History

Fact Explanation
Ring like erythematous, scaly plaques over trunk and limbs. Tinea corporis is a dermatophyte fungal infection involving the skin of trunk and limbs. It is a superficial fungal infection which is limited to stratum corneum. Tinea corporis is caused by organisms of genera Trichophyton, Microsporum and epidermophyton. [1],[2],[4], [6]
Pruritis Most patients complain of pruritis, and it can be mild to intense itching. [1],[2]
Contact history Tinea corporis is a contagious and communicable fungal infection. Therefore contact history with infected family member or sharing clothes, towels, bedlinen or animal contact may be positive in the history. Overcrowding and poor social conditions are possible risk factors in the history. [3],[4],[5]
There may be a history of immunosuppression. Protection against fungal infection is mediated by cell mediated immunity. In conditions such as immunosuppression, AIDS, treating with long term corticosteroids and cytotoxics and malnutrition are possible risk factors in the history. [3],[5]
References
  1. WELLER, Richard P.J.B. HUNTER, John A.A. SAVIN, John A. and DAHL, Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  2. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  3. QADIM, H.H. GOLFOROUSHAN, F. AZIMI, H. and Goldust, M. Factors leading to dermatophytosis. Annals of parasitology. 2013;59(2):99-102. [Viewed on 03.04.2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24171304
  4. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 2012,1200-1201.
  5. GOMES, Fabíola Silveira. DE OLIVEIRA, Elaina Ferreira. NEPOMUCENO, Lívia Barreto. PIMENTEL,Rosiane Ferreira. MARQUES-DA-SILVA, Silvia Helena and MESQUITA-DA-COSTA, Maurimélia. Dermatophytosis diagnosed at the Evandro Chagas Institute, Pará, Brazil, Brazilian Journal of Microbiology. 2013; 44(2): 443–446. [Viewed on 07.042014] doi: 10.1590/S1517-83822013005000049
  6. WEITZMAN, I. and SUMMERBELL, R.C. The dermatophytes. Clinical Microbiology Reviews. Apr 1995; 8(2): 240–259. [Viewed on 07.04.2014]. Available from :http://www.ncbi.nlm.nih.gov/pmc/articles/PMC172857/

Examination

Fact Explanation
Single or numerous circular ring like erythematous, well marginated scaly plaques on the skin over the trunk and limbs. Dermatophyte lesions appear because of delayed or type-4 hypersensitivity reaction as a host response to the metabolic products of fungus. [1],[2],[3],[4]
Small vesicles and pustules may be seen within the lesions. Small vesicles and pustules may be seen, specially in the advancing margin due to the acute inflammation. Fungi coming from human sources (anthrophilic organisms) cause lesions with minimal inflammation. Fungi coming from animal sources (zoophilic fungi) induce a more intense inflammation than those spread from person to person. [1], [2]
Erythema most pronounced at the periphery. Due to acute inflammation in advancing margin erythema most pronounced at the periphery.The lesions expand slowly and healing leaves a typical ring like pattern. [1],[2]
Dry skin Dry skin is a possible finding during general examination. It may cause skin trauma easily and breaks the protective barrier against superficial fungal infection. [4]
References
  1. WELLER, Richard P.J.B. HUNTER, John A.A. SAVIN, John A. and DAHL, Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  2. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  3. 2012 KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER.,1200-1201.
  4. QADIM, H.H. GOLFOROUSHAN, F. AZIMI, H. and Goldust, M. Factors leading to dermatophytosis. Annals of parasitology. 2013;59(2):99-102. [Viewed on 03.04.2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24171304
  5. WEITZMAN, I. and SUMMERBELL, R.C. The dermatophytes. Clinical Microbiology Reviews. Apr 1995; 8(2): 240–259. [Viewed on 07.04.2014]. Available from :http://www.ncbi.nlm.nih.gov/pmc/articles/PMC172857/

Differential Diagnoses

Fact Explanation
Discoid (nummular) Eczema This common pattern of eczema classically affects the limbs of middle-aged males. The lesions are multiple, coin shaped, vesicular or crusted highly itchy plaques. [1],[2],[3]
Plaque psoriasis The lesions are well demarcated and range from a few millimeters to many centimeters in diameter. The lesions are pink or red with large centrally adhered silvery white, polygonal scales. Symmetrical sites on elbows,knees, lower back and scalp are sites of predilection. [1],[2],[3]
Granuloma annulare The lesions of common type of granuloma annulare often lie over the knuckles and are composed of dermal nodules fused in to a rough ring shape. On the hands the lesions are skin colored or slightly pink; elsewhere a purple color may be seen. [1], [2],[3]
Pityriasis rosea Most patients develop one plaque before the others, It is larger (2-5 cm diameter) than later lesions, and is rounder, redder and more scaly. After several days many smaller plaques appear, mainly on the trunk, but some also on neck and extremities. [1],[2],[3]
Cutaneous Candidasis A moist glazed area of erythema and maceration appears in a body fold; the edges show soggy scaling, and outlying satellite papulopustules. These changes are most common under the breasts and the arm pits and groin. [1],[2]
Seborrhoic Dermatitis Erythematous, itchy patches which may become either scaly or exudative and crusted. Commonly involve hair bearing areas such as scalp, forehead, the beard presternal or interscapular areas. [1],[2],[3]
Discoid lupus Erythematosus Plaques show erythema, scaling, scarring and atrophy, telangiectasia, hypopigmentation and peripharal zone of hyperpigmentation. They are well demarcated and lie mostly on sun exposed skin. [1],[3]
Tinea versicolor Depigmented macules with fine scaling develop over the skin commonly involving upper trunk. [1],[2]
Erythasma Presents with symptom free macular wrinkled slightly scaly pink, brown or macerated white areas, most often found in armpits or groins or between toes. [1]
References
  1. WELLER, Richard P.J.B. HUNTER, John A.A. SAVIN, John A. and DAHL, Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 54-70, 71-72, 97-100,131-134, 221, 252-256, 303, 237, 248-252, 325.
  2. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 17, 37-43, 114-118,128-142, 241, 265-266, 277.
  3. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 2012,1200-1201, 1236-1240,1240-1243, 1244,1245.

Investigations - for Diagnosis

Fact Explanation
Woods light examination Uses ultraviolet light to observe skin closely. It reveal some of epidermophytes with green fluorescence. But some causative fungus does not fluoresce. [1],[2],[3]
Light microscopic examination. The skin scrapings should be taken from the scaly margin of a lesion, with a small curette or a scalpel blade. The specimens are cleared in pottassium hydroxide. Branching hyphae and spores can easily be seen. [1],[2],[3],[4]
Culture Culture Should be carried out in a mycology or bacteriology laboratory. Transport medium is not necessary, and specimens can be sent in folded black paper and dry petri dish. The report may take as long as a month; microscopy is much quicker. [1],[2],[3]
References
  1. WELLER, Richard P.J.B. HUNTER, John A.A. SAVIN, John A. and DAHL, Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  2. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  3. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 2012,1200-1201.
  4. GOMES, Fabíola Silveira. DE OLIVEIRA, Elaina Ferreira. NEPOMUCENO, Lívia Barreto. PIMENTEL,Rosiane Ferreira. MARQUES-DA-SILVA, Silvia Helena and MESQUITA-DA-COSTA, Maurimélia. Dermatophytosis diagnosed at the Evandro Chagas Institute, Pará, Brazil, Brazilian Journal of Microbiology. 2013; 44(2): 443–446. [Viewed on 07.042014] doi: 10.1590/S1517-83822013005000049

Management - General Measures

Fact Explanation
Educate the patient. Tinea corporis is a common superficial fungal infection which can be treated successfully. [1],[2],[3]
Advise regarding hygiene. Tinea corporis is a contagious and communicable fungal infection. Therefore advise not to share clothes, towels, bedlinen, etc. Advise regarding importance of daily bathing and wearing clean dry clothes. [1],[2],[3]
Take measures to prevent dry skin. Advise regarding measures can be taken to avoid dry skin such as avoiding detergents, using moisturizing cream etc. [4]
References
  1. WELLER, Richard P.J.B. HUNTER, John A.A. SAVIN, John A. and DAHL, Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  2. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  3. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 2012,1200-1201.
  4. QADIM, H.H. GOLFOROUSHAN, F. AZIMI, H. and Goldust, M. Factors leading to dermatophytosis. Annals of parasitology. 2013;59(2):99-102. [Viewed on 03.04.2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24171304

Management - Specific Treatments

Fact Explanation
Local imidazole preparations An imidazole containing preparation (such as miconazole, econazole and clotrimazole) used twise daily for 3-4 week period is usually adequate. Imidazoles interfere with fungal oxidative enzymes to cause lethal accumulation of hydrogen peroxide. They also reduce the formation of ergosterol, an important constituent of fungal cell wall which thus becomes permeable to intracellular constituents. When topical treatment has failed or for extensive infections systemic drugs needs to be considered. [1],[2],[3],[4]
Terbinafin Has now largely superseded griseofulvin. It acts by inhibiting fungal squalane epoxidase and does not interact with cytochrome p-450 system. It is fungicidal and so cures chronic dermatophyte infections more quickly and more reliably than griseofulvin. 250mg daily given for2-6 weeks. [1],[2],[3],[4]
Itraconazole Is now preferred to ketconazole, which occasionally damages the liver and is a reasonable alternative to terbinafin if this is contraindicated. Fungistatic rather than fungicidal, It interfere with cytochrome p-450 system, so review of any other medication being taken is needed before prescription is issued. 100mg daily given for 2-6weeks . [1],[2],[3],[3]
Ketconazole This drug should be reserved for patients with severe and resistant disease because of the possibility of serious hepatotoxicity and occurrence of other side effects, including rashes, Thrombocytopenia and gastrointestinal disturbances. 200mg daily given for 2-6weeks . [1],[2],[3],[4]
Griseofulvin Was for many years drug of choice for chronic dermatophyte infections, but is now largely reserved for treatment of tinea capitis. Griseofulvin prevents fungal growth by inhibiting mitosis. The therapeutic efficacy of griseofulvin depends on its capacity to bind to keratin. [1],[2],[3],[4]
References
  1. WELLER, Richard P.J.B. HUNTER, John A.A. SAVIN, John A. and DAHL, Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  2. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  3. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 2012,1200-1201.
  4. BENNET, P.N. and BROWN, M.J. CLINICAL PHARMACOLOGY. 9th Ed. CHURCHILL LIVINGSTONE. 2003, 263-267.