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On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.77 no.6 Rio de Janeiro Nov./Dec. 2002
Tinea nigra in the City of Santos: five case reports*
Sandra Lopes Mattos e DinatoI; José Roberto Paes de AlmeidaII; Ney RomitiIII; Fabiana Addário de Abreu CamargoIV
Professor of Dermatology at the Medical Clinical Department, "Faculdade de Ciências
Médicas de Santos - UNILUS"
IIAssistant Lecturer of Dermatology at the Medical Clinical Department, "Faculdade de Ciências Médicas de Santos - UNILUS" and Postgraduate Student of Master's Degree in Health Science - "UNILUS"
IIIAdjunct Professor of Dermatology at the Medical Clinical Department, "Faculdade de Ciências Médicas de Santos"
IVResident M.D. of Dermatology, "Hospital Guilherme Álvaro"
Five cases are reported of tinea nigra palmaris in four female children and one male teenager in Santos, São Paulo's littoral. The history, epidemiology, diagnosis, treatment and prognosis are discussed in a review of the literature.
Key words: cladosporium; epidemiology; exophiala; tinea.
This dermatomycosis is also known as tinea nigra, keratomycosis nigricans palmaris, black pthiriasis, black keratophytosis, microsporosis nigra, keratophytia nigra, epidermal cladosporiosis and keratomycosis nigricans.1,2,3
It is an asymptomatic superficial fungal infection of the stratum corneum and generally affects the skin of the palmar and occasionally the plantar areas, presenting non desquamative maculae, with a coloration that varies from chestnut to black.4 It is considered a rare dermatosis and is more common in tropical and subtropical regions.1,2,3,5,6,7,8
The objective behind the five case reports of this dermatosis observed in Santos, a coastal town of the State of São Paulo, over a one-year period, is to discuss particularly its frequency in the various regions of Brazil.
Case 1 - L.S., white, female, three years of age, born and resident in Santos. Two years previously presented an asymptomatic, nondesquamative and hyperchromic stain with irregular outlines in the left palmar area. She sporadically frequents beaches and does not handle plants.
Case 2 - L.M.R., white, female, four years old, born and resident in Santos. Some four months previously presented an asymptomatic, nondesquamative and hyperchromic conical stain in the right palmar area, measuring approximately 2.5cm across its largest axis (Figure 1). She frequents beaches and does not handle plants.
Case 3 - A.O.C, white, female, six years old, student, born and resident in Santos, complaining of the onset one year ago of an asymptomatic, nondesquamative and brownish stain in the right palmar area with irregular borders and slow growth. She denied contact with plants and occasionally goes to the beach. The patient is right-handed.
Case 4 - B.C., white, female, 12 years old, student, born and resident in Santos. Four years ago presented an asymptomatic, nondesquamative hyperchromic stain, with irregular outlines, involving approximately two thirds of the right palmar area. (Figure 2). She frequents the beach regularly, denies contact with plants and is right-handed.
Case 5 - A.C.B.B., white, male, 16 years old, student, born and resident in Santos. Six months previously he noticed the presence of an asymptomatic, nondesquamative and hyperchromic stain in the right palmar area, measuring approximately 4.5cm in diameter since onset. He frequents the beaches sporadically, handles plants and is right-handed.
In all of these cases, the clinical diagnosis of tinea nigra was confirmed by mycological exams (direct and culture), which revealed dark septal hyphae (Figure 3) with a pigmented aspect (Figures 4 and 5), respectively.
The patients were treated with topical antifungal medication, based on imidazolyl derivatives, with complete regression of the lesions.
The first cases of tinea nigra were probably erroneous descriptions of versicolor pthiriasis.3
The first authentic description was made by Alexandre Cerqueira, in 1891, in Bahia. This research, however, was only widely divulged after publication of the doctoral thesis of his son, Antônio Gil de Cerqueira, in 1916.1,3,7,8,9
In 1921 the fungi was isolated by Parreras Horta, who denominated it Cladosporium werneckii, in honor of the Brazilian dermatologist Werneck Machado.3,6,7,8,10
Later, in 1970, new studies classified it into the genus Exophiala (Exophiala werneckii).5,6,7,8,10,11,17 In 1978, Mc Guinnis demonstrated that Cladosporium and Exophiala presented different conidial ontogeny.3,8,10,17
More recently, in 1985, Nishimura and Miyagi proposed the genus Hortae werneckii in honor of Parreras Horta.10 Mc Guinnis considered this denomination to be without scientific foundation and in the same year, suggested the genus Phaeo annellomyces - since it is a dark (Phaeo = darkness) and ring-like (annellomyces = ring) conidiogenous fungus - a nomenclature that is still used today.3,8,10
Hence, the fungus is denominated Phaeo annellomyces werneckii and belongs to the Phaeoannellomyceae family.1,3,7,8,9,10,12,13
In relation to its habitat, Uijithof et al. (1994), described the presence of the fungi mainly in areas with great saline concentration. It had already been isolated in soil, dirty water, rotting vegetation, forests and extremely humid environments.3,8,14 Inoculation in the skin of susceptible volunteers has reproduced the disease.3
According to the published epidemiological data, it can be seen that tinea nigra is more frequent in tropical and subtropical regions3,5,7,8,9 occurring sporadically in many parts of the world, including the Americas, Caribbean, southern Africa, Australia, Europe and the Far East.3,5,7,8
In Brazil, the cases described to date originate in the states of Paraná, São Paulo, Rio de Janeiro, Espírito Santo and Bahia, besides all other coastal states.3 According to the study by Marques and Camargo (1996), who compiled 39 cases published by various authors in Brazil, from 1921 to 1996, there is a slight prevalence in the Northeast, with 16 cases, followed by the Southeast, 14; the Northern Region presented five cases and the Southern Region, four, with no cases reported in the Central-west (a region without a coastline).7
The literature indicates that the disease is clinically characterized by asymptomatic, nondesquamative lesions with a black or brown coloration, located mainly in the palmar areas or around the fingers. There are cases with a plantar location. Bilateral palmar cases have been reported as well.4,9 There are descriptions, especially in Asia, of involvement of other areas of the body, such as the neck and trunk.. The lesions can eventually coalesce or grow in a centrifugal manner, leading to irregular outlines. Spontaneous cure is very rare.1,2,3,5,6,7
It is opportune to emphasize that the publications show a prevalence of this dermatosis in individuals aged under 20 years, with white skin and females, from a higher socioeconomic level.3,7,8,9,15 The present authors' observations corroborate these findings.
According to research by Montiel, in 1986, the preferential location among children is the palm of the right hand, while in adults it is the palm of the left hand and 50% of the patients of a Venezuelan study also suffered from hyperhidrosis.1,3,16 Of the five patients from Santos, four presented involvement of the right palmar area, including the adolescent, while the three-year-old patient presented a lesion in the palm of the left hand; hyperhidrosis was not observed in the cases from Santos. It was not possible to define the predominant hand in two cases involving infants of three and four years due to their low age. All patients reported sporadic visits to the beach.
In a publication of 1994, Velozo et al. observed that 100% of their patients presented an antecedence of handling plants,9,15 however, among the cases presented in this paper, this factor was only observed in one patient.
Clinical diagnosis can be confirmed in the laboratory, through direct mycological exam which, after clarification with 10 to 20% potassium hydroxide presents dark, irregular and ramified septal hyphae, with melanin pigment.1,2,3,7,8,9,10
Culture in Sabouraud's agar requires from 21 to 25 days in order for the colonies to become apparent. These colonies have a shiny coloration, which is initially white or gray and later becomes profoundly pigmented.3,4,7,9,16 These mycological findings were also confirmed by the authors.
Regarding the histology of the biopsies from the lesions, there is a thickening of the corneum stratum, within which there are dark septal hyphae as well as discreet acanthosis and little to no perivascular lymphocytic inflammatory reaction.3,5,6,8 Histopathology is generally unnecessary in routine exams. However, it is used exceptionally when the main diagnostic hypothesis is not the mycosis under study. This procedure was not undertaken in the patients reported here.
The importance of the differential diagnosis with melanocytic lesions should be underscored, i.e. between cases of junction nevus and melanoma. Furthermore, knowledge of this fungal infection avoids an uncalled for surgical removal of the lesion in cases of erroneously diagnosed tinea nigra.1,3,6,8,9,12,18 The black coloration and absence of desquamation differentiate it from versicolor pthiriasis.5 Sometimes, in the differential diagnosis other dermatopathies should be considered, such as: exogenous pigmentation, contact dermatitis, syphilis, fixed pigmented erythema and hematoma.3
On the other hand, it does not present any difficulty in terms of treatment, which is effected with topical antifungal agents, such as those derived from imidazolyl. It responds in an inconstant manner to undecylenic acid and tolnaftate is ineffective.1,2,3,19,20
In conclusion, this is a dermatosis considered somewhat rare in some Brazilian states, but common in coastal regions. Regarding Santos in particular, it is relatively frequent for patients to present this characteristic superficial mycosis. It is emphasized that this disease is easily treated with an excellent prognostic, provided that it is duly recognized and thereby avoiding unnecessary surgical procedures.
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Sandra Lopes Mattos e Dinato
Rua Bento de Abreu nº 65
Santos SP 11045-140
Tel/Fax: (13) 3233-2964
Received in December,
8th of 2000.
Approved by the Consultive Council and accepted for publication in June, 04th of 2002
* Work done at "Faculdade de Ciências Médicas de Santos - Fundação Lusíada - UNILUS".