Tinea (overview) B35.-

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 09.06.2021

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Synonym(s)

dermatomycosis; Dermatophyte infections; Dermatophytoses; Dermatophytosis; dermatophytosis phylois; Epidermophytia; Filamentous fungal disease; Ring form; Skin fungus; Trichophytosis

Definition
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Tinea is an infection of the stratum corneum of the epidermis, hair and/or nails by dermatophytes.

The name is borrowed from Latin (tinea = moth, woodworm).

Dermatophytes are able to break down keratin by splitting disulfide bridges, which explains their pronounced preference for substrates containing keratin. Even in case of tinea profunda with deep infestation of the hair follicles the pathogens do not penetrate into the dermis. By adding the respective body region, traditionally anchored terms like Eccema marginatum, Tinea inguinalis, Tinea barbae, Kerion Celsi, Tinea capitis profunda etc. become superfluous. The uniformity of the "tinea term" is endangered by designations like Tinea amiantacea for pityriasis amiantacea and Tinea versicolor for pityriasis versicolor.

The targeted treatment of tinea requires an exact diagnosis by detecting the pathogens in the native preparation and by culture.

Pathogen
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Dermatophytes. Dermatophytes include the genera Trichophyton, Epidermophyton and Mikrosporum. A division into geophilic, zoophilic and anthrophilic species is useful for epidemiological but also for clinical reasons. Geophilic and zoophilic dermatophytes cause significantly stronger inflammatory foci in humans than anthrophilic dermatophytes whereas they can be present almost without symptoms in animals. In dermatology the following dermatophytes are relevant among others:

Classification
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The clinical picture of dermatophyte infection varies and is essentially defined by topography:

I. Head:

II. trunk:

III. extremities:

Occurrence/Epidemiology
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Dermatophytes as pathogens of tinea are represented worldwide with different incidence and prevalence. The incidence of dermatomycoses depends mainly on local factors such as outside temperatures, skin perfusion and individual susceptibility. Thus, prevalences of tinea pedis in certain cohorts (e.g. soldiers) are between 10 and 15%.

Clinical features
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Due to clinical, diagnostic and therapeutic peculiarities, a subdivision is made according to localization. In view of the considerable differences that are determined by the respective topography (head, groin, toes, nails), it is not possible to make a generally valid statement about the clinic.

Diagnosis
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Important accompanying phenomena influencing the clinical diagnosis:
    • infestation of hair follicles and/or nails
    • Persistent hyper- or hypopigmentation
    • Secondary bacterial overlaps
    • Secondary contact allergy
    • Surgical pretreatments (incisions)
    • Pretreatment with corticosteroids
    • Intertriginous maceration.
  • See Table 1, see mycoses below.

General therapy
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Prevention and treatment of sources of infection, such as infected animals e.g. cats, dogs, cows, guinea pigs.

External therapy
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External monotherapy is generally considered sufficient for the following types of dermatophytosis: non-inflammatory tinea corporis, tinea faciei, tinea manuum et pedum. The external antimycotics listed below are the most widely used, with comparable quality and effect:

  • Imidazole derivatives: Clotrimazole (e.g. R055 R056, Canesten cream, Clotri OPT, Cutistad), Econazole (e.g. Epi-Pevaryl cream), Ketoconazole (e.g. Nizoral cream), Miconazole (e.g. R173, R172 Daktar solution, Vobamyk, Micotar), Bifonazol (e.g. Mycospor), Oxiconazol (e.g. Myfungar cream), Tioconazol (e.g. Mykontral), Fenticonazol (e.g. Lomexin)
  • Allylamines: Naftifin (e.g. Exoderil cream), Terbinafin (e.g. Lamisil solution seems to have a certain superiority in the practical application compared to the imidazole preparations, as a one-time therapy - "Lamisil Once" - is effective for tinea pedis).
  • Morpholine: Amorolfin (Loceryl cream)
  • Ciclopiroxolamine (e.g. Batrafen cream)
  • Sertaconazole nitrate (e.g. Zalain, Mykosert)
  • Various: Tolnaftat (e.g. Tonoftal cream), colorants (e.g. eosin or methylrosanilinium chloride).
  • Combination preparations with glucocorticoids, disinfectants or antibiotics. Although these combinations are appreciated as "antidepressants", they should only be used in exceptional cases. Glucocorticoid-containing monotherapeutics can be applied passagerly with inflammationally accentuated itchy dermatomycoses.

Internal therapy
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Indication for systemic therapy is given in the following diseases:

  • Inflammatory accentuated dermatomycoses
  • Hyperkeratotic tinea of the palms and soles of the feet
  • Extensive tinea
  • Tinea capitis
  • Granulomatous or nodular tinea
  • Immunocompromised patients
  • Tinea unguium of several toes or fingers
  • Therapy resistance or intolerance to external antimycotics.

The following preparations have found the widest distribution with comparable quality and effect: griseofulvin (e.g. Likuden M), itraconazole (e.g. Sempera), fluconazole (e.g. Diflucan), terbinafine (e.g. Lamisil).

Operative therapie
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Surgical measures are not indicated for dermatomycoses. Even in the case of extensive granulomatous nodular tinea, fluctuating abscesses (analogous to staphylococcal abscesses) are an absolute rarity. Therefore, surgical measures should be limited to openings of the bladders and pustules. An exception is onychomycosis which is limited to the nail and completely covers the nail. In rare cases, a nail extraction of the nail, which is usually largely lifted from the nail bed, can be considered (alternative: Mycospor nail set, urea ointment 20%).

Prophylaxis
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Wearing of bathing shoes in public communal facilities such as changing rooms, showers and sauna. Use of disinfectant foot sprays in swimming pools. Prophylactic use of antimycotic solutions/sprays (e.g. Canesten spray) 2-3 times/week in the inter-toe area and on the soles of the feet. Disinfection of contaminated objects (e.g. disinfection of shoes with Sagrotan spray). Clean rubbing of the feet with a towel or washing the feet with soap can reduce the number of fungi on the soles of the feet. Avoid walking barefoot on the carpet of hotel rooms!

Naturopathy
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There are a number of natural remedies for which in different countries there is a wide range of use. antimycotic effectiveness have been proven in various study designs. These include tea tree oil (in 25% and 50% application form), Solanum chrysotrichum (Mexican tomato) in a cream application, Eucalytus pauciflora 1% oil ( eucalyptus oil with the active ingredient cineol) and ajones, the ingredient of Allium sativum in a 0.4% cream application.

Tables
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Diagnostic criteria for tinea

Medical history

General diseases

Chronic liver diseases

Chronic kidney diseases

Endocrinological diseases (e.g. diabetes mellitus)

Peripheral circulatory disorders (Tinea unguium)

Pretreatment

External pre-therapies (especially pre-treatment with glucocorticoids)

System Therapies

other skin diseases

especially atopy or contact sensitization

Profession

Lifeguard or similar

Agriculture

Veterinary professions

Leisure contacts

Garden

Sports activities with use of common cleaning areas in showers or sauna

Animal contacts

Studies

General physical examination

Localization of the skin changes

Extent of the lesions

Type of lesion

Non-inflammatory, scaling, chronic

Acute or subacute, eczematous, itching

Chronically lichenified

Follicular papules or nodules (abscess)

Vesicular or bullous (Id reaction)

Pustular, similar to pyoderma

Note(s)
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Billing tips:

  • Taking of the smear: The taking of the smear is to be carried out according to the No. 298 GOÄ (also several times, in case of taking of different smears). Body parts and separate preparation). In the case of complex nail collection, the No. 743 GOÄ (analogous) can be applied.
  • Microscopy: In case of microscopic fungus detection with addition of potassium hydroxide solution, No. 4711 GOÄ can be used. Simple staining with methylene blue is accounted for with No. 3509 GOÄ (per preparation).
  • Culture: A Sabouraud agar (simple culture medium) is charged with No. 4715 GOÄ up to 5 times from the same medium. If special culture media (complex culture medium) are used, the number 4716 GOÄ or the No. 4717 (differentiation medium) must be used.
  • Light microscopic examination of cultivated fungi: No. 4722 GOÄ.

Literature
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  1. Brasch J (1990) Pathogen and pathogenesis of dermatophytosis. Dermatologist 41: 9-15
  2. Drake LA et al (1996) Guidelines of care for superficial mycotic infection of the skin: Tinea corporis, tinea cruris, tinea faciei, tinea manuum tinea pedis. J Am Acad Dermatol 34: 282-286
  3. Effendy I (2003) Nail changes during childhood. dermatologist 54: 41-44
  4. Gupta AK et al (2003) Superficial fungal infections: an update on pityriasis versicolor, seborrheic dermatitis, tinea capitis, and onychomycosis. Clin Dermatol 21: 417-425
  5. Ilkit M et al (2014) Tinea pedis: the etiology and global epidemiology of
    acommon fungal infection. Crit Rev Microbiol 41:374-388
  6. Leibovici V et al (2014) Prevalence of tinea pedis in psoriasis, compared to atopic dermatitis andnormal
    controls--a prospective study. Mycoses 57:754-758
  7. Nenoff P et al (2014) Mycology - An Update Part 2: Dermatomycoses: Clinical picture and diagnostics. YYG 12: 749-778
  8. Seebacher C (2003) The change of dermatophyte spectrum in dermatomycoses. Mycoses 46(Suppl1): 42-46
  9. Seebacher C et al (2006) Tinea capitis. J Dtsch Dermatol Ges 4: 1085-1091

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.