History

Fact Explanation
The presentation depends on the site and the strain of the fungus involved. Tinea infections are superficial fungal infections. Dermatophytes of genera Trichophyton, Microsporum and Epidermophyton causes Tinea infections. Trichophyton commonly involve skin, hair and nail. Microsporum commonly involve skin and hair. Epidermophyton commonly involve skin and nails. [1],[2],[3],[4],[5]
In most Tinea infections the patient presents with a scaly rash. Dertmatophytes invade only into the stratum corneum, and the inflammation they cause is a result of metabolic products of the fungus or a delayed hypersensitivity reaction. Usually zoophilic fungi (those transmitted to humans by animals) cause a more severe inflammation than the anthrophillc variety (spread from person to person). [1],[2],[3],[4],[5],
Pruritus Most patients complain of pruritus, it ranges from mild to intense itching. [1],[2],[3],
Contact history Tinea infections are contagious and communicable fungal infections. Therefore contact history with infected family member or sharing clothes, combs, towels, bedlinen or animal contact may be positive in the history. Overcrowding and poor social conditions are risk factors in the history. [1],[2],[3],[4],[5]
History of immunosuppression. Protection against fungal infections is mediated by cell mediated immunity (CMI). Conditions such as long term steroid therapy, Cushing syndrome, HIV infection and malnutrition are possible risk factors in the history. [1],[2],[3],[4]
Common among young adults Due to physiological changes occur with puberty sebum content of skin surface increases. Sebum which is rich in lipids provide a suitable media to growth of causative organisms. [1],[2],[3],
History of living in tropical regions Warmth and humidity provides a suitable environment to pathogenic growth of causative organisms. [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. MARKS JR, James G. and MILLER Jeffery. Lookilgbill & Marks’ Principles of Dermatology. 4thEd. Elesvier. 2006,125-128.
  4. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 2012,1200-1201.
  5. PIRES, Carla Andréa Avelar. CRUZ, Natasha Ferreira Santos da. LOBATO, Amanda Monteiro. SOUSA,, Priscila Oliveira de. CARANEIRO, Francisca Regina Oliveira. and MENDES, Alena Margareth Darwich. Clinical, epidemiological, and therapeutic profile of dermatophytosis. Anais Brasileiros de Dermatologia. 2014; 89(2): 259–265. [Viewed on 27.05.2014] doi: 10.1590/abd1806-4841.20142569. Available from:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4008056/

Examination

Fact Explanation
Round, scaling area of alopecia and diffuse scaling in the scalp Tinea infections involving the scalp is called Tinea capitis. Usually this is a disease of children. Anthrophilic organisms cause bald and scaly areas with minimal inflammation and hair breaks off 3-4 cm from the scalp. Zoophillic fungi induce more intense inflammation causing red boggy area with pustules resulting a kerion. [1],[2],[3],[4],[5],[6]
Single or multiple annular plaques in the trunk and limbs with scalling and erythema most prononced at the periphary. Tinea infections involving the body surface including trunk and limbs are Tinea corporis. The lesions expand slowly and healing in the center leaves a typical ring like pattern. [1],[2],[3],[4],
Sharply demarcated area in the groin with elevated, scaling, serpengious borders. Tinea infections involving the groin is called as Tinea cruris. This is common and affects men more than women. The eruption is sometimes unilateral or asymmetrical. The upper inner thigh is involved and lesions expand slowly. [1],[2],[3],[4],
Interdigital maceration, Diffuse scaling on soles and sides of feet. Tinea infections involving the feet is called as Tinea pedis(athlete's foot). The causative organisms are Trichophyton Rubrum, Trichophyton mentagrophytes and Epidermophyton floccosum. [1],[2],[3],[4],
Diffuse dry scaling on one palm Tinea infections involving the hand is called as Tinea manuum. The causative organisms are Trichophyton Rubrum, Trichophyton mentagrophytes and epidermophyton floccosum. [1],[2],[3],[4],
Slightly scaling, erythematous patches and plaques in face. Tinea infections involving the face are Tinea faciale. When involving the beard are in men it is called as Tinea barbae. Commonly caused by zoophilic organisms. [1],[2],[3],[4],
Subungal debris with separation of the nail bed. Tinea infections involving the nail are Tinea unguium. The initial changes occur at the free edge of the nail, which become yellow and crumbly. Toe nail infection is associated with Tinea pedis. Finger nail infections are similar but less common. [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. MARKS JR, James G. and MILLER Jeffery. Lookilgbill & Marks’ Principles of Dermatology. 4thEd. Elesvier. 2006,125-128.
  4. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 2012,1200-1201.
  5. PIRES, Carla Andréa Avelar. CRUZ, Natasha Ferreira Santos da. LOBATO, Amanda Monteiro. SOUSA,, Priscila Oliveira de. CARANEIRO, Francisca Regina Oliveira. and MENDES, Alena Margareth Darwich. Clinical, epidemiological, and therapeutic profile of dermatophytosis. Anais Brasileiros de Dermatologia. 2014; 89(2): 259–265. [Viewed on 27.05.2014] doi: 10.1590/abd1806-4841.20142569. Available from:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4008056/
  6. MICHAELS, Brent D. and DEL ROSSO, James Q. TineaCapitis in Infants. The Journal of Clinical and Aesthetic Dermatology. Feb 2012; 5(2): 49–59. [Viewed on 27.05.2014] Available from:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3315884/

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],[4]
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],[4]
Chronic Eczema Commonly symmetrical and itchy. The absence of a sharp margin is is a important feature that separates from most other papulo squamous eruptions. [1],[2]
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 on neck and extremities. [1],[2],[3],[4]
Tinea versicolor Depigmented macules with fine scaling develop over the skin, commonly involving upper trunk. [1],[2]
Discoid lupus Erythematosus Plaques show erythema, scaling, scarring and atrophy, telangiectasia, hypopigmentation and a peripheral zone of hyperpigmentation. They are well demarcated and lie mostly on sun exposed skin. [1],[3]
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]
Candidiasis 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]
Erythrasma 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]
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]
Alopecia areata The typical patch of hair loss in the scalp, is not inflamed with no scaling, but with empty hair follicles. The pathognomic 'exclamation mark' pattern may be seen. Usually associated with other auto immune conditions. [1],[2],[3],[4]
Chronic paronychia The nail fold become tender and swollen and small amounts of pus are discharged from the space between nail fold and nail plate. [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, 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. MARKS JR, James G. and MILLER Jeffery. Lookilgbill & Marks’ Principles of Dermatology. 4thEd. Elesvier. 2006,125-128.
  4. 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],[4],[5]
Light microscopic examination The skin scrapings should be taken from the scaly margin of a lesion, with a small curette or a scalpel blade, and clippings or scrapings from the most crumbly part of the nail. Broken hair should be plucked with tweezers. The specimens are cleared in pottassium hydroxide. Branching hyphae and spores can easily be seen. [1],[2],[3],[4],[5],[6]
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],[4],[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. MARKS JR, James G. and MILLER Jeffery. Lookilgbill & Marks’ Principles of Dermatology. 4thEd. Elesvier. 2006,125-128.
  4. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 2012,1200-1201.
  5. PIRES, Carla Andréa Avelar. CRUZ, Natasha Ferreira Santos da. LOBATO, Amanda Monteiro. SOUSA,, Priscila Oliveira de. CARANEIRO, Francisca Regina Oliveira. and MENDES, Alena Margareth Darwich. Clinical, epidemiological, and therapeutic profile of dermatophytosis. Anais Brasileiros de Dermatologia. 2014; 89(2): 259–265. [Viewed on 27.05.2014] doi: 10.1590/abd1806-4841.20142569. Available from:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4008056/
  6. SINGAL, Archana and KHANNA, Deepshikha. Onychomycosis: Diagnosis and management. Indian J Dermatol Venereol Leprol. 2011;77(6):659-72. [Viewed on 27.05.2014] DOI: 10.4103/0378-6323.86475. Available from: http://www.ijdvl.com/article.asp?issn=0378-6323;year=2011;volume=77;issue=6;spage=659;epage=672;aulast=Singal

Investigations - Followup

Fact Explanation
Follow up clinic visits To assess the response to treatments and complications of the disease follow up clinic visits are arranged. [1],[2],[3],[4]
Periodic monitoring When patients are treating with systemic antifungals, periodic monitoring of liver function tests and full blood count is important because of the serious side effects such as hepatotoxicity and thrombocytopenia. [1],[2],[3],[4],[5],[6]
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. MARKS JR, James G. and MILLER Jeffery. Lookilgbill& Marks’ Principles of Dermatology. 4thEd. Elesvier. 2006,125-128.
  4. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 2012,1200-1201.
  5. BENNET, P.N. and BROWN, M.J. CLINICAL PHARMACOLOGY. 9th Ed. CHURCHILL LIVINGSTONE. 2003, 263-267.
  6. KATZUNG, Bertram G. MASTERS, Susan B. and TREVOR, Anthony J. Basic and Clinical Pharmacology. 12th Ed. Tata McGraw-Hill. 2012, 849-860.

Management - General Measures

Fact Explanation
Educate the patient Tinea infections are common superficial fungal infections, that can be treated successfully. [1],[2],[3],[4],[5]
Advise regarding hygiene Tinea infections are contagious and communicable fungal infections. They can be treated successfully but recurrence is common. Therefore advise not to share clothes, towels, bedlinen, etc. Advise regarding importance of daily bathing and wearing clean dry clothes. [1],[2],[3],[4],[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. MARKS JR, James G. and MILLER Jeffery. Lookilgbill & Marks’ Principles of Dermatology. 4thEd. Elesvier. 2006,125-128.
  4. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 2012,1200-1201.
  5. PIRES, Carla Andréa Avelar. CRUZ, Natasha Ferreira Santos da. LOBATO, Amanda Monteiro. SOUSA,, Priscila Oliveira de. CARANEIRO, Francisca Regina Oliveira. and MENDES, Alena Margareth Darwich. Clinical, epidemiological, and therapeutic profile of dermatophytosis. Anais Brasileiros de Dermatologia. 2014; 89(2): 259–265. [Viewed on 27.05.2014] doi: 10.1590/abd1806-4841.20142569. Available from:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4008056/

Management - Specific Treatments

Fact Explanation
Local imidazole preparations An imidazole containing preparation (such as miconazole, econazole and clotrimazole) used twice 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 systemic drugs need to be considered. [1],[2],[3],[4],[5],[6],[7]
Topical nail preparations Many patients now prefer to avoid systemic treatment. For them a nail lacquer containing amorolfine is worth a trial. Ciclopirox is an alternative topical tratment available in USA. Both amorolfine and tioconazole nail solutions can be used as adjunct to systemic therapy. [1],[2]
Terbinafin Has now largely superseded griseofulvin. It acts by inhibiting fungal squalaneepoxidase 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 for 2-6 weeks. [1],[2],[3],[4]
Itraconazole Is now preferred to Ketoconazole , which occasionally damages the liver, and is a reasonable alternative to terbinafin if this is contraindicated. Fungistactic rather than fungicidal, it interferes with cytochrome P-450 system, thus a review of any other medication being taken is needed before a prescription is issued. [1],[2],[3],[4],[5],[6],[7]
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]
Ketoconazole 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],[6],[7]
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. MARKS JR, James G. and MILLER Jeffery. Lookilgbill& Marks’ Principles of Dermatology. 4thEd. Elesvier. 2006,125-128.
  4. BENNET, P.N. and BROWN, M.J. CLINICAL PHARMACOLOGY. 9th Ed. CHURCHILL LIVINGSTONE. 2003, 263-267.
  5. KATZUNG, Bertram G. MASTERS, Susan B. and TREVOR, Anthony J. Basic and Clinical Pharmacology. 12th Ed. Tata McGraw-Hill. 2012, 849-860.
  6. PIRES, Carla Andréa Avelar. CRUZ, Natasha Ferreira Santos da. LOBATO, Amanda Monteiro. SOUSA,, Priscila Oliveira de. CARANEIRO, Francisca Regina Oliveira. and MENDES, Alena Margareth Darwich. Clinical, epidemiological, and therapeutic profile of dermatophytosis. Anais Brasileiros de Dermatologia. 2014; 89(2): 259–265. [Viewed on 27.05.2014] doi: 10.1590/abd1806-4841.20142569. Available from:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4008056/
  7. SINGAL, Archana and KHANNA, Deepshikha. Onychomycosis: Diagnosis and management. Indian J Dermatol Venereol Leprol. 2011;77(6):659-72. [Viewed on 27.05.2014] DOI: 10.4103/0378-6323.86475. Available from: http://www.ijdvl.com/article.asp?issn=0378-6323;year=2011;volume=77;issue=6;spage=659;epage=672;aulast=Singal