Hal 2288-2289 edisi 8

TINEA CORPORIS
Tinea corporis refers to any dermatophytosis of glabrous skin except palms, soles, and the groin.
EPIDEMIOLOGY. Tinea corporis may be transmitted directly from infected humans or animals, via
fomites, or it may occur via autoinoculation from reservoirs of dermatophyte colonization on the
feet.44 Children are more likely to contract zoophilic pathogens, especially M. canis, from dogs or
cats. Occlusive clothing and a humid climate are associated with more frequent and severe
eruptions.45 Wearing of occlusive clothing, frequent skin-to-skin contact, and minor traumas such as
the mat burns competitive wrestling create an environment in which dermatophytes flourish. “Tinea
corporis gladiatorum” is caused most commonly by T. tonsurans, and it occurs most frequently on
the head, neck, and arms.46 ETIOLOGY. Although any dermatophyte may cause tinea corporis, it is
caused most commonly by T. rubrum. T. rubrum is also the most likely candidate in cases with
concomitant follicular involvement.35 Epidermophyton floccosum, T. interdigitale (anthropophilic
and zoophilic strains), M. canis, and T. tonsurans are also common pathogens.1 Tinea imbricata,
caused by T. concentricum, is limited geographically to areas of the Far East, South Pacific, and South
and Central America. CLINICAL FINDINGS. The classic presentation is that of an annular (“ring-
worm”-like; Fig. 188-9A) or serpiginous plaque with scale across the entire active erythematous
border. The border, which may be vesicular, advances centrifugally. The center of the plaque is
usually scaly but it may exhibit complete clearing. Whereas concentric vesicular rings suggest tinea
incognito, often caused by T. rubrum, the erythematous

concentric rings of tinea imbricata demonstrate little to no vesiculation. T. rubrum infections may
also present as large, confluent polycyclic (Fig. 188-9B) or psoriasiform (Fig. 188-9C) plaques,
especially in immunosuppressed individuals. Majocchi’s granuloma is a superficial and subcutaneous
dermatophytic infection involving deeper portions of the hair follicles that presents as scaly follicular
papules and nodules that coalesce in an annular arrangement (Fig. 188-10). It is caused most
commonly by T. rubrum, T. interdigitale, and M. canis. Majocchi’s granuloma is observed on the legs
in women who become inoculated after shaving or who apply topical corticosteroids to the involved
area, which facilitates infection. It is also observed increasingly among immunocompromised
patients.47 DIFFERENTIAL DIAGNOSIS. (Box 188-3) LABORATORY TESTS. (See Tables 188-4, 188-6)
HISTOPATHOLOGY. (See Table 188-4)

A B Figure 188-8 Tinea barbae. A. Superficial type. Scattered follicular papules, pustules and small
nodules that may be easily mistaken for Staphylococcus aureus folliculitis. B. Kerion type. Sharply
demarcated red edematous nodule studded with multiple yellowish weeping pustules. Note hairs
have been lost from this nodule.

BOx 188-3 DIFFERENTIAL DIAGNOSIS OF TINEA CORPORIS Most Likely Erythema annulare
centrifugum, nummular eczema, psoriasis, tinea versicolor, subacute cutaneous lupus
erythematosus, cutaneous candidiasis Consider Contact dermatitis, atopic dermatitis, pityriasis
rosea, seborrheic dermatitis Rule Out Mycosis fungoides, parapsoriasis, secondary syphilis

2289

30
Chapter 188 :: Superficial Fungal Infection

TINEA CRURIS

Tinea cruris is a dermatophytosis of the groin, genitalia, pubic area, and perineal and perianal skin.
The designation is a misnomer, because in Latin “cruris” means of the leg. It is the second-most
common type of dermatophytosis worldwide.

EPIDEMIOLOGY. Much like tinea corporis, tinea cruris spreads via direct contact or fomites, and it is
exacerbated by occlusion and humid climates. Autoinfection from distant reservoirs of T. rubrum or
T. interdigitale on the feet, for example, is common.44 Tinea cruris is three times more common in
men, and adults are affected more commonly than children. ETIOLOGY. Most tinea cruris is caused
by T. rubrum and E. floccosum, the latter being most often responsible for epidemics.42 T.
interdigitale and T. verrucosum are implicated less commonly. CLINICAL FINDINGS. Tinea cruris
presents classically as a well-marginated annular plaque with a scaly raised border which extends
from the inguinal fold on to the inner thigh, often bilaterally. Erythematous scaly patches with
papules and vesicles involving the inner thighs is also a common but perhaps less obvious
presentation. Pruritus is common, as is pain when plaques are macerated or secondarily infected.
Plaques in tinea cruris due to E. floccosum are more likely to demonstrate central clearing, and are
more often limited to the genitocrural crease and the medial upper thigh. In contrast, plaques in
tinea cruris due to T. rubrum coalesce with extension to the pubic, perianal, buttock, and lower
abdominal areas (Fig. 188-11). Genitalia including the scrotum are infrequently affected.42

AB

Figure 188-9 Tinea corporis. A. Annular. Tinea corporis demonstrating the classic annular or “ring
worm” like configuration and advancing raised erythematous and scaly border. Note that because
the dorsum of the foot is predominantly involved, this eruption is considered tinea corporis and not
pedis. B. Polycyclic. Tinea corporis demonstrating multiple polycyclic red erythematous plaques with
a raised scaly border. C. Psoriasiform. Tinea corporis resembling psoriasis.

TABLE 188-10 Treatment of Dermatophytes hal 2294

Disease Topical Treatment Systemic Treatment

Tinea capitis Only as adjuvant Selenium sulfide 1% or 2.5% Zinc pyrithione 1% or 2% Povidone iodine
2.5% Ketoconazole 2%

Adults: Griseofulvin, 20–25 mg/kg/day × 6–8 weeks Terbinafine, 250 mg/day × 2–8 weeks
Itraconazole, 5 mg/kg/day × 2–4 weeks Fluconazole, 6 mg/kg/day × 3 weeks Children: Terbinafine,
3–6 mg/kg/day × 2–8 weeks all others are the same

Tinea barbae Only as adjuvant Topical antifungals

Griseofulvin, 1 g/day × 6 weeks Terbinafine, 250 mg/day × 2–4 weeks Itraconazole, 200 mg/day × 2–
4 weeks Fluconazole, 200 mg/day × 4–6 weeks

Tinea corporis/cruris Allylamines Imidazoles Tolnaftate Butenafine Ciclopirox

Adults: Terbinafine, 250 mg/day × 2–4 weeks Itraconazole, 100 mg/day × 1 week Fluconazole, 150–
300 mg/week × 4–6 weeks Griseofulvin, 500 mg/day × 2–4 weeks Children: Terbinafine, 3–6
mg/kg/day × 2 weeks Itraconazole, 5 mg/kg/day × 1 week Griseofulvin, 10–20 mg/kg/day × 2–4
weeks

Tinea pedis/manuum Allylamine Imidazoles Ciclopirox Benzylamine Tolnaftate Undecenoic acid

Adults: Terbinafine, 250 mg/day × 2 weeks Itraconazole, 200 mg twice daily × 1 week Fluconazole,
150 mg/week × 3–4 weeks Children: Terbinafine, 3–6 mg/kg/day × 2 weeks Itraconazole, 5
mg/kg/day × 2 weeks

Onychomycosis Ciclopirox Amorolfine

Adults: Terbinafine, 250 mg/day × 6–12 weeks Itraconazole, 200 mg/day × 2–3 months Fluconazole,
150–300 mg/week × 3–12 months Children: Terbinafine, 3–6 mg/kg/day × 6–12 weeks Itraconazole,
5 mg/kg/day × 2–3 months Fluconazole, 6 mg/kg/week × 3–6 months

Hal 2295 For isolated plaques on the glabrous skin, topical allylamines, imidazoles, tolnaftate,
butenafine, or ciclopirox are effective. Most are applied twice daily for 2–4 weeks. Oral antifungal
agents are reserved for widespread or more inflammatory eruptions. Comparative studies in adults
show that terbinafine 250 mg daily for 2–4 weeks, itraconazole 200 mg daily for 1 week, and
fluconazole 150–300 mg weekly for 4–6 weeks are preferable over griseofulvin 500 mg daily until
cure is reached.73 Safe and effective regimens for children include terbinafine 3–6 mg/kg/day for 2
weeks, itraconazole 5 mg/kg/day for 1 week, and ultramicrosize griseofulvin 10–20 mg/ kg/day for
up to 2–4 weeks.