The classic ringworm lesion is an erythematous, raised, scaly ring with central clearing. Multiple lesions might be present. The severity of the infection can range from mild, scaly lesions to erythematous, exudative lesions if a bacterial superinfection has developed. Tinea may be difficult to distinguish from other skin conditions. Physical examination and clinical history alone may not be enough to diagnose ringworm. NPs should generally use a diagnostic test to confirm suspected ringworm, especially before prescribing antifungal treatment. Figure 12. Ringworm
Treatment for tinea can be challenging. Identifying the different types of tinea is challenging, but once identified, treatment recommendations are for at least 2 weeks. A good rule of thumb is to have the patient treated for an additional week after the rash has disappeared. Treatment options for the different types of tinea are presented below. ● Tinea pedis: Athlete’s foot can usually be treated with over- the-counter topical antifungal products. Chronic or extensive tinea pedis may require treatment with systemic antifungal agents such as terbinafine, itraconazole, or fluconazole. In addition, chronic tinea pedis may require adjunctive therapy such as foot powder or talcum powder to prevent skin maceration. ● Tinea capitis: Treatment with systemic antifungal medication is required, as topical antifungal products are ineffective for treating tinea capitis. Many experts consider griseofulvin to be the drug of choice. Terbinafine is also Food and Drug Administration (FDA)–approved for treating tinea capitis in patients age 4 years and older. Itraconazole and fluconazole are safe and effective but are not FDA-approved for this indication. Selenium sulfide shampoos can be used as adjunctive therapy. Clinicians should generally confirm the diagnosis of tinea capitis using a laboratory test. ● Tinea corporis/cruris: Tinea corporis and tinea cruris can usually be treated with topical antifungal products. Patients with tinea cruris should be advised to keep the groin area clean and dry, and they should wear cotton underwear. Patients who have extensive or recurrent infections may Pityriasis versicolor, also known as tinea versicolor, is a frequent, benign, superficial fungal skin infection. Clinical features of pityriasis versicolor include either hyperpigmented or hypopigmented finely scaly macules. The most frequently affected sites are the trunk, neck, and proximal extremities. The diagnosis of pityriasis versicolor is often made clinically with history and physical exam. The ultraviolet black light and the microscopic examination of scales soaked in potassium hydroxide may be helpful in doubtful cases (Karray & McKinney, 2022). Pityriasis versicolor responds well to induction therapy. However, long-term maintenance treatment often is required because of the high recurrence rate. Patients should be informed that the causative agent of pityriasis versicolor is a commensal fungal inhabitant of normal skin flora. Therefore, the disease is not considered to be contagious. In addition, pityriasis versicolor does not lead to permanent scarring or pigmentary disorders. Topical medications are considered the first-line therapy for pityriasis versicolor. Topical treatments are divided into nonspecific antifungal agents (sulfur plus salicylic acid, selenium sulfide 2.5%, and zinc-pyrithione) that primarily remove dead tissue and prevent further invasion and specific antifungal drugs that have fungicidal or fungistatic effects. Antifungal agents include imidazole (clotrimazole 1%, ketoconazole 2%, econazole, isoconazole, miconazole), ciclopirox olamine 1%, and allylamine (terbinafine 1%; Karray & McKinney, 2022). Self-Assessment Quiz Question #7 Which of the following antifungal medications is most effective for treating tinea capitis? require systemic antifungal therapy. NP Consideration: Tinea Versicolor
From Georg, L. K. (1964). 22281. https://phil.cdc.gov/Details. aspx?pid=22281. In public domain
Table 6. Diagnostic Tests for Ringworm Diagnostic Test Description Potassium hydroxide preparation
Clinicians can use a potassium hydroxide (KOH) preparation of skin scrapings or nail clippings to confirm a diagnosis of ringworm. This test can provide rapid results, but the test’s accuracy depends on the clinician’s experience and technique A fungal culture can be used to diagnose ringworm. A fungal culture is more specific than a KOH stain, but results may take several weeks. Histopathologic examination of nail clippings with a periodic acid–Schiff (PAS) stain confirms the diagnosis for patients with suspected onychomycosis, a fungal nail infection most often caused by dermatophytes. Polymerase chain reaction (PCR) is a quick and increasingly used method for diagnosing ringworm. Ultraviolet light can be useful for diagnosing ringworm caused by Microsporum canis and Microsporum audouinii. Although both species fluoresce blue-green under a Wood’s lamp, these species are uncommon causes of ringworm infections in people.
Fungal culture
Histopathologic examination with a periodic acid–Schiff stain
Polymerase chain reaction
Ultraviolet light (Wood’s lamp)
a. Terbinafine. b. Griseofulvin. c. Fluconazole. d. Itraconazole.
(CDC, 2022d)
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Book Code: AUS3024
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