Definition
A.Tinea corporis (ringworm) is a fungal infection of the skin tissue (keratin) commonly seen on the face, trunk, and extremities.
B.Tinea capitis is a fungal infection of scalp hair.
C.Tinea cruris is a fungal infection of the groin.
D.Tinea pedis is a fungal infection of the foot.
E.Tinea unguium (dermatophyte onychomycosis) is a fungal infection of the nail.
Incidence
A.Tinea is a fairly common fungal infection seen in adults.
Pathogenesis
A.The causative fungal species varies, depending on the location of the infection. Three common organisms are Epidermophyton, Microsporum, and Trichophyton.
B.The infection can be obtained from other people, environmental contact with inanimate objects, animals (puppies, kittens), and the soil.
Predisposing Factors
A.Exposure to person or facilities (e.g., locker rooms) infected with the fungus.
B.Poor nutrition.
C.Poor health.
D.Poor hygiene.
E.Warm climates.
F.Immunosuppression.
Common Complaints
A.Scaly, itchy skin.
B.When circular in shape, usually tinea corporis (ringworm).
C.When nails are thickened and yellow usually tinea unguium.
Other Signs and Symptoms
A.Tinea capitis: Erythema, scaling of scalp, with hair loss at site asymptomatic.
B.Tinea corporis: Circular, erythematous, well-demarcated lesion on the skin with hypopigmentation in center of lesion; usually pruritic.
C.Tinea cruris: Well-demarcated scaling lesions on groin (not scrotum) or thigh; usually pruritic.
D.Tinea pedis: Scaly, erythemic vesicles on feet, between toes, and in arch, with extreme pruritus.
E.Tinea unguium (onychomycosis): Thickening and yellowing of toenail or fingernail, often with other fungal infection or alone.
Subjective Data
A.Ask the patient about onset, duration, and progression of patch or rash on skin.
B.Assess the patient for other areas of skin involvement.
C.Ask if the lesion is pruritic.
D.Inquire as to the patient’s exposure to anyone with similar symptoms.
E.Determine whether the patient has a history of similar lesions.
F.Query the patient regarding predisposing factors.
G.Review with the patient what remedies were used and with what results.
Physical Examination
A.Check temperature (if indicated).
B.Inspect:
1.Examine all areas of skin.
2.Note type of lesions present.
Diagnostic Tests
A.Obtain scrapings of the border of the lesion for evaluation:
1.Potassium hydroxide (KOH).
2.Wet prep.
3.Fungal cultures.
Differential Diagnoses
A.Tinea corporis.
B.Dermatitis.
C.Alopecia areata.
D.Psoriasis.
E.Contact dermatitis.
F.Atopic eczema.
G.Subacute cutaneous lupus erythematous.
H.Pityriasis rosea.
Plan
A.General interventions:
1.Identify type of lesion.
2.Identify other infected family members or sexual partners for treatment.
B. 
See Section III: Patient Teaching Guide Ringworm.
1.Reinforce medication regimen for a 4- to 8-week period for resolution.
C.Pharmaceutical therapy:
1.Tinea capitis:
a.Adults: Griseofulvin 500 mg by mouth per day for 4 to 8 weeks.
b.Ketoconazole (Nizoral) may also be used.
2.Tinea corporis, pedis, and cruris:
a.Clotrimazole 1% (Lotrimin) cream, or econazole nitrate 1% cream, twice daily for 14 to 28 days.
b.Terbinafine 1% cream (Lamisil), topical; apply once or twice daily for 1 to 4 weeks.
3.Onychomycosis: Successful treatment is difficult:
a.Itraconazole (Sporanox) 100 mg, two tablets by mouth twice daily for 7 days. Repeat in 1 month, then repeat again in 1 more month.
Monitor liver function tests (LFTs) at 6 weeks after starting medication.
b.Terbinafine 1% cream (Lamisil):
i.Fingernail: 250 mg once daily for 6 weeks.
ii.Toenail: 250 mg daily for 12 weeks.
c.Home cure: Apply Vicks VapoRub on toenail bed and cover with a sock every night at bedtime for approximately 4 to 6 months or until resolved. This treatment offers a safe, cost-effective alternative to oral medications.
Follow-Up
A.A 2- to 4-week follow-up is recommended to evaluate progress.
B.When using Sporonox, monitor LFT at 6 weeks. If the medication is continued, monitoring LFTs every 6 to 8 weeks is recommended.
Consultation/Referral
A.Consult a physician if the infection has not improved.
Individual Considerations
A.Pregnancy: Oral antifungal medications are not recommended during pregnancy.
B.Adults:
1.Tinea capitis is rare in adults.
2.Tinea cruris is more common in obese males but rare in females.
3.Transient and/or permanent hearing loss has been documented in some patients with the use of itraconazole. These cases were reported when itraconazole was used with quinidine, which is contraindicated.
C.Elderly:
1.Itraconzaole should be used cautiously in the elderly patient.
2.Recommendation for tinea treatment with the elderly population is Terbinafine because of its decreased risk for cardiac complications and drug interactions.