eMedicine Specialties > Dermatology > Bacterial Infections
Trichomycosis Pubis
Updated: Mar 26, 2009
Introduction
Background
Trichomycosis is a bacterial infection of the hair shaft found in sweat gland–bearing areas; it has been described most commonly in the axillary region. While initially believed to be uncommon in the inguinal region, a series of papers have described trichomycosis particular to the inguinal area and have suggested that this disease is underestimated in the general population.
Pathophysiology
This discussion of trichomycosis, a disease specific to the hair and sweat gland–bearing regions of the body, concentrates on the involvement of the pubic region in men (trichomycosis pubis). First described in the axillary region by Paxton in 1869, the causative role of multiple bacterial Corynebacterium species was established by Freeman et al in 1969.1,2,3,4,5 Use of the term trichomycosis, and the implied causative role of fungi, has been maintained. The color differences noted at presentation of the condition, their association with particular corynebacteria, or the possible role of associated cocci have not been clarified.
The causative organism associated with most cases is Corynebacterium tenuis, which prefers the moist microenvironment of the inguinal regions. While as many as 33% of adults have colonization by bacteria in the inguinal or axillary regions, factors such as hyperhidrosis initiate more extensive growth and clinical manifestation. The exact origin of the cement substance that creates the grossly visible nodules is debated. Electron microscopy studies favor origin from the causative agents, while others have favored elaboration from apocrine sweat.6,7 The actual nidus may be through the modification of apocrine sweat by elaborated cement substance to create the insoluble material that holds bacteria to the hair shaft.
Rho et al describe a so-called "corynebacterial triad" that includes erythrasma and trichomycosis axillaris in soldiers with pitted keratolysis.8
Frequency
United States
Detailed examination of racial, age, or geographic incidence has not been performed, and examinations in the United States are limited to case reports. A more detailed examination (but still limited) has been performed outside the United States.
International
Studies in Panama and the United Arab Emirates revealed rates as high as 39% in patients attending a dermatology clinic.9,10 These results correlated with the notably higher incidence in areas of high humidity, warmth, and poor hygiene. The only other study to mention incidence noted the presence of trichomycosis pubis when examining institutionalized mentally retarded patients for trichomycosis axillaris in Edinburgh, Scotland, and noted that of 609 men examined, 16 (2.6%) had pubic disease, of which 3 of the cases (0.5%) were not associated with axillary involvement. Ages of the males affected were 18 and 21 (3 patients) and can be culled only from case reports.
Mortality/Morbidity
Morbidity is low, with most patients unaware of the colonization. When presenting, the most common complaint is a foul odor, and this may continue to cause problems, since trichomycosis often recurs.
Clinical
History
While many patients are asymptomatic, patients have presented because of pubic rash, foul odor, or growths on the pubic hair. Presenting complaints of colored sweat also have been recorded, resulting in a consideration of chromhidrosis.
Physical
Patients typically present with yellow or red nodules on the hair shafts; yellow is most common. Sweat in the region tends to be colored similarly. Lesions present in the inguinal region, often on the scrotum but occasionally on the base of the shaft of the penis. Lesions can be associated with erythema and itching, and superinfection with dermatophytes has been noted.
Causes
Risk factors appear to be geographic, with the highest incidence in tropic areas. In addition, poor hygiene often is present.
Other diagnostic considerations
Clinical separation from other organisms often is not performed, and treatment focuses on the empirical use of drying agents and topical antibiotics. Thus, the use of topical powders can be a confounding factor in diagnosis. True fungal infections (piedra) also may confound the diagnosis but may be present as superinfection. Piedra presents with nodularity of the hair shafts that is either tan to white (white piedra) or black (black piedra), as opposed to the yellow or red nodules of trichomycosis. White piedra may have a gelatinous appearance.
Differential Diagnoses
Chromhidrosis
Other Problems to Be Considered
Piedra
Pediculosis pubis
Hair casts (peripilar casts, pseudonits)
Workup
Laboratory Studies
Hair culture can be used to grow the anaerobic diphtheroids present as short gram-positive rods. These studies usually are not essential but may be used if no response to initial treatment occurs or targeted antibacterial treatment fails to result in a cure (and fungal superinfection should be eliminated).
Histologic Findings
While usually not performed, in rare cases samples of the hair have been removed and sent for surgical pathology slide preparation. These cases document the presence of filamentous bacterial growth perpendicular to the hair shaft, present in a background of elaborated cement substance that makes up the concretions. The bacteria adhere to but do not penetrate the hair shaft. Superinfection with cocci or fungi also can be present.
Treatment
Medical Care
Treatment involves alleviating the hyperhidrosis through the use of drying agents. Topical clindamycin is helpful in refractory or extensive cases.11,12 Additional recommended agents include naftifine hydrochloride cream (1%), which has been used for its combined antifungal and antibacterial actions.13
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Antifungals
Mechanism of action usually involves inhibiting pathways (enzymes, substrates, transport) necessary for sterol/cell membrane synthesis or altering the permeability of the cell membrane (polyenes) of the fungal cell.
Naftifine (Naftin)
Synthetic allylamine derivative shown to exhibit fungicidal activity in vitro against a broad spectrum of organisms including species of Trichophyton, Microsporum, and Epidermophyton genera. Has shown fungistatic activity against Candida species. Exact mechanism of action is not known; however, appears to interfere with sterol biosynthesis by inhibiting squalene 2,3-epoxidase. Treatment should continue up to 4 wk. If no improvement is noted, re-evaluate patient.
Dosing
Adult
Gently massage (1% cream/gel) sparingly into affected area and surrounding skin qd up to 4 wk
Pediatric
Not established
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
For topical use only; not for ophthalmic use
Antimicrobials
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Antibiotic selection should be guided by blood culture sensitivity whenever feasible.
Clindamycin solution (Cleocin T, Clinda-Derm)
Wide-spectrum antibiotic effective in vivo against various microbial organisms including Corynebacterium species. Antibiotic binds preferentially to the 50S ribosomal subunit affecting the process of peptide chain initiation in bacteria.
Dosing
Adult
Apply to affected area bid
Pediatric
<12 years: Not established
>12 years: Apply as in adults
Interactions
Has neuromuscular blocking properties that may enhance action of other neuromuscular blocking agents
Contraindications
Documented hypersensitivity; history of antibiotic-associated colitis
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Use of topical formulation results in absorption of antibiotic from skin surface; diarrhea and colitis (including pseudomembranous colitis) have been reported with use of topical and systemic clindamycin; discontinue if significant diarrhea occurs
Benzoyl peroxide (Benoxyl, Fostex, Benzac)
Free-radical oxygen is released upon administration and oxidizes bacterial proteins in sebaceous follicles, decreasing the number of anaerobic bacterial and irritating free fatty acids. Has keratolytic and comedolytic effects.
Use gel, pads, or wash.
Dosing
Adult
Apply sufficient quantity to affected and surrounding skin areas bid qam and qpm; reduce dose, frequency, or concentration if excessive dryness or peeling occurs
Pediatric
Not established
Interactions
Potentiates adverse effects of tretinoin
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid contact with lips, eyelids, mucous membranes, and eyes; for external use only; discontinue if swelling, burning, or excessive dryness occurs
Astringents
Agents that work to dry up the sweat glands.
Aluminum chloride (Xerac-AC roll-on, Certain-dry pads, Drysol solution)
Astringent agent used in management of hyperhidrosis.
Dosing
Adult
Apply to affected area hs; to prevent irritation, completely dry area prior to application
Pediatric
Not established
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Not for application on irritated, broken, or recently shaved skin; for external use only
Follow-up
Deterrence/Prevention
Since studies show notably higher incidence in regions of the world with high humidity and temperatures and in people with poor hygiene, emphasize measures aimed at maintaining dry skin and proper hygiene.
Complications
The primary complication appears in individuals who are immunocompromised and can develop septicemia secondary to colonization of catheters and surgical sites. Infection in hosts who are immunocompetent yields few long-term adverse effects.
Recurrence is common, but the simplicity of treatment and improved hygiene make follow-up care simple. In rare cases, shaving the pubic hair after treatment has been advocated to prevent recurrences, although this was met with patient resistance.
Prognosis
Aside from the risk of recurrence, prognosis is excellent, and treatment is effective.
Patient Education
Instruct patients to keep skin dry and to practice proper hygiene.
Miscellaneous
Medicolegal Pitfalls
Since most people with trichomycosis pubis do not seek clinical care, medical pitfalls do not exist. Patients who seek care have fulminant disease and desire treatment.
Special Concerns
Consider examination and treatment of sexual partners, although to date, no studies have compared the incidence of trichomycosis pubis in sexual partners.
References
Crissey JT, Rebell GC, Laskas JJ. Studies on the causative organism of trichomycosis axillaris. J Invest Dermatol. May 1952;19(3):187-97. [Medline].
Freeman RG, McBride ME, Knox JM. Pathogenesis of trichomycosis axillaris. Arch Dermatol. Jul 1969;100(1):90-5. [Medline].
McBride ME, Freeman RG, Knox JM. The bacteriology of trichomycosis axillaris. Br J Dermatol. Aug 1968;80(8):509-13. [Medline].
Paxton FV. On a disease condition of the hairs of the axilla, probably of parasitic origin. J Cutan Med. 1869;3:133.
Savin JA, Somerville A, Noble WC. The bacterial flora of trichomycosis axillaris. J Med Microbiol. May 1970;3(2):352-6. [Medline].
Montes L, Vasquez C, Cataldi M. Electron microscopic study of infected hairs in trichomycosis axillaris. J Invest Dermatol. 1963;40:273-8.
White SW, Smith J. Trichomycosis pubis. Arch Dermatol. Apr 1979;115(4):444-5. [Medline].
Rho NK, Kim BJ. A corynebacterial triad: Prevalence of erythrasma and trichomycosis axillaris in soldiers with pitted keratolysis. J Am Acad Dermatol. Feb 2008;58(2 Suppl):S57-8. [Medline].
Lestringant GG, Qayed KI, Fletcher S. Is the incidence of trichomycosis of genital hair underestimated?. J Am Acad Dermatol. Feb 1991;24(2 Pt 1):297-8. [Medline].
Zaias N, Taplin D, Rebell GS. Final Report, Republic of Panama Medical Research. Washington, DC: Walter Reed Army Institute of Research; 1964.
Bargman H. Trichomycosis of the scrotal hair. Arch Dermatol. Mar 1984;120(3):299. [Medline].
Noble WC, Savin JA. Trichomycosis of the scrotal hair. Arch Dermatol. Jan 1985;121(1):25. [Medline].
Rosen T, Krawczynska AM, McBride ME, Ellner K. Naftifine treatment of trichomycosis pubis. Int J Dermatol. Sep 1991;30(9):667-9. [Medline].
O'Dell ML. Skin and wound infections: an overview. Am Fam Physician. May 15 1998;57(10):2424-32. [Medline]. [Full Text].
Keywords
trichomycosis pubis, trichomycosis, bacterial infection, hair shaft infection
Contributor Information and Disclosures
Author
Vladimir O Osipov, MD, Assistant Professor, Department of Pathology, Section of Bone and Soft Tissue Pathology, Section of Gastrointestinal Pathology, Medical College of Wisconsin
Vladimir O Osipov, MD is a member of the following medical societies: American Society for Clinical Pathology, College of American Pathologists, and United States and Canadian Academy of Pathology
Disclosure: Nothing to disclose.
Coauthor(s)
Scott M Acker, MD, Associate Professor, Director of Dermatopathology, Departments of Dermatology and Pathology, University of Alabama at Birmingham
Scott M Acker, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society for Clinical Pathology, and Southern Medical Association
Disclosure: Nothing to disclose.
Peter Langenstroer, MD, Associate Professor, Department of Urology, Medical College of Wisconsin
Peter Langenstroer, MD is a member of the following medical societies: American Urological Association
Disclosure: Nothing to disclose.
Milton W Datta, MD, Assistant Professor, Departments of Pathology, Urology, and Hematology-Oncology, Emory University School of Medicine
Milton W Datta, MD is a member of the following medical societies: College of American Pathologists and United States and Canadian Academy of Pathology
Disclosure: Nothing to disclose.
Medical Editor
Daniel Mark Siegel, MD, MS, Director, Procedural Dermatology Fellowship Program, Clinical Professor of Dermatology, Department of Dermatology, State University of New York Downstate
Daniel Mark Siegel, MD, MS is a member of the following medical societies: American Academy of Dermatology, American Academy of Facial Plastic and Reconstructive Surgery, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American College of Physician Executives, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, American Society for MOHS Surgery, and International Society for Dermatologic Surgery
Disclosure: Nothing to disclose.
Pharmacy Editor
Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.
Managing Editor
Lester F Libow, MD, Dermatopathologist, South Texas Dermatopathology Laboratory
Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Texas Medical Association
Disclosure: Nothing to disclose.
CME Editor
Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire Consulting
Chief Editor
Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.
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