**3.2 Epidemiology of different types of dermatomycoses in Poland**

Fungal infections are now a major epidemiological and social problem worldwide. According to various data relating to different geographical regions, they concern from 10 to 40% ofthe world's population (Bolinski et al., 2003; Foster et al., 2004; Kaszuba et al., 1997; Szepietowski & Baran, 2005). Research conducted among people living in moderate climate

Epidemiology of Dermatomycoses in Poland over the Past Decades 45

authors estimate the incidence of fungal infection rates similar of 25-30% in the general population, although this is difficult to determine it because in the special risk groups (athletes, miners), it can grow up to 60-70%. In studies of Szepietowski *et al* most common type of *tinea pedis* was a athlete's foot (45.5%), and the most common pathogens causing it were dermatophytes, which were isolated in 88.8% of all patients with fungal infections. Among the most commonly cultured dermatophytes were *Trichophyton rubrum* (51%),

The authors found that athlete's foot in 75.2% of patients occurred together with the other forms of fungal infection of the skin, the most common was onychomycosis found in 69.2% of patients. Described in the literature the simultaneous occurrence of fungal infection of the both feet with one hand forming the so-called two feet and one hand syndrome and was rarely observed, because only in 2.5% of patients (Szepietowski et al., 2001). It is believed that the probability of developing athlete's foot is lower in women than in men. The differences are likely to result from increased exposure to pathogenic fungi associated with

Onychomycosis is often concomitant with athlete`s foot, it is developed by the occurrence of the same favorable environmental conditions for fungi (Elewski, 2000a; Hryncewicz-Gwozdz et al., 2005; Wronski & Nowicki, 2005). Infections concerns mostly the elderly, after 65 years. Its occurence is much rarer in children, it is associated with rapid growth of the nails in young people which hinders the development of infection because the fungus is removed together with the growing plate (Hryncewicz-Gwozdz et al., 2006; Lange & Bykowska, 2004). Epidemiological data from recent years show significant dominance of dermatophyte fungi as a etiological agents of onychomycosis. It is assumed that currently about 80% of fungal infections of nails are caused by *Trichophyton rubrum* (Wronski &

Fungal infection of hands is most common as a secondary infection in patients with athlete`s foot. It can then concern the dominant hand and form the aforementioned two feet and one hand sydrome (Szepietowski et al., 2001). In most cases the etiological factors for mycosis of hands are anthropophilic species of dermatophytes that also cause athlete's foot also: *Trichophyton rubrum*, rarely *Epidermophyton floccosum* and *Trichophyton interdigitale*. Much less fequently hand`s skin can be infected by antropohilic species *Trichophyton violaceum* and some zoophilic species such as *Trichophyton mentagrophytes* (Kobierzycka et al., 2005;

The development of fungal infection of the hands may facilitate various factors causing maceration of the skin, such as wearing rings, watches, anatomical deformities, and environmental factors associated with the professional activities (Kobierzycka et al., 2005). Species of dermatophytes that cause athlete's foot can also cause fungal infection of the groin. The most common pathogen is *Trichophyton rubrum*, while *Trichophyton interdigitale* and *Epidermophyton floccosum* more rarely cause infections of this area. This infection is a common disease, occurring more often in men than in women, but it is rarely observed in children. *Tinea cruris* is a very widespread in the tropics, particularly among immigrants from countries with temperate climates, especially when factors that makes them predisposed to the formation of intertrigos and development of fungal infections are

followed by *Trichophyton mentagrophytes* (33.1%) (Szepietowski et al., 2001).

wearing heavy occlusive footwear by men (Kobierzynska et al., 2005).

Nowicki, 2000).

Hryncewicz-Gwozdz et al., 2005) .

accumulated (Kobierzycka et al., 2005).

zones showed chronic fungal infections among 10-20% of the population (Bolinski et al., 2003; Glinski et al., 2002). Fungi pathogenic for human usually cause infections of the skin and its appendages, although in recent years also increasing recognition of fungal infections of internal organs is seen.

Among the more than 200 000 species of fungi about 200 are pathogenic to human (Szepietowski & Baran, 2005). Their high morphological diversity allows them to survive in different ecosystems. Polymorphism of fungi is also a result of their diverse needs for growth substances in certain ecological niches, because they have a high potential to adapt to the changing resources of their environment (Dworacka-Kaszak, 2004). Among potential fungal skin pathogens are fungi not only highly adapted for parasite on the skin – dermatophytes, but also yeasts and molds.

Observed in recent decades, the increasing incidence of fungal infections of the skin is mainly associated with the constant presence, and even an increase in risk factors for fungal infections. It was established a number of factors predisposing to the development of fungal infections, some of which relate to the host, and other to biological characteristics of the fungal pathogens. One of the main factors is prolongation of the average life span, age proved to be a physiological risk factor for fungal infection. Particularly predisposed group are not only people over 65 years, but also premature newborns and infants. It was found that the presence of multifocal skin infections increases with age and is 2-fold more frequent in men than in women (Kobierzycka et al., 2005).

One of the most important factors influencing the increasing number of fungal infections is the progress in medical science, it now allows the survival of patients with an impaired immune response in the course of chronic, severe illnesses such as cancer, metabolic and endocrine diseases, renal failure, HIV infection and other (Hryncewicz, Gwozdz et al., 2006; Miroszewska-Sobanska & Adamski, 2000). This is related to the development of intensive medical care, dialysis, parenteral nutrition and artificial ventilation, conducting invasive diagnostics, catheterization of vascular and body cavities, and also with the use of modern cardiac transplantation techniques (Glisnki et al., 2002). Very important is also antibiotic therapy, treatment with cytostatics, immunosuppressants and corticosteroids (Krajewska-Kulak et al., 2000).

Superficial mycoses of skin and its appendages are diagnosed in Poland very often. Among the clinical forms of mycoses of skin and its appendages special place because of the prevalence takes athlete's foot and onychomycosis. Athlete's foot occurs mostly in adults, rarely in children and often is acquired early in adolescence.

For example, studies of Kalinowska *et al* on lowersilesian population in years 2004-2008 indicated, that *tinea pedis* and onychomycosis were very often in adults, whereas in children and adolescents *tinea capitis* and *tinea corporis* were predominated (Kalinowska et al., 2010). It is believed that in developed countries athlete`s foot may affect up to 10% of the total population. In recent years, it was found that for most cases of athlete's foot are responsible three anthropophilic species of dermatophytes: *Trichophyton rubrum*, *Trichophyton interdigitale* and *Epidermophyton floccosum* (Kobierzycka et al., 2005).

Studies of Szepietowski *et al* indicate that the athlete's foot was 28% of all fungal infections of skin and nails in Poland and it is the second most common after onychomycosis. Other

zones showed chronic fungal infections among 10-20% of the population (Bolinski et al., 2003; Glinski et al., 2002). Fungi pathogenic for human usually cause infections of the skin and its appendages, although in recent years also increasing recognition of fungal infections

Among the more than 200 000 species of fungi about 200 are pathogenic to human (Szepietowski & Baran, 2005). Their high morphological diversity allows them to survive in different ecosystems. Polymorphism of fungi is also a result of their diverse needs for growth substances in certain ecological niches, because they have a high potential to adapt to the changing resources of their environment (Dworacka-Kaszak, 2004). Among potential fungal skin pathogens are fungi not only highly adapted for parasite on the skin –

Observed in recent decades, the increasing incidence of fungal infections of the skin is mainly associated with the constant presence, and even an increase in risk factors for fungal infections. It was established a number of factors predisposing to the development of fungal infections, some of which relate to the host, and other to biological characteristics of the fungal pathogens. One of the main factors is prolongation of the average life span, age proved to be a physiological risk factor for fungal infection. Particularly predisposed group are not only people over 65 years, but also premature newborns and infants. It was found that the presence of multifocal skin infections increases with age and is 2-fold more frequent

One of the most important factors influencing the increasing number of fungal infections is the progress in medical science, it now allows the survival of patients with an impaired immune response in the course of chronic, severe illnesses such as cancer, metabolic and endocrine diseases, renal failure, HIV infection and other (Hryncewicz, Gwozdz et al., 2006; Miroszewska-Sobanska & Adamski, 2000). This is related to the development of intensive medical care, dialysis, parenteral nutrition and artificial ventilation, conducting invasive diagnostics, catheterization of vascular and body cavities, and also with the use of modern cardiac transplantation techniques (Glisnki et al., 2002). Very important is also antibiotic therapy, treatment with cytostatics, immunosuppressants and corticosteroids (Krajewska-

Superficial mycoses of skin and its appendages are diagnosed in Poland very often. Among the clinical forms of mycoses of skin and its appendages special place because of the prevalence takes athlete's foot and onychomycosis. Athlete's foot occurs mostly in adults,

For example, studies of Kalinowska *et al* on lowersilesian population in years 2004-2008 indicated, that *tinea pedis* and onychomycosis were very often in adults, whereas in children and adolescents *tinea capitis* and *tinea corporis* were predominated (Kalinowska et al., 2010). It is believed that in developed countries athlete`s foot may affect up to 10% of the total population. In recent years, it was found that for most cases of athlete's foot are responsible three anthropophilic species of dermatophytes: *Trichophyton rubrum*, *Trichophyton* 

Studies of Szepietowski *et al* indicate that the athlete's foot was 28% of all fungal infections of skin and nails in Poland and it is the second most common after onychomycosis. Other

of internal organs is seen.

Kulak et al., 2000).

dermatophytes, but also yeasts and molds.

in men than in women (Kobierzycka et al., 2005).

rarely in children and often is acquired early in adolescence.

*interdigitale* and *Epidermophyton floccosum* (Kobierzycka et al., 2005).

authors estimate the incidence of fungal infection rates similar of 25-30% in the general population, although this is difficult to determine it because in the special risk groups (athletes, miners), it can grow up to 60-70%. In studies of Szepietowski *et al* most common type of *tinea pedis* was a athlete's foot (45.5%), and the most common pathogens causing it were dermatophytes, which were isolated in 88.8% of all patients with fungal infections. Among the most commonly cultured dermatophytes were *Trichophyton rubrum* (51%), followed by *Trichophyton mentagrophytes* (33.1%) (Szepietowski et al., 2001).

The authors found that athlete's foot in 75.2% of patients occurred together with the other forms of fungal infection of the skin, the most common was onychomycosis found in 69.2% of patients. Described in the literature the simultaneous occurrence of fungal infection of the both feet with one hand forming the so-called two feet and one hand syndrome and was rarely observed, because only in 2.5% of patients (Szepietowski et al., 2001). It is believed that the probability of developing athlete's foot is lower in women than in men. The differences are likely to result from increased exposure to pathogenic fungi associated with wearing heavy occlusive footwear by men (Kobierzynska et al., 2005).

Onychomycosis is often concomitant with athlete`s foot, it is developed by the occurrence of the same favorable environmental conditions for fungi (Elewski, 2000a; Hryncewicz-Gwozdz et al., 2005; Wronski & Nowicki, 2005). Infections concerns mostly the elderly, after 65 years. Its occurence is much rarer in children, it is associated with rapid growth of the nails in young people which hinders the development of infection because the fungus is removed together with the growing plate (Hryncewicz-Gwozdz et al., 2006; Lange & Bykowska, 2004). Epidemiological data from recent years show significant dominance of dermatophyte fungi as a etiological agents of onychomycosis. It is assumed that currently about 80% of fungal infections of nails are caused by *Trichophyton rubrum* (Wronski & Nowicki, 2000).

Fungal infection of hands is most common as a secondary infection in patients with athlete`s foot. It can then concern the dominant hand and form the aforementioned two feet and one hand sydrome (Szepietowski et al., 2001). In most cases the etiological factors for mycosis of hands are anthropophilic species of dermatophytes that also cause athlete's foot also: *Trichophyton rubrum*, rarely *Epidermophyton floccosum* and *Trichophyton interdigitale*. Much less fequently hand`s skin can be infected by antropohilic species *Trichophyton violaceum* and some zoophilic species such as *Trichophyton mentagrophytes* (Kobierzycka et al., 2005; Hryncewicz-Gwozdz et al., 2005) .

The development of fungal infection of the hands may facilitate various factors causing maceration of the skin, such as wearing rings, watches, anatomical deformities, and environmental factors associated with the professional activities (Kobierzycka et al., 2005).

Species of dermatophytes that cause athlete's foot can also cause fungal infection of the groin. The most common pathogen is *Trichophyton rubrum*, while *Trichophyton interdigitale* and *Epidermophyton floccosum* more rarely cause infections of this area. This infection is a common disease, occurring more often in men than in women, but it is rarely observed in children. *Tinea cruris* is a very widespread in the tropics, particularly among immigrants from countries with temperate climates, especially when factors that makes them predisposed to the formation of intertrigos and development of fungal infections are accumulated (Kobierzycka et al., 2005).

Epidemiology of Dermatomycoses in Poland over the Past Decades 47

Also, Zaba and Danczak-Pazdrowska examining children and adolescents to 18 years of age, living in the area of Greater Poland, found fungal infections of toenails in 34.5% patients and mycoses of hands and feet in 26.1% of cases (Zaba & Danczak-Pazdrowska, 2001). It seems that a particular risk factor in children is a participation in sport activities. It turned out that in this group superficial mycosis of the feet occurs several times more often than in children not involved in sport, which is related to use of occlusive footwear, as well as frequent, repetitive injuries of fingers and toenails. Thus, the results of the Polish authors suggest that fungal infection of the feet and toenails in children and adolescents currently are not that uncommon. Moreover, as in adults, athlete's foot in children can coexist with other clinical forms of fungal infection, especially fungal infection of the toenails (Lange &

The analysis of few described so far cases in the world of dermatomycosis in newborns showed that it could even occur on the second day of life and can be caused both by anthropophilic dermatophytes (*Trichophyton rubrum*) and as well as zoophilic dermatophytes (*Microsporum canis*). The source of infection in case of antropophilic dermatophytes was immediate family and in case of zoophilic dermatophytes – pets, especially cats. Descriptions analyzed by Szepietowski of dermatomycosis in newborns come mostly from India and Japan, which is probably related both to climatic conditions, as well as significantly to local

Fungal infections are a serious problem - not only clinical, but also therapeutic and social. Fungi are widespread in the environment of human life, are ubiquitous, so the disorders caused by them could be classified as a lifestyle diseases, affecting people independtly of age, sex, race or social status. Fortunately, our knowledge about these parasites of the skin and its appendages is growing, new therapies and new methods of treatment of fungal diseases are developed, which allows us to effective protection against these pathogens.

Adamski, Z. & Batura – Gabryel, H. (2007). *Medical mycology for physicians and students, 2nd* 

Bajcar, S & Ratka P. (2002). Epidemiology of dermatophyte infections among inhabitans of

Baran, E. & Szepietowski J. (1994). Geographical distribution of dermatophytes isolated

Baran, E. et al. (1993). Fungal infections in Lower Silesia region in years 1974-1988. *Przeglad* 

Bolinski, J. et al. (2003). Epidemiology of infections of skin and its appendages in material of

*Dermatologiczny*, Vol. 80, pp. 49-58, ISSN 0033-2526

*edition.* Scientific Publishing of Poznan Medical University, Poznan, Poland, ISBN

Subcarpathian region in years 1984-2001. *Mikologia Lekarska*, Vol. 9, No. 2 (June),

from skin lesions in Poland. *Mikologia Lekarska*, Vol. 1, No. 1 (March), pp. 11-18,

Dermatology Clinic in Bialystok. *Mikologia Lekarska*, Vol. 10, No. 2 (June), pp. 119-

Bykowska, 2004).

**4. Conclusion** 

**5. References** 

978-83-60187-76-0

ISSN 1232- 986X

127, ISSN 1232-986X

pp. 101-104, ISSN 1232-986X

practices for baby care (Szepietowski, 1997).

Most dermatophytes can infect hair, the exceptions are, however, some species such as *Epidermophyton floccosum*, *Trichophyton rubrum*, *Trichophyton interdigitale*. Conversely, some dermatophytes (*Microsporum audouinii*, *Trichophyton schoenleinii*, *Trichophyton violaceum*) have a strong affinity for hair structures. It was found that all the dermatophytes, which cause fungal infections of the scalp can also infect glabrous skin (Kobierzycka et al., 2005). Pathogens that cause *tinea capitis* differs between countries and geographic regions. In recent years, it has been observed in most European countries, an increase in the frequency of infections caused by *Microsporum canis*, whereas in the U.S. urban environments - a larger share *Trichophyton tonsurans* was seen (Elewski, 2000b). Mycosis of the scalp concerns mainly children. Peak incidence falls on 4 – 6 years of age, and the infection is spreading especially in boys. Higher incidence of fungal infections in children is associated with the difference of biological characteristics of the skin, including the different composition of sebum in children and adults (Szepietowski & Baran, 2005).

In a study of Lange *et al*, of the pediatric population in the region of Gdansk (midsouthern Poland), fungal infections of skin were usually caused by dermatophytes, which accounted for 60% of all infections. The highest incidence of skin fungal infections was observed in children aged 4-7 years. In this age group, the lesions caused by *Microsporum canis* affected the scalp. In slightly older children, aged 8-12 years, the number of infections of the scalp decreased rapidly, and over 13 years of age lesions in this location rarely have been observed. Most common form of fungal infection, that was seen in the pediatric population studies, was fungal infection of the glabrous skin (30%), mostly caused by *Microsporum canis*, rarely by *Trichophyton mentagrophytes* and by *Trichophyton rubrum*, occurring most often in children aged 8 - 15 years. It is interesting that in children above 12 years of age athlete's foot was also observed (11%), in most cases caused by *Trichophyton rubrum* and *Trichophyton mentagrophytes*, and also fungal infections of the toenails (8%) caused by *Trichophyton rubrum* were seen (Lange et al., 2002). Similar results were obtained in the studies of pediatric patients in the region of Poznan (Central-West Poland) (Zaba & Danczak-Pazdrowska, 2001).

Many authors underline the rarity of these forms of mycoses in children before puberty, in contrast to the fungal infections of glabrous skin and scalp, considered to be typical for the childhood. Accepted view is that the athlete's foot and onychomycosis are very common skin and nails diseases in adults, and their incidence increases with age. However, epidemiological studies on the population of children of different ages and in different regions of the world indicate that the athlete's foot may relate to 2.2-8.2% of the pediatric population (Lange & Bykowska, 2004) In addition, there are also cases of athlete's foot in pediatric patients like *tinea incognito*, proceeding without symptoms or mistakenly acknowledged as bacterial lesions or allergic changes and treated with antibiotics or topical cortycosteroids (O`Grady & Sahn, 1999).

Studies of Lange and Bykowska on recognition of fungal infections in pediatric patients in years 1993-2002 showed an increase in the prevalence rates of onychomycosis in children (Lange & Bykowska, 2004). In the literature, individual national studies of mycoses of the feet and toenails in children and adolescents refers to the area of Wroclaw (Lower Silesia, southwestern Poland), where there has been considerable percentage of fungal infection of the feet and toenails in children under 15 years of age (16.3% and 21%, respectively) (Szepietowski, 1997).

Also, Zaba and Danczak-Pazdrowska examining children and adolescents to 18 years of age, living in the area of Greater Poland, found fungal infections of toenails in 34.5% patients and mycoses of hands and feet in 26.1% of cases (Zaba & Danczak-Pazdrowska, 2001). It seems that a particular risk factor in children is a participation in sport activities. It turned out that in this group superficial mycosis of the feet occurs several times more often than in children not involved in sport, which is related to use of occlusive footwear, as well as frequent, repetitive injuries of fingers and toenails. Thus, the results of the Polish authors suggest that fungal infection of the feet and toenails in children and adolescents currently are not that uncommon. Moreover, as in adults, athlete's foot in children can coexist with other clinical forms of fungal infection, especially fungal infection of the toenails (Lange & Bykowska, 2004).

The analysis of few described so far cases in the world of dermatomycosis in newborns showed that it could even occur on the second day of life and can be caused both by anthropophilic dermatophytes (*Trichophyton rubrum*) and as well as zoophilic dermatophytes (*Microsporum canis*). The source of infection in case of antropophilic dermatophytes was immediate family and in case of zoophilic dermatophytes – pets, especially cats. Descriptions analyzed by Szepietowski of dermatomycosis in newborns come mostly from India and Japan, which is probably related both to climatic conditions, as well as significantly to local practices for baby care (Szepietowski, 1997).
