1. Chapter 33. Topical Fungal Infections Revised 8/15/10

2. Fungal Prevalence 20% of U.S. residents may be affected
Tinea pedis most common
Tinea corporis, cruris next most common
Tinea capitis incidence falling

3. Fungal Epidemiology: General
High temperature
High humidity
More common: tropical and subtropical areas
Immunocompromised patients
Those with mild skin trauma or maceration from occlusion

4. Tinea Pedis Epidemiology
Athlete’s foot; ringworm of foot
White urban dwellers
Adults ages 15-40; more common in males
Those using communal bathing facilities, swimming pools, summer camps, sports clubs, gyms
Marathon running: foot trauma

5. Tinea Corporis Epidemiology
Ringworm of the body
From persons or animals (cat/dog)
Transfer from tinea capitis
Most common prepubertal tinea (day-care center spread common)
Warm climates, overweight, stress
Tinea corporis gladiatorum: wrestling transmission

6. Tinea Cruris Epidemiology
Jock itch
Summer
Intertriginous skin: maceration facilitates warm, moist environment
More in males, scrotal skin folds
Rare in prepubertal children
Postpubertal males highest risk group

7. Tinea Capitis Epidemiology
Ringworm of scalp
More in pediatrics; poorer hygiene
Playing with infected brushes, combs, toys, telephones
Contacting infected cat or dog
Black children: occlusive hair dressings/ tight braids

8. Tinea Unguium Epidemiology
Onychomycosis
30% of those over the age of 60
Toenails of those who also have tinea pedis

9. Tinea Versicolor Epidemiology
Warm, humid weather
Underlying immune deficiency
Oily/greasy skin
Hyperhidrosis: excessive foot sweating

10. Tinea Nigra Epidemiology
Temperate climates
Younger patients
Females
Palms and soles

11. Causes of Superficial Tineas
Trichophyton, Microsporum, Epidermophyton
Anthropophilic fungi: person-to-person (most common)
Zoophilic fungi: animal-to-person
Geophilic fungi: soil-to-person

12. Manifestations of Fungal Skin Infections
Anthropophilic: little inflammation
From pets or soil: Acutely inflamed; allergies to fungal antigens

13. Manifestations: Tinea Pedis
3 forms
Intertriginous: macerated, boggy, white, thick, odorous, pruritic between toes
Acute vesicular: inflammation, fissuring; 2˚ bacterial infections; odorous, pruritic; extreme pain in walking
Moccasin: chronic, nonvesicular, over plantar foot

14. T. Pedis

15. Manifestation: Tinea Pedis
Flares in the summer; abates in winter
May cause tinea manuum: “one-hand, two-foot disease”; Hands are dry, red, scaly

16. Manifestations: Tinea Corporis
Glabrous skin (smooth and bare)
Not on scalp, feet, hands, groin, ears, face
Oval, scaly patch with inflamed border
Centrally, skin often appears lighter or normal; thus, the lesion appears to be a ring circling beneath the skin surface
15-20 lesions over the body
Lesions coalesce: polycyclic appearance

17. T. Corporis Presentations

18. T. Corporis Presentations

19. T. Corporis Presentations

20. T. Corporis Presentations

21. Manifestations: Tinea Cruris
Sharply defined lesions
Inflamed borders, reddish-brown centers
Begins in groin skinfolds
Spreads to perineum, thighs, buttocks
Intense pruritus
Sweating causes overt pain
2˚ bacterial infection possible

22. T. Cruris Presentations

23. T. Cruris Presentations

24. Manifestations: Tinea Capitis
Circular patch of scaly skin
Dry, noninflammatory dermatosis
Patchy areas of hair loss
Crown, parietal areas
“Black dots”: hairs broken off at the scalp
Kerion or favus: both worse involvement

25. T. Capitis Presentation

26. Manifestations: Other Tineas
Unguium: opaque, yellow nails; thickened; brittle, crumbled; nail lifts and may be lost
Versicolor: lesions darken in winter, lighten in summer
Nigra: black, brown discoloration on palms, lesions may coalesce; no scaling, nonpruritic, painless

27. T. Unguium Presentation

28. T. Versicolor Presentations

29. Tinea Incognito
Inappropriate assumption that lesions are allergenic in etiology
Treatment of the lesion with steroids
Steroid decreases inflammatory barriers, allowing spread to accelerate
As spread accelerates, patient increases use of steroids

30. Tinea Incognito

31. Tinea Treatment Guidelines
Be sure lesions are fungal
Check for other medications or medical conditions causing lesions
Ointments last longer than creams
Aerosols easy to use on skin and in shoes
Only self treat: pedis, cruris, corporis
Continue for full course of therapy

32. Tinea Pedis Treatment If topicals ineffective, orals may be necessary
2˚ bacterial infections may require antibiotics
May also need antiperspirants
Recurs in 70% of patients

33. Tinea Corporis Treatment
If condition does not clear, may be
Psoriasis
Eczema
Medication-induced eruptions
More severe fungal pathogens

34. Tinea Cruris Treatment
Responds more readily to therapy than tinea pedis or tinea corporis
Treatment times are shorter

35. Tineas Requiring Referral
Tinea capitis: Topical medications do not penetrate follicles
Tinea Unguium: Forget Fungi-Nail; requires systemic therapy
Tinea Versicolor: Requires Rx meds
Tinea Nigra: Differentiate from other pigmentation such as melanoma: requires Rx meds

36. Self-Care Only pedis, corporis, cruris
Not for nails, scalp, vaginal yeast infections, diaper rash
Supervise children
External use only
Keep from eyes
Clean skin with mild soap first
Apply morning and night

37. Therapeutic Choices: Classify By Cure Rates/Dosing
First Generation: Longest cure rates
Second Generation: Shorter cure rates
Third Generation: Shortest cure rates for tinea pedis coupled with once-daily dosing

38. First Generation (Oldest)
First Generation: use down to 2 years
Undecylenic acid: around pre-1970s
Tolnaftate: OTC in 1971
Miconazole: OTC in 1982
Clotrimazole: OTC in 1989
Use 4 weeks for corporis & pedis, 2 weeks for cruris
Age limit is 2 years

39. Clotrimazole
Occasional burning, stinging, peeling, other minor local reactions

40. Clotrimazole: Lotrimin AF Creams

41. Clotrimazole Products: Lotrimin AF for Her and Fungi Cure Intensive

42. Miconazole Nitrate Occasional burning and irritation
Otherwise, safe and effective ingredient

43. Miconazole Products: Micatin Cream

44. Miconazole Products: Neosporin AF, Desenex Powder, Cruex Spray

45. Miconazole Products: Lotrimin AF Powder and Aerosol Powders

46. Lotrimin AF Differences
Note that some dosage forms of Lotrimin AF are clotrimazole, where others are miconazole
Evidently, clotrimazole cannot be produced in any aerosol form

47. Tolnaftate Irritation on excoriated skin
Only ingredient proven to prevent recurrences: apply to dry feet 1-2 times daily, at start of spring/summer

48. Tolnaftate Products: Tinactins
Tinea pedis spray Jock Itch spray

49. Tolnaftate Products: Tinactins

50. Tolnaftate Products: Lamisil Defense

51. Tolnaftate Products: Fungi Cure Gel

52. Undecylenic Acid Odor slightly unpleasant
Fungi Cure Liquid, Fungi Nail

53. Second Generation Newer Meds (Post-2000): Only 12 and over
Terbinafine: 1999
Butenafine: 2001

54. Terbinafine Lamisil AT Cream, Spray Pump, Solution
Only for those aged 12 and over
Cures pedis between toes if used BID for 1 week
Only Lamisil AT Cream has an indication for pedis on bottom/sides of feet: used twice daily for 2 weeks
Cures cruris and corporis used once daily for 1 week

55. Lamisil AT Products

56. Butenafine Lotrimin Ultra Cream Only for those aged 12 and over
Cures pedis between toes if used BID for 1 week OR once daily for 4 weeks
Efficacy on bottom and sides of feet unknown
Cures cruris and corporis used once daily for 2 weeks

57. Lotrimin Ultra
Tinea pedis box Jock Itch box

58. Third generation Newest Option: Lamisil AT Gel (terbinafine)
Innovative
One large advantage that will cause it to rapidly become the nonprescription standard for tinea pedis treatment
Requires only one application daily to achieve cure for tinea pedis between the toes in only one week
Age cut-off is still 12 years

59. Lamisil AT Gel

60. Lamisil AT Gel
Ability of patient to treat only once daily will increase adherence to dosage regimen and increase the chances of full cure
Efficacy on bottom or sides of feet is unknown

61. Deceptive Product
Fungi Nail: Only 25% undecylenic acid; cannot cure fungal nails; many consumers are misled

62. Deceptive Product
Dr. Scholl’s Fungal Nail: Contains tolnaftate cream, revitalizer cream, a brush and file; cannot cure fungal nails and also misleads consumers

63. Deceptive Product
Blue Star Ointment: Recommended for tinea cruris, pedis, and corporis; camphor 1.24%, methyl salicylate, salicylic acid; junk product; extreme pain if applied to broken skin

64. Prevention of Pedis Keep feet clean & dry
Dry thoroughly after bathing; use antifungal powder
Go barefoot whenever possible
Wear open sandals
Use thongs when in communal bathing or showering facilities
Change shoes/socks daily

65. Prevention of Pedis Never share footwear
See physician immediately if toenails infected
Use preventive tolnaftate if recurrent
If present elsewhere, don’t use same towel to dry the feet
Wear several different shoes so they can dry
Wear cotton socks

66. Prevention of Corporis
Wash/dry with different cloths than those used to wash/dry the feet
Never play with strange cats/dogs
Avoid contact with infected people
Lose weight: less intertriginous skin
Dry thoroughly after bathing, especially intertriginous skin (e.g., beneath breasts)
Never garden in bare feet or knees

67. Prevention of Cruris Lose weight
Wash and dry groin with different towels/wash cloths
Avoid sexual contact with infected individuals
Wear underclothes that allow evaporation