Take a deep breath. Congrats, you just inhaled some fungal spores. Depending on your location and the time of year, you might have inhaled a lot of spores. Scientists estimate that about 10 billion of these microscopic organisms enter our respiratory tract each year, and each one has the potential to set up a life-threatening infection in our sinuses, lungs, bloodstream, or even our brain.
Yet, somehow, here we all are. And, if our constitutional health is strong, a fungal infection is extremely unlikely to harm us.
In this column, we will take a close-up look at fungal infections—also called mycoses—with a special emphasis on skin conditions and on Candida auris, a relatively new player in systemic fungal infections that is changing the way some health-care facilities manage patient care.

What Are Fungi?

In the classifications of living things, fungi are unique: they are neither plant nor animal, but their own full kingdom of organisms. Under the heading of fungi, we find molds, yeasts, lichens, mushrooms, and truffles. Molds and yeasts are typically microscopic, but in the right conditions, colonies can quickly grow to be visible and obvious.
While fungi resemble plants in some ways, they are not capable of photosynthesis—they cannot generate energy from sunlight. Instead, they derive nutrition from their local environment. This might happen simply by living on an organic surface without disrupting it, but some fungi can damage their hosts by destroying and invading vulnerable tissues.
Fungi are inescapable. They can colonize virtually any organic surface. They are on (and in) our food, in our soil, suspended in the air, and inside us. They are found on every continent and in every climate. Some are pathogenic and have the potential to cause problems, some are neutral and don’t affect us one way or the other, and some are beneficial to us. For instance, we have colonies of yeasts in our gut that help us derive nutritional components from our food, and they compete with and help balance out our resident gut bacteria, viruses, and other microorganisms. The colonies of fungi in the digestive tract are sometimes referred to as our mycobiome (myco- is the Greek word root for fungus).
Many fungi in our environment are our friends. We might savor a pan of sautéed mushrooms or enjoy an omelet seasoned with precious truffles. Members of the fungi family ferment our alcohol and kombucha, raise our dough, and make chocolate palatable. And, of course, certain bread molds give rise to penicillin, the first effective antibiotic. Fungi break down biodegradable materials, and many have symbiotic relationships with humans and other animals. But some fungi can decimate food crops and put livestock at risk, so the widespread use of strong fungicides has become commonplace. This may have given rise to some unintended consequences in some fungal microorganisms, which we will revisit shortly.

Types of Fungal Infections

In the context of massage therapy and bodywork, fungal infections in humans are important in two contexts: (1) skin infections that are potentially contagious and (2) internal infections that indicate a person may be immune-compromised because of a disease or medication.
The Centers for Disease Control and Prevention (CDC) created a list of many types of fungal infections they are tracking that affect humans, and each of those may have several subtypes and involve multiple species of fungi. The complete CDC watchlist of fungal infections can be found in the “CDC List of Fungal Infections” sidebar. I have chosen five topics from the CDC list for this discussion: aspergillosis, candidiasis, dermatophytosis, onychomycosis, and Candida auris.
Readers may note that the terminology around fungal infections looks complex: the names are long and strongly tied to Greek and Latin word roots. I have explained some of this vocabulary in the video that accompanies this article.

Aspergillosis

Aspergillosis is an infection of the lungs with any of 160 types of aspergillus fungi, but the most virulent is called Aspergillus flavus. These airborne spores cause no symptoms in most people, but in others they trigger respiratory allergies: coughing, wheezing, and shortness of breath that doesn’t respond to typical allergy treatments. And in some patients, especially those with chronic lung diseases (such as sarcoidosis, chronic bronchitis, or emphysema), this kind of infection can lead to the formation of aspergillomas—literally, “fungus balls” that damage tissue in the lungs, interfere with respiration, and make the patient vulnerable to any number of dangerous secondary infections.

Candidiasis

Candidiasis is the overgrowth of one of 20 species of candida; the most common by far is Candida albicans. These microorganisms are found in the digestive, urinary, and genital tracts of men and women. Under normal circumstances, C. albicans does not disrupt digestive function, but if the gut microbiome—including its mycobiome—is disturbed, then candida can become more active. When the imbalance occurs in the mouth or throat, it causes white patches called thrush. If the overgrowth of yeast occurs in a woman’s genital tract, then she may develop a vaginal yeast infection. (Men can develop candidiasis in their urethras, where it is often symptom-free, but communicable.) Candidiasis can cause skin irritation too, with rashes, blistering, and tissue exudate. In advanced cases, the patient may be at risk for candidemia: the pathogenic microorganisms gain access to the bloodstream, and from there they travel to the heart, brain, eyes, and other tissues. This situation is similar to sepsis. It is a system-wide infection that can be life-threatening.

Dermatophytosis

Dermatophytosis describes infections of the skin that may involve a variety of species of fungus. The signature lesion is called tinea: this comes from the Latin term for worm, and gives rise to the common name for this condition, “ringworm.” I am happy to report that there are no actual worms in ringworm; it’s just that people thought it looked like a circular worm was burrowing in the skin. A typical case of ringworm shows a slightly raised, scaly circle on the skin that is pale in the middle (Image 1).
Image 1 shows roughly where the infection began and where the fungi consumed available nutrients, then spread out looking for new territory. Interestingly, this is essentially how mushrooms often grow in the wild: they start with a central clump, and a circle of them grows outward from the middle.
Ringworm is potentially contagious. People can catch it from other mammals (cats, dogs, and horses are frequent carriers) or from each other, or they can spread it from one area of the body to another. It can also be spread through indirect contact: hairbrushes, towels, or shower room floors can help the fungi move from one host to another. That said, it is seldom a serious or threatening condition, unless a person is immune-compromised in some way. Most healthy people can be exposed to these fungi and never develop any lesions at all.
There are several subtypes of cutaneous fungal infections and, because we work so closely with the skin, it is important for massage therapists and bodywork practitioners to be familiar with them.
Tinea corporis (body ringworm). This is the development of the raised, slightly itchy scaly circles on the skin that widen as the fungi spread out in search of new nutrients. It can develop on the trunk or extremities.

Tinea capitis (head ringworm). This involves infections of the scalp that can leave behind scar tissue and permanent patches of baldness. It is seen most often in pre-adolescent children (Image 2).
Tinea pedis (athlete’s foot). This version often leads to itchy, weeping blisters, with a risk of secondary bacterial infection, between the toes (Image 3).
Another form causes more typical ring-shaped lesions on the rest of the foot; this is sometimes called the moccasin distribution. The fungi that cause athlete’s foot thrive in warm, humid conditions (like the insides of athletic shoes), so it can be hard to get rid of this infection without changing footwear. Tinea pedis can also lead to new infections on the hands if a person isn’t careful about hygiene; this is called tinea manuum.
Tinea cruris (jock itch). Jock itch is a fungal infection around the genitalia. It is usually seen in men, since the female version of this is a vaginal yeast infection. It is important to note that the lesions associated with jock itch can be found on the thighs, buttocks, and over the sacrum—this of course has repercussions for bodywork.

Onychomycosis

Onychomycosis refers to fungal infections of the finger- and toenails (Image 4). These lesions can be long-lasting and disfiguring, sometimes leading to the destruction of the whole nail. They are also resistant to many topical treatments.

Candida auris

Candida auris was first documented in 2009 when a doctor found it in a woman’s ear (auris refers to the ears). This aggressive illness can manifest as a skin infection at the site of a wound, or as an internal infection of the respiratory tract, the blood, bones, or other tissues. The earliest known case in the US was in 2013. Now, the CDC has added C. auris to its list of urgent threats, for several reasons: it can cause extreme illness and death, it is highly contagious, it spreads quickly throughout environments, and it is resistant to standard antifungal medications.
As of this writing, C. auris has been reported in New York, New Jersey, and Illinois, where it has caused infections in almost 600 people so far. Smaller outbreaks have been tracked in California, Texas, Florida, and several other states. It is very hard to get rid of, and some hospitals have had to rip out floor tiles, ceiling tiles, ductwork, and plumbing to eradicate the pathogen.
The people most at risk for infection with C. auris are those whose immune systems are compromised: the elderly, newborns, those with diabetes, organ transplant recipients, people with autoimmune diseases, and people using steroidal anti-inflammatories. However, some epidemiologists are concerned that C. auris could continue to gain strength and may become able to impact healthier populations as well—including health-care professionals charged with caring for people infected with this fungus.
C. auris appears to have arisen from multiple sources around the globe, and all at the same time. Some scientists suggest that the aggressive use of fungicides on crops and in livestock has contributed to the evolution of this drug-resistant microorganism.

Treatment for Fungal Infections

Cutaneous fungal infections, like the types of ringworm covered here, are usually sensitive to topical antifungal medications that are applied to the affected areas. More extreme cases, or cases that have infiltrated the lungs or other tissues, need oral medications.
A variety of treatment options have been developed that interfere with cellular replication of the fungi. Many of these options require several weeks of use, and they can have some serious side effects. C. auris has become resistant to some first-line antifungal medications, and may require nontypical treatments or treatment with multiple antifungals simultaneously.

Implications for Massage Therapy

Fungi are everywhere; they are virtually unavoidable. This turns out to be a good thing, since helpful fungi are key players in healthy digestion and other physiological functions. Even when they are out of optimal balance, most fungal infections are not threatening to fundamentally healthy people. Internal infections of the lungs or other organs indicate that the person has compromised immune system function, but in those circumstances, the fungi are unlikely to be transmitted directly from one person to another—they are not directly contagious. This doesn’t preclude the transfer of fungal parasites from surfaces, however. As we saw, this is an important issue with Candida auris.
If a client has a diagnosed fungal infection of the skin (such as a ringworm lesion or athlete’s foot), then we need to observe basic precautions: we avoid the lesion (which should be covered), and we use standard hygienic practices to safeguard ourselves and other clients. If an infection is widespread and not clearly localized, this may mean delaying an appointment until treatment has been successful. We must also take care not to risk spreading a fungal infection from one area of the body to another—this is particularly relevant for athlete’s foot.
Massage therapists who work in hospitals or with very frail clients are likely to see more extreme and potentially threatening fungal infections than those who work in other settings. These infections may involve the lungs or other internal organs, and the skin as well. In this situation, it is important to be aware of what hygienic protocols are being used for the patient—and to communicate any observations about skin health to the health-care team. The CDC emphasizes the importance of excellent hand hygiene in the context of working with patients who may carry fungal infections.
We can’t get away from fungi, nor do we need to. But we do need to create an environment that limits the risk of our clients (or ourselves) going home with new, unwelcome passengers. Fungi are yet another reason to do a “hygiene audit” and examine our standard practices for how we manage our work environment. Do you see any changes you want to make?

CDC List of Fungal Infections

• Aspergillosis
• Blastomycosis
• Candida auris
• Candidiasis
• Cryptococcus gattii
• Cryptococcus neoformans
• Dermatophytosis
(e.g., ringworm)
• Mucormycosis
• Mycetoma
• Onychomycosis
• Pneumocystis jirovecii
• Sporotrichosis
• Talaromycosis
• Valley Fever (Coccidioidomycosis)

Resources

Barter, Devra M., et al. 2019. “Candida Bloodstream Infections Among Persons Who Inject Drugs—Denver Metropolitan Area, Colorado, 2017–2018.” Morbidity and Mortality Weekly Report 68, no. 12: 285–88. https://doi.org/10.15585/mmwr.mm6812a3.
Beach, Emily. 2018. “Fungus Vs. Mold.” Sciencing. www.sciencing.com/fungus-vs-mold-5529716.html.
Centers for Disease Control and Prevention (CDC). 2018a. “Candida auris: A Drug-Resistant Germ That Spreads in Healthcare Facilities.”
www.cdc.gov/fungal/candida-auris/c-auris-drug-resistant.html.
Centers for Disease Control and Prevention (CDC). 2018b. “Infection Prevention and Control for Candida auris. www.cdc.gov/fungal/
candida-auris/c-auris-infection-control.html.
Centers for Disease Control and Prevention (CDC). 2019a. “Aspergillosis.” www.cdc.gov/fungal/diseases/aspergillosis/index.html.
Centers for Disease Control and Prevention (CDC). 2019b. “Tracking Candida auris.” www.cdc.gov/fungal/candida-auris/tracking-c-auris.html.
Hassan, Mohamed I Abdelwahab, and Kerstin Voigt. 2019. “Pathogenicity Patterns of Mucormycosis: Epidemiology, Interaction with Immune Cells and Virulence Factors.” Medical Mycology 57, Suppl 2: S245–56. https://doi.org/10.1093/mmy/myz011.
Lesher, Jack L., Jr. “Tinea Corporis Treatment and Management: Medical Care, Surgical Care, Complications,” 2018. https://emedicine.medscape.com/article/1091473-treatment.
Mole, Beth. 2017. “We Inhale up to 10 Billion Mold Spores Daily; Here’s Why You Haven’t Died Yet.” Ars Technica. www.arstechnica.com/science/2017/09/moldy-mayhem-can-follow-floods-hurricanes-heres-why-you-likely-wont-die.
Richtel, Matt, and Andrew Jacobs. 2019. “A Mysterious Infection, Spanning the Globe in a Climate of Secrecy.” New York Times, April 9, 2019, sec. Health. www.nytimes.com/2019/04/06/health/drug-resistant-candida-auris.html.
Sam, Qi Hui, et al. 2017. “The Fungal Mycobiome and Its Interaction with Gut Bacteria in the Host.” International Journal of Molecular Sciences 18, no. 2. https://doi.org/10.3390/ijms18020330.
Seladi-Schulman, Jill. 2018. “Candida Albicans: Infections, Symptoms, and Treatments.” Medical News Today. www.medicalnewstoday.com/articles/322722.php.