Use of In-Office Preparations by Dermatologists for the Diagnosis of Cutaneous Fungal Infections

August 2019 | Volume 18 | Issue 8 | Original Article | 798 | Copyright © August 2019

Emily C. Murphy BSa,b and Adam J. Friedman MDa

aThe George Washington School of Medicine and Health Sciences, Washington, DC bGeorgetown University, School of Medicine, Washington, DC

Cutaneous fungal infections account for millions of office visits per year, yet their varied presentations often lead to misdiagnosis. If dermatology clinics are Clinical Laboratory Improvement Amendment (CLIA) certified, direct microscopy with potassium hydroxide or other stains can be used to inexpensively and rapidly diagnose fungal infections. In this survey, we examined dermatologists’ perceptions of fungal preparations and CLIA certification to identify barriers that prevent the use of these bedside diagnostics. The response rate was 13% (n=308, based on the number of emails opened). When a cutaneous fungal infection is suspected, 20.94% rarely/never and 19.86% sometimes perform fungal preparations, often because they think clinical diagnosis is adequate or that preparations take too long. 21.32% reported not having CLIA certification, most frequently because the process requires too much work, or they do not know how to apply. Of providers with CLIA certification, over 25% thought it was difficult to obtain. Our results demonstrate that numerous barriers prevent the common use of fungal preparations, including the perception that clinical diagnosis is sufficient and the lack of required CLIA certification. These barriers emphasize the need for additional education about cutaneous fungal infections and use of bedside diagnostics. Additionally, policy-based interventions are necessary to ease the process of CLIA certification.

J Drugs Dermatol. 2019;18(8):798-802.


Cutaneous fungal infections account for 3.5 to 6.5 million office visits per year1 – despite being common, their diverse presentations frequently lead to misdiagnosis.2,3 In one study, only 4 out of 13 dermatophytosis cases presented were accurately identified by more than 75% of board-certified dermatologists.4 In addition, other conditions can mimic fungal infections, such as mycosis fungoides5 or inflammatory diseases including annular psoriasis, secondary syphilis, and pityriasis rosea.4

Given the many presentations of fungal infections and mimicking diseases, in-office tests are useful to facilitate the diagnosis of cutaneous fungal infections. Direct microscopy using potassium hydroxide (KOH) or other stains is a rapid, inexpensive method to diagnose fungal infections,3 however, it requires clinics to have Clinical Laboratory Improvement Amendment (CLIA) certification.6 Specifically, dermatology clinics must apply for a certificate of Provider-Performed Microscopy Procedures to perform KOH preparations and other waived tests, such as urine pregnancy tests.6 Other confirmatory tests for fungal infections are more expensive and require send out cultures that can take days to weeks, and still may not provide a diagnosis.7,8 Despite the importance of bedside fungal preparations, dermatologists’ attitudes towards and utilization of these tests are unknown. This survey study examined dermatologists’ perceptions of fungal preparations and identified barriers preventing their use.


An IRB-approved survey was disseminated to the Orlando Dermatology Aesthetic and Clinical Conference email list and the data was collected via an internet-based platform. The survey was composed of 18 multiple choice questions and 1 free response question on demographics (Table 1) as well as fungal preparation practices and CLIA certification (Table 2). Before data collection, the survey was reviewed by 10 dermatologists and design suggestions were incorporated into the final survey. Statistical analysis was done using GraphPad Prism, version 7.0 (GraphPad Software Inc.). Survey answers were compared by frequency of fungal preparation performance, practice type (academic versus non-academic practices), and experience level (in residency versus out of residency) using chi-square tests. A P-value less than or equal to 0.05 was considered statistically significant.