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Topical Treatment of Common Superficial Tinea Infections

American Family Physician, May 15, 2002 by Andrew Weinstein, Brian Berman

Tinea infections are superficial fungal infections caused by three species of fungi collectively 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 history 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 antifungal agent. Topical therapy is generally successful unless the infection covers an extensive 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 medication. 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 presence of inflammation may necessitate the use of an agent with inherent anti-inflammatory 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[C] 2002 American Academy of Family Physicians.)

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Tinea infections are superficial fungal infections caused by the three genera of dermatophytes, Trichophyton, Microsporum and Epidermophyton.(1) Commonly, the infections caused by these organisms are named for the sites involved. Tinea capitis refers to a dermatophyte infection of the head, tinea barbae affects the beard area, tinea corporis occurs on the body surface, tinea manuum is limited to the hands, tinea pedis to the feet, and tinea unguium infects the toenails. These names do not distinguish between species (for example, tinea capitis may be caused by Trichophyton or Microsporum genera).

With some pertinent exceptions, dermatomycosis is typically confined to the superficial keratinized tissue(2) and, thus, can often be treated with topical antifungal medications.(3) Because these agents do not penetrate hair or nails, tinea capitis, tinea barbae, and tinea unguium usually require systemic therapy. This article focuses on the diagnosis and treatment of tinea infections with topical medications. Because tinea capitis and tinea unguium are not typically amenable to topical therapy, they will not be discussed in this article.

It is important to note that nondermatophytes and yeasts may infect the sites mentioned above. For example, tinea unguium is only a subset of the onychomycoses, which include other types of fungal infections of the nails. Similarly, tinea corporis refers only to dermatophyte infection of the skin and not other superficial fungal infections such as candidiasis. Although tinea versicolor is commonly called a tinea, it is caused by the nondermatophyte Malassezia furfur (also referred to as Pityrosporum orbiculare and Pityrosporum ovale) and is not a true tinea infection.(4)

Epidemiology

Because tinea infections are highly common, it is likely that the primary care physician will frequently treat affected patients. The estimated lifetime risk of acquiring dermatophytosis (tinea infection) is between 10 and 20 percent.(5) In the United States, dermatophytosis is second only to acne as the most frequently reported skin disease.(6) The majority of superficial fungal infections are tineas and, of those, the most common are tinea pedis, tinea corporis, and tinea cruris.(7) Trichophyton rubrum is the most likely agent in these dermatomycoses. T. rubrum accounted for 76.2 percent of all superficial fungal diseases in a representative sample of the U.S. population.(8) With the exception of tinea capitis (in which Trichophyton tonsurans was the most likely etiologic agent), T. rubrum was the most common dermatophyte isolated in all superficial fungal diseases studied.(8)

Clinical Manifestations

Clinical presentation is the most important clue to accurate diagnosis and treatment. The anthrophilic dermatophytes (commonly isolated from human infection) are the most common source of human dermatomycoses. These tend to evoke a limited host response and are less likely to be accompanied by severe inflammation or to clear spontaneously.(9) Occasionally, severe inflammation is a component of dermatophytosis. This is particularly true in the case of tinea infections caused by zoophilic species (commonly isolated from animal infection). The most common of these is Microsporum canis.

TINEA CORPORIS

Tinea corporis refers to tinea anywhere on the body except the scalp, beard, feet, or hands. This lesion presents as an annular plaque with a slightly raised and often scaly, advancing border and is commonly known as ringworm. Each lesion may have one or several concentric rings with red papules or plaques in the center. As the lesion progresses, the center may clear, leaving post-inflammatory hypopigmentation or hyperpigmentation.

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Topical Treatment of Common Superficial Tinea Infections

American Family Physician, May 15, 2002 by Andrew Weinstein, Brian Berman

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