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Athlete's Foot is a skin disease caused by a fungus that usually occurs between the toes and anywhere on the foot.
Send Home Our method Usage examples Index Contact StatisticsWe do not evaluate or guarantee the accuracy of any content in this site. Despite its large surface area and constant exposure to the environment, the skin resists infection well.
Cutaneous infections occur when the skin’s protective mechanisms fail, especially when trauma, inflammation, maceration from excessive moisture, or other factors disrupt the stratum corneum. Anthropophilic dermatophytes are the most common cause of fungal skin infections in humans.
Dermatophyte infections occur more frequently in certain ethnic groups and in people with impaired cell-mediated immunity. The various forms of dermatophytosis, also called ringworm, are named according to the site involved. Tinea capitis occurs primarily in children but may develop in adults—especially the elderly, those who are unkempt, and the impoverished.
Figure 1 Classic annular lesion of tinea corporis shows a raised or vesicular margin with central clearing. Figure 2 A typical kerion presenting as a zoophilic Microsporum canis infection of the scalp (tinea capitis). Tinea corporis typically appears as a single lesion or multiple circular lesions with scaling, well-delineated margins, and a raised, erythematous edge. Figure 3 (a) The scaling of tinea pedis appears between and under the toes and on the plantar surface. Tinea barbae occurs in adult men and involves the skin and coarse hairs of the beard and mustache area. Tinea faciei occurs as an infection of the face in women and children and infection of the area outside the mustache and beard in men. Tinea cruris, infection of the groin, is much more common in men than women and is often associated with infection of the feet. Clinicians should suspect dermatophyte infection in patients with any scaling, erythematous eruption and in patients whose nails exhibit the characteristics of tinea unguium (see above).
The specimen is prepared for microscopic examination by first placing it on a glass slide and treating it with potassium hydroxide (KOH), which digests the keratin of the skin, nails, and hair, and then heating it to hasten the process. Tinea corporis, tinea cruris, tinea pedis, and tinea faciei respond to topical agents applied once or twice daily to the affected area, usually for 2 to 4 weeks.
The azoles include ketoconazole, itraconazole, and flucona-zole; like griseofulvin, they are fungistatic. The AOCD was recognized in 1958 as a Specialty College of the American Osteopathic Association. This patient presented with ringworm of the foot (tinea pedis) due to the dermatophytic fungus Trichophyton rubrum.
The most important protective factor is an intact stratum corneum, the tough barrier of protein and lipid formed on the cutaneous surface by the underlying epidermis.1 This barricade impedes invasion by environmental pathogens, and its dryness discourages colonization and growth of the many organisms that require moisture to survive, such as gram-negative bacilli.
The organisms causing infection may originate from the victim’s own resident flora, either on the skin or on adjacent mucous membranes, but many come from other people, animals, or the environment. These organisms, which include Trichophyton, Microsporum, and Epidermophyton species, are classified as an-thropophilic, zoophilic, or geophilic, depending on whether their primary source is humans, animals, or the soil, respective-ly.3 Geophilic dermatophyte infections occur sporadically, primarily among gardeners and farm workers. Transmission of these infections occurs from direct contact between people or from exposure to desquamated skin cells present in the environment— arthrospores can survive for months. Involvement of the feet and groin is most common in adolescents and young adults, especially males, but is unusual in children.
These infections include tinea capitis (scalp), tinea corporis (body), tinea barbae (beard area of men), tinea faciei (face), tinea cruris (groin), tinea pedis (feet), tinea unguium (nails), and tinea manuum (hands).
Streptococci do not ordinarily survive on normal skin, but the presence of fungal disease apparently permits streptococci of various groups, including A, B, C, and G, to colonize the toe webs.6 From this location, these bacteria may invade the skin damaged by the tinea pedis or migrate to locations higher up the leg and enter the skin through any defects. The organisms typically invade the nail from the distal or lateral borders, and infection spreads proximally. Most cases have accompanying involvement of the feet; inexplicably, usually only one hand is affected (so-called two-feet, one-hand disease). The basic culture medium for isolating dermatophytes is an agar containing Sabouraud medium, often combined with antibiotics to eliminate bacteria and with cycloheximide to inhibit sapro-phytic fungi. Five oral agents are currently available: griseofulvin, ke-toconazole, itraconazole, fluconazole, and terbinafine.
Ketoconazole is usually well tolerated, but hepatotoxicity occurs in about 1 in 10,000 patients, typically after several weeks of use.

The most effective agent is terbinafine, administered at a dosage of 250 mg daily for 6 weeks for fingernail infections and for 12 weeks for toenail involvement.9 Because terbinafine persists in the nails for many weeks, it continues to exert anti-fungal effects long after it is discontinued.
They may form filamentous projections, which, unlike the hy-phae of molds, do not contain separate cells.
The AOCD now oversees 27 dermatology residency programs that are currently training 119 residents in dermatology. Individuals who practice generally poor hygiene, wear enclosed footwear such as tennis shoes, endure prolonged wetting of the skin, i.e. Furthermore, the constant shedding of cells of the epidermis impedes most microbes from establishing permanent residence. Direct inoculation of the spores through breaks in the skin can lead to germination and subsequent invasion of the superficial cutaneous layers. The characteristic skin lesion is an annular scaly patch [see Figure 1], though the clinical appearance varies not only with the site involved but also with the host’s immune status and the type of infecting organism.
Because the swollen hairs may fracture a few millimeters from the epidermis in this endothrix infection, the scalp sometimes appears to be marked by small black dots.
Hair shedding late in the infection is common because the hair shaft is not damaged until the infection is well advanced. The amount of inflammation varies; when the inflammation is intense, pustules, vesicles, and even bullae may occur. The optimal method of obtaining specimens from the skin is by scraping the scaly lesions; specimens from the nails are best obtained by taking fragments of subungual debris. Griseo-fulvin, a fungistatic agent, is the oldest oral treatment available and is still useful, primarily in infections not involving the nails.
Flucona-zole and itraconazole are very expensive, but they provide protracted levels of antibiotic in the nails, allowing short or intermittent courses of therapy for tinea unguium.
It achieves high levels of drug in the nails, and the drug persists for many weeks after discontinuance. The terbinafine regimens produce short-term eradication of infection in about 70% to 90% of patients with fingernail infection and in about 50% to 80% of patients with toenail infection. It normally colonizes the skin of adults, especially of the scalp and upper trunk, where the presence of sebum is highest.
In general, anthro-pophilic species elicit little inflammation and cause chronic infections. Like all infections with Trichophyton species, these scalp lesions do not fluoresce under a Wood light. The most severe inflammation, usually from a zoophilic species, results in a kerion, a painful, boggy mass in which follicles may discharge pus and in which sinus tracts form [see Figure 2].
Sometimes, involvement of the hair follicles in the middle of a patch of scaling erythema leads to perifollicular nodules, a condition called Majocchi granuloma. They may crack or crumble, and often, subungual hyperkeratosis lifts the nail plate from the underlying bed (a condition known as onycholysis) [see Figure 4]. Occasionally, vesicles, papules, or follicular nodules form on the dorsal surface of the hands. Der-matophyte test medium culture can be used in the office and is both accurate and inexpensive.7 When both KOH preparations and cultures are negative, a biopsy may be useful in identifying the infecting organism, usually by special tissue stains such as periodic acid-Schiff or Gomori methenamine-silver stains. Tinea pedis often recurs after effective therapy, especially in cases of the moccasin form of the disease. Both fluconazole and itraconazole can cause gastrointestinal disorders, rashes, and, occasionally, hepatotoxicity and can have serious interactions with several medications, including cyclosporine, digox-in, and quinidine. Candida species are not part of the normal skin flora, but they commonly reside in the orophar-ynx, vagina, and colon. For unknown reasons, these organisms, which are ordinarily commensals, can become pathogenic and cause tinea versicolor (also known as pityriasis versicolor) or folliculitis.
Sometime the susceptibility will run in the family.Tinea Pedis (Athlete's foot)This is the most common type of fungal infection and only affects humans.
Zoophilic and geophilic species, however, often provoke intense inflammation, which sometimes leads to eradication of the organisms and healing without treatment.
The hairs then become infected, in one of three microscopic patterns: ectothrix, endothrix, or favus. The victims are generally farm workers, and the infection usually causes erythema, scaling, and follicular pustules. Patients often complain of itching and burning, and symptoms may worsen after exposure to sunlight. The lesions are usually red, scaling, sharply demarcated areas with raised, erythematous borders.

The most common form consists of fissuring, scaling, and maceration in the interdigital spaces, especially between the fourth and fifth toes. When infection reappears, the previous therapy can be resumed without loss of effectiveness.
Ketoconazole, itraconazole, and fluconazole can interact with other medications; pharmacologic sources should be consulted for potential interactions. About 75% of patients who receive one or more courses of terbinafine will have a clinical cure 5 years later.
It is spread by direct contact, most often through bare feet in bathrooms and health clubs.
Human infections with zoophilic species have occurred after exposure to dogs, cats, horses, cattle, pigs, rodents, poultry, hedgehogs, and voles.
The lesions may be scaly, annular erythematous patches, but often they are indistinct red areas with little or no scaling.
The infection, which affects the medial portion of the upper thighs but consistently spares the scrotum, may extend to the buttocks, abdomen, and lower back. A second type involves scaling, hyperkeratosis, and erythema of the soles, heels, and sides of the feet. This therapy is very expensive, and clinicians must decide in each case whether treatment is warranted. Alternatively, with reduction in the other flora or with impaired host defense mechanisms, these yeasts may proliferate in large numbers to produce lesions on the mucosal surfaces of the mouth and vagina.
In this kind of tinea pedis, the lesions occur in a so-called moccasin distribution pattern [see Figure 3a].
All these medications are effective in cases of tinea barbae, Majocchi granuloma, extensive tinea corporis, and tinea manuum that are unresponsive to topical agents. It is rare in children.In most cases, the skin becomes white, soft and peels away between the toes (especially between the fourth and little toes). It may infect the sole of the foot resulting in peeling, scaling, itching and sometimes blistering.
A third form demonstrates an inflammatory pattern characterized by vesicles, pustules, or even bullae, usually on the soles [see Figure 3b].
Only one, or both feet may be involved.Onychomycosis (Tinea unguium, nail fungus)Toenail infection is usually associated with tinea pedis. Fingernail infections are similar, but less common.Tinea Cruris (Jock itch)Some subjects with tinea pedis also develop a rash in the groin (tinea cruris), especially if they tend to sweat a lot. It has an itchy spreading red border.Tinea Corporis (Ringworm)Tinea corporis is the name given to a fungus infection of the skin that is not one of the other ones listed here. It may be spread from person to person, from contact with an infected animal, most often a cat, or from exposure to fungus in the soil.
If due to an animal, even if it has no signs of a skin problem it will need treatment too.Tinea Capitis (Scalp ringworm)Tinea capitis usually occurs mostly in children and results in scaling and patchy hair loss.
It is hard to immediately confirm that the symptoms are due to tinea infection and to establish the identity of the infecting organism. This may be treated with prednisone to prevent permanent hair loss.TreatmentTinea infections can be treated by a variety of different medications. For tinea pedis, cruris, and corporis, creams such as Lamisil-AT and Micatin AF can be bought over the counter at a pharmacy. These are very effective, and include griseofulvin (Grispeg, Fulvicin), terbinafine (Lamisil), itraconazole (Sporonox), and fluconazole (Diflucan). Tinea capitis, tinea unguium and chronic tinea pedis are difficult to eradicate completely and require oral treatment.PreventionPeople with tinea pedis should discourage further growth of the fungus by keeping their feet as dry as possible. Wear open-toed sandals whenever possible, avoid boots, dry carefully after washing, and use an antifungal foot powder (Zeasorb-AF) daily. It is not intended nor implied to be a substitute for professional medical advice and shall not create a physician - patient relationship. If you have a specific question or concern about a skin lesion or disease, please consult a dermatologist.
Any use, re-creation, dissemination, forwarding or copying of this information is strictly prohibited unless expressed written permission is given by the American Osteopathic College of Dermatology.

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