Tineas

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Is a superficial fungal infection, most common on the exposed surfaces of the body, face, nails, head and feet. They are not very infectious but are usually recurrent.

Causes

• Trichophyton mentagrophytes or T. rubrum, Epidermophyton, Microsporum

Body parts affected	Features
Tinea capitis	Bald, scaly patches with hairs broken off when very short The lesion may sometimes be inflamed with multiple pustules (pockets of pus) Especially in children and immunosuppressed
Tinea corporis (ringworm)	Single or multiple plaques on the face, trunk or limbs Well-demarcated, scaly and raised border with relatively clear centre Pruritus
Tinea/pityriasis) versicolor	A chronic fungal infection of large areas of skin Well-defined round/oval patches Pale or discoloured spots on the skin, e.g., chest, back, face Not scaly, but peels off when scratched Rare in children, onset usually around puberty
Nails (Onychomycosis)	Thickened, discoloured nails, can be white, yellow, green, or black Brittle nails that break easily
Tinea pedis (Athletes’ foot)	White scaling usually between the 4th and 5th toes or between the 3rd and 4th toes on one foot only Scales, vesicles, cracks Burning or itching between toes and underfoot especially when shoes and socks are removed May be a secondary infection

Differential diagnosis

• Seborrheic dermatitis, eczema, contact dermatitis
• Alopecia areata
• Jiggers, hookworm
• Candida
• Cellulitis
• Psoriasis
• Maceration from tight footwear

Investigations

• Scales from the active edge of the lesions are scraped off, placed in 10-20% potassium hydroxide (KOH) for 30 minutes, and examined microscopically for mycelia
• Culture of specimen on Sabouraud’s agar

Pharmacological treatment

Tinea capitis

Clotrimazole 1% cream

Apply two times daily for 2 weeks

OR

Ketoconazole 2% cream

Apply two times daily for 2 weeks

OR

Imidazole cream

OR

To accelerate clearing of scaly lesions

Benzoic acid + salicylic acid ointment

If extensive

ADD

Griseofulvin oral

Adult

500mg-1g once a day for 2-4 weeks

Child

10-20mg/kg once a day for 2-4 weeks

In severe cases treat for up to 3 months 

OR

Fluconazole oral

Adult

200mg once daily for 4-6 weeks

Child

3-6mg/kg once a day for 4-6 weeks

 

Tinea corporis (ringworm)

Benzoic acid + salicylic acid (Whitfield ointment)

Apply every 12 hours until 2 weeks after lesions clear

Clotrimazole 1% topical

Apply cream twice a day

OR

Miconazole 2% cream

Apply every 12 hours for 2-3 weeks

If topical treatment fails

Griseofulvin oral

10 mg/kg in 2 divided doses for 4-6 weeks

 

Pityriasis versicolor

Clotrimazole cream

Apply every 12 hours until lesions disappear

OR

Miconazole 2% cream

Apply every 12 hours for 2-3 weeks

If topical treatment fails

Fluconazole oral

300 mg once weekly for 2 weeks

OR

Ketoconazole oral

400mg single dose or 200mg daily for 5 consecutive days

 

Nails (Onychomycosis)

Griseofulvin oral

10 mg/kg per day as single dose once daily after meals for 6-12 months

Tinea pedis (Athletes foot)

Clotrimazole cream

Apply every 12 hours and continue for 14 days after the lesions have healed

OR

Miconazole cream

Apply every 12 hours and continue for 14 days after the lesions have healed

Apply powder (not necessarily medicated) to the feet rather than to the shoes

For persistent or non-responsive infection

Griseofulvin oral

10 mg/kg/day as single dose once daily after meals for 4-6 weeks

Prevention

• Clean all contaminated objects, e.g., combs, brushes
• Avoid sharing combs, towels, clothes, etc.
• Advise patient on the need to comply with treatment
• Personal foot hygiene: keep feet clean and dry and wash socks daily
• If patient has repeated fungal infections, refer for HIV counselling and testing

Referral

• If infection persists refer to specialist