11.17 Tinea (Athlete's Foot, ringworm)
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agk's Library of Common Simple Emergencies

Presentation
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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:
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- 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:
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- 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
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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.

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
 Longwood Information LLC 4822 Quebec St NW Wash DC
 1.202.237.0971 fax 1.202.244.8393 electra@clark.net
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