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Dermatology (Skin Conditions)

Tinea Corporis / Cruris / Pedis / Unguium

Superficial fungal infections caused by dermatophytes affecting the smooth skin (corporis), groin (cruris), feet (pedis), or nails (unguium).

Also known as: Ringworm (Body), Jock Itch (Groin), Athlete's Foot (Feet), Nail Fungus

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Referral and warning signs

When to refer

Refer if: Diagnosis uncertain. Extensive involvement. Failure of appropriate topical/oral therapy. Onychomycosis requiring systemic treatment confirmation/monitoring. Suspected secondary bacterial infection needing IV antibiotics.

Red flags

  • Signs of severe secondary bacterial infection / cellulitis.
  • Extensive blistering or ulceration.
  • Failure to respond to standard therapy.
  • Suspicion of non-fungal diagnosis (e.g., psoriasis, eczema).

Signs and symptoms

  • Tinea Corporis (Body Ringworm): Annular (ring-shaped) plaques with raised, erythematous, scaly borders and central clearing. Itchy.
  • Tinea Cruris (Jock Itch): Erythematous, itchy rash in groin folds, upper inner thighs. Sharply demarcated border, may have central clearing. Scrotum usually spared.
  • Tinea Pedis (Athlete's Foot):
  • - Interdigital type: Scaling, maceration, fissures between toes (esp. 4th-5th). Itchy.
  • - Moccasin type: Diffuse scaling, dryness, erythema on soles and sides of feet.
  • - Vesiculobullous type: Itchy blisters on soles or instep.
  • Tinea Unguium (Onychomycosis): Thickened, discoloured (yellow/brown/white), brittle, crumbly nails. Often associated with tinea pedis.

Risk factors

  • Warm, humid environment.
  • Occlusive clothing/footwear.
  • Communal showers/pools.
  • Contact with infected individuals/animals/fomites.
  • Diabetes Mellitus.
  • Immunosuppression.
  • Peripheral vascular disease (for tinea pedis/unguium).

Diagnosis

Clinical assessment

Diagnosis often based on characteristic appearance and location of lesions.

Differential diagnosis

  • Corporis/Cruris: Nummular eczema, Psoriasis, Erythrasma (groin - fluoresces coral-red), Candida intertrigo (satellite pustules, involves scrotum), Contact dermatitis.
  • Pedis: Interdigital maceration (bacterial), Dyshidrotic eczema (vesicles), Psoriasis, Contact dermatitis.
  • Unguium: Psoriatic nails, Lichen planus, Traumatic nail dystrophy, Bacterial infection.

Investigations

  • KOH Microscopy: Scrapings from active border (skin) or nail clippings/subungual debris show hyphae.
  • Fungal Culture: Confirms dermatophyte species.
  • Wood's Lamp: Not useful for these tineas.

Diagnostic criteria

Clinical appearance often sufficient. KOH or culture confirmation ideal, especially if treatment fails or diagnosis uncertain.

Management

Non-pharmacological management

  • Keep affected areas clean and dry.
  • Wear loose-fitting cotton clothing/underwear.
  • Use separate towel for affected area.
  • Tinea Pedis: Dry between toes thoroughly, wear absorbent socks (change frequently), use open footwear when possible, antifungal powders in shoes.

Pharmacological treatment

  • Tinea Corporis / Cruris / Pedis (Localized): (LOC: HC2)
  • - Topical Antifungals: Apply BID for 2-4 weeks (continue 1-2 weeks after clinical resolution).
  • - Imidazoles: Clotrimazole 1% cream, Miconazole 2% cream.
  • - Allylamines: Terbinafine 1% cream (often shorter course needed).
  • - Whitfield's Ointment (Benzoic acid + Salicylic acid) - UCG option.
  • Tinea Corporis / Cruris / Pedis (Extensive or Failed Topical): (LOC: HC3)
  • - Oral Antifungals:
  • - Griseofulvin 10mg/kg/day PO for 3-4 weeks (Corporis/Cruris) or 4-8 weeks (Pedis). (UCG recommended option).
  • - Terbinafine 250mg PO OD for 2-4 weeks.
  • - Itraconazole / Fluconazole.
  • Tinea Unguium (Onychomycosis): Requires systemic therapy. (LOC: HC3/4)
  • - Oral Antifungals: Prolonged course needed (fingernails ~6-12 weeks, toenails ~3-6 months).
  • - Terbinafine 250mg PO OD (often preferred).
  • - Itraconazole (pulse or continuous therapy).
  • - Griseofulvin 10mg/kg/day PO for 6-18 months (less effective, UCG option).
  • - Topical nail lacquers (e.g., Ciclopirox, Amorolfine) - limited efficacy alone for established onychomycosis.

Monitoring

Monitor for clinical resolution of skin lesions. Monitor LFTs if using long-term oral terbinafine/itraconazole.

Complications

  • Secondary bacterial infection (especially tinea pedis).
  • Cellulitis (portal of entry via tinea pedis).
  • Chronic infection, spread to other body sites.
  • Psychosocial impact.

Prevention

  • Good personal hygiene.
  • Keeping skin (especially feet, groin) dry.
  • Wearing appropriate footwear in communal areas.
  • Treating affected family members/contacts.
  • Treating tinea pedis to prevent onychomycosis.

Patient education

  • Explanation of fungal infection type.
  • Correct application and duration of topical antifungals (continue after clearing).
  • Importance of completing full course of oral antifungals if prescribed.
  • Hygiene measures (keeping dry, separate towels, footwear advice).
  • Need to treat associated tinea pedis if onychomycosis present.
  • Long duration of treatment needed for nail infections.

Uganda-specific notes

Tinea infections are very common. Topical Clotrimazole, Miconazole, Whitfield's ointment widely available. Griseofulvin is the commonly listed oral option in UCG, although Terbinafine may be more effective for some types if available. Onychomycosis treatment often difficult due to cost/duration of systemic therapy.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 22, Section 22.3.1 (Specific Tinea sections)

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