Eczematous Fungus Infections

Filed under: 2.3 - Fungus Infections

Twenty years ago I thought it was possible that secondary fungus infec­tion might be important in atopic dermatitis, and that some other eczema-like eruptions in children which did not fit well into classification might be primarily caused by fungi. The two main groups of fungi which have been found to be of importance in eczema-like eruption in adults are the tri-chophyton and the group of yeastlike fungi, particularly Candida (Monilia) albicans. Not being well versed in the intricacies of mycology, it seemed to me that I could probably learn more about this question by doing skin tests than by making cultures or scrapings.

Intracutaneous tests with trichophytin and Oidiomycin, which give the twenty-four-hour delayed tuberculin type of reaction, are quite reliable in indicating whether or not infection with the corresponding organism is or has been present, exactly comparable to the significance of a positive tuberculin test. I tested sixty eczematous infants and children, just as they came, without selecting any special type of erup­tion, with trichophytin 1 to 100. There were two doubtfully positive reactions.

This showed pretty clearly that tricho-phyton infection either primary or secondary is unusual in eczema-like eruptions in children. “Ringworm,” which is caused by a trichophyton, is, of course, common, but is not ordinar­ily classed as an eczema-like eruption, and is not likely to be confused with eczema. One hundred eczematous children were tested with Oidiomycin 1 to 100, with fifteen for the most part strongly positive reactions. Most of these children who gave positive reac­tions showed three types of eruption:

1. Patchy, sharply margined rather superficial areas on the inner side of the thighs, and in the pubic region.

2. The same sort of lesions on the trunk, which in some cases were extensive.

3. Scaly  fingers,   with  involvement  of the nails.   In these patients, except for those who had finger and nail in­volvement, treatment with gentian vio­let was very satisfactory. (See Figs. 9 and 10.)

More recently, Dr. Henry Harris Perlman³ of Philadelphia, who is not only a certified pediatrician but a certified dermatologist as well (I expect the only  one  of  the  species existence), and who therefore knows a great deal more about mycology than I do, studied a series of sixty-eight cases of atopic dermatitis in children to determine whether or not fungi were complicating the situation. He found no pathogenic fungi.

In this, his results agreed very well with mine so far as trichophyton is concerned, but not for monilia. A possible reason for this may be that he investigated only patients with atopic dermatitis. I took consecutive cases of any sort of eczematoid dermatitis. He, being a trained dermatologist, would have excluded eruptions which to him were obviously monilia infections. I did not.

In 1953, King, Walton, and Livingood⁴ reported ten cases of proved trichophyton infection in infants un­der the age of 10 months. This was in a hot, damp climate (Southern Texas), and they were of the opinion that these infections might be more common in such a climate than else­where. They say nothing about the morphology of the eruptions, which is a pity. There is a picture, however, which looks almost exactly like the babies shown in Figs. 11 and 12. I treated these babies about twenty-five years ago and cured them both very easily with antiparasitic treatment be­cause I thought their trouble looked like fungus infection; no cultures or scrapings were made.

Fig.  13.- Moniliasis.    Note sharp borders.    Also note extension to face.     (From Brennemann’s Practice  of Pediatrics.)

In the last five years I have been much impressed with the increasing frequency of skin moniliasis in young infants under the age of 2 months. This often begins in the newborn period, around the anus and in the pubic region, and rapidly spreads, so that it may cover large areas, even invading the chest, neck, and face. These patches are of a beefy red color, usually with slight scaling. The edges arc somewhat raised, with very sharp margins. There are usually, but not always, a number of small satellite lesions, from the size of a pea to that of a dime, which, in their turn, en­large and fuse with the larger areas. There may be cracks with exudation in the larger patches, but I have not seen the vesicular or pustular lesions which have been so often described. There is little itching, and the general health of the baby is good.

Some of these babies have had oral thrush while in the hospital. The mothers of others have had a vaginal infection with C. olbicans during pregnancy. Whether or not the increased incidence of monilia skin infection in infancy is due to wide use of broad spectrum antibiotics, I do not know. Newborn babies do not, as a rule, take antibiotics; perhaps some of the mothers have done so.

Diagnosis is made by the appearance of the skin or by cultures if one is in doubt. I do not think much of smears.

A good treatment is to paint the involved areas twice a day with a 2 per cent aqueous solution of gentian violet, or if the patches are much thickened, the gentian violet is used in 2 per cent strength in petrolatum and well rubbed in. Two per cent Vioform in petrolatum is also good. It is par­ticularly important to see that what­ever preparation is used is well applied to the edges, and rubbed in-the most vigorous fungi are at the edges. A dermatologic friend, in whom I have great confidence, told me not long ago that treatment with 3 per cent sulfur ointment was the best there is and that he had given up the use of gentian violet. He is very likely right, but being a pediatrician and familiar with young babies, I should be a bit shy of using a sulfur ointment as strong as this on them.

Some cases of cutaneous moniliasis apparently arise from an overgrowth of G. albicans in the bowel. For this reason it is desirable to give these pa­tients a diet low in carbohydrate, in order to discourage growth of the fungi in the bowel. This was told me a good many years ago by Dr. Rhoda Benham of New York, in whose mycology laboratory I once spent a very profit­able morning.

*This salve, or any other containing an active drug, should not be used for long over the whole body. There is too much danger of absorption of toxic amounts of the drug.

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