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A. Tinea Pedis navigator

  1. Lifetime prevalence of 70%
  2. More common in summer months with occlusive footwear
  3. Transmitted by walking barefoot on contaminated floors or surfaces
  4. Interdigital type
    1. Most common type
    2. Caused by Trichophytum rubrum or Epidermophyton floccosum
    3. Affects skin between toes particularly 4th and 5th digits
    4. Presents with maceration, peeling and fissuring of toe webs
  5. Moccasin Type
    1. Seen more commonly in atopic individuals
    2. Caused by contact with Trichophytum mentagrophytes
    3. Well-demarcated erythema, minute papules on margin, fine white scaling, and hyperkeratosis
    4. Spread by contact with contaminated surface
  6. Inflammatory Type
    1. Least common type
    2. Caused by Trichophytum mentagrophytes
    3. Contact dermatitis to dermatophyte antigen
    4. Presents with vesicles or bullae filled with clear fluid
  7. Laboratory Diagnosis [3]
    1. Most cutaneous fungi require potassium hydroxide (KOH) preparation of skin
    2. Leading edge of scale or rash is scraped carefully with scalpal onto slide
    3. One drop of 10-15% KOH (in dimethylsulfoxide, DMSO) is added to sample
    4. If DMSO not used, then sample must be heated briefly
    5. Visualization of hyphae on direct microscopy is then made
    6. Alternatively, fungal culture may be performed and requires 1-3 weeks
    7. Cultures are positive for dermatophytes in ~30% of cases
  8. Treatment [4]
    1. Large number of non-prescription and prescription topical antifungals available
    2. Econazole (generic or Spectazole®) qd x 4 weeks
    3. Tolnaftate (generic, Tinactin®, Ting®) bid x 4 weeks
    4. Miconazole (generic, Micatin®, Monistat-Derm®) nitrate 2% bid x 4 weeks
    5. Clotrimazole (generic, Cruex®, Lotrimin AF®, Mycelex®) bid x 4 weeks
    6. Sertaconazole (Ertaczo®) 2% cream bid x 4 weeks
    7. Ketoconazole (generic, Nizoral®) 2% qd for 6 weeks
    8. Terbinafine hydrochloride (Lamisil AT®, Desenex Max®) 1% bid for 6 weeks
    9. Butenafine (Mentax®, Lotrimin Ultra®) qd x 2 weeks
    10. Naftifine (Naftin®) gel qd x 204 weeks
    11. Oral antifungals for recalcitrant cases or moccasin-type tinea pedis
    12. Effective oral agents include itraconazole (Sporanox®) or terbinafine (Lamisil®)
    13. Terbinafine, fluconazole or itraconazole are well tolerated and very effective for treatment of superficial fungal infections (dermatomycoses and onychomycoses) [6]

B. Tinea Capitisnavigator

  1. Dermatophyte infection of scalp caused by:
    1. Trichophyton tonsurans
    2. Microsporum canis
    3. M. audouinii
  2. Peak incidence in children 4 to 14 years of age
  3. Outbreaks occur in schools and other institutions
  4. Causes a well defined area of alopecia with broken hairs
  5. May progress to a kerion: a boggy inflamed oozing nodules and plaques
  6. Laboratory Diagnosis
    1. Microsporum species fluoresce under Wood's lamp
    2. Direct microscopy of hair roots and skin scales
    3. KOH preparation as above with microscopic examination
    4. Fungal culture of infected area (requires 10-14 days for growth)
  7. Treatment
    1. Topical therapies not affective
    2. First line terbinafine 10 mg/kg/day (Lamisil®)
    3. Griseofulvin (20 mg/kg/day) commonly used in pediatric populations
    4. Alternately use itraconazole (5 mg/kg/day)
    5. Continue therapy until symptoms resolve (typically 6-8 weeks)

C. Tinea Corporis [3]navigator

  1. Dermatophtye infection of torso or extremities
    1. All aerobic organisms
    2. Assimilate keratin and penetrate keratinized layers of skin
  2. Causative agents include:
    1. Trichophytum rubrum
    2. T. tonsurans
    3. T. mentagrophytes
    4. Microsporum canis
  3. Spread by auto-innoculation from other parts of body or contact with infected animals
  4. Anular Lesion
    1. Also known as ringworm
    2. Presents with well-circumscribed annular plaques with areas of central clearing
  5. Differential Diagnosis
    1. Pityriasis rosea
    2. Granuloma annulare
    3. Sarcoidosis
    4. Subacute cutaneous lupus erythematosus
    5. Erythema annulare centrifugum
    6. Leprosy
    7. Various other less common diseases
  6. Laboratory Diagnosis
    1. Direct Microscopy identification of hyphae
    2. KOH preparation as above
    3. Fluoresce under Woods light
    4. Positive fungal culture
  7. Treatment with topical antifungals
    1. Econzaole qd for 4 weeks
    2. Miconazole 2% (Monistat®) bid for 2 weeks
    3. Clotrimazole (Lotrimin®) qd for 2 weeks
    4. Terbinafine (Lamisil®) 1% cream qd for 4 weeks
  8. Resistant cases with oral antifungals such as terbinafine or itraconazole (Sporanox®)

D. Tinea Cruris navigator

  1. Dematophyte infection of the groin, pubic regions and thighs
  2. Known as "Jock itch"
  3. Presents as bilateral erythematous plaques
    1. Spreading to buttocks and thighs
    2. Sparing penis and scrotum
  4. Plaques often have with central clearing with papules and vesicles
  5. Symptoms include itching and burning sensations
  6. Causative Fungi
    1. Epidermophyton foccosum
    2. Trichophytum rubrum
    3. T. mentagrophytes
  7. Predisposing factors include humid climates, obesity, and tight clothing
  8. Individuals often have tinea pedis; dermatophyte transferred from feet to groin area
  9. Laboratory Diagnosis
    1. Direct Microscopy
    2. Positive fungal culture
  10. Treatment
    1. Econzole qd for 4 weeks
    2. Miconazole nitrate 2% bid for 2 weeks
    3. Ketoconazole 5% qd for 2 weeks
    4. Terbinafine hydrochloride 1% qd or bid for 4 weeks
    5. Systemic antifungals for topical treatment failures [6]
    6. Recurrence common unless tinea pedis also treated

E. Tinea (Pityriasis) Versicolor [5]navigator

  1. One of most common pigmentary disorders worldwide
    1. Prevalance up to 40% in tropics
    2. Common in temparate areas, up to 3% of cases in dermatology clinics in summer
  2. Cause
    1. Lipophhilic dimorphic yeasts of the genus Malassezia in most cases
    2. Malassezia furfur, globosa and sympodialis most commonly
    3. These are normal inhabitants of the superficial stratum corneum
    4. Disease results from chnage to mycelial state under conditions of high humidity
    5. Malassezia previously called Pityrosporum
  3. Appearance
    1. Causes well-demarcated scaling patches with variable depigmentation
    2. Irregularly shaped slightly scaling macules and papules
    3. Generally cover large areas of body, lesions separated with normal skin
    4. May have inability to tan in areas of infection
  4. Lesions located on head, upper trunk, upper arms, neck, back, abdomen or groin area
  5. Laboratory diagnosis
    1. KOH preparation of scale: filamentous hyphae and globulose yeast forms
    2. Often termed "spaghetti and meatballs"
    3. Wood's lamp examination of skin scale shows blue green flourescence
    4. Biopsy specimen with yeast and hyphae in superficial stratum corneum
  6. Treatment
    1. Topical therapy generally preferred, particularly in children
    2. Selenium sulfide 2.5% qd for 10 days
    3. Propylene glycol 50% solution bid for 2 weeks
    4. Ketoconazole shampoo
    5. Azole creams bid for 2 weeks
    6. Systemic therapy for topical treatment failures
    7. Fluconazole (300mg weekly x 2 weeks) or itraconazole (200mg qd for 5-7 days) effective
    8. High recurrence rate; prophylactic regimen itraconazole 200mg x 2 each month x 6 months

F. Piedra [5]navigator

  1. Asymptomatic fungal infection of hair shaft
  2. Two Types: White and Black
    1. White: most prevalent in temperate and semiropical climates including USA
    2. Black: tropics worldwide
  3. Causes
    1. Mainly Trichosporon species, particularly T. asahii, ovoides, inkin, mucoides
    2. Also by Acremonium and Brevibacterium species
  4. Clinical Presentation
    1. White piedra mainly affects pubic and axillary hair, facial hair, eyebrows, eyelashes
    2. Black piedra usually affects scalp hair, makes metallic sound when brushing
  5. Diagnosis
    1. Conventional fixation methods
    2. Hair sectioned and stained with toluidine blue after 10-15% KOH preparation
    3. White piedra has spores sometimes surrounded by coexistent bacteria
    4. Black piedra have tightly packed and pigmented hyphae, asci or ascospores
  6. Treatment
    1. White piedra treated with topical antifungals
    2. Topicals include ciclopirox, selenium sulfphide, chlorhexidine, imidazoles
    3. Oral itraconazole for uncomplicated white piedra not responsive to topicals
    4. Genital white piedra best treated by shaving pubic hair and adding topical antifungal
    5. Black piedra treated best by cutting hair; also responds to oral terbinafine

G. Tinea Nigra [5]navigator

  1. common in tropical regions of Central and South America, Africa, Asia
    1. Infrequent in USA and Europe
    2. May be found in southern coastal states in USA
  2. Caused by Hortaea werneckii
  3. Arises in areas of body with increased eccrine sweat glands
    1. May be increased in patients with excessive sweating (hyperhidrosis)
    2. Transmitted by traumatic inoculation from soil, sewage, wood, compost
    3. Incubation period 2-7 weeks
  4. One oval-shaped macule or patch; painless, discrete, light brown-black in color
  5. Diagnosis with material from scaple blade scrape of lesion and KOH preparation
  6. Treatment
    1. Topical ciclopirox, tiabendazole, terbinafine
    2. Oral azole therapy also curative
  7. Disease tends not to recur after treatment

References navigator

  1. Elewski BE and Zuber TZ. Diagnosis and Management of Cutaneous Mycoses. AAFP. pp1
  2. Fitzpatrick TB, et. al. 1997. Color Atlas and Synopsis of Clinical Dermatology. McGraw-Hill.
  3. Hsu S, Le EH, Khoshevis MR. 2001. Am Fam Phys. 62(2):289
  4. Topical Sertaconazole. 2004. Med Let. 46(1185):50 abstract
  5. Schwartz RA. 2004. Lancet. 364(9440):1173 abstract
  6. Chang C, Young-Xu Y, Kurth T, et al. 2007. Am J Med. 120(9):791 abstract