Tinea

11.17 Tinea (Athlete's Foot, ringworm)

Presentation
Patients usually seek emergency care for "athlete's foot," "jock itch," or "ringworm" when pruritis is severe or when secondary infection causes pain and swelling. Tinea pedis is usually seen as interdigital scaling, maceration, and fissuring between toes. At times tense vesicular lesions will be present instead. Tinea cruris is usually a moist, mildly erythematous eruption symmetrically affecting both groin and upper inner thigh. Tinea corporis appears most often on the hairless skin of children as dry erythematous lesions with sharp annular and arciform borders that are scaling or vesicular.
What to do:



When microscopic examination of skin scrapings in KOH is readily available, definite identification of the lesion can be made by looking for the presence of hyphae or spores (resembling microscopic spaghetti and meatballs) in the scabs or hair. Treatment can be started presumptively when microscopic examination is not easily accomplished.



Clotrimazole (Lotrimin), miconazole (Micatin) haloprogin (Halotex) and tolnaftate (Tinactin) solution or cream applied to the rash bid will cause involution of most superficial lesions within 1-2 weeks.



With signs of secondary infection, begin treatment first with wet compresses of Burow's solution (2 pks of Domeboro powder in 1 pint water) one half hour every 34 hours. With signs of deep infection (cellulitis, lymphangitis) begin systemic antibiotics in addition, like cefadroxil (Duricef) lgm qd x 5-7 day or cephalexin or dicloxacillin 250-500mg tid x 5-7 days.



With inflammation and weeping lesions, a topical antifungal and steroid cream such as (Vioform- Hydrocortisone) in addition to the compresses will be most effective. Warn patients that this medication will stain white clothing yellow.
What not to do:



Do not attempt to treat deep, painful fungal infections of the scalp (tinea capitis) with local therapy. A deep boggy swelling (tinea kerion) or patchy hair loss with inflammation and scaling requires systemic antifungal antibiotics like griseofulvin.



Do not treat with corticosteroids alone. They will reduce signs and symptoms, but allow increased fungal growth.

Discussion
Tinea versicolor is asymptomatic, and its presentation to an acute care facility usually is incidental with some other problem. There is, however, no reason to ignore this fungal infection, which causes cosmetically unpleasant, irregular patches of varying pigmentation that tend to be lighter than the surrounding skin in the summer and darker than the surrounding skin in the winter. Prescribe a 25% sodium hyposulfite lotion (Tinver) bid for several weeks or a 2.5% selenium sulfide lotion (Selsun). Superficial scaling will resolve in a few days and the pigmentary changes will slowly clear over a period of several months.