Diagnosis and Management of

Common Tinea Infections

SARA L. NOBLE, PHARM.D., and ROBERT C. FORBES, M.D., University of
Mississippi Medical Center, Jackson, Mississippi
PAMELA L. STAMM, PHARM.D, Auburn University School of Pharmacy, Auburn,
Alabama
Am Fam Physician. 1998 Jul 1;58(1):163-174.
See related patient information handout on tinea infections, written by the
authors of this article.
The estimated lifetime risk of acquiring a dermatophyte infection is
between 10 and 20 percent. Recognition and appropriate treatment of these
infections reduces both morbidity and discomfort and lessens the
possibility of transmission. Dermatophyte infections are classified
according to the affected body site, such as tinea capitis (scalp), tinea barbae (beard area), tinea corporis (skin other than bearded area, scalp, groin,
hands or feet), tinea cruris (groin, perineum and perineal areas), tinea pedis
(feet), tinea manuum (hands) and tinea unguium (nails). To determine the
best treatment approach, the physician must consider several factors: (1)
the anatomic locations of the infection, (2) the safety, efficacy and cost of
treatment options and (3) the likelihood that the patient will comply with
treatment. Newer medications in both oral and topical forms, including
imidazoles and allylamines, have greatly increased the cure rate for tinea
infections. Certain types of tinea may be treated with pulse regimens;
these innovative therapies lower treatment costs and improve patient
compliance.
Superficial fungal infections are among the most common skin
diseases,1 affecting millions of people throughout the world.2 These infections,

which occur in both healthy and immunocompromised persons, are caused by

dermatophytes, yeasts and nondermatophyte molds. Effective treatment can
reduce the duration of symptoms in patients with superficial fungal infections.
Dermatophytes, specifically Trichophyton, Epidermophyton and Microsporum
species, are responsible for most superficial fungal infections.1,3,4 The estimated
lifetime risk of acquiring a dermatophyte infection is between 10 and 20 percent.5
The term tinea refers exclusively to dermatophyte infections. Tinea infections
are classified according to their anatomic location. (Pityriasis versicolor,
sometimes referred to as tinea versicolor, is caused by Malassezia furfur and
therefore is not discussed in this article.)
Fungal transmission occurs through direct contact with infected persons,
animals, soil or fomites. Depending on their habitat, dermatophytes are described
as anthropophilic (human), zoophilic (animal) or geophilic (soil). Anthropophilic
dermatophytes are the most common sources of tinea infections, but zoophilic
sources should be identified (if possible) and treated to prevent human
reinfection.6
The classic presentation of tinea infection, known as ringworm, is a lesion with
central clearing surrounded by an advancing, red, scaly, elevated border. One or
more lesions may appear. Inflammation assists in colonization and may result in
vesicles on the border of the affected area. Atopic persons and those infected
with zoophilic fungi tend to have more inflammation.
The presentations of tinea infections range from mild scaling and erythema to
severe inflammation with bacterial superinfection. The differential diagnosis for
suspected tinea infection is listed in Table 1.

Tinea Infections

TYPE

Tinea capitis

COMMON CAUSATIVE
SPECIES

DIFFERENTIAL
DIAGNOSIS

Trichophyton tonsurans

Alopecia areata

Microsporum andouinii*

Impetigo

Microsporum canis*

Pediculosis

Psoriasis

Seborrhea

Trichotillomania

Tinea barbae

Trichophyton verrucosum

Folliculitis

Malignant lymphoma

TYPE

COMMON CAUSATIVE
SPECIES

DIFFERENTIAL
DIAGNOSIS

Sporotrichosis

Tinea
corporis

Trichophyton rubrum

Cutaneous lupus
erythematous

M. canis*

Drug eruption

T. tonsurans

Eczema

T. verrucosum

Erythema multiforme

Granuloma annulare

Nummular dermatitis

Pityriasis rosea

Pityriasis versicolor*

TYPE

COMMON CAUSATIVE
SPECIES

DIFFERENTIAL
DIAGNOSIS

Psoriasis

Secondary syphilis

Tinea cruris

T. rubrum

Candidal intertrigo

Epidermophyton floccosum

Contact dermatitis

Erythrasma*

Psoriasis

Seborrhea

Tinea pedis

T. rubrum

Bacterial or candidal

TYPE

COMMON CAUSATIVE
SPECIES

DIFFERENTIAL
DIAGNOSIS

infection

Trichophyton mentagrophytes

Contact or atopic dermatitis

var interdigitale

Dyshidrosis

E. floccosum

Eczema

Pitted keratolysis

Psoriasis

Tinea
manuum

T. rubrum

Same as for tinea pedis

Tinea
unguium

T. rubrum

Contact dermatitis

Trichophyton mentagrophytes

Lichen planus

TYPE

COMMON CAUSATIVE
SPECIES

var mentagrophyte

DIFFERENTIAL
DIAGNOSIS

Onychodystrophy

Psoriasis

*These dermatophytes fluoresce under a Wood's light: Microsporum

andouinii and Microsporum canis fluoresce blue-green; Corynebacterium
minutissimum, the bacterium that causes erythrasma, fluoresces coral-red;
and Malassezia fur-fur, the causative fungus in pityriasis versicolor, fluoresces
pale yellow. 6
Zoophilic species.

Diagnosis
WOOD'S LIGHT EXAMINATION
Most dermatophytes do not fluoresce. The exceptions are two zoophilic
dermatophytes, Microsporum canis and Microsporum andouinii. These minor
causes of tinea capitis fluoresce blue-green. Wood's light examination can also
help to differentiate erythrasma caused by the bacterium Corynebacterium
minutissimum, which fluoresces coral-red, from tinea cruris, which does not
fluoresce.

When positive, a Wood's light examination can be helpful in determining the

extent of infection, identifying areas for sampling and evaluating treatment
response. The examination is also useful for examining the contacts of an
infected person.

MICROSCOPY
Microscopic examination is central to the office diagnosis of any tinea
infection.7 Material is scraped from an active area of the lesion, placed in a drop
of potassium hydroxide solution and examined under a microscope. The
examination, which can be done quickly and easily, is highly sensitive and
specific for dermatophyte identification.
Microscopy is positive if hyphae are identified in fungal infections and if
pseudohyphae or yeast forms are seen in Candida or Pityrosporum infections. A
positive examination is sufficient to justify starting treatment,7,8 because species
identification does not usually influence treatment choices.7

CULTURE
Because cultures are both expensive and time-consuming, they are not routinely
performed in suspected tinea infections. However, cultures should be obtained
when long-term oral drug therapy is being considered, the patient has a
recalcitrant infection or the diagnosis is in doubt.
Identification of a specific zoophilic species as the infection source can be helpful
in preventing recurrent infection. It is also important to confirm the specific fungus
that is causing a nail infection, because the spectrum of activity for oral antifungal
agents varies.

Clinical Presentations
TINEA CAPITIS
Tinea capitis, sometimes called ringworm of the scalp, primarily affects schoolaged children. It often appears as one or more annular patches of inflammatory
or noninflammatory alopecia. Noninflamed areas, characteristic of Trichophyton

tonsurans infection, may appear as black dots, which are actually infected hair
shafts broken off at the scalp. Sometimes tinea capitis appears only as nonspecific dandruff. Microsporum infection presents as gray patches of hairs that
are lusterless because of a coating of spores. Inflamed areas usually have
scales, pustules and erythema. Some patients develop a localized, boggy,
indurated granuloma called a kerion (Figure 1). A kerion can cause scarring and
permanent hair loss.
View/Print Figure

FIGURE 1.
Kerion, a severely inflammatory, boggy, indurated, tumor-like mass that may occur in
tinea capitis.

Tinea capitis should be treated with oral therapy. Griseofulvin (Fulvicin PG, GrisPEG, Grisactin Ultra) is the only oral anti-fungal agent approved by the U.S.
Food and Drug Administration for the first-line treatment of tinea capitis.
However, itraconazole (Sporanox) and terbinafine (Lamisil) are good
alternatives.911

TINEA BARBAE
Tinea barbae affects the beard area of men who work with animals (Figure 2). It
is often accompanied by bacterial folliculitis and inflammation secondary to
ingrown hairs. In the treatment of tinea barbae, oral therapy is preferred over
topical therapy because the involved hair follicles do not respond well to topical
therapy. The agents used to treat tinea capitis are also used to treat tinea barbae.
View/Print Figure

FIGURE 2.
Tinea barbae.

TINEA CORPORIS
Tinea corporis, also called ringworm of the body, often affects children and
adults who live in hot, humid climates. The classic presentation of this infection is
a circular plaque with a well-demarcated border (Figure 3). Since tinea corporis
can be asymptomatic, it can spread rapidly among children in day-care settings.
View/Print Figure

FIGURE 3.
Tinea corporis.

Unless only one or two lesions are present, tinea corporis should be treated
orally. Terbinafine and itraconazole are equally effective in treating tinea
corporis.12,13 Furthermore, these agents each have a better mycologic cure rate
and a lower relapse rate than griseofulvin.1416 An alternative is fluconazole
(Diflucan), which is given orally once a week for up to four consecutive weeks.17,18

TINEA CRURIS
Tinea cruris, commonly referred to as jock itch, involves the medial aspect of
the upper thighs (groin). Unlike yeast infections, tinea cruris generally does not
involve the scrotum or the penis(Figure 4). This dermatophyte infection occurs
more often in men than in women and rarely affects children.
View/Print Figure

FIGURE 4.
Tinea cruris.

In this infection, erythematous plaques often develop bilaterally. Pruritus is

common.
Topical therapy is sufficient in most patients with tinea cruris. If the infection
spreads to the lower thighs or buttocks, oral therapy is preferred. Itraconazole
and terbinafine are more efficacious than griseofulvin.14,15

TINEA PEDIS
Tinea pedis, generally known as athlete's foot, is the most common
dermatophyte infection. Tinea pedis infection is usually related to sweating and
warmth, and use of occlusive footwear. Men between 20 and 40 years of age are
most frequently affected. The infection often presents as white, macerated areas
in the third or fourth toe webs (Figure 5). It may also present with a classic
pattern on the dorsal surface of the foot or as chronic dry, scaly hyperkeratosis of
the soles and heels. Because of its distribution, the latter presentation, which is

typical of Trichophyton rubrum infection, is sometimes referred to as moccasin

type.
View/Print Figure

FIGURE 5.
Tinea pedis involving the toe webs.

Occasionally, tinea pedis may produce acute, highly inflamed, sterile vesicles
and pustules at distant sites (arms, chest, sides of fingers). Referred to as the
dermatophytid or id reaction, these vesicles and pustules probably represent
an immunologic response to the fungus; they subside when the primary infection
is controlled. The id reaction can be the only manifestation of an asymptomatic
web space maceration.
Tinea pedis is often treated with topical therapy. Since oral agents provide better
skin penetration than most topical preparations, oral therapy may be more
efficacious in the treatment of hyperkeratotic tinea pedis. Itraconazole, terbinafine
and griseofulvin are good choices for oral therapy. Itraconazole and terbinafine
are slightly more effective than griseofulvin.14,19 Once-weekly dosing with
fluconazole is another option, especially in non-compliant patients.17

TINEA MANUUM
Tinea manuum (Figure 6), a fungal infection of the hands, is less common than
tinea pedis. Like tinea pedis, tinea manuum also presents with the classic pattern
of erythema and mild scaling on the dorsal aspect of the hands or as a chronic,
dry, scaly hyperkeratosis of the palms. When the palms are infected, the feet are

also commonly infected. A typical pattern of involvement is either one hand and
both feet or both hands and one foot. Treatment options are the same as for
tinea pedis.
View/Print Figure

FIGURE 6.
Tinea manuum involving the palms.

TINEA UNGUIUM
Tinea unguium is a dermatophyte infection of the nails. It is a subset of
onychomycosis, which includes dermatophyte, nondermatophyte and yeast
infections of the nails. Toe-nails are involved more frequently than fingernails.
Tinea unguium affects adults more often than children. Risk factors for this fungal
infection include increasing age, diabetes, poor venous and lymphatic drainage,
ill-fitting shoes and sports participation. However, most infections have no
underlying cause. Involvement of the toenail usually implies an extremely
resistant infection with a tendency to recur. Chemical or surgical avulsion may be
helpful in patients with recalcitrant infection, especially when only a single nail is
involved.
The clinical presentation of tinea unguium depends on whether the fungus has
invaded the distal, proximal or superficial nail. Distal involvement is the most
common presentation. With distal involvement, the affected nail is hyperkeratotic,
chalky and dull. The brownish-yellow debris that forms beneath the nail causes
the nail to separate from its bed. The nail plate may become brittle, but the nail
fold is seldom involved (Figure 7). Although inflammation is uncommon, up to 45

percent of patients experience pain.20 Coexistent tinea manuum or tinea pedis is

common.
View/Print Figure

FIGURE 7.
Tinea unguium with distal invasion of the nail.

Tinea unguium requires oral antifungal therapy. Itraconazole, terbinafine and, to a

lesser extent, griseofulvin are effective in treating fingernail infections.21
23
Itraconazole or terbinafine are better choices for treatment of toenails.2 The
FDA has approved the use of itraconazole pulse therapy (i.e., a series of brief
medication courses) for the treatment of tinea unguium of the fingernails. The
total drug exposure is less with pulse therapy21; therefore, its cost is also lower
than traditional treatment. Furthermore, because of the drug-free intervals,
patients may be more likely to comply with therapy.
For toenail infections, itraconazole pulse therapy appears to be as effective as
daily dosing.2426However, the FDA has not approved pulse therapy for treatment
of tinea unguium of the toenails.
Terbinafine pulse therapy may also be effective. At this time, however, data are
insufficient to recommend pulsed terbinafine therapy.26 Data suggest that
fluconazole may be another alternative for treatment of fungal nail infections,
especially if yeast is involved. To date, however, few trials of this therapy have
been conducted, and only small numbers of patients have been studied.2729

When itraconazole or terbinafine is used in the treatment of tinea unguium, the

nail may not appear clinically cured at the end of therapy. A new nail may require
three to 12 months to grow out. Thus, patients should be reminded that the
resolution of tinea unguium requires four to six months for fingernails and even
longer for toenails.

Treatment Selection
TOPICAL ANTIFUNGAL PREPARATIONS
The topical antifungal agents currently available in the United States are listed
in Table 2.30 Although tinea infections are most commonly treated with topical
preparations, therapeutic success is limited because of the lengthy duration of
treatment, poor patient compliance and high relapse rates at specific body sites.

Topical Treatments and Available Formulations in the Treatment

of Tinea Pedis, Tinea Cruris and Tinea Corporis

ANTIF
UNGA
L
AGENT

PRESC
RIPTION

CR
EA
M

SOL
UTIO
N OR
SPRA
Y

LO
TIO
N

PO
WDE
R

GEL
OR
OINT
MEN
T

FREQU
ENCY
OF
APPLIC
ATION*

Miscellaneous

Undecyl
enic acid
(Cruex,
Desenex
)

Twice
daily

ANTIF
UNGA
L
AGENT

PRESC
RIPTION

Tolnaftat
e1
percent
(Aftate,
Tinactin)

CR
EA
M

Halopro
gin 1
percent
(Halotex
)

Ciclopiro
x1
percent
(Loprox)
Imidazol
es

Clotrima
zole 1
percent

SOL
UTIO
N OR
SPRA
Y

LO
TIO
N

PO
WDE
R

GEL
OR
OINT
MEN
T

FREQU
ENCY
OF
APPLIC
ATION*

Twice
daily

Twice
daily

Twice
daily

Twice
daily

ANTIF
UNGA
L
AGENT

PRESC
RIPTION

CR
EA
M

SOL
UTIO
N OR
SPRA
Y

LO
TIO
N

PO
WDE
R

GEL
OR
OINT
MEN
T

FREQU
ENCY
OF
APPLIC
ATION*

(Lotrimin
,
Mycelex
)

Miconaz
ole 2
percent
(Micatin,
Monistat
-Derm)

Econazo
le 1
percent
(Spectaz
ole)

Ketocon
azole 2
percent

Twice
daily

Once
daily

Once
daily

ANTIF
UNGA
L
AGENT

PRESC
RIPTION

CR
EA
M

SOL
UTIO
N OR
SPRA
Y

LO
TIO
N

PO
WDE
R

GEL
OR
OINT
MEN
T

FREQU
ENCY
OF
APPLIC
ATION*

(Nizoral)

Oxicona
zole 1
percent
(Oxistat)

Sulcona
zole 1
percent
(Exelder
m)
Allylami
nes

Naftifine
1
percent
(Naftin)

Terbinafi

Once
daily or
twice
daily

Once
daily or
twice
daily

Once
daily or
twice
daily

Once

ANTIF
UNGA
L
AGENT

CR
EA
M

PRESC
RIPTION

SOL
UTIO
N OR
SPRA
Y

LO
TIO
N

PO
WDE
R

ne 1
percent
(Lamisil)
Benzyla
mines

Butenafi
ne 1
percent
(Mentax)

GEL
OR
OINT
MEN
T

FREQU
ENCY
OF
APPLIC
ATION*

daily or
twice
daily

Once
daily

*Durations of therapy vary based on the type of tinea: tinea pedis requires four
weeks of therapy, while tinea cruris and tinea corporis must be treated for two to
three weeks. Continue treatment for at least two weeks after symptom resolution.
Includes nail tincture.
Indicates shampoo, which should be used twice weekly (at least three days
apart) for a total of four weeks.
Used twice daily only for treatment of tinea pedis.
Only gel or ointment form is used twice daily.

Adapted from Diehl KB. Topical antifungal agents: an update. Am Fam Physician
1996;54:168792.

Factors to consider in selecting an antifungal agent include the route of delivery,

efficacy (defined as mycologic and/or clinical cure, and duration of remission),
patient compliance and cost. Compared with fungistatic drugs, fungicidal agents
are associated with higher cure rates, lower relapse rates and shorter treatment
periods.
The clinical state of the lesion also must be considered. Ointment preparations
soften thickened, hyperkeratotic lesions. Lotions and solutions prevent
maceration in intertriginous areas and hairy areas of the body. They are also
appropriate for treating moist, oozy, weepy lesions. Cream formulations are
beneficial in the treatment of scaling, non-oozing lesions. Powders alone are less
effective in treating existing tinea infections. However, they are helpful as
adjunctive agents for reducing moisture and maceration, and they can prevent
fungal infections in intertriginous areas.
Topical antifungal agents have been reviewed in American Family
Physician.30 Since that time, the first prescription spray, terbinafine 1 percent
solution, and a new topical antifungal agent, butenafine 1 percent cream
(Mentax), have been approved for use in the treatment of interdigital tinea pedis,
tinea corporis and tinea cruris. Butenafine and terbinafine appear to have similar
mycologic cure rates, although no direct comparative studies have been
performed. Compared with terbinafine, butenafine is effective against fewer
organisms. Average wholesale costs for the two drugs are the same.31

ORAL ANTIFUNGAL AGENTS

Oral therapy is often chosen because of its shorter duration and the potential for
greater patient compliance. However, oral agents must be used in the treatment
of disease that is extensive, that affects hair and nails, and that does not respond
to topical agents.2 Important information about the oral antifungal agents
currently available in the United States is presented in Table 3.4,23 Physicians

also must be aware of the hematotoxicity and drug interactions of these agents.
Drug regimens and medication costs for the treatment of different types of tinea
are provided in Table 4.4,9,1214,1619,26,3235 (Ketoconazole [Nizoral] is omitted because
it is not a first-line therapy.)

TABLE 3
Considerations in Prescribing Oral Antifungal Agents
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For the missing item, see the original print version of this publication.

TABLE 4
Recommended Dosages and Durations of First-Line Oral Therapy in
the Treatment of Specific Types of Tinea*
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For the missing item, see the original print version of this publication.
Absorption properties of oral antifungal agents vary. For optimal absorption,
griseofulvin should be taken with a fatty meal.23 Ultramicrosize griseofulvin was
designed to decrease the need to be taken with food to achieve the best drug
absorption. Itraconazole and ketoconazole rely on gastric acidity for optimal
absorption. Therefore, patients being treated with these agents should avoid
taking antacids, proton pump inhibitors and histamine H2-receptor blockers.
Achlorhydria also decreases the absorption of itraconazole and ketoconazole. If
patients drink a cola beverage before they take these drugs, they may acidify
their stomach and thereby increase drug absorption by up to 60
percent.36,37 Because the absorption of terbinafine and fluconazole is not
influenced by gastric pH, these agents are preferable for use in patients with
achlorhydria.22,38 Many oral antifungal agents interact with other
medications (Table 3).4,23 Terbinafine has fewer drug interactions because it
minimally affects the cytochrome P450 enzyme system.22 Itraconazole, fluconazole
and ketoconazole significantly inhibit this system, particularly the subgroup
3A4.21,38,39Side effects that influence the selection of an oral antifungal agent are

also listed in Table 3.4,23 For example, griseofulvin causes side effects in 20
percent of patients.34 This agent most often causes headache or gastrointestinal
complaints, but it can also cause rare and more serious adverse reactions, such
as toxic epidermal necrolysis and photodermatitis myositis.22,34
Studies of tinea unguium show that itraconazole is better tolerated than
griseofulvin.33,40 As with griseofulvin, the most common complaints with
itraconazole are headache and gastrointestinal distress. Reversible elevations in
liver enzyme levels occur in 0.9 percent of patients treated with
itraconazole.41 More serious but rare events include hepatotoxicity, hallucinations,
hypokalemia and edema.34,41
Ketoconazole is reserved for the second-line treatment of recalcitrant superficial
fungal infections. Of the antifungal agents, this drug has the highest risk for
hepatotoxicity, with a reported incidence ranging from one case per 10,00039 to
one case per 70,00041 recipients. Patients who are taking ketoconazole should be
instructed to immediately report symptoms of hepatotoxicity such as anorexia,
nausea and vomiting. Hepatotoxicity appears to be idiosyncratic.42 Risk factors
possibly associated with ketoconazole-induced hepatotoxicity include female
gender, onychomycosis, alcoholism, ketoconazole therapy lasting more than two
weeks and previous griseofulvin treatment.41Ketoconazole therapy should be
discontinued if symptomatic liver inflammation occurs or if the results of liver
function tests are three times higher than normal. Liver enzyme levels usually
return to normal after ketoconazole is discontinued.42
Ketoconazole is also associated with asymptomatic increases in transaminase
levels in 5 to 10 percent of patients.34 More common side effects include
gastrointestinal complaints and pruritus.39
The side effects most often associated with fluconazole are rash, headache,
gastrointestinal disorders and elevated liver function levels.35,38 Rarely, erythema
multiforme can occur in patients treated with this antifungal agent.35
Skin rashes and gastrointestinal side effects are common with terbinafine.
Terbinafine has also been associated with Stevens-Johnson syndrome, blood

dyscrasias, hepatotoxicity and ocular disturbances, as well as elevated liver

enzyme levels in 0.5 percent of recipients.22,41 In addition, some patients have
noted losing their sense of taste for up to six weeks.22,41

ADJUNCTIVE TOPICAL CORTICOSTEROIDS

Topical corticosteroids are commonly used as adjuncts to antifungal therapy.
These agents are especially beneficial in the initial stages of treatment because
they suppress the inflammatory response and provide symptomatic relief.
Because of the possibility of fungal proliferation, topical corticosteroids should not
be used alone in the treatment of tinea infections.

The Authors
show all author info
SARA L. NOBLE, PHARM.D., is assistant professor in the Department of Family
Medicine at the University of Mississippi Medical Center, Jackson. Dr. Noble
earned a doctorate in pharmacy from the University of Mississippi....

Figures 1 through 7 used with permission from Habif TP. Superficial fungal
infections. In: Habif P, ed. Clinical dermatology: a color guide to diagnosis and
therapy. 3d ed. St. Louis: Mosby, 1996:362408.

REFERENCES
show all references
1. Cohn MS. Superficial fungal infections. Topical and oral treatment of common

types. Postgrad Med. 1992;91:23944....