Patients usually seek emergency care for "athlete's foot,"
"jock itch," or "ringworm" when pruritis is severe or when
secondary infection causes pain and swelling. Tinea pedis is
usually seen as interdigital scaling, maceration, and
fissuring between toes. At times tense vesicular lesions
will be present instead. Tinea cruris is usually a moist,
mildly erythematous eruption symmetrically affecting both
groin and upper inner thigh. Tinea corporis appears most
often on the hairless skin of children as dry erythematous
lesions with sharp annular and arciform borders that are
scaling or vesicular.
What to do:
When microscopic examination of skin scrapings in KOH is
readily available, definite identification of the lesion
can be made by looking for the presence of hyphae or
spores (resembling microscopic spaghetti and meatballs) in
the scabs or hair. Treatment can be started presumptively
when microscopic examination is not easily accomplished.
Clotrimazole (Lotrimin), miconazole (Micatin) haloprogin
(Halotex) and tolnaftate (Tinactin) solution or cream
applied to the rash bid will cause involution of most
superficial lesions within 1-2 weeks.
With signs of secondary infection, begin treatment first
with wet compresses of Burow's solution (2 pks of Domeboro
powder in 1 pint water) one half hour every 34 hours.
With signs of deep infection (cellulitis, lymphangitis)
begin systemic antibiotics in addition, like cefadroxil
(Duricef) lgm qd x 5-7 day or cephalexin or dicloxacillin
250-500mg tid x 5-7 days.
With inflammation and weeping lesions, a topical
antifungal and steroid cream such as (Vioform-
Hydrocortisone) in addition to the compresses will be most
effective. Warn patients that this medication will stain
white clothing yellow.
What not to do:
Do not attempt to treat deep, painful fungal infections of
the scalp (tinea capitis) with local therapy. A deep boggy
swelling (tinea kerion) or patchy hair loss with
inflammation and scaling requires systemic antifungal
antibiotics like griseofulvin.
Do not treat with corticosteroids alone. They will reduce
signs and symptoms, but allow increased fungal growth.
Discussion
Tinea versicolor is asymptomatic, and its presentation to
an acute care facility usually is incidental with some other
problem. There is, however, no reason to ignore this fungal
infection, which causes cosmetically unpleasant, irregular
patches of varying pigmentation that tend to be lighter than
the surrounding skin in the summer and darker than the
surrounding skin in the winter. Prescribe a 25% sodium
hyposulfite lotion (Tinver) bid for several weeks or a 2.5%
selenium sulfide lotion (Selsun). Superficial scaling will
resolve in a few days and the pigmentary changes will slowly
clear over a period of several months.
