tinea: head to toe

Tinea: Head to ToeA dermatophyte tour of human skin

Renee Howard, MDAssistant Clinical Professor of

Dermatology, UCSF

Tour de Tinea Head to Toe

CapitisFacieiCorporisPedisUnguim (onychomycosis)

Tips for Tinea Head to Toe

DiagnosticTherapeutic

Non-inflammatory Tinea CapitisSeborrheic dermatitis: thick greasy scale frontal scalp & vertexAtopic dermatitis: fine scale all over; itchyPsoriasis: thick silvery-white scale sticks to hair– Williams JV et al Pediatrics

2005;115:e1-6.

Psoriasis

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Psoriasis



Tinea?



No, Langerhans cell histiocytosis



Inflammatory Tinea Capitis

DDx Inflammatory Tinea Capitis

Folliculitis: just pustules with no scaleDiscoid lupus: scarring “skating rink”alopecia with scale in hair follicle openingsAlopecia areata: smooth pink-orange discrete patches with no scale

Tinea Capitis Diagnostic Tip

See the scaleDo fungal culture!

Tinea Capitis Rx

First line still Griseofulvin 20-25mg/kg micronized for 6-8 weeks with fatty meal.Second line agents for griseofulvin failure or intolerance are not FDA approved– Lamisil 6 mg/kg/day– Itraconazole 5 mg/kg/day– Fluconazole 6 mg/kg/day

• Sethi A, Antaya R. Pediatr Infect Dis J 2006;25:643

Tinea Capitis Treatment Tip

Must use systemic therapy; topical is adjunctive onlyIf patient fails griseofulvin– Check compliance– Treat family members with antifungal

shampoo; look for school contacts– If inflammatory check history carefully for

animal source (rabbits, guinea pigs, horses, puppies, kittens)



Rash for a month; failed topical tolnaftate



Tinea facei Dx TipCan appear seborrheicdermatitis-like– Gorani et al Pediatr

Dermatol 2005;22:243.

Look for tinea capitis or corporisLook for animal contact





Tinea facei?

Tinea corporis? Neonatal lupus erythematosus

Granuloma annulare Annular urticaria Tinea Corporis Diagnostic Tips

All that is annular is not fungalIf it scales, scrape it!If KOH negative, do fungal cultureRemember pustular, vesicular and crusted plaques can also be tinea



Leismaniasis? Leishmaniasis? I think not

17 year old just back from summer trip to Costa RicaItchy rash on feet came up the last few days there“OMG I have leishmaniasis,” says she in a panic

Tinea Corporis Diagnostic TipScrape edge for KOHDo fungal culture if KOH negative or in an outbreak e.g. tinea gladiatorumUse moist cotton swab or toothbrush and rub scaliest area, usually borderSwab media & send

Tinea Corporis Treatment TipTopicals: terbinafine, clotrimazole, miconazole, butenifine cream BID for 2 weeksAvoid combination topical steroid/antifungal creams– Alston et al Pediatrics 2003;111:201

Nystatin for candida; not effective for dermatophyteIf fails topical, use oral griseofulvin15-20mg/kg for 3 weeks

The many feet of tinea pedis







Tinea Pedis Diagnostic Tip

Do fungal culture if KOH negative or fails antifungal topical therapyIf negative, consider inflammatory dermatoses such as psoriasis, atopic dermatitis, allergic contact dermatitis and juvenile plantar dermatosis.

Juvenile Plantar Dermatosis



Tinea Pedis Therapeutic TipAvoid potent topical steroid/antifungal combinations– Greenberg et al Pediatr Dermatol 2002;19:78.

If treating chronic inflammatory dermatosis such as psoriasis with topical steroids, monitor for fungal superinfection and addseparate antifungal cream to regimenAddress hyperhidrosis

Onychomycosis: distal subungual⌃



Onychomycosis Diagnostic Tip

Scrape under nail with 15 blade or curetteKOH and fungal culture of scaleClip affected distal nail plate and send to pathology for special stains



Onychomycosis Rx TipSystemic terbinafine 6 mg/kg/day for 3 monthsPulse itraconazole 5 mg/kg one week of every month for 3 monthsFluconazole 3-6 mg/kb once weekly for 5 mos.Do baseline LFT’s & repeat after 1 month.All off-label for children <18 years– Sethi A, Antaya R. Pediatr Infect Dis J 2006;25:643

Onychomycosis in a 10 year old



Onychomycosis Rx Tip

Topical therapy worth a try in young children because their nail plates are thinnerCombine keratolytic with antifungal cream– 40% urea cream and terbinafine cream

Better topical treatments on the horizonUsually are treating parents…

Tour de Tinea



tinea: head to toe

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