Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Tinea Cruris
TINEA CRURIS
Ringworm of the groin, or “jock itch”; a superficial fungal infection of the groin.
I. Etiology: Epidermophyton floccosum and Trichophyton sp. dermatophyte fungi
II. Incidence
A. Seen most often in athletes and obese children
B. Incidence increases in hot, humid weather.
C. More common in males
III. Subjective data
A. Groin and upper inner thighs are red, raw, and sore
B. Pruritic when healing
C. Hurts with activity
D. Complaint of jock itch
E. History of exposure to tinea cruris
IV. Objective data
A. Symmetric rash with butterfly appearance on groin and inner aspects of thighs; scrotum, gluteal folds, and buttocks may also be involved.
B. Rash erythematous with a sharp, raised border with tiny vesicles, central clearing, and peripheral spreading
C. Check the entire body.
1. Tinea pedis is often present.
2. Intertriginous areas are susceptible to infection.
V. Assessment
A. Diagnosis
1. History and physical findings are generally adequate for diagnosis.
2. Scrapings from active borders of lesions in potassium hydroxide fungal preparation reveal hyphae and spores.
B. Differential diagnosis
1. Intertrigo: Rash is erythematous with oozing, exudation, and crusting; borders are not sharply defined, with no central clearing.
2. Seborrheic dermatitis: Lesions are semiconfluent, yellow, and thick with greasy scaling.
3. Candidiasis: Lesions are moist and intensely erythematous with sharply defined borders and satellite lesions; more common in females.
4. Contact dermatitis: Distribution and configuration are the distinguishing features; rash is erythematous with vesicles, oozing, erosion, and eventually ulceration; often coexistent.
5. Psoriasis: Usually unilateral; other psoriatic lesions on body; plaques with silvery scales
VI. Plan
A. For lesions with erythema and pruritus, order one of the following:
1. Spectazole 1% Cream, once daily (also effective against C. albicans)
2. Loprox cream, for children older than 10 years, tid (also effective against C. albicans)
3. Oxistat 1%, bid for 2 weeks (also effective against C. albicans)
4. Tinactin cream tid (over-the-counter preparation; ineffective against C. albicans).
B. For acute inflammatory lesions, order the following:
1. Domeboro solution compresses: 30 minutes tid for 3 days; dissolve 1 powder packet in 1 pint of warm water
or
2. Vinegar wet packs: 1⁄2 cup vinegar to 1 quart warm water; apply 15 minutes, bid.
3. Antifungal cream as above
C. Systemic treatment: For resistant cases
1. Diflucan (fluconazole): 150 mg/wk for 4 weeks
2. Sporanox (Itraconazole): 200 mg/d for 7 days
VII. Education
A. Expect gradual improvement once treatment is instituted.
B. Continue treatment for 1 week after lesions have cleared.
C. Domeboro solution becomes concentrated on exposure to air; keep in covered container.
D. Use a soft cloth for soaks.
E. Eliminate sources of heat and friction.
F. Hygiene
1. Bathe daily; dry thoroughly after bathing.
2. Use talcum or antifungal powder in intertriginous and interdigital areas.
3. Use cotton underwear.
4. Change clothing daily.
5. Use clean athletic supporter daily.
6. Use fresh towels daily.
7. Launder linens and clothing in hot water.
G. Tinea is highly communicable and is transmitted by both direct and indirect contact.
H. Check siblings carefully for signs of infection.
I. Alert child and parents to signs and symptoms of secondary infection.
J. Note: Prevention is of primary importance. Athletes in particular should be educated about the need for clean, dry clothing and the importance of avoiding direct contact with someone who has jock itch. Athletic supporters, shorts, and socks should not be loaned or borrowed. Daily showers should be encouraged, as should the prophylactic use of antifungal powders, such as Caldesene or Tinactin, daily or twice daily.
VIII. Follow-up
A. Telephone call in 3 to 4 days
B. If severe with oozing, consider rechecking in 5 days.
IX. Complications
A. Secondary infection
B. Chronic infection (80% of patients acquire immunity; 20% may develop chronic infection).
C. Allergic response to topical antifungal cream (erythema, stinging, blistering, peeling, pruritus)
X. Consultation/referral
A. No clinical improvement after 2 weeks.
B. Griseofulvin may be indicated.