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

Table 7.33 Doses of oral terbinafine

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