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Year : 2020  |  Volume : 25  |  Issue : 2  |  Page : 107-109

Cutaneous dermatophyte invasion below the stratum corneum in an immunocompetent patient: To blame mixed creams or not?

Department of Dermatology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India

Date of Submission21-Mar-2019
Date of Acceptance24-Feb-2020
Date of Web Publication15-Dec-2020

Correspondence Address:
Dr. Hari S Pathave
Department of Dermatology, Seth GS Medical College and KEM Hospital, Parel, Mumbai - 400 012, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmgims.jmgims_19_19

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Dermatophytes are pathogenic fungi that infect human skin, nails, and hair. Dermatophytes very rarely invade the epidermis below the stratum corneum in an immunocompetent host. Herein, we report a case of invasive cutaneous dermatophytosis in a 30-year-old immunocompetent male who had a history of intermittent mixed cream application on the lesion. Biopsy from the plaque showed neutrophilic spongiosis with superficial perivascular infiltrate of neutrophils, eosinophils, and lymphocytes. On periodic acid–Schiff staining, multiple branched septate hyphae in the stratum corneum were seen. Some of them were seen invading the stratum granulosum and upper spinous layer. On culture, Trichophyton schoenleinii species was isolated.

Keywords: Cutaneous dermatophyte invasion, mixed cream, Trichophyton schoenleinii

How to cite this article:
Pathave HS, Dongre AM, Nikam VV. Cutaneous dermatophyte invasion below the stratum corneum in an immunocompetent patient: To blame mixed creams or not?. J Mahatma Gandhi Inst Med Sci 2020;25:107-9

How to cite this URL:
Pathave HS, Dongre AM, Nikam VV. Cutaneous dermatophyte invasion below the stratum corneum in an immunocompetent patient: To blame mixed creams or not?. J Mahatma Gandhi Inst Med Sci [serial online] 2020 [cited 2023 Jun 4];25:107-9. Available from: https://www.jmgims.co.in/text.asp?2020/25/2/107/303416

  Introduction Top

Skin infection due to dermatophytes is distributed worldwide. These fungi have been shown to have keratolytic and other proteolytic and lipolytic activities.[1],[2] They invade the stratum corneum or keratinized structures causing skin, hair, and nail infection. Dermatophytic fungi are usually restricted to the stratum corneum and are unable to penetrate into the viable epidermis due to non-specific defense mechanisms in an immunocompetent individual. Invasive dermatophytoses are usually reported in immunocompromised individuals. Chronic, widespread, and invasive cutaneous dermatophytoses due to Trichophyton rubrum are common in immunocompromised patients.[3]

  Case Report Top

A 30-year-old male presented with an itchy scaly lesion localized to the left arm. Two months before, it started as a small itchy lesion on the outer aspect of the left mid-arm which gradually increased in size. On detailed inquiry, he gave a history of intermittently mixed cream (clobetasol, gentamicin, and miconazole) application and intake of antihistamines with some relief. There was no history suggestive of atopy or any systemic disease.

Cutaneous examination revealed a single erythematous annular plaque of size 18 cm × 15 cm on the outer aspect of the lower half of the left arm [Figure 1]. Erythema and scaling were present throughout the plaque with few normal skin areas at places. The border of plaque was slightly raised and more erythematous than the central area with a collarette of scales. Hair, nail, and scalp were normal. Systemic examination did not reveal any abnormalities. Routine blood investigations, including fasting and postprandial blood sugar, were within the normal limits. ELISA for HIV was negative.

A punch skin biopsy from the border of plaque showed neutrophilic spongiosis, superficial perivascular dermatitis, and few neutrophils in orthokeratotic stratum corneum and upper dermis [Figure 2]a and [Figure 2]b. Periodic acid–Schiff stain showed multiple branched septate hyphae in the stratum corneum. Surprisingly, few of them were seen invading the stratum granulosum and upper spinous layer [Figure 3]a and [Figure 3]b. Skin scrapings from the lesion for fungal culture on Sabouraud dextrose agar showed velvety, heaped, and folded colonies with surface white to cream and reverse tan to brown pigmentation suggestive of Trichophyton schoenleinii species [Figure 4]a and [Figure 4]b. Slide culture and lactophenol cotton blue staining showed dichotomously branching hyphae with flattened tips (termed chandelier or antler hyphae) without conidia, characteristics of the T. Schoenleinii species [Figure 5].
Figure 1: Erythematous scaly annular plaque having slightly risen and more erythematous border than the central area with a collarette of scales on the left arm

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Figure 2: (a) Biopsy from plaque showing orthohyperkeratosis, spongiosis, and superficial perivascular lymphohistiocytic infiltrate (H and E, ×4), (b) Biopsy shows spongiosis, neutrophilic infiltrate in the epidermis and dermis (H and E, ×100)

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Figure 3: (a) Periodic acid–Schiff stain showing multiple red-branched septate hyphae in the stratum corneum (periodic acid–Schiff, ×4), (b) Few branched septate hyphae (black arrows) invaded in the stratum granulosum and the upper part of the stratum spinosum (periodic acid–Schiff, ×100)

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Figure 4: (a) Culture on Sabouraud dextrose agar showing velvety, heaped, and folded colonies with surface white to cream suggestive of Trichophyton schoenleinii species, (b) reverse of colonies having tan to brown pigmentation

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Figure 5: Slide culture showing dichotomously branching hyphae with flattened tips (termed chandelier or antler hyphae) without conidia, characteristics of the Trichophyton schoenleinii species (LCB, ×100)

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  Discussion Top

Dermatophytes are common fungal pathogens that produce mainly superficial infections of the skin, nails, and hair. Invasion of the epidermis below the stratum corneum in an immunocompetent host is very rarely seen.

In long-standing infections, especially in immunocompromised states such as post-renal transplantation, leukemia, myelodysplastic syndromes, lymphoma, diabetes mellitus, long-term steroid use, immunosuppressive drugs, and AIDS, the infection can disseminate into the deeper tissues and other organs, resulting in invasive dermatophytosis.[4],[5]

Most reported cases of invasive dermatophytosis are caused by T. rubrum.[4],[6],[7] The other causes of deep dermatophytosis include Trichophyton violaceum, T. schoenleinii, Trichophyton verrucosum, Trichophyton tonsurans, Microsporum audouinii, Trichophyton mentagrophytes, and Epidermophyton floccosum.[4],[6],[7],[8],[9]

Infection of the skin tissues includes several stages, i.e., adhesion to the surface of the skin, invasion into the sublayers by the penetration of fungal elements, and secretion of enzymes that degrade the skin components.[10] The dermatophyte may use the proteolytic enzymes to invade the surface and also the deep layer of the skin in immunocompromised patients.

Hemolysins produced by Trichophyton species may play an important role in balancing the host's cellular immunity and the ability of the fungus to diminish the immune response. Hemolytic activity levels in dermatophytes have been shown to correlate with the severity and chronicity of clinical infection. Some of the extracellular enzymes such as keratinase, elastase, collagenase, and lipase that diffuse through the cornified layer of the skin during infection may allow persistence of fungi in the skin and lead to chronicity and deeper infection.[11]

Potent fluorinated topical corticosteroid creams, inappropriately applied to superficial dermatophyte infections, may also cause local invasions by suppressing the cellular response.[12] In our case, the patient had applied a steroid-containing mixed cream intermittently over 2 months. Long-term steroid application as one of the possible mechanisms for the development of deep dermatophytosis due to T. rubrum in an immunocompetent individual has been reported.[13]

In our case, topical steroid was part of a mixed cream combination, which could be responsible for the deeper invasion of dermatophytes. Furthermore, in our case, the responsible species was anthropophilic.

This case indicates that minimal inflammatory and less virulent dermatophyte species such as T. schoenleinii can invade the epidermis below the stratum corneum even after a short duration of the use of topical steroids.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Monod M, Capoccia S, Léchenne B, Zaugg C, Holdom M, Jousson O. Secreted proteases from pathogenic fungi. Int J Med Microbiol 2002;292:405-19.  Back to cited text no. 1
Hellgren L, Vincent J. Lipolytic activity of some dermatophytes. II. Isolation and characterisation of the lipase of Epidermophyton floccosum. J Med Microbiol 1981;14:347-50.  Back to cited text no. 2
Balci DD, Cetin M. Widespread, chronic, and fluconazole-resistant Trichophyton rubrum infection in an immunocompetent patient. Mycoses 2008;51:546-8.  Back to cited text no. 3
Lestringant GG, Lindley SK, Hillsdon-Smith J, Bouix G. Deep dermatophytosis to Trichophyton rubrum and T. verrucosum in an immunosuppressed patient. Int J Dermatol 1988;27:707-9.  Back to cited text no. 4
Tsang P, Hopkins T, Jimenez-Lucho V. Deep dermatophytosis caused by Trichophyton rubrum in a patient with AIDS. J Am Acad Dermatol 1996;34:1090-1.  Back to cited text no. 5
Swart E, Smit FJ. Trichophyton violaceum abscesses. Br J Dermatol 1979;101:177-84.  Back to cited text no. 6
Nir-Paz R, Elinav H, Pierard GE, Walker D, Maly A, Shapiro M, et al. Deep infection by Trichophyton rubrum in an immunocompromised patient. J Clin Microbiol 2003;41:5298-301.  Back to cited text no. 7
Seddon ME, Thomas MG. Invasive disease due to Epidermophyton floccosum in an immunocompromised patient with Behçet's syndrome. Clin Infect Dis 1997;25:153-4.  Back to cited text no. 8
Blank H, Smith JG Jr. Widespread Trichophyton rubrum granulomas treated with griseofulvin. Arch Dermatol 1960;81:779-89.  Back to cited text no. 9
Kaufman G, Horwitz BA, Duek L, Ullman Y, Berdicevsky I. Infection stages of the dermatophyte pathogen Trichophyton: Microscopic characterization and proteolytic enzymes. Med Mycol 2007;45:149-55.  Back to cited text no. 10
Schaufuss P, Steller U. Haemolytic activities of Trichophyton species. Med Mycol 2003;41:511-6.  Back to cited text no. 11
Chang SE, Lee DK, Choi JH, Moon KC, Koh JK. Majocchi's granuloma of the vulva caused by Trichophyton mentagrophytes. Mycoses 2005;48:382-4.  Back to cited text no. 12
Tejasvi T, Sharma VK, Sethuraman G, Singh MK, Xess I. Invasive dermatophytosis with lymph node involvement in an immunocompetent patient. Clin Exp Dermatol 2005;30:506-8.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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