Tinea

Latest update 06/10/2010

This chapter is set out as follows:

• Introduction
• Tinea unguium (syn. onychomycosis) - nails
• Tinea pedis – feet
• Tinea manuum – hands
• Tinea cruris - groin
• Tinea corporis – body
• Tinea faciei – face
• Tinea barbae – beard
• Tinea capitis – scalp
• Tinea incognito (steroid exacerbated)

Introduction

• Tinea is a common fungal infection caused by a dermatophyte (syn. ringworm)
• Depending on the host on which they survive they are defined as either:
  • Anthropophilic – human host
  • Zoophilic – animal host
  • Geophilic – live in the soil
• Most infections are anthropopilic i.e. passed from human to human. Zoophilic species can occasionally infect humans and tend to cause a more vigorous inflammatory reaction
• There are three genera of derma tophytes – Trichophyton, Microsporum and Epidermophyton
• The most common organism in the UK is Trichophyton rubrum
• Tinea should be part of the differential diagnosis of any rash that is asymmetrical and/or has a leading edge, which is erythematous and scaly

Tinea unguium

• Refers to involvement of the nails
• Clinical features
  • Toenails > fingernails
  • May be asymmetrical, but not always
  • May be associated with interdigital infection, especially the 4th web space, which can be dry and scaly or white, maceated and malodorous
  • In most cases the nail thickens and turns yellow. If the infection starts distally the nail plate can be seen to crumble
  • With superficial involvement the nail surface becomes white and powdery
  • Exclude skin diseases that may cause similar nail changes e.g. psoriasis by taking a good history and examining the whole of skin
• Psoriasis may co-exist with fungal infection, as may any dystrophic conditi on
• Investigations
  • Infection should be confirmed prior to treatment
  • In order to prevent high rates of false negative results it is important to the cut the nail back and remove the subungual debris by careful curettage or by using a scalpel blade, and sending all of the specimen for mycology
• Treatment
  • Treatment is not always indicated
  • Topical treatments – these have a low cure rate but may be suitable for treating distal nail infection (as opposed to involvement of the nail matrix) or superficial white infection. Options include Tioconazole ® nail solution BD for 6-12 months or Loceryl ® nail lacquer 1-2 times per week for 3-6 months for finger nails, 6-12 months for toenails. Nails should be filed / cut back as much as possible prior to applying the treatment
  • Systemic treatment in adults – Lamisil ® (terbinafine) is the most effective treatment with eradication rates of 69% against 48% for Sporanox ® (Itraconazole). Lamisil 250mg OD should be given for 6 weeks for fingernails and 3-4 months for toenails. If the patient is unable to take Lamisil or the tinea appears resistant to treatment then Sporanox ® (Itraconazole) can be considered. Sporanox can be used as pulse therapy - 400mg OD for one week out of 4 (one cycle), 3-4 cycles will be needs for toe nail involvement, 2 cycles for finger nails. Treatment success is denoted by the continued growth of new, healthy proximal nail. Once treatment is complete it can still takes a number of months for any previously affected nail to fully grow out
  • Recurrent episodes – may be due to tinea pedis, in which case once the infection has been eradicated it is worth considering the use of terbinafine cream once to twice a week to the feet (including interdigital spaces) to try and prevent recurrence
• Treatment in children
  • Lamisil ® for 6-12 weeks (weight > 40 kg use 250 mg OD; weight 20-40 kg use 125 mg OD; weight up to 20kg use 62.5 mg o.d.). Lamisil is 'off-license' in children but is listed in the children's BNF
  • Griseofulvin 10 mg/kg up to a dose of 1000 mg daily, for a year or more, with food

	Figure 1 – Tinea unguium Yellow, thickened nails
	Figure 2 – Tinea unguium
	Figure 3 – Tinea unguium Close up showing marked subungual hyperkeratosis
	Figure 4 – Superficial tinea unguium with whitening
	Figure 5 – Tinea unguium of fingernails  Additional involvement of right forearm (arrow)
	Figure 6 – Tinea unguium and recurrent cellulitis (resolving) This patient had developed recurrent episodes of cellulitis with unilateral, ascending, tender erythema of the left lower leg - by the time the patient was seen in clinic the cellulitis had almost settled Patients with cellulitis should have a thorough inspection of the skin of the lower legs including the feet and nails. The presence of tinea can act as a route in for the bacterial infection causing cellulitis. Nail mycology was positive for tinea and the patient was treated with systemic Lamisil
	Figure 7 – Tinea unguium with a bullous reaction Several old blisters can be seen along the lateral margins of the foot and forefoot. The arrow points to the fine white scale of the tinea. Mycology of scrapings taken from the scale confirmed the diagnosis

Tinea pedis

• Refers to infection on feet, which can be general, interdigital or both
  
• Clinical features
  • Interdigital involvement can affect any web space, especially the 4th web space. Findings vary from dry and and scaly or to white, maceated and malodorous
  • Erythema and scaling of the foot. The scale is most prominent at the edge of the rash and in the skin creases
  • On occasions tinea pedis can cause a bullous reaction
• Diagnosis can be confirmed by sending adequate scale for mycology
• Treatment - for interdigital involvement or fine scaling consider Canestan ® or Daktarin ® cream as first line. For more significant inflammation consider Lamisil ® cream. Topical treatments need to involve the soles of the feet as well as the interdigital spaces and should be contiuned with for two weeks after the rash has settled. Systemic treatment should be used if there is co-existent nail involvement in which case treat as per tinea unguium
• Recurrence are common and patients need to be advised to keep feet well aerated by wearing breathable footware and leaving shoes off around the home. Prophylactic treatment with topical antifungals used once to twice a week can help

	Figure 8 – Tinea pedis Fine scaling, especially of the creases. Patient treated with Canestan cream
	Figure 9 – Tinea pedis Scale and well-defined erythema, which has a clear margin. Nails also involved and so patient was treated with systemic Lamisil as per tinea unguium
	Figure 10 – Interdigital involvement Interdigital spaces can be affected by several organisms at once, including both tinea and candida. Patient treated with Canestan cream (copied with kind permission from Dermatoweb)

Tinea manuum

• Refers to any involvement of the hands
• Clinical features – red and/or scaly areas. Involvement of the creases gives the impression that the patient has been decorating with white paint
• ‘Two foot, one hand’ disease is the name given to a common pattern of infection where both feet and only one hand is infected. Always examine hands and feet
• Treatment is with a topical antifungal agent (Daktarin, Canestan or Lamisil BD), which should be continued with for two weeks after the infection has cleared. Systemic treatment should be used if there is co-existent nail involvement in which case treat as per tinea unguium

Figure 11 – Tinea manuum Fine scaling of palmar creases

Tinea cruris

• Tinea cruris refers to involvement of the groin
• Men are affected more than women
• Clinical features include erythema and scale with annular borders. The features are most pronounced at the edge of the rash
• It is commonly bilateral
• Treatment is normally with a topical antifungal agent, which should be continued with for two weeks after the infection has cleared. If the rash is very extensive or inflammatory (pustules present) treat systemically with Lamisil ® 250mg OD for 2 weeks
• The feet can act as the source of infection and so should be examined and treated if they are involved

Figure 12 – Tinea cruris Treated with topical anti-fungals

Tinea corporis

• Tinea corporis refers to ringworm of the body
• Clinical features – large red scaly lesions with raised scaly borders. Lesions are often multiple and can be itchy. Occasionally small pustules may be present
• Scrapings for mycology should be taken from the advancing scaly edge of the lesion
• Treatment is normally with a topical antifungal agent, which should be continued with for two weeks after the infection has cleared. If the rash is very extensive or inflammatory (pustules present) treat systemically with Lamisil ® for 2 weeks

	Figure 13 – Tinea corporis Features most prominant at the periphery (copied with kind permission from Dermatoweb)
	Figure 14 – Tinea corporis, close up (copied with kind permission from Dermatoweb)
	Figure 15 – Extensive tinea corporis Given the extensive nature of the rash the patient was treated systemically with Lamisil ®

Tinea faciei

• Fungal infection of the face is often overlooked as a possible diagnosis
• Clinical features are as above although scaling may be absent in some cases – an asymmetrical rash should raise the index of suspicion
• Treatment is normally with a topical antifungal agent, which should be continued with for two weeks after the infection has cleared. If the rash is very extensive or inflammatory (pustules present) treat systemically with Lamisil ® for 2 weeks

	Figure 16 – Tinea faciei Extensive and asymmetrical involvement of the right side of the face. Top arrow denotes involvement of upper eyelid. Bottom arrow denotes the medial margin of the rash
	Figure 17 - Tinea faciei Left cheek
	Figure 18 – Tinea of the elbow Brother of patient in figure 15 above. Always ask if other family members are affected

Tinea barbae

• Fungal infections occasionally affect the beard / moustache areas
• Clinical features
  • Often presents with marked inflammation and aggregated pustules, exudation and crusting. Affected hairs tend to come away quite easily. It is frequently misdiagnosed as a bacterial infection although it may be distinguished from boils secondary to bacteria by the relative lack of pain and the ease with which the hairs come away
  • Milder cases need to be differentiated from bacterial folliculitis, pseudofolliculitis, acne or rosacea
• Investigations – the presence of Staph. aureus on a swab does not exclude tinea as bacterial colonisation or infection may occur as a secondary event. Scrapings and affected hairs should be sent for mycology – false negative results are not uncommon
• Treatment with a systemic agent (normally Lamisil ®) is needed, sometimes for several weeks

Figure 19 – Tinea barbae Inflammed papules and pustules

Tinea capitis

• Most common in young children
• Various clinical presentations
  • A circumscribed patch of alopecia (sometimes can have multiple patches) with a few broken-off hairs, scaling may not be obvious. In the majority of cases inflammation is minimal. Broken-off hairs need to be distinguished from the exclamation-mark hairs of alopecia areata
  • Fine scaling without alopecia
  • A painful inflammatory mass of tissue with crusting, known as a kerion, usually caused by animal ringworm
• Investigations – both skin scrapings and a plucked hair follicle should be sent for mycology. An alternative way of obtaining a sample is by using a disposable plastic tooth brush (if you are going to use this method then first discuss with microbiology)
• Treatment of affected individuals – due to the risk of scaring alopecia treatment is usually with a with systemic agents, normally Lamisil (weight > 40 kg use 250 mg OD; weight 20-40 kg use 125 mg OD; weight up to 20 kg use 62.5 mg o.d.), for approximately four weeks
• Family members - treat all with ketoconazole shampoo

	Figure 20 – Tinea capititis. Scale, no scaring
	Figure 21 – Tinea capitis
	Figure 22 – Tinea capitis
	Figure 23 – Tinea capitis. Scale and early scaring
	Figure 24 – Tinea capitis. Scaring
	Figure 25 – A kerion This has been caused by an animal ringworm   (copied with kind permission from Dermatoweb)

Tinea incognito

• Refers to tinea that has been wrongly misdiagnosed and treated with topical steroids - the itch and inflammation settles with topical steroids giving a false sense of security as the fungus spreads
• Treatment often requires a short course (initially two weeks) of systemic Lamisil

Figure 26 – Tinea incognito Topical steroids will aggravate cases of tinea