What Are the Different Types of Tinea?

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Patient Presentation
A 10-year-old male came to clinic for some peeling skin on his feet. His mother had noticed it the night before and was concerned that it was “athlete’s foot” or that it might spread into the nails. He denied any pain, pruritis, redness, or swelling. He had a recent blister from wearing flip-flops while playing a sport. The pertinent physical exam showed a healthy male in no distress. His skin examination overall showed some freckling of his face and arms, and a mild healing sunburn. On the plantar surface of his right great toe there was an unroofed blister and some dried, fissured areas on the instep of the ball of the foot consistent with callus formation. There were no skin changes between the digits.

The diagnosis of callus formation, a healing unroofed blister and sunburn was made. The physician recommended conservative treatments for the feet and sunscreen use before going outside. The mother said that she was very worried because she was going to cosmetology school and had been reading and reviewing pictures about fungal scalp and nail infections. The physician re-iterated that the minor skin peeling and fissuring appeared to be because of overuse. He also told the mother that if the foot became painful, had burning, itching, or redness especially between the toes, then the child may need to be treated for a fungal infection.

Discussion
Tinea infections are caused by fungi that infect the outer layer of skin, hair and nails and are generally classified by anatomic location. Tinea is also called ringworm particularly if located on the body. Tinea can be spread in 3 different ways with human-to-human transmission being the most common.

  • Anthropophiic organisms – human-to-human transmission.
    Common examples include Trichophyton rubrum, Triphophyton mentagrophytes Trichophyton tonsurans, Epidermophyton floccosum

  • Zoophilic – animal-to-human transmission. Common examples include Microsporum canis, Trichophyton verrucosum
  • Geophilic – soil or fomite-to-human transmission. A common example includes Microsporum gypseum

Species greatly differ around the world and over time and by body location. Overall the most common dermatophyte is Trichophyton rubrum.

The differential diagnosis of tinea commonly includes:

  • Contact dermatitis
  • Eczema
  • Herpes
  • Impetigo/pyoderma
  • Pediculosis
  • Psoriasis
  • Seborrhea

If nails are involved then onchodystrophy is also a possibility. If in a hairy area, alopecia areata, traction alopecia or trichotillomania should also be considered. Drug eruptions should be considered especially if lesions are located on the body.

Learning Point
Common presentations of tinea include:

  • Barbae
    • Location: beard and surrounding skin of male adolescents and adults
    • Description: may be isolated or confluent, highly inflammatory reaction with papules, pustules, exudates, crusts, hair may be absent or loose
    • Common causative species: Trichophyton rubrum, Trichophyton mentagrophytes, Trichophyton verrucosum
    • Common treatment: Griseofulvin
  • Capitus
    • Location: head
    • Description: round or oval, single or multiple patches with broken hairs near base of shaft. May have alopecia.
    • Common causative species: Trichophyton tonsurans, Microsporum canis
    • Common treatment: Griseofulvin, terbinafine
  • Corporis
    • Location: body
    • Description: non-hairy areas with annular, ovoid or circular lesions. Central clearing with finer scale at the edge is characteristic.
    • Common causative species: Trichophyton rubrum, Epidermophyton floccosum
    • Common treatment: Terbinafine, Miconazole, Clotrimazole, Ketoconazole
  • Cruris
    • Location: groin and upper thighs
    • Description: often sharply marcated lesions or area, occurs symmetrically often, may be confluent or have central clearing, pruritis is common
    • Common causative species: Trichophyton rubrum, Trichophyton mentagrophytes
    • Common treatment: Terbinafine, Miconazole, Clotrimazole, Ketoconazole
  • Imbricata
    • Location: Body
    • Description: tile-like or shingle-like plaques, may be circumferential
    • Common causative species: Trichophyton concentricum
    • Common treatment: Griseofulvin, Terbinafine
    • Other: Other name is Tokelau, occurs in the archipeligos of South Pacific, South Asia and some areas of South America
  • Nigra
    • Location: hands
    • Description: brown or black macules on palmar or dorsal surfaces
    • Common causative species: Hortaea werneckii (a mold)
    • Common treatment: benzoic acid or midazole
  • Manuum
    • Location: hand
    • Description: erythematous, often confluent areas with scale at the edge
    • Common causative species: Tinea rubrum
    • Common treatment: Terbinafine, Miconazole, Clotrimazole,
  • Pedis
    • Location: foot
    • Description: erythematous, often confluent areas with scale at the edge which may be macerated. Fissuring and pruritis is common. Interdigital location is common
    • Common causative species:Trichophyton rubris, Trichophyton mentagrophytes
    • Common treatment: Terbinafine, Miconazole, Clotrimazole, Ketoconazole
    • Other: A common name is Athlete’s foot
  • Unguium
    • Location: nails
    • Description: lateral and distal nail edges but all of nail may be involved. Hyperkeratosis with discoloration of the nail. Concurrent tinea pedis or manuum is common.
    • Common causative species: Trichophyton rubris, Trichophyton mentagrophytes, Epidermophyton floccosum
    • Common treatment: Griseofulvin, Terinafine, Itraconazole
  • Versicolor
    • Location: trunk, face arms
    • Description: oval macules and patches with multiple scales, hypo or hyper-pigmentation is common
    • Common causative species: Pityrosporum orbiculare (yeast)
    • Common treatment: Selenium sulfide, topical antifungals, Ketoconazole
    • Other: Other name is Pityriasis versicolor

Tineas that aren’t real tineas

  • Tinea incognito – the true clinical appearance of tinea is masked because of inappropriate treatment, such as a topical steroid.
  • Tinea ambiantacea – also known as pityriasis amiatacea is a papulosquamous disorder associated with psoriasis and not a mycosis.

Questions for Further Discussion
1. What is the cause of a kerion?
2. When are oral antifungal medication indicated?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Tinea Infection.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Hurwitz S. Clinical Pediatric Dermatology. Second Edit. WB. Saunders and Co. Philadelphia PA. 1993:108-109, 373-389.

Andrews MD, Burns M. Common tinea infections in children. Am Fam Physician. 2008 May 15;77(10):1415-20.

Seebacher C, Bouchara JP, Mignon B. Updates on the epidemiology of dermatophyte infections. Mycopathologia. 2008 Nov-Dec;166(5-6):335-52.

Andrews RM, McCarthy J, Carapetis JR, Currie BJ. Skin Disorders, Including Pyoderma, Scabies, and Tinea Infections. Pediatric Clin N Am. 2009;56:1421-1440.

Bonifaz A, Vazquez-Gonzalez D. Tinea imbricata in the Americas. Curr Opin Infect Dis. 2011 Apr;24(2):106-11.

University of Adelaide. Tinea nigra. Mycology online.Available from the Internet at http://www.mycology.adelaide.edu.au/Mycoses/Superficial/Tinea_nigra/ (rev. 2012, cited 6/4/12).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    • Published