PERSONAL NOTES ON TINEA

Dr. Saleh Mohammad Shoaib, Assistant Surgeon, Fakirhat UHC, Bagerhat

DMC (K – 67), MD resident (Phase – A, Neurology, NINS), Mob: 01757370094

GENERAL MEASURES & PREVENTION (FOR ALL TYPES OF TINEA)

• Moist skin favors the growth of fungi. • The use of topical steroids for other diseases may be
complicated by fungal infection, and topical antifungals are often
• Dry the skin carefully after bathing or after perspiring heavily. used in intertriginous areas with steroids to prevent this.
Talc or other drying powders may be useful.

TINEA CAPITIS
• Occurs mainly in children.  Terbinafine: usually effective at 3 – 6 mg/kg/day for 1 – 4 weeks.
Alternate dosing: one 250 – mg tablet for patients over 40 kg, 125
• Consider Tinea in acute inflammatory and purulent reactions of mg (1/2 tablet) for those 20 – 40 kg, and 62.5 mg (1/4 tablet) for
the scalp and beard. those under 20 kg.

Treatment  Itraconazole: Effective at 5 mg/kg/day for 2–3 weeks.

 Griseofulvin: Most frequently used in children. Ultramicronized
form: doses start at 10 mg/kg/day. The tablets can be crushed and
given with ice cream. Griseofulvin V oral suspension: less readily
absorbed. The dose is 20 mg/kg/day. Treatment should continue
for 2 – 4 months, or for at least 2 wks after negative lab
examinations are obtained.
 Fluconazole: 6 mg/kg/day for 2–3 weeks.
 Selenium sulfide shampoo or ketoconazole shampoo: left on
the scalp for 5 min 3 times a week – adjunctive therapy to oral
antifungal agents. Combs, brushes, and hats should be cleaned
carefully.

TINEA CORPORIS (TINEA CIRCINATA)

 Includes all superficial dermatophyte infections of the skin other  Terbinafine and Butenafine: require shorter courses and lead to
than those involving the scalp, beard, face, hands, feet, and groin. the most rapid response. Terbinafine may be used once a day.

 Morphology: one or more circular, sharply circumscribed,
slightly erythematous, dry, scaly, usually hypopigmented
patches with a distinct border and an advancing scaling edge.
Progressive central clearing produces annular outlines that give
them the name “ringworm.”
 In some cases, concentric circles or polycyclic lesions form,
making intricate patterns.
 Treatment should be continued for 1–2 weeks after clinical
clearing***.
 Combination products with a potent corticosteroid such as
clotrimazole/betamethasone frequently produce widespread
Tinea and fungal folliculitis. Their use should be discouraged***.
B. Systemic Measures

 Widespread Tinea corporis may be related to AIDS, use of a Itraconazole: 200 mg orally daily for 1 wk
topical steroid or calcineurin inhibitor.
Terbinafine: 250 mg orally daily for 1 month
Prevention
Fluconazole: 150 mg once weekly for 4 weeks
 Treat infected household pets.
Prognosis
Treatment
Tinea corporis usually responds promptly to topical/oral agent
A. Local Measures within 4 wks.

TINEA CRURIS (JOCK ITCH/CROTCH ITCH)

 Marked itching in intertriginous areas, usually sparing the  Area should be kept as dry as possible by the wearing of loose
scrotum. Lesions confined to the groin and gluteal cleft. underclothing and trousers.

 Intractable pruritus ani may occasionally be caused by a Tinea  Plain talcum powder or antifungal powders are helpful.
infection.
Treatment
 Peripherally spreading, sharply demarcated, centrally clearing
erythematous lesions. A. Local Measures

 Itching may be severe, or the rash may be asymptomatic. Terbinafine: curative in over 80% of cases after once – daily use
for 7 days.
 Occurs most frequently in men on the upper and inner surfaces
of the thighs, especially during the summer when the humidity is B. Systemic Measures
high.
Itraconazole: 200 mg orally daily for 1 wk or
 May extend downward on the thighs and backward on the
Terbinafine: 250 mg orally daily for 1 wk
perineum or about the anus.
Prognosis
Prevention
Tinea cruris usually responds promptly to topical or systemic
 Reduction of perspiration and enhancement of evaporation
treatment but often recurs.
from the crural area are important.

TINEA OF HANDS AND FEET (TINEA MANUUM & TINEA PEDIS)

 Most often asymptomatic scaling. Treatment

 May progress to fissuring or maceration in toe web spaces. A. Local Measures

 May be a portal of entry for bacteria causing lower extremity 1. Macerated stage—Aluminum sub – acetate solution soaks: for
cellulitis. (Caution: Diabetic peripheral neuropathy > loss of 20 minutes twice daily.
sensation > Tinea pedis > cellulitis > amputation, widespread
infection, sepsis etc) Terbinafine or Butenafine: once–daily topically for 1 week will
often result in clearing.
 Itching, burning, and stinging of interdigital web; scaling palms
2. Dry and scaly stage—Use Terbinafine.
and soles; vesicles, bullae, or generalized exfoliation of the skin of
the soles, or nail involvement in the form of discoloration,
Addition of urea 10 – 20% lotion or cream may increase the
friability, and thickening of the nail plate.
efficacy of topical treatments in thick (“moccasin”) Tinea of the
soles.
Prevention

B. Systemic Measures
 Maintain good personal hygiene.
Itraconazole: 200 mg orally daily for 2 weeks or 400 mg daily for 1
 Wear open–toed sandals if possible.
week or
 Use sandals in community showers and bathing places.
Terbinafine: 250 mg orally daily for 2 – 4 weeks
 Carefully dry between the toes after showering. A hair dryer
If the infection is cleared by systemic therapy, the patient should
used on low setting may be used.
be encouraged to begin maintenance with topical therapy, since
 Socks should be changed frequently, absorbent nonsynthetic recurrence is common.
socks are preferred.
Prognosis
 Apply dusting and drying powders as necessary.
Tinea pedis is usually chronic, temporarily cleared by therapy
only to recur.
 The use of powders containing antifungal agents or long–term
use of antifungal creams may prevent recurrences of Tinea
pedis.
 ONYCHOMYCOSIS (TINEA UNGUIUM)
 Fungal infection of the nail plate. Fig: Psoriatic nail dystrophy

 Presentation(s): Yellow/brown nail discoloration, crumbling, A. Local Measures

thickening and subungual hyperkeratosis.
 Usually, some nails are spared, there is asymmetry.
 Toenails are more commonly involved.
[Features of psoriatic nail dystrophy: ‘Thimble pitting’,
onycholysis (separation of the nail from the nail bed), subungual
hyperkeratosis and periungual involvement].
Ciclopirox and amorolfine nail lacquers: apply once daily
preferably at bedtime to all affected nails by applicator for 1 year.
Modestly effective.
B. Systemic measures
Fingernail involvement: Terbinafine – 250 mg/day for 6 – 8 weeks
or Itraconazole – 200 mg twice daily for 1 week of each month for
2 months

??Continuous therapy with terbinafine for 2 months is cost –

effective compared with other possible agents and regimens.

Toenails involvement: Terbinafine – 250 mg/day for 12 – 16

weeks or Itraconazole – 200 mg twice daily for 1 week of each
month for 3 – 4 months. Fluconazole: 150 – 300 mg once weekly
for 6 – 12 months, also appears to be effective. Albaconazole also
appears promising.

Continuous therapy with terbinafine for 4 months is cost –

effective compared with other possible agents and regimens.

STEROID‐MODIFIED TINEA (e.g: TINEA INCOGNITO)

 These are ringworm infections modified by systemic or topical
steroids.
 Clinical diagnosis of Tinea depends heavily on the inflammatory
changes involved. This inflammatory response may be almost
totally suppressed by systemic or topical steroids.
 Also, immune response against pathogens is diminished by
steroids.
bruise‐like brownish discoloration is seen, especially in the groins.
Concentric rings of erythema may be seen among the atrophy and
telangiectasia. Presumably, these represent waves of fungal
growth. The eruption remains localized but it may spread more
widely than one would expect in an unmodified case.
 Potent steroids most likely produces this syndrome, but even
1% hydrocortisone cream can sometimes modify Tinea to a
confusing extent.

 So, the patient suffers doubly: the infection is less likely to be
diagnosed, and the patient has been rendered more susceptible
to that infection.
 History is typical. A patient with Tinea is prescribed
topical/systemic steroids by mistake. Patient is often satisfied
initially with the treatment. Itching is controlled and the
inflammatory signs settle. But there is a relapse on stopping
treatment, with varying rapidity. Further applications bring
renewed relief and the cycles are repeated.
Management
 Whatever site is affected, treat steroid‐modified Tinea with oral
therapy, allowing a few applications of topical steroid to
continue until the terbinafine or itraconazole has begun to take
effect.
 Use 1% hydrocortisone cream or at least a weaker steroid than
that originally prescribed, and also to warn the patient about a
possible rebound in spite of these measures.

 Morphology: Raised margin is diminished. Scaling is lost.  Follow‐up to ensure steroid cream has been stopped and cure
Inflammation reduced to a few nondescript nodules. Often, a obtained is mandatory.

TOPICAL STEROIDS ACCORDING TO POTENCY

Potency Name Cost
Mild • Hydrocortisone 0.5%, 1%, 2.5% (Intasone 1%, Topicort 1%, Cortider 1%, Unicort 1%) 10 gm cream = 30 tk
• Hydrocortisone 1% and fusidic acid 2% (Fusibac H, Fusicort, Fusidate H, Fusitop HC, 10 gm cream = 125 tk
 Facid HC, Fortison)
Moderate • Clobetasone butyrate 0.05% (Ezex) 25 gm cream/ointment = 75.5 tk
Potent • Betamethasone valerate 0.1% (Betaderm, Bet – A, Betson, Betaval, Diprobet, Sinacort) 15 gm ointment = 35 tk
15 gm cream = 33 tk
• Fluocinolone acetonide 0.025% (Skinalar) 5 gm ointment/cream = 38 tk
• Mometasone furoate 0.1% (Soneta, Meloderm, Momeson, Mometa) 5 gm cream/ointment = 100 tk
30 gm cream = 500 tk
30 gm ointment = 550 tk
• Triamcinolone acetonide 0.1% (Aristocort, Cortefin, Trialon) 10 gm ointment/cream = 25 tk
Very • Clobetasol propionate 0.05% (Dermasol, Exovate, Aclobet, Clobesol, Clovate, Dermex, 20 gm cream = 70.5 tk
potent Nyclobate, Topiclo, Xenovate) 20 gm ointment = 75.5 tk
• Clobetasol propionate 0.05% + 3%/6% salicylic acid (Topiclo S 3%/6%) 3% 10 gm ointment = 70 tk
3% 20 gm ointment = 120 tk
6% 10 gm ointment = 80 tk
• Halobetasol propionate 0.05% (Halobet) 10 gm ointment/cream = 90 tk

ROLE OF ANTI – FUNGAL + STEROID COMBINATION

 Combination products with a potent corticosteroid such as
clotrimazole/betamethasone for Tinea frequently produce
widespread Tinea and fungal folliculitis.
 Prophylactic topical anti – fungal therapy with topical steroids:
The use of topical steroids for other diseases (i.e: Eczema) may be
complicated by intercurrent Tinea or candidal infection, and
topical antifungals are often used in intertriginous areas with
steroids to prevent this.
***So, Never use anti – fungal + steroid combination (e.g:
Pevitin, Econate plus etc.) in fungal infections, but you can use it
as prophylaxis against fungal infections in conditions where
topical steroids are primarily indicated (e.g; Eczema).
 STEROID FAILURE IN ECZEMA?
Your patient’s asymmetrical ‘eczema’ is spreading despite local steroids – think of Tinea.

TREATMENT OF VARIOUS FORMS OF TINEA

Variety of Duration of Mode of
Route Treatment Prognosis
Tinea therapy therapy
Tinea Oral Griseofulvin: Ultramicronized: start at 10 2 – 4 months, or for Oral plus Recurrence
capitis mg/kg/day. Griseofulvin V oral suspension: 20 at least 2 weeks topical uncommon
mg/kg/day or after negative lab May relapse on
results exposure to infected
Terbinafine: 3 – 6 mg/kg/day. Alternate daily dose: 1 – 4 weeks persons,
wt. > 40 kg = 250 mg, wt. 20 – 40 kg = 125 mg (1/2 asymptomatic
tablet), wt. < 20 kg = 62.5 mg (1/4 tablet) or carriers, or
Itraconazole: 5 mg/kg/day or 2 – 3 weeks contaminated
Fluconazole: 6 mg/kg/day 2 – 3 weeks fomites.
Topical Selenium sulfide/ketoconazole shampoo: left on 3 times a week Usually spontaneous
the scalp for 5 min during each application – clearing at about age
adjunctive therapy to oral antifungals. 15 years without
drugs.
Tinea Topical Terbinafine or Butenafine: apply once daily 1 – 2 weeks after Topical (+ Usually prompt
corporis clinical clearing oral in response to
(Tinea Oral Itraconazole: 200 mg orally daily or 1 week extensive topical/oral agent
circinata) Terbinafine: 250 mg orally daily or 1 month disease) within 4 wks.
Fluconazole: 150 mg once weekly 4 weeks
Tinea Topical Terbinafine: Once daily 7 days Topical (+ Usually prompt
cruris Oral Itraconazole: 200 mg daily or 1 week oral in response to
(jock itch) Terbinafine: 250 mg daily 1 week extensive topical/oral agent but
disease) often recurs.
Tinea of Topical Macerated stage — Terbinafine or Butenafine: 1 week Topical (+ Usually chronic,
hands and Once daily oral in temporarily cleared
feet Add Aluminum sub – acetate solution soaks: for 20 extensive by therapy only to
(Tinea minutes twice daily disease) recur.
manuum Dry and scaly stage— Terbinafine: Once daily 1 week
& Tinea Add urea 10 – 20% lotion/cream in thick
pedis) (“moccasin”) Tinea of the soles
Oral Itraconazole: 200 mg daily or 2 weeks
Itraconazole: 400 mg daily or 1 week
 Terbinafine: 250 mg daily (If infection cleared by 2 – 4 weeks
oral therapy, maintain with topical therapy, since
recurrence is common.)
Onychom Topical Ciclopirox and amorolfine nail lacquers: apply once Minimum 1 year Oral plus Disease course is
ycosis daily. modestly effective. topical chronic.
(Tinea
unguium) Oral Fingernail Terbinafine – 250 mg/day 6 – 8 weeks
involvement or
Itraconazole – 200 mg 1 week of each
twice daily month for 2
months
Toenails involvement Terbinafine – 250 mg/day 12 – 16 weeks
or
Itraconazole – 200 mg 1 week of each
twice daily or month for 3 – 4
months
Fluconazole: 150 – 300 mg 6 – 12 months
once weekly
Steroid ‐ Oral Itraconazole: 200 mg daily or Oral plus
modified Terbinafine: 250 mg daily slow
Tinea Topical Allow a few applications of 1% hydrocortisone continue until oral tapering
(Tinea cream or a weaker steroid than that originally therapy has begun topical
incognito) prescribed to take effect steroid

MY FAVOURITE ANTI – FUNGAL DRUGS

Name of drug
Terbinafine (Telfin, Xfin,
Mycofree, Terbifin,
Mycofin, Terbex)
Itraconazole (Itra, Itracon)
Fluconazole (Flugal,
Nispore, F–zol)
Ketoconazole shampoo
(Dancel, Ketocon,
Nizoder, Select plus)
Ciclopirox cream
(Clopirox, Cicloderm,
Candirox)
Ciclopirox nail lacquer
(Candirox)
Dose
Topical: once to twice daily
Oral: 250 mg daily
Oral: 200 – 400 mg/day
Oral: 50 – 400 mg daily to 150
– 300 mg weekly
left on the scalp for 5 min
during each application 3 times
a week
Topical: twice daily for 4 weeks
Nail lacquer: once daily (at
bedtime) to all affected nails
by applicator for 1 year
Cost Comment
1% 10 gm cream = 60 tk Fast clinical response.
250 mg tab = 25 tk Preferred topical therapy.
A/E: (rare) GI upset, headache, hepatotoxicity.
Topical: local irritation, burning sensation,
erythema.
Avoid contact with mucous membranes.
100 mg cap = 15 tk Preferred oral therapy.
Shorter duration of therapy.
Take capsules after meal for better absorption.
st
50 mg cap = 8 tk Not 1 line for Tinea.
150 mg cap = 22 tk Longer duration of therapy.
200 mg cap = 25 tk Preferred for Candidiasis.
50 mg/5 ml (35 ml
bottle) susp. = 80 tk
2% 100 ml bottle = 230 Application: Wet affected scalp/skin with water.
tk Apply shampoo to it and a large area around it.
Use fingers to rub the shampoo until it forms
lather. Wait for 5 minutes. Rinse the shampoo off
with water.
1% 10gm cream = 110 tk Anti – fungal activity: broad spectrum
Anti – bacterial activity: effective against Gram ‐
positive and Gram ‐ negative bacteria including
8% Nail lacquer = 160 tk meticillin – resistant Staphylococcus aureus.
No topical toxicity.
S/E: hypersensitivity.

MY FAVOURITE ANTI – ITCHING DRUGS

Name of drug Dose Cost Comment
Chlorpheniramine (Histacin) 12 mg daily in 3 – 4 divided doses 4 mg tab = 0.29 tk Sedating anti – histamines
Hydroxyzine (Artica, Xyril, Roxyzine) 10/25 mg daily to 25 mg 4 times daily 10 mg tab = 1.25 tk Sedating anti – histamines
25 mg tab = 2 tk
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HOW TO PRESCRIBE FOR TINEA?

 Tinea capitis: give 1 oral drug along with ketoconazole/selenium shampoo.

 Onychomycosis: give 1 (or 2) oral drugs with topical nail lacquer.

 Steroid – modified Tinea: give 1 (or 2) oral drugs with topical slow tapering steroid.

 Tinea corporis, Tinea cruris, Tinea manuum and Tinea pedis:

Mild disease: only topical therapy.

Extensive disease: give 1 (or 2) topical drug PLUS 1 or 2 oral drugs.

 Give all treatments in full dose and adequate duration.

 My rule: Over – treatment is better than under – treatment. Costly treatment (if necessary) is better than cheaper treatment on patient
request. I never prescribe Benzoic acid + Salicylic acid (Whitfield) supplied free of cost in hospital pharmacy if my provisional diagnosis is
Tinea, even if the patient try eagerly to convince me (saying that only and only hospital free supplies work good for his/her illness(es), or
he/she has no money etc. etc.)

HOW TO MANAGE ITCHING IN TINEA?

Not all itch are histamine dependent. So, non – sedating anti – histamine may have no role. Always use sedating anti – histamines
(Chlorpheniramine [Histacin], Hydroxyzine [Artica] etc.) for Tinea: at least the sedation will give relief from sleep loss.

EXAMPLES OF PRESCRIBING ANTI – TINEA DRUGS

f/u = follow up, A/M = After meal

Example 1 – Tinea corporis (mild): A 25 y old female presents with 1 well circumscribed itchy lesion (diameter = 2 cm) with central clearing in
upper back.

Advice***

Drugs: 1. Telfin 1% cream: apply locally once/twice daily – until 1–2 weeks after clinical clearing 2. Tab. Artica 25 1 + 1 + 1 + 1 – if itching

f/u after 2 wks.

Example 2 – Tinea cruris (severe): A 34 y old male presents with multiple circumscribed itchy lesions with central clearing in intertriginous
area, extending towards umbilicus through lower abdomen.

Advice***

Drugs: 1. Xfin 1% cream: apply locally once/twice daily – until 1–2 weeks after clinical clearing 2. Cap. Itra 100 1 + 0 + 1 (A/M) – 2 wks 3. Tab.
Roxyzin 25 1 + 1 + 1 + 1 – if itching

f/u after 2 wks.

th th
Example 3 – Tinea pedis: A 57 y old diabetic male presents with painless white lesion between 4 and 5 toe in both feet. His FBS = 8.9, 2HAB
= 17.9.

Advice***

Control Diabetes***

Drugs (only for Tinea): 1. Terbifin 1% cream: apply locally once/twice daily – 2 wks 2. Cap. Itracon 100 1 + 0 + 1 (A/M) – 2 wks 3. Tab. Xyril 25 1
+ 1 + 1 + 1 – if itching

f/u after 2 wks.

Example 4 – Onychomycosis: A 65 y old diabetic female presents with multiple fingernail and toenail dystrophy. Investigations confirm Tinea.

Advice***

Control Diabetes***

Drugs (only for Tinea): 1. Candirox 8% nail lacquer: apply topically daily = 1 year or as needed 2. Tab. Mycofree 250 0 + 0 + 1 = 4 months 3.
Tab. Histacin 4 1 + 1 + 1 – if itching

f/u after 2 wks.

Example 5 – Steroid ‐ modified Tinea: A 35 y old male visited a quack with the complaints of multiple itchy well circumscribed lesions with
central clearing on his torso. He was treated with topical clobetasol and oral prednisolone, an IM shot of triamcinolone, IV meropenem 2g stat,
Paracetamol suppository 4 stick P/R stat, some vitamins, calcium, Iron and sex stimulants for a diagnosis of “Ostopresiss” (The visit was 111 tk,
1 tk less). The patient compliance was very good as the quack was very popular and his behavour was very modest, smile was very bright.
Initially, there was reduced scaling. Raised margin was diminished. After some days, the patient developed increased number of ring shaped
lesions, now involving multiple sites over upper and lower limbs. Pt.’s wife compelled him to come to you.

Advice***

Tell that it was very bad to go to that quack, and some damage has been done. But it’s not the end. There’s a way out.

Don’t forget that severe clinical flare (increased itching, swelling, redness etc) may occur on abrupt discontinuation/withdrawal of steroid.
But don’t panic if it occurs. Counsel the patient beforehand and just follow the protocol. Refer to a dermatologist if necessary.

Drugs: 1. Bet – A (Betamethasone) cream: apply topically twice daily – 2 wks, then once daily – 2 wks, then switch to 1% Topicort
(Hydrocortisone) cream: apply topically twice daily – 2 wks, then once daily – 2 wks, then once every alternate day – 2 wks, then twice weekly
– 2 wks, thus slow taper to nil until oral therapy takes significant effect 2. Cap. Itracon 100 1 + 0 + 1 – until 2 weeks after clinical clearing 3. Tab.
Artica 25 1 + 1 + 1 + 1 – if itching

f/u after 2 wks.

Continue therapy until complete cure obtained and ensure that steroid cream has been completely stopped.

You can use Bet – CG (Betamethasone + Clotrimazole + Gentamicin) and Fungidal - HC (Miconazole + hydrocortisone) instead of only
steroids for additional effect.

Example 6 – Shotgun approach: A 23 y old female comes to your Upazilla Health Complex with some hyperpigmented lesions over Rt.
forearm. It is moderately itchy. Border is partially circumscribed. There is no definite central clearing. There is some papules and pustules over
the lesion. She has allergy to some foods. She took fluconazole 50 mg capsules daily for a few days but is not sure about the response. She
scratched over the lesion and produced ulceration over sites. Her husband has some itchy conditions in his groins.

[It is not possible to exactly diagnose the condition. You do not have lab supports. So, target fungus, bacteria and inflammation – all 3 in a safe
way.]

Advice***

Drugs: 1. 1% Cicloderm cream: apply topically twice daily – 4 wks 2. Tab. Xyril 25 1 + 1 + 1 + 1 – if itching

f/u after 2 wks.

[N.B. Pharmaceuticals companies tell that Ciclopirox has anti – fungal, anti – bacterial and anti – inflammatory actions. But I didn’t find any
evidence in favour of that in textbooks.]

COLOUR ATLAS OF TINEA

TINEA CORPORIS
TINEA CAPITIS
TINEA CRURIS
TINEA PEDIS
TINEA MANUUM
ONYCHOMYCOSIS
OTHER TINEA
STEROID MODIFIED TINEA