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Tinea infections are superficial fungal infections caused by three species of fungi collec-
tively known as dermatophytes. Commonly these infections are named for the body part
affected, including tinea corporis (general skin), tinea cruris (groin), and tinea pedis (feet).
Accurate diagnosis is necessary for effective treatment. Diagnosis is usually based on his-
tory and clinical appearance plus direct microscopy of a potassium hydroxide preparation.
Culture or histologic examination is rarely required for diagnosis. Treatment requires
attention to exacerbating factors such as skin moisture and choosing an appropriate anti-
fungal agent. Topical therapy is generally successful unless the infection covers an exten-
sive area or is resistant to initial therapy. In these cases, systemic therapy may be required.
Tinea corporis and cruris infections are usually treated for two weeks, while tinea pedis
is treated for four weeks with an azole or for one to two weeks with allylamine medica-
tion. Treatment should continue for at least one week after clinical clearing of infection.
Newer medications require fewer applications and a shorter duration of use. The pres-
ence of inflammation may necessitate the use of an agent with inherent anti-inflamma-
tory properties or the use of a combination antifungal/steroid agent. The latter agents
should be used with caution because of their potential for causing atrophy and other
steroid-associated complications. (Am Fam Physician 2002;65:2095-102. Copyright© 2002
American Academy of Family Physicians.)
T
inea infections are superficial fun- are not typically amenable to topical therapy,
gal infections caused by the three they will not be discussed in this article.
genera of dermatophytes, Tri- It is important to note that nondermato-
chophyton, Microsporum and phytes and yeasts may infect the sites men-
Epidermophyton.1 Commonly, tioned above. For example, tinea unguium is
the infections caused by these organisms are only a subset of the onychomycoses, which
named for the sites involved. Tinea capitis refers include other types of fungal infections of the
to a dermatophyte infection of the head, tinea nails. Similarly, tinea corporis refers only to
barbae affects the beard area, tinea corporis dermatophyte infection of the skin and not
occurs on the body surface, tinea manuum is other superficial fungal infections such as can-
limited to the hands, tinea pedis to the feet, and didiasis. Although tinea versicolor is com-
tinea unguium infects the toenails. These names monly called a tinea, it is caused by the non-
do not distinguish between species (for exam- dermatophyte Malassezia furfur (also referred
ple, tinea capitis may be caused by Trichophy- to as Pityrosporum orbiculare and Pityrospo-
ton or Microsporum genera). rum ovale) and is not a true tinea infection.4
With some pertinent exceptions, dermato-
mycosis is typically confined to the superficial Epidemiology
keratinized tissue2 and, thus, can often be Because tinea infections are highly com-
treated with topical antifungal medications.3 mon, it is likely that the primary care physi-
Because these agents do not penetrate hair or cian will frequently treat affected patients. The
nails, tinea capitis, tinea barbae, and tinea estimated lifetime risk of acquiring dermato-
unguium usually require systemic therapy. phytosis (tinea infection) is between 10 and
This article focuses on the diagnosis and treat- 20 percent.5 In the United States, dermatophy-
ment of tinea infections with topical medica- tosis is second only to acne as the most fre-
tions. Because tinea capitis and tinea unguium quently reported skin disease.6 The majority
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Trichophyton rubrum is the most common pathogen causing
dermatomycoses, including tinea pedis, tinea corporis, and
tinea cruris.
Clinical Manifestations
Clinical presentation is the most important
clue to accurate diagnosis and treatment. The
anthrophilic dermatophytes (commonly iso-
lated from human infection) are the most
common source of human dermatomycoses. FIGURE 2. Tinea pedis presenting with toe-
web maceration and minimal inflammation. A
These tend to evoke a limited host response presentation like this may be accompanied by
and are less likely to be accompanied by severe a dermatophytid (“id”) reaction.
inflammation or to clear spontaneously.9
Occasionally, severe inflammation is a com-
ponent of dermatophytosis. This is particu- TINEA CRURIS
larly true in the case of tinea infections caused Because it affects the groin area, tinea cruris
by zoophilic species (commonly isolated from is also known as “jock itch.” It is characterized
animal infection). The most common of these by red scaling plaques on the medial thighs and
is Microsporum canis. inguinal folds (Figure 1). The plaques are typi-
cally bilateral but usually spare the penis and
TINEA CORPORIS scrotum, in contrast to candidiasis.10 Many
Tinea corporis refers to tinea anywhere on people with tinea cruris have coincident tinea
the body except the scalp, beard, feet, or hands. pedis, and it has been postulated that the tinea
This lesion presents as an annular plaque with cruris is spread by hand from the tinea pedis.11
a slightly raised and often scaly, advancing
border and is commonly known as ringworm. TINEA PEDIS
Each lesion may have one or several concen- Tinea pedis, or athlete’s foot, is the most
tric rings with red papules or plaques in the common dermatophyte infection (Figure 2).
center. As the lesion progresses, the center may Its etiology is closely tied to the use of occlusive
clear, leaving post-inflammatory hypopig- footwear.12 Most commonly, tinea pedis pre-
mentation or hyperpigmentation. sents with toe-web maceration.13 This fairly
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Tinea Infections
MAY 15, 2002 / VOLUME 65, NUMBER 10 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 2097
growth.17 A dermatophyte test medium
Gentle heating may enhance detection of fungal elements (DTM) indicator can also be used. The latter
on potassium hydroxide testing. has the added advantage of a phenol indicator
that turns red in the alkaline environment pro-
duced by dermatophytes.18 Although DTM has
the advantage of simplicity, it has a high rate of
The slide should be covered with a cover false-positive and false-negative results.1
slip, and KOH (5 to 20 percent) should be All media require collection of an adequate
added to the side of the cover slip, allowing sample of infected material. Scale may be col-
capillary action to draw the KOH to the scaly lected in a manner similar to that used for the
sample. The preparation may be heated gently KOH preparation or with a cotton swab. The
over a flame to highlight the fungal elements. swab must first be moistened with sterile
If dimethyl sulfoxide has been added to the water and then rubbed vigorously over the
KOH, heating is not required. active border of the lesion. This method is best
During examination of the sample, the con- used when the lesion is not scaly or when the
denser of the microscope should be in the use of a blade or slide is impractical.19 The
down position. The presence of septate physician performing the culture must com-
hyphae confirms the diagnosis of tinea. The ply with stricter CLIA regulations. Performing
examiner should make sure that hyphae are cultures requires a level of certification that
being seen rather than the edge of an epithe- necessitates a laboratory inspection.
lial cell. It is helpful to visualize the hyphae
crossing the path of more than one cell. HISTOPATHOLOGIC EVALUATION
If clinical decisions are to be made based on When the diagnosis of a dermatophyte
microscopic examination, practitioners must infection remains in question after office test-
comply with Clinical Laboratory Improve- ing or failure to respond to treatment, biopsy
ment Amendments (CLIA) regulations. Per- specimens may be submitted to a pathologist
forming KOH examinations requires a for evaluation. Fungal staining with periodic
Provider–Performed Microscopy (PPM) cer- acid–Schiff highlights fungal elements.17
tificate. Obtaining the latter requires comple-
tion of paperwork and does not require a site Treatment
inspection. The American Academy of Derma- Most tinea corporis, cruris, and pedis infec-
tology publishes a handbook with directions tions can be treated with topical agents.
for compliance with the PPM regulation.16 Consideration should be given to systemic
treatment when lesions covering a large body-
Culture surface area fail to clear with repeated treat-
Mycologic culture is rarely indicated in the ment using different topical agents.3 In treat-
diagnosis of tineas other than tinea unguium ing dermatophytosis, the physician must also
and tinea capitis. In some cases, even though address environmental factors that lead to or
clinical suspicion is high, diagnosis may be a exacerbate tinea infection and select an appro-
challenge. Culture, while relatively simple to priate topical therapy for the infection.
perform, requires one to four weeks to grow
and clinical expertise to interpret the result. The NONPHARMACOLOGIC MEASURES
most common medium used for isolating der- Because fungi thrive in moist warm envi-
matophytes is Sabouraud’s peptone-glucose ronments, patients should be encouraged to
agar.1 Various formulations of this medium are wear loose-fitting garments made of cotton or
commercially available; some have additives synthetic materials designed to wick moisture
that inhibit bacterial and nondermatophyte away from the surface. Socks should have sim-
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Tinea Infections
ilar properties. Areas likely to become infected will provide clinical and mycologic cure,
should be dried completely before being cov- symptomatic relief, and low relapse rate, along
ered with clothes. Patients should also be with ease of use. In addition to specific anti-
advised to avoid walking barefoot and sharing fungal properties, some preparations have
garments.
MAY 15, 2002 / VOLUME 65, NUMBER 10 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 2099
antibacterial and anti-inflammatory proper- tive bacteria. It has been shown to be more
ties that may influence their efficacy. Combi- effective than the nonprescription agent clotri-
nation therapy (antifungal plus steroid) can mazole (Lotrimin) in the treatment of tinea
be considered when inflammation is an issue. pedis.25 It requires twice-daily application.
Combination agents should not be used when Ciclopirox 8 percent lacquer (Penlac), which
the diagnosis is in question because that may was approved for treatment of onychomycosis
lead to their overuse or to adverse effects. in late 1999, has limited efficacy. In two trials of
The mechanism of action may have an daily application to infected toenails for
effect on efficacy. The newer agents have 48 weeks, complete cure was achieved in
fungicidal activity, which may translate into 5.5 and 8.5 percent of patients. Only the latter
higher cure rates and lower relapse rates. Clin- was statistically significant compared with
ical judgment with regard to prior treatments placebo. Partial clearance was also low (12 per-
and complicating conditions (bacterial cent in the more successful trial). Penlac
growth or intense inflammation), along with requires daily application for up to 48 weeks
knowledge of the agent’s properties, will help and monthly follow-up for nail debridement.26
guide the choice of therapy. When inflamma- Butenafine. This agent is similar in structure
tion is a salient clinical feature, it must be con- to that of the allylamines. Butenafine is fungi-
sidered in the selection of a treatment option. cidal for dermatophytes in vitro.27 It is applied
Tolnaftate. This narrow-spectrum antifun- once daily and, after four weeks of use, is asso-
gal has no antibacterial or anticandidal activ- ciated with high cure rates and a long disease-
ity.21 It is effective in most dermatophytoses free interval.28
and for treatment of tinea versicolor.22 It is Azoles. This class includes many over-the-
available as an over-the-counter medication counter and prescription preparations. Mem-
and requires twice-daily application. bers of this class include clotrimazole, econa-
Haloprogin. Introduced after tolnaftate, zole (Spectazole), ketoconazole (Nizoral),
haloprogin combines equivalent efficacy with miconazole (Micatin), oxiconazole (Oxistat),
a broadened fungal spectrum (including and sulconazole (Exelderm). These agents
yeasts).23 It is associated with higher rates of have broad-spectrum activity, including activ-
irritant dermatitis.24 It is applied twice daily. ity against some gram-positive bacteria. Keto-
Ciclopirox. This broad-spectrum agent is conazole,29 sulconazole and oxiconazole30
effective against dermatophytes, yeasts, and require only once-daily application because of
some bacteria.3 It has in vitro antibacterial their long durability in the superficial layers of
activity against gram-negative and gram-posi- the skin. Clotrimazole, miconazole, and
econazole require twice-daily application.
Allylamines. Naftifine (Naftin) and terbina-
fine (Lamisil) are applied once-daily and
The Authors
remain active in the skin for up to one week
ANDREW WEINSTEIN, M.D., M.P.H., is a resident in the Department of Dermatology after application.31,32 Both agents have fungi-
and Cutaneous Surgery at the University of Miami School of Medicine. He received his
medical degree from the University of Illinois College of Medicine at Urbana-Cham- cidal activity in vitro, but the clinical signifi-
paign and a master of public health degree from Florida International University, Miami. cance of this point is uncertain.33,34 Terbina-
BRIAN BERMAN, M.D., PH.D., is professor in the departments of Dermatology and fine has been compared with ketoconazole
Cutaneous Surgery, and Internal Medicine at the University of Miami School of Medi- and miconazole. Terbinafine was more effica-
cine. He received his medical and postdoctoral degrees from New York University cious after one week than ketoconazole was
School of Medicine, New York. He completed residency training in dermatology at
New York University School of Medicine. after two weeks.35 In addition, one week of
terbinafine was found to be as effective as four
Address correspondence to Brian Berman, M.D., Ph.D., Department of Dermatology
and Cutaneous Surgery, University of Miami School of Medicine, P.O. Box 016250 weeks of miconazole.36 Evidence also suggests
(R-250), Miami, FL 33101. Reprints are not available from the authors. that terbinafine may be effective in curing
2100 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 65, NUMBER 10 / MAY 15, 2002
Tinea Infections
tinea pedis in as few as three applications.37 ing areas of thin skin and naturally occluded
Naftifine has intrinsic anti-inflammatory body areas, such as the groin, axillae, breast,
properties equivalent to members of the azole and face. Treatment of these areas should be
class plus 1 percent hydrocortisone.38 Evi- avoided whenever possible. When the groin is
dence suggests that the fungicidal activity of affected by dermatophytosis, the cream
naftifine and its duration of activity result in should be used sparingly and only for two
higher cure rates and a lower relapse rate.39 weeks. The recommended duration of treat-
ment for tinea pedis is four weeks. This com-
COMBINED STEROID/ANTIFUNGAL AGENTS bination should not be used in children
In the United States, the only combination younger than 12 years.
steroid/antifungal agent indicated for the
treatment of dermatophytosis is clotrimazole- The authors indicate that they do not have any con-
betamethasone (Lotrisone). This formulation flicts of interest. Sources of funding: none reported.
combines an effective antifungal agent with a
potent steroid. Patients who have sympto- REFERENCES
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