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. 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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" ]
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