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Tinea pedis is a dermatophytosis of the feet, whereas tinea manus affects the palmar and interdigital areas of the hand. Tinea manus may be acquired by direct contact with an infected person or animal, the soil, or autoinoculation.
Usually bilateral with patchy or diffuse scaling limited to the thick skin, soles, and the lateral and medial aspects of the feet, this is also known as “moccasin-type” tinea pedis. Unilateral tinea manuum commonly occurs in association with hyperkeratotic tinea pedis, resulting in the “two feet-one hand syndrome” . The vesiculo-bullous and acute ulcerative types commonly produce a vesicular id reaction, either as a dyshidroticlike distribution on the hands or on the lateral foot or toes. For vesiculo-bullous lesions, examination of the roofs yields the highest rate of positivity on KOH examination. Histologically, hyperkeratotic tinea pedis or tinea manuum is characterized by acanthosis, hyperkeratosis, and a sparse, chronic, superficial perivascular infiltrate in the dermis. Tinea unguium, also called onychomycosis is a contagious fungal infection of the nail tissue which can affect both finger and toenails. Once the infection is acquired, it will not heal spontaneously and because of that, the incidence increases with age.
Commonly, the infection of the nails is preceded by tinea pedis (fungal infection of the skin on feet) from where the pathogens can easily invade the nail tissue and act as a reservoir for other kinds of tineas (on the body, groin, scalp etc.). Clinical manifestation of onychomycosis: about 80% of nail fungal infections occur on toe nails (especially the big toes). The distal lateral subungual onychomycosis: where a white patch is visible on the distal or lateral undersurface of the nail and the nail bed. The white superficial onychomycosis: where on the proximal nail plate there is a white, chalk like plaque. The proximal subungual onychomycosis: which occurs usually on the toenails and looks like a white spot. Differential diagnosis: tinea unguium can sometimes look a lot like psoriasis, eczema, Reiter syndrome, onycogryphosis, some congenital nail dystrophies, chemical or traumatic injuries to nails, lichen planus, yellow nail syndrome and Darier-White syndrome. Diagnosis: with onychomicosis, clinical diagnosis (just by looking at the nails) is usually not enough. Treatment: of the nails infected with fungi is difficult because the organisms that cause the infection are inside the tissue and difficult to reach. Prognosis: as mentioned before, fungal infection of the nails will not go away if not treated. Arnold, Harry L, Odom, Richard B, James, William D and Andrews, George Clinton, 1990, Andrews’ diseases of the skin. Fitzpatrick, Thomas B and Freedberg, Irwin M, 2003, Fitzpatrick’s dermatology in general medicine. Wolff, Klaus, Johnson, Richard Allen and Fitzpatrick, Thomas B, 2009, Fitzpatrick’s color atlas and synopsis of clinical dermatology. Tinea versiolor (also called dermatomycosis furfuracea, pityriasis versicolor or tinea flava) is a common skin fungal infection that occurs usually on the chest and back. Malassezia is present worldwide and is more common in areas with high humidity and temperatures. Tinea versicolor is a benign disease which is thought to be non contagious (because it already is present on the skin of people as part of the normal flora).
Appearance: normally, the main compliant of the patients is the cosmetic effect of Malassezia – it causes small, round patches of skin discolouration.
Oral, systemic antifungal treatment: is the disease affects a very large area of the skin or if the topical treatment is not effective. Tinea nigra (also called superficial phaeohyphomycosis or tinea nigra palmaris et plantaris) is a uncommon infection of the skin usually caused by Hortaea werneckii (a species of fungi).
Treatment: tinea nigra is an infection that responds well to topical anti fungal treatment in about two to four weeks. Tinea corporis also known as ringworm infection, tinea circinata or tinea glabrosa is a skin fungal infection that affects the skin of the trunk, arms, legs or neck but does not appear on the feet, hands, scalp or the groin area. There are some environmental factors that predispose to the infection and are typical for fungi. A very broadly spread disease can be the first sign of AIDS or it might follow the use of topical corticosteroids (anti – inflammatory drug).
Differential diagnosis: ringworm infection can sometimes look a lot like nummular eczema, psoriasis, tinea versicolor, infection with candida, lupus erythematosus or different types of dermatitis (contact, atopic, seborrhoeic).
Diagnosis: beside its typical appearance, the doctor might have to scrape a bit the border of the lesion and examine the specimen under a microscope. Fungal folliculitis (infection of the hair follicles): also called Majocchi granuloma is a deeper form of tinea corporis which can resemble a carbuncle (localized skin infection from which pus can be passed) or kerion (a very nasty form of ringworm of the scalp). Tinea incognito: is a term which describes a ringworm infection of the skin which has been previously treated with corticosteroids because it was mistaken for another dermatological disease.
Tinea cruris also called jock itch, crotch itch, ringworm of the groin, gym itch or Tinea inguinalis is a disease caused by fungi which live on the skin. Ringworm of the groin is more common in hot, humid climates and in people who emigrate from such places. This type of fungal infection can also be sexually transmitted and can cause epidemics in bathing facilities, dormitories or between soldiers.
It appears as a circular patch, which is easily distinguishable from the surroundings and has a raised, scaly border.
If topical corticosteroid have been used in the course of the disease, symptoms can be suppressed and the diagnosis difficult to determine. After a careful examination, the doctor might collect some scales of skin from the margin of the lesion and then examine them under a microscope. Prognosis is very good unless the subjected area is not kept dry – if not, recurrence is frequent.
Tinea manuum or ringworm infection of the hands, is a fungal infection occurring on the skin of the hands. Transmission:it can be acquired through contact with an infected person, soil, by touching an infected animal or by touching a previously infected part of your own body (like picking on infected feet, nails or groin area).
Aetiology: predominantly caused by Trichophyton rubrum, Trichophyton interdigitale or Epidermophyton floccosum. Differential diagnosis: psoriasis, keratolysis exfoliativa, contact dermatitis, lichen simplex, atopic dermatitis. For the disease to heal it is mandatory to eradicate the nail infections on both hands and feet and on the skin of feet and groin. Dermatophytic infection of the feet also called ringworm infection of the feet, Tinea pedis, athlete’s foot or jungle rot is a contagious fungal infection of the skin of the feet. Epidemiology frequently affects older children and young adults and is most commonly found in those aged twenty to fifty years. The interdigital type: is most commonly found between the forth and fifth toe and can spread to other parts of the feet. The moccasin type: is most commonly located on heels, soles and the lateral borders of the feet. The ulcerative type: is observed when the interdigital infection has extended to the plantar or lateral part of the foot. Differential diagnosis: includes several different dermatological diseases like psoriasis, eczematous dermatitis, bullous impetigo, allergic contact dermatitis and dyshidrotic eczema. Tinea pedis is treated with anti fungal drugs which can be taken orally or applied topically (in form of a cream, powder, gel or spray). Patients with extensive hyperkeratotic or vesicular infections, those with accompanying infection of the nails, patients with diabetes, a compromised immune system (cancer, transplant patients) or disease of the peripheral vessels have to take oral anti fungal medications.
Because Tinea pedis can be quite itchy, scratching it can cause a bacterial infection of the already damaged skin. Tinea facei (also called ringworm of the face) is a fungal infection of the face area (excluded the moustache and beard areas of men – called tinea of the barb). The inflammation is usually caused either by Trichophyton rubrum, Trichophyton mentagrophytes of Microsporum canis – all species of fungi. Although all ages can be affected by Tinea faciei, two groups of patients show increased incidence: children who come in contact with animals more often (also possible in neonates) and those aged between twenty to forty years. Pathogenesis: the infectious agents can spread to the skin by direct contact with an external, infected source (a pet mouse for example) or by spreading from another part of the body which is already affected.
The doctor may perform some small scrapings from the lesion to microscopically determine the involved pathogen.

The disease can be frequently mistaken for seborrhoeic dermatitis, contact dermatitis, the rash seen in Lyme disease, lupus, photo-toxic eruptions, rosacea and skin infections with Candida. The prognosis with this type of infection is usually good and it should respond to treatment in about four to six weeks. Fitzpatrick, Thomas B and Wolff, Klaus, 2008, Fitzpatrick’s dermatology in general medicine.
Wolff, Klaus, Johnson, Richard Allen and Fitzpatrick, Thomas B, 2009, Fitzpatrick’s colour atlas and synopsis of clinical dermatology. In most of the cases the lesion is present on one side of the face or neck and involves the beard area (rarely moustache area and upper lip). Although some forms of Tinea can be cured with topical agents this is not one of those cases. The child or baby can get infected with ringworms by having contacts with an infected person, animal (pets like dogs or cats), by picking it up from floors, soil or by coming into contact with an object which contains pathogens (towels, combs, different pieces of clothing).
If the child’s organism responds to the ringworm infection with a vivid immune response, a condition called kerion might follow. Children should use appropriate footwear when walking around pool areas and avoid sharing personal care objects like combs, towels etc. The affected child should wear light, cotton made garments which breathe in order to stay dry. The prevalence of tinea pedis is approximately 10 percent, primarily attributable to modern occlusive footwear, although increased worldwide travel has also been implicated. However, it is nearly always associated with tinea pedis and occurs most commonly in the hand used to excoriate the feet. When tinea manus extend to the dorsum of a hand, it assumes the clinical pattern of tinea corporis .
Vesiculo-bullous forms display spongiosis, parakeratosis, and sub-corneal or spongiotic intraepithelial vesiculation.
It is a common disease affecting about 14% of the adult population and can be caused by dermatophytes (fungi living on the skin), nondermatophyte types of molds or yeasts. It has a greater prevalence in older people and shows an increasing rate of incidence (also in younger people and children). Just about 10% of the toenail infections are caused by other organisms (nondermatophyte molds and yeasts) like: Acremonium, Aspergillus, Fusarium, Scopulariopsis brevicaulis and Scytalidium. The organisms can invade the nails after a direct contact with an infected individual or with items that contain infected particles of skin (common transmission between family members). The doctor has to take a bit of the nail to examine it under a microscope or plant it into a medium to grow a fungal culture. They have to be applied for a long time (about a year) and include ciclopirox nail paint amorolfine and efinaconazole.
The indications for prescribing these type of drugs include affected fingernails, limited function of the infected part, pain, a greater potential for bacterial infections, physical and other disabilities. The toenails should be regularly clipped and one should avoid walking bare feet in areas where the infection is possible (locker rooms,swimming, bathing areas).
This organism is normally found on the skin of many different animals an humans (by some estimates it has been found on 18% of infants and 90-100% of the adults). The prevalence is not associated with race or sex and it is more common in people aged fifteen to twenty – four years. The affected skin can look hypo or hyperpigmentated (too light or too dark discolouration of the skin). If the origin of the lesions is not so clear, the doctor might use a special lamp called Wood’s lamp that makes Malassezia glow or examine a small part of the skin under a microscope.
It does not leave any marks or scars and the skin discolouration should disappear in about one to two months after the treatment has been initiated.
As the fungus is not very common is the United states, patients have usually travelled elsewhere (especially to the Caribbean islands) prior to noticing the lesions on the skin. When symptoms are present, they usually consist of dark brown or even black patches on the skin of the hands and feet (usually on the palmar and plantar side). With time, the changes progress outwards and show a almost complete central clearing with some scaling. In cases, where the diagnosis of ringworms is suspected but cannot be proven otherwise, the specimen can be put in a culture medium and in about a week or two, the organism should show signs of growth.
Typically, they have to be applied twice daily for about two to four weeks (but the regimen depends on the drug) and another seven days after the symptoms have disappeared. It’s usually caused by Trichophyton rubrum or Trichophyton mentagrophytes and shows up in places where hairs have been shaved. Because of this treatment, lesions do not appear as typical as always and a biopsy is sometimes in order. The routes of infection are similar to all other fungal infections caused by dermatophytes (commonly called ringworm infections).
The species most frequently implicated in Tinea cruris include Trichophyton rubrum, Epidermophyton floccosum, Trychophyton interdigitale and Trichophyton verrucosum. Affected patients may have been wearing tight-fitting garments for longer periods or have been suffering from diabetes or obesity. Another possible clinical picture involves red, scaly changes with blisters and small bumps. If the patient is unable to apply it regularly or if the infection has spread to a large area, orally taken systemic drugs might be subscribed. It is less common than the same infection affecting the feet and appears to be frequently misdiagnosed because its clinical presentation is similar to other dermatological diseases. Less commonly diagnosed species include: Microsporum canis, Trichophyton verrucosum and Microsporum gypseum. If topical corticosteroid creams have been used, diagnosis can be even more difficult to determine.
Oral anti fungal therapy is advised and includes drugs like terbinafine, itraconasole and fluconasole (the prescribed regimen depends on the used medication).
Frequently, bacterial inflammation of the skin,the lymph nodi and fever are associated with this form.
With the moccasin type, the topical medication has to be applied to the bottom and sides of the feet, with the interdigital type to the affected part plus the soles (because often the infection spreads). By touching the site of the inflammation, the pathogens can also spread to other parts of the body and cause the infection.
If the patient has issues with veins in his legs, the pathogens can enter into more deeply lying tissues.
It is a condition which is commonly misdiagnosed (more than any other ringworm infections) and wrongly attributed to other diseases (lupus for example). However, fungi that cause it like warmer, moister climates so it is more frequent in tropical areas. The scaling (present in less that two thirds of cases), red, elevated periphery of the skin changes points in the direction of a fungal infection. Sometimes a small piece of skin has to be taken to further clarify the origin of the disease. Because of the specificity of the involved areas and structures (beard and moustache areas with invasion of hairs) it is a disease of adult males. This type develops slowly, with nodular thickening of the involved skin and swelling that reminds of kerion (a severe ringworm infection of the scalp). The inflammation usually appears to be milder in nature and the affected hairs can sometimes be extracted with ease. It is confirmed by microscopically examining the hairs extracted from the affected part of the skin (treated with potassium hydroxide) or by performing a skin biopsy. Usually they present as a scaly patch which can be found almost anywhere on the body (scalp, face, body, hands, legs). It is characterised by a swollen, moist area of inflammation with pus filled bumps (called pustules). If the diagnosis is not as straightforward, he might use a special lamp called Wood’s lamp or perform a small scraping of the diseased skin which will get examined under a microscope.
When scratched, dirt and bacteria can get in the already damaged skin and cause a bacterial infection. The incidence of tinea pedis is higher among those using communal baths, showers, or pools.
Oral antifungals are often required for treatment due to the high incidence of concomitant onychomycosis and relapse.

Probably, the increased prevalence reflects the widespread usage of immunosuppresive drugs, usage of locker rooms and wearing of modern, tight shoes. It is more commonly found in immuno compromised patients (patients with this type of disease should be screened for HIV).
The medications used in the treatment are anti fungals, which can be taken orally or applied topically. Even if topical therapy alone is not considered adequate, it might be an option in patients who cannot take systemic treatment.
Because of the disease, the protective barrier of the skin is damaged and other organisms (like bacteria) can enter into the blood easily (happens frequently after a vein from the leg has been taken in a heart operation). It is present on the areas of the skin that show disease in and those that appear completely normal. The lesions are covered by very fine scales and are usually found on the trunk, back, abdomen and the proximal part of the limbs. However, recurrence is quite common and the treatment regimen frequently has to be repeated. Fungi affect both males and females and the prevalence peaks in the pre-adolescent children.
If the disease has spread to a larger area, if there is involvement of the hair follicles or if the infection does not respond to topical treatment, systemic anti-fungal agents have to be taken. In patients with a compromised immune system (cancer, AIDS etc.), lesions appear to be even more deeply located and nodule-like. If other parts of the body are infected (like nails or feet) they should be cured in order to prevent the tinea to reoccur. It is important for the patient to keep the affected part of the skin dry, clean and to change into dry clothes as soon as possible after getting wet. If an infection is taking place, the patient should not share towels or any piece of clothing with others in order to refrain from spreading the pathogens. Bad peripheral circulation in hands and excessive sweating can both play an important role in the development of the inflammation. The peripheral part of the lesion is well demarcated and the centre often appears to be clearing off.
Because the skin barrier is damaged, a new route for bacteria and possible infections is opened. Together with fungal infections of the hands, they are believed to be the most common dermatophytoses. If a bacterial infection follows it, the skin lesion is itchy, painful and emits a foul smell. The skin is red, with small superficial elevations called papulae on the margin, finely scaly and hyperkeratotic (excessive thickening of the horny layer of the skin). Commonly, patients complain of itching, burning sensations which get worse after being exposed to the sun.
If corticosteroids have been used, cessation of therapy of a few days can make symptoms more prominent and therefore the diagnosis easier.
It is not a very common infection, mostly affecting people working in the agriculture field (more common if working in contact with farm animals – cattle, horses or dogs may be the source). The most common causative pathogens are Trichophyton mentagrophytes and Trichophyton verrucosum – both types of fungi. In some cases the doctor can make an attempt to grow a fungal culture (plant the extracted hair or a piece of skin in the appropriate medium), although this is rarely performed. With barber’s itch systemic, orally taken anti fungals must be prescribed by a doctor and local creams serve merely as part of an adjunctive (joined) therapy. These pathogens can affect people of any age, but are more common in children older that two years (also possible in younger babies but quite rarely).
The patch grows with time and it’s usually round in shape, red coloured with a smooth, sometimes clear centre. If the lesions are located on the body of the baby, topical anti fungal creams will usually be enough (for example clotrimasole cream used twice daily).
Even though it can affect almost anyone, some are at greater danger of catching this type of infection. Even though it may not cause any disease, it is thought to be associated many different skin conditions like: Pityrosporum folliculitis, confluent and reticulate papillomatosis, seborrheic dermatitis, and atopic dermatitis.
Such conditions are encountered in those who practice contact sports (wrestling for example) and are often called Tinea corporis gladiatorum.
The types of fungi which have been contracted from animals usually show a more pronounced immune response. Jock itch is frequently found on both legs where it extends from the inguinal fold to the inner part of the thigh and backward towards the anus. It is also advisable to put on socks before putting on underwear in order to refrain from spreading the infection. The involved species of fungi include Trichophyton rubrum, Trichophyton interdigitale and Epidermophyton floccosum and a combined infection can sometimes be seen. Predisposing factors include wearing tight footwear and having a condition called hypertrichosis (an abnormal amount of body hair). Sometimes, urea based creams have to be applied together with topical anti fungals in order to soften it. The lesions can affect any area of the facial skin and are usually not symmetric to both sides.
The shift of prevalence towards farmers and ranchers occurred after hygiene in barbers shops improved and the transmission by infected razors decreased. The involved pathogens include Trichophyton violaceum and Trichophyton rubrum, just rarely Epidermophyton floccosum.
In most of the cases, in a couple of weeks the infection should go away (about three to four). Predisposing factors include the HIV infection, diabetes (one third of diabetics is supposed to be affected) and poor peripheral circulation. Diabetic patients are at a significantly greater risk of having fungal nail infections and should be screened regularly. The skin changes are often itchy, if bacteria join the infection they can even get painful.
Because of widespread wearing of modern, tight shoes and world travelling, these infections have a very high incidence.
The most commonly affected parts of the face are as follows: cheeks, nose, area around the eyes, the chin and the forehead. On general, Tinea barbae can be caused by fungi which have adopted to animal or human hosts (in Latin they are called zoophilic and antropophilic species respectively). The hairs may be absent or very loose, from the remaining follicular openings pus might be expressed. Usually the lesions are confined to one part of the face or neck skin.
If the lesion is located on the head, there might be scaly areas with missing or broken – off hair. After there are no more visible signs of the disease, the cream should be used for another seven days to prevent possible relapses. Commonly, the skin of the scrotum is affected, with some species invading the skin of the buttocks, skin of the lower back or abdomen.
The lesions are often found on just one hand (the dominant one more commonly) and are associated with Tinea pedis (fungal infection of feet) and Tinea cruris (fungal infection of the groin area). They are also commonly acquired by walking bare-feet in pool and shower areas and can be transmitted between members of the same household. If the patient has previously been using corticosteroid creams (a type of anti inflammatory drug), involvement of hair follicles can be seen. This condition can be mistaken for another one called cradle cap (greasy, scaly patches that sometimes appears on the head of a baby) or for other, rash causing diseases (like psoriasis, eczema, seborrhoea or contact dermatitis). If fungi are present and infect another part of the body, it is possible for them to spread to the feet. Sometimes, lesions of the facial skin can appear at the same time as the ones on the body or scalp. In most of the cases, topical medications will suffice, only sometimes oral anti fungals will be recommended (when the infection is located on the scalp of the baby).

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