AUTHOR INFORMATION

Section 1 of 10

Authored by Jerome FX Naradzay, MD, FACEP, Emergency Services Medical Director, Department of Emergency Medicine, Maria Parham Medical Center

Coauthored by Nelly Rubeiz, MD, Consulting Staff, Department of Dermatology, American University of Beirut Medical Center; Associate Professor, Department of Dermatology, American University of Beirut, Lebanon; Zeina Tannous, MD, Consulting Staff, Department of Dermatology, Massachusetts General Hospital, Harvard Medical School

Jerome FX Naradzay, MD, FACEP, is a member of the following medical societies: American College of Emergency Physicians, and Society for Academic Emergency Medicine

Edited by Theodore Gaeta, DO, MPH, Residency Director, Clinical Associate Professor of Emergency Medicine in Medicine, Department of Emergency Medicine, New York Methodist Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Eddy Lang, MDCM, CCFP (EM), CSPQ, Assistant Professor, Department of Family Medicine, McGill University; Consulting Staff, Department of Emergency Medicine, The Sir Mortimer B Davis-Jewish General Hospital; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Charles V Pollack, Jr, MD, MA, FACEP, Professor, Department of Emergency Medicine, University of Pennsylvania College of Medicine; Chairman, Department of Emergency Medicine, Pennsylvania Hospital

Author's Email:	Jerome FX Naradzay, MD, FACEP
Editor's Email:	Theodore Gaeta, DO, MPH

eMedicine Journal, November 15 2006, VOLUME 7, Number 11

INTRODUCTION

Section 2 of 10

Background: The dermatophytes are a group of fungi (ringworm) that invade the dead keratin of skin, hair, and nails. Several species of dermatophytes infect humans; these belong to the Epidermophyton, Microsporum, and Trichophyton genera.

Dermatophytosis (tinea) is a fungal infection caused by dermatophytes. The infection may spread from person to person (anthropophilic), animal to person (zoophilic), or soil to person (geophilic). The most common of these organisms are Trichophyton rubrum, Trichophyton tonsurans, Trichophyton interdigitale and/or Trichophyton mentagrophytes, Microsporum canis, and Epidermophyton floccosum.

Pathophysiology: Dermatophytes have the ability to invade keratinized tissue (eg, hair, nails, any area of the skin) but are restricted to the dead cornified layer of the epidermis. Humid or moist skin provides a very favorable environment for the establishment of fungal infection. Clinically, tinea infections are classified according to the body region involved.

• Tinea capitis is infection of scalp hair.

• Tinea corporis is infection of the trunk and extremities.

• Tinea manuum and tinea pedis is infection of palms, soles, and interdigital webs.

• Tinea cruris is infection of the groin.

• Tinea barbae is infection of the beard area and neck.

• Tinea faciale is infection of the face.

• Tinea unguium (onychomycosis) is infection of the nail.

Frequency:

• In the US: Fungal infection occurs worldwide. Tinea pedis is the most common type in the US and in the rest of the world.

  Tinea capitis (ringworm of the head) is the most common dermatophytosis of childhood with an increasing incidence worldwide.

  Onychomycosis is a common problem, especially in adults. In a survey in the US, the prevalence of onychomycosis was approximately 3% in males and 1.4% in females. In a sample of North American children, 0.44% had onychomycosis.

• Internationally: Among adolescent boys in Saudi Arabia, 1.9% had tinea pedis. In Mali, the prevalence of tinea capitis in children is 9.5%. In Greece, approximately 5% of people with skin problems have dermatophyte infections. In a survey of British adults, the prevalence of dermatophyte nail infection was 2.7-4.7%. Onychomycosis accounts for roughly 30% of all cutaneous fungal infections. Among pupils from primary schools in Nigeria, 13.4% had a dermatophyte infection. T rubrum is the most common cause of tinea corporis, tinea cruris, tinea pedis, and nail infection worldwide.

Mortality/Morbidity:

• Cellulitis in the lower extremities, which causes a breach in the skin and allows the inoculation of opportunistic bacteria, is a frequent complication of interdigital fungal infection.

• In patients with impaired cell-mediated immune function, atypical and locally aggressive presentations of dermatophyte infection may occur. These include extensive skin disease, subcutaneous abscesses, and dissemination.

Race: Fungal infection affects all races; however, the prevalence of organisms varies by country.

Sex: Both sexes are affected by fungal infection. Tinea cruris is much more common in males because of the male anatomy, which allows moisture to accumulate in the crural folds.

Age:

• Fungal infection affects all ages.

• Tinea capitis mainly is a disease in children; however, adults can be affected.

• Tinea cruris, tinea pedis, and onychomycosis predominantly affect the adult population.

CLINICAL

Section 3 of 10

History:

• Pruritus (itching) is the main symptom in most forms of tinea.

• Patients with tinea capitis have hair loss.

• Asking the patient about participation in sports, such as judo, karate, wrestling, and other contact sports, is important. Likewise, asking the patient about military enrollment and any contacts with similar skin disease is important.

Physical: At physical examination, the various types of tinea may have different findings, as follows:

• Tinea capitis

• The clinical appearance of fungal infection of the scalp varies depending on the type of hair invasion.

• Alopecia (hair loss), with hairs breaking at the scalp surface, usually is present.

• Tinea corporis

• Infection typically is on the exposed skin of the trunk and extremities.

• It is characterized by annular scaly plaques with raised edges, pustules, and vesicles.

• Tinea pedis

• This is a fungal infection of the toe webs and plantar surface occur and often affect only one foot.

• Toe-web scaling, fissuring, and maceration; scaling of soles and lateral surfaces; erythema; vesicles; pustules; and bullae may be present.

• Tinea manuum

• This is a fungal infection of the palms and finger webs that usually occurs in association with tinea pedis.

• Usually, only one hand is involved.

• Scaling and erythema may be present.

• Tinea cruris

• It is a dermatophytic infection of the groin and pubic region.

• It is characterized by erythematous lesions with central clearing and raised borders.

• Tinea barbae

• The beard and neck area are affected.

• Erythema, scaling, and pustules are present.

• Tinea unguium

• Also called onychomycosis, this is an infection of the nail.

• It is characterized by onycholysis (nail plate separation from nail bed) and thickened, discolored (white, yellow, brown, black), broken, and dystrophic nails.

Causes: The various tinea infections are caused chiefly by species of the genera Microsporum, Trichophyton, and Epidermophyton. Risk factors include the following:

• Moist conditions

• Use of communal baths

• Immunocompromised states

• Cushing syndrome

• Atopy

• Genetic predisposition

• Athletic activity that causes skin tears, abrasions, or trauma such as wrestling, judo, or soccer

DIFFERENTIALS

Section 4 of 10

Candidiasis
Cellulitis
Dermatitis, Atopic
Dermatitis, Contact
Erysipelas
Impetigo
Psoriasis
Vulvovaginitis

Other Problems to be Considered:

Alopecia areata
Atopic eczema
Erythrasma
Intertrigo
Seborrheic dermatitis

WORKUP

Section 5 of 10

Lab Studies:

• Direct microscopic examination may be performed.

• Skin scrapings, nail specimens, or plucked hairs are treated with potassium hydroxide and examined.

• Hyphae can be visualized in skin and nails.

• Spores within or around the hair shaft can be detected.

• Fungal cultures can be performed for precise identification of the species.

• Wood light (UV light) examination may be performed.

• This examination is used mainly for the diagnosis of tinea capitis.

• Hairs infected with Microsporum audouinii and M canis produce a brilliant yellow-green fluorescence.

• Trichophyton schoenleinii causes a dull green fluorescence.

Other Tests:

• A polymerase chain reaction (PCR) identification system is being developed. It is specific for T tonsurans and is rapid, sensitive, and specific.

TREATMENT

Section 6 of 10

Emergency Department Care: Certain forms of tinea easily can be identified and treated with antifungals in the ED. However, the diagnosis should probably be confirmed with a potassium hydroxide smear and/or cultures.

Consultations: A dermatologist may be consulted.

MEDICATION

Section 7 of 10

Fungal infections may be treated with topical agents (ie, creams, lotions, solutions, powders, sprays) or with oral antifungals in extensive or recalcitrant disease. Topical therapy is ineffective in treating tinea of the hair and nails. Findings with onychomycosis treatment were discouraging because of the need for prolonged therapy and the low success rate. However, in recent years, new oral antimycotic drugs have been developed; these have greatly improved the outlook (especially for patients with fungal toenail infection).

Drug Category: Antifungals -- The optimal duration of topical therapy for dermatophytic infections of the skin has never been established. In most cases of tinea corporis and tinea cruris, 2 weeks of treatment may suffice. Tinea pedis may require treatment for as long as 8 weeks.

Drug Name	Ketoconazole 2% cream (Nizoral) -- Imidazole, broad-spectrum antifungal agent indicated for the topical treatment of tinea corporis, tinea cruris, and tinea pedis. Inhibits synthesis of ergosterol (main sterol of fungal cell membranes), causing cellular components to leak; results is cell death.
Adult Dose	Rub gently into affected area qd or bid for 2-4 wk
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	If sensitivity or irritation develops, discontinue use; for external use only; avoid contact with eyes

Drug Name	Clotrimazole 1% cream or lotion (Lotrimin, Mycelex) -- Indicated for topical treatment of tinea corporis, tinea cruris, and tinea pedis. Broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing fungal cell death.
Adult Dose	Gently massage into affected and surrounding skin areas bid for 2-6 wk
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	If sensitivity or chemical irritation occurs, discontinue use; use only externally; avoid contact with eyes

Drug Name	Econazole 1% cream or lotion (Spectazole) -- Effective in cutaneous infections. Interferes with RNA and protein synthesis and metabolism. Disrupts fungal cell-wall membrane permeability, causing fungal cell death.
Adult Dose	Apply sparingly over affected areas qd for 2-6 wk
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	If sensitivity or irritation develops, discontinue use; for external use only; avoid contact with eyes

Drug Name	Miconazole 2% cream (Monistat, Daktarin) -- Damages fungal cell-wall membrane by inhibiting biosynthesis of ergosterol. Membrane permeability is increased, causing nutrients to leak and resulting in fungal-cell death. The lotion is preferred in intertriginous areas. If the cream is used, apply sparingly to avoid maceration effects.
Adult Dose	Cream and lotion: Cover affected areas bid for 2-6 wk Powder: Spray or sprinkle liberally over affected area bid
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	If sensitivity or chemical irritation occurs, discontinue use; use only externally; avoid contact with eyes

Drug Name	Terbinafine (Lamisil) -- Synthetic allylamine derivative that inhibits squalene epoxidase, a key enzyme in sterol biosynthesis of fungi, resulting in a deficiency in ergosterol that causes fungal cell death. Use until symptoms significantly improve.
Adult Dose	Terbinafine tab Tinea cruris, tinea corporis: 250 mg/d PO for 2-4 wk Tinea pedis: 250 mg/d PO for 2-6 wk Tinea capitis: 250 mg/d PO for 4 wk Fingernail infection: 250 mg/d PO for 6-8 wk Toenail infection: 250 mg/d PO for 3-4 mo Terbinafine 1% cream Tinea corporis, tinea cruris: Apply to affected area qd for 1-4 wk Tinea pedis: Apply to affected area bid for 1-4 wk
Pediatric Dose	Terbinafine tab, treatment duration similar to that in adults 12-20 kg: 62.5 mg/d PO 20-40 kg: 125 mg/d PO >40 kg: 250 mg/d PO Terbinafine 1% cream <12 years: Not established >12 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Coadministration of PO form may increase cyclosporine clearance; rifampin and phenobarbital may decrease terbinafine level; cimetidine may decrease terbinafine clearance
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Discontinue use if chemical irritation or signs of hepatobiliary dysfunction develop; topical dosage form is for external use only; avoid contact with eyes

Drug Name	Naftifine 1% cream (Naftin) -- Indicated for the treatment of tinea corporis, tinea cruris, and tinea pedis. Broad-spectrum antifungal agent that appears to interfere with sterol biosynthesis by inhibiting the enzyme squalene 2,3-epoxidase. This inhibition results in decreased amounts of sterols, causing cell death. If no clinical improvement occurs after 4 weeks of treatment, reevaluate the patient.
Adult Dose	Cream: Gently massage sufficient quantity into affected area and surrounding skin qd for 2-4 wk Gel: Gently massage sufficient quantity into affected and surrounding skin areas bid for 2-4 wk
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Discontinue use if sensitivity or chemical irritation occurs; for external use only; avoid contact with eyes

Drug Name	Griseofulvin (Gris-PEG, Grifulvin V, Fulvicin, Griseofulvin) -- Extensively used in the past to treat dermatophytic infections of the skin. However, with new antifungals now available, use is now limited. An antibiotic derived from a species of Penicillium that is deposited in the keratin precursor cells, which are gradually replaced by noninfected tissue; the new keratin then becomes highly resistant to fungal invasions. Most used therapy for treating tinea capitis, especially if caused by M canis.
Adult Dose	Tinea corporis, tinea cruris, and tinea capitis: 500 mg microsize (330-375 mg ultramicrosize) PO in single or divided daily doses for 2-6 wk Tinea pedis, tinea unguium: 0.75-1 g microsize (660-750 mg ultramicrosize) PO in single or divided doses for 2-6 wk
Pediatric Dose	11 mg microsize/kg/d (5 mg/lb/d) PO or 7.3 mg ultramicrosize/kg/d (3.3 mg/lb/d) PO
Contraindications	Documented hypersensitivity
Interactions	May decrease hypoprothrombinemic activity of warfarin; patients may require a dosage adjustment; oral contraceptives may lose effectiveness when administered concurrently, possibly leading to breakthrough bleeding, amenorrhea, or unintended pregnancy; may reduce effects of cyclosporine; may decrease serum salicylate concentrations; barbiturates may decrease serum levels
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	For prolonged therapy, observe patients closely; monitor renal, hepatic, and hematopoietic function regularly; lupus-like syndromes or exacerbation of lupus erythematosus may occur; photosensitivity may occur; patients should take protective measures against exposure to UV light or sunlight

Drug Name	Itraconazole (Sporanox) -- Synthetic triazole antifungal agent that inhibits fungal cell growth by inhibiting the cytochrome P-450–dependent synthesis of ergosterol, a vital component of fungal cell membranes. A 30-d course of 100 mg of itraconazole daily has been shown to effectively treat tinea capitis. This treatment could prove to be a beneficial alternative to griseofulvin therapy.
Adult Dose	Tinea corporis, tinea cruris: 100 mg/d PO 2 wk or 200 mg/d PO for 1 wk Tinea pedis: 200 mg bid PO for 1 wk Toenail infection: 200 mg bid PO 1 for wk, given 1 wk/mo for 3-4 mo Fingernail infection: 200 mg PO bid for 1 wk, given 1 wk/mo for 1-2 mo Tinea capitis: 5 mg/kg/d (max dose 100 mg/d) PO for 2-4 wk
Pediatric Dose	Not established Suggested dose in children 3-16 years: 100 mg/d PO for 1 wk
Contraindications	Documented hypersensitivity
Interactions	Antacids may reduce absorption; edema may occur with coadministration of calcium-channel blockers (eg, amlodipine, nifedipine); hypoglycemia may occur with sulfonylureas; may increase tacrolimus and cyclosporine plasma concentrations when high doses are used; rhabdomyolysis may occur with coadministration of HMG-CoA reductase inhibitors (lovastatin or simvastatin); coadministration with cisapride can cause cardiac rhythm abnormalities and death; may increase digoxin levels; coadministration may increase plasma levels of midazolam or triazolam; phenytoin and rifampin may reduce itraconazole levels (phenytoin metabolism may be altered)
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in hepatic insufficiencies; absorption impaired when gastric acidity is decreased; discontinue if neuropathy attributable to itraconazole occurs

Drug Name	Fluconazole (Diflucan) -- Broad-spectrum triazole antifungal agent. A potent and selective inhibitor of fungal enzymes necessary for ergosterol synthesis. Most commonly used in the treatment of candidiasis.
Adult Dose	Tinea corporis, tinea cruris: 150 mg/wk PO for 2-4 wk Tinea pedis: 150 mg/wk PO for as long as 6 wk Toenail infection: 150 mg/wk PO for 6-12 mo Fingernail infection: 150 mg/wk PO for 3-6 mo
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	Levels may increase with hydrochlorothiazides; levels may decrease with chronic coadministration of rifampin; coadministration may decrease phenytoin concentrations; may increase concentrations of theophylline, tolbutamide, glyburide, and glipizide; effects of anticoagulants may increase with coadministration; increases in cyclosporine concentrations may occur when administered concurrently
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Monitor patient closely if rashes develop, and discontinue drug if lesions progress; may cause clinical hepatitis, cholestasis, and fulminant hepatic failure (including death) with underlying medical conditions such as AIDS, malignancy, or multiple concomitant medications; not recommended for breastfeeding women

Drug Name	Sertaconazole nitrate cream (Ertaczo) -- Topical imidazole antifungal active against T rubrum, T mentagrophytes, E floccosum. Indicated for tinea pedis.
Adult Dose	Apply topically bid to clean, dry skin between the toes and the immediate surrounding healthy skin
Pediatric Dose	<12 years: Not established >12 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	For topical use only; may cause dermatitis, dry skin, burning sensation, pruritus, hyperpigmentation, desquamation, or skin tenderness

FOLLOW-UP

Section 8 of 10

Deterrence/Prevention:

• Practice proper hygiene.

• Avoid contact with suspicious lesions.

Complications:

• Bacterial superinfection

• Generalized invasive dermatophyte infection

Prognosis:

• Infection generally resolves without sequelae within 1-2 weeks of therapy.

Patient Education:

• For excellent patient education resources, visit eMedicine's Skin, Hair, and Nails Center. Also, see eMedicine's patient education articles Ringworm on Body and Ringworm on Scalp.

TEST QUESTIONS

Section 9 of 10

CME Question 1: Which of the following should be considered when choosing drug therapy for fungal toenail infection?

A: Oral griseofulvin
B: Causative agent, likelihood of patient compliance, medication accessibility, and cost of therapy including medication, lab test, and follow-up requirements
C: Topical miconazole
D: Topical ketoconazole
E: Pulse therapy with a topical and oral agent

The correct answer is B: The practitioner should consider the patient`s resources, likelihood of follow-up to monitor therapeutic efficacy and side effects when more than one medication is available for therapy. The practitioner must include the patient about the financial impact of noncompliance as well as the cost of compliance. Sending a patient to a pharmacy to get a prescription without discussing or appreciating the cost of therapy could contribute to noncompliance. Successful educational interventions can improve compliance with treatment goals.

CME Question 2: A child has a patch of hair loss that is associated with scales. What is the most likely diagnosis?

A: Alopecia areata
B: Pediculosis capitis
C: Tinea capitis
D: Psoriasis
E: Impetigo

The correct answer is C: Alopecia areata causes patchy hair loss; however, the skin surface remains intact without scales. Psoriasis is scaly but rarely leads to hair loss. Pediculosis capitis does not cause hair loss. Impetigo results in yellowish (pus) crust.

Pearl Question 1 (T/F): Tinea cruris is best treated with a topical allylamine or an azole antifungal.

The correct answer is True: Multiple randomized controlled trials support treating tinea cruris with a topical allylamine (naftifine and terbinafine) or an azole antifungal (clotrimazole, econazole, ketoconazole, oxiconazole, miconazole, and sulconazole).

Pearl Question 2 (T/F): For tinea capitis, a safe and effective alternative to griseofulvin is itraconazole.

The correct answer is True: Griseofulvin has historically been considered the standard treatment of tinea capitis; however, recent studies support the efficacy and safety of itraconazole therapy.

Pearl Question 3 (T/F): Combination therapy of oral terbinafine and ciclopirox nail lacquer is a safe and more effective treatment for onychomycosis.

The correct answer is True: Combination therapy of oral terbinafine and ciclopirox nail lacquer is a safe and more effective treatment for onychomycosis than terbinafine alone, especially in younger patients and in shorter-duration onychomycosis.

Pearl Question 4 (T/F): Scalp skin is unique on the body due to the density of hair follicles and high rate of sebum production.

The correct answer is True: Scalp skin is unique on the body due to the density of hair follicles and high rate of sebum production. These features make it susceptible to superficial mycotic conditions (dandruff, seborrheic dermatitis, and tinea capitis), parasitic infestation (pediculosis capitis), and inflammatory conditions (psoriasis).

BIBLIOGRAPHY

Section 10 of 10

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