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Fungal skin infections

Acknowledgements

Developed in collaboration with the University of Auckland Goodfellow Unit in 2007.

Author: Hon A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand, 2009.  

Images have been sourced from the following:

  • Hon Assoc Prof Amanda Oakley
  • The Department of Dermatology, Health Waikato
  • Prof Raimo Suhonen (Finland)

 goodfellow unit logo

Tinea pedis

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Learning objectives

  • Identify and manage tinea pedis

Clinical features

Tinea pedis is most frequently due to Trichophyton rubrum, T. interdigitale (formerly known as T. mentagrophytes var. interdigitale) or Epidermophyton floccosum. Tinea pedis has various patterns and may affect one or both feet.

  • Chronic hyperkeratotic tinea refers to patchy fine dry scaling on the sole of the foot
  • Moccasin tinea is hyperkeratotic tinea affecting the skin of the entire sole, heel and sides of the foot
  • Athlete's foot refers to moist peeling irritable skin between the toes, most often in the cleft between the fourth and fifth toes. It is not always fungal in origin and is often associated with bacterial infection and irritant dermatitis
  • Clusters of blisters or pustules on the sides of the feet or insteps are confused with pompholyx eczema
  • Round dry patches on the top of the foot may appear similar to psoriasis

Tinea pedis is more common in adults than in children and frequently recurs after initially successful treatment with topical antifungal agents because of reinfection. Fungal spores can persist for months or years in bathrooms, changing rooms and around swimming pools.

Management

First confirm the diagnosis of tinea (scrapings and clippings) and look for other sites of infection (groin, nails). Consider alternative explanations including:

  • Bacterial infection (Staph – exudative; gram negative organisms – green; anaerobes – malodorous)
  • Dermatitis (intensely itchy and scratched, associated with rash elsewhere e.g. atopic flexural eczema; contact allergy corresponding with shoe material)
  • Psoriasis (hyperkeratotic, non-itchy, often signs elsewhere such as scalp, elbows, knees, flexures, nails)
  • Corns (pressure areas, painful)

Mild and localised tinea pedis can be managed with education and topical antifungal agents. Tell the patient to hot wash socks and stockings, and to wipe out shoes with formalin or meths solution. They should be advised that the condition is mildly contagious, and to wear sandals in changing rooms and not to share towels and footwear. It is likely to recur, so suggest they dry carefully and apply an antifungal powder after bathing long term.

There are numerous topical antifungal agents, of which terbinafine cream (Lamisil™) is probably the most effective. Fully funded options in New Zealand (April 2005) are:

  • Clotrimazole cream
  • Econazole cream
  • Miconazole cream

Whitfield's ointment is also effective (benzoic acid 6%, salicyclic acid 3% in emulsifying ointment).

Resistant and extensive culture-confirmed cases of tinea pedis will require oral therapy for one to four weeks, usually with terbinafine or itraconazole (the latter requires specialist approval for PHARMAC subsidy).

Confirmed tinea unguium may require oral antifungal agents for 3 months or longer if the infection is clinically significant and there are no contraindications to treatment. Cure rates depend on the severity of infection, the infecting organism, comorbidities and the age of the patient.

Activity

Find out how tinea manuum differs from tinea pedis.

Related information

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