Tinea Tinea is a highly contagious fungal infection that can infect the skin. The most commonly affected areas include the feet, groin, scalp and beneath the breasts. Tinea can be spread by skin-to-skin contact or indirectly through contact with fungal cells, from skin and scalp lesions of people who have the infection, lesions of animals, contaminated floors, shower cubicles, benches, clothing and towels. Tinea is also known as ringworm, which is a misleading name since no worm is involved! Types of Tinea Tinea pedis—athlete’s foot or tinea of the foot— best treatment Lamisil/Tamsil Tinea versicolor—a type of tinea corporis with hypo-pigmentation of the skin (very commonly seen in our tropical pharmacies where tourists get a tan then notice the discolouration of their skin) - best treatment Pevaryl foaming—important to note that if the condition seems extensive, it has probably been there for a long time (years sometimes, if they live in a cool climate and don't get a tan that often to make it visible). Tinea cruris—jock itch or tinea of the groin— best treatment Lamisil/Tamsil Tinea barbae—tinea of the beard—best treatment Lamisil/Tamsil cream or gel Tinea capitis—tinea of the head or ringworm of the scalp—best treatment Pevaryl foaming/Nilstat shampoo Tinea corporis—ringworm of the body—best treatment terbinafine cream (Lamisil or Tamsil), 2nd line Pevaryl foaming wash (especially if quite extensive on the body) Onychomycosis—tinea of the toe or finger nails, known as tinea unguium— best treatment Loceryl , 2nd line Daktarin tincture Signs and symptoms          Itching and stinging Red, scaly rash that is shaped like a ring (annular) Red patches that are often redder around the outside with normal skin tone in the centre Moist, red areas with cracking, splitting and peeling in the toe web spaces Small fluid filled blisters that may ooze Yellow or white discoloration of the nails that may thicken and even crumble Bald spots on the scalp On the feet, between the toes looks like soggy white skin, which peels off, and it is really itchy. It can also be on the sole of the foot, or on top of it. It can start out looking like a blistery red dot, which quickly becomes a peeling area of the skin. The skin on the body can sometimes look healthy, with no scales, just lighter colour than the skin around it (referred to as tinea versicolour, shown on the previous page of module). It is also important to note that in this particular type of tinea, the skin is not necessarily “itchy” or “irritated.” Risk factors Tinea infection on any body area is more likely to develop if you:  Live or work in hot, humid climates  Handle animals who have the infection  Perspire a lot  Do not dry skin well after bathing  Are a child or spend time with children  Have diabetes  Have a weakened immune system Tinea on the feet is more likely to develop if you:  Wear synthetic socks that make feet sweat  Go barefoot in public showers and around pools  Wear tightly fitting shoes or plastic or rubber shoes (e.g. Gum boots)  Don’t wash and dry between the toes properly Groin tinea is more likely to develop if you:  Perspire a lot  Are overweight  Are a male Lifestyle advice               After washing, dry the skin thoroughly, particularly between the toes and within skin folds. Expose the skin to the air as much as possible. Wear cotton socks instead of synthetics. Use antiperspirant deodorants to control excessive perspiration (sweating). Wear thongs to swimming pools, locker rooms, gyms and other communal areas. Wash socks, underwear, towel and bathmats in hot water and detergent, or use a laundry product designed to prevent re-infection. While infected, avoid transferring the tinea to another body area. Use a separate, fresh towel to dry infected area and wash hands well after touching infected area. Check family animals for tinea. On animals it looks like a patch of skin with fur missing—consult your vet. Do not share towels, shoes, socks, underwear, hats or hair brushes and combs. Clean the base of the shower or bath with disinfectant, so you don’t re-infect yourself or others. Allow sweaty shoes to dry out before wearing again. Use antiperspirants to avoid excessive sweating Avoid using soap as it is alkaline (high pH) and will cause the skin to lose its natural acidity, allowing fungi to flourish. Using a soap free alternative (such as Pinetarsol) is a good alternative, as it will keep the skin acidic and relieves itching. Change out of wet swimmers/wetsuits as soon as possible, as the moisture can worsen fungal infections Treatment for “optimal care” Antifungal creams—these preparations are applied directly to the area and work by killing the fungus causing symptoms. Some common ingredients in these preparations and examples of their brand names are as below:  Clotrimazole S2 (e.g. Canesten, clonea, Pharmacy Action antifungal cream, Amcal anti-fungal cream)  Bifonazole S2 (e.g. Canesten once daily, mycospor)  Miconazole S2 (e.g. Resolve, Daktarin)  Terbinafine S2 (e.g. Lamisil and generic Tamsil) NB this is a very convenient product as it is applied only once daily for 7 days. This is because terbinafine is the only topical antifungal that kills the fungus (fungicidal); the rest are fungistatic - they stop it growing while the ingredient is used, then if use stops the fungus starts to grow again. This is why Terbinafine works so much better and faster, which is definitely what we want! Especially great if you don’t think you will apply other treatments twice or three times daily. Antifungal tinctures—These alcoholic liquids are designed for the treatment of fun- gal nail infections and penetrate the nail, drying to leave a protective coating. They provide effective treatment for fungal infections in the fingernails and toenails, but must be used until the infected nail is completely grown out (6-12 months!!!) and are only effective before the fungus reaches the nail bed, otherwise oral prescription medicines are required (consult your pharmacist). Some examples include:  Loceryl (contains amorolfine and is applied only once or twice weekly—very effective treatment and although seeming expensive, has enough volume to treat 1-2 nails for up to 12 months) **Most effective over-the-counter product**  Daktarin tincture (contains miconazole and is applied several times daily)  Canesten tincture (contains clotrimazole and is applied several times daily)  Canesten Fungal Nail Treatment Set (contains a urea cream for softening the nail and a bifonazole cream for treating the fungus in the nail bed after removal of the infected nail—course is much shorter than other treatments and is usually finished in 6-7 weeks). Antifungal/cortisone combination creams— hydrocortisone is often used in conjunction with antifungal creams initially, if the itching is severe and/or there is significant redness/inflammation. However, please note you should not use hydrocortisone alone on fungal infections because although it removes the redness, it allows the infection to spread rapidly and uncontrolled. Some common examples include:  Miconazole + hydrocortisone (Resolve plus—0.5% S2, 1% S3)  Clotrimazole + hydrocortisone (Hydrozole S3) Antifungal gels—similar to creams, these are applied directly to the skin for tinea infections; the difference being that these products are very cooling/soothing to the area and so sometimes are preferred.  Lamisil dermgel (contains terbinafine and should be applied once daily for 7 days) Antifungal once treatment solution—Lamisil Once is the only product that needs only one single application. When applied, Lamisil Once builds a film on the skin. After about three days, the film disappears but the active ingredient, terbinafine, remains in the skin where it works hard to fight off the infection. Antifungal powders—these powders are infused with antifungal agents and treat the condition similarly to creams/gels, but with more of a “drying effect” for those people who feel that moisture is contributing to their tinea infection (e.g. people wearing boots and socks all day at work or sweating profusely). They are also particularly useful to use alongside creams/gels by dusting the shoes and socks for extra protection against the fungus.  Daktarin Powder/spray powder—contains myconazole and should be applied twice daily every day until 2 weeks after symptoms subside **Most effective powder and should be used when possible before mycil and tinaderm**  Mycil Powder—contains the antifungal agent tolnaflate and the antibacterial agent chlorhexidine and should be applied 2-3 times daily every day until 2 weeks after symptoms subside  Tinaderm Powder/spray powder—also contains tolnaflate similar to Mycil Power above Treatment for “optimal care” continued..... Shampoos and washes—these are very useful for the treatment of tinea capitis and tinea corporis.  Pevaryl foaming wash—this treatment contains 3 sachets for treatment of tinea versicolor. One sachet is used every night for 3 nights, by wetting the skin then applying the contents of the sachet all over the body and letting it dry. You then sleep with the treatment on the skin and wash it off the next morning. This is then repeated in one month and three months. **Most effective treatment—poor compliance with others. You should purchase 3 boxes to ensure you don’t forget to do the 2 follow up treatment courses to clear the fungal infection from the deepest layers of skin**  Nizoral shampoo—available as a 1% or 2% - the shampoo is applied and left on for 10 minutes, then washed off. For tinea versicolour (a variety of tinea corporis mentioned earlier in the module), use daily for 10 days.  Selsun yellow—applied to the body for tinea versicolour and washed off once it dries on the skin (usually around 30 minutes) and this is repeated several times over a 2 week period.  Head and Shoulders Shampoo/Conditions—contains zinc which can help with itching on the scalp and the dry, flaky skin that may accompany tinea. Tea tree oil—Preliminary studies report tea tree oil to have activity against several fungal species. However, there is no conclusive evidence at this time and the use of this product should be “complementary” to other anti-fungal treatments listed above. At this stage, the recommended application for this product for tinea pedis (based on those used in studies) is: a 10% tea tree oil cream applied twice daily to the feet after they have been thoroughly washed and dried, or a 25 -50% tea tree oil solution applied twice daily to the affected area for 4 weeks. For a fungal nail infection (onychomycosis): 100% tea tree oil, applied to the affect area twice daily for 6 months. Canesten Hygiene Rinse—Normal washing, especially at cold temperatures, may not completely remove the bacteria or fungal spores. This often leads to the bacteria and fungal spores being passed on to other garments, and ultimately re-infection or cross infection. Canesten Hygiene Rinse can break the cycle of re-infection and cross infection by helping to eliminate fungal spores that can remain in your clean washing increasing the risk of re-infection. Thongs—if you are travelling and believe you may have picked up tinea pedis from public showers along the way, you could consider getting some rubber thongs! Antiperspirants—you may be able to prevent the growth of some fungus by keeping the skin as dry as possible and avoiding excess perspiration.