Background Tinea cruris, a pruritic superficial fungal infection of the groin and adjacent skin, is the second most

common clinical presentation for dermatophytosis. Tinea cruris is a common and important clinical problem that may, at times, be a diagnostic and therapeutic challenge. Oother eMedicine articles on tinea infections include Tinea Barbae, Tinea Capitis,Tinea Corporis, Tinea Faciei, Tinea Nigra, Tinea Pedis, and Tinea Versicolor. Pathophysiology The most common etiologic agents for tinea cruris include Trichophyton rubrumand Epidermophyton floccosum; less commonly Trichophyton mentagrophytes andTrichophyton verrucosum are involved. Tinea cruris is a contagious infection transmitted by fomites, such as contaminated towels or hotel bedroom sheets, or by autoinoculation from a reservoir on the hands or feet (tinea manuum, tinea pedis, tinea unguium). The etiologic agents in tinea cruris produce keratinases, which allow invasion of the cornified cell layer of the epidermis. The host immune response may prevent deeper invasion. Risk factors for initial tinea cruris infection or reinfection include wearing tight-fitting or wet clothing or undergarments. Epidemiology Frequency United States Dermatophytosis accounts for approximately 10-20% of all visits to dermatologists. International Tinea cruris has a worldwide distribution but is found more commonly in hot humid climates. Mortality/Morbidity No mortality is associated with tinea cruris. Associated pruritus leads to morbidity resulting from lichenification, secondary bacterial infection, and irritant and allergic contact dermatitis caused by topically applied medications. Sex Tinea cruris is 3 times more common in men than in women. Age Adults are affected by tinea cruris much more commonly than are children. However, the prevalence of several risk factors for tinea cruris, such as obesity and diabetes mellitus, is rapidly increasing among adolescents. History Patients with tinea cruris report pruritus and rash in the groin. A history of previous episodes of a similar problem usually is elicited. Additional historical information in patients with tinea cruris may include recently visiting a tropical climate, wearing tight-fitting clothes (including bathing suits) for extended periods, sharing clothing with others, participating in sports, or coexisting diabetes mellitus or obesity. Prison inmates, members of the armed forces, members of athletic teams, and people who wear tight clothing may be subject to independent or additional risk for dermatophytosis.
[4] [2, 3] [1]

Secondary changes of excoriation. the rash may be moist and exudative. followed by T tonsurans (6%) and T mentagrophytes (4%). while infection by T mentagrophytes often is associated with an acute inflammatory clinical presentation. Chronic infections typically are dry with a papular annular or arciform border and barely perceptible scale at the margin.Physical Tinea cruris manifests as a symmetric erythematous rash in the groin. Scale is demarcated sharply at the periphery. followed by T tonsurans (6%) and T mentagrophytes (4%). cause an identical clinical condition. In a Brazilian series. Tinea cruris. lichenification. T rubrum was the prevalent dermatophyte in 90% of the cases. Chronic infections modified by the application of topical corticosteroids are more erythematous. however. In acute tinea cruris infections. Approximately one half of patients with tinea cruris have coexisting tinea pedis. Causes The dermatophyte T rubrum is the most common etiologic agent for tinea cruris. Erythematous-scale plaques and erythematous-liquenificated plaques were the most frequently found clinical types in an excellent Brazilian study. Tinea cruris. and may have follicular pustules. as shown in the images below. Other organisms. Central areas typically are hyperpigmented and contain a scattering of erythematous papules and a little scale. Cutaneous Contact Dermatitis. T rubrum and E floccosum infections are more apt to become chronic and noninflammatory. including E floccosum and T verrucosum. the infection may extend to the perineum and buttocks.           Large patches of erythema with central clearing are centered on the inguinal creases and extend distally down the medial aspects of the thighs and proximally to the lower abdomen and pubic area. Allergic . The penis and scrotum typically are spared in tinea cruris. Differential Diagnoses    Acanthosis Nigricans Candidiasis. and impetiginization may be present as a result of pruritus. T rubrum was the prevalent dermatophyte [5] [6] [5] in 90% of the tinea cruris cases. less scaly. Tinea cruris.

The keratin and debris should dissolve after a few minutes. Using periodic acid-Schiff stain (fungal elements appear pink) or methenamine silver stains (fungal elements appear brown or black) on the processed tissue enhances the sensitivity of the biopsy procedure. The addition of 1 drop of lactophenol cotton blue solution to the wet mount preparation heightens the contrast and aids in the diagnosis. Scale culture is useful for fungal identification but is a more specific. use a scalpel or the edge of a glass slide for this purpose. Plaque Seborrheic Dermatitis Laboratory Studies         Microscopic examination of a potassium hydroxide (KOH) wet mount of scales is diagnostic in tinea cruris. If tinea cruris still is suggested. Punch biopsy is diagnostic but has low sensitivity and low specificity. Tinea . Tinea cruris (hematoxylin and eosin stain). Collect scales from the margin of the lesion. Irritant Erythrasma Familial Benign Pemphigus (Hailey-Hailey Disease) Folliculitis Intertrigo Psoriasis. The procedure for KOH wet mount is as follows: Clean the area with 70% alcohol. allow a drop of KOH (10-15% wt/vol) to run under the cover slip.   Wood lamp examination may be helpful to exclude erythrasma. Negative results on KOH preparation do not exclude fungal infection. repeat the tests. several times if necessary. Cover the collected scales with a cover slip. Growth on Mycosel or Sabouraud agar plates usually is sufficient within 3-6 weeks to allow specific fungal identification.       Contact Dermatitis. albeit less sensitive. The process can be hastened by heating the slide or by the addition of a keratolytic or dimethyl sulfoxide to the KOH formulation. diagnostic test than KOH wet mount. The images below demonstrate the appearance of tinea cruris using a variety of staining techniques. which reveals coral red florescence of the affected area. Procedures   Negative KOH wet mount examination and cultures exclude other conditions in the differential diagnosis.

Consider patients unable to use topical treatments consistently or with extensive or recalcitrant infection as candidates for systemic administration of antifungal therapy.cruris (periodic acid-Schiff stain. Further Outpatient Care  Repeat scraping or culture may be indicated if initial treatment of tinea cruris is unsuccessful. the epidermis exhibits spongiosis or a psoriasiform pattern of hyperplasia. Histologic Findings Microscopic examination of hematoxylin and eosin–stained tissue sections reveals patterns of inflammation strongly suggestive of dermatophyte infection. The upper zone of the cornified cell layer has a typical basket-weave pattern of orthokeratosis. Tinea cruris (Gomori methenamine-silver stain. which has been proven safe in immunocompetent persons. The inflammation typically is perivascular. Advise patients with tinea cruris to dry the crural folds completely after bathing and to use separate towels for drying the groin and other parts of the body. in which fungal elements are sandwiched between 2 zones of differing structure within the cornified cell layer. [8] Prevention of tinea cruris reinfection is an essential component of disease management. Diet Recommend weight loss for patients who are obese and have tinea cruris. but histologic examination provides no clues regarding the dermatophyte species. magnification X 20).    Treat all active areas of tinea cruris infection simultaneously to prevent reinfection of the groin from other body sites. Patients with tinea cruris often have concurrent dermatophyte infections of the feet and hands. The presence of spores and branching hyphae can be confirmed using periodic acid-Schiff or methenamine silver stains. Medical Care Clinical cure of an uncomplicated tinea cruris infection usually can be achieved using topical antifungal agents of the imidazole or allylamine family. Advise patients with tinea pedis to put on their socks before their undershorts to reduce the possibility of direct contamination. magnification X 20). Deterrence/Prevention . Granulomatous dermatitis may accompany folliculitis. while the lower zone consists of more compact orthokeratosis and parakeratosis. Specific diagnostic findings include the presence of neutrophils in the cornified cell layer and the sandwich sign.

Prognosis  The prognosis of tinea cruris is excellent with appropriate diagnosis and treatment. Advise patients with tinea cruris who are obese to lose weight. Recurrence of tinea cruris is common. Advise patients to put on socks before undergarments to minimize the possibility of fungal transfer from the feet to the groin. the infection may spread. may be helpful in preventing recurrence of tinea cruris. Antifungal powders. Patient Education  Educate patients about the risks of sharing sheets and undergarments with others and about the need to keep the groin region dry (see Deterrence/Prevention). http://emedicine.     Advise patients with tinea cruris to avoid wearing tight-fitting clothing to prevent moisture build-up. In addition. therefore. Advise patients to dry the area after bathing. recurrence is likely if the groin region is not kept dry. using a towel or a hair dryer.medscape. Mistreatment of tinea cruris with topical steroids can result in exacerbation of the disease. it is of utmost importance to treat concurrent fungal infections and to keep the groin region dry to prevent recurrence of tinea cruris. the area can become lichenified and hyperpigmented in the setting of a chronic fungal infection. which have the added benefit of drying the . however. Complications   Tinea cruris can become infected secondarily by candidal or bacterial organisms. Although patients may note initial relief of symptoms.

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