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Basics

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BASICS

Definition!!navigator!!

  • Superficial cutaneous fungal infections develop in the stratum corneum, hair, and hoof. They include dermatophytoses and yeast dermatoses
  • Dermatophytoses are generally highly contagious dermatoses due to keratinophilic fungi of the Microsporum and Trichophyton genera
  • Yeast—superficial fungal dermatoses. Most important yeasts are Malassezia and Candida albicans

Pathophysiology!!navigator!!

  • Dermatophytoses—2 zoophilic species identified specifically in horses: Trichophyton equinum and Microsporum equinum
  • Transmission by contact with clinically infected or asymptomatic carrier horses, other animal species, insect bites, or fomites. Dermatophyte spores have a very long resistance in the environment (months to years)
  • The spores remain quiescent until local conditions stimulate arthroconidia to germinate and invade the stratum corneum and hair follicles. Protease production digests keratin and initiates skin and hair damage
  • Yeast(Malassezia spp.) is a lipophilic yeast present on the skin of most horses. Proliferation may induce inflammation

Systems Affected!!navigator!!

Skin/exocrine

Genetics!!navigator!!

N/A

Incidence/Prevalence!!navigator!!

Dermatophytoses—1 of the 10 most frequent skin conditions in horses. Higher incidence on training farms than breeding farms.

Geographic Distribution!!navigator!!

  • Dermatophytoses—worldwide
  • Yeast—presumably worldwide

Signalment!!navigator!!

  • Dermatophytes—any age. More frequent in young horses
  • Yeast—no breed predilection. Malassezia (intermammary fossa) possibly more frequent in mares. Nonseasonal

Signs!!navigator!!

Dermatophytes

  • Clinical disease is usually evident within 1–6 weeks after exposure and clinical signs are highly variable
  • Evolution influenced by host (age, immune status), fungus, and time. More inflammation is frequent with Trichophyton sp. Papules, tufted hairs, or urticaria-like lesions at early stage
  • Annular alopecia (1–10 cm in diameter) and scaling with an erythematous margin. Become polycyclic by coalescence or grow centripetally. New hair growth may occur in the center of the lesion but active disease continues to occur at the periphery
  • May have single or multiple lesions in a cluster or generalized
  • Moderate erythema (visible on white horses)
  • Crusts occasionally thick. Infrequently multiple papular forms (miliary). Subcutaneous forms (mycetomas) are rare in horses
  • Pruritus usually minimal, except with Trichophyton bullosum

Physical Examination Findings

  • Frequently starts on areas exposed to trauma or are in contact with saddles, bridles, and harness
  • Most lesions are located on the face, neck, dorsolateral thorax, forelimbs, and girth
  • More or less rapidly extensive
  • Individual lesions spontaneously cure with regrowth of hair from the center (occasionally darker in color)
  • Mane and tail generally spared

Yeast

  • Malassezia—intertrigo (axillae, groin, mammary gland, prepubital fossa); odor; greasiness and sticky brownish material
  • Candida—acute inflammation, erythema, pustular, erosion, exudates (occasionally whitish) mainly periorificial, vulvovaginal, perineal, or intertriginous areas, occasionally pruritic (even painful if Candida). Nodular cutaneous candidiasis represented as firm, painful nodules covered by a normal hair coat has been reported

Causes!!navigator!!

  • Yeast—immunosuppressive diseases (viral infections, neoplasia) or immunosuppressive drug therapy may predispose to candidiasis
  • Vulvovaginal candidiasis was reported in Thoroughbred mares following oral administration of a synthetic progestogen
  • Defects in cornification and hypersensitivity

Risk Factors!!navigator!!

Dermatophytes

  • Contaminated barns and confined animals
  • Young age (<3 years) and high humidity
  • Recent introduction of new horses or other animals

Yeast

Candidosis precipitated by antibiotic treatments.

Diagnosis

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DIAGNOSIS

Differential Diagnosis!!navigator!!

Dermatophytoses

  • Bacterial folliculitis (mainly staphylococcal)—similar to identical annular lesions; same predisposed body locations, more frequent during hot periods
  • Dermatophilosis (folliculitis with thick crusts and alopecia)
  • Urticaria (atopy, food, drug intolerances), rapid onset, alopecia is rare
  • Alopecia areata (minimal reaction of skin)
  • Pemphigus foliaceus (crusts, frequently perioral)
  • Eosinophilic folliculitis
  • Any nodular lesions (bacterial, fungal, foreign body granulomas, neoplasms) in cases of dermatophytic mycetoma

Yeast

  • Other causes of greasiness, intertrigo, or periorificial inflammation
  • Other rare fungal superficial dermatoses (Alternaria, Geotrichum)
  • Mucocutaneous candidiasis differentials include systemic lupus erythematosus, pemphigus vulgaris, erythema multiforme, drug eruptions, and vasculitis
  • Nodular forms of candidiasis include infectious and sterile granulomatous disorders

CBC/Biochemistry/Urinalysis!!navigator!!

Not indicated unless suspect systemic disease that is causing immunosuppression.

Other Laboratory Tests!!navigator!!

Dermatophytes—Fungal Culture

  • Gold standard to identify the dermatophyte and possible origin
  • Selective dermatophyte test media are required to prevent overgrowth of commensal fungi
  • Wipe the lesion with 70% alcohol, allow to dry, and then pluck the lesional hair with sterile hemostats
  • May need to include inoculation of crusts

Yeast—Fungal Culture

  • Necessary to identify C. albicans. Pathogenic when isolated from skin
  • Malassezia pachydermatis is the only species that develops on routine medium agar at 30°C

Imaging!!navigator!!

N/A

Other Diagnostic Procedures!!navigator!!

Dermatophytoses—Scrapings and Trichoscopy

Direct microscopic examination of infected hairs—broken, embedded in crusts, thickened, and fibrous; may contain hyphae, with surrounding arthrospores.

Yeast—Cytology on Direct Smears

Abundance of narrow (Candida) or wide (Malassezia) based budding yeasts. Occasionally hyphae (C. albicans).

Cytology

  • Abundant neutrophils, acantholytic cells (confusion with pemphigus); occasionally arthrospores (confusion with yeasts)
  • Rarely concurrent bacterial folliculitis

Treatment

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TREATMENT

Aims!!navigator!!

Dermatophytoses

  • Although considered self-limiting, the infection may last for months and horses remain carriers and sources
  • The aim is to shorten the evolution, reduce lesions, and limit the risk of contamination
  • Topical therapy applied to the entire body is mandatory. Other mandatory therapy includes clipping and destruction of infected hairs

Yeast

  • Correction of the predisposing causes is fundamental
  • Excessive moisture must be avoided

Appropriate Health Care!!navigator!!

Outpatient medical management is appropriate.

Nursing Care!!navigator!!

N/A

Activity!!navigator!!

Dermatophytes—identification and isolation of infected horses are important to limit the contagion.

Diet!!navigator!!

N/A

Client Education!!navigator!!

Dermatophytoses

  • Inform clients that the disease is contagious to other horses and eventually humans. Other hosts may be of concern
  • The disinfection of all materials and housing is imperative for clinical success
  • The appropriate application of topical treatment is crucial for cure

Surgical Considerations!!navigator!!

N/A except for mycetomas (wide excision).

Medications

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MEDICATIONS

Drug(s) of Choice!!navigator!!

Dermatophytoses

Topical

  • Lotions or rinses are preferred to creams. Miconazole 1–2%, terbinafine 1%, or natamycin can be used for smaller, localized lesions but are not practical for treatment of generalized disease
  • Lime sulfur 2%, enilconazole 0.2% (Imaverol), ketoconazole 1–2%, miconazole 2%, chlorhexidine 2–4%, and combinations of miconazole/ketoconazole with chlorhexidine. Applied at least 2 or 3 times weekly for initial therapy
  • Every case should receive topical therapy

Systemic

  • Griseofulvin (Fulvicin) powder. Labeled for use in horses in many countries. Proposed dosages highly variable. Most have found no evidence that oral griseofulvin powder at the labeled dose is efficacious in horses. However, 100 mg/kg/day for 10 days was reported to be effective in a small number of horses. Superiority of benefit remains controversial especially compared with topical therapy
  • Equine pharmacokinetics of terbinafine at 20 mg/kg have been determined with clinical trials demonstrating efficacy still needed

Yeast

Topical

Apply 2 or 3 times a week for at least 3 weeks.

Shampoos

  • Chlorhexidine (2–4%) or preferably combined with miconazole (2%)/ketoconazole (1–2%)
  • If skin is particularly greasy (Malassezia), use a keratolytic shampoo
  • Selenium sulfide 1% or lime sulfur 2%
  • For localized dermatitis, consider clipping and applying topical chlorhexidine/miconazole or azole creams, ointments, or mousses every 12 h for 3–4 weeks

Contraindications!!navigator!!

See Pregnancy/Fertility/Breeding.

Precautions!!navigator!!

Selenium sulfide can be irritating (rinse thoroughly).

Possible Interactions!!navigator!!

Not reported in horses.

Alternative Drugs!!navigator!!

Dermatophytoses

Essential oils have the potential to be natural fungicides. A small, randomized, open clinical trial evaluated the use of 25% tea tree oil in sweet almond oil compared with enilconazole 2% solution. Use of 25% tea tree oil mixture twice a day for 15 days was well tolerated. Horses in both groups reached clinical cure.

Oral Azoles (Fluconazole, Voriconazole, Itraconazole)

Generally cost prohibitive. Fluconazole is effective against dermatophytes and yeast dermatitis. Dose is 5 mg/kg every 24 h PO with a half-life of 38 h. Voriconazole is effective against dermatophytes. Oral absorption is 92% and half-life is 13 h. Dose is 2-4 mg/kg every 24 h or 3 mg/kg every 12 h PO.

Vaccines

  • Have been developed in different species, including horses, in some countries
  • Vaccination may provide a reasonable degree of protection in horses, but they are not commercially available in many regions.

Yeast

  • Treatment with systemic azoles—a possible alternative but prohibitive cost
  • For refractory cases, consider the use of leave-on 2% lime sulfur or enilconazole rinses applied after twice-weekly medicated shampoos

Follow-up

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FOLLOW-UP

Patient Monitoring!!navigator!!

Control at 7–10 day intervals and verify the clinical recovery.

Prevention/Avoidance!!navigator!!

The owner has to look carefully at other animals to detect new cases. Quarantine of new arrivals and prevent sharing of tack.

Possible Complications!!navigator!!

N/A

Expected Course and Prognosis!!navigator!!

Dermatophytoses—with appropriate therapy, the extension is rapidly stopped and hair regrowth is noted. Complete cure in 1–4 months.

Miscellaneous

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MISCELLANEOUS

Associated Conditions!!navigator!!

Yeast—possible allergic dermatitis.

Age-Related Factors!!navigator!!

Any age, although young horses frequently concerned.

Zoonotic Potential!!navigator!!

Dermatophytoses

Human contamination is not rare—mainly from Trichophyton mentagrophytes, Trichophyton verrucosum, or Microsporum canis; occasionally from M. equinum, T. bullosum; rarely from T. equinum.

Yeast

A minor concern, easily prevented by simple handwashing.

Pregnancy/Fertility/Breeding!!navigator!!

The use of griseofulvin and oral azoles is contraindicated in pregnant animals.

Synonyms!!navigator!!

Dermatophytoses

  • Ringworm
  • Microsporosis
  • Trichophytosis

Yeast

  • Candidosis
  • Thrush

Suggested Reading

Weese JS, Yu AA. Infectious folliculitis and dermatophytosis. Vet Clin North Am Equine Pract 2013;29:559575.

Author(s)

Author: Gwendolen Lorch

Consulting Editor: Gwendolen Lorch

Acknowledgment: The author/editor acknowledges the prior contribution of Patrick Bourdeau.

Additional Further Reading

Click here for Additional Further Reading