Presentations of tinea infection

Contributed by Dr Jean Watkins, a GP in Ringwood, Hampshire

Tinea corporis
Tinea corporis presents with itchy, annular, scaly plaques with raised, well-defined margins that have a tendency to heal centrally. Lesions usually occur on exposed areas of the trunk and extremities. Diagnosis can be confirmed by microscopic examination and culture. Epidermophyton floccosum, microsporum or trichophyton species may be the cause.

Treatment is with a topical antifungal cream or a four-week course of systemic terbinafine or itraconazole. Contact with others should be avoided until the treatment is working.

Tinea capitis
The patient presents with alopecia with broken hairs at the scalp. Itching is a feature. If caused by M audouini there is scaling with minimal inflammation and green fluorescence under Wood's lamp. T tonsuran causes an inflammatory boggy mass with broken hairs and oozing pus. Hyphae may be identified by microscopic examination of hairs and/or scales with confirmation by culture. It affects mainly children.

Systemic treatment is required with griseofulvin or terbinafine.

Tinea cruris
Tinea cruris is a dermatophyte infection of the groin, usually seen in men. It is caused by T rubrum, E floccosum or T mentagrophytes. It presents with an itchy, red and scaly rash with a raised, red margin. Skin scraping, microscopy and culture will confirm diagnosis. Co-existing infection of the feet and toenails is common.

A two- to four-week course of terbinafine is the treatment of choice.

Tinea manuum
Tinea manuum presents as dryness and scaling of the palm of one hand and is associated with T rubrum. It remains unilateral even when it persists untreated. The skin creases have a powdery filling and there is often involvement of the nails, feet and toenails.

Treatment with systemic terbinafine for two to six weeks is recommended. Griseofulvin or itraconazole can be alternatives.

Tinea pedis
Tinea pedis involves the web spaces between the toes and the plantar surface of the foot. It presents with peeling, maceration and fissuring. Chronic tinea pedis affects the soles and sides of the foot and is usually caused by T rubrum or E floccosum. Diagnosis can be confirmed by microscopy or culture of skin scrapings.

Treatment is with topical and/or systemic antifungal agents.

Acute tinea pedis
In acute tinea pedis erythema, vesicles and blisters may form. The unilateral nature of this condition distinguishes it from pompholyx eczema. Secondary infection is especially possible when the blisters break down. The patient may develop a lymphangitis and lymphadenopathy. This tinea is usually caused by T mentagrophytes or sometimes E floccosum.

Antifungal treatment as for tinea pedis should be given, together with antibiotics for any secondary infection.

Tinea unguium
Tinea unguium is a dermatophyte infection of the nail plate. It initially affects the sides of the nail but gradually the plate separates from the bed (onycholysis). Nails become thickened and discoloured and, in severe cases, dystrophic and broken. It is commonly caused by T rubrum and T mentagrophytes. Diagnosis is confirmed by a culture of nail clippings, including the subungual hyperkeratotic matter.

Treatment is a six-week to three-month course of systemic terbinafine.

Tinea incognito
It is not uncommon for tinea incognito to be mistaken for eczema and be treated with topical steroids. If mistakenly diagnosed and treated the problem will fail to respond and the rash will become more extensive, less scaly and often develops pustules in the central area that would otherwise appear to be clearing. The main clue is a red, slightly raised margin to the rash. Skin scrapings should confirm the diagnosis. Antifungal treatment,as for tinea corporis, should be given.

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