Dermatophyte (Tinea) Infections

7/7/23, 21:19 Dermatophyte (tinea) infections - UpToDate
Official reprint from UpToDate®

www.uptodate.com © 2023 UpToDate, Inc. and/or its affiliates. All Rights Reserved.
Dermatophyte (tinea) infections

AUTHORS: Adam O Goldstein, MD, MPH, Beth G Goldstein, MD
SECTION EDITORS: Robert P Dellavalle, MD, PhD, MSPH, Moise L Levy, MD, Ted Rosen, MD
DEPUTY EDITOR: Abena O Ofori, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2023.

This topic last updated: Jun 30, 2023.
INTRODUCTION
Dermatophyte infections are common worldwide, and dermatophytes are the prevailing
causes of fungal infection of the skin, hair, and nails [1-3]. These infections lead to a variety of
clinical manifestations, such as tinea pedis ( picture 1A-C), tinea corporis ( picture 2A-D),
tinea cruris ( picture 3A-E), tinea capitis ( picture 4A-B), dermatophyte onychomycosis
(tinea unguium ( picture 5)), and Majocchi's granuloma ( picture 6A-C).
The clinical features, diagnosis, and management of dermatophyte infections of the skin will
be reviewed here ( algorithm 1). Dermatophyte infections of scalp hair (tinea capitis), beard
hair (tinea barbae), and nails (tinea unguium or dermatophyte onychomycosis) are discussed
in detail separately.
● (See "Tinea capitis".)
● (See "Infectious folliculitis", section on 'Dermatophytic folliculitis'.)
● (See "Onychomycosis: Epidemiology, clinical features, and diagnosis".)
● (See "Onychomycosis: Management".)
The term "tinea" is also used in the names of some cutaneous fungal infections that are not
caused by dermatophytes. These disorders are reviewed separately.
● (See "Tinea versicolor (pityriasis versicolor)".)
● (See "Tinea nigra".)
https://www.uptodate.com/contents/dermatophyte-tinea-infections/print?search=tiña de la cabeza&topicRef=99983&source=see_link 1/99

MICROBIOLOGY
Dermatophytes are filamentous fungi in the genera Trichophyton, Microsporum, and

Epidermophyton. Dermatophytes metabolize and subsist upon keratin in the skin, hair, and
nails.
CLINICAL SUBTYPES
The major clinical subtypes of dermatophyte infections include infections of the epidermis,
hair, and nails:
● Epidermis:
• Tinea corporis – Infection of body surfaces other than the feet, groin, face, scalp
hair, or beard hair
• Tinea pedis – Infection of the foot
• Tinea cruris – Infection of the groin, proximal inner thighs, or buttocks
• Tinea faciei – Infection of the face
• Tinea manuum – Infection of the hand
● Hair:
• Tinea capitis – Infection of scalp hair

• Tinea barbae – Infection of beard hair
● Nails:
• Dermatophyte onychomycosis (tinea unguium)
Majocchi's granuloma is an additional subtype of dermatophyte infection characterized by

the spread of epidermal infection into deep portions of the hair follicle and dermis. (See
"Infectious folliculitis", section on 'Dermatophytic folliculitis'.)
DIAGNOSIS
Cutaneous dermatophyte infections may be strongly suspected based upon the physical
examination. However, because the physical findings can overlap with other cutaneous
disorders, we typically confirm the diagnosis with testing:
● Physical examination – A careful physical examination of the affected areas allows for
recognition of findings consistent with or inconsistent with the suspected dermatophyte

infection. (See 'Tinea pedis' below and 'Tinea corporis' below and 'Tinea cruris' below
and 'Other clinical variants' below.)
Because the simultaneous presence of more than one type of dermatophyte infection is
not uncommon (eg, tinea pedis and tinea cruris or tinea pedis and tinea unguium),
performance of a full skin examination including the skin, hair, and nails aids in the
detection of additional sites of infection.
● Diagnostic tests – The approach to diagnostic testing differs based upon the suspected
type of infection:
• Epidermal infections (eg, tinea pedis, tinea corporis, tinea cruris) – A potassium
hydroxide (KOH) preparation performed with skin scrapings from the affected areas
is the primary method of confirming dermatophyte infections of the epidermis (eg,
tinea corporis, tinea pedis, tinea cruris, tinea manuum, tinea faciei) ( algorithm 1).
A major advantage of the KOH preparation is the rapid availability of results, as the
test can be performed by the evaluating clinician. Fungal culture is an alternative,
albeit slower, method for diagnosis. (See "Office-based dermatologic diagnostic
procedures", section on 'Potassium hydroxide preparation' and "Office-based
dermatologic diagnostic procedures", section on 'Fungal culture'.)
The detection of segmented hyphae on a KOH preparation confirms a dermatophyte

infection ( picture 7A-B). This finding should be distinguished from the findings of
budding yeasts, pseudohyphae, and septate hyphae on a KOH preparation from
Candida infection ( picture 8A-B) and the short hyphae and yeast cells found in a
KOH preparation from tinea versicolor ( picture 9). Clinician experience and proper
technique influence the diagnostic accuracy of a KOH preparation [4]. The technique
for performing a KOH preparation is reviewed separately. (See "Office-based
dermatologic diagnostic procedures", section on 'Potassium hydroxide preparation'.)
Collection of an adequate specimen for a KOH preparation or fungal culture is

important. In patients with tinea corporis or tinea cruris, the highest yield may be
obtained from skin scrapings taken from the active border of a plaque or patch. In
vesicobullous tinea pedis, the roof of a vesicle can provide an adequate specimen.
Polymerase chain reaction (PCR) tests have an emerging role in the diagnosis of
dermatophytoses. (See "Onychomycosis: Epidemiology, clinical features, and
diagnosis", section on 'Polymerase chain reaction'.)
• Hair or nail infections – The approach to the diagnosis of infections of the hair or
nails is reviewed separately.
- (See "Tinea capitis", section on 'Diagnosis'.)

- (See "Infectious folliculitis", section on 'Diagnosis'.)
- (See "Onychomycosis: Epidemiology, clinical features, and diagnosis", section on

'Diagnosis'.)
COMPLICATIONS
Potential complications of dermatophyte infection include secondary bacterial infection, tinea

incognito, Majocchi's granuloma, and id reactions.
Secondary infection — Secondary bacterial infection can occur in association with

dermatophyte infections, particularly in moist or occluded skin areas (eg, the feet) [5].
Patients who exhibit significant erosions, ulceration, pain, or malodor in the affected area
should have a Gram stain and culture to evaluate for secondary bacterial infection. (See
'Tinea pedis' below.)
Tinea incognito and Majocchi's granuloma — Misdiagnosis of a dermatophyte infection as

a corticosteroid-responsive dermatosis (eg, eczema) may result in the inadvertent use of
topical corticosteroids for treatment. The local immunosuppressive effects of topical
corticosteroids can exacerbate dermatophyte infections and alter the clinical findings,
making diagnosis more difficult (ie, tinea incognito) [6]. Alterations to the clinical presentation
may include diminished erythema and scale or loss of a well-defined border.
Although the term "tinea incognito" is extensively used in the literature, it is grammatically
incorrect according to Latin grammar rules [7,8]. The grammatically correct term, "tinea
incognita," is also used.
In addition, topical corticosteroid use may promote extension of the infection into the hair
follicle and dermis, resulting in Majocchi's granuloma, which requires oral antifungal
treatment [9]. Similarly, in immunosuppressed patients, the depression of cell-mediated
immunity and the inflammatory response may contribute to progression of epidermal
dermatophyte infections to Majocchi's granuloma [10-13]. (See "Infectious folliculitis", section
on 'Dermatophytic folliculitis'.)
Id reactions — Autoeczematization reactions (also known as id reactions) are secondary,

dermatitic eruptions that occur in association with primary, often inflammatory, skin
disorders. The term "dermatophytid reaction" describes this occurrence in relation to a
dermatophyte infection. The pathogenesis may involve an immunologic reaction to fungal
antigens similar to a delayed-type hypersensitivity response [14].
Dermatophytid reactions can occur in patients with tinea pedis, tinea manuum, tinea cruris,
tinea corporis, or tinea capitis [14-16]. Patients typically present with pruritic, papulovesicular

eruptions that can be quite distant from the site of infection ( picture 10A-B).
In one series of 213 patients with tinea pedis, 37 patients (17 percent) were diagnosed with
dermatophytid reactions characterized by vesicular eruptions on the hands [17]. A separate
series of five children with dermatophytid reactions due to tinea capitis found that in addition
to involvement on the head and neck, trunk and extremity lesions were common [14].
The management of dermatophytid reactions involves the successful treatment of the

dermatophyte infection; this may be compromised if the reaction is mistaken for a drug
eruption related to antifungal therapy. Topical corticosteroids and antipruritic agents are
typically used for acute management. Rarely, systemic glucocorticoids are needed.
TREATMENT PRINCIPLES
Treatment of dermatophyte infections is generally indicated. Treatment is given to alleviate

symptoms (eg, pruritus), reduce risk for secondary bacterial infection, and limit spread of the
infection to other body sites or other individuals.
Treatment options — Treatment consists of topical or systemic antifungal drugs with

antidermatophyte activity ( algorithm 1).
Most cutaneous dermatophyte infections limited to the epidermis can be managed with
topical antifungal therapy. Examples of agents effective for dermatophyte infections include
azoles, allylamines, butenafine, ciclopirox, and tolnaftate ( table 1).
Oral treatment with agents such as terbinafine, itraconazole, fluconazole, and griseofulvin is
used for extensive infections, infections that are refractory to topical therapy, or infections
extending into follicles or the dermis (eg, tinea capitis, tinea barbae, Majocchi's granuloma)
or involving nails. Oral therapy is typically reserved for these presentations because of the
broader side effect profile compared with topical therapy. Cutaneous adverse reactions,
hepatotoxicity, and drug interactions are among the potential complications of oral
antifungal therapy. (See "Terbinafine (systemic): Drug information" and "Itraconazole: Drug
information" and "Fluconazole: Drug information" and "Griseofulvin: Drug information".)
Use of oral ketoconazole is no longer recommended because of risk for severe liver injury,
adrenal insufficiency, and drug interactions. (See "Pharmacology of azoles", section on
'Ketoconazole'.)
Nystatin ineffective — Nystatin, an effective treatment for cutaneous Candida infections, is

not effective for dermatophyte infections.
Adjunctive corticosteroid therapy — In general, we do not use topical corticosteroids in the

treatment of dermatophyte infections. Although combination antifungal and low-potency
corticosteroid products can be effective and may accelerate resolution of the clinical
manifestations of superficial dermatophyte infections [18], combination therapy is not
necessary for achieving cure. In particular, use of products that include medium- or high-
potency corticosteroids (eg, betamethasone-clotrimazole) is discouraged because use of a
topical corticosteroid introduces risk for topical corticosteroid-induced skin atrophy.
Treatment failures have also been reported [19-21], and some authors postulate that overuse
of topical corticosteroids may contribute to the emergence of resistant dermatophyte
infections. (See 'Treatment failure' below.)
An infrequent exception to our avoidance of combination therapy is the addition of a low-

potency topical corticosteroid (group 6 or 7) to antifungal therapy for patients with highly
inflammatory lesions associated with severe pruritus ( table 2). Some topical antifungal
drugs (eg, allylamines and ciclopirox) have intrinsic anti-inflammatory properties that may
also help to reduce inflammation [22,23].
Treatment failure — Dermatophyte infections usually respond well to a course of

appropriate treatment:
● Patient assessment – Common reasons for failure to respond to antifungal therapy

include inadequate administration of treatment (eg, stopping treatment as visible scale
resolves) or an incorrect diagnosis ( algorithm 1). Therefore, an evaluation of
apparent treatment failure should include discussion of the use of the prescribed
therapy and consideration of alternative diagnoses. The possibility of reinfection should
also be reviewed.
Immunosuppression may increase risk for dermatophyte infection and may contribute
to the development of extensive or persistent disease. The possibility of an underlying
immune disorder should be considered in patients with particularly severe, treatment-
refractory disease. (See "Initial evaluation of adults with HIV", section on 'Physical
examination'.)
● Antifungal resistance – Emerging resistance of dermatophyte infections to antifungal

therapy may account for some treatment failures. Terbinafine resistance secondary to
single point mutations in the squalene oxidase gene has been reported most frequently
[24]. Examples of other proposed mechanisms for resistance to antifungal therapies
include upregulation of efflux pumps and mutations in the lasnosterol-14-alhpa
demethylase gene [24]. Although not routinely performed in many locations,
susceptibility testing may be of value for patients with confirmed dermatophyte
infections that fail to respond to appropriate course of treatment [24].
• Trichophyton indotineae – Trichophyton indotineae is a highly transmissible species of

dermatophyte that is often associated with resistance to antifungal therapy,

particularly terbinafine [25,26]. Infections have been reported in Asia, Europe, North
America, and the Middle East [27]. Infections most often present as annular,
inflamed, scaly plaques on multiple body areas (tinea corporis, tinea cruris, and/or
tinea faciei) [25,27].
T. indotineae cannot be identified through routine laboratory techniques due to

morphologic similarities among T. indotineae, Trichophyton mentagrophytes, and
Trichophyton interdigitale. Genomic sequencing is required for identification. Misuse
and overuse of topical antifungal drugs and topical corticosteroids are proposed to
contribute to the spread of resistant T. indotineae infections [25,26].
TINEA PEDIS
Overview — Tinea pedis (also known as athlete's foot) is a dermatophyte infection of the skin
on the foot:
● Etiology and risk factors – Tinea pedis usually occurs in adults and adolescents and is
rare prior to puberty [28]. Common causes are Trichophyton rubrum, T.
mentagrophytes/interdigitale complex, and Epidermophyton floccosum.
Infection is usually acquired by means of direct contact with the causative organism, as
may occur by walking barefoot in locker rooms or swimming pool facilities. Other
predisposing factors may include diabetes mellitus and the wearing of occlusive
footwear [29-31].
● Clinical features – Tinea pedis may manifest in a variety of ways. The three major
clinical types of tinea pedis are:
• Interdigital tinea pedis – Interdigital tinea pedis manifests as pruritic erosions or

scales between the toes, especially in the third and fourth digital interspaces
( picture 1A). Associated interdigital fissures may cause pain.
• Hyperkeratotic (moccasin-type) tinea pedis – Hyperkeratotic tinea pedis is

characterized by a diffuse, hyperkeratotic eruption involving the soles and medial
and lateral surfaces of the feet, resembling a "moccasin" distribution ( picture 1B).
There is a variable degree of underlying erythema.
• Vesiculobullous (inflammatory) tinea pedis – Vesiculobullous tinea pedis is

characterized by a pruritic, sometimes painful, vesicular or bullous eruption
( picture 1C-D). Underlying erythema may be evident. The medial foot is often
affected.

Infrequently, tinea pedis may manifest with interdigital erosions and ulcers (ulcerative
tinea pedis) ( picture 11A-B). This presentation is usually associated with secondary
bacterial infection.
Tinea pedis can occur in association with onychomycosis, tinea cruris, or tinea manuum
( picture 12A).
Differential diagnosis — The differential diagnosis of tinea pedis is broad and varies

according to the clinical subtype:
● Interdigital tinea pedis:
• Erythrasma ( picture 13)

• Interdigital Candida infection (erosio interdigitalis blastomycetica ( picture 14))
● Hyperkeratotic (moccasin-type) tinea pedis:
• Atopic dermatitis
• Chronic contact dermatitis ( picture 15)
• Chronic palmoplantar (dyshidrotic) eczema ( picture 16)
• Palmoplantar psoriasis ( picture 17)
• Pitted keratolysis ( picture 18)
• Juvenile plantar dermatosis ( picture 19A-B) (see "Overview of dermatitis
(eczematous dermatoses)", section on 'Juvenile plantar dermatosis')
• Keratolysis exfoliativa ( picture 20) (see "Peeling skin syndromes", section on
'Keratolysis exfoliativa')
• Keratodermas (see "Palmoplantar keratoderma")
● Vesiculobullous (inflammatory) tinea pedis:
• Acute palmoplantar (dyshidrotic) eczema ( picture 21)

• Acute contact dermatitis
• Palmoplantar pustulosis ( picture 22)
• Scabies ( picture 23)
A positive potassium hydroxide (KOH) preparation demonstrating segmented hyphae

distinguishes tinea pedis from nonfungal diseases. Interdigital Candida infection will
demonstrate budding yeasts, pseudohyphae, and septate hyphae on a KOH preparation
( picture 8A-B). (See 'Diagnosis' above.)
Treatment — Topical antifungal therapy is the treatment of choice for most patients.

Systemic antifungal agents are primarily reserved for patients who fail topical therapy
( algorithm 1):

● Initial treatment – Examples of topical drugs effective for tinea pedis include azoles,
allylamines, butenafine, ciclopirox, tolnaftate, and amorolfine ( table 1). Topical
nystatin is not effective for dermatophyte infections. Amorolfine is not available in the
United States. (See 'Treatment principles' above.)
Topical antifungal treatment is generally applied once or twice daily and continued for
four weeks. Shorter treatment courses may be effective; high cure rates have been
obtained with terbinafine 1% cream applied to interdigital tinea pedis for one week [32].
A meta-analysis of randomized trials published prior to February 2005 supports efficacy

of topical therapy, finding strong evidence of superiority of topical antifungal agents
(azoles, allylamines, ciclopirox, tolnaftate, butenafine, and undecanoate) over placebo
[33]. Allylamines may be slightly more effective than azoles. A meta-analysis of data
from 11 trials that compared topical allylamines with topical azoles found slightly higher
cure rates with allylamines (risk ratio of treatment failure 0.63, 95% CI 0.42-0.94) [33].
● Refractory disease – Patients with confirmed tinea pedis who fail topical therapy may
be treated with an oral antifungal drug. Potential causes of treatment failure should be
reviewed (see 'Treatment failure' above):
• Adults – Adults are usually treated with terbinafine, itraconazole, or fluconazole.

Typical treatment regimens for adults include [34]:
- Terbinafine – 250 mg per day for two weeks

- Itraconazole – 200 mg twice daily for one week
- Fluconazole – 150 mg once weekly for two to six weeks
Griseofulvin, an oral antifungal agent frequently used for tinea capitis in children,
can treat tinea pedis but may be less effective than other oral antifungals and
requires a longer duration of therapy [34]. In a systematic review, terbinafine was
found more effective than griseofulvin, while the efficacy of terbinafine and
itraconazole were similar [35].
Typical adult doses of griseofulvin for tinea pedis are 1000 mg per day of griseofulvin
microsize for four to eight weeks or 750 mg per day of griseofulvin ultramicrosize for
four to eight weeks [34].
• Children – Dosing for children is weight based, with similar durations of treatment
compared with adults. Typical pediatric doses include:
- Terbinafine tablets:
10 to 20 kg – 62.5 mg per day

20 to 40 kg – 125 mg per day

Above 40 kg – 250 mg per day
- Itraconazole – 3 to 5 mg/kg per day

- Fluconazole – 6 mg/kg once weekly
- Griseofulvin microsize – 10 to 20 mg/kg per day
- Griseofulvin ultramicrosize – 5 to 15 mg/kg per day
● Adjunctive therapy – In our experience, patients with hyperkeratotic tinea pedis may
benefit from combining antifungal treatment with a topical keratolytic, such as salicylic
acid.
Patients with vesiculation or maceration may benefit from Burow solution (1%
aluminum acetate or 5% aluminum subacetate) wet dressings to reduce moisture and
maceration. The wet dressings can be applied for 20 minutes two to three times per day.
Placing gauze or cotton between toes may also be helpful.
● Prevention – Interventions that may help to reduce recurrences include use of socks
with wick-away material, use of desiccating foot powders, treatment of hyperhidrosis if
there is a history of moist feet, treatment of shoes with antifungal powder, and
avoidance of occlusive footwear.
TINEA CORPORIS
Overview — The term "tinea corporis" refers to epidermal dermatophyte infections in sites

other than the feet, groin, face, or hand:
● Etiology and risk factors – T. rubrum is the most common cause of tinea corporis.
Other notable causes include Trichophyton tonsurans, Microsporum canis, T.
mentagrophytes/interdigitale complex, T. indotineae, Microsporum gypseum, Trichophyton
violaceum, and Microsporum audouinii.
Acquisition of infection may occur by direct skin contact with an infected individual or
animal, contact with fomites, or from secondary spread from other sites of
dermatophyte infection (eg, scalp, feet, etc). In particular, T. tonsurans tinea corporis in
adults may result from contact with a child with tinea capitis, which is often caused by
this organism. M. canis tinea corporis is often acquired by contact with an infected cat or
dog.
Tinea corporis can also occur in outbreaks among athletes who have skin-to-skin
contact, such as wrestlers (tinea corporis gladiatorum). T. tonsurans is a common cause
of tinea corporis gladiatorum [36].

● Clinical features – Tinea corporis often begins as a pruritic, circular or oval,

erythematous or hyperpigmented, scaling patch or plaque that spreads centrifugally.
Central clearing follows, while an active, advancing, raised border remains. The result is
an annular (ring-shaped) plaque from which the disease derives its common name
(ringworm ( picture 2A-D)). Multiple plaques may coalesce ( picture 24A-B). Pustules
occasionally appear ( picture 25).
Extensive tinea corporis should prompt consideration of an underlying immune

disorder, such as HIV, or for diabetes.
Differential diagnosis — Examples of features that should prompt consideration of

alternative diagnoses include extensive skin involvement and an absence of scale. A positive
potassium hydroxide (KOH) preparation distinguishes tinea corporis.
Tinea corporis may be confused with other annular skin eruptions, particularly subacute
cutaneous lupus erythematosus (SCLE), granuloma annulare, and erythema annulare
centrifugum:
● Subacute cutaneous lupus erythematosus (SCLE) – SCLE is a subtype of cutaneous

lupus erythematous that can manifest as annular or polycyclic, scaly plaques on sun-
exposed skin ( picture 26). SCLE can be idiopathic or occur in association with
systemic lupus erythematosus or drug exposure. (See "Overview of cutaneous lupus
erythematosus", section on 'Subacute cutaneous lupus erythematosus'.)
● Granuloma annulare – Granuloma annulare is a benign, inflammatory condition that

classically presents with one or more erythematous or violaceous, annular plaques on
the extremities ( picture 27A-C). Unlike tinea corporis, scale is absent. (See
"Granuloma annulare: Epidemiology, clinical manifestations, and diagnosis".)
● Erythema annulare centrifugum – Erythema annulare centrifugum, an inflammatory

skin disorder of unknown etiology, exhibits annular plaques ( picture 28A-B). A trailing
rim of scale is often evident in the superficial variant of this disorder. (See "Erythema
annulare centrifugum".)
Other disorders, such as nummular eczema ( picture 29A-B), psoriasis, pityriasis rosea
( picture 30A-B), and disciform erythrasma ( picture 31), may also exhibit scaling plaques
that resemble tinea corporis. (See "Approach to the patient with annular skin lesions".)
Treatment — The extent of skin involvement with tinea corporis influences the approach to
treatment ( algorithm 1):
● Limited disease – Tinea corporis usually responds well to topical antifungal drugs, such
as azoles, allylamines, butenafine, ciclopirox, tolnaftate, and amorolfine ( table 1)

[18,37]. Topical nystatin is not effective for dermatophyte infections. Amorolfine is not
available in the United States.
Topical antifungal treatment is generally administered once or twice per day for one to
three weeks ( table 1). The endpoint of treatment is clinical resolution.
The topical antifungal agents listed above are all considered effective. Pooled data from
randomized trials supports the efficacy of two allylamines, terbinafine and naftifine, for
tinea corporis and tinea cruris [18]. There are also data that suggest similar efficacy of
topical allylamines and topical azoles [18].
● Extensive or refractory disease – Oral treatment is an alternative for patients with

extensive skin involvement and patients who fail topical therapy. Potential causes of
treatment failure should be reviewed. (See 'Treatment failure' above.)
Terbinafine and itraconazole are common treatments. Griseofulvin and fluconazole can
also be effective but may require longer courses of therapy. Randomized trials support
the efficacy of systemic therapy [38-41]:
• Adults – Reasonable regimens in adults include [42]:
- Terbinafine – 250 mg per day for one to two weeks [43,44]

- Itraconazole – 200 mg per day for one week (longer courses may be necessary in
some patients [45])
- Fluconazole – 150 to 200 mg once weekly for two to four weeks
- Griseofulvin – Griseofulvin microsize 500 to 1000 mg per day or griseofulvin
ultramicrosize 375 to 500 mg per day for two to four weeks
• Children – Children are treated for similar durations. Reasonable pediatric doses are:
- Terbinafine tablets:
10 to 20 kg – 62.5 mg per day

20 to 40 kg – 125 mg per day
Above 40 kg – 250 mg per day
- Itraconazole – 3 to 5 mg/kg per day (up to 200 mg per day)

- Fluconazole – 6 mg/kg once weekly
- Griseofulvin – Griseofulvin microsize 10 to 20 mg/kg per day or griseofulvin
ultramicrosize 5 to 15 mg/kg per day
TINEA CRURIS

Overview — Tinea cruris (also known as jock itch) is a dermatophyte infection involving the
crural fold:
● Etiology and risk factors – The most common cause is T. rubrum. Other frequent
causes include E. floccosum, T. mentagrophytes/interdigitale complex, and T. indotineae.
Tinea cruris is far more common in males than females. Often, infection results from the
spread of the dermatophyte infection from concomitant tinea pedis. Predisposing
factors include copious sweating, obesity, diabetes, and immunodeficiency.
● Clinical features – Tinea cruris often begins with an erythematous or hyperpigmented

patch on the proximal medial thigh. The infection spreads centrifugally, with partial
central clearing and a slightly elevated, erythematous or hyperpigmented, sharply
demarcated border ( picture 3A-E).
Infection may spread to the perineum and perianal areas, into the gluteal cleft, or onto
the buttocks. In males, the scrotum is typically spared.
Differential diagnosis — Other common skin disorders that may present with erythematous
patches or plaques in the inguinal region include:
● Candidal intertrigo – Candidiasis is suggested by inflamed patches with satellite

papules and pustules ( picture 32). Candidal pseudohyphae, hyphae, and yeast cells
are seen on potassium hydroxide (KOH) preparation ( picture 8A-B). In contrast to
tinea cruris, scrotal involvement is common in males with candidiasis of the crural folds.
(See "Intertrigo".)
● Seborrheic dermatitis – Intertriginous seborrheic dermatitis may present as moist,

erythematous, or hyperpigmented patches in the genitocrural area ( picture 33).
Patients may also have findings of seborrheic dermatitis in other body areas. (See
"Seborrheic dermatitis in adolescents and adults".)
● Inverse psoriasis – Inverse psoriasis typically presents as smooth, shiny plaques with
absent or minimal scale in intertriginous areas ( picture 34A-B). Patients may or may
not have psoriasis in other body areas. (See "Psoriasis: Epidemiology, clinical
manifestations, and diagnosis", section on 'Inverse (intertriginous) psoriasis'.)
● Erythrasma – Erythrasma is a superficial bacterial infection of the skin caused by

Corynebacterium minutissimum. Intertriginous involvement may present as
erythematous to brown patches or thin plaques ( picture 35A-B). The detection of
coral red fluorescence during examination with a Wood's lamp can confirm the
diagnosis ( picture 36). (See "Erythrasma".)
A KOH preparation positive for hyphae rules out nonfungal disorders. (See 'Diagnosis' above.)

Treatment — Treatment is similar to treatment of tinea corporis ( algorithm 1):
● Initial therapy – Topical therapy with antifungal agents, such as azoles, allylamines,
butenafine, ciclopirox, tolnaftate, or amorolfine, is effective ( table 1) [18,37]. Nystatin
is not effective for dermatophyte infections. (See 'Tinea corporis' above.)
● Extensive or refractory to topical therapy – Tinea cruris that is extensive or fails to

resolve with topical therapy can be treated with the oral antifungal regimens used for
tinea corporis. (See 'Tinea corporis' above.)
Potential causes for treatment failure should be reviewed. (See 'Treatment failure'
above.)
● Prevention – Recurrence of tinea cruris is common. Concomitant tinea pedis should be

treated to reduce risk for recurrence. Treatment of onychomycosis may also reduce
recurrences. Other interventions that may be helpful include daily use of desiccant
powders or drying lotions in the inguinal area and avoidance of tight-fitting clothing
and noncotton underwear.
OTHER CLINICAL VARIANTS
Various other terms are used to describe additional clinical subtypes of dermatophyte
infection.
Onychomycosis — Dermatophyte infection is a common cause of onychomycosis (fungal

infection of the nail). Clinical manifestations include nail discoloration, subungual
hyperkeratosis, and other forms of nail dystrophy ( picture 5). Onychomycosis is reviewed
separately. (See "Onychomycosis: Epidemiology, clinical features, and diagnosis" and
"Onychomycosis: Management".)
Tinea faciei — Tinea faciei is a dermatophyte infection of facial skin devoid of terminal hairs.
The eruption may begin as small, scaly papules that evolve to form an annular plaque
( picture 37) [28]. Tinea faciei is managed similarly to tinea corporis. (See 'Tinea corporis'
above.)
Tinea manuum — Tinea manuum is a dermatophyte infection of the hand. Patients present

with a hyperkeratotic eruption on the palm or annular plaques similar to tinea corporis on
the dorsal hand.
Tinea manuum commonly occurs in association with tinea pedis and is often unilateral
( picture 12A-B). This clinical presentation is often referred to as "two feet-one hand
syndrome." The approach to treatment is similar to tinea pedis. (See 'Tinea pedis' above.)

Tinea capitis — Tinea capitis, a dermatophyte infection of scalp hair, usually occurs in small
children ( picture 4A-B). Oral antifungal therapy is the treatment of choice. Tinea capitis is
reviewed in detail separately. (See "Tinea capitis".)
Tinea barbae — Tinea barbae is a dermatophyte infection involving beard hair in adolescent

and adult males ( picture 38A-B). Oral antifungal therapy is necessary. Tinea barbae is
reviewed separately. (See "Infectious folliculitis", section on 'Dermatophytic folliculitis' and
"Infectious folliculitis", section on 'Management'.)
Majocchi's granuloma — Majocchi's granuloma is an uncommon subtype of dermatophyte

infection in which the dermatophyte invades the deep follicle and dermis. The clinical
findings are typically characterized by a localized area with erythematous or hyperpigmented,
perifollicular papules or small nodules ( picture 6A-C). Pustules may also be present.
Treatment consists of oral antifungal therapy. Majocchi's granuloma is reviewed separately.

(See "Infectious folliculitis", section on 'Dermatophytic folliculitis' and "Infectious folliculitis",
section on 'Management'.)
Tinea imbricata — Tinea imbricata (also known as Tokelau ringworm) is a variant of tinea

corporis caused by Trichophyton concentricum. The disorder primarily occurs in the South
Pacific Islands, South Asia, and South America.
Tinea imbricata is characterized by concentric, annular, scaly, erythematous plaques

( picture 39A-B). A potassium hydroxide (KOH) preparation demonstrates hyphae, and
fungal culture confirms T. concentricum infection.
The most effective treatments may be oral terbinafine and griseofulvin [46]. Systemic therapy
is often combined with a topical keratolytic agent.
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Dermatophyte
infections".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview and
who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles on
a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: Ringworm, athlete's foot, and jock itch (The
Basics)" and "Patient education: Fungal nail infections (The Basics)")
● Beyond the Basics topics (see "Patient education: Ringworm (including athlete's foot and
jock itch) (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
● Overview – Superficial fungal infections are most commonly caused by dermatophytes

in the Trichophyton, Epidermophyton, and Microsporum genera. These organisms
metabolize keratin and cause a range of pathologic clinical presentations, including
tinea pedis ( picture 1A-C), tinea corporis ( picture 2A-D), tinea cruris
( picture 3A-E), tinea capitis, and onychomycosis. (See 'Microbiology' above and 'Tinea
pedis' above and 'Tinea corporis' above and 'Tinea cruris' above and 'Other clinical
variants' above.)
● Diagnosis – A diagnosis of a cutaneous dermatophyte infection may be strongly

suspected based upon the clinical findings. A potassium hydroxide (KOH) preparation
can be used to confirm the diagnosis ( picture 7A). (See 'Diagnosis' above.)
● Treatment of limited infection – Most dermatophyte infections can be managed with

topical antifungal treatments. For patients with tinea pedis, limited tinea corporis, or
limited tinea cruris, we suggest initial treatment with a topical antifungal drug with
antidermatophyte activity rather than oral antifungal therapy ( algorithm 1) (Grade
2C). (See 'Treatment principles' above.)
Examples of effective topical antifungal agents are azoles, allylamines, ciclopirox,

butenafine, and tolnaftate. Nystatin is not effective for dermatophyte infections.
● Treatment of extensive infection or infections refractory to topical treatment – For

patients with extensive infections or infections refractory to topical therapy, we suggest
oral antifungal therapy rather than topical antifungal treatment ( algorithm 1) (Grade
2C). For patients who fail topical therapy, reasons for treatment failure should be
reviewed. (See 'Tinea pedis' above and 'Tinea corporis' above and 'Tinea cruris' above.)

● Recurrence – Recurrences of tinea pedis and tinea cruris are common. For patients with
tinea pedis, use of desiccating foot powders, placement of antifungal powder in shoes,
and avoidance of occlusive footwear may help to reduce recurrences. Patients with tinea
cruris may benefit from treatment of concomitant tinea pedis or tinea unguium, use of
desiccating powders in the groin, and avoidance of occlusive clothing and noncotton
underwear. (See 'Tinea pedis' above and 'Tinea cruris' above.)
● Dermatophytid reactions – Dermatophytid reactions are secondary, dermatitic

eruptions that may be precipitated by an immunologic response to dermatophyte
infection ( picture 10A-B). Management of dermatophytid reactions involves
treatment of the associated dermatophyte infection. Topical corticosteroids and
antipruritic agents may be beneficial for symptom relief. (See 'Id reactions' above.)
Use of UpToDate is subject to the Terms of Use.
REFERENCES
1. Havlickova B, Czaika VA, Friedrich M. Epidemiological trends in skin mycoses worldwide.

Mycoses 2008; 51 Suppl 4:2.
2. Seebacher C, Bouchara JP, Mignon B. Updates on the epidemiology of dermatophyte

infections. Mycopathologia 2008; 166:335.
3. Ameen M. Epidemiology of superficial fungal infections. Clin Dermatol 2010; 28:197.
4. Levitt JO, Levitt BH, Akhavan A, Yanofsky H. The sensitivity and specificity of potassium
hydroxide smear and fungal culture relative to clinical assessment in the evaluation of
tinea pedis: a pooled analysis. Dermatol Res Pract 2010; 2010:764843.
5. Solomon M, Greenbaum H, Shemer A, et al. Toe Web Infection: Epidemiology and Risk
Factors in a Large Cohort Study. Dermatology 2021; 237:902.
6. Meena S, Gupta LK, Khare AK, et al. Topical Corticosteroids Abuse: A Clinical Study of
Cutaneous Adverse Effects. Indian J Dermatol 2017; 62:675.
7. Verma SB. A Closer Look at the Term "Tinea Incognito:" A Factual as Well as Grammatical
Inaccuracy. Indian J Dermatol 2017; 62:219.
8. Holubar K, Male O. Tinea incognita vs. tinea incognito. Acta Dermatovenerol Croat 2002;
10:39.
9. Ilkit M, Durdu M, Karakaş M. Majocchi's granuloma: a symptom complex caused by
fungal pathogens. Med Mycol 2012; 50:449.
10. Smith KJ, Neafie RC, Skelton HG 3rd, et al. Majocchi's granuloma. J Cutan Pathol 1991;
18:28.

11. Tse KC, Yeung CK, Tang S, et al. Majocchi's granuloma and posttransplant
lymphoproliferative disease in a renal transplant recipient. Am J Kidney Dis 2001; 38:E38.
12. Kim ST, Baek JW, Kim TK, et al. Majocchi's granuloma in a woman with iatrogenic
Cushing's syndrome. J Dermatol 2008; 35:789.
13. Akiba H, Motoki Y, Satoh M, et al. Recalcitrant trichophytic granuloma associated with
NK-cell deficiency in a SLE patient treated with corticosteroid. Eur J Dermatol 2001; 11:58.
14. Cheng N, Rucker Wright D, Cohen BA. Dermatophytid in tinea capitis: rarely reported
common phenomenon with clinical implications. Pediatrics 2011; 128:e453.
15. Romano C, Rubegni P, Ghilardi A, Fimiani M. A case of bullous tinea pedis with
dermatophytid reaction caused by Trichophyton violaceum. Mycoses 2006; 49:249.
16. Al Aboud K, Al Hawsawi K, Alfadley A. Tinea incognito on the hand causing a facial
dermatophytid reaction. Acta Derm Venereol 2003; 83:59.
17. Veien NK, Hattel T, Laurberg G. Plantar Trichophyton rubrum infections may cause
dermatophytids on the hands. Acta Derm Venereol 1994; 74:403.
18. El-Gohary M, van Zuuren EJ, Fedorowicz Z, et al. Topical antifungal treatments for tinea
cruris and tinea corporis. Cochrane Database Syst Rev 2014; :CD009992.
19. Alston SJ, Cohen BA, Braun M. Persistent and recurrent tinea corporis in children treated
with combination antifungal/ corticosteroid agents. Pediatrics 2003; 111:201.
20. Greenberg HL, Shwayder TA, Bieszk N, Fivenson DP. Clotrimazole/betamethasone
diproprionate: a review of costs and complications in the treatment of common
cutaneous fungal infections. Pediatr Dermatol 2002; 19:78.
21. Rosen T, Elewski BE. Failure of clotrimazole-betamethasone dipropionate cream in

treatment of Microsporum canis infections. J Am Acad Dermatol 1995; 32:1050.
22. Nahm WK, Orengo I, Rosen T. The antifungal agent butenafine manifests anti-
inflammatory activity in vivo. J Am Acad Dermatol 1999; 41:203.
23. Rosen T, Schell BJ, Orengo I. Anti-inflammatory activity of antifungal preparations. Int J
Dermatol 1997; 36:788.
24. Gupta AK, Renaud HJ, Quinlan EM, et al. The Growing Problem of Antifungal Resistance
in Onychomycosis and Other Superficial Mycoses. Am J Clin Dermatol 2021; 22:149.
25. Gupta AK, Venkataraman M, Hall DC, et al. The emergence of Trichophyton indotineae:
Implications for clinical practice. Int J Dermatol 2023; 62:857.
26. Caplan AS, Chaturvedi S, Zhu Y, et al. Notes from the Field: First Reported U.S. Cases of
Tinea Caused by Trichophyton indotineae - New York City, December 2021-March 2023.
MMWR Morb Mortal Wkly Rep 2023; 72:536.
27. Jabet A, Normand AC, Brun S, et al. Trichophyton indotineae, from epidemiology to
therapeutic. J Mycol Med 2023; 33:101383.

28. Hawkins DM, Smidt AC. Superficial fungal infections in children. Pediatr Clin North Am
2014; 61:443.
29. Sasagawa Y. Internal environment of footwear is a risk factor for tinea pedis. J Dermatol
2019; 46:940.
30. Al-Mahmood A, Al-Sharifi E. Epidemiological Characteristics and Risk Factors of Tinea
Pedis Disease Among Adults Attending Tikrit Teaching Hospital/ Iraq. Infect Disord Drug
Targets 2021; 21:384.
31. Oz Y, Qoraan I, Oz A, Balta I. Prevalence and epidemiology of tinea pedis and toenail
onychomycosis and antifungal susceptibility of the causative agents in patients with
type 2 diabetes in Turkey. Int J Dermatol 2017; 56:68.
32. Korting HC, Tietz HJ, Bräutigam M, et al. One week terbinafine 1% cream (Lamisil) once
daily is effective in the treatment of interdigital tinea pedis: a vehicle controlled study.
LAS-INT-06 Study Group. Med Mycol 2001; 39:335.
33. Crawford F, Hollis S. Topical treatments for fungal infections of the skin and nails of the
foot. Cochrane Database Syst Rev 2007; :CD001434.
34. Gupta AK, Cooper EA. Update in antifungal therapy of dermatophytosis. Mycopathologia
2008; 166:353.
35. Bell-Syer SE, Khan SM, Torgerson DJ. Oral treatments for fungal infections of the skin of
the foot. Cochrane Database Syst Rev 2012; 10:CD003584.
36. Adams BB. Tinea corporis gladiatorum. J Am Acad Dermatol 2002; 47:286.
37. van Zuuren EJ, Fedorowicz Z, El-Gohary M. Evidence-based topical treatments for tinea
cruris and tinea corporis: a summary of a Cochrane systematic review. Br J Dermatol
2015; 172:616.
38. Bourlond A, Lachapelle JM, Aussems J, et al. Double-blind comparison of itraconazole

with griseofulvin in the treatment of tinea corporis and tinea cruris. Int J Dermatol 1989;
28:410.
39. Cole GW, Stricklin G. A comparison of a new oral antifungal, terbinafine, with griseofulvin
as therapy for tinea corporis. Arch Dermatol 1989; 125:1537.
40. Panagiotidou D, Kousidou T, Chaidemenos G, et al. A comparison of itraconazole and

griseofulvin in the treatment of tinea corporis and tinea cruris: a double-blind study. J Int
Med Res 1992; 20:392.
41. Faergemann J, Mörk NJ, Haglund A, Odegård T. A multicentre (double-blind) comparative
study to assess the safety and efficacy of fluconazole and griseofulvin in the treatment of
tinea corporis and tinea cruris. Br J Dermatol 1997; 136:575.
42. Elewski BE, Hughey LC, Sobera JO. Fungal diseases. In: Dermatology, 3rd ed, Bolognia JL, J
orizzo JL, Schaffer JV (Eds), Elsevier Limited, 2012. Vol 2, p.1251.

43. Voravutinon V. Oral treatment of tinea corporis and tinea cruris with terbinafine and
griseofulvin: a randomized double blind comparative study. J Med Assoc Thai 1993;
76:388.
44. Farag A, Taha M, Halim S. One-week therapy with oral terbinafine in cases of tinea
cruris/corporis. Br J Dermatol 1994; 131:684.
45. Khurana A, Agarwal A, Agrawal D, et al. Effect of Different Itraconazole Dosing Regimens
on Cure Rates, Treatment Duration, Safety, and Relapse Rates in Adult Patients With
Tinea Corporis/Cruris: A Randomized Clinical Trial. JAMA Dermatol 2022.
46. Bonifaz A, Vázquez-González D. Tinea imbricata in the Americas. Curr Opin Infect Dis
2011; 24:106.
Topic 4030 Version 45.0

GRAPHICS
Tinea pedis with interdigital maceration
Erythema and white, macerated skin between the toes in a patient with
tinea pedis.
Reproduced with permission from: www.visualdx.com. Copyright VisualDx. All rights reserved.
Graphic 76067 Version 8.0

Hyperkeratotic (moccasin-type) tinea pedis
Diffuse scale on the plantar surface and side of the foot.

Bullous tinea pedis
Vesicles and bullae on the plantar skin of a patient with tinea pedis.

Tinea corporis
Thin, slightly hyperpigmented plaque with fine scales over the posterior neck.

Tinea corporis
Annular, scaly plaques.

Tinea corporis
Erythematous plaque with scale on the knee.

Tinea corporis
An inflammatory, annular plaque with peripheral scale is present.

Tinea cruris
Erythematous and scaly plaque with ring-like, raised borders in the groin,
characteristic of tinea cruris.

Tinea cruris of inner thigh, vulva, and mons of female patient

Tinea cruris
A large, scaly, violaceous plaque spanning the inguinal fold, with an accentuated, raised border in areas.
Image created by Richard P. Usatine, MD. Reproduced with permission from: www.visualdx.com. Copyright VisualDx. All rights
reserved.

Tinea cruris
Erythematous patch with central clearing and an advancing, scaly border in the
groin.

Tinea cruris, involvement of buttocks
This patient with tinea cruris exhibited extension of disease to the

buttocks and gluteal cleft.
Reproduced with permission from: Goodheart HP. Goodheart's Photoguide of

Common Skin Disorders, 2nd ed, Lippincott Williams & Wilkins, Philadelphia 2003.
Copyright © 2003 Lippincott Williams & Wilkins.

Tinea capitis
Scaly patch with hair loss on the posterior scalp.

Tinea capitis
A scaly plaque with associated hair loss is present on the scalp.

Onychomycosis
Distal, lateral, subungual onychomycosis with associated toenail discoloration, subungual debris, and
dermatophytoma. Dermatophytomas appear as opaque, white or yellow, linear bands in the nail.

Majocchi's granuloma
Papules and pustules within an erythematous plaque on the dorsal hand.

Hyperpigmented plaques studded with papules on the buttocks and lower back.

Papular and pustular eruption on the extremity secondary to dermatophyte infection.

Approach to the treatment of tinea pedis, tinea corporis, and

tinea cruris
KOH: potassium hydroxide.
* Diagnostic accuracy of a KOH preparation is influenced by factors such as clinician

experience and collection of an adequate specimen.
¶ The recognition of classic physical findings supports high confidence in the clinical
diagnosis. Refer to UpToDate topics on dermatophyte (tinea) infections for classic
clinical findings.
Δ Localized infection may be considered infection limited to a single body area (eg,
feet) or limited skin involvement for which topical application would be feasible.
◊ Fungal culture is an alternative method of confirming fungal infection; however,

results may not be available for a few weeks. The differential diagnosis determines the
need for skin biopsy or other diagnostic tests.
§ A trial of antifungal therapy may be reasonable for patients with limited skin
involvement while awaiting other diagnostic tests or referral. Patients given a trial of
topical antifungal therapy should be reassessed for improvement within a few weeks.
¥ Topical therapy with antifungal agents such as azoles, allylamines, butenafine,

ciclopirox, tolnaftate, or amorolfine is effective. Nystatin is not effective for
dermatophyte infections.
‡ Patients who find topical therapy challenging may benefit from oral antifungal
treatment.
† Emerging resistance of dermatophytes to antifungal therapies may account for

some treatment failures. However, availability of susceptibility testing is limited, and
the prevalence of resistance varies. Resistance appears to be infrequent in many
locations but may be underestimated [1] .
** Refer to UpToDate topics on dermatophyte (tinea) infections for details on

preventive measures.
Reference:
1. Gupta AK, Renaud HJ, Quinlan EM, et al. The Growing Problem of Antifungal Resistance in
Onychomycosis and Other Superficial Mycoses. Am J Clin Dermatol 2021; 22:149.

Potassium hydroxide (KOH) preparation from dermatophyte infection
Multiple septate hyphae on a background of squamous cells in a KOH preparation taken from the site of a
dermatophyte infection.
Courtesy of Beth G Goldstein, MD.

Dermatophyte potassium hydroxide (KOH) preparat
ion
Septate hyphae are visible on a background of squamous cells in

this KOH preparation taken from a lesion of tinea corporis.
KOH preparations from tinea pedis and tinea cruris have a similar
appearance.
Reproduced with permission from: www.visualdx.com. Copyright VisualDx. All rights

reserved.

Candida albicans
KOH preparation of Candida infection.


Candida albicans
Pseudohyphae of Candida with budding yeasts in

a KOH preparation. Pseudohyphae are chains of elongated yeast
cells that fail to detach after budding.


Microscopic tinea versicolor
Potassium hydroxide preparation of tinea versicolor demonstrating short hyphae and yeast cells.

Autoeczematization (id reaction)
Numerous pinpoint vesicles are present on the hand.

Dermatophytid reaction (autoeczematization or id

reaction due to dermatophyte infection)
A widespread, eczematous eruption primarily distributed on the

face, neck, and ears developed in this child with tinea capitis. The
terms "autoeczematization" and "id reaction" are also used to refer
to this phenomenon.
Copyright © Bernard Cohen, MD, Dermatlas; http://www.dermatlas.org.

Topical antifungal agents
Drug Dose How supplied*
Azoles ¶
Clotrimazole Δ Twice per day Cream 1%
Ointment 1%
Solution 1%
Econazole Once per day (twice per day for Cream 1%

candidiasis)
Foam 1%
Efinaconazole ◊ Once per day Solution 10%
Ketoconazole Once per day Cream 2%
Shampoo 2% (1% shampoo is

available over the counter)
Gel 2%
Foam 2%
Luliconazole Once per day Cream 1%
Miconazole Δ Twice per day Cream 2%
Ointment 2%
Solution 2%
Powder 2%
Aerosol solution 2%
Aerosol powder 2%
Oxiconazole Once to twice per day Cream 1%
Lotion 1%
Sertaconazole Twice per day Cream 2%
Sulconazole Once or twice per day Cream 1%
Solution 1%
Allylamines §
Naftifine Once per day (cream), twice Cream 1%

per day (gel)
Cream 2%
Gel 1%
Gel 2%
Terbinafine Δ Once to twice per day Cream 1%
Spray solution 1%

Benzylamine §
Butenafine Δ Once per day (twice per day for Cream 1%

tinea pedis)
Polyene: Treats Candida infections only
Nystatin 2 to 3 times per day Cream 100,000 units/gram
Ointment 100,000 units/gram
Powder 100,000 units/gram
Other
Ciclopirox ¥ Twice per day Cream 0.77%
Gel 0.77%
Suspension 0.77%
Shampoo 1%
Solution 8%
Tolnaftate Δ ‡ Twice per day Cream 1%
Powder 1%
Aerosol:
Liquid 1%
Powder 1%
Solution 1%
For additional details on available formulations and frequency of application, refer to the
Lexicomp drug-specific monographs included with UpToDate.
* Preparations available in the United States and some other countries.
¶ Azoles have activity against dermatophytes, tinea versicolor, and Candida. Sulconazole,
oxiconazole, and luliconazole may be less effective for Candida infection than other azoles.
Δ Available in over-the-counter (nonprescription) preparations in the United States and some

other countries.
◊ Indicated for onychomycosis.
§ Can treat Candida in addition to dermatophytes and tinea versicolor but may be less effective
than azoles and ciclopirox for Candida infection.
¥ Treats dermatophytes, tinea versicolor, and Candida.
‡ Does not treat Candida; less effective than other options for dermatophytes.
Prepared with data from: US Food & Drug Administration (FDA) approved product information. US National Library of
Medicine. (Available online at: https://dailymed.nlm.nih.gov/dailymed/).


Comparison of representative topical corticosteroid preparations

(classified according to the United States system)
Available
Brand names strength(s),
Potency Vehicle
Corticosteroid (United percent
group* type/form
States) (except as
noted)
Super-high Betamethasone Ointment Diprolene 0.05

potency dipropionate, (optimized)
(group 1) augmented
Gel, lotion [Generic only] 0.05
Clobetasol Cream, ointment Temovate 0.05

propionate
Gel, solution [Generic only] 0.05
(scalp)
Cream Tasoprol 0.05
Cream (emollient Temovate E ¶ 0.05

base)
Lotion, shampoo, Clobex 0.05

spray aerosol
Foam aerosol Olux, Olux-E, 0.05

Tovet
Lotion Impeklo 0.05
Ointment Clobetavix 0.05
Shampoo Clodan 0.05
Solution (scalp) Cormax ¶ 0.05
Diflucortolone Ointment, oily Nerisone Forte 0.3

valerate (not cream (United Kingdom,
available in others)
United States)
Fluocinonide Cream Vanos 0.1
Flurandrenolide Tape (roll) Cordran 4 mcg/cm 2
Halobetasol Lotion Ultravate 0.05

propionate
Cream, ointment [Generic only] 0.05
Foam Lexette 0.05
High potency Amcinonide Ointment Cyclocort ¶ , 0.1

(group 2) Amcort ¶
Betamethasone Ointment Diprosone ¶ 0.05

dipropionate

Cream, Diprolene AF 0.05

augmented
formulation (AF)
Clobetasol Cream Impoyz 0.025

propionate
Desoximetasone Cream, ointment, Topicort 0.25

spray
Gel Topicort 0.05
Diflorasone Ointment ApexiCon ¶ , 0.05

diacetate Florone ¶
Cream ApexiCon E 0.05

(emollient)
Fluocinonide Cream, gel, Lidex ¶ 0.05

ointment,
solution
Halcinonide Cream, ointment, Halog 0.1

solution
Halobetasol Lotion Bryhali 0.01

propionate
High potency Amcinonide Cream Cyclocort ¶ , 0.1

(group 3) Amcort ¶
Lotion Amcort ¶ 0.1
Betamethasone Cream Diprosone ¶ 0.05

dipropionate (hydrophilic
emollient)
Betamethasone Ointment Valisone ¶ 0.1

valerate
Foam Luxiq 0.12
Desoximetasone Cream, ointment Topicort, Topicort 0.05

LP ¶
Diflorasone Cream Florone ¶ , 0.05

diacetate Psorcon
Diflucortolone Cream, oily Nerisone (United 0.1

valerate (not cream, ointment Kingdom, others)
available in
United States)
Fluocinonide Cream (aqueous Lidex-E ¶ 0.05

emollient)
Fluticasone Ointment Cutivate ¶ 0.005

propionate
Mometasone Ointment Elocon ¶ 0.1

furoate

Triamcinolone Cream, ointment Aristocort HP ¶ , 0.5

acetonide Kenalog ¶ ,
Triderm
Medium Betamethasone Spray Sernivo 0.05

potency dipropionate
(group 4)
Clocortolone Cream Cloderm 0.1
pivalate
Fluocinolone Ointment Synalar 0.025

acetonide
Flurandrenolide Ointment Cordran 0.05
Fluticasone Cream Cutivate ¶ 0.05

propionate
Hydrocortisone Ointment Westcort ¶ 0.2

valerate
Mometasone Cream, lotion, Elocon ¶ 0.1

furoate solution
Triamcinolone Cream Kenalog ¶ , 0.1

acetonide Triderm
Ointment Kenalog ¶ 0.1
Ointment Trianex, Tritocin 0.05
Aerosol spray Kenalog 0.2 mg per 2

second spray
Dental paste Oralone 0.1
Lower-mid Betamethasone Lotion Diprosone ¶ 0.05

potency dipropionate
(group 5)
Betamethasone Cream Beta-Val ¶ , 0.1
valerate Valisone ¶
Desonide Ointment DesOwen ¶ , 0.05

Tridesilon ¶
Gel Desonate, DesRx 0.05
Fluocinolone Cream Synalar 0.025

acetonide
Flurandrenolide Cream, lotion Cordran, Nolix 0.05
Fluticasone Lotion Beser ¶ , 0.05

propionate Cutivate ¶
Hydrocortisone Cream, lotion Locoid, Locoid 0.1

butyrate Lipocream
Ointment, [Generic only] 0.1

solution

Hydrocortisone Cream Pandel 0.1

probutate
Hydrocortisone Cream Westcort ¶ 0.2

valerate
Prednicarbate Cream Dermatop ¶ 0.1

(emollient),
ointment
Triamcinolone Lotion Kenalog ¶ 0.1

acetonide
Ointment Kenalog ¶ 0.025
Low potency Alclometasone Cream, ointment Aclovate ¶ 0.05

(group 6) dipropionate
Betamethasone Lotion Beta-Val ¶ , 0.1

valerate Valisone ¶
Desonide Cream DesOwen, 0.05

Tridesilon
Lotion DesOwen ¶ , 0.05

LoKara ¶
Foam Verdeso 0.05
Fluocinolone Cream, solution Synalar 0.01

acetonide
Shampoo Capex 0.01
Oil Δ Derma- 0.01

Smoothe/FS
Body, Derma-
Smoothe/FS
Scalp
Triamcinolone Cream, lotion Kenalog ¶ , 0.025

acetonide Aristocort ¶
Least potent Hydrocortisone Cream Ala-Cort, 2.5

(group 7) (base, ≥2%) Hytone ¶ ,
Nutracort ¶
Ointment Hytone ¶ 2.5
Lotion Hytone ¶ , Ala 2

Scalp, Scalacort
DK
Solution Texacort 2.5
Hydrocortisone Ointment Cortaid ¶ , 1

(base, <2%) Cortizone 10,
Hytone ¶ ,
Nutracort ¶
Cream Ala-Cort, 1
Cortaid ¶ ,

Cortizone 10,
Hytone ¶ ,
KeriCort,
Synacort ¶
Gel Cortizone 10 1
Lotion Aquanil HC, 1

Cortizone 10,
Sarnol-HC
Spray Cortaid ¶ 1
Solution Cortaid ¶ , 1
Noble ¶ , Scalp
Relief, Scalpicin
Cream, ointment Cortaid ¶ 0.5
Cream Instacort 0.5
Hydrocortisone Cream MiCort-HC ¶ 2.5

acetate
Cream Vanicream HC 1
Lotion Nucort 2
* Listed by potency according to the United States classification system: group 1 is the most
potent, group 7 is the least potent. Other countries use a different classification system with only
4 or 5 groups.
¶ Inactive United States brand name for specific product; brand may be available outside United
States. This product may be available generically in the United States.
Δ 48% refined peanut oil.
Data from:
1. Lexicomp Online. Copyright © 1978-2023 Lexicomp, Inc. All Rights Reserved.
2. Tadicherla S, Ross K, Shenefelt D. Topical corticosteroids in dermatology. Journal of Drugs in Dermatology 2009;
12:1093.
3. U.S. Food & Drug Administration Approved Drug Products with Therapeutic Equivalence (Orange Book). Available
at: https://www.accessdata.fda.gov/scripts/cder/ob/default.cfm (Accessed on June 18, 2017).
4. The British Association of Dermatologists' information on topical corticosteroids – established and alternative
proprietary names, potency, and discontinuation. British Association of Dermatologists. Available at:
https://www.bad.org.uk/shared/get-file.ashx?id=3427&itemtype=document (Accessed on April 26, 2021).

Tinea pedis
Erythematous and hyperpigmented plaque with vesicles on the plantar foot.

Ulcerative tinea pedis
Extensive erosions in a patient with tinea pedis.

Ulcerative tinea pedis
Erosions and ulceration on the distal plantar foot.

Tinea pedis and tinea manuum
Scaly plaques involving the toe webs and dorsal feet (tinea pedis) along with fine scaling on the palm
(tinea manuum). Note the associated onychomycosis.

Erythrasma
Interdigital scale and maceration on the foot.

Candidal intertrigo of the finger web
Erosio interdigitalis blastomycetica (interdigital candidal infection) in

a bartender whose hands were constantly wet. In the acute phase,
erosio interdigitalis blastomycetica may have a more macerated
appearance.
Reproduced with permission from: Habif T. Clinical Dermatology: A Color Guide to

Diagnosis and Therapy, 4th ed, Mosby, New York 2004. Copyright © 2004 Elsevier.

Allergic contact dermatitis
Erythematous, scaly plaques on the dorsum of the feet of a patient with

shoe allergic contact dermatitis.
Reproduced with permission from: Stedman's Medical Dictionary. Copyright © 2008 Lippincott
Williams & Wilkins.

Dyshidrotic foot eczema
Desquamation following vesicle desiccation in a patient with plantar

dyshidrotic eczema.

Palmoplantar psoriasis
Erythematous, scaly plaques with fissures on the palms and soles.

Pitted keratolysis
Asymptomatic, deep, cribriform pits on soles of the feet of a patient

with plantar hyperhidrosis. The feet were malodorous.
Copyright © Shahbaz A Janjua, MD, Dermatlas; http://www.dermatlas.org.

Juvenile plantar dermatosis
Shiny-appearing plantar skin with accentuation of the skin folds and

fissures in a teenager with juvenile plantar dermatosis.

reserved.

Juvenile plantar dermatosis 2
Shiny and cracked appearance of the plantar skin in a child with

juvenile plantar dermatosis.

reserved.

Keratolysis exfoliativa (dyshidrosis lamellosa sicca)
Epidermal peeling of the sole.

Dyshidrotic eczema
Multiple small vesicles and postinflammatory hyperpigmentation on the foot.

Palmoplantar pustulosis
Pustules within an erythematous, scaly plaque on the foot.

Scabies
Erythematous and hyperpigmented papules and crusts on the foot

of a child with scabies.

reserved.

Tinea corporis
Multiple annular, erythematous plaques with peripheral scale are present.

Tinea corporis
Multiple round, erythematous plaques of variable size, some with signs of

central resolution, on the leg of a patient with tinea corporis.

Tinea corporis
Annular, erythematous plaque with pustules.

Subacute cutaneous lupus erythematosus
Erythematous, annular plaques with scale.

reserved.

Granuloma annulare
Annular, erythematous plaques with central clearing.

Granuloma annulare
Nonscaly, violaceous, annular plaque on an extremity.
Reproduced with permission from: www.skinsight.com. Copyright VisualDx. All rights

reserved.

Granuloma annulare, localized
A 27-year-old presented with a 9-month history of a solitary, slowly

enlarging, annular patch of granuloma annulare 10 cm in diameter
on the right hand. It has 1 to 1.5 mm skin-colored papules at the
periphery and complete clearing in the center of the lesion.

Superficial erythema annulare centrifugum
Annular, erythematous plaques with "trailing scale" are classic

features of superficial erythema annulare centrifugum.

reserved.

Superficial erythema annulare centrifugum
Erythematous, annular plaques with "trailing scale" are classic

features of superficial erythema annulare centrifugum.

reserved.

Nummular eczema
Nummular eczema of the thigh typically presenting as round, coin-shaped, erythematous, scaly plaques.

Nummular eczema
A plaque of nummular eczema with erythema, vesiculation, and crusting.

Pityriasis rosea
Erythematous plaques with trailing collarettes of scale.

Pityriasis rosea
Multiple erythematous, scaly papules and plaques on the trunk in a "Christmas tree" distribution.

Disciform erythrasma

Candidal intertrigo
Erythematous plaque with satellite papules and pustules in the abdominal and inguinal folds.

Seborrheic dermatitis
Erythematous patch in the inguinal crease.

Inverse psoriasis
Shiny, erythematous plaques within skin folds of the suprapubic region and inguinal creases.
Erythematous, scaly plaques on the scrotum.

Inverse psoriasis
Well-demarcated, erythematous plaque in the axilla.

Erythrasma
Erythematous patches with fine scale in the groin.

Erythrasma
Hyperpigmented patch with fine scale in the axilla.

Erythrasma under light from a Wood's lamp
Examination with a Wood's lamp reveals coral red fluorescence on

the inner thighs of this patient with erythrasma.

reserved.

Tinea faciei
An erythematous, oval plaque and pustules on the face.

Tinea pedis and tinea manuum
This image shows concomitant tinea pedis and tinea manuum, also
known as the "two feet-one hand presentation."


Tinea barbae
Large, erythematous, papulopustular lesions in the beard area of a patient

with Trichophyton infection.

Tinea barbae
Follicular pustules and crusted lesions in a patient with tinea barbae.

Tinea imbricata
Scaly eruption in a concentric pattern on the extremity.

Tinea imbricata
Patterned, scaly eruption on the extremity.

Contributor Disclosures
Adam O Goldstein, MD, MPH No relevant financial relationship(s) with ineligible companies to
disclose. Beth G Goldstein, MD Equity Ownership/Stock Options: Skinvest, Inc [Skincare]. All of the
relevant financial relationships listed have been mitigated. Robert P Dellavalle, MD, PhD, MSPH Equity
Ownership/Stock Options: Altus Labs [Itch, eczema]. Grant/Research/Clinical Trial Support: Pfizer
[Patient decision aids, inflammatory and immune-mediated skin disease]. Other Financial Interest:
Cochrane Council meetings [Expense reimbursement]. All of the relevant financial relationships listed
have been mitigated. Moise L Levy, MD Grant/Research/Clinical Trial Support: Castle Creek Biosciences
[Epidermolysis bullosa]; Janssen Pharmaceuticals [Psoriasis]; Krystal Biotech [Epidermolysis bullosa];
Regeneron Pharmaceuticals [Atopic dermatitis]. Consultant/Advisory Boards: Abeona Therapeutics
[Epidermolysis bullosa]; Castle Creek Biosciences [Epidermolysis bullosa]; Novan [Molluscum
contagiosum treatment]; Regeneron Pharmaceuticals [Atopic dermatitis]. Other Financial Interest:
Mayne Pharma [Data and safety monitoring board for ichthyosis trial]. All of the relevant financial
relationships listed have been mitigated. Ted Rosen, MD Consultant/Advisory Boards: Almirall [Actinic
keratosis]; Beiersdorf [Dry skin]; DermTech [Melanoma]. All of the relevant financial relationships listed
have been mitigated. Abena O Ofori, MD No relevant financial relationship(s) with ineligible companies
to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for references
to be provided to support the content. Appropriately referenced content is required of all authors and
must conform to UpToDate standards of evidence.
Conflict of interest policy

Dermatophyte (Tinea) Infections - UpToDate

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Dermatophyte (Tinea) Infections - UpToDate

Uploaded by

Copyright:

Available Formats

7/7/23, 21:19 Dermatophyte (tinea) infections - UpToDate

Official reprint from UpToDate®

Literature review current through: Jun 2023.

● (See "Tinea capitis".)

● (See "Infectious folliculitis", section on 'Dermatophytic folliculitis'.)

● (See "Onychomycosis: Epidemiology, clinical features, and diagnosis".)

● (See "Onychomycosis: Management".)

● (See "Tinea versicolor (pityriasis versicolor)".)

● (See "Tinea nigra".)

https://www.uptodate.com/contents/dermatophyte-tinea-infections/print?search=tiña de la cabeza&topicRef=99983&source=see_link 1/99

Dermatophytes are filamentous fungi in the genera Trichophyton, Microsporum, and

• Tinea capitis – Infection of scalp hair

• Dermatophyte onychomycosis (tinea unguium)

Majocchi's granuloma is an additional subtype of dermatophyte infection characterized by

https://www.uptodate.com/contents/dermatophyte-tinea-infections/print?search=tiña de la cabeza&topicRef=99983&source=see_link 2/99

The detection of segmented hyphae on a KOH preparation confirms a dermatophyte

Collection of an adequate specimen for a KOH preparation or fungal culture is

- (See "Tinea capitis", section on 'Diagnosis'.)

https://www.uptodate.com/contents/dermatophyte-tinea-infections/print?search=tiña de la cabeza&topicRef=99983&source=see_link 3/99

- (See "Infectious folliculitis", section on 'Diagnosis'.)

- (See "Onychomycosis: Epidemiology, clinical features, and diagnosis", section on

Potential complications of dermatophyte infection include secondary bacterial infection, tinea

Secondary infection — Secondary bacterial infection can occur in association with

Tinea incognito and Majocchi's granuloma — Misdiagnosis of a dermatophyte infection as

Id reactions — Autoeczematization reactions (also known as id reactions) are secondary,

https://www.uptodate.com/contents/dermatophyte-tinea-infections/print?search=tiña de la cabeza&topicRef=99983&source=see_link 4/99

The management of dermatophytid reactions involves the successful treatment of the

Treatment of dermatophyte infections is generally indicated. Treatment is given to alleviate

Treatment options — Treatment consists of topical or systemic antifungal drugs with

Nystatin ineffective — Nystatin, an effective treatment for cutaneous Candida infections, is

Adjunctive corticosteroid therapy — In general, we do not use topical corticosteroids in the

An infrequent exception to our avoidance of combination therapy is the addition of a low-

Treatment failure — Dermatophyte infections usually respond well to a course of

● Patient assessment – Common reasons for failure to respond to antifungal therapy

● Antifungal resistance – Emerging resistance of dermatophyte infections to antifungal

• Trichophyton indotineae – Trichophyton indotineae is a highly transmissible species of

https://www.uptodate.com/contents/dermatophyte-tinea-infections/print?search=tiña de la cabeza&topicRef=99983&source=see_link 6/99

T. indotineae cannot be identified through routine laboratory techniques due to

• Interdigital tinea pedis – Interdigital tinea pedis manifests as pruritic erosions or

• Hyperkeratotic (moccasin-type) tinea pedis – Hyperkeratotic tinea pedis is

• Vesiculobullous (inflammatory) tinea pedis – Vesiculobullous tinea pedis is

https://www.uptodate.com/contents/dermatophyte-tinea-infections/print?search=tiña de la cabeza&topicRef=99983&source=see_link 7/99

Differential diagnosis — The differential diagnosis of tinea pedis is broad and varies

● Interdigital tinea pedis:

• Erythrasma ( picture 13)

● Hyperkeratotic (moccasin-type) tinea pedis:

● Vesiculobullous (inflammatory) tinea pedis:

• Acute palmoplantar (dyshidrotic) eczema ( picture 21)

A positive potassium hydroxide (KOH) preparation demonstrating segmented hyphae

Treatment — Topical antifungal therapy is the treatment of choice for most patients.

https://www.uptodate.com/contents/dermatophyte-tinea-infections/print?search=tiña de la cabeza&topicRef=99983&source=see_link 8/99

A meta-analysis of randomized trials published prior to February 2005 supports efficacy

• Adults – Adults are usually treated with terbinafine, itraconazole, or fluconazole.

- Terbinafine – 250 mg per day for two weeks

10 to 20 kg – 62.5 mg per day

https://www.uptodate.com/contents/dermatophyte-tinea-infections/print?search=tiña de la cabeza&topicRef=99983&source=see_link 9/99

Above 40 kg – 250 mg per day

- Itraconazole – 3 to 5 mg/kg per day

Overview — The term "tinea corporis" refers to epidermal dermatophyte infections in sites

https://www.uptodate.com/contents/dermatophyte-tinea-infections/print?search=tiña de la cabeza&topicRef=99983&source=see_link 10/99

● Clinical features – Tinea corporis often begins as a pruritic, circular or oval,

Extensive tinea corporis should prompt consideration of an underlying immune