#M10 drg. Suryono, PhD

SKIN DISEASES & FUNGI

Immunity Against Fungi

Manusia memiliki tingkat imunitas yang tinggi terhadap jamur. Kebanyakan infeksi yang disebabkan oleh jamur tergolong infeksi ringan dan dapat hilang dengan sendirinya. Karena:

1. Asam lemak dalam kulit,2. pH kulit, permukaan mukosa, 3. Cairan tubuh,4. Epitel sel yang mengalami regenerasi5. Flora normal,6. Transferrin,7. Silia (rambut halus) pada saluran pernapasan

What Happen When Fungi Do Pass The Resistance Barriers Of The Human Body?

Infeksi berdasarkan tingkat jaringan yang terinfeksi:

a. Superficial mycoses Infeksi pada lapisan terluar kulit dan rambut

b. Cutaneous mycoses Infeksi yang lebih dalam sampai ke lapisan epidermis, misalnya penyakit invasive rambut dan kuku

c. Subcutaneous mycoses Infeksi yang melibatkan dermis, subkutan, otot dan fascia. Infeksi ini kronis dan diindikasikan dengan trauma pada kulit. Infeksi ini sulit diobati dan mungkin memerlukan intervensi pembedahan

Skin Anatomy

DEDICATED FOR MOLAR PSPDG UMY 2012

#M10 drg. Suryono, PhD

Fungal Infections (Mycoses)

Principal tissue sites of deep mycoses in comparison to those of the superficial, cutaneous, and subcutaneous mycoses

Portals of entry of pathogenic and opportunistic fungi causing deep mycoses

Superficial Mycoses

Disease Etiological Agent Symptoms Identification Of Organism

Pityriasis versicolor

Malassezia furfurhypopigmented macules

"Spaghetti and meatballs" appearance of organims in skin scrapings.

Tinea nigraExophiala werneckii

black macules Black, 2-celled oval yeast in skin scrapings

Black piedra

Piedraia hortaiblack nodule on hair shaft

black nodule on hair shaft composed of spore sacs and spores

White piedra

Trichosporom beigelii

creme-colored nodules on hair shaft

white nodule on hair shaft composed of mycelia that fragment into arthrospores

DEDICATED FOR MOLAR PSPDG UMY 2012

#M10 drg. Suryono, PhD

Pityriasis Versicolor

Keluhan kulit yang umum dengan penampilan patch yang tidak berwarna terutama pada dada dan punggung. Istilah “pityriasis” digunakan untuk mendeskripsikan kondisi dimana skala patch sama seperti bran. Sedangkan “versicolor” digunakan untuk menggambarkan warna-warna yang muncul. Terkadang penyakit ini disebut “Tinea versicolor” meskipun kata “tinea” secara langsung dimaksudkan untuk infeksi dengan jamur dermatrofit.

Clinical Features

• Pityriasis versicolor menyerang bagian tenggorokan, leher, dan/atau lengan, jarang terdapat pada bagian lain tubuh. Patch berwarna pink, coklat tembaga atau lebih pucat daripada kulit di sekitarnya dan sedikit gatal. Patch pucat biasanya pada kulit yang lebih gelap, kondisi ini dikenal dengan Pityriasis versicolor alba dan cenderung tidak gatal. Terkadang patch bersisik dan berwarna coklta, kemudian menjadi tidak bersisik dan berwarna putih.

• A yellow-green fluorescence dapat diamati dengan Wood's light (long wave ultraviolet A) pada daerah yang terinfeksi.

• Pityriasis versicolor sering terjadi di daerah panas, beriklim lembab atau pada seseorang yang berkeringat banyak, sehingga bias kambuh pada setiap musim panas. Pityriasis versicolor tidak muncul pada area yang terkena sinar matahari langsung.

Patch Putih Persistent Pale Marks Patch Coklat

Hypopigmented Macules Black Nodule On Hair Shaft Creme -Colored Nodules On Hair Shaft

DEDICATED FOR MOLAR PSPDG UMY 2012

#M10 drg. Suryono, PhD

M. furfur

M. furfur skin scraping with calcifluor stain. Observe the detail of the fungal features with

this technique that stains the fungal elements green-white.

Superficial dermatophytes

Hypopigmented tinea versicolor

Hypopigmented tinea versicolor Hypopigmented tinea versicolor.

Small, pale macules coalesce into larger patches on this patient's neck.

Glossary

• Dermatophyte ; A type of fungus that causes diseases of the skin, including tinea or ringworm.

• KOH ;The chemical formula for potassium hydroxide, which is used to perform the KOH test. The tests is also called a potassium hydroxide preparation.

• Thrush ; A disease of the mouth, caused by and characterized by a whitish growth and ulcers. It can be diagnosed with the KOH test.

• Tinea ; A superficial infection of the skin, hair, or nails, caused by a fungus and commonly known as ringworm.

Ring Worm

DEDICATED FOR MOLAR PSPDG UMY 2012

#M10 drg. Suryono, PhD

Ring Worm

Patient with ringworm on the arm, or Tinea corporis due to Trichophyton mentagrophytes

Ringworm, stained preparation, Macroconidia of Microsporum canis

Dermatomycosis (ringworm) of hair follicles

Ringworm, stained preparation, Macroconidia of Microsporum canis

Cutaneous Mycoses

Infeksi yang lebih dalam ke lapisan epidermis, contohnya penyakit invasive rambut dan kuku. Penyakit ini terbatas pada lapisan keratin di kulit, rambut, dan kuku. Tidak seperti superficial mycoses, host dari respon imun dapat diaktifkan, menghasilkan perubahan patalogis pada lapisan yang lebih dalam pada kulit. Organisme yang menyebabkan penyakit ini adalah Dermatophytes. Penyakit ini sering disebut dengan ingworm atau Tinea. Semua penyakit tersebut disebabkan oleh Microsporum, Trichophyton, dan Epidermophyton, yang terdiri dari 41 spesies.

DEDICATED FOR MOLAR PSPDG UMY 2012

#M10 drg. Suryono, PhD

Microsporum Trichophyton Epidermophyton

Disease Symptoms Identification Of Organism

Tinea capitis

Ringworm of scalpPresence/absence and shape of micro- and macroconidia in scrapings of lesion, KOH mount

Tinea corporis

Ringworm of trunk, arms, legsPresence/absence and shape of micro- and macroconidia in scrapings of lesion, KOH mount

Tinea manuum

Ringworm of handPresence/absence and shape of micro- and macroconidia in scrapings of lesion, KOH mount

Tinea cruris Ringworm of groin "jock itch"Presence/absence and shape of micro- and macroconidia in scrapings of lesion, KOH mount

DEDICATED FOR MOLAR PSPDG UMY 2012

#M10 drg. Suryono, PhD

Tinea pedis

Ringworm of foot "athlete's foot

Presence/absence and shape of micro- and macroconidia in scrapings of lesion, KOH mount

Tinea unguium

Infection of nailsPresence/absence and shape of micro- and macroconidia in scrapings of lesion, KOH mount

Ectothrix

Infection of hair shaft surface Mycelium and spores on hair shaft

Endothrix Infection of hair shaft interior Mycelium and spores in hair shaft

Subcutaneous Mycoses

Infeksi ini melibatkan dermis, jaringan subkutan, otot, dan fascia. Infeksi ini kronis dan diindikasikan dengan trauma pada kulit. Infeksi ini sulit diobati dan mungkin membutuhkan intervensi pembedahan.

Jenis-jenis subcutaneous mycoses:

1. Chromoblastomycosis Ditandai dengan lesi verrucoid pada kulit (biasanya pada ekstremitas bawah) dari hasil pemeriksaan histologis menunjukkan sel multiform (dengan septations tegak lurus) disebut dengan "copper pennies" yang merupakan ciri khas dari infeksi ini.

2. Mycetoma

Infeksi subkutan supuratif dan granulomatosa mikosis yang merusak tulang contiguous, tendon, dan otot rangka. Mycetoma dicirikan dengan adanya saluran sinus kering dari butiran kecil yang berpigmen tetapi terlihat jelas sebagai butiran yang ekstrusi.

3. Sporotrichosis

DEDICATED FOR MOLAR PSPDG UMY 2012

#M10 drg. Suryono, PhD

Disease Etiological Agent Symptoms Id Of Organism

SporotrichosisSporothrix schenckii

1. yeast

2. mold

Nodules and ulcers along lymphatics and at site of inoculation

Yeast in tissue; mold at rm temp with "rosette pattern"

Chromoblastomycosis

Fonsecaea pedrosoi or compacta, Wangiella dermatitidis

Warty nodules that progress to "cauliflower-like" appearance a inoculation site.

Copper-colored spherical yeasts called "Medlar bodies" in tissue

Mycetoma

Pseudallescheria boydii, Madurella grisea or mycetomatis

Draining sinus tracts at site of inoculation

White, brown, yellow or black granules in exudate that are fungal colonies

Systemic Mycoses

Infeksi yang berasal dari paru-paru dan dapat menyebar ke banyak system organ. Organisme ini adalah organisme inheren virulen, kecuali Cryptococcus adalah jamur dimorfik.

Opportunistic Mycoses

• Infeksi pada pasien dengan defisiensi imun, contohnya: AIDS, perubahan flora normal, DM, terapi immunosuppressive, keganasan

• Candidiasis (Candida albicancs ) tumbuh seperti krim pada permukaan tubuh contohnya, mulut, kulit, vagina. Budding yeast. Berbentuk pseudohyphae pada jaringan, grem tube dalam serum

• Aspergillosis (Aspergillus niger )

DEDICATED FOR MOLAR PSPDG UMY 2012

#M10 drg. Suryono, PhD

Oral Candidiasis

• Synonyms: Candidosis, Thrush, Moniliasis

• Infeksi opportunistic yang disebabkan oleh jamur Obiquitous, saprophytic dari genus Candida yang mencakup 8 jenis jamur, yang paling umum Candida albicans

• Candidiasis is usually limited to the skin and mucous membranes.

• Common clinical types of mucocutaneous candidiasis include:

a. oropharyngeal (affecting the oral cavity and/or pharynx)b. vulvovaginal (affecting the vaginal and vulvar mucosa)c. paronychial (affecting the nail beds and folds)d. interdigital (usually affecting the skin in between the fingers)e. intertriginous (affecting the skin of the submammary areas or the groin and/or scrotum)

• infeksi Candidiasis, sistemik dan invasive dapat terjadi khususnya pada pasien dengan immunosuppression berat. Saluran pencernaan, trakea, paru-paru, hati, ginjal, dan system saraf pusat berpotensial untuk terkena infeksi Candidiasis yang nantinya akan nerakibat septicemia, meningitis, hepatosplenic, dan endocarditis

Epidemiology

Oral candidiasis disebabkan paling dominan oleh Candida albicans, meskipun Candidajenis lain juga terlibat pada infeksi tersebut. Candida merupakan bagian dari flora normal mulut yaitu sekitar 30% - 50% dari populasi. Dan dapat menyebabkan infeksi opportunistic pada oral cavity dengan berbagai jenis factor predisposisi yang lain.

Etiology and Pathogenesis

Factor yang menyebabkan Candidiasis:

1. The immune status of the host2. The oral mucosal environment3. The particular strain of Candida albicans (the hyphal form is usually associated with

pathogenic infection).

Specific Conditions That May Predispose A Patient To Develop Oral Candidiasis

1. Factors that alter the immune status of the host:

• Blood dyscrasias or advanced malignancy

• Old age/Infancy

• Radiation therapy/Chemotherapy

• HIV infection or other immunodeficiency disorders

• Endocrine abnormalities:

DEDICATED FOR MOLAR PSPDG UMY 2012

#M10 drg. Suryono, PhD

• Diabetes mellitus

• Hypothyroidism or Hypoparathyroidism

• Pregnancy

• Corticosteroid therapy/Hypoadrenalism

2. Factors that alter the oral mucosal environment:

• Xerostomia

• Antibiotic therapy

• Poor oral or denture hygiene

• Malnutrition/Gastrointestinal malabsorption

• Iron, folic acid, or vitamin deficiencies

• Acidic saliva/Carbohydrate-rich diets

• Heavy smoking

• Oral epithelial dysplasia

Clinical Presentation And Treatment

I. (Acute) Pseudomembranous Candidiasis

• Pseudomembranous candidiasis is the most common form of oral candidiasis.

• The most common sites include buccal mucosa, dorsal tongue, and palate.

• Most frequent etiologies include antibiotic therapy or immunosuppression.

• It appears as soft, creamy white to yellow, elevated plaques, that are easily wiped off affected oral tissues and leave an erythematous, eroded, or ulcerated surface which may be tender.

Rationale for Treatment: Topical vs. Systemic Drugs

• Topical antifungals are usually the drug of choice for uncomplicated, localized candidiasis in patients with normal immune function.

• Systemic antifungals are usually indicated in cases of disseminated disease and/or in immunocompromised patients.

• Duration of therapy: Medication should be continued for at least 48 hours after the disappearance of clinical signs of candidiasis along with complete healing and the absence of mucosal erythema. Some sources recommend drug therapy should be continued for 10-14 days regardless of the disappearance of clinical signs of candidiasis.

DEDICATED FOR MOLAR PSPDG UMY 2012

#M10 drg. Suryono, PhD

II. Chronic Hyperplastic Candidiasis

• The most common sites are the anterior buccal mucosa along the occlusal line, and laterodorsal surfaces of the tongue.

• The etiology may be idiopathic or associated with immunosuppression.

• The most common appearance is that of asymptomatic white plaques or papules (sometimes against an erythematous background) that are adherent and do not scrape off.

• Some sources believe that hyperplastic candidiasis may have the ability to promote the development of oral epithelial carcinogenesis.

Treatment of hyperplastic candidiasis:

• Use topical or systemic medications as was recommended for pseudomembranous candidiasis

III. Chronic Atrophic (Erythematous) Candidiasis

• The most common site is the hard palate under a denture, but atrophic candidiasis may also be found on the dorsal tongue and other mucosal surfaces.

• The most common etiology is poor denture hygiene, and/or continuous denture insertion, but it may also be caused by immunosuppression, xerostomia, or antibiotic therapy.

• The most common appearance is that of a red patch or velvet textured plaque. When atrophic candidiasis occurs on the hard palate in association with a denture, it is frequently associated with papillary hyperplasia.

• Patients may complain of a burning sensation associated with this type of candidiasis

• It is important to remember to treat both the denture (if present) and the oral tissues. (The denture will act as a reservoir for the Candida and reinfect the tissues if they are not treated concurrently).

IV. Median Rhomboid Glossitis

• Median rhomboid glossitis is a form of chronic atrophic candidiasis characterized by an asymptomatic, elongated, erythematous patch of atrophic mucosa of the posterior mid-dorsal surface of the tongue due to a chronic Candida infection. (In the past, median rhomboid glossitis was thought to be a developmental defect resulting from a failure of the tuberculum impar to retract before fusion of the lateral processes of the tongue).

• A concurrent "kissing lesion" of the palate is sometimes noted.

• Specific predisposing etiologic factor(s) for median rhomboid glossitis have not been clearly established.

DEDICATED FOR MOLAR PSPDG UMY 2012

#M10 drg. Suryono, PhD

V. Angular Cheilitis (Perleche)

• Clinical appearance is that of red, eroded, fissured lesions which occur bilaterally in the commissures of the lips and are frequently irritated and painful.

• The most common etiology is loss of vertical occlusal dimension, but it may also be associated with immunosuppression.

Diagnosis

• The diagnosis of oral candidiasis is most frequently made on the basis of clinical appearance along with exfoliative cytology examination. This involves the histologic examination of intraoral scrapings which have been smeared microscope glass slides. A 10% - 20% potassium hydroxide preparation ("KOH prep") can be used for immediate microscopic identification of yeast cell forms. Alternatively, the slide containing the cytologic smear can be sprayed with a cytologic fixative and stained using PAS (Periodic acid - Schiff) stain prior to microscopic examination.

Candida

Candidiasis

DEDICATED FOR MOLAR PSPDG UMY 2012

Alhamdulillah selesai juga ngedit materi SUPER yang satu ini. Maaf ya teman-teman ngga

bisa maksimal translate semuanya. Banyak (banget)

kakaa –o-a

Anyway, hope you guys can understand the main point of

this lecture

Oke, ada satu quote nih dari om Aristoteles yang mungkin

bisa bikin kalian lebih semangat.

Here is …

“Pendidikan mempunyai akar yang pahit, tapi buahnya

manis”

Semangat Haphap!!