You are in: eMedicine Specialties > Dermatology > BACTERIAL INFECTIONS Trichomycosis PubisArticle Last Updated: Feb 1, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Vladimir O Osipov, MD, Assistant Professor, Department of Pathology, Section of Bone and Soft Tissue Pathology, Section of Gastrointestinal Pathology, Medical College of Wisconsin Vladimir O Osipov is a member of the following medical societies: American Medical Association, American Society of Clinical Pathologists, College of American Pathologists, and United States and Canadian Academy of Pathology Coauthor(s): Scott M Acker, MD, Associate Professor, Director of Dermatopathology, Departments of Dermatology and Pathology, University of Alabama at Birmingham; Peter Langenstroer, MD, Assistant Professor, Department of Surgery, Division of Urology, Medical College of Wisconsin; Milton W Datta, MD, Assistant Professor, Departments of Pathology, Urology, and Hematology-Oncology, Emory University School of Medicine Editors: Daniel Mark Siegel, MD, MS, Director, Procedural Dermatology Fellowship Program, Clinical Professor of Dermatology, Department of Dermatology, State University of New York Downstate; Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center; Lester F Libow, MD, Dermatopathologist, South Texas Dermatopathology Laboratory; Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania; Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center Author and Editor Disclosure Synonyms and related keywords: bacterial infection, hair shaft infection INTRODUCTIONSection 2 of 10
  BackgroundTrichomycosis is a bacterial infection of the hair shaft found in sweat gland–bearing areas; it has been described most commonly in the axillary region. While initially believed to be uncommon in the inguinal region, a series of papers have described trichomycosis particular to the inguinal area and have suggested that this disease is underestimated in the general population. PathophysiologyThis discussion of trichomycosis, a disease specific to the hair and sweat gland–bearing regions of the body, concentrates on the involvement of the pubic region in men (trichomycosis pubis). First described in the axillary region by Paxton in 1869, the causative role of multiple bacterial Corynebacterium species was established by Freeman in 1969. Use of the term trichomycosis, and the implied causative role of fungi, has been maintained. The color differences noted at presentation of the condition, their association with particular corynebacteria, or the possible role of associated cocci have not been clarified. The causative organism associated with most cases is Corynebacterium tenuis, which prefers the moist microenvironment of the inguinal regions. While as many as 33% of adults have colonization by bacteria in the inguinal or axillary regions, factors such as hyperhidrosis initiate more extensive growth and clinical manifestation. The exact origin of the cement substance that creates the grossly visible nodules is debated. Electron microscopy studies favor origin from the causative agents, while others have favored elaboration from apocrine sweat. The actual nidus may be through the modification of apocrine sweat by elaborated cement substance to create the insoluble material that holds bacteria to the hair shaft. FrequencyUnited StatesDetailed examination of racial, age, or geographic incidence has not been performed, and examinations in the United States are limited to case reports. A more detailed examination (but still limited) has been performed outside the United States. InternationalStudies in Panama and the United Arab Emirates revealed rates as high as 39% in patients attending a dermatology clinic. These results correlated with the notably higher incidence in areas of high humidity, warmth, and poor hygiene. The only other study to mention incidence noted the presence of trichomycosis pubis when examining institutionalized mentally retarded patients for trichomycosis axillaris in Edinburgh, Scotland, and noted that of 609 men examined, 16 (2.6%) had pubic disease, of which 3 of the cases (0.5%) were not associated with axillary involvement. Ages of the males affected were 18 and 21 (3 patients) and can be culled only from case reports. Mortality/MorbidityMorbidity is low, with most patients unaware of the colonization. When presenting, the most common complaint is a foul odor, and this may continue to cause problems, since trichomycosis often recurs. CLINICALSection 3 of 10
HistoryWhile many patients are asymptomatic, patients have presented because of pubic rash, foul odor, or growths on the pubic hair. Presenting complaints of colored sweat also have been recorded, resulting in a consideration of chromhidrosis. PhysicalPatients typically present with yellow or red nodules on the hair shafts; yellow is most common. Sweat in the region tends to be colored similarly. Lesions present in the inguinal region, often on the scrotum but occasionally on the base of the shaft of the penis. Lesions can be associated with erythema and itching, and superinfection with dermatophytes has been noted. CausesRisk factors appear to be geographic, with the highest incidence in tropic areas. In addition, poor hygiene often is present. Other diagnostic considerations: Clinical separation from other organisms often is not performed, and treatment focuses on the empirical use of drying agents and topical antibiotics. Thus, the use of topical powders can be a confounding factor in diagnosis. True fungal infections (piedra) also may confound the diagnosis but may be present as superinfection. Piedra presents with nodularity of the hair shafts that is either tan to white (white piedra) or black (black piedra), as opposed to the yellow or red nodules of trichomycosis. White piedra may have a gelatinous appearance. DIFFERENTIALSSection 4 of 10
Chromhidrosis
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| Drug Name | Naftifine (Naftin) |
|---|---|
| Description | Synthetic allylamine derivative shown to exhibit fungicidal activity in vitro against a broad spectrum of organisms including species of Trichophyton, Microsporum, and Epidermophyton genera. Has shown fungistatic activity against Candida species. Exact mechanism of action is not known; however, appears to interfere with sterol biosynthesis by inhibiting squalene 2,3-epoxidase. Treatment should continue up to 4 wk. If no improvement is noted, re-evaluate patient. |
| Adult Dose | Gently massage (1% cream/gel) sparingly into affected area and surrounding skin qd up to 4 wk |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity |
| Interactions | None reported |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | For topical use only; not for ophthalmic use |
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Antibiotic selection should be guided by blood culture sensitivity whenever feasible.
| Drug Name | Clindamycin solution (Cleocin T, Clinda-Derm) |
|---|---|
| Description | Wide-spectrum antibiotic effective in vivo against various microbial organisms including Corynebacterium species. Antibiotic binds preferentially to the 50S ribosomal subunit affecting the process of peptide chain initiation in bacteria. |
| Adult Dose | Apply to affected area bid |
| Pediatric Dose | <12 years: Not established >12 years: Apply as in adults |
| Contraindications | Documented hypersensitivity; history of antibiotic-associated colitis |
| Interactions | Has neuromuscular blocking properties that may enhance action of other neuromuscular blocking agents |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | Use of topical formulation results in absorption of antibiotic from skin surface; diarrhea and colitis (including pseudomembranous colitis) have been reported with use of topical and systemic clindamycin; discontinue if significant diarrhea occurs |
| Drug Name | Benzoyl peroxide (Benoxyl, Fostex, Benzac) |
|---|---|
| Description | Free-radical oxygen is released upon administration and oxidizes bacterial proteins in sebaceous follicles, decreasing the number of anaerobic bacterial and irritating free fatty acids. Has keratolytic and comedolytic effects. Use gel, pads, or wash. |
| Adult Dose | Apply sufficient quantity to affected and surrounding skin areas bid qam and qpm; reduce dose, frequency, or concentration if excessive dryness or peeling occurs |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity |
| Interactions | Potentiates adverse effects of tretinoin |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Avoid contact with lips, eyelids, mucous membranes, and eyes; for external use only; discontinue if swelling, burning, or excessive dryness occurs |
Agents that work to dry up the sweat glands.
| Drug Name | Aluminum chloride (Xerac-AC roll-on, Certain-dry pads, Drysol solution) |
|---|---|
| Description | Astringent agent used in management of hyperhidrosis. |
| Adult Dose | Apply to affected area hs; to prevent irritation, completely dry area prior to application |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity |
| Interactions | None reported |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Not for application on irritated, broken, or recently shaved skin; for external use only |
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Article Last Updated: Feb 1, 2007
