Tinea Gladiatorum (Capitis, Corporis, Cruris, Pedis)

By admin Last updated Nov 13, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Philipp Underwood

Basics

Description

This group of topical fungal infections commonly affects athletes, particularly swimmers, soccer players, and wrestlers. They are classified by site of infection: Tinea capitis involves the scalp and hairline; tinea corporis involves the trunk, face, or extremities; tinea cruris involves inguinal folds; tinea pedis involves the feet. Infection is caused by a dermatophyte, most commonly from the Trichophyton, Epidermophyton, and Microsporum species. This is typically an infection of the stratum corneum that results in thickening of the epidermis and scale formation. Majocchi's granuloma is an infection of the dermis, usually as a result of fungal entry through hair follicles.
Synonym(s): Ring worm (tinea corporis); Jock itch (tinea cruris); Athlete's foot (tinea pedis); Tinea gladiatorum (most commonly Trichophyton tonsurans and T. rubrum)

Epidemiology

Varies from 25–35% of all wrestlers during any given season
10–20% lifetime risk for nonathletes
More common in African Americans and Asians
2–20 days from inoculation to subsequent development of identifiable skin lesions

Risk Factors

Spread by direct contact with a pet or human carrier
Fomite transmission may occur from wrestling mats, pieces of athletic equipment, shower floor, etc.

Diagnosis

Scraping of the leading edge of the skin plaque and preparation with potassium hydroxide (KOH) 5–20% can be examined under the microscope. This will reveal hyphae and pseudohyphae, which are diagnostic of tinea infection. For Tinea capitis, spores are visualized by KOH preparation of the hair shaft. Microsporum canis may fluoresce bright green under a Wood's lamp. Fungal culture using Sabouraud dextrose agar also can be used, but in athletes, use is limited by time and expense involved. Most tinea infections do not fluoresce under Wood's light examination.

History

Determine when and where lesions appeared and exposure history.
Other wrestlers on the team are infected

Physical Exam

Lesions present with erythema, pruritus, and scaling.
Tinea capitis: 2 distinct types:
- Black dot: Most common form seen in U.S. and most commonly caused by T. tonsurans. Usually children and elderly. Erythematous, scaling patch that enlarges slowly. Hairs break off flush with scalp causing alopecia, which may be permanent.
- Gray patch: Uncommon in U.S. and caused by Microsporum canis contracted usually from dogs and cats. Erythematous, scaling patch that enlarges slowly. Hairs break off 1–2 mm above the scalp.
Tinea corporis: Circular, erythematous, scaling plaques with central clearing on trunk, face, and extremities
Tinea cruris: Pruritic, scaling, erythematous patches in inguinal folds and/or medial thighs. If lesions present on penis or scrotum, consider candidal infection rather than tinea.
Tinea pedis: Pruritic, erythematous scaly skin along the sole of foot. Cracking and maceration of the web spaces also may be present. Bullous form will have bullae or vesicles filled with clear fluid.

Differential Diagnosis

Tinea capitis: Alopecia areata, impetigo, psoriasis, seborrhea, trichotillomania
Tinea corporis: Impetigo, eczema, psoriasis, contact or atopic dermatitis, drug eruption, cutaneous herpes, lupus, pityriasis rosea
Tinea cruris: Contact dermatitis, candidal intertrigo, erythrasma, psoriasis, seborrhea
Tinea pedis: Eczema, contact or atopic dermatitis, dyshidrosis, pitted keratolysis, psoriasis

Treatment

Medication

Primary treatment for tinea corporis, cruris, and pedis is with topical antifungal agents. Primary treatment for tinea capitis is oral antifungal agents.
Initial treatment also may include a topical corticosteroid. This may help reduce the associated pruritus and erythema; however, this may exacerbate tinea infections and lead to treatment failure.
Tinea capitis and diffuse, multiple lesions in other areas should be treated with oral antifungal agents.
When using oral agents, give consideration to drug interactions, potential for toxicity, and cost of medication.
Prevention is key: Emphasize proper personal hygiene; use dry, cotton clothing; and keep athletic equipment disinfected properly.
Tolnaftate and clotrimazole only suppress the fungus and are not cidal.
Shampooing hair and body with selenium (Selsun Blue) may be useful prophylaxis.
Failure to treat all areas simultaneously may result in treatment failure.

P.601

Tinea capitis requires oral treatment:
- Griseofulvin: Treat for 6 wks. Monitor CBC, liver function tests (LFTs). Side effects: Photosensitivity, headache, neutropenia, elevated LFTs, paresthesia, rash. Pregnancy Category C.
  - Adults: 500 mg microsize or 330–375 mg ultramicrosize daily for 6 wks
  - Children: 11 mg microsize/kg/d or 7.3 mg ultramicrosize/kg/d for 6 wks
- Terbinafine: Treat for 4 wks. Monitor CBC, LFTs. Pregnancy Category B.
  - 10–20 kg: 62.5 mg daily
  - 20–40 kg: 125 mg daily
  - Above 40 kg: 250 mg daily
- Itraconazole: Treat for 2–6 wks. Monitor LFTs. Caution: Hypoglycemia with sulfonylureas, rhabdomyolysis with HMG-CoA reductase inhibitors. Pregnancy Category C.
  - Adults: 100 mg daily up to 200 mg b.i.d.
  - Children: 3–5 mg/kg daily
- Fluconazole: Treat for 2–4 wks. Increased international normalized ratio (INR) on warfarin. Pregnancy Category C.
  - Adults: 200 mg daily
  - Children: 6 mg/kg/d
Tinea corporis, cruris, and pedis: Topical antifungals are first-line treatment. Topical nystatin is ineffective. Oral therapy for failed topical, extensive lesions or immunocompromised.
- Topical therapy: Treat for 2–6 wks (continue treatment additional week after resolution of rash):
  - Ciclopirox: Apply twice daily
  - Clotrimazole: Apply twice daily
  - Econazole: Apply once daily
  - Ketoconazole: Apply once daily
  - Miconazole: Apply twice daily
  - Naftifine: Gel, apply twice daily; cream, apply once daily
  - Oxiconazole: Apply once to twice daily
  - Sertaconazole: Apply twice daily
  - Sulconazole: Apply once to twice daily
  - Terbinafine: Apply once to twice daily
  - Tolnaftate: Apply twice daily
- Oral therapy: Treat for 2–6 wks:
  - Griseofulvin: 500 mg daily OR 500 mg b.i.d. OR 250 mg t.i.d.
  - Fluconazole: 150–200 mg once weekly for 2–4 wks or 400 mg one-time dose
  - Itraconazole: 100–200 mg daily
  - Terbinafine: 250 mg daily

Additional Treatment

Prophylaxis for tinea gladiatorum:

Recommended for recurrent episodes (exclude immunocompromised state)
Use by some prior to wrestling tournaments or during season:
- Fluconazole: 200 mg once weekly
- Itraconazole: 400 mg once every 2 mos

Ongoing Care

Wrestling return to play:

NCAA: A minimum of 2 wks of systemic antifungal therapy is required for scalp lesions. A minimum of 72 hr of topical therapy is required for skin lesions. Wrestlers with extensive and active lesions will be disqualified. Activity of treated lesions can be judged either by use of KOH preparation or a review of therapeutic regimen. Wrestlers with solitary or closely clustered, localized lesions will be disqualified if lesions are in a body location that cannot be “properly covered” (a gas-permeable dressing, eg, Op-site, Tegaderm, Bioclusive, Duoderm, then covered by elastic/stretch tape). The disposition of tinea cases will be decided on an individual basis as determined by the examining physician and/or athletic trainer. (NCAA Sports Medicine Handbook 2009–2010)
NFHS: Tinea lesions (ringworm scalp, skin): Oral or topical treatment for 72 hr on skin and 14 days on scalp (NFHS revised/approved April 2008)

Follow-Up Recommendations

Most infections are easily treated with topical or oral antifungal agents; therefore, referral is rare. However, for cases that do not respond as expected, further evaluation to rule out an immunocompromised state or other systemic illness should be considered.

Additional Reading

Doncker PD, Gupta AK, Marynissen G, et al. Itraconazole pulse therapy for onychomycosis and dermatomycoses: an overview. J Am Acad Dermatol. 1997;37:969–974.

Goldstein AO, Goldstein BG. Dermatophyte (tinea) infections. Available at: www.uptodate.com/online/content/topic.do?topicKey=dermatol/5934&view=print Accessed August 24, 2009.

González U, Seaton T, Bergus G, et al. Systemic antifungal therapy for tinea capitis in children. Cochrane Database Syst Rev. 2007;CD004685.

Hazen PG, Weil ML. Itraconazole in the prevention and management of dermatophytosis in competitive wrestlers. J Am Acad Dermatol. 1997;36:481–482.

Kohl TD, Martin DC, Berger MS. Comparison of topical and oral treatments for tinea gladiatorum. Clin J Sport Med. 1999;9:161–166.

Lesher JL. Oral therapy of common superficial fungal infection. J Am Acad Dermatol 1999;40(suppl):31–34.

Noble SL, Forbes RC, Stamm PL. Diagnosis and management of common tinea infections. Am Fam Physician. 1998;58:163–174, 177–178.

Codes

ICD9

110.0 Dermatophytosis of scalp and beard
110.3 Dermatophytosis of groin and perianal area
110.4 Dermatophytosis of foot
110.5 Dermatophytosis of the body