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Subject: Tinea (Capitis, Corporis, Cruris)
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Superficial fungal infections of the skin/scalp; various forms of dermatophytosis; the names relate to the particular area affected (1).
Tinea cruris: infection of crural fold and gluteal cleft
Tinea corporis: infection involving the face, trunk, and/or extremities; often presents with ring-shaped lesions, hence the misnomer ringworm
Tinea capitis: infection of the scalp and hair; affected areas of the scalp can show characteristic black dots resulting from broken hairs.
Dermatophytes have the ability to subsist on protein, namely keratin.
They cause disease in keratin-rich structures such as skin, nails, and hair.
Infections result from contact with infected persons/animals.
Zoophilic infections are acquired from animals.
Anthropophilic infections are acquired from personal contact (e.g., wrestling) or fomites.
Geophile infections are acquired from the soil.
System(s) affected: skin, exocrine
Synonym(s): jock itch, ringworm
Predominant age: any age; rare in children
Predominant sex: male > female
Predominant age: all ages
Predominant sex: male = female
Predominant age: 3 to 9 years; almost always occurs in young children
Tinea cruris is rare prior to puberty.
Tinea capitis is common in young children.
Tinea cruris is more common in the geriatric population due to an increase in risk factors.
Tinea cruris and capitis are rare in pregnancy.
Tinea cruris: Source of infection is usually the patient’s own tinea pedis, with agent being transferred from the foot to the groin via the underwear when dressing; most common causative dermatophyte is Trichophyton rubrum; rare cases caused by Epidermophyton floccosum and Trichophyton mentagrophytes
Tinea corporis: most commonly caused by T. rubrum; Trichophytontonsurans most often found in patients with tinea gladiatorum
Tinea capitis: T. tonsurans found in 90% and Microsporum sp. in 10% of patients
Warm climates; summer months and/or copious sweating; wearing wet clothing/multiple layers (tinea cruris)
Daycare centers/schools/confined quarters (tinea corporis and capitis)
Depression of cell-mediated immune response (e.g., individuals with atopy or AIDS)
Obesity (tinea cruris and corporis)
Direct contact with an active lesion on a human, an animal, or rarely, from soil; working with animals (tinea corporis)
Avoidance of risk factors, such as contact with suspicious lesions
Fluconazole or itraconazole may be useful in wrestlers to prevent outbreaks during competitive season.
Lesions range from asymptomatic to pruritic.
In tinea cruris, acute inflammation may result from wearing occlusive clothing; chronic scratching may result in an eczematous appearance.
Previous application of topical steroids, especially in tinea cruris and corporis, may alter the overall appearance causing a more extensive eruption with irregular borders and erythematous papules. This modified form is called tinea incognito.
Tinea cruris: well-marginated, erythematous, half-moon–shaped plaques in crural folds that spread to upper thighs; advancing border is well defined, often with fine scaling and sometimes vesicular eruptions. Lesions are usually bilateral and do not include scrotum/penis (unlike with Candida infections) but may migrate to perineum, perianal area, and gluteal cleft and onto the buttocks in chronic/progressive cases. The area may be hyperpigmented on resolution.
Tinea corporis: scaling, pruritic plaques characterized by a sharply defined annular pattern with peripheral activity and central clearing (ring-shaped lesions); papules and occasionally pustules/vesicles present at border and, less commonly, in center
Tinea capitis: commonly begins with round patches of scale (alopecia less common). In its later stages, the infection frequently takes on patterns of chronic scaling with either little/marked inflammation or alopecia. Less often, patients will present with multiple patches of alopecia and the characteristic black-dot appearance of broken hairs. Extreme inflammation results in kerion formation (exudative, pustular nodulation).
Intertrigo: inflammatory process of moist-opposed skin folds, often including infection with bacteria, yeast, and fungi; painful longitudinal fissures may occur in skin folds.
Erythrasma: diffuse brown, scaly, noninflammatory plaque with irregular borders, often involving groin; caused by bacterial infection with Corynebacterium minutissimum; fluoresces coral red with Wood lamp
Seborrheic dermatitis of groin
Psoriasis of groin (“inverse psoriasis”)
Candidiasis of groin (typically involves the scrotum)
Alopecia areata and trichotillomania
Aplasia cutis congenital
Subacute systemic lupus erythematosus (SLE)
Erythema annulare centrifugum
Erythema multiforme; erythema migrans
Potassium hydroxide (KOH) preparation of skin scrapings from dermatophyte leading border shows characteristic translucent, branching, rod-shaped hyphae.
Arthrospores can be visualized within hair shafts. Spores and/or hyphae may be seen on KOH exam.
Reevaluate to assess response, especially in resistant/extensive cases.
Fungal culture using Sabouraud dextrose agar/dermatophyte test medium
Skin scrapings show fungal hyphae in epidermis.
Arthrospores found in hair shafts; spores and/or hyphae seen on KOH exam
Careful hand washing and personal hygiene; laundering of towels/clothing of affected individual; no sharing of towels/clothes/headgear/pillows
Evaluate other family members, close contacts, or household pets (especially kittens and puppies).
Use of prophylactic antifungal shampoo by all household members for 2 to 4 weeks in cases of tinea capitis
Avoid predisposing conditions such as hot baths and tight-fitting clothing (boxer shorts are better than briefs).
Keep area as dry as possible (talcum/powders may be beneficial).
Itching can be alleviated by OTC preparations such as Sarna or Prax.
Topical steroid preparations should be avoided, unless absolutely needed to control itching and only after definitive diagnosis and initiation of antifungal treatment.
Nystatin should be avoided in tinea infections but is indicated for cutaneous candidal infections.
Avoid contact sports (e.g., wrestling) temporarily while starting treatment.
Tinea cruris/corporis (2)[C]
Topical azole antifungal compounds
Terbinafine 1% (Lamisil): OTC inexpensive and effective compound; can be applied once or BID for 1 to 2 weeks
Econazole 1% (Spectazole), ketoconazole (Nizoral): usually applied BID for 2 to 3 weeks
Butenafine 1% (Mentax): applied once daily for 2 weeks; also very effective. To prevent relapse, use for 1 week after resolution.
Tinea capitis (3)[A]
PO griseofulvin for Trichophyton and Microsporum sp.; microsized preparation available; dosage 10 to 20 mg/kg/day (max 1,000 mg); taken BID or as a single dose daily for 6 to 12 weeks
PO terbinafine can be used for Trichophyton sp. at 62.5 mg/day in patients weighing 10 to 20 kg; 125 mg/day if weight 20 to 40 kg; 250 mg/day if weight >40 kg; use for 4 to 6 weeks.
PO itraconazole can be used for Microsporum sp. and matches griseofulvin efficacy while being better tolerated. Dosage of 3 to 5 mg/kg/day, but most studies have used 100 mg/day for 6 weeks in children >2 years of age.
Oral antifungal agents are effective but not indicated in uncomplicated tinea cruris/corporis cases. They can be used for resistant and extensive infections or if the patient is immunocompromised. If topical therapy fails, consider possible oral therapy. Griseofulvin can be given 500 mg/day for 1 to 2 weeks.
The following oral regimens have been reported in medical literature as being effective but currently are not specifically approved by FDA for tinea cruris:
PO terbinafine (Lamisil): 250 mg/day for 1 week
PO itraconazole (Sporanox): 100 mg BID once and repeated 1 week later
PO fluconazole (Diflucan): 150 mg once per week for 4 weeks
Topical terbinafine 1% solution has been studied recently and appears effective as a once-daily application for 1 week.
Oral antifungals have many interactions including warfarin, OCPs, and alcohol; advise checking for drug interactions prior to use; contraindicated in pregnancy. Monitor for liver toxicity when using oral antifungals.
Excellent prognosis for cure with therapy in tinea cruris and corporis
In tinea capitis, lesions will heal spontaneously in 6 months without treatment but scarring is more likely.
Secondary bacterial infection
Generalized, invasive dermatophyte infection
Secondary eruptions called dermatophytid reactions may occur at distant sites.
Akinwale SO. Personal hygiene as an alternative to griseofulvin in the treatment of tinea cruris. Afr J Med Med Sci. 2000;29(1):41–43. [View Abstract on OvidMedline]
Bonifaz A, Saúl A. Comparative study between terbinafine 1% emulsion-gel versus ketoconazole 2% cream in tinea cruris and tinea corporis. Eur J Dermatol. 2000;10(2):107–109. [View Abstract on OvidMedline]
González U, Seaton T, Bergus G, et al. Systemic antifungal therapy for tinea capitis in children. Cochrane Database Syst Rev. 2007;(4):CD004685. [View Abstract on OvidMedline]
Mirmirani P, Tucker LY. Epidemiologic trends in pediatric tinea capitis: a population-based study from Kaiser Permanente Northern California. J Am Acad Dermatol. 2013;69(6):916–921. [View Abstract on OvidMedline]
Nozickova M, Koudelkova V, Kulikova Z, et al. A comparison of the efficacy of oral fluconazole, 150 mg/week versus 50 mg/day, in the treatment of tinea corporis, tinea cruris, tinea pedis, and cutaneous candidosis. Int J Dermatol. 1998;37(9):703–705. [View Abstract on OvidMedline]
Seebacher C, Bouchara JP, Mignon B. Updates on the epidemiology of dermatophyte infections. Mycopathologia. 2008;166(5–6):335–352. [View Abstract on OvidMedline]
Tey HL, Tan AS, Chan YC. Meta-analysis of randomized, controlled trials comparing griseofulvin and terbinafine in the treatment of tinea capitis. J Am Acad Dermatol. 2011;64(4):663–670. [View Abstract on OvidMedline]
B35.0 Tinea barbae and tinea capitis
B35.4 Tinea corporis
B35.6 Tinea cruris
110.0 Dermatophytosis of scalp and beard
110.5 Dermatophytosis of the body
110.3 Dermatophytosis of groin and perianal area
110.8 Dermatophytosis of other specified sites
110.2 Dermatophytosis of hand
5441008 Tinea capitis (disorder)
84849002 Tinea corporis (disorder)
399029005 Tinea cruris (disorder)
371042002 Tinea due to Trichophyton rubrum (disorder)
403084009 Tinea due to Trichophyton tonsurans (disorder)
Tinea corporis is characterized by scaly plaque, with peripheral activity and central clearing.
Tinea cruris is characterized by erythematous plaque in crural folds usually sparing the scrotum. Treatment of concomitant tinea pedis is advised.
Tinea capitis is a fungal infection of the scalp affecting hair growth. Topical therapy is ineffective for this infection.