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Tinea in Emergency Medicine

  • Author: Shari Andrews, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
 
Updated: Jan 11, 2016
 

Background

The dermatophytes are a group of fungi that invade and grow in the dead keratin of skin, hair, and nails. Dermatophytes are, by far, the most prevalent of the 3 major classes of superficial infections.[1] Less frequently, superficial skin infections are caused by nondermatophyte fungi (eg, Malassezia furfur in tinea versicolor) and Candida species.

Several species of dermatophytes commonly invade human keratin, and these belong to the Epidermophyton, Microsporum, and Trichophyton genera. They tend to grow outwards on skin, producing a ringlike pattern, hence the term "ringworm". They are very common and affect different parts of the body. Clinically, dermatophytosis infections, also known as tinea, are classified according to the body regions involved.

The type and severity of the host response is often related to the species and strain of the dermatophyte causing the infection. The dermatophytes are the only fungi that have evolved a dependency on human or animal infection for the survival and dissemination of their species. The infection may spread from person to person (anthropophilic), animal to person (zoophilic), or soil to person (geophilic). The most common of these organisms are Trichophyton rubrum, Trichophyton tonsurans, Trichophyton interdigitale and/or Trichophyton mentagrophytes, Microsporum canis, and Epidermophyton floccosum.

Table. Ecology of Common Human Dermatophyte Species. Table reprinted with permission from David Ellis, Bsc (Hons), MSc, PhD, FASM, FRCPA (Hon), Affiliate Associate Professor, The University of Adelaide (http://www.mycology.adelaide.edu.au/mycoses/cutaneous/dermatophytosis). (Open Table in a new window)

Species Natural habitat Incidence
E floccosum Humans Common
T rubrum Humans Very common
T interdigitale Humans Very common
T tonsurans Humans Common
Trichophyton violaceum Humans Less common
Trichophyton concentricum Humans Rare
Trichophyton schoenleinii Humans Rare
Trichophyton soudanense Humans Rare
Microsporum audouinii Humans Less common
Microsporum ferrugineum Humans Less common
T mentagrophytes Mice, rodents Common
Trichophyton equinum Horses Rare
Trichophyton erinacei Hedgehogs Rare
Trichophyton verrucosum Cattle Rare
M canis Cats Common
Microsporum gypseum Soil Common
Microsporum nanum Soil/pigs Rare
Microsporum cookei Soil Rare
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Pathophysiology

Dermatophytes are keratinophilic fungi and have the ability to invade keratinized tissue (eg, hair, nails, any area of the skin). They invade, infect, and persist in the stratum corneum of the epidermis and rarely penetrate below the surface of the epidermis and its appendages. Humid or moist skin provides a very favorable environment for the establishment of fungal infection. At a minimum, the skin responds to the irritation of the superficial infection by increased proliferation in the basal cell layer, which causes scaling and epidermal thickening. Clinically, tinea infections are classified according to the body region involved/infected, as follows:

  • Tinea capitis - Scalp (see the image below)
    Tinea capitis; gray patch ringworm. Gray patch ref Tinea capitis; gray patch ringworm. Gray patch refers to the scaling with lack of inflammation, as noted in this patient. Hairs in the involved areas assume a characteristic dull, grayish, discolored appearance and are broken and shorter.
  • Tinea manuum and tinea pedis - Palms, soles, and interdigital webs
  • Tinea corporis - Body (shown in the image below)
    Annular plaque (tinea corporis). Annular plaque (tinea corporis).
  • Tinea cruris - Groin
  • Tinea barbae - Beard area and neck (shown in the image below)
    Wax model of kerionlike tinea barbae. Courtesy of Wax model of kerionlike tinea barbae. Courtesy of the Museum of the Department of Dermatology, University of Medicine, Wroclaw, Poland.
  • Tinea faciale - Face
  • Tinea unguium ( onychomycosis) - Nail

Tinea capitis (caused by the species of genera Trichophyton and Microsporum) is the most common pediatric dermatophyte infection. The age predilection is believed to result from the lack of certain florae and fungistatic sebum in this age group. It usually takes 2 weeks to produce clinically visible changes. The natural course of tinea capitis is of a spontaneous cure at puberty, once sebum production begins. Hair invasion is divided into several types. The site of formation of spore-forming bodies classifies the species causing the invasion, as follows:

  • Ectothrix species: Conidia form on the exterior of the hair shaft; the cuticle is destroyed and involved areas fluoresce a green-yellow under a Wood lamp; this is caused by M canis, Microsporum distortum, M ferrugineum, M audouinii, as well as nonfluorescent T rubrum, T verrucosum, Trichophyton megninii, T mentagrophytes, M gypseum, and M nanum
  • Endothrix species: Conidia form within the hair shaft, and each is filled with hyphae and spores; the cuticle is not affected, and hairs do not fluoresce under a Wood lamp; this is caused by anthropophilic ( T rubrum, Trichophyton gourvilii, T tonsurans, T violaceum, Trichophyton yaoundei, T soudanense) organisms
  • Favus species: Hyphae arrange within and around the hair shaft; this is a rare and severe form resulting in favuslike crusts or scutula and hair loss with honey comb destruction pattern of the follicles; this is caused by T schoenleinii (see the image below)
    Tinea favosa of the scalp shows erythematous lesio Tinea favosa of the scalp shows erythematous lesions with pityroid scaling. Some hairs are short and brittle.
  • Kerion: Thick plaques and boggy skin that form often with bacterial infection superimposed; mainly caused by M canis [2] ; this pattern develops in such a manner that it is often believed to be a response to the dermatophyte (see the image below)
    Typical lesions of kerion celsi on the vertex scal Typical lesions of kerion celsi on the vertex scalp of a young Chinese boy. Note numerous bright yellow purulent areas on skin surface, surrounded by adjacent edematous, erythematous, alopecic areas. Culture from the lesion grew Trichophyton mentagrophytes. Courtesy of Skin Diseases in Chinese by Yau-Chin Lu, MD. Permission granted by Medicine Today Publishing Co, Taipei, Taiwan, 1981.

The specific etiologic agent is often associated with a specific region of infection. Further elaboration of the discussion below can be found in the tinea articles of the Medscape Reference Dermatology volume (Tinea Barbae, Tinea Capitis, Tinea Corporis, Tinea Cruris, Tinea Faciei, Tinea Nigra, Tinea Pedis, Tinea Versicolor).

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Epidemiology

Frequency

United States

A recent study found tinea capitis present in more than 30% of children at certain grade levels in some urban areas of the United States.[3]

High prevalence rates of tinea pedis and onychomycosis have been linked to increased urbanization, community showers, sports, and the use of occlusive footwear.[4] These factors are thought to contribute to the high prevalence of tinea pedis in certain occupational groups, including marathon runners (22-31% prevalence), miners (21-72.9% prevalence), and soldiers (16.4-58% prevalence). Several of these studies also found high rates of onychomycosis presenting with tinea pedis. Outbreaks of infections can occur in schools, households, and institutional settings.

International

Although dermatophytes are found throughout the world, the most prevalent strains and the most common sites of infection vary by region. Hot, humid climates and overcrowding predispose populations to skin diseases, including tinea infections. Developing countries have high rates of tinea capitis, while developed countries have high rates of tinea pedis and onychomycosis.

Low socioeconomic conditions are strongly linked to higher prevalence rates for skin infections, including tinea infections. A review of 18 studies representing large geographical areas determined that tinea capitis is present in up to 19.7% of the general population in developing countries.

Mortality/Morbidity

While mortality due to dermatophytes is very low, there is significant morbidity associated with these infections, particularly in the armed forces and active adults.

Cellulitis in the lower extremities, which causes a breach in the skin and allows the inoculation of opportunistic bacteria, is a frequent complication of interdigital fungal infection.

In patients with impaired cell-mediated immune function, atypical and locally aggressive presentations of dermatophyte infection may occur. These include extensive skin disease, subcutaneous abscesses, and dissemination.

Race

Fungal infection affects all races; however, the prevalence of organisms varies by country.

Sex

Both sexes are affected by fungal infection. Tinea cruris is much more common in males because of the male anatomy, which allows moisture to accumulate in the crural folds.

Age

In the United States, tinea pedis is the most common in adults and tinea capitis is the most common in children. Tinea corporis is present in all ages, although it is more frequent in adolescents and pregnant females.

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Contributor Information and Disclosures
Author

Shari Andrews, MD Attending Faculty, Department of Emergency Medicine, North Shore-Long Island Jewish Medical Center, Hofstra University School of Medicine

Shari Andrews, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Coauthor(s)

Mityanand Ramnarine, MD, FACEP Assistant Professor of Emergency Medicine, Program Director, Emergency/Internal Medicine/Critical Care, Hofstra Northwell School of Medicine at Hofstra University; Attending Physician, Department of Emergency Medicine, Long Island Jewish Medical Center

Mityanand Ramnarine, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American College of Physicians, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eddy S Lang, MDCM, CCFP(EM), CSPQ Associate Professor, Senior Researcher, Division of Emergency Medicine, Department of Family Medicine, University of Calgary Faculty of Medicine; Assistant Professor, Department of Family Medicine, McGill University Faculty of Medicine, Canada

Eddy S Lang, MDCM, CCFP(EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Canadian Association of Emergency Physicians

Disclosure: Nothing to disclose.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, South Carolina Medical Association, Columbia Medical Society, South Carolina College of Emergency Physicians, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Chief Editor for Medscape.

Additional Contributors

Theodore J Gaeta, DO, MPH, FACEP Clinical Associate Professor, Department of Emergency Medicine, Weill Cornell Medical College; Vice Chairman and Program Director of Emergency Medicine Residency Program, Department of Emergency Medicine, New York Methodist Hospital; Academic Chair, Adjunct Professor, Department of Emergency Medicine, St George's University School of Medicine

Theodore J Gaeta, DO, MPH, FACEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of Medicine, Society for Academic Emergency Medicine, Council of Emergency Medicine Residency Directors, Clerkship Directors in Emergency Medicine, Alliance for Clinical Education

Disclosure: Nothing to disclose.

Acknowledgements

Andrew C Miller, MD Fellow, Critical Care Medicine Department, National Institutes of Health; Fellow, Department of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center

Andrew C Miller, MD is a member of the following medical societies: American College of Emergency Physicians and Society of Critical Care Medicine (USA)

Disclosure: Nothing to disclose.

Rashid M Rashid, MD, PhD Medical Director, Department of Hair Transplants and Dermatology, Mosaic Clinic and Morzak Research Initiative

Rashid M Rashid, MD, PhD is a member of the following medical societies: American Academy of Dermatology, Council for Nail Disorders, Houston Dermatological Society, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Mark A Silverberg, MD, MMB, FACEP Assistant Professor, Associate Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate Medical Center

Mark A Silverberg, MD, MMB, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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Wax model of kerionlike tinea barbae. Courtesy of the Museum of the Department of Dermatology, University of Medicine, Wroclaw, Poland.
Tinea capitis; gray patch ringworm. Gray patch refers to the scaling with lack of inflammation, as noted in this patient. Hairs in the involved areas assume a characteristic dull, grayish, discolored appearance and are broken and shorter.
Typical lesions of kerion celsi on the vertex scalp of a young Chinese boy. Note numerous bright yellow purulent areas on skin surface, surrounded by adjacent edematous, erythematous, alopecic areas. Culture from the lesion grew Trichophyton mentagrophytes. Courtesy of Skin Diseases in Chinese by Yau-Chin Lu, MD. Permission granted by Medicine Today Publishing Co, Taipei, Taiwan, 1981.
Annular plaque (tinea corporis).
Tinea favosa of the scalp shows erythematous lesions with pityroid scaling. Some hairs are short and brittle.
Table. Ecology of Common Human Dermatophyte Species. Table reprinted with permission from David Ellis, Bsc (Hons), MSc, PhD, FASM, FRCPA (Hon), Affiliate Associate Professor, The University of Adelaide (http://www.mycology.adelaide.edu.au/mycoses/cutaneous/dermatophytosis).
Species Natural habitat Incidence
E floccosum Humans Common
T rubrum Humans Very common
T interdigitale Humans Very common
T tonsurans Humans Common
Trichophyton violaceum Humans Less common
Trichophyton concentricum Humans Rare
Trichophyton schoenleinii Humans Rare
Trichophyton soudanense Humans Rare
Microsporum audouinii Humans Less common
Microsporum ferrugineum Humans Less common
T mentagrophytes Mice, rodents Common
Trichophyton equinum Horses Rare
Trichophyton erinacei Hedgehogs Rare
Trichophyton verrucosum Cattle Rare
M canis Cats Common
Microsporum gypseum Soil Common
Microsporum nanum Soil/pigs Rare
Microsporum cookei Soil Rare
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