Dermatophytosis in Western Africa: A Review
Dermatophytic fungal infections are one of the most common infectious diseases in the world and are among the most commonly diagnosed skin diseases in Africa. They are caused by several dermatophyte species made up of three genera: Trichophyton, Microsporum and Epidermophyton. The pathogen spectrum and the clinical manifestations are totally different from those seen in other continents. The hot and humid environment in Africa is probably the major reason for their high prevalence. In this era of rapid movement from one continent to another and the increasing mobility of humans, agents of dermatophytic infections can no longer be said to be restricted within a given geographical area. This implies that an infection contracted in one part of the world may become manifest in another country where the etiological agent is not normally found. Therefore, updating our knowledge of the geographical distribution of the predominant causative agents of dermatophytosis will provide a better understanding of the risk factors and future epidemiologic trends. This review discusses the clinical signs and manifestations of dermatophytoses and attempts to summarize the current epidemiological trends on dermatomycosis of glabrous skin in Western Africa.
Received: March 15, 2010;
Accepted: May 22, 2010;
Published: July 08, 2010
Dermatophytosis is caused by dermatophytes which comprise a group of closely
related fungi made up of three genera: Trichophyton, Microsporum and
Epidermophyton (Weitzmann and Summerbell, 1995;
Emmons, 1934). They have the ability to invade the stratum
corneum of the epidermis and keratinized tissues derived from it, such as skin,
hair and nail of humans and other animals (Weitzmann and
Summerbell, 1995). It is one of the most common cutaneous infections all
over the world (Ameen, 2010; Nweze
and Okafor, 2005). They cause superficial fungal infections that pose public
health problems to man and animals (Havlickova et al.,
2008). Dermatophyte infections can be disfiguring and recurrent and generally
need long-term treatment with antifungal agents (Nweze et
In recent times, infections caused by dermatophytes have assumed greater significance.
The increasing number of patients with immunocompromised states, such as AIDS,
diabetes mellitus, cancer and organ transplantation, has given these infections
more prominence (Berg et al., 2007; Nir-Paz
et al., 2003; Smith and Stiller, 1997). Infact,
it has been estimated that 20 to 25% of the world's population are infected
by dermatophytes and the incidence continues to increase on a steady basis (Male,
1990). The causative species vary with geographic region and vice versa
(Nweze, 2001, 2005, 2006;
Nweze and Okafor, 2005, 2007;
Ngwogu and Otokunefor, 2007). However, the epidemiology
of dermatophyte infection is affected by migration pattern, increase in tourism,
locality and changes in socioeconomic condition of the people.
Dermatophytes are known to grow best in warm and humid environments and are,
therefore, more common in tropical and subtropical regions and this probably
explains why they are very common in Africa. For instance, some species of dermatophytes
such as Trichophyton mentagrophytes var. interdigitale, Microsporum
canis, Epidermophyton floccosum and Trichophyton rubrum are
distributed all over the world. However, other species probably have partial
geographic restriction. For example, Trichophyton schoenleinii is found
in Africa and Eurasia while Trichophyton soudanense is also restricted
within Africa (Weitzmann and Summerbell, 1995). Others
are Trichophyton violaceum which are associated to Asia, Africa and Europe
and Trichophyton concentricum is known to be common in the Far East,
India and the Pacifics (Ameen, 2010).
There are several known clinical types of dermatophytoses. This review will
discuss them in more details in the subsequent sections. However, in Africa
and several other countries in Latin America and the Middle East, there is a
kind of variability and geographical/regional associations in the pattern of
dermatophytic infections. For instance, tinea capitis is known to be very common
in Western Africa especially among children and several species of dermatophytes
are known to be responsible. Tinea cruris, tinea pedis, tinea corporis and tinea
unguium are caused by T. rubrum in many urban areas of developing countries
(Hernandez-Salazar et al., 2007) and even in
developed countries (Borman et al., 2007; Foster
et al., 2004). Microsporum audouinii is the predominant dermatophyte
species in many parts of Africa. T. violaceum is reportedly endemic in
several parts of South and Northern Africa and T. soudanense in central
Northwestern parts of Africa (Ellabib et al., 2002;
Morar et al., 2004; Woldeamanuel
et al., 2005). Conversely, M. canis predominates other dermatophytes
in Southern and Central European countries as the most common cause of tinea
capitis while T. mentagrophytes and T. rubrum are the cause of
increasing cases of tinea unguium and pedis, respectively (Tao-Xiang
et al., 2005; Tan, 2005).
CLINICAL SIGNS AND MANIFESTATIONS
Dermatophytes typically do not affect the mucus membranes but rather affect the keratinized tissues. They grow on nails, hairs and the outer layer of the skin of both man and other animals. Although, the clinical signs of dermatophytoses may vary depending on the affected region of the body, pruritis is the most common symptom in humans. The lesions on the skin are often characterized by inflammation. Severity of the lesions is often obvious at the edges. Scaling, erythema and sometimes, blister formation are evident. This results in clinical ring worm formation as seen in tinea corporis often resembling a central clearance. Hair loss often results, especially on the facial hair and the scalp.
There are three ecological groups of dermatophytes: anthropophilic (mostly
associated with humans), zoophilic (associated with animals) and geophilic (found
in the soil) (Ajello, 1962; Georg,
1960). Anthropophilic dermatophytes produce fewer lesions in humans compared
to geophilic or zoophilic forms. Generally, speaking, dermatophytic infections
in humans are referred to as tinea infections and are consequently named with
specific reference to the area of the body involved (Weitzmann
and Summerbell, 1995).
One of the foremost clinical manifestations of dermatophytic infection is tinea
capitis. It is a dermatophytic infection of the hair and the scalp and begins
with a small papule which spreads to form irregular and scaly forms of alopecia.
Typical cases mostly result in the enlargement of cervical and occipital lymph
nodes. Sometimes, a boggy inflammatory mass known as a kerion is formed. This
is common in children worldwide, especially in African countries (Macura,
1993). Clinical presentation depends on the etiology. However, three kinds
are recognized: non-inflammatory, inflammatory or black dot type. The non-inflammatory
form is most commonly caused by M. audouinii or M. ferrugineum
and usually begins as a small erythematous papule surrounding a single hair
shaft, which spreads centrifugally to other hairs. The hair turns grey following
scaling. The inflammatory type is usually associated with zoophilic or geophilic
dermatophytes such as M. canis and M. gypseum, respectively. Black
dot tinea capitis is caused by T. tonsurans or T. violaceum,
T. verrucosum is highly contagious and virulent and is the only dermatophyte
able to thrive at 37°C. Tinea capitis infections caused by zoophilic dermatophytes
usually result in suppurative lesions. It is widespread and a well-known occupational
disease especially among cattle keepers. Several species of dermatophytes have
been recovered from tinea capitis infections. They include M. audouinii,
M. canis, T. tonsurans and T. mentagrophytes. Others are,
T. schoenleinii, T. soudanense, T. verrucosum, T. violaceum,
M. ferrugineum, M. gypseum, M. nanum, M. persicolor and
T. megninii (Weitzmann and Summerbell, 1995).
Tinea corporis affects the trunk, especially in exposed areas like the abdomen
or limbs, causing red patches. It is more common in children than in adults
and occurs most frequently in hot climates similar to that found in many African
countries (Macura, 1993). Tinea corporis often referred
to as ringworm, is characterized by single or sometimes multiple scaly lesion,
occurs on the trunk, extremities and face of humans. The edge of the lesions
is also elevated, scaly and erythematous with sharp margin and central clearing.
Follicular papules, pustules or vesicles may be found on the borders of the
lesion. Lesions may be variably pruritic. Dermatophyte infection affecting nearly
the entire integument is referred to as tinea corporis generalisata. A generalised
dermatophytosis caused by T. rubrum can occur as a result of wrong diagnosis
or treatment. Misread tinea corporis generalisata caused by T. rubrum
is named tinea incognita. Zoophilic and anthropophilic dermatophytes are common
cause of dermatophytic infections in children and on the neck and wrists of
adults in contact with the infected child. Tinea corporis is most times often
the result of chronic infection with T. rubrum, an anthropophilic dermatophyte.
Untreated tinea corporis infections could resolve in a couple of months especially
when it is caused by a geophilic or zoophilic dermatophyte. Most common agents
include: M. canis, M. tonsurans, T. verrucosum and T.
rubrum. Others are E. floccosum, M. audouinii, M. gypseum,
M. persicolor, T. equinum, T. mentagrophytes, T. raubitschekii,
T. schoenleinii, T. violaceum and M. nanum.
Tinea imbricata is a specialized manifestation of tinea corporis caused only
by T. concentricum. It is chronic and usually characterized by concentric
rings of overlapping scales scattered throughout the body. It is geographically
restricted to certain areas of the Pacific islands of Oceana, Southeast Asia,
Mexico and Central and South America (Rippon, 1988).
Tinea faciei is seen on the face especially on the non-bearded areas. The lesions are mostly pruiritic with itching and with burning sensation. Exposure to sunlight could make infected cases worse due to itching and burning. Some lesions resemble those of tinea corporis while others may have little or no scaling or raised edges. Tinea faciei is always confused with other skin diseases of the face especially in atypical cases. Most common agents include T. tonsurans, T. mentagrophytes and T. rubrum.
Tinea barbae is an infection of the skin and hairs in the beard and mustache area. It is more common in men. The lesions may include erythema, scaling and follicular pustules. Zoophilic or anthropophilic dermatophytes are often implicated in tinea barbae infections. Most common agents include: T. verrucosum, M. canis, T. megninii, T. mentagrophytes, T. rubrum and T. violaceum.
Tinea pedis is usually referred to as Athletes foot. It is an infection
of the foot, characterized by fissures, scales and maceration in the toe web,
or scaling of the soles and lateral surfaces of the feet. It is more common
in those who wear occlusive shoes (Macura, 1993). In
majority of cases, vesicles, erythema, pustules and bullae may also be present.
Anthropophilic dermatophytes are the major cause of tinea pedis. Most common
agents are T. rubrum, T. mentagrophytes var interdigitale,
E. floccosum, M. persicolor, T. raubitschekii and T.
violaceum. It has been estimated that tinea pedis is so common that one
in five adults is affected (Male, 1990). The incidence
also increases with age from adolescence (Male, 1990).
During the past 3 decades, the incidence of tinea pedis has increased worldwide
with an estimated prevalence of 10% in the developed world (Nelson
et al., 2003) and expectedly higher rate in most developing countries.
Tinea cruris, an infection of the groin, is an itchy, red rash in the groin
and surrounding area which is commonly seen in young men living in a warm climate
(Macura, 1993). Tinea pedis can co-exist if the infection
is spread by scratching the feet and then the groin. Axillary infection can
be seen as an analogous tinea pattern in women. Tinea cruris is predominantly
caused by anthropophilic dermatophytes. Burning and pruritus are common symptoms.
Pustules and vesicles at the active edge of the infected area, along with maceration,
are found in a background of red, scaling lesions with raised borders. E.
floccosum and T. rubrum are the most common cause of tinea cruris.
Other species include M. nanum, T. mentagrophytes and T.
Tinea unguium, a dermatophyte infection of the nail, is usually characterized
by thickened, broken and discolored nails. It is often referred to as onychomycoses
and may result in the separation of the nail plate from the nail bed. Both anthropophilic
and zoophilic dermatophytes can cause tinea unguium. T. rubrum and
T. mentagrophytes var mentagrophytes are the most common agents. Others
are E. floccosum, T. tonsurans, T. violaceum. T. interdigitale,
M. gypseum, T. soudanense (considered by some mycologists to be
an African variant of T. rubrum rather than a distinct full-fledged species)
and the cattle ringworm fungus, T. verrucosum (Macura,
1993). Furthermore, T. interdigitale is still sometimes referred
to as T. mentagrophytes var. interdigitale. The latter ought to be used
to describe the zoophilic form of the dermatophyte and T. interdigitale
used to describe its anthropophilic form. Recent molecular studies have shown
that T. mentagrophytes var. granulosum is the same as T. interdigitale
(Nenoff et al., 2007).
Tinea manuum is a dermatophyte infection of one or, occasionally, both hands.
It is most often caused by anthropophilic dermatophytes although zoophilic dermatophytes
have also been reportedly recovered from tinea manuum infections (Weitzmann
and Summerbell, 1995). In this form, the palms become diffusely dry, scaly
and erythematous. Most common agents are T. rubrum, E. floccosum,
M. canis, M. gypseum, T. mentagrophytes and T. verrucosum.
Tinea favosa is a severe and chronic infection which is caused by Trichophyton
schoenleinii. It is characterized by scutula-the presence of yellowish,
cup-shaped crusts on the scalp and glabrous skin. It is composed of epithelial
debris and dense masses of mycelium. The disease is often common in Africa and
the Eurasia (Weitzmann and Summerbell, 1995).
EPIDEMIOLOGY OF DERMATOPHYTOSIS IN WESTERN AFRICA
In Nigeria, there are varying reports of dermatophytosis in different cities
and communities (Nweze and Okafor, 2005). Considering
its human and socioeconomic diversity and the staggering population, this is
understandable. This author carried out an extensive survey of dermatophytosis
in Nigerias Northeastern state of Borno. The study involved 2193 children
aged between 4-16 years in different local and urban communities of the state.
Seven percent were proved to be positive for dermatophytosis. Incidence was
significantly higher in young children aged 7-11 years and 4-6 years than in
older children aged 12-16 years. Moreover, there was a significant difference
in the incidence of dermatophytoses amongst children in urban and rural areas,
thereby emphasizing the role of locality in dermatophytoses.
Tinea capitis was the predominant clinical type followed by tinea corporis.
Trichophyton schoenleinii was the most prevalent etiological agent (28.1%),
followed by T. verrucosum (20.2%) and M. gallinae (18.4%). Other
species recovered included T. mentagrophytes (16.7%), T. tonsurans
(10.5%), T. yaoundei (4.4%) and M. gypseum (1.8%) (Nweze,
2001). In a similar study carried out in Kano State Nigeria, 2150 itinerant
quranic scholars were screened. Only 9.5% were found to be infected and the
age group 10-14 years was most affected. T. rubum (50.2%) was the most
prevalent followed by M. audouinii (26.5%). T. rubrum was the
only dermatophyte that was recovered from all sites apart from the buttocks
(Adeleke et al., 2008).
Out of a total of 6987 primary school children sampled across 4 schools in
Jos, Plateau state Nigeria, only 3.4% were found to be infected by this disease.
There was a high incidence of both scalp and foot ringworms among the infected
children. A large spectrum of fourteen species of dermatophytes was isolated
from the ringworm cases. The scalp ringworm had the highest number of fungal
isolates. Trichophyton mentagrophyte and T. rubrum had the highest
frequencies of occurrence (Ogbonna et al., 1985).
Ten years later, Ayanbimpe et al. (1994) found
that Trichophyton soudanense was the major aetiological agent in the
same area, indicating a shift in the pathological spectrum of the species. In
a recent and more expanded study involving several states in Central Nigeria,
a total of 28505 primary school children aged between 3 and 16 years were sampled
from 12 primary schools. Tinea capitis was found to be the most prevalent superficial
mycoses. The most common aetiological agent was T. soudanense, (30.6%),
followed by M. ferrugineum, (7.7%) and M. audouinii, (7.7%) (Ayanbimpe
et al., 2008).
In Ogun state, South Western Nigeria, a total of 2772 randomly selected junior
secondary school pupils between the ages of 8-14 years from 60 schools were
examined. The prevalence of dermatophytosis was 23.21%. Etiological agents identified
with infection were M. canis (30.19%), M. audouinii (32.92%),
T. interdigitale (14.37%), T. soudanense (9.73%) and T. tonsurans
(12.05%). Most of the dermatophytes encountered were anthropophilic species.
M. canis was the only zoophilic dermatophyte (Popoola
et al., 2006).
In a much older study in Lagos Southwest Nigeria (Adetosoye,
1977), 3860 school children were screened. The prevalence at the time was
just 2.1%. Seven species of dermatophytes were recovered from specimens collected
from the hair, skin and scalp scrapings of 81 school children. T. soudanense
was the most etiological agent followed by M. canis.
Years later, another study in Lagos involving patients attending the Lagos
State University Teaching Hospital, Lagos found that 162 (41% ) of the patients
were infected by dermatophytoses. Microsporum species were the most common
species (74.1%), followed by E. floccosum (4.3%). Superficial mycosis
of the skin was the most prevalent (59.3%), followed by that of the hairs (27.2%)
while infection of the nails (13.6%) was the least. Those aged five years and
below had the lowest isolation rate (3.7%) (Nwobu and Odugbemi,
In Mid-western state of Edo state Nigeria, another group found a prevalence
of 13.4% among primary school children infected with dermatophytosis (Enweani
et al., 1996).
In one of the earlier studies carried out between 1974-1977 in the old Anambra
state of Nigeria, (now subdivided into two States: Enugu and the new Anambra
states), 3478 primary school children aged 4-13 years made up of 1868 males
and 1610 females were screened for dermatophytoses. A total of 303 (8.7%) mycologically
proven cases of tinea capitis were detected. Microsporum audouinii was
the commonest etiological agent (48.3%) followed next by T. soudanense
(26.6%) and T. tonsurans (15.2%). Other dermatophytes occasionally represented
were M. ferrugineum (3.4%), T. violaceum (3.7%), T. yaoundei
(1.2%), T. mentagrophytes (0.9%) and T. schoenleinii (0.6%). Investigation
of scalp carriage of dermatophytes by the authors showed that approximately
9% of children without any clinical signs of tinea capitis harbor dermatophytes
in their scalp hair (Gugnani and Njoku-Obi, 1986).
More recently, further studies involving this author were conducted in the
new Anambra State by screening 1624 children with clinically suggestive lesions.
These children aged between 4 and 16 years were sampled in selected urban and
rural areas of the State. Our data showed that tinea capitis was the predominant
clinical type. T. tonsurans was the most prevalent etiological agent
while M. audouinii was the least in occurrence (Nweze
and Okafor, 2005). Emele and Oyeka (2008) in another
larger study which involved a total of 47723 primary school children residing
in different regions of Anambra State, found that 4498 (9.4%) had tinea capitis.
The highest prevalence of the disease occurred in the Southern region of the
state (12.6%). Schools in urban areas recorded lower prevalence of the disease.
Moreso, tinea capitis occurred significantly more in children below 10 years
of age than in those above this age. This agrees in part with the findings in
Anambra state by Nweze and Okafor (2005). M. audouinii
was the most prevalent (42%), followed by M. ferrugineum (17%) and T.
In Aba, Abia State in Southeast Nigeria, T. mentagrophytes was however
observed to be predominant in primary school children (Okafor
and Agbugbaeruleke, 1998). In a neighbouring local community of Arochukwu,
also in Abia state Nigeria, it was found that tinea capitis was the predominant
clinical type of dermatophytoses affecting 13.7% of the total population studied.
T. soudanense and T. tonsurans were the predominant etiological
agents of dermatophytoses with a prevalence of 26.2 and 21.6%, respectively
(Ngwogu and Otokunefor, 2007).
In Togo, a study involving 374 children from primary schools in North and Southern
part of the country revealed that 11% of the children in the North (dry and
urban area) and 20% in the South (wet and rural area) had obvious clinical lesions.
Two species of dermatophytes were isolated: Microsporum langeronii and
T. soudanense; this second dermatophyte being uncommon in the South.
Moreover, 15% of the children in the North and 42% of the children in the South
were asymptomatic carriers (Dupouy-Camet et al.,
1988). This suggests that the locality predispose to dermatophytoses and
concurs with the findings in Nigeria (Nweze, 2001; Nweze
and Okafor, 2005). In another study in Germany involving children arriving
from Togo including an 8 week-old male baby, T. soudanense was recovered
from discrete lesions on the hairy scalp and neck of these patients, thus confirming
that this agent was indeed common in Togo (Faulhaber and
Korting, 1999). A ten year retrospective study had indicated that dermatosis
was a significant public health problem in Togo (Napo-Koura
et al., 1997)
In Dakar, Senegal, Gaye et al. (1994) found
that the poor school and home background along with other socioeconomic factors
were responsible for the high prevalence of tinea capitis. In another study
conducted in the Mycology laboratory of Hospital A. Le Dantec, Dakar, Senegal,,
1512 patients aged from 14 days to 70 years with a mean age of 21.4 years including
882 with suspected tinea were screened and a prevalence of 25.7% was established.
The main etiological agents were T. soudanense (47.3%), followed by T.
rubrum (33.41%) and Microsporum langeronii (11.3%). Only a single
case of T. violaceum was isolated. These species were earlier shown to
be the predominating agents of dermatophytosis in Senegal. The prevalence of
dermatophytosis seems to vary across various regions of Senegal. Develoux
et al (2002) found a frequency of 26.4% in Dakar, whereas Silverberg
et al., (2002) and Cremer et al. (1997)
reported 11.4 and 11%, respectively. In a recent two year study involving three
dermatology Centers in Senegal, 16% of HIV patients with dermatosis had dermatophytic
infections suggesting that dermatophytoses could pose a future problem in this
country with the increasing incidence of HIV/AIDS among the inhabitants of this
country (Monsel et al., 2008).
In the Northern flanks of West African countries of Guinea Conakry and Burkina
Faso T. violaceum, T. rubrum and T. soudanense were the
predominating etiological agents of dermatophytoses (Menan
et al., 2002; Guiguemde et al., 1992).
The report from Guinea Conakry indicated a shifting trend as it was noted earlier
in 1959 that T. soudanense and M. audouinii were more prevalent
in that country. The two agents were often seen in tinea capitis while the former
was responsible for tinea corporis cases (Philpot, 1978).
A study conducted at the Dermatology Center of Treichville Hospital in Abidjan,
Cote d'Ivoire found a three fold higher incidence of tinea capitis in boys than
in girls and a peak during childhood especially those aged between 5 and 9 years.
The most frequent etiologic agents were T. soudanense and M. audouinii
var langeronii in 63.6 and 31.3% of cases respectively (Adou-Bryn
et al., 2004). This finding is in agreement with earlier reports
in that country (Deblock et al., 1959).
In Ghana, studies conducted among 463 in the Greater Accra region showed that
T. violaceum (26%) was the most prominent species in Ghana, followed
by T. tonsurans (22%). The percentage occurrence of M. audouinii
(15%) was relatively low compared to other studies performed in Africa. The
prevalence of T. rubrum was 11% and no T. soudanense was recovered
in the study (Hogewoning et al., 2006). Tietz
et al. (2002) recovered a rare species of the T. rubrum complex
(Trichophyton raubitschekii) in Germany from a set of four African immigrant
patients who presented with typical lesions of tinea corporis. One of the patients
was from Ghana and the other three were from Cameroon. In a similar incident
in the USA, two African children internationally adopted from Liberia in West
Africa, who were residing in Cincinnati, Ohio, presented with tinea capitis
associated with T. soudanense, a dermatophyte that is not common in the
whole of North America (Markey et al., 2003).
It was previously reported that tinea capitis is the most clinical form of
dermatophytosis in both Liberia and the Republic of Chad where T. soudanense
was the main etiological agent (Philpot, 1978). This
finding in Germany confirmed earlier observations that T. rubrum is a
major etiological agent of dermatophytosis in Cameroon, making up about 81.8%,
followed by T. soudanense (12.1%) and T. interdigitale (6.1%).
(Lohoue-Petmy et al., 2004). Tinea corporis constituted
up to 10.5% of cases followed by tinea pedis (8.9%).
In Mali, out of a total of 517 isolations of dermatophytes collected, Trichophyton
species were more common than Microsporum species. T. verrucosum and
M. canis were reported in Mali for the first time in this study. T. schonleinii
and T. soudanense were also found to be prevalent in the sub-saharian
areas of the country (Mahe et al., 1997). Tinea
capitis was also reported to be the second most common cause of skin infections
in Mali being responsible for about 9.5% of all skin diseases (Mahe
et al., 1995).
In summary, it may be concluded that the most common etiological agents of
dermatophytoses in the West African sub-region are T. soudanense and
M. audouinii, with T. rubrum, T. mentagrophytes, T.
tonsurans and T. violaceum recently playing dominant role in some
locations in the region. Although, dermatophytes respond well to conventional
antifungal agents (Weitzmann and Summerbell, 1995; Nweze
et al., 2007), many patients usually cannot afford the cost of conventional
antifungal antibiotics but use local medicinal plants to treat the infections.
Our laboratory tested some of these plant extracts which are in use in Nigeria
against dermatophytes recovered from patients and indeed found that some of
them have good in vitro activities against dermatophytes (Okafor
et al., 2001; Nweze et al., 2004).
This may have helped a great deal in reducing these dermatophytic infections
in western African countries such as Nigeria.
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