project on anatomy of foot & skin

7/31/2019 Project on Anatomy of Foot & Skin

1/29

ATHLETES FOOT (TENIA

PEDIS)

A Project work submitted to

Hemwati Nandan Bahyguna Garhwal University,

Srinagar (U.K.)

In Partial Fulfillment of the Requirement for the

Bachelor of Physiotherapy

Under the guidance of

DR. P. NANDITA, PTMPT (Sports)

By

Aprana AgarwalDepartment of Physiotherapy


2/29

Shri Guru Ram Rai Institute of Medical Health &

Sciences, Patel Nagar, Dehradun- 248001

(2006-2010)


3/29

DECLARATION BY THE CANDIDATE

I hereby declare that the project entitled

Atheletes Foot (Tinea Pedis) embodies the work

done by me at Shri Ram Rai Institute of Medical

Health and Sciences, Patel Nagar Dehradun. This work

in part or full has not been submitted to any other

university.

(Aprana Agarwal)

(BPT IV year)


4/29

CERTIFICATE BY THE GUIDE

This is to certify that the project work entitled

Athletes Foot (Tinea Pedis) submitted by Aprana

Agarwal in partial fulfillment of the requirements for

the award of degree of Bachelor of Physiotherapy of the

Hemwati Nandan Bahuguna University, Srinagar

(Garhwal), is a bonafide work carried out by her under

my supervision and guidance during the academic year

2006-2010. Neither this project nor the part of it has

been submitted for any degree or diploma.

(Signature of Guide)

Dr. P. Nandita, PT

M.P.T. (Sports)

Place:

Date:


5/29

ENDORSEMENT BY THE HEAD OF THE

DEPARTMENT

This is to certify that the project entitled Athletes

Foot (Tinea Pedis) bonafied project work done by

Aprana Agarwal under the guidance of Dr. P. Nandita

PT, MPT (Sports) in the partial fulfillment of

requirement for the degree of bachelor of

Physiotherapy.

(Seal and Signature of HOI)

DR. TARANG SRIVASTAVA, PT

M.P.T. (Ortho)

Head of Department of Physiotherapy

SGRRIMHS of SMI Hospital Patel Nagar,

Dehradun (U.K.)

Place:Date:


6/29

CERTIFICATE BY THE EXAMINER

This is to certify that the project entitled Athletes

Foot (Tinea Pedis) submitted by Aprana Agarwal in

partial fulfillment of the requirements for the award of

degree of bachelor of Physiotherapy of Hemwati

Nandan Bahuguna Garhwal University, Srinagar(Garhwal) has been thoroughly examined and approved

by us.

Accepted/Not accepted

(Sign. of Internal Examiner) (Sign. Of External Examiner)

Place:

Date:


7/29

Copyright

DECLARATION BY THE CANDIDATE

I hereby declare that HNB Garhwal University,

Srinagar (Uttrakhand) shall have the rights to preserve,

use and disseminate this project in print or electronicformat for academic/research purpose.

Date: Aprana AgarwalPlace: Dehradun (BPT IV year)

HNB Garhwal University, Srinagar Garhwal (Uttrakhand)


8/29

DEDICATED TO


9/29

Acknowledgement

It gives me immense pleasure and satisfaction to place on

record my sincere thanks and appreciation with respect andregards for an adorable person, Dr. P. Nandita PT, NPT

(Sports), Department of Physiotherapy, SGRR Institute of

Medical Health and Sciences, Dehradun (U.K.), as it was her

blessings, guidance, valuable suggestions and constant

encouragement which helped me to greatly ease the task of

completing this project a reality.

I seek to express my indebted to the all teaching and non-teaching members of the department for their support and

assistance in any way during the work. I would like to thanks

Chirman Shri Mahant Devendra Das Ji Maharaj for

providing al the facilities to carry out the project work.

I also want to express my thanks to Principal Dr. J.B. Gogoi

for their support during the work.

Words fall short to express my gratitude to my father,

mother, brothers and friends whose inspiration, everlasting

moral support and love always elevated my confidence

during the work.


10/29

CONTENTS

Page No.

Declaration by the Candidate iiCertificate (Guide) iii

Endorsement by the HOD iv

Certificate (Examiner) v

Copyright vi

Dedication vii

Acknowledgement viii

Chapters

1. Introduction 12. Anatomy

3. Pathogen

4. Pathogenesis

5. Aetiology

6. Types of Tinea Pedis

7. Clinical Features

8. Risk Factors9. Investigations

10. Differential Diagnosis

11. Diagnosis

12. Treatment

13. Discussion

14. Conclusion

15. References


11/29

INTRODUCTION OF TINEA PEDISAthletes foot (also plus ringworm of the foot and Tinea Pedis) is a fungal

infection of the skin that causes scaling, flaking and itch of affected areas.

Although the condition typically affects the feet, it can spread to other areas ofthe body including the grain.

In fact, its so common that most people will have at least one episode at lead

once in their lives.

Its less often found in women and children under age 12.

Because the fungi grow well in worm, damp areas, they flourish in and around

swimming pools, showers and locker rooms.

Tinea Pedis got its common name because the infection was common among

athletes who often used these areas-

Carol A Tarkington

Synonyms :- Tinea Pedies, foot ringworm, Ringworm, Athletes foot

Tinea Pedis is used the most common form of ringworm in the UK and USA

and is usually caused by anthropophilie fungi such as Trichophyton rubrum,

T. mentagrophytes and Epidermophyton flouovem (Davidson).

These three species of fungi are together responsible for the vast majority of

cases of tinea pedis through out the world.

Trichophyton rubrum is the mostcommon pathogen associatd with

chronic tinea pedis, while other fungal pathogens have also been

associated with the disorder.

The factors affecting the transmission of these dermatophytic pathogens

are dependent on the source of inflation which is usually either human

(anthropophillic), animal (zoophilic) or Soil (geophilic).

Athletes foot spread into the American English vocabulary in a 1928

issue of literary digest: Athlete foot.. is a popular name for


12/29

ringworm of the foot, from which more than ten million persons in the

United States are now suffering.

The association of athletes and this variety of ringworm had to wait

until the twentieth century, when Americans, including athletes finallybegan to take a serious interest in hygiene. Occasional baths had been

the limits of American cleanliness in previous centuries.

Now, not only did athletes have running water in their locker rooms

(itself a term of the first dude of the 20 th Century), they had communal

showers. Floors in the locker room environment are usually wet,

making ideal conditions for lurking fungi.

In fact, medical authorities say, the association with athletes is

unfounded. Most people already carry the fungi, one recent estimate is

that 70 percent of the population may be affected to one degree or

another.

The little organisms thrives in moist and airless environments like that

created by wet feet in shoes. If the skin between the toes is kept healthy

and dry, we rarely have problems with athletes foot.

How do you catch tinea pedis People often caqtch tinea pedis by

walking barefoot where there are fragments of skin or nail shed by an

influted person. This most commonly occurs around swimming pools

and public showers. It can also be picked up in showers at home.

If tinea pedis is not treated or is particularly bad sometimes the nails

can also become influted. This causes them to become chalky and

thickened.

Athletes foot can be treated but it can be tenacious and different to

clear up completely.

Athletes foot can be prevented by good hygiene, and is treated by a

number of pharmaceutical and other treatments.


13/29

ANATOMY OF FOOT & SKIN

FOOT:

The foot is the region of the lower limb distal to the ankle joint. It is

subdivided into the ankle, the meta-travels & the digits.There are five digits consisting of the medially positioned great toe (digit I)

and four more laterally placed digit, ending laterally with the little toe (digitV)

The foot has a superior surface (dorsum of foot) and an inferior surface

(soles).

BONES:

There are three groups of bones in the foot:-

The seven tarsal bones which from the skeletal framework for the

ankle. Meta farsals ( I to V) which are the bones of the metatarsus.

The phalanges which are the bones of the toes-each toe has three

phalanges, except for the great toe, which has two-

o Proximal Group:-

It contains Talus: It is the superior bone of the foot. It articulates

with the tibia & fibula to form the ankle it.

o Callaneus: it is largest of tarsal bone. It articulate with one of the

distol group of tarsal bones.o Intermediate:

o Navicular: It is boat shaped. This bone articulates behind with the

talus and articulates in front & on the lateral side with the distol

group of tarsal bones.

o Distal Group:-

o Cuboid: Articulates behind with the caleaneus & in front with the

base of lateral two metatarsals.

o

Cuneiform: Lateral, medial & intermediate cuneiform bonearticulates with naucular bone & in front with bases of medial

three metatarsal.

o Metatarsals: There are five metatarsals in the foot, numbered I to

V from medial to lateral.


14/29

Each metatarsal has a head at the distal end, an elongate shaft in

the middle & a pronimal base.

The head of each metatarsals articulates with the pronimal

phalamn of a toe and the base articulates with one or more of the

distal group of tarsal bones. Plantar surface of the head ofmetatarsal I also articulates with two lesamoid bones.

PHALANGES:

Are the bones of the toes. Each toe has three phalanges (Pronimal,

middle and distal) except for great toe which has only two (proximal & distal)

I. Appendix of skin:

a. Nails are hardened keratin plates on the dorsal surface of the lips of

fingers & toes.

b. Hairsc. Sweat glands

d. Sebaceous gland

Function of skin:

Protection

Sensory

Regulation of body temp

Absorption

Sevelion Regulation of pH

Synthesis

Repair alive

II. Superfival fascia: It is general coating of the body beneath the skin,

made up of loose areola tissue with varying amounts of fat.

III. Deep fascia: is a fibrous sheet which invents the body beneath the

superfavial fascia. It is devoid of fat & is usually inelastic & touch.

SKINIt is the general covering of the entire internal surface of the body.

The colour of the skin is determined by at least five pigments present at

different levels and places of the skin. There are-

1. Melanin: brown in clour.

2. Melanoid : resembles melanin


15/29

3. Carotene : yellow to orange in colour

4. Hemoglobin : Purple

5. Oxyhalmoglobin : Red

Thickness : The thickness of skin various from about 0.5 to 3 mm.

Structure of Skin:Skin is composed of two distinct layers, epidermis & dermis.

(A)Epidermis: It is the superficial, a vascular layer of stratified squamous

epithelium. It is ectodermal in origin and gives rise to the appendages

of the skin, namely hair, nails, sweat glands and sebaceous gland.

*Structurally, the epidermis is made up of

Superficial cornfield zone.

A deep germinative zone

The cornfield zone includes three strata of cells namely - Stratum corneum

Lucidum

granulosum

The Germinative zone inclues two strata-

Stratum Spinosum

basale (Stratum germinatium or malpighion layer) of a

single layer of columnar cells).

(B)Dermis or Corium: It is the deep, vascular layer of the skin, derivedfrom mesoderm, it is made up of connective tissue mined with blood

vessels, lymphaties and nerves.

The connective tissue is arranged into a superfivial papinary layer and a

deep reticular layer.

Synovial shealb in the ankle region:-

The tendons that cross the ankle joint are all deflated to some degree

from a straipht course, and must therefore be hold down by retinacula

and enclosed in synowal shealths.Plantas fascia: or aponeurosis is compound of densely con-paited collegen

fibres oriented mainly lorfiludinally, but also transversely. It have three parts=

(1)Central Part:- It is attached to the medial process of the caleaneal

tuberovity. It becomes broader and somewhat timers as it diverges

towards the metatarsal heads.


16/29

(2)Lacteal part:- It forms a stronger band, sometimes containing nurell

fibers.

(3)Medial part:- It is continuous pronumally with the plen retin acleem.

Foxial Compartment of the foot:

There are four main compartments of the plants aspect of the foot (Jones1949) (Fog 115.7).

Medial Compartment

Central Compartment

Lateral Compartment

Interossous Compartment

Muscular of the sole of foot:

It have been divided into four layers:

Plants muscular of foot (first layer) Abductor nalluis: Abdwlion of xallure

Flenor degelorum breuis: flexes the lesser tol

Abdutos digiti mimimi: it is more a plenor of the little toe metatarso

phalangeal joint than an abduetor.

Pto Second layer: Intermsus numerals

Flexon diglorum layers

Flexon halluis layer

Hlenos dijitorum ouessoriusLumbrual muscles:

Entension of the interphalangeal joint of toes there are four muscle numbered

from medal to lateral:

Planfor third layer :

Hlexor Halluis breuis: flexes the pronemal phalamx of the halluse

Addiction halluis: partly flexes the pronemal phalamx of the halluse but also

stabeleres the metaforsal heads.

Flenon digiti mimimi breuis : flenes the M7PJt of little toePlantas fourth layer:

Dassal Interossei: Flex M7PJt & entend the JPJt of lesse toes the

hallum & little toe have their own abdutos.

Plantar interossei: Adduit the 3 & 4, J toes, flex the M7PJy & extend

the JPJt.


17/29

Tibialis pusterion

Peroneur lonyus


18/29

PATHOGENS

There are three species of fungi:

1. Trichophyton Rubrum

2. Trichophyton mentagropfytes

3. Epidermophyron flousoum

There are together responsible for the vast majority of cases of tinea pedis

through out the world.

1. T. rubrum: A recent study showed that T. rubrum accounted for over

76% of all dermatophite infections including tinea pedis and may

account for over 213 of all tinea pedis infections.

It appears in two forms:

a. The first is typically white and fluffy in appearance with several

aerial hypae and is called the downy form.

b. The second is granular form, however & flat and has no acuial

hyphae.

T.Rubrum not always, wine colored on the bottom.

2. T. mentaqrophytes: is morphologically and characteristically similar to

T. rubrum. Both have a downy or granular appearance and are

sometimes indistinguishable under the microscope.

T. Mentaqrophytes species can be pale yellow on the underside.

3. Epidermophyton flouosum: is an anthrophilic fungus found worldwide

and has been ineriminated in several types of tinea inflections.

Colonies of this fungus are flat and grainy and range in colour from

yellow to brown.


19/29

PATHOGENESIS

T. Rubrum, T. Mentagrophytes, Epidermophyton flououm most

commonly cause tinea pedis, with T. rubrum being the most common

cause world wide.

Trihopyton tonsurans has also been implicated in children.

Nondermatophyte causes include seytalidim dimidiatum, scytalidium

hyalinum an merely, candida species.

Using enymes called keratinases, dermatophyte fungi include the

superfinial keratin of the skin and the infection remains limited to this

layer. Dermatophyte cell walls also contains manners that may reduce

keratinoyte proliferation, hesulting in a decreased rate of sloughing anda chronic state of infection.

Temperature and serum factors, such as beta globulins and ferritin,

appear to have a growth inhibitory effect on dermatophytes; however

this patho genesis is not completely understood. Sebum also is

inhibitory,thus partly explaining the propensity for dermatophte

inflation of the feet, which have no sebaueous glands. Host factors such

as breaks in the skin and maceration of the skin may aid in

dermatophate incasion.

The cutaneous presentation of tinea pedis is also dependent on the

hosts immune system and the infecting dermatophyte.


20/29

AETIOLOGY

Athletes foot is caused by a fungal infection of either one, or both of

your feet. All have bacteria and fungi on skin, most of which are

harmless. However, in some conditions, these organisms can multiply

and cause skin to become infected.

Athlete foot is caused by a group of fungi dermatophytes. These fungi

are parasitic, which means they feed off other organisms to stay alive.

Feet provide a warm, dark and humid environment, which are the ideal

conditions needed for dermatophyte to grow.

Mostly athletes foot is caused by one of two of types of fungus.

Truchophton mentagrophytes:- Often cause toe web or vericular

infection.

Trichophyton rubrum:- often causes moccasin type inflections. Thiscondition lasts for a long time (Chronic) and is difficult to treat.

Athlete foot when come in contact with the fungus, it begins to grow

on skin. Fungi commonly grow on or in the top layer of human skin

and may or may not cause infections.

Athlete foot is easily spread (containers):- we get it by touching the

affected area of a person who have it. More commonly, pick up the

fungi; from damp, contaminated surfaces, such as the floors in

public showers or locker rooms. Although athletes foot is contagious, some people are likely to get it

(susceptible) than others.

Susceptibility may increase with age. Experts dont know why some

people are more likely to get it. After athletes foot, people are more

likely to get it again.

After coming in contact with the fungi that cause athlete foot have

the channel of spreading the fungi to others, whether you get the

infection or not.Additional causes include irritant or contact dermatitis, allergic

rashes from shoes or other creams, dyshidrotic eczema (skin allergy

rash), psoriasis, keratodermie blenorrhagium, yeast inflections and

bacterial infections.


21/29

TYPES OF TINEA PEDIS (FIGURES)

Depending on the pathogen and anatomical distribution, tinea pedis may

present in a given patient as one of several syndromes. Typically, three

variants are seen and include the interdigital, Bilateral moccasin and

vericobullous forms of the disease.

(1) Interdigital Tinea Pedis:- It is the most common form and usually

manifests in the inter space of the fourth and fifth digits and may spread to

the undervide of the toes (figure 1) (4,8) Patient complains of itching and

burning sensations on the feet auompainted by malodor. T. melagrophytes

are mainly isolated with this. There are generally two types of interdigital

tinea pedis:-

a. Moccasin type tinea pedis: It is a more severe, prolonged form oftinea pedis that covers the bottom and lateral aspects of the foot. Its

appearance is that of a slipper or moccasin covering the foot. T.

rubrum is most commonly associated with this 2A gif shows

xyperkerototc skin on the medial

(2) Vesiculabullous tinea pedis: Comprises pustules or vesicles on the instep

and adjunct planter surfaces of the feet and is less common.


22/29

CLINICAL FEATURES

Chronic kyperkeratotic refers to patehy fine dry scaling on the sole

of the feet.

Moccasin tinea is entensive hyperkeratotic tinea: in which skin of

the entire sole, heal and sides of the foot is dry but not inflamed.

Athletes foot is most peeling irritable skin between the toes, most

often in the cleft between the fourth & fifth does.

Clusters of blisters or pustules on the sides of the feet or insteps

(more likely with T interdigitale)

Round dry patches on the top of the foot (ringworm like tineacorporals)

Ringworm

Jock itch

Dryness

Itching

Burning

Scaling

Gauked skin

Nail infection


23/29

RISK FACTORS

Risk of getting athlete foot increase if, by mayo clinic staff.

Are a man

Frequently wear damp socks re light filling shoes.

Wear closed shoes, especially if they are plastic lined.

Share mats, rugs, bed linens, clothes, shoes with someone who has a

fungal infection.

Sweat a lot.

Develop a menor skin or nail injury.

Frequently visit public areas where the infection can spread such as

locker rooms, saunad, swimming pools, communal baths & showers.

Have a weakened immune system.

Reference:

Nov. 22, 2008

1998-2010 Mayo foundation for medical education & research (MEMER)

Mayo Clinic, :Mayo Clinic.com.


24/29

INVESTIGATION

Physician can perform a simple test called a KOH, or potassium

hydroxide for microscope fungal-examination, in the office or

laboratory to confirm the presence of a fungal infection. This test isperformed using small flakes of skin that are examined under the

microscope. Many dermatologists perform this test in their office

with results available within minutes. Rarely, a small piece of skin

may be removed and sent for biopsy to help confirm the diagnosis.


25/29

DIFFERENTIAL DIAGNOSIS Psoriasis

Contact dermatitis

Dyshidrotic ecrema

Scabis Pithed kerololysis

Eczema

Erythema

Diabetes

Gout

Ingrown toe nail

Clelluclies

Phleliutes

Asteomy eliteb

Paronyehia

Pseudogoul

Psoriasis : It is a non-infectious, chronic inflammatory disease of the skin,

characterized by well defined erythematous plagues with slvery scale.

Contact Dermatitis:- Inflammation of skin caused by numerous condition

including contact with skin irritants. Marked by itching and redness.

Scabis:- A contagious infection of the skin with he itch mite, sarcoptes

scabiei. It typically presents as an intensely prurtic rash, composed of scaly

papules and secondarily infected lesion distributed in the webs between the

fingers.

Eczema :- It is an itchy red rash may result from various causes including

allergies, irritating chemicals, drys or rubbing the skin, sun exposure.

Dyshedrotic & Pompholyx

Erythema:- Reddening of the skin. It is a common but non specifc sign of

skin urrelalion, injury or inflammation.

Clelluclies :- A spreading bacterial infection of the skin, caused by

strephocoual or staphylocoual infections, result in severe information with

eryhema, warmth and localized edema.


26/29

Phlebitis: - Inflammation of vein caused by chemical or mechanical

irritation of veins by thrombosis, indwelling catheter or venous infections vein

may be painful, tender, red or swollen.

Paronyehia:- Bacterial infection of the posterior nail folds.

Irgrown nail:- Causes severe pain in the distal nail folds with associated

erythema, edema and tenderness.

Gout:- Monosodium urate bustal deposition secondary to hypercurillmia

Severe pain, redness and swelling occurring in one joint usually of the lower

intermity, and mainly MJP joint of great toe (Podagra).

Pseudogout:- Calcium pyrophosphate deposition disease can affect the

toe, but the knee is most common.

Osteomyelitis:- Infection of the bone by micro-organism it is also used for

infection of the bone by pyogenic organism.

Diabetes


27/29

DIAGNOSIS

Diagnosis of tenia pedis is based on history and clinical appearance of the feet

in addition to direct microscopy of a potassium hydroxide (KOX) preparation.

Cultures or histological examinations are rarely required.

A woods lamp is not usually helpful in diagnosing tinea Pedis but can be

used to rule out other diagnosis like infection with Malasseria furfur (1) or

ertthrasma.

Malasseria furfur and corynebaiterium minutissimum both fluoresce under

ultraviolet light while other common dermatophytes do not.

KOX preparations are simple, inexpensive, efficient and widely used.

KOX preparation has an excellent positive predictive value.

Occasionally, false negative results may be obtained, especially if treatment

has already begun.

DIAGNOSTIC TEST INCLUDE:

A CBC

Sedimentation rate

Chemistry Panel

VDRL test

X-ray of foot

If peripheral pulses are diminished, Doppler studies and angiography

should be considered.

If there is diffuse swelling and erythema: venography may need to be

done.

If there are neurologic findings: nerve condition velocity studies and

EMGs (electromyograms) may be helpful.


28/29

PESTS

CONTROLA Project work submitted to

RAM LUBHAI SAHANI GOVT. MAHILA

MAHA VIDHYALAYA (PILIBHIT)

In Partial Fulfillment of the Requirement for the

Bachelor of Science (ZOOLOGY)

By

MAHIMA SAXENAB.Sc. (Final) Zoology


29/29

Affiliated to M.J.P. Rohilkhand University, Bareilly

project on anatomy of foot & skin

Documents