By tanzeel ahmad Contents History Definition Etiology Epidemiology Pathophysiology Clinical classification ID: 912378
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Slide1
Qooba (ringworm)
By
tanzeel
ahmad
Slide2Contents HistoryDefinitionEtiology
Epidemiology
Pathophysiology
Clinical classification
Differential Diagnosis
Diagnosis
Management
Conclusion
Slide3Introduction
The first recorded reference to a dermatophyte infection is attributed to
Aulus Cornelius Celsus
, the Roman encyclopaedist, who in his “
De Re Medicina
” written around 30 A.D., described a suppurative infection of scalp that came to be known the
Kerion of Celsus
.
After Celsus it was
Disqoridoos
(
Dioscorides
, 60 A.D.) who gave description of
Qooba
in children
in
his “
De
Materia
Medica
”.
Jalinoos
(
Galenus
of
Pergamon
, 129-200 A.D.) described
Qooba, its
cause and treatment and classified it into acute and chronic in his book “
Mayameer
”.
Slide4From the 5th to 15th centuries which are considered as middle age,with the advent of Islam, Arabs acquired, collected, translated and documented the knowledge of existing medicine from almost all the famous civilizations especially from the Greek which was based on humoral theory of Hippocrates. Rabban Al-
Tabri
(810-895 A.D.),
Zakaria
Al-
Razi
(850-923 A.D.)
Hasan
Al-
Quamari
(9th Century A.D.)
Abbas
Al-
Majoosi
(930-999 A.D.)
Ibn
Sina
(980-1037 A.D.)
Ahmad Al-
Tabri
(10th century A.D.)
Ismail
Jurjani
(12th century A.D.)
Dawood
Al-
Antaki
(1514-1599 A.D.)
Akbar
Arzani
(17th century A.D.)
Azam
Khan
(19th century A.D.) Almost all the renowned Arab physicians described the disease in their treatises.
Slide5Historically, medical mycology, specifically relating to human disease, began with the discovery of the fungal aetiology of favus and centred around three European physicians
in the mid-
19th
century:
Robert Remak
,
Johann L.
Scho¨nlein
, and
David Gruby
.
Raimond
Sabouraud
,
a medical
mycologists, began his scientific studies of the dermatophyte around
1890. He
classified the dermatophyte into four genera:
Achorion
,
Epidermophyton
,
Microsporum
and
Trichophyton
,
primarily on the basis of the clinical aspects of the disease, combined with
culture
and microscopic observations. The medium that he developed is in use today for culturing fungi (although the ingredients are modified) and is named in his
honour,
Sabouraud glucose (dextrose) agar
Slide6In 1934, Chester Emmons modernized the
taxonomic
scheme of Sabouraud He eliminated the genus
Achorion
and recognized only the
three
genera:
Microsporum
,
Trichophyton
and
Epidermophyton
on the basis of mycological principles
.
Slide7Definition
Qooba
is a roughness which appears over skin surface, associated with
itching, scaling, dryness and some time fish like scales sheds off from them. It may
be of black or red
color
usually periphery is red and occasionally yellowish fluid
discharges from them.
Slide8The term dermatophytosis refers to superficial infection of skin, nail, and hair due to a group of filamentous fungi, belong to three genera namely Microsporum,
Trichophyton,
and
Epidermophyton
.
The infection commonly referred to as
ringworm
or
tinea
. Infection
is generally cutaneous and restricted to the non living cornified layer of skin because
of the fungi to penetrate the deeper tissue or organs of immunocompetent host. The
atypical lesion of dermatophytosis is an annular scaly patches associated with
erythema and vesicles
.
Slide9Etiology
The
cause of
Qooba
is similar to that of the
sa’fa
; that is the
haad
(sharp),
harrif
(astringent) or pungent fluid which is mixed with
ghaleez
saudavi
madda
(viscous melancholic humour) more viscous than the matter of
jarab
(scabies). And it
may be due to
balgham
maleh
(saline phlegm) which is burnt and converted into
sauda
(melancholic
homour
).
Slide10Dermatophytosis is colonization of keratinized tissues, the hairs, nails, and stratum corneum of skin by dermatophytes.Dermatophyte:
the term dermatophyte is defined primarily
by functional
characteristics and not by strict
taxonomical criteria.
A dermatophyte is a
hyalo
hyphomycete, morphologically and
physiologically
related fungi, and possesses
keratinophilic
and
keratinolytic
properties i.e. they rely on keratin and invade keratinized tissues and degrade them,
and consequently cause communicable skin infection in humans and/or in
animals
.
Slide11Ecology: The dermatophytes and their congeners have long been divided into three ecological groups, based on their reservoir and habitat;
Anthropophilic
(humans),
Zoophilic
(animals),
and
Geophilic (soil).
Slide12Ecology of Common Human Dermatophyte SpeciesspeciesNatural habitatincidence
Epidermophyton floccosum
Humans
Common
Trichophyton rubrum
Humans
Very Common
Trichophyton
interdigitale
Humans
Very Common
Trichophyton tonsurans
Humans
Common
Trichophyton
violaceum
Humans
Less Common
Trichophyton
concentricum
Humans
Rare*
Trichophyton
schoenleinii
Humans
Rare*
Trichophyton
soudanense
Humans
Rare*
Microsporum audouinii
Humans
Less Common*
Microsporum
ferrugineum
Humans
Less Common*
Trichophyton
mentagrophytes
Mice, rodents
Common
Microsporum canis
Cats
Common
* Geographically restricted.
Slide13Epidemiology
The high prevalence of superficial mycotic infections shows that 20-25% of the world’s population has skin mycoses, making these one of the most frequent form of infection.
Dermatomycoses
, the most common of mycotic infections, occur worldwide. There has been a steady rise in the incidence of cutaneous fungal infections and an increasing rate of treatment failure or relapse among mycotic patients undergoing treatment. Almost every human alive will be infected by at some point over the course of his or her lifetime.
Slide14Tinea or ringworm are among the most common and widespread endemic infectious diseases. In some geographic areas or environments more than 30% of the population is affected. Therefore, dermatophytoses poses a considerable worldwide health problem. Prevalence of various species varies from country to country but Trichophyton rubrum is the most common dermatophyte of tinea pedis, tinea
ungium
, tinea cruris, and tinea corporis worldwide.
In India, superficial infection of skin, nails, hair account for 8-10% of all skin outpatient attendance. Tinea cruris and corporis are the commonest varieties seen in India, followed by Tinea pedis, capitis, barbae, unguium and manum in descending order of frequency. Etiologically, T. rubrum tops the list followed by
T.
mentegrophyte
and
E. Floccosum, T.
verrucosum
, M. canis
and
M.
gypseum
.
Slide15Host Factors;Race: All races, clinical varieties and prevalence depend mainly on environmental factors.Age: The different incidence of ringworm between various age groups and sex is thought to be due to different rates of physical activities and exposure to risk factors and of sebum production, and fluctuation of immunity with old age.
Children below the age of 12 years-Tinea capitis.
Adults are more susceptible to
onychomycoses
.
Sex:
Dermatophyte infections are in general less prevalent in females, more common in males.
Socioeconomic Status:
The prevalence of tinea capitis is closely related with socioeconomic status and life style and commonly occurred under poor hygienic conditions
Slide16Customs and Habits: Vegetable oils were believed to be a protective factor for acquiring tinea capitis. Mustard oil used in North and North-east India for hair dressing was found to have an inhibitory effect on fungi affecting scalp.وسببها حرافة الاغذیة وادمان اكل ما غلظ كلحم البقر والباذىجانEnvironmental Factors: Raised CO2 tension is known to facilitate
arthroconidial
formation, also aids in adhesion or penetration. Moisture is also important for the
germination of arthroconidia on
keratinocytes
.
Maximum number of cases of dermatophytic infection occurs during rains.
و هو مرض خریفى
Associated diseases
: Susceptibility to persistent dermatophyte infection has been associated with a number of underlying conditions such as DM, Cushing’s syndrome and Lymphoma, frequent usage of antibiotics, immunosuppressive drugs, and organ transplantation
Slide17Agent factors;Virulence of infecting organism: The geophilic and zoophilic infections are usually of inflammatory type and are seen only sporadically in humans. Infections produced by zoophilic are inflammatory and short lasting in humans. Anthropophilic species produce mild but chronic infection.
The degree of inflammatory response depends in part on the site of infection (large follicles of scalp and beard are associated with an intense reaction) and the immune status of host.
T.
mentagrophytes
var
mentagrophytes
produce marked inflammatory reaction.
T.
mentagrophytes
var
interdigitale
produce non-inflammatory reaction.
Competing organism and co-pathogen:
Staphylococcus aureus acts as a
copathogen
, increases the degree of inflammation in dermatophyte infection.
Slide18PATHOPHYSIOLOGYTabiyat (Natural Power) is the driving force which pulls out the morbid matters from Aazae
Raeesa
(Principal Organ) and expels them toward the surface of skin. This morbid matter is composed of
Akhlate
Harra
wa
Lateefa
(Hot and Thin Humours) mixed with
Akhlate
Arzia
Ghaleeza
(Thick and Earthy Humour). Due to this duplicity in the nature of
Akhlat
, the disease spreads in both directions. The disease spreads rapidly due to the
Hiddat
(acuteness) and
Latafat
(thinness) of
Madda
(Matter), while the spread is slow owing to the thickness and tardiness of
Madda
. Moreover, the disease both fulminates and heals faster if there is preponderance of
Akhlate
Harra
in the causative material while it develops and heals slowly if
Akhlate
Arzia
are in excess.
Slide19The factors that play a crucial role apart from the fungal inoculums are: (a) Trauma and maceration, (b) Increased hydration of skin. invasion of stratum corneum of the scalp skin is an absolute necessity to cause actual hair infection. Minor trauma assists inoculation, which is followed, after approximately 3 weeks, by clinical evidence of hair shaft infection.Kligman divided the infection into the following stages:1. Period of incubation 2. Period of enlargement3. Refractory period 4. Stage of involutionSkin:
During the incubation period of 1-3 weeks, the dermatophyte grows in stratum corneum with minimal clinical signs of infection Once the infection is established in stratum corneum, two factors are important in determining the size and the duration of lesion: 1. The rate of growth of organism 2. The epidermal turnover rate.
Slide20The fungal growth rate must equal or exceed the epidermal turnover rate or the organism will be shed quickly. During the stage of enlargement, there is spread of the fungus from the site of inoculation in a radial fashion producing clinical symptoms of an expanding ring with a central clearing.For unknown reasons, the fungus ceases to grow after the clinical lesion has reached a certain size. Following this, the infection may spontaneously terminate. These are the stages of refractory period
and of
involution
. It appears that the inflammatory response at the periphery of lesion stimulates an increased epidermal turnover in an effort to shed the organisms. The central area of clearing means that the newly healed skin which has recovered from the dermatitic reaction is resistant to further infection. Hence, clinically the lesion appears annular with an elevated, red and infiltrated border often containing papulovesicles.
Slide21ImmunologyThe disease process in dermatophytosis is greatly influenced by the host reaction to the dermatophyte involved. Immunity to dermatophytosis in humans varies considerably with each species and with the individual host involved.There are two major classes of dermatophyte antigens: glycopeptides preferentially stimulates cellmediated
immunity
(CMI)
and humoral immunity. Keratinase, produced by the dermatophytes to enable skin invasion, elicit delayed-type hypersensitivity
(DTH)
responses. The classical studies in human volunteers suggested that CMI is the major immunological defence in clearing dermatophyte infection.
Slide22Clinical Presentation and ClassificationIbne Sina
classified it according to its cause, disease pattern and appearance, and included it in seasonal disease that occurs in spring
1.
Damwi
(
Ratab
): That oozes , but it is easily curable.
2.
Saudawi
(
Yabis
): It is produced by
sauda
, which is formed by the
ihteraq
(combustion) of
balgham
maleh
(saline
phleghm
).
3.
Mutaqashshir
: It is characterized by scaling due to extreme dryness. It may be deeply seated sometime and resembles
Barse
aswad
, or it may appear like slough
..
4
.
Ghair
mutaqashshir
: It does not scale.
5.
Saee
Khabees
: It is of spreading in nature, and malignant i.e. not easily curable.
Slide236.Waqif: It is localized and does not spread.7.
Haad
: It is of short duration, acute in condition, and easily curable.
8.
Raddi
: it is malignant in prognosis i.e. not easily curable.
All
these conditions develop due to the
hiddat
,
khabasat
,
latafat
, and
kasafat
of causative matters.
Slide24Anatomical Classification 1. Glabrous skin (tinea corporis, tinea cruris, and tinea faciei)2. Skin rich in terminal hair follicles e.g. scalp and beard (tinea capitis, tinea barbae)
3. Highly keratinised skin e.g. palms, soles (tinea pedis and tinea manum)
4. Nail infections (
onychomycosis
)
Involved site -Clinical type
Anatomo
clinical classification
Glabrous skin T. corporis I. limited to keratinized structure
Groin T. cruris (Tinea corporis, cruris, pedis etc.)
Hair/scalp T. capitis II. Perforating dermatophytoses
Face T. facie (P
erforating folliculitis, Kerion, Favus)
Hands T. manuum III. actively invading dermal tissue
Nails T. unguium (Dermatophytic
granuloma
)
Feet T. pedis IV. Generalized dermatophytosis
Beard area T. barbae (Dermatophytic disease)
Slide25Clinical ManifestationsThe clinical features of dermatophyte infections results from a combination of keratin destruction and an inflammatory host response. The atypical lesion of dermatophytosis is an
annular scaling patch
with a
raised margin
showing a variable degree of
inflammation
, the
centre
usually being
less inflamed
than the edge. The wide variation in clinical presentation depends upon the
species
and probably the strain of fungus concerned,
size of
inoculum
,
site
of body infected and
immune
status of the host.
Tinea Corporis:
circular, marginated pink, erythematous patch, raised edge, The advancing border is more or less scaling, but in inflammatory forms crusts, vesicles, papules or even pustules can develop.
Slide26Tinea Cruris: The lesions can begin unilateral, but very soon both groins are affected. Patches with erythema with central clearing. Extends both distally on the medial part of the thighs, and proximally to the lower abdomen and pubic area, the perineum and buttocks. The peripheral activity is characterised by fine scaling and the presence of some papules, vesicles and pustules. itching or a burning sensation and by rubbing and scratching, lichenification or impetiginisation.Tinea
Faciei
:
Erythematous, scaling, pruritic lesions on the face; discrete, raised, scaling borders, flat erythematous patches. Itching and burning.
Tinea Capitis:
The infection may range from mild, almost subclinical, with slight erythema, patchy areas of scaling, dull gray hair stumps to a highly inflammatory reaction with folliculitis, kerion formation, extensive areas of scarring, sometimes accompanied by fever, malaise, and regional
lymphadenopathy
.
Slide27Tinea Barbae: As with tinea corporis, ranging from lesion with follicular pustules to non inflammatory scaly patches.Tinea Mannum: usually unilateral, the right hand affected > left. Lesion on the dorsum appears similar to those of tinea corporis. This presents a diffuse hyperkeratosis, with accentuation of fissuring in the palmer crease. Inflammatory vesicular, pustular.
Tinea Pedis:
Most inflammatory reactions result in vesicular-bullous or even pustular lesions. Lack of inflammation is characterised by pink to red discoloration and diffuse scaling. dryness, scaling and fissuring or by white, moist maceration. Irritation and itching.
Tinea Unguium:
thickening of the horny layer, raising the free edge of the nail plate, destruction of nail plate and separation of nail from nail bed. Discoloration ranges from white to brown. The nail crumbles, disappears, leaving a thickened, abnormal nail bed retaining
keratotic
nail debris.
Slide28Slide29Slide30Slide31Slide32LABORATORY DIAGNOSIS Direct Microscopic Examination: Direct examination is essential, as it allows the clinician to start treatment, pending culture. Although false-negative results have been reported in 5–15% of cases in routine practice. Correct visualization of the fungal elements requires the dissociation of collected material. The specimen is placed on a glass slide to which one or 2 drops of a 10%-20% KOH solution is added and a cover slip applied and allowed to remain at room temperature for 15-20 min. This allows KOH to dissolve the keratinous material, leaving hyphae and spores more easily visible. The dermatophytes appear as hyaline, septate, branched or unbranched hyphae. The presence of septate hyphae confirms the diagnosis of tinea.
Stains and Fluorochromes (Woods light examination)
Visualization of fungal elements at direct examination is sometimes difficult. Staining can increase sensitivity of direct examination by facilitating the visualization of fungal structures. Various stains which can be associated to clearing agents may be used
.
Slide33Culture: Culture is a valuable and often obligate complement to direct examination. The most common medium used for isolating dermatophytes is Sabouraud’s peptone-glucose agar. Various formulations of this medium are commercially available; some have additives that inhibit bacterial and non dermatophyte growth. A dermatophyte test medium (DTM) indicator can also be used. The latter has the added advantage of a phenol indicator that turns red in the alkaline environment produced by dermatophytes.Sabouraud’s
dextrose agar at pH 5.6 containing;
1. Glucose - 4% (40gm) 2. Peptone - 1% (10gm)
3. Agar - 2% (20gm) 4. Distilled water -1000ml is routinely used.
The specimens are inoculated onto the slanted surface of the culture media tubes. The tubes are incubated at room temperature (25-30c) and cultures are held for a maximum of 3-4 weeks.
Slide34Management Treatment of
Qooba
basically depends on the causative substances i.e.
Akhlat
(humours), clinical presentation, severity and duration of disease. Both, local and systemic therapy is advised for the treatment, following the principle
of
nuzj-wa-istifragh
(concoction and removal of morbid substance and fluid) to normalize the
humors
and maintaining their equilibrium for health.
Therapy should be constituted of drugs that have the effects of
Tahleel
,
Taqtee
,
Izabat
and
Talteef
for
ghaleez
madda
(thick morbid matter) along with
Taskeen
and
Tarteeb
for
haar
and
raqeeq
madda
(hot and thin morbid matter).
Inspite
of the drug therapy, there are some regimens as advised in the treatment of this disease.
Ibne
Sina
advised
leech therapy
and dietary recommendation, providing moist and wet environment, and avoiding dryness to come in contact, and
hammam
.
Ibne
Sina
held leeching better than drug therapy and
hammam
is a good option for treatment. As a prophylaxis as well as treatment,
luk
maghsool
in
sibra
(aloe) along with
matbookh
rehani
(decoction) can be used
Slide35A-Jinse Damwi: Perform fasd
(
venesection
) on a nearest vein for removal of morbid matters.
Ghassal
(detergent)
advia
should be applied locally.
Leech
should be applied if these regimens fail.
B-
Jinse
Ratoobi
:
Use
matbookh
aftimoon
(decoction) and
ayarij
faiqara
for the removal of morbid fluid.
Gargle:
make a decoction of
Maveezaj
,
Aqarqarha
in honey water and gargle it.
Tila
:
Aqlimia
zahab
and
hadtal
should be ground in
gulnar
and
gule
surkh
, mixed into vinegar and applied locally on lesions as a
tila
.
C-
Jinse
Saudawi
:
This is the worst among all the types of
Qooba, which does not
respond treatment and does not heal easily. Use decoction of
matbookh
aftimoon
and
laughazia
with
aabe
halela
siyah
and
zabeeb
.
Perform
fasd
(
venesection
) of
vareede
basaleeque
(
basalic
vein).
Tila
:
fats of ducks and cocks, wax, and oils should be applied regularly