eMedicine Specialties > Dermatology > Fungal Infections

Tinea Cruris: Differential Diagnoses & Workup

Author: Michael Wiederkehr, MD, Consulting Staff, Livingston Dermatology Associates; Consulting Staff, Comprehensive Dermatology and Laser Center
Coauthor(s): Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Contributor Information and Disclosures

Updated: Dec 2, 2009

Differential Diagnoses

Acanthosis Nigricans
Folliculitis
Candidiasis, Cutaneous
Intertrigo
Contact Dermatitis, Allergic
Psoriasis, Plaque
Contact Dermatitis, Irritant
Seborrheic Dermatitis
Erythrasma
Familial Benign Pemphigus (Hailey-Hailey Disease)

Other Problems to Be Considered

Histiocytosis X7
Psoriasis inversus

Workup

Laboratory Studies

  • Microscopic examination of a potassium hydroxide (KOH) wet mount of scales is diagnostic in tinea cruris. The procedure for KOH wet mount is as follows:
    • Clean the area with 70% alcohol.
    • Collect scales from the margin of the lesion; use a scalpel or the edge of a glass slide for this purpose. Cover the collected scales with a cover slip; allow a drop of KOH (10-15% wt/vol) to run under the cover slip.
    • The keratin and debris should dissolve after a few minutes. The process can be hastened by heating the slide or by the addition of a keratolytic or dimethyl sulfoxide to the KOH formulation.
    • The addition of 1 drop of lactophenol cotton blue solution to the wet mount preparation heightens the contrast and aids in the diagnosis.
    • Negative results on KOH preparation do not exclude fungal infection.
    • Scale culture is useful for fungal identification but is a more specific, albeit less sensitive, diagnostic test than KOH wet mount.
  • Growth on Mycosel or Sabouraud agar plates usually is sufficient within 3-6 weeks to allow specific fungal identification.

Procedures

  • Negative KOH wet mount examination and cultures exclude other conditions in the differential diagnosis. If tinea cruris still is suggested, repeat the tests, several times if necessary.
  • Punch biopsy is diagnostic but has low sensitivity and low specificity. Using periodic acid-Schiff stain (fungal elements appear pink) or methenamine silver stains (fungal elements appear brown or black) on the processed tissue enhances the sensitivity of the biopsy procedure.
  • Wood lamp examination may be helpful to exclude erythrasma, which reveals coral red florescence of the affected area.
  • The images below demonstrate the appearance of tinea cruris using a variety of staining techniques.

  • Tinea cruris (hematoxylin and eosin stain).

    Tinea cruris (hematoxylin and eosin stain).

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    Tinea cruris (hematoxylin and eosin stain).

    Tinea cruris (hematoxylin and eosin stain).


  • Tinea cruris (periodic acid-Schiff stain, magnifi...

    Tinea cruris (periodic acid-Schiff stain, magnification X 20).

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    Tinea cruris (periodic acid-Schiff stain, magnifi...

    Tinea cruris (periodic acid-Schiff stain, magnification X 20).


  • Tinea cruris (Gomori methenamine-silver stain, ma...

    Tinea cruris (Gomori methenamine-silver stain, magnification X 20).

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    Tinea cruris (Gomori methenamine-silver stain, ma...

    Tinea cruris (Gomori methenamine-silver stain, magnification X 20).

Histologic Findings

Microscopic examination of hematoxylin and eosin–stained tissue sections reveals patterns of inflammation strongly suggestive of dermatophyte infection. The inflammation typically is perivascular; the epidermis exhibits spongiosis or a psoriasiform pattern of hyperplasia. Granulomatous dermatitis may accompany folliculitis.

Specific diagnostic findings include the presence of neutrophils in the cornified cell layer and the sandwich sign, in which fungal elements are sandwiched between 2 zones of differing structure within the cornified cell layer. The upper zone of the cornified cell layer has a typical basket-weave pattern of orthokeratosis, while the lower zone consists of more compact orthokeratosis and parakeratosis. The presence of spores and branching hyphae can be confirmed using periodic acid-Schiff or methenamine silver stains, but histologic examination provides no clues regarding the dermatophyte species.

More on Tinea Cruris

Overview: Tinea Cruris
Differential Diagnoses & Workup: Tinea Cruris
Treatment & Medication: Tinea Cruris
Follow-up: Tinea Cruris
Multimedia: Tinea Cruris
References
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References

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Further Reading

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Keywords

tinea cruris, tinea inguinalis, groin dermatophytosis, ringworm of the groin, gym itch, eczema marginatum, dhobie itch, jock itch, crotch rot,

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Contributor Information and Disclosures

Author

Michael Wiederkehr, MD, Consulting Staff, Livingston Dermatology Associates; Consulting Staff, Comprehensive Dermatology and Laser Center
Michael Wiederkehr, MD is a member of the following medical societies: Alpha Omega Alpha and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Gregory J Raugi, MD, PhD, Professor, Department of Internal Medicine, Division of Dermatology, University of Washington at Seattle; Chief, Dermatology Section, Primary and Specialty Care Service, Veterans Administration Medical Center of Seattle
Gregory J Raugi, MD, PhD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Lester F Libow, MD, Dermatopathologist, South Texas Dermatopathology Laboratory
Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Texas Medical Association
Disclosure: Nothing to disclose.

CME Editor

Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital
Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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