Tinea corporis, tinea cruris ( groin ringworm ), Tinea capitis ( scalp ringworm ), onychomycosis ( fungal nail disease) and tinea pedis ( athletes's foot ) in adults and children in secondary care - Guideline for the treatment of

Publication: 01/04/2008  --
Last review: 06/10/2021  
Next review: 06/10/2024  
Clinical Guideline
CURRENT 
ID: 1350 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

GUIDELINE FOR THE TREATMENT OF TINEA CORPORIS, TINEA CRURIS (GROIN RINGWORM), TINEA CAPITIS (SCALP RINGWORM), ONYCHOMYCOSIS (FUNGAL NAIL DISEASE) AND TINEA PEDIS (ATHLETE'S FOOT) IN ADULTS AND CHILDREN IN SECONDARY CARE

This guideline covers patients who are under the care of Leeds Teaching Hospitals Trust.
Primary Care have separate guidelines for Fungal nail infections and a pathway for Tinea capitis.

DIAGNOSTICS

Uncomplicated infection

No diagnostics usually required. Treat empirically.

For patients with a presumed diagnosis of tinea corporis, cruris or pedis which is complex, severe, extensive or unresponsive to topical agents, and for all patients with tinea capitis and onychomycosis, the following diagnostic tests should be taken to confirm diagnosis:

Tinea corporis, cruris or pedis

Skin scraping from active edge of a skin lesion using the edge of a rounded scalpel blade or glass slide

Tinea capitis

Scalp skin scale, hair plucks, scalp brushings using sterile brushes; kerion: (deep inflammation / abscess caused by fungus) swab or biopsy

Nail disease

Scrapings from any discoloured, dystrophic or brittle parts of the most proximal involved part of the nail.  The sample should include nail and crumbly material. In suspected superficial white onychomycosis, a sample may be collected using a curette.

  • For all samples, specimens should be collected into a Dermapak or similar black card packet.
  • If these are not available, then a sterile plain plastic universal container may be used, but there is a greater risk of overgrowth of contaminants.
  • Send to mycology for microscopy and culture.
  • A positive microscopy or a positive culture of skin scrapings is recommended before starting oral treatment.
  • If test results are negative but the clinical appearance is very suggestive of fungal infection, repeat the sample and start treatment.

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EMPIRICAL TREATMENT

Empirical options for Tinea corporis, cruris, pedis. 
 

Recommended (1st line) treatment

2nd line treatment

Tinea pedis

Adults (≥18 years):
Terbinafine electronic Medicines Compendium information on Terbinafine 1% cream. Apply twice daily for 1 week.

Child (<18 years):
Terbinafine electronic Medicines Compendium information on Terbinafine 1% cream apply twice daily for 1 week

Adult & Child: Clotrimazole cream 1% apply twice a day for at least 4 weeks

Other infections

Terbinafine electronic Medicines Compendium information on Terbinafine 1% cream Apply twice a day for 1-2 weeks 

For skin inflammation in children and for flexural/facial sites in adults, consider adding mildly potent topical corticosteroid cream (e.g. hydrocortisone 1%) for max 7 days
Or for body/scalp sites in adults, consider adding potent topical steroid (e.g. betamethasone 0.1% valerate)

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DIRECTED THERAPY7

 

Adults (≥18 years)

Children (<18 years)

1st line

Tinea corporis, cruris or pedis

Terbinafine electronic Medicines Compendium information on Terbinafine 250mg tablet once daily1,2 for up to 6 weeks

Terbinafine electronic Medicines Compendium information on Terbinafine1,3
10-19kg: 62.5mg  once daily
20-39kg: 125mg once daily
≥40kg: 250mg once daily

Duration:
Pedis 2-6 weeks 
Corporis 4 weeks
Cruris 2-4 weeks

2nd line

Tinea corporis or cruris

Itraconazole electronic Medicines Compendium information on Itraconazole 200mg once daily
Duration: 7 days

 

Itraconazole electronic Medicines Compendium information on Itraconazole

  • 1 month-11 years:

3-5mg/kg once daily (max per dose 100mg)
Duration: 15 days

  • 12-17 years:

200mg once daily
Duration: 7 days

For children <1 month consult microbiology

Tinea pedis or manuum

Itraconazole electronic Medicines Compendium information on Itraconazole 200mg twice daily
Duration: 7 days

Itraconazole electronic Medicines Compendium information on Itraconazole5

  • 1 month-11 years: 3-5mg/kg once daily (max per dose 100mg)

Duration: 30 days

  • 12-17yrs 200mg twice daily

Duration: 7 days

For children <1month consult microbiology

3rd line

Tinea corporis, curis, or pedis

Fluconazole electronic Medicines Compendium information on Fluconazole  50mg once daily
Duration: 2-4 weeks (up to 6 weeks in tinea pedis)

Fluconazole electronic Medicines Compendium information on Fluconazole 3mg/kg once daily (max per dose 50mg)
Duration: 2-4 weeks (up to 6 weeks in tinea pedis)

Tinea capitis

Please send in repeat scraping samples following treatment, to ensure clearance of the organism, otherwise repeated infections can occur.
Antifungal shampoos have a role in reducing spread of the fungus but are rarely curative.
Look out for spread from animals or cases in other children or adults.
Children do not need to be kept out of school or childcare settings

1st line

Trichophyton infections

Terbinafine electronic Medicines Compendium information on Terbinafine
250mg once daily1,2
Duration: 4 weeks

Terbinafine electronic Medicines Compendium information on Terbinafine1,3,4

  • 10-19kg 62.5mg once daily
  • 20-39kg 125mg once daily
  • ≥40kg 250mg once daily

Duration: 4 weeks

Microsporum infections

 

Griseofulvin
1gram daily or in divided doses
Duration: 6-8 weeks

Griseofulvin
From 1 month

  • weighing <50kg: 15-20mg/kg in single or divided doses (max per dose 1g)
  • weighing >50kg 1g daily (in single or divided doses)

Duration: 6-8 weeks

2nd line

Any Cause

Itraconazole electronic Medicines Compendium information on Itraconazole 50-100mg a day5
Duration: 4 weeks

Aged 1-17
Itraconazole electronic Medicines Compendium information on Itraconazole 5mg/kg daily (max 200mg per dose)5
Duration: 2-4 weeks

Age <1 year - discuss with microbiology

Onychomycosis

Combine with Amorolfine 5% lacquer in distal nail disease and for treatment resistant cases.
Mechanically remove fungal reservoir by filing down the nail or dissolving the nail plate with 30-40% urea paste.
Send repeat samples to mycology if no clinical response.
Itraconazole pulse regime less effective than continuous treatment.

1st line

Dermatophyte infection6.

Terbinafine electronic Medicines Compendium information on Terbinafine 250mg once daily2
Duration:

  • at least for 6 weeks for fingernails
  • 3-4 months for toe nails. Longer courses may be required if there is slow nail growth.

Terbinafine electronic Medicines Compendium information on Terbinafine
10-19kg: 62.5mg  once daily
20-39kg: 125mg once daily
≥40kg: 250mg once daily
Duration:

  • at least for 6 weeks for fingernails
  • 3-4 months for toe nails. Longer courses may be required if there is slow nail growth.

Non-Dermatophyte infection6

Itraconazole electronic Medicines Compendium information on Itraconazole 200mg daily5
Duration: 3 months
or
200mg twice daily for 7days repeated monthly
Duration: 2 months for finger nails and 3 months for toenails.

Itraconazole electronic Medicines Compendium information on Itraconazole5
1-11 years:
5mg/kg daily (max per dose 200mg) for 7 days repeated monthly for 2 months for finger nails and 3 months for toenails
12-17 years:
200mg once daily for 3 months
Or
200mg twice daily for 7 days, repeated monthly for 2 months for fingernails and 3 months for toenails

2nd line

Dermatophyte infection

 

Itraconazole electronic Medicines Compendium information on Itraconazole5 200mg daily for 3 months or 200mg twice daily for 7days repeated monthly for 2 months for finger nails and 3 months for toenails

Itraconazole electronic Medicines Compendium information on Itraconazole5
1-11years:
5mg/kg daily (max per dose 200mg) for 7 days repeated monthly for 2 months for finger nails and 3 months for toenails
12-17years:
200mg once daily for 3 months
Or
200mg twice daily for 7 days, repeated monthly for 2 months for fingernails and 3 months for toenails.

Non-Dermatophyte infection

Contact Mycology

Contact Mycology

3rd line

Dermatophyte infection   

Fluconazole electronic Medicines Compendium information on Fluconazole 450mg once weekly for 3 months for fingernails and 6 months for toenails

Contact Mycology

Non-Dermatophyte infection

 

Contact Mycology

Contact Mycology

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TREATMENT FAILURE

  • Review diagnosis, were correct investigations carried out?
  • Repeat culture and discuss sensitivity testing with mycology
  • For patients where disease is extensive or severe, consider dermatology referral

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PREVENTION OF RECURRENCE / RE-INFECTION OF ONYCHOMYCOSIS

  • 60 degree wash of socks
  • Naphthalene moth balls placed in shoes for 3 days and kept in plastic bag, then aired
  • Prevent/treat Tinea pedis: keep feet dry
    • Regular use of anti-mycotic foot powder

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FOOTNOTES

  1. Very rarely Terbinafine causes hepatotoxicity. Patients should be counselled on this risk before starting treatment. Periodic monitoring of LFTs (at baseline and after 4-6 weeks of treatment) is recommended
  2. Use half normal terbinafine dose if eGFR <50 by using standard dose on alternate days
  3. For children’s dose use quarter, half or full terbinafine 250mg tablet (no liquid preparation available)
  4. Although griseofulvin is the only licenced antifungal for tinea capitis for children in the UK, terbinafine and itraconazole are effective and safe and their use is recommended in the Paediatric BNF.
  5. When itraconazole is used for more than 1 month liver function should be monitored.
  6. Dermatophytes are fungi in the genera Trichophyton, Microsporum and Epidermophyton. Non-dermatophyte fungal genera that are relevant here include Fusarium, Acremonium, Neoscytalidium, Scopulariopsis, Onychocola.
  7. Ensure that information in clinic letters and EDANs about treatment courses and further sampling are clear for GPs.

Provenance

Record: 1350
Objective:
Clinical condition:

Tinea corporis, tinea cruris ( groin ringworm ), Tinea capitis ( scalp ringworm ), onychomycosis ( fungal nail disease) and tinea pedis ( athletes's foot )

Target patient group: Adult and children in the care of LTHT
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Pharmacists
Adapted from:

Evidence base

  • BNF Online, available via https://bnf.nice.org.uk/, accessed 28/7/20
  • NICE Clinical Knowledge Summary: Fungal skin infection- foot. Available via https://cks.nice.org.uk/fungal-skin-infection-foot#!prescribingInfoSub, Accessed 6/8/20
  • BNF Children online. Available via https://bnfc.nice.org.uk/  , accessed 28/7/20
  • NICE Clinical Knowledge Summary: Fungal skin infection- body & groin. Available via https://cks.nice.org.uk/fungal-skin-infection-body-and-groin , accessed 28/7/20
  • Fuller et al 2014, BAD Tinea Captis guidelines BJD 171:454-463.
  • NICE Clinical Knowledge Summary: Onychomycosis, Available via https://cks.nice.org.uk/fungal-nail-infection, Accessed 4/8/20
  • Ameen et al 2014 , BAD Onchyomycosis guidelines BJD 171:937-958

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 2.0

Related information

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