MYCOSES 34,
ACCEPTED:MARCH20, 1990
339-344 (1991)
Fungal infection as a cause of skin disease in the Eastern Province of Saudi Arabia: tinea pedis and tinea manuurn
Pilzinfektionen als Ursache von Hautkrankheiten in der Ostprovinz Saudi-Arabiens: Tinea pedis und Tinea manuum S. M. Al-Sogair', M. K. Moawad2 and Y. M. Al-Humaidan3 Key words. Dermatophytes, yeasts, skin diseases, tinea pedis, tinea manuurn, Saudi Arabia. Schliisselworter. Dermatophyten, Hefen, Hau tkrankheiten, Tinea pedis, Tinea manuum, Saudi-Arabien.
Summary. I n the period between April 1984 and April 1988 a total of 4294 clinically suspected cases of dermatomycoses were examined for causative fungi. Of these cases 680 were suspected as tinea pedis and tinea manuum. These cases belonged to 21 different nationalities. Both sexes were represented and 649 cases (95.4%) were adults while 31 (4.6%) were prepubertals. Clinical diagnosis was confirmed by direct microscopy in 505 cases or 74.4% (485 adults and 20 prepubertal children). Out of these, 504 cases were positive on culture and yielded 516 isolates. Candida species and other yeasts were responsible for 88.9% and dermatophytes for 1 1.1 yo of these infections. The interdigital type of lesions was the most common type (91.9% of all infections) followed by the hyperkeratotic scaling type (6.9%) while the acute inflammatory type was only 1.2y0 of infections. Treatment showed satisfactory results in most of the cases. Zusammenfassung. Zwischen April 1984 und April 1988 wurden im Dammam-Zentralhospital in der saudiarabischen Ostprovinz insgesamt 4 294 Dermatomykosen-Verdachtsfalle mykologisch untersucht. Hiervon prasentierten sich 680 Falle als Tinea pedis und Tinea manuum. Die Patienten gehorten 2 l unterschiedlichen Nationalitaten an. Hierunter waren 649 Erwachsene (95,4 yo)und 31
Directorate of Health Affairs, Ministry of Health, Mycologist: Regional Laboratory and Blood Bank and Department of Dermatology, Dammam Central Hospital, Dammam, Kingdom of Saudi Arabia. I
Correspondence: Dr Sami Mohamed Al-Sogair, Director General of Health Affairs, Darnmam - 3 1176, Saudi Arabia.
Prapubertale (4,6 yo).Die klinische Diagnose wurde direktmikroskopisch bei 505 Patienten (74,3 %, 485 Erwachsene und 20 Kinder) bestatigt. Von diesen waren bei 504 Patienten die Kulturen positiv und lieferten 5 16 Isolate. Candida-Arten und andere Hefen verursachten 88,9 yo, Dermatophyten 1 1,l % dieser Infektionen. Der interdigitale Typ herrschte bei diesen Lasionen vor (91,9 yo aller Infektionen), gefolgt vom hyperkeratotischen schuppenden Typ (6,9 %), wahrend der akute entziindliche Typ nur bei 1,2 yo aller Infektionen beobachtet wurde. Die Behandlung war in den meisten Fallen zufriedenstellend. Introduction
Fungus infection of the feet is one of the most common dermatoses found in man and a disease which is usually recognized as readily by non-specialists as by specialists [l]. Stein [2] described the three different types of tinea pedis: The moccasin and interdigital varieties and in a third variety there are scaly plaques resembling tinea corporis on the dorsal aspect of the feet. According to the same author, fungal infection of the hand is much less common than of the foot and is rarely seen alone but generally with the latter. The classically described pattern of infection according to this author is that of both feet and one hand. However, involvement of both hands also occur and the clinical presentation is generally the same as that seen on the feet of the same patient. The infrequent occurrence of tinea pedis in children before the age of puberty has been discussed by several authors [3-51. However, Kearse & Miller [6] identified dermatophyte infection in 8 out of 15 children examined who had foot dermatitis.
340
S. M. AL-SOGAIR ET AL.
This study on tinea pedis and tinea manuum is a part of a more comprehensive one on the epidemiology of fungal infection as a cause of skin disease in the Eastern Province of Saudi Arabia [7].
Materials and methods Six hundred and eighty suspected cases of tinea pedis and tinea manuum (512 cases as tinea pedis, 131 cases as tinea manuum and 37 cases of both hands and feet involvement) belonging to 2 1 different nationalities (Table 1) were examined by direct microscopy and by culture. These cases comprised 649 adults and 31 prepubertal children (Tables 2, 3). Standard methods were followed for specimen collection, culture and identification of isolated pathogens [8]. Treatment of positive cases varied according to the variety of infection. For inflammatory variety, topical antifugal cream or lotion (imidazole derivative) was applied twice daily for 6-12 weeks in addition to oral griseofulvin (daily dose of 10 mg kg-' body weight) for 6-8 weeks. For dry scaling hyperkeratotic variety of infection, topical antifungal cream (imidazole derivative) was applied twice daily for 6-12 weeks in addition to oral griseofulvin (6-8 weeks). For interdigital variety of infection, topical imidazole or tolnaftate lotion was applied three times daily for 612 weeks. For all varieties of infection, patients were instructed to keep the feet as dry as possible and to use antifungal powder inside the socks. Results Of the 680 patients clinically suspected as tinea pedis and tinea manuum, the diagnosis was confirmed by direct microscopy in 505 cases (74.3%) and of these in 504 patients the etiology was determined. The nationality, incidence of cases, sex, age, types of lesions and isolated pathogens are shown in Tables 1-4. Treatment of positive cases following the schedule mentioned before showed satisfactory results. Discussion
Of the 505 positive cases of tinea pedis and tinea manuum the interdigital type of lesions was the most common type and constituted 91.9% of all infections. Interdigital dry lesions due to dermatophytes were seen in 12 cases only. T. mentagrophytes was isolated from 6, T. rubrum from 5 and T. violaceum from 1. On the other hand, wet lesions due to Candida species and other yeasts were seen in 447 cases
Table 1. Distribution of nationalities in the 680 cases examined and clinically suspected as tinea pedis and tinea manuum Nationality
No. of cases examined
Percentage
Saudi Yemani Egyptian Palestinian Syrian Jordanian Indian Lebanese Sudanese Tunesian Pakistani Philippino Bengali Moraccan Korean Bahraini Omani Kuwaiti Turkish Srilankan Thai
440 66 61 21 17 14 10 9 8 7 7 6 4
1 1 1
0.9 0.6 0.3 0.3
ACCEPTED:MARCH20, 1990
339-344 (1991)
Fungal infection as a cause of skin disease in the Eastern Province of Saudi Arabia: tinea pedis and tinea manuurn
Pilzinfektionen als Ursache von Hautkrankheiten in der Ostprovinz Saudi-Arabiens: Tinea pedis und Tinea manuum S. M. Al-Sogair', M. K. Moawad2 and Y. M. Al-Humaidan3 Key words. Dermatophytes, yeasts, skin diseases, tinea pedis, tinea manuurn, Saudi Arabia. Schliisselworter. Dermatophyten, Hefen, Hau tkrankheiten, Tinea pedis, Tinea manuum, Saudi-Arabien.
Summary. I n the period between April 1984 and April 1988 a total of 4294 clinically suspected cases of dermatomycoses were examined for causative fungi. Of these cases 680 were suspected as tinea pedis and tinea manuum. These cases belonged to 21 different nationalities. Both sexes were represented and 649 cases (95.4%) were adults while 31 (4.6%) were prepubertals. Clinical diagnosis was confirmed by direct microscopy in 505 cases or 74.4% (485 adults and 20 prepubertal children). Out of these, 504 cases were positive on culture and yielded 516 isolates. Candida species and other yeasts were responsible for 88.9% and dermatophytes for 1 1.1 yo of these infections. The interdigital type of lesions was the most common type (91.9% of all infections) followed by the hyperkeratotic scaling type (6.9%) while the acute inflammatory type was only 1.2y0 of infections. Treatment showed satisfactory results in most of the cases. Zusammenfassung. Zwischen April 1984 und April 1988 wurden im Dammam-Zentralhospital in der saudiarabischen Ostprovinz insgesamt 4 294 Dermatomykosen-Verdachtsfalle mykologisch untersucht. Hiervon prasentierten sich 680 Falle als Tinea pedis und Tinea manuum. Die Patienten gehorten 2 l unterschiedlichen Nationalitaten an. Hierunter waren 649 Erwachsene (95,4 yo)und 31
Directorate of Health Affairs, Ministry of Health, Mycologist: Regional Laboratory and Blood Bank and Department of Dermatology, Dammam Central Hospital, Dammam, Kingdom of Saudi Arabia. I
Correspondence: Dr Sami Mohamed Al-Sogair, Director General of Health Affairs, Darnmam - 3 1176, Saudi Arabia.
Prapubertale (4,6 yo).Die klinische Diagnose wurde direktmikroskopisch bei 505 Patienten (74,3 %, 485 Erwachsene und 20 Kinder) bestatigt. Von diesen waren bei 504 Patienten die Kulturen positiv und lieferten 5 16 Isolate. Candida-Arten und andere Hefen verursachten 88,9 yo, Dermatophyten 1 1,l % dieser Infektionen. Der interdigitale Typ herrschte bei diesen Lasionen vor (91,9 yo aller Infektionen), gefolgt vom hyperkeratotischen schuppenden Typ (6,9 %), wahrend der akute entziindliche Typ nur bei 1,2 yo aller Infektionen beobachtet wurde. Die Behandlung war in den meisten Fallen zufriedenstellend. Introduction
Fungus infection of the feet is one of the most common dermatoses found in man and a disease which is usually recognized as readily by non-specialists as by specialists [l]. Stein [2] described the three different types of tinea pedis: The moccasin and interdigital varieties and in a third variety there are scaly plaques resembling tinea corporis on the dorsal aspect of the feet. According to the same author, fungal infection of the hand is much less common than of the foot and is rarely seen alone but generally with the latter. The classically described pattern of infection according to this author is that of both feet and one hand. However, involvement of both hands also occur and the clinical presentation is generally the same as that seen on the feet of the same patient. The infrequent occurrence of tinea pedis in children before the age of puberty has been discussed by several authors [3-51. However, Kearse & Miller [6] identified dermatophyte infection in 8 out of 15 children examined who had foot dermatitis.
340
S. M. AL-SOGAIR ET AL.
This study on tinea pedis and tinea manuum is a part of a more comprehensive one on the epidemiology of fungal infection as a cause of skin disease in the Eastern Province of Saudi Arabia [7].
Materials and methods Six hundred and eighty suspected cases of tinea pedis and tinea manuum (512 cases as tinea pedis, 131 cases as tinea manuum and 37 cases of both hands and feet involvement) belonging to 2 1 different nationalities (Table 1) were examined by direct microscopy and by culture. These cases comprised 649 adults and 31 prepubertal children (Tables 2, 3). Standard methods were followed for specimen collection, culture and identification of isolated pathogens [8]. Treatment of positive cases varied according to the variety of infection. For inflammatory variety, topical antifugal cream or lotion (imidazole derivative) was applied twice daily for 6-12 weeks in addition to oral griseofulvin (daily dose of 10 mg kg-' body weight) for 6-8 weeks. For dry scaling hyperkeratotic variety of infection, topical antifungal cream (imidazole derivative) was applied twice daily for 6-12 weeks in addition to oral griseofulvin (6-8 weeks). For interdigital variety of infection, topical imidazole or tolnaftate lotion was applied three times daily for 612 weeks. For all varieties of infection, patients were instructed to keep the feet as dry as possible and to use antifungal powder inside the socks. Results Of the 680 patients clinically suspected as tinea pedis and tinea manuum, the diagnosis was confirmed by direct microscopy in 505 cases (74.3%) and of these in 504 patients the etiology was determined. The nationality, incidence of cases, sex, age, types of lesions and isolated pathogens are shown in Tables 1-4. Treatment of positive cases following the schedule mentioned before showed satisfactory results. Discussion
Of the 505 positive cases of tinea pedis and tinea manuum the interdigital type of lesions was the most common type and constituted 91.9% of all infections. Interdigital dry lesions due to dermatophytes were seen in 12 cases only. T. mentagrophytes was isolated from 6, T. rubrum from 5 and T. violaceum from 1. On the other hand, wet lesions due to Candida species and other yeasts were seen in 447 cases
Table 1. Distribution of nationalities in the 680 cases examined and clinically suspected as tinea pedis and tinea manuum Nationality
No. of cases examined
Percentage
Saudi Yemani Egyptian Palestinian Syrian Jordanian Indian Lebanese Sudanese Tunesian Pakistani Philippino Bengali Moraccan Korean Bahraini Omani Kuwaiti Turkish Srilankan Thai
440 66 61 21 17 14 10 9 8 7 7 6 4
1 1 1
0.9 0.6 0.3 0.3
