Thai variant”). This genotype is clearly set up from other clusters of T. mentagrophytes, e. g. zoophilic strains isolated from animals and human dermatophytoses, and from T. mentagrophytes genotype VIII “India”. This genotype, as the other zoophilic T. mentagrophytes genotypes, can also be distinguished from the anthropophilic Trichophyton interdigitale.

Scabies or mange is currently a common dermatosis in Germany and other countries, and should be more important in health policy. It affects a cross-section of society, including all age groups, from infants to the aged. Locals and people with a migration background both suffer from this highly contagious ectoparasite infection with excessive, predominately nocturnal itching. Clinical diagnosis represents a challenge for the experienced dermatologist due to the variety of dermatosis to be considered in the differential diagnosis. It is still unclear whether treatment failure or the recurrences observed everywhere are due to in vitro and in vivo resistance of the pathogen agent Sarcoptes scabiei against permethrin or ivermectin. Therapeutic errors seem to play a role as often not all direct contact persons are recorded and treated with antiscabious treatment. They form the reservoir for reinfections. In the event of repeated nonresponse to topical (permethrin) and/or oral antiscabious treatment, alternative topical preparations-benzyl benzoate or crotamiton-should be used. Combination with ivermectin is mandatory.Die Skabies oder Krätze ist aktuell in Deutschland und darüber hinaus eine häufige Dermatose, der schon allein aus gesundheitspolitischer Perspektive Aufmerksamkeit geschenkt werden sollte. Betroffen ist ein Querschnitt der Gesellschaft unter Einbeziehung aller Altersstufen, vom Säugling bis zum Greis. Einheimische und Menschen mit Migrationshintergrund leiden in gleicher Weise unter der mit übermäßigem, vorzugsweise nächtlich auftretendem Juckreiz einhergehenden hochkontagiösen Ektoparasitose. Die Diagnostik stellt aufgrund der vielfältigen differenzialdiagnostisch ins Kalkül zu ziehenden Dermatosen auch für den erfahrenen Dermatologen eine Herausforderung dar. Nach wie vor ist nicht geklärt, ob das allerorten zu beobachtende Therapieversagen auf einer In-vitro- und In-vivo-Resistenz des Erregers Sarcoptes scabiei gegenüber Permethrin oder auch Ivermectin beruht. Therapiefehler – unzureichende Behandlungen – scheinen aber zumindest für Rezidive eine Rolle zu spielen. So werden oft nicht alle direkten Kontaktpersonen erfasst und antiskabiös behandelt. Sie bilden das Reservoir für Reinfektionen. Bei mehrfachem Nichtansprechen auf die topische (Permethrin) und/oder orale antiskabiöse Behandlung, sollte auf die alternativen topischen Präparate – Benzylbenzoat oder Crotamiton – ausgewichen werden. Eine Kombination mit Ivermectin ist dann zwingend.

Tinea capitis describes a dermatophyte infection of scalp and hair that predominately occurs in children. The diagnostic workup includes microscopic examination, culture and/or molecular tests. Treatment is guided by the specific organism involved and should consist of systemic agents as well as adjuvant topical treatment. The aim of the present update of the interdisciplinary German S1 guidelines is to provide dermatologists, pediatricians and general practitioners with a decision tool for selecting and implementing appropriate diagnostic and therapeutic measures in patients with tinea capitis. The guidelines were developed based on current international guidelines, in particular the 2010 European Society for Pediatric Dermatology guidelines and the 2014 British Association of Dermatologists guidelines, as well as on a review of the literature conducted by the guideline committee. This multidisciplinary committee consists of representatives from the German Society of Dermatology (DDG), the German-Speaking Mycological Society (DMykG), the German Society for Hygiene and Microbiology (DGHM), the German Society of Pediatric and Adolescent Medicine (DGKJ) and the German Society for Pediatric Infectious Diseases (DGPI). The Division of Evidence-based Medicine (dEBM) provided methodological assistance. The guidelines were approved by the participating medical societies following a comprehensive internal and external review.

Die pubogenitale Tinea oder auch Tinea genitalis ist eine zwar insgesamt seltene Form einer Dermatophytose, sie wird jedoch aktuell zunehmend haufiger diagnostiziert. Betroffen sind der Mons pubis, jedoch auch die auseren Genitalorgane bis zum Penisschaft und den Schamlippen sowie die Leisten. Neben einer oberflachlichen erythrosquamosen Form der pubogenitalen Tinea kommen uberwiegend stark entzundlich verlaufende Dermatomykosen des Genitalbereiches im Sinne einer Tinea genitalis profunda bis hin zum Kerion Celsi vor. Insgesamt 30 Patienten im Alter von 14 bis 63 Jahren mit einer pubogenitalen Tinea werden hier beschrieben, darunter 11 Manner und 19 Frauen. Der Hauptteil der Patienten stammte aus Graz in Osterreich, nur 2 Patienten aus Deutschland (Sachsen und Insel Sylt). Erreger waren uberwiegend zoophile Dermatophyten, am haufigsten Microsporum (M.) canis (11), gefolgt von Trichophyton (T.) interdigitale (9), T.-Spezies von Arthroderma benhamiae (2) und T. verrucosum (2). Anthropophile Erreger waren T. rubrum (6) und T. tonsurans (1). Anamnestisch sollte immer nach Haustieren, sportlichen Aktivitaten und Reisen gefragt werden. Genitalrasur und eine gleichzeitig bestehende Tinea pedis und Onychomykose sind disponierende Faktoren. Die Behandlung erfolgte auser bei den 3 schwangeren Patientinnen immer systemisch antimykotisch. Die systemische antimyzetische Therapie erfolgte vorzugsweise mit Itraconazol oder Terbinafin, in einem Einzelfall mit Fluconazol. Griseofulvin wurde nicht verwendet, v. a. auch deshalb, weil dieses klassische systemische Antimykotikum in Osterreich nicht mehr zugelassen ist. Bei fehlendem Ansprechen musste im Einzelfall auch ein Wechsel der antimykotischen Behandlung von Itraconazol auf Terbinafin vorgenommen werden.

The term dermatomycoses comprises superficial fungal infections of the skin and their appendages like the hair follicles and the nail apparatus. These superficial mycoses may be caused by dermatophytes or yeasts and, to a less extend, by moulds. These infections are of high importance in medical disciplines not only for the dermatologist but also for physician and the paediatrician and of course for the patients affected. With regard to the treatment of these fungal infections, the costs of topical antifungals will surpass topical corticosteroids in the healthcare system.

Zusammenfassung Die Behandlung der Dermatophytosen basiert auf dem klinischen Bild und dem mykologischen Erregernachweis. Die Onychomykose kann bei richtiger Indikationsstellung topisch mit antimykotischem Nagellack behandelt werden. Die atraumatische Nagelabrasion mit 40 % Harnstoff-Salbe hat einen gunstigen Einfluss auf die Heilung. Die kontinuierliche Behandlung der Onychomykose mit Terbinafin ist die wirksamste systemische Therapieform. Terbinafin oder Itraconazol sind die sichersten und wirksamsten Antimykotika zur Behandlung der Onychomykose im Kindesalter. Zur Lasertherapie der Onychomykose liegen bislang wenige Studien zur klinischen Wirksamkeit vor. Fur die Tinea capitis wird heute eine gezielte „Spezies-spezifische“ Therapie der Dermatophytosen des Kapillitiums empfohlen. Terbinafin, jedoch auch Itraconazol und Fluconazol sind wirksam bei Tinea capitis durch Trichophyton-Arten. Microsporum-Infektionen der Kopfhaut lassen sich am besten mit Griseofulvin behandeln, alternativ mit Itraconazol oder Fluconazol, Terbinafin ist weniger wirksam. Kutane intertriginose Candidosen werden mit Nystatin, aber auch mit Azolen oder Ciclopirox topisch antimykotisch behandelt. Die systemische Therapie erfolgt mit Fluconazol oder Itraconazol. Topische und systemisch applizierbare Antimykotika sind ebenburtige Therapieformen bei akuten Formen der vulvovaginalen Mykose. Mittel der Wahl zur Therapie der chronisch-rezidivierenden Vulvovaginalmykosen durch Candida albicans ist Fluconazol. Ketoconazol hat eine sehr gute Wirkung bei Pityriasis versicolor. Fur die systemische Behandlung bei ausgepragter grosflachiger Pityriasis versicolor ist Itraconazol das Mittel der Wahl.

Treatment of dermatophyte infections is based on the clinical picture and mycological detection of the causative pathogen. Based on the appropriate indication, onychomycosis can be treated topically using an antimycotic nail lacquer. Atraumatic nail abrasion with 40 % urea ointment has a beneficial effect on healing. Continuous treatment of onychomycosis with terbinafine represents the most effective systemic therapy. Terbinafine or itraconazole are the safest and most effective antimycotic agents for the treatment of onychomycosis in children. For laser therapy of onychomycosis, only a few studies on clinical efficacy are available. Regarding tinea capitis, targeted species-specific therapy of dermatophytosis of the scalp is currently recommended. Terbinafine, yet also itraconazole and fluconazole, are effective in tinea capitis caused by Trichophyton species. Microsporum infections of the scalp are preferably treated with griseofulvin, alternatively with itraconazole or fluconazole. Terbinafine is less effective. Candidal intertrigo are topically treated with nystatin, but azoles or ciclopirox olamine are also suitable candidates. Systemically, fluconazole or itraconazole are used. Topical and systemic antimycotics are equivalent forms of therapy in acute vulvovaginal mycosis. Fluconazole is the drug of choice in chronic recurrent vulvovaginal mycosis caused by Candida albicans. Ketoconazole shows very good efficacy in tinea versicolor. With respect to systemic treatment of severe and widespread tinea versicolor, itraconazole is the drug of choice.

Zusammenfassung Pilzinfektionen der Haut werden in Deutschland und weltweit am haufigsten durch Dermatophyten verursacht. Die Tinea pedis ist die haufigste Pilzinfektion in den Industriestaaten der westlichen Welt. Ausgehend von dieser Dermatophytose entwickelt sich eine Tinea unguium. Insbesondere bei alteren Patienten kommt es infolge Autoinokulation von der Tinea pedis et unguium zu Tinea-Formen der freien Haut. Die Tinea capitis tritt bei Erwachsenen selten auf. Dagegen gilt sie als haufigste Pilzinfektion im Kindesalter. Bei der antimykotischen Behandlung der Tinea unguium und der Tinea capitis kann ein Dermatophytid auftreten. Hefepilzinfektionen betreffen die Schleimhaut von Orointestinaltrakt und Genitalsystem. Die Candidose der Haut betrifft vorzugsweise die intertriginosen Regionen der Hautfalten. Dagegen ist die Pityriasis versicolor eine oberflachliche Pilzinfektion am Korperstamm. Schimmelpilzinfektionen sind selten und spielen fast nur bei der Onychomykose eine Rolle. Die Diagnostik von Dermatomykosen umfasst den mikroskopischen Pilznachweis mittels Kaliumhydroxid- bzw. alternativ fluoreszenzoptischem Blankophor-Praparat und den kulturellen Pilznachweis. Dem histologischen Pilznachweis mittels PAS-Farbung sollte aufgrund der hohen Empfindlichkeit insbesondere bei der Onychomykose-Diagnostik ein wesentlich hoherer Stellenwert zukommen. Mit der PCR, u. a. einem Dermatophyten-PCR-ELISA, lassen sich die Erreger direkt im klinischen Material spezifisch und hoch empfindlich nachweisen. Molekulare Methoden, auch die MALDI-TOF (matrix-assisted laser desorption ionization-time of flight)-Massenspektrometrie (MS) als Kulturbestatigungstest, erganzen die konventionelle mykologische Diagnostik.

Most fungal infections of the skin are caused by dermatophytes, both in Germany and globally. Tinea pedis is the most frequent fungal infection in Western industrial countries. Tinea pedis frequently leads to tinea unguium, while in the elderly, both may then spread causing tinea corporis. A variety of body sites may be affected, including tinea glutealis, tinea faciei and tinea capitis. The latter rarely occurs in adults, but is the most frequent fungal infection in childhood. Following antifungal treatment of tinea unguium and also tinea capitis a dermatophytid or hyperergic reaction to dermatophyte antigens may occur. Yeast infections affect the mucous membranes both of the gastro-intestinal system and the genital tract as candidiasis mostly due to Candida albicans. Cutaneous candidiasis affects predominantely the intertriginous regions such as groins and the inframammary area, but also the intertriginous space of fingers and toes. In contrast, pityriasis versicolor is a superficial epidermal fungal infection primarily on the the trunk. Mold infections are rare in dermatology; they play a role nearly exclusively in nondermatophyte-mold (NDM) onychomycosis. The diagnosis of dermatomycoses comprises the microscopic detection of fungi using the potassium hydroxide preparation or alternatively the fluorescence optical Blankophor preparation together with culture. The histological fungal detection with PAS staining possesses a high sensitivity, and it should play a more important role in particular for diagnosis of onychomycosis. Molecular biological methods, based on the amplification of fungal DNA with use of specific primers for the distinct causative agents are on the rise. With PCR, such as dermatophyte-PCR-ELISA, fungi can be detected directly in clinical material in a highly specific and sensitive manner without prior culture. Today, molecular methods, such as Matrix Assisted Laser Desorption/Ionization Time-Of-Flight Mass Spectrometry (MALDI TOF MS) as culture confirmation assay, complete the conventional mycological diagnostics.

Summary Dermatomycoses are caused most commonly by dermatophytes. The anthropophilic dermatophyte Trichophyton rubrum is still the most frequent causative agent worldwide. Keratinolytic enzymes, e.g. hydrolases and keratinases, are important virulence factors of T. rubrum. Recently, the cysteine dioxygenase was found as new virulence factor. Predisposing host factors play a similarly important role for the development of dermatophytosis of the skin and nails. Chronic venous insufficiency, diabetes mellitus, disorders of cellular immunity, and genetic predisposition should be considered as risk factors for onychomycosis. A new alarming trend is the increasing number of cases of onychomycosis – mostly due to T. rubrum – in infancy. In Germany, tinea capitis is mostly caused by zoophilic dermatophytes, in particular Microsporum canis. New zoophilic fungi, primarily Trichophyton species of Arthroderma benhamiae, should be taken into differential diagnostic considerations of tinea capitis, tinea faciei, and tinea corporis. Source of infection are small household pets, particularly rodents, like guinea pigs. Anthropophilic dermatophytes may be introduced by families which immigrate from Africa or Asia to Europe. The anthropophilic dermatophytes T. violaceum, T. tonsurans (infections occurring in fighting sports clubs as “tinea gladiatorum capitis et corporis”) and M. audouinii are causing outbreaks of small epidemics of tinea corporis and tinea capitis in kindergartens and schools. Superficial infections of the skin and mucous membranes due to yeasts are caused by Candida species. Also common are infections due to the lipophilic yeast fungus Malassezia. Today, within the genus Malassezia more than 10 different species are known. Malassezia globosa seems to play the crucial role in pityriasis versicolor. Molds (also designated non-dermatophyte molds, NDM) are increasingly found as causative agents in onychomycosis. Besides Scopulariopsis brevicaulis, several species of Fusarium and Aspergillus are found.

The medical term onychomycosis should be understood as chronic infection of the nails caused by a fungus. The most common causative agents are the dermatophytes and Candida species. The less common are certain types of moulds (nondermatophyte moulds or NDMs). In approximately 60-80 % of the cases, onychomycosis is due to dermatophytes. Among dermatophytes, the most often isolated causative pathogen is Trichophyton (T.) rubrum. Other common species are T. interdigitale (formerly T. mentagrophytes), Epidermophyton floccosum, and T. tonsurans. The most significant yeasts causing onychomycosis are Candida albicans and Candida parapsilosis. Predisposing factors for onychomycosis include mainly diseases such as diabetes mellitus, peripheral vascular arterial disease, chronic venous insufficiency, polyneuropathies of diverse etiologies, and immunosuppression, e.g., myeloproliferative diseases (such as lymphoma and paraproteinemia), HIV/AIDS, etc. Other factors facilitating the fungal infection are frequent trauma in professional sportsmen, often accompanied by excessive perspiration. The diagnostic methods that are often applied in different dermatologic departments and ambulatory units are also different. This precludes the creation of a unified diagnostic algorithm that could be used everywhere as a possible standard. In most of the cases, the method of choice depends on the specialist's individual experience. The therapeutic approach depends mostly on the fungal organism identified by the dermatologist or mycologist. This review hereby includes the conventional as well as the newest and most reliable and modern methods used for the identification of the pathogens causing onychomycosis. Moreover, detailed information is suggested, about the choice of therapeutic scheme in case whether dermatophytes, moulds, or yeasts have been identified as causative agents. A thorough discussion of the schemes and duration of the antifungal therapy in certain groups of patients have been included.

Die Onychomykose (OM) ist eine chronische Pilzinfektion der Nagel, am haufigsten verursacht durch Dermatophyten, meist Trichophyton rubrum, auserdem spielen Hefepilze (z. B. Candida parapsilosis), seltener Schimmelpilze (Scopulariopsis brevicaulis) eine Rolle. Im Einzelfall ist zu klaren, ob es sich lediglich um eine Kontamination oder nur um sekundares Wachstum auf pathologisch verandertem Nagelmaterial handelt. Die „Foot Check-Studie“ im Rahmen des europaischen Achilles-Projektes hat fur Deutschland eine bevolkerungsbezogene Punktpravalenz fur die OM von 12,4% ergeben. Bislang sah man die OM nur sehr selten bei Kindern und Jugendlichen, es kommt jedoch offenbar zu einer langsamen Zunahme der Nagelpilzinfektionen auch in der Kindheit. Mehr und mehr ruckt als disponierender Faktor fur die Tinea pedis und Onychomykose der Diabetes mellitus in den Blickpunkt. Im Umkehrschluss muss die Onychomykose als unabhangiger und wichtiger Pradiktor eines diabetischen Fussyndroms und Fusulkus angesehen werden. Eine Vielzahl von infektiosen und nichtinfektiosen Nagelveranderungen ist differenzialdiagnostisch auszuschliesen. Die Psoriasis der Nagel stellt wahrscheinlich keinen speziellen Risikofaktor fur die OM dar, jedoch muss damit gerechnet werden, dass bei Psoriasis unguium zumindest Hefe- und Schimmelpilze vermehrt isoliert werden konnen. Es handelt sich hierbei aber eher um ein sekundares Wachstum. Stigmatisierung und Beeintrachtigung der Lebensqualitat durch eine Onychomykose sind mittlerweile ebenfalls nachgewiesen.

Summary Phaeohyphomycosis is a distinct mycotic infection of the skin or internal organs caused by darkly pigmented (dematiaceous) fungi, which are widely distributed in the environment. Phaeohyphomycosis is most frequently an opportunistic infection in immunosuppressed patients (HIV, corticotherapy, transplant patients) or is frequently associated with chronic diseases and diabetes. The spectrum of the disease is broad and includes superficial infections, onychomycosis, subcutaneous infections, keratitis, allergic disease, pneumonia, brain abscesses and disseminated disease. Rarely, immunocompetent patients may be affected. We describe two new cases of subcutaneous phaeohyphomycosis in immunocompetent patients: in the first patient, the causative agent was Exophiala jeanselmei, a common cause of phaeohyphomycosis; and in the second, Cladophialophora carrionii, which could be identified by culture. Cladophialophora carrionii is mainly the aetiological agent of chromoblastomycosis and only rarely the cause of phaeohyphomycosis. The first patient was treated with surgical excision and oral itraconazole, and the second patient responded to oral itraconazole only. Lesions improved in both patients and no recurrence was observed at follow-up visits.

Summary Tinea capitis is the most common dermatophyte infection in childhood, but may rarely occur in adults and the elderly. Causative agents vary within different geographical areas as well as during decades. The aim of this study was to evaluate the prevalence and causative agents of tinea capitis in Southeastern Austria. Retrospective analysis of 714 patients diagnosed with tinea capitis seen at the outpatient Department of Dermatology/Medical University of Graz during the time period 1985–2008 was carried out. A total of 517 of the 714 patients were children, 21 adults and in the case of 176 patients age was not available. Microsporum canis was found in 84.4%. Trichophyton soudanense tinea capitis is seen since 1998, Trichophyton tonsurans for the first time in 2008. Tinea capitis has become very important for the public health. Besides an increasing incidence, there is a change in age of the patients affected and with the pattern of causative agents as a result of immigration movements and lifestyle habits mainly influenced by domestic pets. Our situation reflects nearly the epidemiology of the bordering countries of Austria mainly in the Southeastern surroundings. These epidemiological changes are a challenge for general practitioners, dermatologists and veterinarians to work close together for advice on control, early diagnosing and adequate treatment.

Summary Griseofulvin has been introduced in 1958, ever since it remained the gold standard for the treatment of tinea capitis in the United States. Despite the availability of new antifungals like terbinafine, itraconazole and fluconazole –with few exceptions not licensed for their use in children – duration of tinea capitis treatment could not be shortened. The reasons therefore are the anatomic structure of the hair follicle, the dormant sebum-production before onset of puberty, and the way of action of the new antifungals. Although data concerning the pharmacokinetics of allylamines and triazoles in childhood-populations are lacking, some experience confirms a correlation of the way of action of modern antifungals and the causative pathogen. In children the treatment of Microsporum infections of the scalp is crucial. That may be explained by the unique pharmacokinetic features of the substance of terbinafine: Terbinafine neither can be excreted by sweat nor by sebum before onset of puberty. Terbinafine is incorporated in the keratin of mature terminal hair in the anagen phase. In children it will not be built in the hair shaft and therefore it will not reach the surface of the scalp where the sheets of arthro-conidia in microsporosis are located. This peculiar fact was not yet considered in clinical studies.

Infektionen durch Dermatophyten, sog. "Dermatophytosen", zahlen zu den haufigsten Infektionskrankheiten des Hautorgans, mit unterschiedlicher Verteilung. In Abhangigkeit von geographischen Regionen sowie von soziookonomischen Umstanden sind schatzungsweise 10–15 % der Weltbevolkerung davon betroffen. Wahrend Pilzinfektionen des Hautorgans bislang ahnlich wie Ektoparasitosen (Ungezieferbefall der Haut) mit mangelnder Hygiene, schlechten Wohn- und Lebensbedingungen und Krankheit in engen kausalen Bezug gebracht wurden, hat sich dieses atiologische Muster in den letzten Jahrzehnten drastisch geandert: Gerade in hoch entwickelten, d. h. zivilisierten Landern des europaischen Kontinents, aber auch in den USA wird seit 1990 eine signifikante Zunahme von Kopfpilz- (Tinea capitis) sowie Nagelpilz-Infektionen beobachtet.

The estrogenized vagina is colonized by Candida species in at least 20 % of women; in late pregnancy and in immunosuppressed patients this increases to at least 30 %. In most cases Candida albicans is involved. Host factors, particularly local defense mechanisms, gene polymorphisms, allergies, serum glucose levels, antibiotics, psycho-social stress and estrogens influence the risk of candidal vulvovaginitis. Non-albicans species, particularly Candida glabrata, and in rare cases also Saccharomyces cerevisiae, cause less than 10 % of all cases of vulvovaginitis with some regional variation; these are generally associated with milder signs and symptoms than normally seen with a Candida albicans-associated vaginitis. Typical symptoms include premenstrual itching, burning, redness and odorless discharge. Although itching and redness of the introitus and vagina are typical symptoms, only 35–40 % of women reporting genital itching in fact suffer from vulvovaginal candidosis. Medical history, clinical examination and microscopic examination of vaginal content using 400 × optical magnification, or preferably phase contrast microscopy, are essential for diagnosis. In clinically and microscopically unclear cases and in chronically recurring cases, a fungal culture for pathogen determination should be performed. In the event of non-Candida albicans species the minimum inhibitory concentration (MIC) should also be determined. Chronic mucocutaneous candidosis, a rarer disorder which can occur in both sexes, has other causes and requires different diagnostic and treatment measures. Treatment with all antimycotic agents on the market (polyenes such as nystatin; imidazoles, such as clotrimazole; and many others including ciclopirox olamine) is easy to administer in acute cases and is successful in more than 80 % of cases. All vaginal preparations of polyenes, imidazoles and ciclopirox olamine and oral triazoles (fluconazole, itraconazole) are equally effective ([Table 4]), however oral triazoles should not be administered during pregnancy according to the manufacturers. Candida glabrata is not sufficiently sensitive to the usual dosages of antimycotic agents approved for gynecological use. In other countries vaginal suppositories of boric acid (600 mg, 1–2 times daily for 14 days) or flucytosine are recommended. Boric acid treatment is not allowed in Germany and flucytosine is not available. 800 mg oral fluconazole per day for 2–3 weeks is therefore recommended in Germany. Due to the clinical persistence of Candida glabrata despite treatment with high-dose fluconazole, oral posaconazole and, more recently, echinocandins such as micafungin are under discussion; echinocandins are very expensive, are not approved for this indication and are not supported by clinical evidence of their efficacy. In cases of vulvovaginal candidosis, resistance to Candida albicans does not play a significant role in the use of polyenes or azoles.

Vulvovaginal candidasis (VVC) is a common disease. The majority of cases is caused by Candida albicans, but in recent years an increase has been observed in the frequency of non-albicans Candida infections, especially due to C. glabrata and C. tropicalis. The aim of the study was to assess the prevalence of non-albicans Candida infections in patients suffering from VVC. Therefore, the statistical data of culture-confirmed VVC ascertained at the Institute of Hygiene (Medical University Graz) have been studied. Altogether, 10,463 samples from patients with vulvovaginal complaints were analysed in the years 2000-2004, a number of 3184 proved to be culture-positive for yeast. Candida albicans was the most prevalent cause in 87.9% of all cases. Non-albicans Candida yeast were detected in 12.1%, mainly C. glabrata and Saccharomyces cerevisiae. During a 1-year period 185 patients showed more than one episode of VVC. Patients aged 21-40 years were significantly more prone to suffer from VVC compared with other age-related groups.

The oestrogenised vagina is colonised by Candida species in at least 20% of women; in late pregnancy and in immunosuppressed patients, this increases to at least 30%. In most cases, Candida albicans is involved. Host factors, particularly local defence mechanisms, gene polymorphisms, allergies, serum glucose levels, antibiotics, psycho-social stress and oestrogens influence the risk of candidal vulvovaginitis. Non-albicans species, particularly Candida glabrata, and in rare cases also Saccharomyces cerevisiae, cause less than 10% of all cases of vulvovaginitis with some regional variation; these are generally associated with milder signs and symptoms than normally seen with a C. albicans-associated vaginitis. Typical symptoms include premenstrual itching, burning, redness and odourless discharge. Although itching and redness of the introitus and vagina are typical symptoms, only 35-40% of women reporting genital itching in fact suffer from vulvovaginal candidosis. Medical history, clinical examination and microscopic examination of vaginal content using 400× optical magnification, or preferably phase contrast microscopy, are essential for diagnosis. In clinically and microscopically unclear cases and in chronically recurring cases, a fungal culture for pathogen determination should be performed. In the event of non-C. albicans species, the minimum inhibitory concentration (MIC) should also be determined. Chronic mucocutaneous candidosis, a rarer disorder which can occur in both sexes, has other causes and requires different diagnostic and treatment measures. Treatment with all antimycotic agents on the market (polyenes such as nystatin; imidazoles such as clotrimazole; and many others including ciclopirox olamine) is easy to administer in acute cases and is successful in more than 80% of cases. All vaginal preparations of polyenes, imidazoles and ciclopirox olamine and oral triazoles (fluconazole, itraconazole) are equally effective (Table ); however, oral triazoles should not be administered during pregnancy according to the manufacturers. C. glabrata is not sufficiently sensitive to the usual dosages of antimycotic agents approved for gynaecological use. In other countries, vaginal suppositories of boric acid (600 mg, 1-2 times daily for 14 days) or flucytosine are recommended. Boric acid treatment is not allowed in Germany and flucytosine is not available. Eight hundred-milligram oral fluconazole per day for 2-3 weeks is therefore recommended in Germany. Due to the clinical persistence of C. glabrata despite treatment with high-dose fluconazole, oral posaconazole and, more recently, echinocandins such as micafungin are under discussion; echinocandins are very expensive, are not approved for this indication and are not supported by clinical evidence of their efficacy. In cases of vulvovaginal candidosis, resistance to C. albicans does not play a significant role in the use of polyenes or azoles. Candida krusei is resistant to the triazoles, fluconazole and itraconazole. For this reason, local imidazole, ciclopirox olamine or nystatin should be used. There are no studies to support this recommendation, however. Side effects, toxicity, embryotoxicity and allergies are not clinically significant. Vaginal treatment with clotrimazole in the first trimester of a pregnancy reduces the rate of premature births. Although it is not necessary to treat a vaginal colonisation of Candida in healthy women, vaginal administration of antimycotics is often recommended in the third trimester of pregnancy in Germany to reduce the rate of oral thrush and napkin dermatitis in healthy full-term newborns. Chronic recurrent vulvovaginal candidosis continues to be treated in intervals using suppressive therapy as long as immunological treatments are not available. The relapse rate associated with weekly or monthly oral fluconazole treatment over 6 months is approximately 50% after the conclusion of suppressive therapy according to current studies. Good results have been achieved with a fluconazole regimen using an initial 200 mg fluconazole per day on 3 days in the first week and a dosage-reduced maintenance therapy with 200 mg once a month for 1 year when the patient is free of symptoms and fungal infection (Table ). Future studies should include Candida autovaccination, antibodies to Candida virulence factors and other immunological experiments. Probiotics with appropriate lactobacillus strains should also be examined in future studies on the basis of encouraging initial results. Because of the high rate of false indications, OTC treatment (self-treatment by the patient) should be discouraged.

Background Tinea capitis is the most common fungal infection of the scalp in childhood, but a very rare disorder in the first year of life. Objective To evaluate the efficacy, tolerability and safety of itraconazole in 7 children aged between 3 and 46 weeks (median: 36 weeks) suffering from tinea capitis caused by Microsporum canis. Methods Prospective case note study. In all patients KOH testing and fungal cultivation on Sabouraud dextrose agar were performed. Results 7 patients (5 girls and 2 boys) were included in the period between 2001 and 2008. The causative etiologic agent was Microsporum canis in all children. The patients received itraconazole 5mg/kg bodyweight daily for 3 to 6 weeks with no clinically side effects being noted. In all patients clinical and mycological cure could be achieved. Conclusion Itraconazole proved to be a safe and effective treatment option for Microsporum canis induced tinea capitis in children in their first year of life.

Most fungal infections of the skin are caused by dermatophytes, both in Germany and globally. Tinea pedis is the most frequent fungal infection in Western industrial countries. Tinea pedis frequently leads to tinea unguium, while in the elderly, both may then spread causing tinea corporis. A variety of body sites may be affected, including tinea glutealis, tinea faciei and tinea capitis. The latter rarely occurs in adults, but is the most frequent fungal infection in childhood. Following antifungal treatment of tinea unguium and also tinea capitis a dermatophytid or hyperergic reaction to dermatophyte antigens may occur. Yeast infections affect the mucous membranes both of the gastro-intestinal system and the genital tract as candidiasis mostly due to Candida albicans. Cutaneous candidiasis affects predominantely the intertriginous regions such as groins and the inframammary area, but also the intertriginous space of fingers and toes. In contrast, pityriasis versicolor is a superficial epidermal fungal infection primarily on the the trunk. Mold infections are rare in dermatology; they play a role nearly exclusively in nondermatophyte-mold (NDM) onychomycosis. The diagnosis of dermatomycoses comprises the microscopic detection of fungi using the potassium hydroxide preparation or alternatively the fluorescence optical Blankophor preparation together with culture. The histological fungal detection with PAS staining possesses a high sensitivity, and it should play a more important role in particular for diagnosis of onychomycosis. Molecular biological methods, based on the amplification of fungal DNA with use of specific primers for the distinct causative agents are on the rise. With PCR, such as dermatophyte-PCR-ELISA, fungi can be detected directly in clinical material in a highly specific and sensitive manner without prior culture. Today, molecular methods, such as Matrix Assisted Laser Desorption/Ionization Time-Of-Flight Mass Spectrometry (MALDI TOF MS) as culture confirmation assay, complete the conventional mycological diagnostics.

Dermatomycoses are caused most commonly by dermatophytes. The anthropophilic dermatophyte Trichophyton rubrum is still the most frequent causative agent worldwide. Keratinolytic enzymes, e.g. hydrolases and keratinases, are important virulence factors of T. rubrum. Recently, the cysteine dioxygenase was found as new virulence factor. Predisposing host factors play a similarly important role for the development of dermatophytosis of the skin and nails. Chronic venous insufficiency, diabetes mellitus, disorders of cellular immunity, and genetic predisposition should be considered as risk factors for onychomycosis. A new alarming trend is the increasing number of cases of onychomycosis - mostly due to T. rubrum - in infancy. In Germany, tinea capitis is mostly caused by zoophilic dermatophytes, in particular Microsporum canis. New zoophilic fungi, primarily Trichophyton species of Arthroderma benhamiae, should be taken into differential diagnostic considerations of tinea capitis, tinea faciei, and tinea corporis. Source of infection are small household pets, particularly rodents, like guinea pigs. Anthropophilic dermatophytes may be introduced by families which immigrate from Africa or Asia to Europe. The anthropophilic dermatophytes T. violaceum, T. tonsurans (infections occurring in fighting sports clubs as "tinea gladiatorum capitis et corporis") and M. audouinii are causing outbreaks of small epidemics of tinea corporis and tinea capitis in kindergartens and schools. Superficial infections of the skin and mucous membranes due to yeasts are caused by Candida species. Also common are infections due to the lipophilic yeast fungus Malassezia. Today, within the genus Malassezia more than 10 different species are known. Malassezia globosa seems to play the crucial role in pityriasis versicolor. Molds (also designated non-dermatophyte molds, NDM) are increasingly found as causative agents in onychomycosis. Besides Scopulariopsis brevicaulis, several species of Fusarium and Aspergillus are found.

Jeder kennt den Begriff "Allergie" und fast scheint es, dass jeder unter einer Allergie leidet. Das Wort Allergie stammt vom griechischen αλλως (allos), anders, fremd, eigenartig, und eργον (ergon), Arbeit, Reaktion, Verrichtung, und wird laut Pschyrembel so definiert: "angeborene od. erworbene spezif. Anderung der Reaktionsfahigkeit des Immunsystems gegenuber korperfremden, eigentlich unschadlichen und zuvor tolerierten Substanzen, die als Allergen erkannt werden" (Pschyrembel, 263. Auflage, Walter de Gruyter Verlag, Berlin).

We report on 3 patients with cutaneous mycotic infections (superficial dermatophytosis, 1 patient; trichophytia, 2 patients), who on histological examination revealed dense, superficial, and deep lymphoid infiltrates admixed with variable numbers of eosinophils and with large, atypical-looking, partly CD30-positive lymphocytes. All 3 patients had received steroid therapy (locally and/or orally) upon a clinical misdiagnosis of granuloma annulare. This unusual histopathologic presentation of cutaneous mycotic infections may be mistaken for a lymphoproliferative disorder, particularly for lymphomatoid papulosis.

A 19-year-old previously well female veterinary student with regular contact with diverse species of animals presented with an initially small red plaque on her left cheek. During the next 3 weeks the lesion developed into an ulcerated nodule 4 cm in size with a brownish eschar on top, a satellite papule, and marked infl ammation of the surrounding skin (fi gure). The patient had malaise and a painful pronounced cervical lymphadenopathy. Laboratory investigations were unremarkable except for a transient elevation of C-reactive protein (820 mg/L), neutropenia (38%), and eosinophilia (11%). During 2 weeks of intravenous treatment with piperacillin and tazobactam combined fi rst with clindamycin then doxycycline, the nodule demarcated but persisted, and a complete necrectomy was done. The resulting large tissue defect was reconstructed in a separate operation. Serology for Francisella tularensis, Bartonella henselae, Yersinia enterocolitica O3 and O9 antigens, Leishmania spp, Rickettsia conorii, and R mooseri were all negative. Bacterial cultures were negative, including Bacillus anthracis and Mycobacterium tuberculosis. Histopathology showed full-thickness necrosis of the skin. Brick-shaped orthopoxvirus particles were evident on electron microscopy (fi gure) and quantitative real-time PCR of the haemagglutinin gene of the cowpox virus was positive, leading to the diagnosis of human cowpox. Sequence analysis by direct DNA sequencing identifi ed the isolate AT_Styria/84/09 (Genbank accession number FJ7692784) that is closely related to a cowpox virus isolated from domestic cats in Austria. Cowpox virus infections represent a very rare zoonosis in human beings. However, increasing numbers of cases in young people have been documented recently, presumably because of a lack of cross-reactive immunity after the end of routine smallpox vaccination in the late 1970s. The disease remains localised and is self-limiting in patients that are immunocompetent, although dissemination and fatal courses have been reported. After an incubation period of 7–12 days after direct skin contact with cats, which are the main source of infections in people, patients develop a necrotising nodule with consecutive scar formation, accompanied by malaise, raised temperature, and long-lasting, pronounced, and painful regional lymphadenopathy. Diagnosis is made on the basis of electron microscopy and PCR of the lesion. Although no approved specifi c antiviral treatment exists against infections with the cowpox virus, cidofovir can be given in complicated cases. Plastic surgery might be necessary to avoid substantial aesthetic consequences.

Tinea capitis is the most common dermatophyte infection in childhood, but may rarely occur in adults and the elderly. Causative agents vary within different geographical areas as well as during decades. The aim of this study was to evaluate the prevalence and causative agents of tinea capitis in Southeastern Austria. Retrospective analysis of 714 patients diagnosed with tinea capitis seen at the outpatient Department of Dermatology/Medical University of Graz during the time period 1985-2008 was carried out. A total of 517 of the 714 patients were children, 21 adults and in the case of 176 patients age was not available. Microsporum canis was found in 84.4%. Trichophyton soudanense tinea capitis is seen since 1998, Trichophyton tonsurans for the first time in 2008. Tinea capitis has become very important for the public health. Besides an increasing incidence, there is a change in age of the patients affected and with the pattern of causative agents as a result of immigration movements and lifestyle habits mainly influenced by domestic pets. Our situation reflects nearly the epidemiology of the bordering countries of Austria mainly in the Southeastern surroundings. These epidemiological changes are a challenge for general practitioners, dermatologists and veterinarians to work close together for advice on control, early diagnosing and adequate treatment.

Background Onychomycosis is a rare disease in children with an estimated prevalence ranging from 0% to 2.6%. Thus far, only limited experience with itraconazole and terbinafine treatment in children with onychomycosis is available in the literature. Aim of the study Evaluation of treatment experience with itraconazole or terbinafine in childhood onychomycosis. Subjects Thirty-six children and adolescents (aged 4–17 years, 18 males and 18 females) with clinical and mycologically proven onychomycosis were enrolled in the present study. Methods and outcome In 27 of 36 patients, the causative agent (Trichophyton rubrum in 26 cases and Trichophyton interdigitale in one patient) could be identified by means of cultivation. Nineteen patients were treated with itraconazole 200 mg once daily for 12 weeks, and 17 patients were treated with terbinafine for 12 weeks in a dosage according to their body weight, respectively. Clinical cure was achieved within 1 to 5 months after discontinuation in all patients treated with itraconazole and in all but two patients after cessation of terbinafine treatment. Neither in the itraconazole nor in the terbinafine group were serious adverse events reported.Clinical cure was achieved within 1 to 5 months after discontinuation in all patients treated with itraconazole and in all but two patients after cessation of terbinafine treatment. Neither in the itraconazole nor in the terbinafine group were serious adverse events reported. Conclusion To our experience, a mycological and clinical cure appears in children in a shorter time after treatment discontinuation (average 2–5 months) compared with adults. Itraconazole and terbinafine seem to be safe and effective in childhood onychomycosis; therefore, these antifungals seem to be potential alternatives to griseofulvin.

Superficial fungal infections caused by dermatophytes (dermatophytoses) are the most common skin infections with about 10-15% of the population throughout the world being affected. Up to now the occurrence of fungal infections of the skin has been connected, like ectoparasitic infections with poor hygiene and poor living conditions. During the last decades, however, there has been a dramatic change with a significant increase in mycotic scalp infections as well as fungal nail disease mainly in highly developed countries like the US and those on the European continent.

PubMedID: 17681048 Tinea capitis (scalp ringworm) is the most common dermatophyte infection of the scalp affecting mainly children and rarely adults. The epidemiology of tinea capitis varies within different geographical areas throughout the world. It may occur sporadically or epidemically and an increase in its incidence has been noted over the last few decades. The aim of the study is to obtain a general overview of the current state and changing pattern of tinea capitis in Europe. According to the literature, there has been a significant increase in the incidence of tinea capitis and a change in the pattern of infectious agents in particular. Microsporum canis, a zoophilic dermatophyte, is still the most common reported causative agent of tinea capitis in Europe. The countries reporting the highest incidence of M. canis infections are mainly in the Mediterranean but also bordering countries like Austria, Hungary, Germany and Poland. Besides the increase in Microsporum-induced tinea capitis, there is a shift towards anthrophilic tinea capitis mainly in urban areas in Europe. The largest overall increase with anthropophilic dermatophytes has been noted with Trichophyton tonsurans mainly in the UK and with Trichophyton soudanense and Microsporum audouinii in France. The occurrence of anthropophilic infections seems to be geographically restricted and is possibly linked to the immigration from African countries. Children (aged 3-7 years with no predilection of gender) remain the most commonly affected, but recently an increase of tinea capitis has been observed in adults and in the elderly. The results of the study clearly demonstrate the importance of diagnosing and proper treatment of mycotic scalp infection in the Europe. If not diagnosed and treated properly, its prevalence might reach epidemic proportions in the near future. Therefore, an increased level of surveillance (screening in schools), and a highly effective interdisciplinary cooperation among general practitioners, mycologists, veterinarians and dermatologists are strongly recommended. © 2007 Blackwell Publishing Ltd.

A 29-year-old man presented with generalized erythroderma and scaling. Physical examination revealed erythema with lamellar ichthyotic scales over the entire body and focal erosions on the back (Figure 1 and Figure 2). Although growth of scalp hairs was abundant, individual hairs appeared to be brittle. The skin condition had been present since birth, and the patient reported episodic erythrodermic flares with scaling. Examination of his teeth and nails revealed no abnormalities. His family history was noncontributory, with the exception of a distant relative who had an unspecified skin condition. Laboratory tests showed pronounced elevation of IgE levels ( 2000 kU/L; reference range, 100 kU/L), with specific IgE reagins to various airborne and food allergens. A routine histopathologic section of erythrodermic skin is shown in Figure 3, and a microscopic photograph of a hair shaft is shown in Figure 4. What is your diagnosis?