{"id":916,"date":"2016-11-04T03:35:41","date_gmt":"2016-11-04T03:35:41","guid":{"rendered":"https:\/\/courses.lumenlearning.com\/microbiology\/?post_type=chapter&#038;p=916"},"modified":"2018-07-12T11:27:48","modified_gmt":"2018-07-12T11:27:48","slug":"mycoses-of-the-skin","status":"publish","type":"chapter","link":"https:\/\/courses.lumenlearning.com\/suny-mcc-microbiology\/chapter\/mycoses-of-the-skin\/","title":{"raw":"Fungal Infections of the Skin","rendered":"Fungal Infections of the Skin"},"content":{"raw":"<div class=\"textbox learning-objectives\">\r\n<h3>Learning Objectives<\/h3>\r\n<ul>\r\n \t<li>Identify the most common fungal pathogens associated with cutaneous and subcutaneous mycoses<\/li>\r\n \t<li>Compare the major characteristics of specific fungal diseases affecting the skin<\/li>\r\n<\/ul>\r\n<\/div>\r\nMany fungal infections of the skin involve fungi that are found in the normal skin microbiota. Some of these fungi can cause infection when they gain entry through a wound; others mainly cause opportunistic infections in immunocompromised patients. Other fungal pathogens primarily cause infection in unusually moist environments that promote fungal growth; for example, sweaty shoes, communal showers, and locker rooms provide excellent breeding grounds that promote the growth and transmission of fungal pathogens.\r\n\r\nFungal infections, also called <strong>mycoses<\/strong>, can be divided into classes based on their invasiveness. Mycoses that cause superficial infections of the epidermis, hair, and nails, are called <strong>cutaneous mycoses<\/strong>. Mycoses that penetrate the epidermis and the dermis to infect deeper tissues are called <strong>subcutaneous mycoses<\/strong>. Mycoses that spread throughout the body are called <strong>systemic mycoses<\/strong>.\r\n<h2>Tineas<\/h2>\r\nA group of cutaneous mycoses called <strong>tineas<\/strong> are caused by <strong>dermatophytes<\/strong>, fungal molds that require keratin, a protein found in skin, hair, and nails, for growth. There are three genera of dermatophytes, all of which can cause cutaneous mycoses: <strong><em>Trichophyton<\/em><\/strong>, <strong><em>Epidermophyton<\/em><\/strong>, and <strong><em>Microsporum<\/em><\/strong>. Tineas on most areas of the body are generally called <strong>ringworm<\/strong>, but tineas in specific locations may have distinctive names and symptoms (see Table 1\u00a0and Figure\u00a01). Keep in mind that these names\u2014even though they are Latinized\u2014refer to locations on the body, not causative organisms. Tineas can be caused by different dermatophytes in most areas of the body.\r\n<table id=\"fs-id1167661316692\" class=\"span-all\" summary=\"Table titled Some Common Tineas and Location on Body. Tinea corporis (ringworm); body. Tinea capitis (ringworm); scalp. Tinia pedis (athlete's foot); feet. Tinea barbae (barber's itch); beard. Tinea cruris (jock itch); groin. Tinea unguium (onychomycosis); toenails, fingernails.\">\r\n<thead>\r\n<tr>\r\n<th colspan=\"2\">Table 1. Some Common Tineas and Location on the Body<\/th>\r\n<\/tr>\r\n<\/thead>\r\n<tbody>\r\n<tr valign=\"top\">\r\n<td>Tinea corporis (ringworm)<\/td>\r\n<td>Body<\/td>\r\n<\/tr>\r\n<tr valign=\"top\">\r\n<td>Tinea capitis (ringworm)<\/td>\r\n<td>Scalp<\/td>\r\n<\/tr>\r\n<tr valign=\"top\">\r\n<td>Tinea pedis (athlete\u2019s foot)<\/td>\r\n<td>Feet<\/td>\r\n<\/tr>\r\n<tr valign=\"top\">\r\n<td>Tinea barbae (barber\u2019s itch)<\/td>\r\n<td>Beard<\/td>\r\n<\/tr>\r\n<tr valign=\"top\">\r\n<td>Tinea cruris (jock itch)<\/td>\r\n<td>Groin<\/td>\r\n<\/tr>\r\n<tr valign=\"top\">\r\n<td>Tinea unguium (onychomycosis)<\/td>\r\n<td>Toenails, fingernails<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n[caption id=\"\" align=\"aligncenter\" width=\"1300\"]<img src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/1094\/2016\/11\/03173219\/OSC_Microbio_21_04_tineas.jpg\" alt=\"a) large red bumps on a cheek. B) white crusty skin on a foot. C) an orange ring on skin.\" width=\"1300\" height=\"348\" \/> Figure\u00a01. Tineas are superficial cutaneous mycoses and are common. (a) Tinea barbae (barber\u2019s itch) occurs on the lower face. (b) Tinea pedis (athlete\u2019s foot) occurs on the feet, causing itching, burning, and dry, cracked skin between the toes. (c) A close-up view of tinea corporis (ringworm) caused by <em>Trichophyton mentagrophytes<\/em>. (credit a, c: modification of work by Centers for Disease Control and Prevention; credit b: modification of work by Al Hasan M, Fitzgerald SM, Saoudian M, Krishnaswamy G)[\/caption]\r\n\r\nDermatophytes are commonly found in the environment and in soils and are frequently transferred to the skin via contact with other humans and animals. Fungal spores can also spread on hair. Many dermatophytes grow well in moist, dark environments. For example, <strong>tinea pedis<\/strong> (athlete\u2019s foot) commonly spreads in public showers, and the causative fungi grow well in the dark, moist confines of sweaty shoes and socks. Likewise, <strong>tinea cruris<\/strong> (jock itch) often spreads in communal living environments and thrives in warm, moist undergarments.\r\n\r\nTineas on the body (<strong>tinea corporis<\/strong>) often produce lesions that grow radially and heal towards the center. This causes the formation of a red ring, leading to the misleading name of ringworm recall <a href=\".\/chapter\/unicellular-eukaryotic-parasites\/\" target=\"_blank\" rel=\"noopener\">the Clinical Focus case that started in Unicellular Eukaryotic Parasites<\/a>.\r\n\r\n[caption id=\"attachment_1775\" align=\"alignright\" width=\"450\"]<img class=\" wp-image-1775\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/1094\/2016\/11\/11185557\/OSC_Microbio_21_04_dermatophy1.jpg\" alt=\"A photo of a large blackn, fuzzy colony.\" width=\"450\" height=\"324\" \/> Figure\u00a02. To diagnose tineas, the dermatophytes may be grown on a Sabouraud dextrose CC agar plate. This culture contains a strain of <em>Trichophyton rubrum<\/em>, one of the most common causes of tineas on various parts of the body. (credit: Centers for Disease Control and Prevention)[\/caption]\r\n\r\nSeveral approaches may be used to diagnose tineas. A <strong>Wood\u2019s lamp<\/strong> (also called a black lamp) with a wavelength of 365 nm is often used. When directed on a tinea, the ultraviolet light emitted from the Wood\u2019s lamp causes the fungal elements (spores and hyphae) to fluoresce. Direct microscopic evaluation of specimens from skin scrapings, hair, or nails can also be used to detect fungi. Generally, these specimens are prepared in a wet mount using a potassium hydroxide solution (10%\u201320% aqueous KOH), which dissolves the keratin in hair, nails, and skin cells to allow for visualization of the hyphae and fungal spores. The specimens may be grown on Sabouraud dextrose CC (chloramphenicol\/cyclohexamide), a selective agar that supports dermatophyte growth while inhibiting the growth of bacteria and saprophytic fungi (Figure\u00a02). Macroscopic colony morphology is often used to initially identify the genus of the dermatophyte; identification can be further confirmed by visualizing the microscopic morphology using either a slide culture or a sticky tape prep stained with lactophenol cotton blue.\r\n\r\nVarious antifungal treatments can be effective against tineas. Allylamine ointments that include <strong>terbinafine<\/strong> are commonly used; <strong>miconazole<\/strong> and <strong>clotrimazole<\/strong> are also available for topical treatment, and <strong>griseofulvin<\/strong> is used orally.\r\n<div class=\"textbox key-takeaways\">\r\n<h3>Think about It<\/h3>\r\n<ul>\r\n \t<li>Why are tineas, caused by fungal molds, often called ringworm?<\/li>\r\n<\/ul>\r\n<\/div>\r\n<h2>Cutaneous Aspergillosis<\/h2>\r\nAnother cause of cutaneous mycoses is <strong><em>Aspergillus<\/em><\/strong>, a genus consisting of molds of many different species, some of which cause a condition called <strong>aspergillosis<\/strong>. Primary cutaneous aspergillosis, in which the infection begins in the skin, is rare but does occur. More common is secondary cutaneous aspergillosis, in which the infection begins in the respiratory system and disseminates systemically. Both primary and secondary cutaneous aspergillosis result in distinctive eschars that form at the site or sites of infection (Figure\u00a03). Pulmonary aspergillosis will be discussed more thoroughly in <a href=\".\/chapter\/respiratory-mycoses\/\" target=\"_blank\" rel=\"noopener\">Respiratory Mycoses<\/a>).\r\n\r\n[caption id=\"attachment_1776\" align=\"aligncenter\" width=\"1024\"]<img class=\"size-large wp-image-1776\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/1094\/2016\/11\/11185757\/OSC_Microbio_21_04_aspergillo1-1024x451.jpg\" alt=\" a) photo of a large, round, dark area on their leg. B) many think strands and small dots. One of the strands ends in a sphere with long chains of dots around the top part of the structure.\" width=\"1024\" height=\"451\" \/> Figure\u00a03. (a) Eschar on a patient with secondary cutaneous aspergillosis. (b) Micrograph showing a conidiophore of <em>Aspergillus<\/em>. (credit a: modification of work by Santiago M, Martinez JH, Palermo C, Figueroa C, Torres O, Trinidad R, Gonzalez E, Miranda Mde L, Garcia M, Villamarzo G; credit b: modification of work by U.S. Department of Health and Human Services)[\/caption]\r\n\r\nPrimary cutaneous aspergillosis usually occurs at the site of an injury and is most often caused by <em>Aspergillus fumigatus<\/em> or <em>Aspergillus flavus<\/em>. It is usually reported in patients who have had an injury while working in an agricultural or outdoor environment. However, opportunistic infections can also occur in health-care settings, often at the site of intravenous catheters, venipuncture wounds, or in association with burns, surgical wounds, or occlusive dressing. After candidiasis, aspergillosis is the second most common hospital-acquired fungal infection and often occurs in immunocompromised patients, who are more vulnerable to opportunistic infections.\r\n\r\nCutaneous aspergillosis is diagnosed using patient history, culturing, histopathology using a skin biopsy. Treatment involves the use of antifungal medications such as <strong>voriconazole<\/strong> (preferred for invasive aspergillosis), <strong>itraconazole<\/strong>, and <strong>amphotericin B<\/strong> if itraconazole is not effective. For immunosuppressed individuals or burn patients, medication may be used and surgical or immunotherapy treatments may be needed.\r\n<h2>Candidiasis of the Skin and Nails<\/h2>\r\n<strong><em>Candida albicans<\/em><\/strong> and other yeasts in the genus <em>Candida<\/em> can cause skin infections referred to as cutaneous candidiasis. <em>Candida<\/em> spp. are sometimes responsible for <strong>intertrigo<\/strong>, a general term for a rash that occurs in a skin fold, or other localized rashes on the skin. <em>Candida<\/em> can also infect the nails, causing them to become yellow and harden (Figure\u00a04).\r\n\r\n[caption id=\"\" align=\"aligncenter\" width=\"1300\"]<img src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/1094\/2016\/11\/03173228\/OSC_Microbio_21_04_candidiasi.jpg\" alt=\"A) a dark, lumpy rash. B) a broken, yellow nail. C) large, white, fuzzy colonies on a plate.\" width=\"1300\" height=\"373\" \/> Figure\u00a04. (a) This red, itchy rash is the result of cutaneous candidiasis, an opportunistic infection of the skin caused by the yeast <em>Candida albicans.<\/em> (b) Fungal infections of the nail (tinea unguium) can be caused by dermatophytes or <em>Candida<\/em> spp. The nail becomes yellow, brittle, and prone to breaking. This condition is relatively common among adults. (c) <em>C. albicans<\/em> growing on Sabouraud dextrose agar. (credit a: modification of work by U.S. Department of Veterans Affairs; credit c: modification of work by Centers for Disease Control and Prevention)[\/caption]\r\n\r\nCandidiasis of the skin and nails is diagnosed through clinical observation and through culture, Gram stain, and KOH wet mounts. Susceptibility testing for anti-fungal agents can also be done. Cutaneous candidiasis can be treated with topical or systemic azole antifungal medications. Because candidiasis can become invasive, patients suffering from HIV\/AIDS, cancer, or other conditions that compromise the immune system may benefit from preventive treatment. Azoles, such as <strong>clotrimazole<\/strong>, <strong>econazole<\/strong>, <strong>fluconazole<\/strong>, <strong>ketoconazole<\/strong>, and <strong>miconazole<\/strong>; <strong>nystatin<\/strong>; <strong>terbinafine<\/strong>; and <strong>naftifine<\/strong> may be used for treatment. Long-term treatment with medications such as <strong>itraconazole<\/strong> or <strong>ketoconazole<\/strong> may be used for chronic infections. Repeat infections often occur, but this risk can be reduced by carefully following treatment recommendations, avoiding excessive moisture, maintaining good health, practicing good hygiene, and having appropriate clothing (including footwear).\r\n\r\n<em>Candida<\/em> also causes infections in other parts of the body besides the skin. These include vaginal yeast infections (see <a href=\".\/chapter\/fungal-infections-of-the-reproductive-system\/\" target=\"_blank\" rel=\"noopener\">Fungal Infections of the Reproductive System<\/a>) and oral thrush (see <a href=\".\/chapter\/microbial-diseases-of-the-mouth-and-oral-cavity\/\" target=\"_blank\" rel=\"noopener\">Microbial Diseases of the Mouth and Oral Cavity<\/a>).\r\n<h2>Sporotrichosis<\/h2>\r\nWhereas cutaneous mycoses are superficial, <strong>subcutaneous mycoses<\/strong> can spread from the skin to deeper tissues. In temperate regions, the most common subcutaneous mycosis is a condition called <strong>sporotrichosis<\/strong>, caused by the fungus <strong><em>Sporothrix<\/em> <em>schenkii<\/em><\/strong> and commonly known as <strong>rose gardener\u2019s disease<\/strong> or <strong>rose thorn disease<\/strong> (recall <a href=\".\/chapter\/physical-defenses\/\" target=\"_blank\" rel=\"noopener\">\"Every Rose Has Its Thorn\" in Physical Defenses<\/a>). Sporotrichosis is often contracted after working with soil, plants, or timber, as the fungus can gain entry through a small wound such as a thorn-prick or splinter. Sporotrichosis can generally be avoided by wearing gloves and protective clothing while gardening and promptly cleaning and disinfecting any wounds sustained during outdoor activities.\r\n\r\n<em>Sporothrix<\/em> infections initially present as small ulcers in the skin, but the fungus can spread to the lymphatic system and sometimes beyond. When the infection spreads, <strong>nodules<\/strong> appear, become necrotic, and may ulcerate. As more lymph nodes become affected, abscesses and ulceration may develop over a larger area (often on one arm or hand). In severe cases, the infection may spread more widely throughout the body, although this is relatively uncommon.\r\n\r\n<em>Sporothrix<\/em> infection can be diagnosed based upon histologic examination of the affected tissue. Its macroscopic morphology can be observed by culturing the mold on potato dextrose agar, and its microscopic morphology can be observed by staining a slide culture with lactophenol cotton blue. Treatment with <strong>itraconazole<\/strong> is generally recommended.\r\n<div class=\"textbox shaded\">\r\n<h3>Mycoses of the Skin<\/h3>\r\nCutaneous mycoses are typically opportunistic, only able to cause infection when the skin barrier is breached through a wound. Tineas are the exception, as the dermatophytes responsible for tineas are able to grow on skin, hair, and nails, especially in moist conditions. Most mycoses of the skin can be avoided through good hygiene and proper wound care. Treatment requires antifungal medications. Table 2\u00a0summarizes the characteristics of some common fungal infections of the skin.\r\n<table>\r\n<thead>\r\n<tr>\r\n<th colspan=\"5\">Table 2.\u00a0Mycoses of the Skin<\/th>\r\n<\/tr>\r\n<\/thead>\r\n<tbody>\r\n<tr>\r\n<th style=\"width: 18%\">Disease<\/th>\r\n<th style=\"width: 20%\">Pathogen<\/th>\r\n<th style=\"width: 20%\">Signs and Symptoms<\/th>\r\n<th style=\"width: 24%\">Transmission<\/th>\r\n<th style=\"width: 18%\">Antimicrobial Drugs<\/th>\r\n<\/tr>\r\n<tr>\r\n<td>Aspergillosis (cutaneous)<\/td>\r\n<td><em>Aspergillus fumigatus<\/em>, <em>Aspergillus flavus<\/em><\/td>\r\n<td>Distinctive eschars at site(s) of infection<\/td>\r\n<td>Entry via wound (primary cutaneous aspergillosis) or via the respiratory system (secondary cutaneous aspergillosis); commonly a hospital-acquired infection<\/td>\r\n<td>Itraconazole, voriconazole, amphotericin B.<\/td>\r\n<\/tr>\r\n<tr>\r\n<td>Candidiasis (cutaneous)<\/td>\r\n<td><em>Candida albicans<\/em><\/td>\r\n<td>Intertrigo, localized rash, yellowing of nails<\/td>\r\n<td>Opportunistic infections in immunocompromised patients<\/td>\r\n<td>Azoles<\/td>\r\n<\/tr>\r\n<tr>\r\n<td>Sporotrichosis (rose gardener\u2019s disease)<\/td>\r\n<td><em>Sporothrix schenkii<\/em><\/td>\r\n<td>Subcutaneous ulcers and abscesses; may spread to a large area, e.g., hand or arm<\/td>\r\n<td>Entry via thorn prick or other wound<\/td>\r\n<td>Itraconazole<\/td>\r\n<\/tr>\r\n<tr>\r\n<td>Tineas<\/td>\r\n<td><em>Trichophyton<\/em> spp., <em>Epidermophyton<\/em> spp., <em>Microsporum<\/em> spp.<\/td>\r\n<td>Itchy, ring-like lesions (ringworm) at sites of infection<\/td>\r\n<td>Contact with dermatophytic fungi, especially in warm, moist environments conducive to fungal growth<\/td>\r\n<td>Terbinafine, miconazole, clotrimazole, griseofulvin.<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<\/div>\r\n<div class=\"textbox key-takeaways\">\r\n<h3>Key Concepts and Summary<\/h3>\r\n<ul>\r\n \t<li><strong>Mycoses<\/strong> can be <strong>cutaneous<\/strong>, <strong>subcutaneous<\/strong>, or <strong>systemic.<\/strong><\/li>\r\n \t<li>Common cutaneous mycoses include <strong>tineas<\/strong> caused by <strong>dermatophytes<\/strong> of the genera <em>Trichophyton<\/em>, <em>Epidermophyton<\/em>, and <em>Microsporum.<\/em> <strong>Tinea corporis<\/strong> is called <strong>ringworm<\/strong>. Tineas on other parts of the body have names associated with the affected body part.<\/li>\r\n \t<li><strong>Aspergillosis<\/strong> is a fungal disease caused by molds of the genus <em>Aspergillus<\/em>. Primary cutaneous aspergillosis enters through a break in the skin, such as the site of an injury or a surgical wound; it is a common hospital-acquired infection. In secondary cutaneous aspergillosis, the fungus enters via the respiratory system and disseminates systemically, manifesting in lesions on the skin.<\/li>\r\n \t<li>The most common subcutaneous mycosis is <strong>sporotrichosis<\/strong> (rose gardener\u2019s disease), caused by <em>Sporothrix schenkii.<\/em><\/li>\r\n \t<li>Yeasts of the genus <em>Candida<\/em> can cause opportunistic infections of the skin called <strong>candidiasis<\/strong>, producing <strong>intertrigo<\/strong>, localized rashes, or yellowing of the nails.<\/li>\r\n<\/ul>\r\n<\/div>\r\n<div class=\"textbox exercises\">\r\n<h3>Multiple Choice<\/h3>\r\n________ is a superficial fungal infection found on the head.\r\n<ol style=\"list-style-type: lower-alpha\">\r\n \t<li>Tinea cruris<\/li>\r\n \t<li>Tinea capitis<\/li>\r\n \t<li>Tinea pedis<\/li>\r\n \t<li>Tinea corporis<\/li>\r\n<\/ol>\r\n[reveal-answer q=\"427288\"]Show Answer[\/reveal-answer]\r\n[hidden-answer a=\"427288\"]Answer b. Tinea capitis is a superficial fungal infection found on the head.[\/hidden-answer]\r\n\r\nFor what purpose would a health-care professional use a Wood\u2019s lamp for a suspected case of ringworm?\r\n<ol style=\"list-style-type: lower-alpha\">\r\n \t<li>to prevent the rash from spreading<\/li>\r\n \t<li>to kill the fungus<\/li>\r\n \t<li>to visualize the fungus<\/li>\r\n \t<li>to examine the fungus microscopically<\/li>\r\n<\/ol>\r\n[reveal-answer q=\"780409\"]Show Answer[\/reveal-answer]\r\n[hidden-answer a=\"780409\"]Answer c. A\u00a0health-care professional would use a Wood\u2019s lamp for a suspected case of ringworm in order to visualize the fungus.[\/hidden-answer]\r\n\r\nSabouraud dextrose agar CC is selective for\u00a0________.\r\n<ol style=\"list-style-type: lower-alpha\">\r\n \t<li>all fungi<\/li>\r\n \t<li>non-saprophytic fungi<\/li>\r\n \t<li>bacteria<\/li>\r\n \t<li>viruses<\/li>\r\n<\/ol>\r\n[reveal-answer q=\"704921\"]Show Answer[\/reveal-answer]\r\n[hidden-answer a=\"704921\"]Answer b.\u00a0Sabouraud dextrose agar CC is selective for non-saprophytic fungi.[\/hidden-answer]\r\n\r\nThe first-line recommended treatment for sporotrichosis is\u00a0________.\r\n<ol style=\"list-style-type: lower-alpha\">\r\n \t<li>itraconazole<\/li>\r\n \t<li>clindamycin<\/li>\r\n \t<li>amphotericin<\/li>\r\n \t<li>nystatin<\/li>\r\n<\/ol>\r\n[reveal-answer q=\"742801\"]Show Answer[\/reveal-answer]\r\n[hidden-answer a=\"742801\"]Answer a.\u00a0The first-line recommended treatment for sporotrichosis is itraconazole.[\/hidden-answer]\r\n\r\n<\/div>\r\n<div class=\"textbox exercises\">\r\n<h3>Fill in the Blank<\/h3>\r\nThe most common subcutaneous mycosis in temperate regions is ________.\r\n\r\n[reveal-answer q=\"380586\"]Show Answer[\/reveal-answer]\r\n[hidden-answer a=\"380586\"]The most common subcutaneous mycosis in temperate regions is <strong>sporotrichosis<\/strong>.[\/hidden-answer]\r\n\r\n<\/div>\r\n<div class=\"textbox key-takeaways\">\r\n<h3>Think about It<\/h3>\r\n<ol>\r\n \t<li>What yeasts commonly cause opportunistic infections?<\/li>\r\n \t<li>What steps might you recommend to a patient for reducing the risk of developing a fungal infection of the toenails?<\/li>\r\n<\/ol>\r\n<\/div>","rendered":"<div class=\"textbox learning-objectives\">\n<h3>Learning Objectives<\/h3>\n<ul>\n<li>Identify the most common fungal pathogens associated with cutaneous and subcutaneous mycoses<\/li>\n<li>Compare the major characteristics of specific fungal diseases affecting the skin<\/li>\n<\/ul>\n<\/div>\n<p>Many fungal infections of the skin involve fungi that are found in the normal skin microbiota. Some of these fungi can cause infection when they gain entry through a wound; others mainly cause opportunistic infections in immunocompromised patients. Other fungal pathogens primarily cause infection in unusually moist environments that promote fungal growth; for example, sweaty shoes, communal showers, and locker rooms provide excellent breeding grounds that promote the growth and transmission of fungal pathogens.<\/p>\n<p>Fungal infections, also called <strong>mycoses<\/strong>, can be divided into classes based on their invasiveness. Mycoses that cause superficial infections of the epidermis, hair, and nails, are called <strong>cutaneous mycoses<\/strong>. Mycoses that penetrate the epidermis and the dermis to infect deeper tissues are called <strong>subcutaneous mycoses<\/strong>. Mycoses that spread throughout the body are called <strong>systemic mycoses<\/strong>.<\/p>\n<h2>Tineas<\/h2>\n<p>A group of cutaneous mycoses called <strong>tineas<\/strong> are caused by <strong>dermatophytes<\/strong>, fungal molds that require keratin, a protein found in skin, hair, and nails, for growth. There are three genera of dermatophytes, all of which can cause cutaneous mycoses: <strong><em>Trichophyton<\/em><\/strong>, <strong><em>Epidermophyton<\/em><\/strong>, and <strong><em>Microsporum<\/em><\/strong>. Tineas on most areas of the body are generally called <strong>ringworm<\/strong>, but tineas in specific locations may have distinctive names and symptoms (see Table 1\u00a0and Figure\u00a01). Keep in mind that these names\u2014even though they are Latinized\u2014refer to locations on the body, not causative organisms. Tineas can be caused by different dermatophytes in most areas of the body.<\/p>\n<table id=\"fs-id1167661316692\" class=\"span-all\" summary=\"Table titled Some Common Tineas and Location on Body. Tinea corporis (ringworm); body. Tinea capitis (ringworm); scalp. Tinia pedis (athlete's foot); feet. Tinea barbae (barber's itch); beard. Tinea cruris (jock itch); groin. Tinea unguium (onychomycosis); toenails, fingernails.\">\n<thead>\n<tr>\n<th colspan=\"2\">Table 1. Some Common Tineas and Location on the Body<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr valign=\"top\">\n<td>Tinea corporis (ringworm)<\/td>\n<td>Body<\/td>\n<\/tr>\n<tr valign=\"top\">\n<td>Tinea capitis (ringworm)<\/td>\n<td>Scalp<\/td>\n<\/tr>\n<tr valign=\"top\">\n<td>Tinea pedis (athlete\u2019s foot)<\/td>\n<td>Feet<\/td>\n<\/tr>\n<tr valign=\"top\">\n<td>Tinea barbae (barber\u2019s itch)<\/td>\n<td>Beard<\/td>\n<\/tr>\n<tr valign=\"top\">\n<td>Tinea cruris (jock itch)<\/td>\n<td>Groin<\/td>\n<\/tr>\n<tr valign=\"top\">\n<td>Tinea unguium (onychomycosis)<\/td>\n<td>Toenails, fingernails<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<div style=\"width: 1310px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/1094\/2016\/11\/03173219\/OSC_Microbio_21_04_tineas.jpg\" alt=\"a) large red bumps on a cheek. B) white crusty skin on a foot. C) an orange ring on skin.\" width=\"1300\" height=\"348\" \/><\/p>\n<p class=\"wp-caption-text\">Figure\u00a01. Tineas are superficial cutaneous mycoses and are common. (a) Tinea barbae (barber\u2019s itch) occurs on the lower face. (b) Tinea pedis (athlete\u2019s foot) occurs on the feet, causing itching, burning, and dry, cracked skin between the toes. (c) A close-up view of tinea corporis (ringworm) caused by <em>Trichophyton mentagrophytes<\/em>. (credit a, c: modification of work by Centers for Disease Control and Prevention; credit b: modification of work by Al Hasan M, Fitzgerald SM, Saoudian M, Krishnaswamy G)<\/p>\n<\/div>\n<p>Dermatophytes are commonly found in the environment and in soils and are frequently transferred to the skin via contact with other humans and animals. Fungal spores can also spread on hair. Many dermatophytes grow well in moist, dark environments. For example, <strong>tinea pedis<\/strong> (athlete\u2019s foot) commonly spreads in public showers, and the causative fungi grow well in the dark, moist confines of sweaty shoes and socks. Likewise, <strong>tinea cruris<\/strong> (jock itch) often spreads in communal living environments and thrives in warm, moist undergarments.<\/p>\n<p>Tineas on the body (<strong>tinea corporis<\/strong>) often produce lesions that grow radially and heal towards the center. This causes the formation of a red ring, leading to the misleading name of ringworm recall <a href=\".\/chapter\/unicellular-eukaryotic-parasites\/\" target=\"_blank\" rel=\"noopener\">the Clinical Focus case that started in Unicellular Eukaryotic Parasites<\/a>.<\/p>\n<div id=\"attachment_1775\" style=\"width: 460px\" class=\"wp-caption alignright\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-1775\" class=\"wp-image-1775\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/1094\/2016\/11\/11185557\/OSC_Microbio_21_04_dermatophy1.jpg\" alt=\"A photo of a large blackn, fuzzy colony.\" width=\"450\" height=\"324\" \/><\/p>\n<p id=\"caption-attachment-1775\" class=\"wp-caption-text\">Figure\u00a02. To diagnose tineas, the dermatophytes may be grown on a Sabouraud dextrose CC agar plate. This culture contains a strain of <em>Trichophyton rubrum<\/em>, one of the most common causes of tineas on various parts of the body. (credit: Centers for Disease Control and Prevention)<\/p>\n<\/div>\n<p>Several approaches may be used to diagnose tineas. A <strong>Wood\u2019s lamp<\/strong> (also called a black lamp) with a wavelength of 365 nm is often used. When directed on a tinea, the ultraviolet light emitted from the Wood\u2019s lamp causes the fungal elements (spores and hyphae) to fluoresce. Direct microscopic evaluation of specimens from skin scrapings, hair, or nails can also be used to detect fungi. Generally, these specimens are prepared in a wet mount using a potassium hydroxide solution (10%\u201320% aqueous KOH), which dissolves the keratin in hair, nails, and skin cells to allow for visualization of the hyphae and fungal spores. The specimens may be grown on Sabouraud dextrose CC (chloramphenicol\/cyclohexamide), a selective agar that supports dermatophyte growth while inhibiting the growth of bacteria and saprophytic fungi (Figure\u00a02). Macroscopic colony morphology is often used to initially identify the genus of the dermatophyte; identification can be further confirmed by visualizing the microscopic morphology using either a slide culture or a sticky tape prep stained with lactophenol cotton blue.<\/p>\n<p>Various antifungal treatments can be effective against tineas. Allylamine ointments that include <strong>terbinafine<\/strong> are commonly used; <strong>miconazole<\/strong> and <strong>clotrimazole<\/strong> are also available for topical treatment, and <strong>griseofulvin<\/strong> is used orally.<\/p>\n<div class=\"textbox key-takeaways\">\n<h3>Think about It<\/h3>\n<ul>\n<li>Why are tineas, caused by fungal molds, often called ringworm?<\/li>\n<\/ul>\n<\/div>\n<h2>Cutaneous Aspergillosis<\/h2>\n<p>Another cause of cutaneous mycoses is <strong><em>Aspergillus<\/em><\/strong>, a genus consisting of molds of many different species, some of which cause a condition called <strong>aspergillosis<\/strong>. Primary cutaneous aspergillosis, in which the infection begins in the skin, is rare but does occur. More common is secondary cutaneous aspergillosis, in which the infection begins in the respiratory system and disseminates systemically. Both primary and secondary cutaneous aspergillosis result in distinctive eschars that form at the site or sites of infection (Figure\u00a03). Pulmonary aspergillosis will be discussed more thoroughly in <a href=\".\/chapter\/respiratory-mycoses\/\" target=\"_blank\" rel=\"noopener\">Respiratory Mycoses<\/a>).<\/p>\n<div id=\"attachment_1776\" style=\"width: 1034px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-1776\" class=\"size-large wp-image-1776\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/1094\/2016\/11\/11185757\/OSC_Microbio_21_04_aspergillo1-1024x451.jpg\" alt=\"a) photo of a large, round, dark area on their leg. B) many think strands and small dots. One of the strands ends in a sphere with long chains of dots around the top part of the structure.\" width=\"1024\" height=\"451\" \/><\/p>\n<p id=\"caption-attachment-1776\" class=\"wp-caption-text\">Figure\u00a03. (a) Eschar on a patient with secondary cutaneous aspergillosis. (b) Micrograph showing a conidiophore of <em>Aspergillus<\/em>. (credit a: modification of work by Santiago M, Martinez JH, Palermo C, Figueroa C, Torres O, Trinidad R, Gonzalez E, Miranda Mde L, Garcia M, Villamarzo G; credit b: modification of work by U.S. Department of Health and Human Services)<\/p>\n<\/div>\n<p>Primary cutaneous aspergillosis usually occurs at the site of an injury and is most often caused by <em>Aspergillus fumigatus<\/em> or <em>Aspergillus flavus<\/em>. It is usually reported in patients who have had an injury while working in an agricultural or outdoor environment. However, opportunistic infections can also occur in health-care settings, often at the site of intravenous catheters, venipuncture wounds, or in association with burns, surgical wounds, or occlusive dressing. After candidiasis, aspergillosis is the second most common hospital-acquired fungal infection and often occurs in immunocompromised patients, who are more vulnerable to opportunistic infections.<\/p>\n<p>Cutaneous aspergillosis is diagnosed using patient history, culturing, histopathology using a skin biopsy. Treatment involves the use of antifungal medications such as <strong>voriconazole<\/strong> (preferred for invasive aspergillosis), <strong>itraconazole<\/strong>, and <strong>amphotericin B<\/strong> if itraconazole is not effective. For immunosuppressed individuals or burn patients, medication may be used and surgical or immunotherapy treatments may be needed.<\/p>\n<h2>Candidiasis of the Skin and Nails<\/h2>\n<p><strong><em>Candida albicans<\/em><\/strong> and other yeasts in the genus <em>Candida<\/em> can cause skin infections referred to as cutaneous candidiasis. <em>Candida<\/em> spp. are sometimes responsible for <strong>intertrigo<\/strong>, a general term for a rash that occurs in a skin fold, or other localized rashes on the skin. <em>Candida<\/em> can also infect the nails, causing them to become yellow and harden (Figure\u00a04).<\/p>\n<div style=\"width: 1310px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/1094\/2016\/11\/03173228\/OSC_Microbio_21_04_candidiasi.jpg\" alt=\"A) a dark, lumpy rash. B) a broken, yellow nail. C) large, white, fuzzy colonies on a plate.\" width=\"1300\" height=\"373\" \/><\/p>\n<p class=\"wp-caption-text\">Figure\u00a04. (a) This red, itchy rash is the result of cutaneous candidiasis, an opportunistic infection of the skin caused by the yeast <em>Candida albicans.<\/em> (b) Fungal infections of the nail (tinea unguium) can be caused by dermatophytes or <em>Candida<\/em> spp. The nail becomes yellow, brittle, and prone to breaking. This condition is relatively common among adults. (c) <em>C. albicans<\/em> growing on Sabouraud dextrose agar. (credit a: modification of work by U.S. Department of Veterans Affairs; credit c: modification of work by Centers for Disease Control and Prevention)<\/p>\n<\/div>\n<p>Candidiasis of the skin and nails is diagnosed through clinical observation and through culture, Gram stain, and KOH wet mounts. Susceptibility testing for anti-fungal agents can also be done. Cutaneous candidiasis can be treated with topical or systemic azole antifungal medications. Because candidiasis can become invasive, patients suffering from HIV\/AIDS, cancer, or other conditions that compromise the immune system may benefit from preventive treatment. Azoles, such as <strong>clotrimazole<\/strong>, <strong>econazole<\/strong>, <strong>fluconazole<\/strong>, <strong>ketoconazole<\/strong>, and <strong>miconazole<\/strong>; <strong>nystatin<\/strong>; <strong>terbinafine<\/strong>; and <strong>naftifine<\/strong> may be used for treatment. Long-term treatment with medications such as <strong>itraconazole<\/strong> or <strong>ketoconazole<\/strong> may be used for chronic infections. Repeat infections often occur, but this risk can be reduced by carefully following treatment recommendations, avoiding excessive moisture, maintaining good health, practicing good hygiene, and having appropriate clothing (including footwear).<\/p>\n<p><em>Candida<\/em> also causes infections in other parts of the body besides the skin. These include vaginal yeast infections (see <a href=\".\/chapter\/fungal-infections-of-the-reproductive-system\/\" target=\"_blank\" rel=\"noopener\">Fungal Infections of the Reproductive System<\/a>) and oral thrush (see <a href=\".\/chapter\/microbial-diseases-of-the-mouth-and-oral-cavity\/\" target=\"_blank\" rel=\"noopener\">Microbial Diseases of the Mouth and Oral Cavity<\/a>).<\/p>\n<h2>Sporotrichosis<\/h2>\n<p>Whereas cutaneous mycoses are superficial, <strong>subcutaneous mycoses<\/strong> can spread from the skin to deeper tissues. In temperate regions, the most common subcutaneous mycosis is a condition called <strong>sporotrichosis<\/strong>, caused by the fungus <strong><em>Sporothrix<\/em> <em>schenkii<\/em><\/strong> and commonly known as <strong>rose gardener\u2019s disease<\/strong> or <strong>rose thorn disease<\/strong> (recall <a href=\".\/chapter\/physical-defenses\/\" target=\"_blank\" rel=\"noopener\">&#8220;Every Rose Has Its Thorn&#8221; in Physical Defenses<\/a>). Sporotrichosis is often contracted after working with soil, plants, or timber, as the fungus can gain entry through a small wound such as a thorn-prick or splinter. Sporotrichosis can generally be avoided by wearing gloves and protective clothing while gardening and promptly cleaning and disinfecting any wounds sustained during outdoor activities.<\/p>\n<p><em>Sporothrix<\/em> infections initially present as small ulcers in the skin, but the fungus can spread to the lymphatic system and sometimes beyond. When the infection spreads, <strong>nodules<\/strong> appear, become necrotic, and may ulcerate. As more lymph nodes become affected, abscesses and ulceration may develop over a larger area (often on one arm or hand). In severe cases, the infection may spread more widely throughout the body, although this is relatively uncommon.<\/p>\n<p><em>Sporothrix<\/em> infection can be diagnosed based upon histologic examination of the affected tissue. Its macroscopic morphology can be observed by culturing the mold on potato dextrose agar, and its microscopic morphology can be observed by staining a slide culture with lactophenol cotton blue. Treatment with <strong>itraconazole<\/strong> is generally recommended.<\/p>\n<div class=\"textbox shaded\">\n<h3>Mycoses of the Skin<\/h3>\n<p>Cutaneous mycoses are typically opportunistic, only able to cause infection when the skin barrier is breached through a wound. Tineas are the exception, as the dermatophytes responsible for tineas are able to grow on skin, hair, and nails, especially in moist conditions. Most mycoses of the skin can be avoided through good hygiene and proper wound care. Treatment requires antifungal medications. Table 2\u00a0summarizes the characteristics of some common fungal infections of the skin.<\/p>\n<table>\n<thead>\n<tr>\n<th colspan=\"5\">Table 2.\u00a0Mycoses of the Skin<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<th style=\"width: 18%\">Disease<\/th>\n<th style=\"width: 20%\">Pathogen<\/th>\n<th style=\"width: 20%\">Signs and Symptoms<\/th>\n<th style=\"width: 24%\">Transmission<\/th>\n<th style=\"width: 18%\">Antimicrobial Drugs<\/th>\n<\/tr>\n<tr>\n<td>Aspergillosis (cutaneous)<\/td>\n<td><em>Aspergillus fumigatus<\/em>, <em>Aspergillus flavus<\/em><\/td>\n<td>Distinctive eschars at site(s) of infection<\/td>\n<td>Entry via wound (primary cutaneous aspergillosis) or via the respiratory system (secondary cutaneous aspergillosis); commonly a hospital-acquired infection<\/td>\n<td>Itraconazole, voriconazole, amphotericin B.<\/td>\n<\/tr>\n<tr>\n<td>Candidiasis (cutaneous)<\/td>\n<td><em>Candida albicans<\/em><\/td>\n<td>Intertrigo, localized rash, yellowing of nails<\/td>\n<td>Opportunistic infections in immunocompromised patients<\/td>\n<td>Azoles<\/td>\n<\/tr>\n<tr>\n<td>Sporotrichosis (rose gardener\u2019s disease)<\/td>\n<td><em>Sporothrix schenkii<\/em><\/td>\n<td>Subcutaneous ulcers and abscesses; may spread to a large area, e.g., hand or arm<\/td>\n<td>Entry via thorn prick or other wound<\/td>\n<td>Itraconazole<\/td>\n<\/tr>\n<tr>\n<td>Tineas<\/td>\n<td><em>Trichophyton<\/em> spp., <em>Epidermophyton<\/em> spp., <em>Microsporum<\/em> spp.<\/td>\n<td>Itchy, ring-like lesions (ringworm) at sites of infection<\/td>\n<td>Contact with dermatophytic fungi, especially in warm, moist environments conducive to fungal growth<\/td>\n<td>Terbinafine, miconazole, clotrimazole, griseofulvin.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<div class=\"textbox key-takeaways\">\n<h3>Key Concepts and Summary<\/h3>\n<ul>\n<li><strong>Mycoses<\/strong> can be <strong>cutaneous<\/strong>, <strong>subcutaneous<\/strong>, or <strong>systemic.<\/strong><\/li>\n<li>Common cutaneous mycoses include <strong>tineas<\/strong> caused by <strong>dermatophytes<\/strong> of the genera <em>Trichophyton<\/em>, <em>Epidermophyton<\/em>, and <em>Microsporum.<\/em> <strong>Tinea corporis<\/strong> is called <strong>ringworm<\/strong>. Tineas on other parts of the body have names associated with the affected body part.<\/li>\n<li><strong>Aspergillosis<\/strong> is a fungal disease caused by molds of the genus <em>Aspergillus<\/em>. Primary cutaneous aspergillosis enters through a break in the skin, such as the site of an injury or a surgical wound; it is a common hospital-acquired infection. In secondary cutaneous aspergillosis, the fungus enters via the respiratory system and disseminates systemically, manifesting in lesions on the skin.<\/li>\n<li>The most common subcutaneous mycosis is <strong>sporotrichosis<\/strong> (rose gardener\u2019s disease), caused by <em>Sporothrix schenkii.<\/em><\/li>\n<li>Yeasts of the genus <em>Candida<\/em> can cause opportunistic infections of the skin called <strong>candidiasis<\/strong>, producing <strong>intertrigo<\/strong>, localized rashes, or yellowing of the nails.<\/li>\n<\/ul>\n<\/div>\n<div class=\"textbox exercises\">\n<h3>Multiple Choice<\/h3>\n<p>________ is a superficial fungal infection found on the head.<\/p>\n<ol style=\"list-style-type: lower-alpha\">\n<li>Tinea cruris<\/li>\n<li>Tinea capitis<\/li>\n<li>Tinea pedis<\/li>\n<li>Tinea corporis<\/li>\n<\/ol>\n<div class=\"qa-wrapper\" style=\"display: block\"><span class=\"show-answer collapsed\" style=\"cursor: pointer\" data-target=\"q427288\">Show Answer<\/span><\/p>\n<div id=\"q427288\" class=\"hidden-answer\" style=\"display: none\">Answer b. Tinea capitis is a superficial fungal infection found on the head.<\/div>\n<\/div>\n<p>For what purpose would a health-care professional use a Wood\u2019s lamp for a suspected case of ringworm?<\/p>\n<ol style=\"list-style-type: lower-alpha\">\n<li>to prevent the rash from spreading<\/li>\n<li>to kill the fungus<\/li>\n<li>to visualize the fungus<\/li>\n<li>to examine the fungus microscopically<\/li>\n<\/ol>\n<div class=\"qa-wrapper\" style=\"display: block\"><span class=\"show-answer collapsed\" style=\"cursor: pointer\" data-target=\"q780409\">Show Answer<\/span><\/p>\n<div id=\"q780409\" class=\"hidden-answer\" style=\"display: none\">Answer c. A\u00a0health-care professional would use a Wood\u2019s lamp for a suspected case of ringworm in order to visualize the fungus.<\/div>\n<\/div>\n<p>Sabouraud dextrose agar CC is selective for\u00a0________.<\/p>\n<ol style=\"list-style-type: lower-alpha\">\n<li>all fungi<\/li>\n<li>non-saprophytic fungi<\/li>\n<li>bacteria<\/li>\n<li>viruses<\/li>\n<\/ol>\n<div class=\"qa-wrapper\" style=\"display: block\"><span class=\"show-answer collapsed\" style=\"cursor: pointer\" data-target=\"q704921\">Show Answer<\/span><\/p>\n<div id=\"q704921\" class=\"hidden-answer\" style=\"display: none\">Answer b.\u00a0Sabouraud dextrose agar CC is selective for non-saprophytic fungi.<\/div>\n<\/div>\n<p>The first-line recommended treatment for sporotrichosis is\u00a0________.<\/p>\n<ol style=\"list-style-type: lower-alpha\">\n<li>itraconazole<\/li>\n<li>clindamycin<\/li>\n<li>amphotericin<\/li>\n<li>nystatin<\/li>\n<\/ol>\n<div class=\"qa-wrapper\" style=\"display: block\"><span class=\"show-answer collapsed\" style=\"cursor: pointer\" data-target=\"q742801\">Show Answer<\/span><\/p>\n<div id=\"q742801\" class=\"hidden-answer\" style=\"display: none\">Answer a.\u00a0The first-line recommended treatment for sporotrichosis is itraconazole.<\/div>\n<\/div>\n<\/div>\n<div class=\"textbox exercises\">\n<h3>Fill in the Blank<\/h3>\n<p>The most common subcutaneous mycosis in temperate regions is ________.<\/p>\n<div class=\"qa-wrapper\" style=\"display: block\"><span class=\"show-answer collapsed\" style=\"cursor: pointer\" data-target=\"q380586\">Show Answer<\/span><\/p>\n<div id=\"q380586\" class=\"hidden-answer\" style=\"display: none\">The most common subcutaneous mycosis in temperate regions is <strong>sporotrichosis<\/strong>.<\/div>\n<\/div>\n<\/div>\n<div class=\"textbox key-takeaways\">\n<h3>Think about It<\/h3>\n<ol>\n<li>What yeasts commonly cause opportunistic infections?<\/li>\n<li>What steps might you recommend to a patient for reducing the risk of developing a fungal infection of the toenails?<\/li>\n<\/ol>\n<\/div>\n\n\t\t\t <section class=\"citations-section\" role=\"contentinfo\">\n\t\t\t <h3>Candela Citations<\/h3>\n\t\t\t\t\t <div>\n\t\t\t\t\t\t <div id=\"citation-list-916\">\n\t\t\t\t\t\t\t <div class=\"licensing\"><div class=\"license-attribution-dropdown-subheading\">CC licensed content, Shared previously<\/div><ul class=\"citation-list\"><li>OpenStax Microbiology. <strong>Provided by<\/strong>: OpenStax CNX. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"http:\/\/cnx.org\/contents\/e42bd376-624b-4c0f-972f-e0c57998e765@4.2\">http:\/\/cnx.org\/contents\/e42bd376-624b-4c0f-972f-e0c57998e765@4.2<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by\/4.0\/\">CC BY: Attribution<\/a><\/em>. <strong>License Terms<\/strong>: Download for free at http:\/\/cnx.org\/contents\/e42bd376-624b-4c0f-972f-e0c57998e765@4.2<\/li><\/ul><\/div>\n\t\t\t\t\t\t <\/div>\n\t\t\t\t\t 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