Tinea

• Common fungal infection especially in hot climates
• May get secondary bacterial infection
• Usually spreads between people but can spread from animals
• Help stop spread of infection by reducing fungal spores
• Wash clothes and sheets with laundry detergent and dry in sun
• Vacuum/sweep and mop floors, wipe over surfaces. Use disinfectant if available

Tinea of body skin (ringworm, jock itch, athlete's foot)

• Often lasts a long time
• In tropical Northern Australia it can affect any area and be very widespread
• In other places it is most common on warm, moist skin — between toes, under breasts, armpits, groin, around waist and spreading down

Check

• Head-to-toe exam — with attention to
• Dusty-looking, irregular areas of skin with fine scale and raised spreading edge — silver on dark skin, reddish on pale skin
• Itch
• May also have weeping or crusty bacterial infection
• Consider crusted scabies, kava dermatitis, pityriasis versicolor, leprosy (uncommon)
• If leprosy suspected — refer to PHU for specialist review and treatment plan

Do

• Collect skin scrapings from scaly edge of ring — MC&S, fungal culture

For small areas of tinea

• Terbinafine 1% cream or gel, once a day for 1 week
• OR miconazole 2% cream, twice a day (bd) for 4–6 weeks — including 2 weeks after rash gone
• If treatment doesn't work OR small patches in hairy areas, palms or soles of feet — medical consult

For widespread tinea

• Give terbinafine oral — Table 7.33 for doses, once a day for 2 weeks
  
• See Precautions with oral terbinafine 
• If rash remains — medical consult about another 2 weeks of treatment

Precautions with oral terbinafine

Rare but serious side effects can develop after about 4 weeks of treatment — liver toxicity, blood abnormalities, skin rashes

• Check for drug interactions before treatment 
• If treatment lasts more than 2 weeks — medical follow-up
• If person is over 40 years or has kidney disease, acute or chronic liver disease or drinks too much alcohol — check LFT, FBC and UEC before treatment
• If LFT abnormal but not more than twice the normal — start terbinafine and retest after 2 weeks
• If LFT have then risen further — stop terbinafine and medical consult
• If LFT more than twice normal and strong indication for treatment, eg onychomycosis, diabetes, recurrent cellulitis, not cosmetic — can still consider terbinafine but only under close medical supervision
• Follow-up with LFT after 1 and 2 weeks of treatment
• If adult with no risk factors — check LFT and FBC after every 4 weeks of treatment
• If child to be on treatment longer than 6 weeks — check LFT and FBC at 4 weeks. Make sure results followed up
• If symptoms of low white cell count or liver toxicity, eg fever, nausea — check LFT and FBC again
• Avoid use in pregnancy AND breastfeeding —  medical consult

Tinea capitis (tinea of the scalp)

Usually a combination of mild scale and broken hairs often with hair loss —hairs can be broken off at different lengths or all close to scalp, giving a black dot appearance

Check

• Head-to toe exam — attention to scalp
• Scaly rash or kerion (looks like boil but itchy)
• Broken hairs

Do

• Collect skin scrapings — pull some broken hairs (include root) with forceps  — MC&S, fungal culture
• Give terbinafine oral once a day for 4 weeks — then reassess
• Table 7.33 for doses
• See Precautions with oral terbinafine 
• Medical supervision needed
• Also use  selenium sulfide 2.5% shampoo or ketoconazole 2% shampoo
• Shampoo 3–5 minutes then rinse off — once a day for 5 days

Tinea of the nails

More common on toenails — usually tinea on skin as well

Check

• Head-to-toe exam — with attention to
• Nails thick, irregular, white, lifting up with chalky material under nail

Do

• Collect nail clippings — MC&S, fungal culture
• Cut nails as far back as comfortable
• Scrape and collect chalky material from under nail
• If person high risk (eg recurrent cellulitis, diabetes) OR concerned about appearance, even after reassured it is not dangerous
• Give terbinafine oral once a day — 6 weeks for fingernails, 12 weeks for toenails — Table 7.33 — for doses
• See Precautions with oral terbinafine 

Pityriasis versicolor (tinea versicolor, white spot)

• Common in hot, humid areas in all age groups
• Tends to be a chronic problem but only important because of how it looks

Check

• Head-to-toe exam — with attention to skin
• Most common on upper trunk, shoulders, upper arms, neck — occasionally on face
• Round or oval patches — pale on dark skin, tan on light skin
• Wood’s lamp (black light) — shows pale areas more clearly. Pityriasis versicolor may appear pale greenish-yellow
• Lots of small hypopigmented (pale) blotches grouped together — scale may be noticed when scraping skin surface
• Could be ringworm — pityriasis versicolor has finer scale, no raised edge and is usually not itchy

Do

• If diagnosis unclear — collect skin scrapings for microscopy 
• Use selenium sulfide 2.5% shampoo
• Rub on affected skin and leave on for 10 minutes — do every day for 7-10 days
• AND shampoo hair every second day for 2 weeks
• OR use ketoconazole 2% shampoo

• Rub on affected skin and leave on overnight — repeat after 1 week
• AND shampoo hair every day for 1 week
• No scale means treatment worked
• May take several months for colour to return to skin even after successful treatment

Follow-up

• Often comes back even after successful treatment — repeat treatment if needed
• If not improving — consider dermatitis or leprosy (uncommon)
• If leprosy suspected — refer to PHU for specialist review and treatment plan

Supporting resources

• Skin conditions visual treatment guide
• National healthy skin guidelines