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

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

Next review: 06/10/2024

Clinical Guideline

CURRENT

ID: 1350

Approved By: Improving Antimicrobial Prescribing Group

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

Diagnostics
Empirical treatment
Directed therapy
Treatement failure
Prevention of recurrence/reinfection of onychomycosis
Footnotes

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.

EMPIRICAL TREATMENT

Empirical options for Tinea corporis, cruris, pedis.
	Recommended (1st line) treatment	2nd line treatment
Tinea pedis	Adults (≥18 years): Terbinafine 1% cream. Apply twice daily for 1 week. Child (<18 years): 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 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)

DIRECTED THERAPY⁷

	Adults (≥18 years)	Children (<18 years)
1st line	Tinea corporis, cruris or pedis
	Terbinafine 250mg tablet once daily^1,2 for up to 6 weeks	Terbinafine ^1,3 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 200mg once daily Duration: 7 days	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 200mg twice daily Duration: 7 days	Itraconazole ⁵ 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 50mg once daily Duration: 2-4 weeks (up to 6 weeks in tinea pedis)	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 250mg once daily^1,2 Duration: 4 weeks	Terbinafine ^1,3,4 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 50-100mg a day⁵ Duration: 4 weeks	Aged 1-17 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 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 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 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 ⁵ 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 ⁵ 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 ⁵ 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 450mg once weekly for 3 months for fingernails and 6 months for toenails	Contact Mycology
	Non-Dermatophyte infection
	Contact Mycology	Contact Mycology

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

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

FOOTNOTES

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
Use half normal terbinafine dose if eGFR <50 by using standard dose on alternate days
For children’s dose use quarter, half or full terbinafine 250mg tablet (no liquid preparation available)
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.
When itraconazole is used for more than 1 month liver function should be monitored.
Dermatophytes are fungi in the genera Trichophyton, Microsporum and Epidermophyton. Non-dermatophyte fungal genera that are relevant here include Fusarium, Acremonium, Neoscytalidium, Scopulariopsis, Onychocola.
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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