Superficial fungal infection diagnosis and treatments

Tinea Type	Risk Factors	Treatment	Complications

Tinea Capitis (Scalp Ringworm)

Young children poor hygiene contact with infected pet sharing combs/hats

Oral antifungals (e.g., griseofulvin terbinafine itraconazole)

Permanent hair loss, secondary bacterial infection, kerion formation

Tinea Corporis (Body Ringworm)

Contact with infected individuals or animals warm and humid climates compromised immunity

Topical antifungals (e.g., clotrimazole, miconazole) for mild cases; oral antifungals (e.g., terbinafine, itraconazole) for extensive or refractory infections

Secondary bacterial infection, autoinoculation to other body parts

Tinea Cruris (Jock Itch)

Male gender obesity sweating tight clothing warm climate

Topical antifungals (e.g., clotrimazole, terbinafine); keeping the area dry and clean; using antifungal powders to prevent recurrence

Secondary bacterial infections, chronic infection, pigment changes

Tinea Pedis (Athlete’s Foot)

Frequenting damp communal areas like gyms or pools tight footwear sweaty feet

Topical antifungals (e.g., terbinafine, clotrimazole); oral antifungals for severe or moccasin-type infections

Secondary bacterial infections, lymphangitis, id reaction

Tinea Manuum (Hand Fungus)

Contact with another site of infection (e.g., tinea pedis) compromised immune system

Topical antifungals for localized infection oral antifungals for more extensive cases

Chronic infection, spread to other parts of the body

Tinea Unguium (Onychomycosis)

Aging diabetes nail trauma poor circulation public showers

Oral antifungals (e.g., terbinafine, itraconazole) most effective; topical treatments for mild cases

Permanent nail damage, spread of infection, cellulitis

Tinea Barbae (Barber’s Itch)

Male adults farming contact with infected animals shaving irritation

Oral antifungals (e.g., terbinafine, itraconazole) due to the depth of hair follicle involvement topical steroids to reduce inflammation

Scarring, permanent hair loss, secondary bacterial infections

Tinea Faciei (Face Fungus)

Direct contact with infected animals or individuals use of topical steroids (tinea incognito) environmental exposure

Topical antifungals usually suffice oral antifungals for extensive cases or when topical treatment fails

Misdiagnosis as eczema or psoriasis leading to inappropriate use of topical steroids

Tinea Capitis (Scalp Ringworm)

Risk Factors:

• Young children
• Poor hygiene
• Contact with infected pets
• Sharing combs/hats

Treatment:

• Oral antifungals (e.g., griseofulvin, terbinafine, itraconazole) are necessary as topical treatments do not penetrate the hair follicle deeply enough.

Complications:

• Permanent hair loss
• Secondary bacterial infection
• Kerion formation

Tinea Corporis (Body Ringworm)

Risk Factors:

• Contact with infected individuals or animals
• Warm and humid climates
• Compromised immunity

Treatment:

• Topical antifungals (e.g., clotrimazole, miconazole) for mild cases
• Oral antifungals (e.g., terbinafine, itraconazole) for extensive or refractory infections

Complications:

• Secondary bacterial infection
• Autoinoculation leading to infection in other body parts

Tinea Cruris (Jock Itch)

Risk Factors:

• Male gender
• Obesity
• Sweating
• Tight clothing
• Warm climate

Treatment:

• Topical antifungals (e.g., clotrimazole, terbinafine)
• Keeping the area dry and clean
• Using antifungal powders to help prevent recurrence

Complications:

• Secondary bacterial infections
• Chronic infection
• Pigment changes

Tinea Pedis (Athlete’s Foot)

Risk Factors:

• Frequenting damp communal areas like gyms or pools
• Tight footwear
• Sweaty feet

Treatment:

• Topical antifungals (e.g., terbinafine, clotrimazole)
• Oral antifungals may be necessary for severe or moccasin-type infections

Complications:

• Secondary bacterial infections
• Lymphangitis
• Allergic reaction to fungus causing blistering elsewhere (id reaction)

Tinea Manuum (Hand Fungus)

Risk Factors:

• Contact with another site of infection (e.g., tinea pedis)
• Compromised immune system

Treatment:

• Topical antifungals for localized infection
• Oral antifungals for more extensive cases

Complications:

• Chronic infection
• Spread to other parts of the body, especially if hygiene practices are poor

Tinea Unguium (Onychomycosis)

Risk Factors:

• Aging
• Diabetes
• Nail trauma
• Poor circulation
• Public showers

Treatment:

• Oral antifungals (e.g., terbinafine, itraconazole) are most effective
• Topical treatments are less effective but may be used in mild cases

Complications:

• Permanent nail damage
• Spread of infection
• Cellulitis

Tinea Barbae (Barber’s Itch)

Risk Factors:

• Male adults
• Farming
• Contact with infected animals
• Shaving irritation

Treatment:

• Oral antifungals (e.g., terbinafine, itraconazole) due to the depth of hair follicle involvement
• Topical steroids might be used to reduce inflammation

Complications:

• Scarring
• Permanent hair loss
• Secondary bacterial infections

Tinea Faciei (Face Fungus)

Risk Factors:

• Direct contact with infected animals or individuals
• Use of topical steroids (tinea incognito)
• Environmental exposure

Treatment:

• Topical antifungals usually suffice
• Oral antifungals may be used for extensive cases or when topical treatment fails

Complications:

• Misdiagnosis as eczema or psoriasis leading to inappropriate use of topical steroids, which can worsen the infection

Assessment

• Initial Assessment:
  • Suspect based on clinical history and physical examination.
  • Confirm diagnosis through investigations, especially important as many conditions mimic tinea.
• Empirical Treatment:
  • Localized infections may be initially treated with topical therapy.
  • Testing is recommended before starting systemic therapy to guide duration of treatment.
• Identifying Reservoirs:
  • Check for potential reservoirs of infection, particularly toenails, which can lead to recurrent tinea pedis and spread to other areas like hands and groin.
  • Animals, especially cats and dogs, can also be reservoirs for dermatophytes like Microsporum canis.

Diagnostic Tests

• Fungal Microscopy and Culture:
  • Perform on skin scrapings and nail clippings using KOH for rapid results.
  • Fungal culture is more definitive but can take 4-6 weeks, with a notable false-negative rate for nail samples.
• Repeat Testing:
  • Necessary if clinical suspicion remains high despite negative initial results.

Advice on Specimen Collection

• Pre-collection Precautions:
  • Remove any topical antifungal or corticosteroid cream to avoid false negatives.
  • Label each specimen container separately for accurate site identification.
• Collection Techniques:
  • Skin Scrapings: Use a scalpel blade, sampling from the active edge of the lesion.
  • Nail Clippings/Scrapings: Clip the infected nail portion, collecting subungual debris using a curette.
  • Hair Specimen: Use forceps or a brush, ensuring to collect the hair root.
• Special Considerations:
  • For children, a sterile moistened cotton swab can be used as an alternative, less invasive method.

Treatment Modalities

• Extent and Location Dependent:
  • Treatment varies based on the severity and location of the infection.
• Systemic Therapy:
  • Oral terbinafine and azoles are commonly used, especially in extensive or severe cases.

Topical Antifungal Therapy

• Suitable for: Tinea corporis, tinea cruris, tinea pedis.
• First-line Topical Agents:
  • Terbinafine 1% cream, applied once or twice daily for 1-2 weeks.
• Onychomycosis Topical Treatment:
  • Ciclopirox 8% nail lacquer, daily for 9-12 months.
  • Amorolfine 5% nail lacquer, daily for 9-12 months with nail debridement.
  • Mycological cure rates: 29-36% for ciclopirox and 38% for amorolfine.

Oral Antifungal Therapy

• Indicated for:
  • Onychomycosis.
  • Tinea capitis.
  • Extensive tinea on the skin.
  • Failed topical treatment.
  • Immunocompromised patients.
• First-line Oral Antifungal:
  • Terbinafine 250 mg daily for adults. Check pediatric dosing in specific references.
  • Generally safe without the need for routine blood monitoring.
  • Contraindicated in severe liver impairment, dosage adjustments needed for significant renal impairment.
• Duration by Infection Site:
  • Scalp: 4 weeks.
  • Fingernails: 6 weeks.
  • Toenails: 12 weeks.
  • Skin (excluding scalp and nails): 2 weeks.
• Comparative Efficacy:
  • Terbinafine superior to fluconazole and itraconazole for onychomycosis according to a 2017 Cochrane review.
• Griseofulvin:
  • Dosage for tinea capitis: 10 mg/kg up to 500 mg for 6-8 weeks.
  • Third-line for tinea corporis due to lower efficacy compared to terbinafine and azoles.
  • Not recommended for onychomycosis due to longer treatment duration and higher adverse events.
  • Dosing varies: 500 mg daily for tinea capitis, corporis, cruris; 1 g daily for tinea pedis and onychomycosis.

Laser Therapy

• Efficacy: Significantly lower cure rates compared to topical and oral therapies.
• Recommendation: Not advised as a first-line treatment for onychomycosis due to limited efficacy and high cost.

Prevention of Recurrence

• Recurrence Rate: Up to 25% post-treatment.
• Preventive Measures:
  • Avoid sharing personal items like hairbrushes, clothes, or shoes.
  • Avoid walking barefoot in public areas.
  • Regularly alternate footwear and change socks.
• Prophylactic Topical Antifungal Therapy:
  • Apply ciclopirox, amorolfine, bifonazole, or terbinafine weekly.
  • Shown to significantly reduce recurrence rates.
  • Optimal duration of prophylaxis remains unclear, potentially indefinite.

Management Tips

• Examination: Complete skin and nail examinations to determine the full extent of involvement and identify any dermatophyte reservoirs.
• Monitoring Therapy:
  • Use photographic monitoring and mark the nail at the proximal end of the dystrophy to track treatment progress.
  • Topical treatments are generally ineffective against onychomycosis; consider systemic options for severe cases.
• Preventive Measures:
  • Use antifungal shampoos for tinea capitis to reduce transmission risk, though they do not cure the infectio