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Positive fungal studies distinguish tinea corporis from other skin lesions with annular configuration, such as the annular lesions of psoriasis, lupus erythematosus, syphilis, granuloma annulare, and pityriasis rosea Psoriasis has typical lesions on elbows, knees, scalp, and nails Secondary syphilis is often manifested by characteristic palmar, plantar, and mucous membrane lesions Tinea corporis rarely has the large number of lesions seen in pityriasis rosea Granuloma annulare lacks scales

Complications include extension of the disease down the hair follicles (in which case it becomes much more difficult to cure) and pyoderma

Since moist skin favors the growth of fungi, dry the skin carefully after bathing or after perspiring heavily Talc or other drying powders may be useful The use of topical corticosteroids for other diseases may be complicated by intercurrent tinea or candidal infection, and topical antifungals are often used in intertriginous areas with corticosteroids to prevent this

Treat infected household pets (Microsporum infections)

Tinea corporis responds to most topical antifungals, including miconazole, clotrimazole, butenafine, and terbinafine, which are available over the counter (Table 6 2) Terbinafine and butenafine require shorter courses and lead to the most rapid response Treatment should be continued for 1 2 weeks after clinical clearing Betamethasone dipropionate with clotrimazole (Lotrisone) is not recommended Longterm improper use may result in side effects from the highpotency corticosteroid component, especially in body folds Cases of tinea that are clinically resistant to this combination have been reported

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1 Tinea Corporis or Tinea Circinata (Body Ringworm)

Ring-shaped lesions with an advancing scaly border and central clearing or scaly patches with a distinct border (Plates 7 and 8)

8:

Griseofulvin (ultramicrosize), 250 500 mg twice daily, is used Typically, only 4 6 weeks of therapy are required Itraconazole as a single week-long pulse of 200 mg daily is also effective in tinea corporis Terbinafine, 250 mg daily for 1 month, is an alternative

psoriatic involvement should be checked, and the KOH examination will be negative Erythrasma is best diagnosed with Wood s light a brilliant coral-red fluorescence is seen

Drying powder (eg, miconazole nitrate [Zeasorb-AF]) should be dusted into the involved area in patients with excessive perspiration or occlusion of skin due to obesity Underwear should be loose-fitting

Body ringworm usually responds promptly to conservative topical therapy or to an oral agent within 4 weeks

2 Tinea Cruris (Jock Itch)

Any of the preparations listed in Table 6 2 may be used Terbinafine cream is curative in over 80% of cases after once-daily use for 7 days

Marked itching in intertriginous areas, usually sparing the scrotum Peripherally spreading, sharply demarcated, centrally clearing erythematous lesions May have associated tinea infection of feet or toenails Laboratory examination with microscope or culture confirms diagnosis

FIGURE 8-39

Griseofulvin ultramicrosize is reserved for severe cases Give 250 500 mg orally twice daily for 1 2 weeks One week of either itraconazole, 200 mg daily, or terbinafine, 250 mg daily, can be effective

Tinea cruris lesions are confined to the groin and gluteal cleft Intractable pruritus ani may occasionally be caused by a tinea infection

3 Tinea Manuum & Tinea Pedis (Dermatophytosis, Tinea of Palms & Soles, Athlete s Foot )

Itching may be severe, or the rash may be asymptomatic The lesions have sharp margins, cleared centers, and active, spreading scaly peripheries Follicular pustules are sometimes encountered The area may be hyperpigmented on resolution

Most often presenting with asymptomatic scaling May progress to fissuring or maceration in toe web spaces (Plate 9) Common cofactor in lower leg cellulitis Itching, burning, and stinging of interdigital web; scaling palms, and soles; vesicles of soles in inflammatory cases The fungus is shown in skin scrapings examined microscopically or by culture of scrapings

The hypertension is reversible in about two-thirds of cases but persists or returns in spite of surgery in the remainder The prognosis is much improved by early diagnosis and treatment Only 2% of aldosterone-secreting adrenal tumors are malignant The low renin levels found in this condition (and in about 25% of cases of essential hypertension) also imply a relatively good prognosis

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