Tinea corporis, tinea manuum ( ringworm ) or tinea pedis ( athlete's foot ) - Guideline for the treatment of

Publication: 01/04/2008  
Last review: 22/02/2017  
Next review: 22/02/2020  
Clinical Guideline
CURRENT 
ID: 1350 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

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 manuum (ringworm) or tinea pedis (athlete's foot)

Clinical Diagnosis

Athlete's foot commonly causes skin scaling, maceration, and fissuring. It mainly affects the interdigital web space between the fourth and fifth toes. It may spread to the skin of the plantar surface of the foot, the dorsum of the foot, and between the other toes.
Moccasin-type (dry-type) athlete's foot is less common, and presents as diffuse erythema and dry, scaling (hyperkeratosis) over the sole, often extending to the lateral borders of the foot.  A more unusual inflammatory variant of athlete's foot presents with vesicles or bullous lesions on the instep of one foot or both feet.
Ringworm of the trunk or limbs typically begins as single or multiple scaly, circular, erythematous plaques with a slightly raised, advancing border. These may show a variable degree of inflammation, and have papules, vesicles or pustules at their border. As the lesion progresses, the central inflammation may clear and the lesion may appear as a ring or as several concentric rings. Sometimes several rings develop and merge.

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Investigation

Samples for microscopy and culture can help to confirm the diagnosis and identify the causative micro-organism in fungal skin infections. Microscopy provides the most rapid means of diagnosis, and results are generally available after 1-2 days. Culture is more sensitive than microscopy, but results may take up to 4 weeks to become available. Dermatophyte infections may be diagnosed on the basis of positive microscopy, culture of a significant organism, or both.
There is a significant (but unquantified) false-negative rate for both microscopy and culture. A negative result therefore does not exclude fungal infection.
Samples should be collected by scraping the active edge of a skin lesion using the edge of a rounded scalpel blade or glass slide. The sample should be as large as the lesion allows.

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Treatment
  • Topical antifungals are recommended for first-line treatment:
    • First Line -  cream applied twice a day for one week.
    • If allergy or intolerance to Terbinafine electronic Medicines Compendium information on Terbinafine use Clotrimazole electronic Medicines Compendium information on Clotrimazole cream 1% applied twice a day for 2-4 weeks2. Evidence level C
    • For skin that is particularly inflamed, consider prescribing a mildly potent topical corticosteroid (for example hydrocortisone 1%), to be used in addition to the topical antifungal, for a maximum of seven days.
    • Do not give a corticosteroid preparation alone as there is potential for fungal proliferation, worsening of symptoms, and the development of tinea incognito (an atypical skin appearance due to local corticosteroid application, which may mask true dermatophyte infection)
  • Oral treatment is recommended if there is severe and/or extensive disease, or if topical treatment has failed. A positive microscopy or a positive culture of skin scrapings is recommended before starting treatment. If test results are negative but the clinical appearance is very suggestive of fungal infection, repeat the sample and start treatment:
    • First line - Terbinafine electronic Medicines Compendium information on Terbinafine 250mg daily for up to six weeks.
    • If allergy or intolerance to Terbinafine electronic Medicines Compendium information on Terbinafine use Itraconazole electronic Medicines Compendium information on Itraconazole 200mg daily (tinea corporis) or twice daily (for tinea pedis/manuum) for 7 days. Evidence level C
    • Very rarely Terbinafine electronic Medicines Compendium information on Terbinafine causes hepatotoxicity. Patients should be counseled on this risk before starting treatment Evidence level C
    •  Fluconazole electronic Medicines Compendium information on Fluconazole may be used as an alternative to Terbinafine electronic Medicines Compendium information on Terbinafine or Itraconazole electronic Medicines Compendium information on Itraconazole 1. In patients with liver disease Fluconazole electronic Medicines Compendium information on Fluconazole should be given at 50mg daily for 2-4 weeks (max 6 weeks in tinea pedis) 2 Evidence level C
  • Dermatological referral is recommended in the following situations:
    • Diagnosis is uncertain
    • There is no response to primary management
    • There is severe and/or extensive infection
    • There are recurrent infections
    • The patient is immunocompromised

Evidence Level: C

Recommendations:

  • A clinical diagnosis of uncomplicated athlete's foot, mild groin infection or mild skin ringworm can be treated empirically without the need for mycological sampling2. Evidence level C
  • Samples for microscopy and culture should be taken where the diagnosis is uncertain, in severe infections (e.g. moccasin-type athlete's foot), in infections refractory to initial treatment, in infections of the hands or where there has been animal contact (to exclude animal ringworm) or when oral treatment is being considered2. Evidence level C
  • Negative culture & microscopy results do not exclude fungal infection. Treatment should be started on the basis of a clinical diagnosis if signs are suggestive and not explained by another diagnosis2. Evidence level C
  • Samples should be submitted to the laboratory in a folded square of paper or commercial pack designed for this purpose (e.g. Dermapak - supplied by Microbiology). Evidence level C

Treatments not recommended:

  • Oral fluconazole: although there is evidence that fluconazole is effective for treating fungal infections of the body and groin, there is more evidence to support the use of griseofulvin, terbinafine, and itraconazole.
  • Oral ketoconazole — the European Medicines Agency’s (EMA) Committee for Medicinal Products for Human Use (CHMP) has suspended the marketing authorisation for oral ketoconazole, and it should not be prescribed for the treatment of fungal infections [MHRA, 2013b]. The decision was made because some people taking these medicines may be at an increased risk of liver damage and the risk outweighs the benefits. Alternative antifungal treatments are available.

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Provenance

Record: 1350
Objective:

To provide evidence-based recommendations for appropriate investigation of tinea corporis & tinea pedis in adults.
To provide evidence-based recommendations for appropriate empirical or directed antimicrobial therapy of tinea corporis & tinea pedis in adults.
To recommend appropriate dose, route of administration and duration of antimicrobial agents.
To advise in the event of antimicrobial allergy.
To set-out criteria for referral to specialists.

Clinical condition:

Tinea corporis, tinea manuum (ringworm) or tinea pedis (athlete’s foot).

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

Adapted from NHS Clinical Knowledge Summary


Evidence base

  • Bell-Syer SEM, Hart R, Crawford F, Torgerson DJ, Tyrrell W, Russell I. Oral treatments for fungal infections of the skin of the foot. Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD003584. DOI: 10.1002/14651858.CD003584
  • NHS Clinical Knowledge Summary at http://cks.nice.org.uk/fungal-skin-infection-body-and-groin#!scenario (accessed 1st February 2016).

Evidence levels:
A.  Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B.  Robust experimental or observational studies
C.  Expert consensus.

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

Not supplied

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