dermatology handout
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Types of ringworm: tinea corporis and tinea cruris. What are the symptoms?
Tinea corporis: When fungus affects the skin of the body, it often produces the round spots of classic ringworm. Sometimes, these spots have an "active" outer border as they slowly grow and advance. Sometimes, scaling, crusting, raised areas, or even blister-like lesions can appear, particularly in the active border. It is important to distinguish this rash from other even more common rashes, such as nummular eczema. This condition, and ot
rashes, such as nummular eczema. This condition, and others, may appear similar to ringworm, but they are not due to a fungal infection and require different treatment.
See Related Images
Tinea Corporis
Tinea cruris: Tinea of the groin ("jock itch") tends to have a reddish-brown color and extends from the folds of the groin down onto one or both thighs. Other conditions that can mimic tinea cruris include yeast infections, psoriasis, and intertrigo, a chafing rash that results from the skin rubbing against the skin.
Tinea infections are superficial fungal infections caused by three species of fungi collectively known as dermatophytes. Commonly these infections are named for the body part affected, including tinea corporis (general skin), tinea cruris (groin), and tinea pedis (feet). Accurate diagnosis is necessary for effective treatment. Diagnosis is usually based on history and clinical appearance plus direct microscopy of a potassium hydroxide preparation. Culture or histologic examination is rarely required for diagnosis. Treatment requires attention to exacerbating factors such as skin moisture and choosing an appropriate antifungal agent. Topical therapy is generally successful unless the infection covers an extensive area or is resistant to initial therapy. In these cases, systemic therapy may be required. Tinea corporis and cruris infections are usually treated for two weeks, while tinea pedis is treated for four weeks with an azole or for one to two weeks with allylamine medication. Treatment should continue for at least one week after clinical clearing of infection. Newer medications require fewer applications and a shorter duration of use. The presence of inflammation may necessitate the use of an agent with inherent anti-inflammatory properties or the use of a combination antifungal/steroid agent. The latter agents should be used with caution because of their potential for causing atrophy and other steroid-associated complications.
Tinea infections are superficial fungal infections caused by the three genera of dermatophytes, Trichophyton, Microsporum and Epidermophyton.1 Commonly, the infections caused by these organisms are named for the sites involved. Tinea capitis refers to a dermatophyte infection of the head, tinea barbae affects the beard area, tinea corporis occurs on the body surface, tinea manuum is limited to the hands, tinea pedis to the feet, and tinea unguium infects the toenails. These names do not distinguish between species (for example, tinea capitis may be caused by Trichophyton or Microsporum genera).
With some pertinent exceptions, dermatomycosis is typically confined to the superficial keratinized tissue2 and, thus, can often be treated with topical antifungal medications.3 Because these agents do not penetrate hair or nails, tinea capitis, tinea barbae, and tinea unguium usually require systemic therapy. This article focuses on the diagnosis and treatment of tinea infections with topical medications. Because tinea capitis and tinea unguium are not typically amenable to topical therapy, they will not be discussed in this article.
It is important to note that nondermatophytes and yeasts may infect the sites mentioned above. For example, tinea unguium is only a subset of the onychomycoses, which include other types of fungal infections of the nails. Similarly, tinea corporis refers only to dermatophyte infection of the skin and not other superficial fungal infections such as candidiasis. Although tinea versicolor is commonly called a tinea, it is caused by the non-dermatophyte Malassezia furfur (also referred to as Pityrosporum orbiculare and Pityrosporum ovale) and is not a true tinea infection.4
Epidemiology
Because tinea infections are highly common, it is likely that the primary care physician will frequently treat affected patients. The estimated lifetime risk of acquiring dermatophytosis (tinea infection) is between 10 and 20 percent.5 In the United States, dermatophytosis is second only to acne as the most frequently reported skin disease.6 The majority of superficial fungal infections are tineas and, of those, the most common are tinea pedis, tinea corporis, and tinea cruris.7 Trichophyton rubrum is the most likely agent in these dermatomycoses. T. rubrum accounted for 76.2 percent of all superficial fungal diseases in a representative sample of the U.S. population.8 With the exception of tinea capitis (in which Trichophyton tonsurans was the most likely etiologic agent), T. rubrum was the most common dermatophyte isolated in all superficial fungal diseases studied.8
Clinical Manifestations
Clinical presentation is the most important clue to accurate diagnosis and treatment. The anthrophilic dermatophytes (commonly isolated from human infection) are the most common source of human dermatomycoses. These tend to evoke a limited host response and are less likely to be accompanied by severe inflammation or to clear spontaneously.9 Occasionally, severe inflammation is a component of dermatophytosis. This is particularly true in the case of tinea infections caused by zoophilic species (commonly isolated from animal infection). The most common of these is Microsporum canis.
TINEA CORPORIS
Tinea corporis refers to tinea anywhere on the body except the scalp, beard, feet, or hands. This lesion presents as an annular plaque with a slightly raised and often scaly, advancing border and is commonly known as ringworm. Each lesion may have one or several concentric rings with red papules or plaques in the center. As the lesion progresses, the center may clear, leaving post-inflammatory hypopigmentation or hyperpigmentation.
TINEA CRURIS
Because it affects the groin area, tinea cruris is also known as “jock itch.” It is characterized by red scaling plaques on the medial thighs and inguinal folds (Figure 1). The plaques are typically bilateral but usually spare the penis and scrotum, in contrast to candidiasis.10 Many people with tinea cruris have coincident tinea pedis, and it has been postulated that the tinea cruris is spread by hand from the tinea pedis
TINEA PEDIS
Tinea pedis, or athlete's foot, is the most common dermatophyte infection (Figure 2). Its etiology is closely tied to the use of occlusive footwear.12 Most commonly, tinea pedis presents with toe-web maceration.13 This fairly subtle presentation is contrasted with the moccasin distribution affecting the soles and lateral feet that is often seen in patients with T. rubrum infection (Figure 3). In the latter cases, the feet tend to be hyperkeratotic with scale and some erythema (Figure 4). In some cases of tinea pedis, a dermatophytid (also known as “id”) reaction may occur in which small vesicles or pustules appear at distant sites. The id reaction may be the only manifestation of an otherwise asymptomatic webspace maceration and usually resolves with treatment of the primary fungal infection.
Diagnosis
The clinical suspicion of dermatophytosis can be confirmed with diagnostic tests. Because other entities may mimic tinea infection, treatment should not be initiated on the basis of clinical presentation alone. In most cases, a simple potassium hydroxide (KOH) preparation with mycologic examination under a light microscope can confirm the presence of dermatophytes. Occasionally, culture media (including indicator media) or histologic examination may be useful in making the diagnosis. A Wood's light is not helpful in diagnosing tinea infections of the skin and is mainly used to identify fungal elements in hairs infected with Microsporum, which is a less common dermatophyte. The latter fluoresce green under Wood's light. This light may also be helpful in diagnosing erythrasma by its coral-red fluorescence when this condition is part of the differential diagnosis of a tinea skin condition.14
KOH Preparation for Direct Microscopy
The KOH preparation, a relatively simple diagnostic method with excellent positive predictive value, is used to visualize the hyphae that characterize dermatophytes. Additional confirmatory tests are rarely needed for the diagnosis of tinea.15 The KOH helps dissolve the epithelial tissue, allowing the hyphae to be seen on microscopy.
Because the organisms live in the superficial keratinized tissue, a sample of scale should be visualized under low or medium power. Scale is collected from the active border of a lesion. This is done by scraping the lesion with the edge of a rounded scalpel blade or the edge of a glass slide. The debris is collected on another slide and concentrated in the middle. If a vesicle is being examined, it may be unroofed, and that material can be examined.
The slide should be covered with a cover slip, and KOH (5 to 20 percent) should be added to the side of the cover slip, allowing capillary action to draw the KOH to the scaly sample. The preparation may be heated gently over a flame to highlight the fungal elements. If dimethyl sulfoxide has been added to the KOH, heating is not required.
During examination of the sample, the condenser of the microscope should be in the down position. The presence of septate hyphae confirms the diagnosis of tinea. The examiner should make sure that hyphae are being seen rather than the edge of an epithelial cell. It is helpful to visualize the hyphae crossing the path of more than one cell.
If clinical decisions are to be made based on microscopic examination, practitioners must comply with Clinical Laboratory Improvement Amendments (CLIA) regulations. Performing KOH examinations requires a Provider–Performed Microscopy (PPM) certificate. Obtaining the latter requires completion of paperwork and does not require a site inspection. The American Academy of Dermatology publishes a handbook with directions for compliance with the PPM regulation.16
Culture
Mycologic culture is rarely indicated in the diagnosis of tineas other than tinea unguium and tinea capitis. In some cases, even though clinical suspicion is high, diagnosis may be a challenge. Culture, while relatively simple to perform, requires one to four weeks to grow and clinical expertise to interpret the result. The most common medium used for isolating dermatophytes is Sabouraud's peptone-glucose agar.1 Various formulations of this medium are commercially available; some have additives that inhibit bacterial and nondermatophyte growth.17 A dermatophyte test medium (DTM) indicator can also be used. The latter has the added advantage of a phenol indicator that turns red in the alkaline environment produced by dermatophytes.18 Although DTM has the advantage of simplicity, it has a high rate of false-positive and false-negative results.1
All media require collection of an adequate sample of infected material. Scale may be collected in a manner similar to that used for the KOH preparation or with a cotton swab. The swab must first be moistened with sterile water and then rubbed vigorously over the active border of the lesion. This method is best used when the lesion is not scaly or when the use of a blade or slide is impractical.19 The physician performing the culture must comply with stricter CLIA regulations. Performing cultures requires a level of certification that necessitates a laboratory inspection.
HISTOPATHOLOGIC EVALUATION
When the diagnosis of a dermatophyte infection remains in question after office testing or failure to respond to treatment, biopsy specimens may be submitted to a pathologist for evaluation. Fungal staining with periodic acid–Schiff highlights fungal elements.17
Treatment
Most tinea corporis, cruris, and pedis infections can be treated with topical agents. Consideration should be given to systemic treatment when lesions covering a large body-surface area fail to clear with repeated treatment using different topical agents.3 In treating dermatophytosis, the physician must also address environmental factors that lead to or exacerbate tinea infection and select an appropriate topical therapy for the infection.
NONPHARMACOLOGIC MEASURES
Because fungi thrive in moist warm environments, patients should be encouraged to wear loose-fitting garments made of cotton or synthetic materials designed to wick moisture away from the surface. Socks should have similar properties. Areas likely to become infected should be dried completely before being covered with clothes. Patients should also be advised to avoid walking barefoot and sharing garments.
NONSPECIFIC AGENTS
A variety of traditional agents without specific antimicrobial function are still in use, including Whitfield's ointment and Castellani's (carbol fuchsin solution) paint. The efficacy of these preparations has not been well quantified.
ANTIFUNGAL AGENTS
The antifungal agents can be grouped by structure and mechanism of action. The two principal pharmacologic groups are the azoles and the allylamines. Polyenes (amphotericin B [Fungizone] and nystatin [Mycostatin]) are not discussed in this article because this group of compounds is not effective in the treatment of dermatophyte infections. Other agents that do not fit into the two main groupings are tolnaftate (Tinactin), haloprogin (Halotex), ciclopirox (Loprox) and butenafine (Mentax).3
Because there are few direct comparisons of individual topical agents, it can be difficult to justify the choice of one preparation over another. This choice is made less clear because several genera and species may produce the same clinical condition. When treating a dermatophyte infection, it is unlikely that the physician will know the infecting species. In general, tinea corporis and tinea cruris require once- to twice-daily treatment for two weeks. Tinea pedis may require treatment for four weeks.3 Treatment should continue for at least one week after symptoms have resolved.17 Some of the newer agents require only once-daily application and shorter courses of treatment, and are associated with lower relapse rates.
The application area should include normal skin about 2 cm beyond the affected area. Guidelines regarding the optimal vehicle of treatment (e.g., cream, ointment, gel, or lotion) are given in Table 1.20 Ideally, an agent will provide clinical and mycologic cure, symptomatic relief, and low relapse rate, along with ease of use. In addition to specific anti-fungal properties, some preparations have antibacterial and anti-inflammatory properties that may influence their efficacy. Combination therapy (antifungal plus steroid) can be considered when inflammation is an issue. Combination agents should not be used when the diagnosis is in question because that may lead to their overuse or to adverse effects.
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Clinical features of tinea corporis
Tinea corporis may be acute (sudden onset and rapid spread) or chronic (slow extension of a mild, barely inflamed, rash). It usually affects exposed areas but may also spread from other infected sites.
Acute tinea corporis presents as itchy inflamed red patches and may be pustular. The cause is often infection by an animal (zoophilic) fungus such as M canis.
Chronic tinea corporis tends to be most prominent in body folds (spreading from tinea cruris). T. rubrum is the most common cause. If widespread, the condition tends to be stubborn to treat and prone to recurrence. This is possibly due to a decreased natural skin resistance to fungi or because of reinfection from the environment.
The term ringworm refers to round or oval red scaly patches, often less red and scaly in the middle or healed in the middle. Sometimes one ring arises inside another older ring.
Kerion is an inflamed fungal abscess. It presents as a boggy mass studied with pustules, often with satellite spots. It is often confused with a large boil or carbuncle or a tumour such as a skin cancer.
Majocchi granuloma describes tinea corporis involving the hair follicles resulting in pustules and nodules.
Tinea corporis: When fungus affects the skin of the body, it often produces the round spots of classic ringworm. Sometimes, these spots have an "active" outer border as they slowly grow and advance. Sometimes, scaling, crusting, raised areas, or even blister-like lesions can appear, particularly in the active border. It is important to distinguish this rash from other even more common rashes, such as nummular eczema. This condition, and ot
rashes, such as nummular eczema. This condition, and others, may appear similar to ringworm, but they are not due to a fungal infection and require different treatment.
See Related Images
Tinea Corporis
Tinea cruris: Tinea of the groin ("jock itch") tends to have a reddish-brown color and extends from the folds of the groin down onto one or both thighs. Other conditions that can mimic tinea cruris include yeast infections, psoriasis, and intertrigo, a chafing rash that results from the skin rubbing against the skin.
Tinea infections are superficial fungal infections caused by three species of fungi collectively known as dermatophytes. Commonly these infections are named for the body part affected, including tinea corporis (general skin), tinea cruris (groin), and tinea pedis (feet). Accurate diagnosis is necessary for effective treatment. Diagnosis is usually based on history and clinical appearance plus direct microscopy of a potassium hydroxide preparation. Culture or histologic examination is rarely required for diagnosis. Treatment requires attention to exacerbating factors such as skin moisture and choosing an appropriate antifungal agent. Topical therapy is generally successful unless the infection covers an extensive area or is resistant to initial therapy. In these cases, systemic therapy may be required. Tinea corporis and cruris infections are usually treated for two weeks, while tinea pedis is treated for four weeks with an azole or for one to two weeks with allylamine medication. Treatment should continue for at least one week after clinical clearing of infection. Newer medications require fewer applications and a shorter duration of use. The presence of inflammation may necessitate the use of an agent with inherent anti-inflammatory properties or the use of a combination antifungal/steroid agent. The latter agents should be used with caution because of their potential for causing atrophy and other steroid-associated complications.
Tinea infections are superficial fungal infections caused by the three genera of dermatophytes, Trichophyton, Microsporum and Epidermophyton.1 Commonly, the infections caused by these organisms are named for the sites involved. Tinea capitis refers to a dermatophyte infection of the head, tinea barbae affects the beard area, tinea corporis occurs on the body surface, tinea manuum is limited to the hands, tinea pedis to the feet, and tinea unguium infects the toenails. These names do not distinguish between species (for example, tinea capitis may be caused by Trichophyton or Microsporum genera).
With some pertinent exceptions, dermatomycosis is typically confined to the superficial keratinized tissue2 and, thus, can often be treated with topical antifungal medications.3 Because these agents do not penetrate hair or nails, tinea capitis, tinea barbae, and tinea unguium usually require systemic therapy. This article focuses on the diagnosis and treatment of tinea infections with topical medications. Because tinea capitis and tinea unguium are not typically amenable to topical therapy, they will not be discussed in this article.
It is important to note that nondermatophytes and yeasts may infect the sites mentioned above. For example, tinea unguium is only a subset of the onychomycoses, which include other types of fungal infections of the nails. Similarly, tinea corporis refers only to dermatophyte infection of the skin and not other superficial fungal infections such as candidiasis. Although tinea versicolor is commonly called a tinea, it is caused by the non-dermatophyte Malassezia furfur (also referred to as Pityrosporum orbiculare and Pityrosporum ovale) and is not a true tinea infection.4
Epidemiology
Because tinea infections are highly common, it is likely that the primary care physician will frequently treat affected patients. The estimated lifetime risk of acquiring dermatophytosis (tinea infection) is between 10 and 20 percent.5 In the United States, dermatophytosis is second only to acne as the most frequently reported skin disease.6 The majority of superficial fungal infections are tineas and, of those, the most common are tinea pedis, tinea corporis, and tinea cruris.7 Trichophyton rubrum is the most likely agent in these dermatomycoses. T. rubrum accounted for 76.2 percent of all superficial fungal diseases in a representative sample of the U.S. population.8 With the exception of tinea capitis (in which Trichophyton tonsurans was the most likely etiologic agent), T. rubrum was the most common dermatophyte isolated in all superficial fungal diseases studied.8
Clinical Manifestations
Clinical presentation is the most important clue to accurate diagnosis and treatment. The anthrophilic dermatophytes (commonly isolated from human infection) are the most common source of human dermatomycoses. These tend to evoke a limited host response and are less likely to be accompanied by severe inflammation or to clear spontaneously.9 Occasionally, severe inflammation is a component of dermatophytosis. This is particularly true in the case of tinea infections caused by zoophilic species (commonly isolated from animal infection). The most common of these is Microsporum canis.
TINEA CORPORIS
Tinea corporis refers to tinea anywhere on the body except the scalp, beard, feet, or hands. This lesion presents as an annular plaque with a slightly raised and often scaly, advancing border and is commonly known as ringworm. Each lesion may have one or several concentric rings with red papules or plaques in the center. As the lesion progresses, the center may clear, leaving post-inflammatory hypopigmentation or hyperpigmentation.
TINEA CRURIS
Because it affects the groin area, tinea cruris is also known as “jock itch.” It is characterized by red scaling plaques on the medial thighs and inguinal folds (Figure 1). The plaques are typically bilateral but usually spare the penis and scrotum, in contrast to candidiasis.10 Many people with tinea cruris have coincident tinea pedis, and it has been postulated that the tinea cruris is spread by hand from the tinea pedis
TINEA PEDIS
Tinea pedis, or athlete's foot, is the most common dermatophyte infection (Figure 2). Its etiology is closely tied to the use of occlusive footwear.12 Most commonly, tinea pedis presents with toe-web maceration.13 This fairly subtle presentation is contrasted with the moccasin distribution affecting the soles and lateral feet that is often seen in patients with T. rubrum infection (Figure 3). In the latter cases, the feet tend to be hyperkeratotic with scale and some erythema (Figure 4). In some cases of tinea pedis, a dermatophytid (also known as “id”) reaction may occur in which small vesicles or pustules appear at distant sites. The id reaction may be the only manifestation of an otherwise asymptomatic webspace maceration and usually resolves with treatment of the primary fungal infection.
Diagnosis
The clinical suspicion of dermatophytosis can be confirmed with diagnostic tests. Because other entities may mimic tinea infection, treatment should not be initiated on the basis of clinical presentation alone. In most cases, a simple potassium hydroxide (KOH) preparation with mycologic examination under a light microscope can confirm the presence of dermatophytes. Occasionally, culture media (including indicator media) or histologic examination may be useful in making the diagnosis. A Wood's light is not helpful in diagnosing tinea infections of the skin and is mainly used to identify fungal elements in hairs infected with Microsporum, which is a less common dermatophyte. The latter fluoresce green under Wood's light. This light may also be helpful in diagnosing erythrasma by its coral-red fluorescence when this condition is part of the differential diagnosis of a tinea skin condition.14
KOH Preparation for Direct Microscopy
The KOH preparation, a relatively simple diagnostic method with excellent positive predictive value, is used to visualize the hyphae that characterize dermatophytes. Additional confirmatory tests are rarely needed for the diagnosis of tinea.15 The KOH helps dissolve the epithelial tissue, allowing the hyphae to be seen on microscopy.
Because the organisms live in the superficial keratinized tissue, a sample of scale should be visualized under low or medium power. Scale is collected from the active border of a lesion. This is done by scraping the lesion with the edge of a rounded scalpel blade or the edge of a glass slide. The debris is collected on another slide and concentrated in the middle. If a vesicle is being examined, it may be unroofed, and that material can be examined.
The slide should be covered with a cover slip, and KOH (5 to 20 percent) should be added to the side of the cover slip, allowing capillary action to draw the KOH to the scaly sample. The preparation may be heated gently over a flame to highlight the fungal elements. If dimethyl sulfoxide has been added to the KOH, heating is not required.
During examination of the sample, the condenser of the microscope should be in the down position. The presence of septate hyphae confirms the diagnosis of tinea. The examiner should make sure that hyphae are being seen rather than the edge of an epithelial cell. It is helpful to visualize the hyphae crossing the path of more than one cell.
If clinical decisions are to be made based on microscopic examination, practitioners must comply with Clinical Laboratory Improvement Amendments (CLIA) regulations. Performing KOH examinations requires a Provider–Performed Microscopy (PPM) certificate. Obtaining the latter requires completion of paperwork and does not require a site inspection. The American Academy of Dermatology publishes a handbook with directions for compliance with the PPM regulation.16
Culture
Mycologic culture is rarely indicated in the diagnosis of tineas other than tinea unguium and tinea capitis. In some cases, even though clinical suspicion is high, diagnosis may be a challenge. Culture, while relatively simple to perform, requires one to four weeks to grow and clinical expertise to interpret the result. The most common medium used for isolating dermatophytes is Sabouraud's peptone-glucose agar.1 Various formulations of this medium are commercially available; some have additives that inhibit bacterial and nondermatophyte growth.17 A dermatophyte test medium (DTM) indicator can also be used. The latter has the added advantage of a phenol indicator that turns red in the alkaline environment produced by dermatophytes.18 Although DTM has the advantage of simplicity, it has a high rate of false-positive and false-negative results.1
All media require collection of an adequate sample of infected material. Scale may be collected in a manner similar to that used for the KOH preparation or with a cotton swab. The swab must first be moistened with sterile water and then rubbed vigorously over the active border of the lesion. This method is best used when the lesion is not scaly or when the use of a blade or slide is impractical.19 The physician performing the culture must comply with stricter CLIA regulations. Performing cultures requires a level of certification that necessitates a laboratory inspection.
HISTOPATHOLOGIC EVALUATION
When the diagnosis of a dermatophyte infection remains in question after office testing or failure to respond to treatment, biopsy specimens may be submitted to a pathologist for evaluation. Fungal staining with periodic acid–Schiff highlights fungal elements.17
Treatment
Most tinea corporis, cruris, and pedis infections can be treated with topical agents. Consideration should be given to systemic treatment when lesions covering a large body-surface area fail to clear with repeated treatment using different topical agents.3 In treating dermatophytosis, the physician must also address environmental factors that lead to or exacerbate tinea infection and select an appropriate topical therapy for the infection.
NONPHARMACOLOGIC MEASURES
Because fungi thrive in moist warm environments, patients should be encouraged to wear loose-fitting garments made of cotton or synthetic materials designed to wick moisture away from the surface. Socks should have similar properties. Areas likely to become infected should be dried completely before being covered with clothes. Patients should also be advised to avoid walking barefoot and sharing garments.
NONSPECIFIC AGENTS
A variety of traditional agents without specific antimicrobial function are still in use, including Whitfield's ointment and Castellani's (carbol fuchsin solution) paint. The efficacy of these preparations has not been well quantified.
ANTIFUNGAL AGENTS
The antifungal agents can be grouped by structure and mechanism of action. The two principal pharmacologic groups are the azoles and the allylamines. Polyenes (amphotericin B [Fungizone] and nystatin [Mycostatin]) are not discussed in this article because this group of compounds is not effective in the treatment of dermatophyte infections. Other agents that do not fit into the two main groupings are tolnaftate (Tinactin), haloprogin (Halotex), ciclopirox (Loprox) and butenafine (Mentax).3
Because there are few direct comparisons of individual topical agents, it can be difficult to justify the choice of one preparation over another. This choice is made less clear because several genera and species may produce the same clinical condition. When treating a dermatophyte infection, it is unlikely that the physician will know the infecting species. In general, tinea corporis and tinea cruris require once- to twice-daily treatment for two weeks. Tinea pedis may require treatment for four weeks.3 Treatment should continue for at least one week after symptoms have resolved.17 Some of the newer agents require only once-daily application and shorter courses of treatment, and are associated with lower relapse rates.
The application area should include normal skin about 2 cm beyond the affected area. Guidelines regarding the optimal vehicle of treatment (e.g., cream, ointment, gel, or lotion) are given in Table 1.20 Ideally, an agent will provide clinical and mycologic cure, symptomatic relief, and low relapse rate, along with ease of use. In addition to specific anti-fungal properties, some preparations have antibacterial and anti-inflammatory properties that may influence their efficacy. Combination therapy (antifungal plus steroid) can be considered when inflammation is an issue. Combination agents should not be used when the diagnosis is in question because that may lead to their overuse or to adverse effects.