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Geriatric Considerations
Tinea cruris is more common in the geriatric population due to an increase in risk factors.
Pregnancy Considerations
Tinea cruris and capitis are rare in pregnancy.
ETIOLOGY AND PATHOPHYSIOLOGY
Superficial fungal infection of skin/scalp
- Tinea cruris: Source of infection is usually the patient 's own tinea pedis, with agent being transferred from the foot to the groin via the underwear when dressing; most common causative dermatophyte is Trichophyton rubrum; rare cases caused by Epidermophyton floccosum and T. mentagrophytes.
- Tinea corporis: most commonly caused by T. rubrum; T. tonsurans most often found in patients with tinea gladiatorum.
- Tinea capitis: T. tonsurans found in 90% and Microsporum sp. in 10% of patients
Genetics
Evidence suggests a genetic susceptibility in certain individuals.
RISK FACTORS
- Warm climates; summer months and/or copious sweating; wearing wet clothing/multiple layers (tinea cruris)
- Daycare centers/schools/confined quarters (tinea corporis and capitis)
- Depression of cell-mediated immune response (e.g., individuals with atopy or AIDS)
- Obesity (tinea cruris and corporis)
- Direct contact with an active lesion on a human, an animal, or rarely, from soil; working with animals (tinea corporis)
GENERAL PREVENTION
- Avoidance of risk factors, such as contact with suspicious lesions
- Fluconazole or itraconazole may be useful in wrestlers to prevent outbreaks during competitive season.
COMMONLY ASSOCIATED CONDITIONS
Tinea pedis, tinea barbae, tinea manus
DIAGNOSIS
HISTORY
- Lesions range from asymptomatic to pruritic.
- In tinea cruris, acute inflammation may result from wearing occlusive clothing; chronic scratching may result in an eczematous appearance.
- Previous application of topical steroids, especially in tinea cruris and corporis, may alter the overall appearance causing a more extensive eruption with irregular borders and erythematous papules. This modified form is called tinea incognito.
PHYSICAL EXAM
- Tinea cruris: well-marginated, erythematous, half-moon " shaped plaques in crural folds that spread to upper thighs; advancing border is well defined, often with fine scaling and sometimes vesicular eruptions. Lesions are usually bilateral and do not include scrotum/penis (unlike with Candida infections) but may migrate to perineum, perianal area, and gluteal cleft and onto the buttocks in chronic/progressive cases. The area may be hyperpigmented on resolution.
- Tinea corporis: scaling, pruritic plaques characterized by a sharply defined annular pattern with peripheral activity and central clearing (ring-shaped lesions); papules and occasionally pustules/vesicles present at border and, less commonly, in center.
- Tinea capitis: commonly begins with round patches of scale (alopecia less common). In its later stages, the infection frequently takes on patterns of chronic scaling with either little/marked inflammation or alopecia. Less often, patients will present with multiple patches of alopecia and the characteristic black-dot appearance of broken hairs. Extreme inflammation results in kerion formation (exudative, pustular nodulation).
DIFFERENTIAL DIAGNOSIS
- Tinea cruris
- Intertrigo: inflammatory process of moist-opposed skin folds, often including infection with bacteria, yeast, and fungi; painful longitudinal fissures may occur in skin folds.
- Erythrasma: diffuse brown, scaly, noninflammatory plaque with irregular borders, often involving groin; caused by bacterial infection with Corynebacterium minutissimum; fluoresces coral red with Wood lamp
- Seborrheic dermatitis of groin
- Psoriasis of groin ( "inverse psoriasis " )
- Candidiasis of groin (typically involves the scrotum)
- Acanthosis nigricans
- Tinea capitis
- Psoriasis
- Seborrheic dermatitis
- Pyoderma
- Alopecia areata and trichotillomania
- Aplasia cutis congenital
- Tinea corporis
- Pityriasis rosea
- Eczema (nummular)
- Contact dermatitis
- Syphilis
- Psoriasis
- Seborrheic dermatitis
- Subacute systemic lupus erythematosus (SLE)
- Erythema annulare centrifugum
- Erythema multiforme; erythema migrans
- Impetigo circinatum
- Granuloma annulare
DIAGNOSTIC TESTS & INTERPRETATION
Wood lamp exam reveals no fluorescence in most cases (Trichophyton sp.); 10% of infections, those caused by T. rubrum will fluoresce with a green light.
Initial Tests (lab, imaging)
- Potassium hydroxide (KOH) preparation of skin scrapings from dermatophyte leading border shows characteristic translucent, branching, rod-shaped hyphae.
- Arthrospores can be visualized within hair shafts. Spores and/or hyphae may be seen on KOH exam.
Follow-Up Tests & Special Considerations
- Reevaluate to assess response, especially in resistant/extensive cases
- Fungal culture using Sabouraud dextrose agar/dermatophyte test medium
Test Interpretation
- Skin scrapings show fungal hyphae in epidermis.
- Arthrospores found in hair shafts; spores and/or hyphae seen on KOH exam.
TREATMENT
GENERAL MEASURES
- Careful handwashing and personal hygiene; laundering of towels/clothing of affected individual; no sharing of towels/clothes/headgear
- Evaluate other family members, close contacts, or household pets.
- Avoid predisposing conditions such as hot baths and tight-fitting clothing (boxer shorts are better than briefs).
- Keep area as dry as possible (talcum/powders may be beneficial).
- Itching can be alleviated by OTC preparations such as Sarna or Prax.
- Topical steroid preparations should be avoided (see "Tinea Incognito " ), unless absolutely needed to control itching and only after definitive diagnosis and initiation of antifungal treatment.
- Nystatin should be avoided in tinea infections but is indicated for cutaneous candidal infections.
- Avoid contact sports (e.g., wrestling) temporarily while starting treatment.
MEDICATION
First Line
- Tinea cruris/corporis (2)[C]
- Topical azole antifungal compounds
- Terbinafine 1% (Lamisil): OTC inexpensive and effective compound; can be applied once or BID for 1 to 2 weeks
- Econazole 1% (Spectazole), ketoconazole (Nizoral): usually applied BID for 2 to 3 weeks
- Butenafine 1% (Mentax): applied once daily for 2 weeks; also very effective. To prevent relapse, use for 1 week after resolution.
- Tinea capitis (3)[A]
- PO griseofulvin for Trichophyton and Microsporum sp.; microsized preparation available; dosage 10 to 20 mg/kg/day (max 1,000 mg); taken BID or as a single dose daily 6 to 12 weeks
- PO terbinafine can be used for Trichophyton sp. at 62.5 mg/day in patients weighing 10 to 20 kg; 125 mg/day if weight 20 to 40 kg; 250 mg/day if weight >40 kg; use for 4 to 6 weeks.
- PO itraconazole can be used for Microsporum sp. and matches griseofulvin efficacy while being better tolerated. Dosage of 3 to 5 mg/kg/day, but most studies have used 100 mg/day for 6 weeks in children >2 years of age.
Second Line
Tinea cruris/corporis
- Oral antifungal agents are effective but not indicated in uncomplicated tinea cruris/corporis cases. They can be used for resistant and extensive infections or if the patient is immunocompromised. If topical therapy fails, consider possible oral therapy. Griseofulvin can be given 500 mg/day for 1 to 2 weeks.
- The following oral regimens have been reported in medical literature as being effective but currently are not specifically approved by FDA for tinea cruris:
- PO terbinafine (Lamisil): 250 mg/day for 1 week
- PO itraconazole (Sporanox): 100 mg BID once and repeated 1 week later
- PO fluconazole (Diflucan): 150 mg once per week for 4 weeks
- Topical terbinafine 1% solution has been studied recently and appears effective as a once-daily application for 1 week.
- Oral antifungals have many interactions including warfarin, OCPs, and alcohol; advise checking for drug interactions prior to use; contraindicated in pregnancy. Monitor for liver toxicity when using oral antifungals.
ISSUES FOR REFERRAL
Refer if disease is nonresponsive/resistant, especially in immunocompromised host.
ADDITIONAL THERAPIES
Treatment of secondary bacterial infections
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Reevaluate response to treatment.
Patient Monitoring
Liver function testing prior to therapy and at regular intervals during course of therapy for patients requiring oral terbinafine, fluconazole, itraconazole, and griseofulvin.
PATIENT EDUCATION
Explain the causative agents, predisposing factors, and prevention measures.
PROGNOSIS
- Excellent prognosis for cure with therapy in tinea cruris and corporis.
- In tinea capitis, lesions will heal spontaneously in 6 months without treatment but scarring is more likely.
COMPLICATIONS
- Secondary bacterial infection
- Generalized, invasive dermatophyte infection
- Secondary eruptions called dermatophytid reactions may occur at distant sites.
REFERENCES
11 Ameen M. Epidemiology of superficial fungal infections. Clin Dermatol. 2010;28(2):197 " ;201.22 Gupta AK, Cooper EA. Update in antifungal therapy of dermatophytosis. Mycopathologia. 2008;166(5 " ;6):353 " ;367.33 Gupta AK, Drummond-Main C. Meta-analysis of randomized, controlled trials comparing particular doses of griseofulvin and terbenafine for the treatment of tinea capitis. Pediatr Dermatol. 2013;30(1):1 " 6.
ADDITIONAL READING
- Akinwale SO. Personal hygiene as an alternative to griseofulvin in the treatment of tinea cruris. Afr J Med Med Sci. 2000;29(1):41 " 43.
- Bonifaz A, Sa Ίl A. Comparative study between terbinafine 1% emulsion-gel versus ketoconazole 2% cream in tinea cruris and tinea corporis. Eur J Dermatol. 2000;10(2):107 " 109.
- Gonz ‘lez U, Seaton T, Bergus G, et al. Systemic antifungal therapy for tinea capitis in children. Cochrane Database Syst Rev. 2007;(4):CD004685.
- Lesher JLJr, Babel DE, Stewart DM, et al. Butenafine 1% cream in the treatment of tinea cruris: a multicenter, vehicle-controlled, double-blind trial. J Am Acad Dermatol. 1997;36(2, Pt 1):S20 " S24.
- Nozickova M, Koudelkova V, Kulikova Z, et al. A comparison of the efficacy of oral fluconazole, 150 mg/week versus 50 mg/day, in the treatment of tinea corporis, tinea cruris, tinea pedis, and cutaneous candidosis. Int J Dermatol. 1998;37(9):703 " ;705.
- Seebacher C, Bouchara JP, Mignon B. Updates on the epidemiology of dermatophyte infections. Mycopathologia. 2008;166(5 " ;6):335 " ;352.
- Tey HL, Tan AS, Chan YC. Meta-analysis of randomized, controlled trials comparing griseofulvin and terbinafine in the treatment of tinea capitis. J Am Acad Dermatol. 2011;64(4):663 " ;670.
CODES
ICD10
- B35.0 Tinea barbae and tinea capitis
- B35.4 Tinea corporis
- B35.6 Tinea cruris
ICD9
- 110.0 Dermatophytosis of scalp and beard
- 110.5 Dermatophytosis of the body
- 110.3 Dermatophytosis of groin and perianal area
- 110.8 Dermatophytosis of other specified sites
- 110.2 Dermatophytosis of hand
SNOMED
- 5441008 Tinea capitis (disorder)
- 84849002 Tinea corporis (disorder)
- 399029005 Tinea cruris (disorder)
- 371042002 Tinea due to Trichophyton rubrum (disorder)
- 403084009 Tinea due to Trichophyton tonsurans (disorder)
CLINICAL PEARLS
- Tinea corporis is characterized by scaly plaque, with peripheral activity and central clearing.
- Tinea cruris is characterized by erythematous plaque in crural folds usually sparing the scrotum. Treatment of concomitant tinea pedis is advised.
- Tinea capitis is a fungal infection of the scalp affecting hair growth. Topical therapy is ineffective for this infection.