Videos of Surgical Procedures in Dermatology
Sample Taking and Direct Examination in Dermatomycoses
Toma de muestras y examen directo en dermatomicosis
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Padilla-España, V. Crespo-Erchiga" "autores" => array:3 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "del Boz" "email" => array:1 [ 0 => "javierdelboz@yahoo.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "L." "apellidos" => "Padilla-España" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "V." "apellidos" => "Crespo-Erchiga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Costa del Sol, Marbella, Málaga, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Carlos Haya, Málaga, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Toma de muestras y examen directo en dermatomicosis" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1297 "Ancho" => 1400 "Tamanyo" => 205152 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Recommended instruments for taking mycology samples.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Laboratory diagnosis of the dermatomycoses is based on identification of the causative species by culture and by direct examination.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> The aim of this latter technique is to detect the fungi directly in the pathology sample using simple reagents or stains.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Direct examination has several advantages: it aids diagnosis in clinically atypical presentations (as occurs with tinea incognito); it provides diagnostic security, which is essential when costly, long-term treatments with potential side effects are to be initiated, as may be required for tinea capitis and the onychomycoses; it can suggest the probable causative fungi (for example, from the pattern of parasitization of the hair in cases of tinea capitis); and it favors therapeutic compliance by the patient.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> Despite this, the majority of Spanish dermatologists do not routinely perform direct examination. The video accompanying this article presents a review of this procedure.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Description of the Technique</span><p id="par0015" class="elsevierStylePara elsevierViewall">First, a correct sampling technique is essential. Antifungal treatments must be interrupted at least 2 weeks before obtaining the sample. Instruments appropriate for the type of sample should be used (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–3</span></a> In moist lesions it is better to use a brush or swab, whereas in dry lesions it is better to use a scalpel blade or lancet. In the case of samples from a nail, manicure clippers (or else curved scissors), and the Le Cron knife, commonly used in dentistry, are all practical alternatives.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">It can also be useful to take samples from skin lesions using sterile carpet, which can then be placed on the culture medium, making detection of bacterial infection or superinfection possible. This is important in tinea pedis, which not infrequently coexists with intertrigo due to <span class="elsevierStyleItalic">Pseudomonas</span> or other gram-negative bacteria or due to <span class="elsevierStyleItalic">Candida</span> infection. However, taking samples using sterile carpet makes it difficult to perform direct examination.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Prior to sampling, the area must be cleansed gently with a swab or cotton-wool soaked in 70<span class="elsevierStyleSup">o</span> alcohol. The sample must be taken from the border of the lesion (the most active area). In tinea capitis, we must also aim to include some hair follicles in the sample (fragments of affected hairs are often found; on rubbing the area, these hairs typically become loose and pulling is not required). When distal onychomycosis is suspected, the most distal area of onycholysis should be removed and the sample taken more proximally.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">An effort should be made to obtain sufficient material. Part of the material obtained is deposited in the center of a microscope slide (or, if the sample is obtained by brushing, the brush is wiped against the slide) and a drop of the chosen stain is placed on the surface. At the present time, the most widely used is Swartz-Lamkins solution (Parker permanent black ink in equal parts with 20% potassium hydroxide), though other stains, such as those that combine potassium hydroxide and calcofluor, are also employed.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,4</span></a> The preparation is then covered by a coverslip.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">When the material contains scales, the keratinous material can be dissolved by gently heating the preparation over a cigarette lighter flame or by pressing gently and repeatedly on the coverslip. The sample is then examined by microscopy, first at low magnification (×<span class="elsevierStyleHsp" style=""></span>10) and then at high magnification (×<span class="elsevierStyleHsp" style=""></span>20 and ×<span class="elsevierStyleHsp" style=""></span>40).</p><p id="par0040" class="elsevierStylePara elsevierViewall">On direct examination, dermatophytes appear as septate and branching filaments with clear, regular hyaline borders that slowly take up the blue color from the ink (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). In cases of tinea capitis, special attention should be paid to parasitization of the hair (either externally, <span class="elsevierStyleItalic">ectothrix</span>, or internally, <span class="elsevierStyleItalic">endothrix</span>) to determine the best antifungal therapy while waiting for the culture results (griseofulvin for <span class="elsevierStyleItalic">ectothrix</span> and terbinafine for <span class="elsevierStyleItalic">endothrix</span>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Yeasts, which can be difficult to detect, usually present as budding blastoconidia and pseudohyphae. Pityriasis versicolor produces a pathognomic image (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) in which there is a mixture of individual blastospores with clear collarettes and short and thick pseudohyphae; these structures stain very rapidly.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Opportunistic moulds rarely show up on direct examination, except in the onychomycoses, in which hyphae and conidia can often be observed; these have a specific morphology that differs from dermatophytes and yeasts.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Advantages and Disadvantages of Direct Examination</span><p id="par0055" class="elsevierStylePara elsevierViewall">The advantages of this technique include the large amount of information rapidly provided, at low cost and with minimal instrument requirements. Furthermore, it has a high sensitivity, it enables us to distinguish between dermatophytes and <span class="elsevierStyleItalic">Candidas</span>, and it is particularly useful in atypical cases (tinea incognito) and in the onychomycoses, in which its sensitivity is much higher than that of culture.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,4,5</span></a> A positive direct examination is considered a necessary criterion to establish pathogenicity in suspected onychomycosis due to non-<span class="elsevierStyleItalic">albicans Candida</span> or nondermatophyte moulds.</p><p id="par0060" class="elsevierStylePara elsevierViewall">A disadvantage, as with any technique, is the learning curve required. In addition, it is time consuming and does not distinguish between species.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="par0065" class="elsevierStylePara elsevierViewall">A correct technique when taking samples and the performance of direct examination is very important in the investigation of a possible dermatomycosis, although mycology study must be completed by performing culture.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of Interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Description of the Technique" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Advantages and Disadvantages of Direct Examination" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of Interest" ] 5 => array:2 [ "identificador" => "xack278585" "titulo" => "Acknowledgments" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: del Boz J, Padilla-España L, Crespo-Erchiga V. Toma de muestras y examen directo en dermatomicosis. Actas Dermosifiliogr. 2016;107:64–66.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0085" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0035" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1297 "Ancho" => 1400 "Tamanyo" => 205152 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Recommended instruments for taking mycology samples.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1024 "Ancho" => 1280 "Tamanyo" => 342621 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Direct examination of a tinea. The dermatophytes appear as septate and branching filaments with clear, regular hyaline borders that have taken up the blue color from the ink. Original magnification, ×<span class="elsevierStyleHsp" style=""></span>40.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 872 "Ancho" => 1323 "Tamanyo" => 172195 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Direct examination of <span class="elsevierStyleItalic">Pityriasis versicolor</span>. The image shows blastospores with a clear budding collarette and short and thick pseudohyphae that have taken up the blue color from the ink. Original magnification, ×<span class="elsevierStyleHsp" style=""></span>40.</p>" ] ] 3 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 49264768 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Crespo Erchiga V, Delgado Florencio V, Martínez García S. El diagnóstico de laboratorio. In: Micología dermatológica. Barcelona: MRA; 2006. p. 35-52." ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Estado actual de la micología en la dermatología en España" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "V. Crespo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Dermatol Dermocosm Clínica" "fecha" => "2001" "volumen" => "4" "paginaInicial" => "495" "paginaFinal" => "496" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "La importancia de la preparación del paciente en el examen micológico de laboratorio" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R. Garzón" 1 => "M. Carballo" 2 => "E. del Valle" 3 => "L.A. Cipittelli" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Iberoam Micol" "fecha" => "1998" "volumen" => "15" "paginaInicial" => "307" "paginaFinal" => "308" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18473525" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Estudio comparativo del cultivo micológico y las tinciones con potasa-tinta y potasa-calcoflúor en el diagnóstico de onicomicosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Ojeda" 1 => "V. Crespo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Actas Dermosifiliogr" "fecha" => "1998" "volumen" => "89" "paginaInicial" => "169" "paginaFinal" => "172" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Examen direct versus culture. Etude sur 1115 cas de dermatomycoses" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "V. Crespo" 1 => "C. Casañas" 2 => "A. Ojeda" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Mycol Med" "fecha" => "1999" "volumen" => "9" "paginaInicial" => "154" "paginaFinal" => "157" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack278585" "titulo" => "Acknowledgments" "texto" => "<p id="par0075" class="elsevierStylePara elsevierViewall">We would like to thank the Dermatology Departments of Hospital Costa del Sol in Marbella and Hospital Carlos Haya in Malaga, for their help in preparing this publication.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010700000001/v2_201704190205/S1578219015003170/v2_201704190205/en/main.assets" "Apartado" => array:4 [ "identificador" => "6209" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Videos of Surgical Procedures in Dermatology" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010700000001/v2_201704190205/S1578219015003170/v2_201704190205/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219015003170?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 14 | 5 | 19 |
| 2024 October | 140 | 48 | 188 |
| 2024 September | 138 | 26 | 164 |
| 2024 August | 146 | 71 | 217 |
| 2024 July | 119 | 34 | 153 |
| 2024 June | 137 | 54 | 191 |
| 2024 May | 186 | 32 | 218 |
| 2024 April | 137 | 31 | 168 |
| 2024 March | 175 | 27 | 202 |
| 2024 February | 99 | 28 | 127 |
| 2024 January | 115 | 33 | 148 |
| 2023 December | 92 | 24 | 116 |
| 2023 November | 127 | 28 | 155 |
| 2023 October | 99 | 28 | 127 |
| 2023 September | 134 | 33 | 167 |
| 2023 August | 74 | 13 | 87 |
| 2023 July | 102 | 35 | 137 |
| 2023 June | 96 | 32 | 128 |
| 2023 May | 134 | 34 | 168 |
| 2023 April | 120 | 22 | 142 |
| 2023 March | 101 | 29 | 130 |
| 2023 February | 102 | 21 | 123 |
| 2023 January | 55 | 34 | 89 |
| 2022 December | 66 | 39 | 105 |
| 2022 November | 55 | 19 | 74 |
| 2022 October | 24 | 21 | 45 |
| 2022 September | 29 | 62 | 91 |
| 2022 August | 32 | 48 | 80 |
| 2022 July | 37 | 55 | 92 |
| 2022 June | 28 | 21 | 49 |
| 2022 May | 109 | 47 | 156 |
| 2022 April | 140 | 43 | 183 |
| 2022 March | 166 | 56 | 222 |
| 2022 February | 149 | 33 | 182 |
| 2022 January | 165 | 40 | 205 |
| 2021 December | 123 | 41 | 164 |
| 2021 November | 115 | 38 | 153 |
| 2021 October | 109 | 46 | 155 |
| 2021 September | 70 | 46 | 116 |
| 2021 August | 70 | 33 | 103 |
| 2021 July | 41 | 33 | 74 |
| 2021 June | 60 | 37 | 97 |
| 2021 May | 50 | 36 | 86 |
| 2021 April | 102 | 50 | 152 |
| 2021 March | 83 | 30 | 113 |
| 2021 February | 84 | 28 | 112 |
| 2021 January | 35 | 16 | 51 |
| 2020 December | 48 | 7 | 55 |
| 2020 November | 35 | 28 | 63 |
| 2020 October | 21 | 12 | 33 |
| 2020 September | 39 | 18 | 57 |
| 2020 August | 24 | 17 | 41 |
| 2020 July | 17 | 14 | 31 |
| 2020 June | 40 | 25 | 65 |
| 2020 May | 23 | 22 | 45 |
| 2020 April | 29 | 21 | 50 |
| 2020 March | 26 | 18 | 44 |
| 2020 February | 4 | 0 | 4 |
| 2019 December | 4 | 2 | 6 |
| 2019 November | 0 | 1 | 1 |
| 2019 October | 0 | 4 | 4 |
| 2019 September | 6 | 0 | 6 |
| 2019 May | 3 | 1 | 4 |
| 2019 April | 0 | 2 | 2 |
| 2019 March | 0 | 3 | 3 |
| 2019 February | 4 | 0 | 4 |
| 2018 December | 2 | 0 | 2 |
| 2018 November | 6 | 0 | 6 |
| 2018 October | 7 | 0 | 7 |
| 2018 September | 6 | 0 | 6 |
| 2018 March | 7 | 1 | 8 |
| 2018 February | 30 | 2 | 32 |
| 2018 January | 32 | 3 | 35 |
| 2017 December | 48 | 8 | 56 |
| 2017 November | 18 | 4 | 22 |
| 2017 October | 26 | 6 | 32 |
| 2017 September | 29 | 6 | 35 |
| 2017 August | 31 | 6 | 37 |
| 2017 July | 28 | 10 | 38 |
| 2017 June | 52 | 11 | 63 |
| 2017 May | 27 | 6 | 33 |
| 2017 April | 36 | 10 | 46 |
| 2017 March | 17 | 7 | 24 |
| 2017 February | 16 | 8 | 24 |
| 2017 January | 10 | 11 | 21 |
| 2016 December | 25 | 18 | 43 |
| 2016 November | 23 | 17 | 40 |
| 2016 October | 25 | 19 | 44 |
| 2016 September | 0 | 5 | 5 |
| 2016 August | 0 | 2 | 2 |
| 2016 July | 0 | 2 | 2 |
| 2016 June | 0 | 2 | 2 |
| 2016 April | 0 | 3 | 3 |
| 2016 March | 0 | 1 | 1 |
| 2016 February | 0 | 2 | 2 |
| 2016 January | 0 | 4 | 4 |
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