Guidelines of care for superficial mycotic infections of the skin: tinea corporis, tinea cruris, tinea faciei, tinea manuum, and tinea pedis. Guidelines/Outcomes Committee. American Academy of Dermatology

Dermatophyte virulence factors: identifying and analyzing genes that may contribute to chronic or acute skin infections

Dermatophytes are prevalent causes of cutaneous mycoses and, unlike many other fungal pathogens, are able to cause disease in immunocompetent individuals. They infect keratinized tissue such as skin, hair, and nails, resulting in tinea infections, including ringworm. Little is known about the molecular mechanisms that underlie the ability of these organisms to establish and maintain infection. The recent availability of genome sequence information and improved genetic manipulation have enabled researchers to begin to identify and study the role of virulence factors of dermatophytes. This paper will summarize our current understanding of dermatophyte virulence factors and discuss future directions for identifying and testing virulence factors.

Efficacy and tolerability of sertaconazole nitrate 2% cream vs. miconazole in patients with cutaneous dermatophytosis

Sertaconazole is a new antifungal agent. To compare the efficacy and tolerability of sertaconazole and miconazole cream in cutaneous dermatophytosis, this prospective, randomized, multicentric comparative, phase 4 study was undertaken in 260 patients with cutaneous dermatophytosis after approvals from Institutional Ethics Committees. Patients were assigned to sertaconazole cream (2%) or miconazole cream (2%) topically twice daily for 2 weeks after obtaining informed consent. Efficacy variables included changes in mean scores of erythema, pruritus, desquamation, erythema/itching, burning/weeping, scaling/pustule and overall global assessment. Safety and tolerability were also assessed. A total of 122 patients in the sertaconazole group and 128 in the miconazole group completed the study with 10 drop-outs. There was a significant decrease (P < 0.05) in mean symptom scores and total scores from the first week onwards, sustained till 2 weeks and statistically significant (P < 0.05) in favour of sertaconazole. Moreover, 62.3% patients had complete clinical cure in the sertaconazole group (P < 0.05) compared with 44.6% in miconazole users. Both drugs were well tolerated and five patients in the sertaconazole group and nine in the miconazole group reported mild to moderate adverse events. Therapy with sertaconazole cream (2%) provided a better efficacy and tolerability compared with the miconazole cream (2%) and could thus be a therapeutic option in cutaneous dermatophytosis.

National athletic trainers' association position statement: skin diseases

OBJECTIVE

To present recommendations for the prevention, education, and management of skin infections in athletes.

BACKGROUND

Trauma, environmental factors, and infectious agents act together to continually attack the integrity of the skin. Close quarters combined with general poor hygiene practices make athletes particularly vulnerable to contracting skin diseases. An understanding of basic prophylactic measures, clinical features, and swift management of common skin diseases is essential for certified athletic trainers to aid in preventing the spread of infectious agents.

RECOMMENDATIONS

These guidelines are intended to provide relevant information on skin infections and to give specific recommendations for certified athletic trainers and others participating in athletic health care.

Fluconazole as a prophylactic measure for tinea gladiatorum in high school wrestlers

OBJECTIVE

To evaluate the use of prophylactic oral fluconazole in reducing the incidence of tinea gladiatorum in high school wrestlers.

DESIGN

A prospective longitudinal study was conducted on high school wrestlers in northwest Ohio between 1997 and 2007.

SETTING

Two northwest Ohio high school wrestling teams.

PARTICIPANTS

High school wrestlers (373).

INTERVENTIONS

Prophylactic fluconazole at a daily oral dosage of 100 mg for a 3-day regimen prior to the onset of the competitive interscholastic wrestling season and 6 weeks into the wrestling season. Guardians of participants signed consent forms outlining the risks associated with fluconazole prior to being enrolled into the study.

MAIN OUTCOME MEASURES

Incidence of tinea gladiatorum in participants.

RESULTS

Over the course of this 10-year study, out of 373 participants using prophylactic fluconazole, the incidence rate of tinea gladiatorum dropped from 67.4% to 3.5%. It should be noted that more than 50% of these infections occurred within the initial year of this study when the second administration of fluconazole was given at week 8 instead of week 6. No adverse effects were reported over the 10-year study period.

CONCLUSIONS

The twice-per-season regimen of 100 mg daily for 3 days was highly effective in dramatically reducing the incidence of these skin lesions. The success of our study is 2-fold: First, fluconazole provided prophylaxis. Second, the overall incidence of fungal disease throughout the entire wrestling team was markedly decreased because most of the wrestlers participated in this study, significantly reducing exposure to these lesions through wrestling practice. No adverse effects in the use of fluconazole over this 10-year study period were reported.

Rapid detection of dermatophytes from skin and hair

Background

Dermatophytes are a group of closely related keratinophilic fungi that can invade keratinized humans and animals tissues such as skin, hair and nails causing dermatophytosis. They are an important cause of superficial fungal infection.

Findings

Conventional methods like potassium hydroxide (KOH) microscopy and fungal culture lacks the ability to make an early and specific diagnosis. In this study we have evaluated nested Polymerase chain reaction (PCR) using primers targeting dermatophyte specific sequence of chitin synthase 1 (CHS1) gene and compared with conventional test. A total of 155 patients clinically suspected with dermatophytosis were included in the study. Of which 105 specimens were skin scrapings and 50 were hair. KOH microscopy, fungal culture and first round and nested PCR were done on clinical specimens, and results compared. Nested PCR for dermatophytes was positive in 83.8% specimens, followed by KOH microscopy (70%), first round PCR (50.8) and fungal culture (25.8).

Conclusion

Results indicate that nested PCR may be considered as gold standard for the diagnosis of dermatophytosis and can aid the clinician in initiating prompt and appropriate antifungal therapy.

Single-step PCR using (GACA)4 primer: utility for rapid identification of dermatophyte species and strains

Dermatophytes are fungi that belong to three genera: Epidermophyton, Microsporum, and Trichophyton. Identification of dermatophyte species is essential for appropriate diagnosis and treatment of dermatophytosis. Routine identification depends on macroscopic and microscopic morphology, which is time-consuming and does not identify dermatophyte strains. In this study, two PCR-based methods were compared for their abilities to identify 21 dermatophyte isolates obtained from Egyptian patients to the species and strain levels. The first method employed a two-step method: PCR amplification, using ITS1 and ITS4 as primers, followed by restriction enzyme digestion using the endonuclease MvaI. The second method employed a one-step approach employing the repetitive oligonucleotide (GACA)(4) as a primer. Dermatophyte strains were also identified using a conventional culture method. Our results showed that the conventional culture method identified four species: Microsporum canis, Trichophyton mentagrophytes, Trichophyton rubrum, and Trichophyton violaceum. Moreover, both PCR methods agreed with the diagnosis made using the conventional approach. Furthermore, ITS1/ITS4-based PCR provided no strain differentiation, while (GACA)(4)-based PCR identified different varieties among the T. mentagrophytes isolates. Taken together, our results suggest that (GACA)(4)-based PCR has utility as a simple and rapid method for identification of dermatophyte species as well as utility for differentiation of T. mentagrophytes variants.

Topical delivery of fluconazole: in vitro skin penetration and permeation using emulsions as dosage forms

We investigated in vitro skin penetration and permeation of fluconazole from emulsions containing different penetration enhancers. Fluconazole permeation was high (15-65% of the applied dose) across hairless mouse skin and low (8-9%) across pig ear skin. Permeation across mice skin from a formulation containing propyleneglycol and isopropyl myristate was significantly higher than that observed with the paraffin oil and propyleneglycol or Transcutol emulsions. With pig skin, the paraffin oil or isopropyl myristate and propyleneglycol emulsions showed similar skin permeation and penetration. However, these emulsions provided epidermal concentrations higher than the minimal inhibitory concentrations for most dermatophytes.

Tracking Trichophyton tonsurans through a large urban child care center: defining infection prevalence and transmission patterns by molecular strain typing

OBJECTIVES

Trichophyton tonsurans is the single most common cause of pediatric dermatophytoses in North America and is observed with increasing frequency in other countries. This investigation was designed to gain insight into the natural course of T. tonsurans infection.

PATIENTS AND METHODS

This 2-year prospective, longitudinal study evaluated all preschool-aged children attending a single child care center. Scalp cultures were collected monthly from each child in attendance, and the presence of disease symptoms recorded at each visit. Dermatophyte genotype was assigned based on the combination of stable sequence variations (2 length variants, 8 single-nucleotide polymorphisms, a 10-base pair insertion, a 14-base pair deletion) present in 2 gene loci.

RESULTS

A total of 3541 scalp cultures were collected from 446 children during 24 months. Twenty-two percent to 51% of scalp cultures per month were positive, contributing 1390 fungal cultures of which 1048 were typeable. Among children with multiple typeable isolates, 51% exclusively carried the same strain, 37% demonstrated a single predominant strain with secondary strains transiently acquired, and 12% harbored a different strain of T. tonsurans with each typeable culture. The probability that the same strain persisted in subsequent months was 0.898 and unlikely to have arisen by chance. Rates of symptomatic disease were significantly different between exclusive, predominant, and transient carriers of T. tonsurans.

CONCLUSIONS

In contrast to dermatophyte infections in older individuals, where symptomatic disease seems to be a consequence of pathogen acquisition and carriers can be traced to an index case, in this preschool-aged population infection was endemic, and symptomatic disease seemed to represent activation of a single strain that persisted on the scalp.

PCR fingerprinting of Trichophyton mentagrophytes var. interdigitale using polymorphic subrepeat loci in the rDNA nontranscribed spacer

The sequence of the nontranscribed spacer (NTS) region of the rDNA of Trichophyton mentagrophytes var. interdigitale strain 2111 was determined, and three individual subrepeat loci identified. The first repeat region contained eight tandem copies of a degenerate 33-43 bp sequence, whilst the second had two complete and two partial 300 bp repeats. The third locus contained six tandemly repetitive elements of between 67 and 89 bp, which showed sequence identity to the TrS2 repeats of Trichophyton rubrum. PCR amplification of the individual repetitive regions from 42 random isolates of T. mentagrophytes var. interdigitale identified fragment length polymorphisms at each locus. Sequence analysis of the PCR products revealed that the size variations resulted from differences in the copy number of each of the three sets of subrepeat elements, TmiS0, TmiS1 and TmiS2. In addition, some indels were present in the flanking regions of the TmiS1 repeats. Combining PCR fingerprints from each of the three polymorphic loci produced a total of 19 individual strain profiles. The method was rapid, reproducible and discriminatory, and the fragment patterns simple to interpret. PCR fingerprint analysis of variable tandem repeat loci in the T. mentagrophytes var. interdigitale NTS represents a valuable molecular typing method for future epidemiological investigations in this species.

Review of in vitro activity of sertaconazole nitrate in the treatment of superficial fungal infections

The evaluation of susceptibility patterns of clinical and laboratory isolates of dermatophytes and Candida to sertaconazole nitrate has been determined using macrodilution and microdilution test methods in laboratories worldwide. Antimycotics that have been compared to sertaconazole nitrate include itraconazole, clotrimazole, miconazole, and terbinafine. A comparison of the minimum inhibitory concentrations clearly shows differences in potency and spectrum among the various agents. This article reviews the antifungal activity of sertaconazole nitrate against major fungal pathogens that cause and complicate tinea pedis. In light of the new topical formulation of sertaconazole nitrate, this compilation of data from the literature is helpful for relating in vitro data to the tissue concentrations required for effective eradication of cutaneous fungal infections.

Specific primers for rapid detection of Microsporum audouinii by PCR in clinical samples

This report describes application of PCR fingerprinting to identify common species of dermatophytes using the microsatellite primers M13, (GACA)4, and (GTG)5. The initial PCR analysis rendered a specific DNA fragment for Microsporum audouinii, which was cloned and sequenced. Based on the sequencing data of this fragment, forward (MA_1F) and reverse (MA_1R) primers were designed and verified by PCR to establish their reliability in the diagnosis of M. audouinii. These primers produced a singular PCR band of 431 bp specific only to strains and isolates of M. audouinii, based on a global test of 182 strains/isolates belonging to 11 species of dermatophytes. These findings indicate these primers are reliable for diagnostic purposes, and we recommend their use in laboratory analysis.

Pharmacokinetics of terbinafine in young children treated for tinea capitis

BACKGROUND

Dermatophytes are the most common cause of human fungal infections. Response rates to existing therapy are lower than optimal, but newer agents like terbinafine hold promise for improved management of such infections. This investigation was designed to evaluate the single dose and steady state pharmacokinetics of terbinafine in young children with tinea capitis.

METHODS

Twenty-two otherwise healthy children (4-8 years) with tinea capitis were eligible for enrollment. Children were treated with terbinafine once daily according to body weight (<25 kg, 125 mg; 25-35 kg, 187.5 mg), and pharmacokinetic sampling was conducted after the first dose, at the midpoint of treatment and at steady state. Plasma terbinafine concentrations were quantitated, and the pharmacokinetic indices compared with adult data.

RESULTS

Absolute estimates of Cmax and area under the concentration curve (AUC)0-24 were comparable between children and adults for the administered dose; however, children demonstrated significantly lower estimates of exposure when dose was corrected for weight (Cmax SS 200 +/- 104 versus 454 +/- 185 ng/mL per mg/kg dose, P < 0.01; AUCSS: 1110 +/- 640 versus 2756 +/- 1775 ng*h/mL per mg/kg dose, P < 0.01). When examined along a continuum, age accounted for approximately 50% of the variability observed in dose-normalized Cmax and AUC (P < 0.01). A slight but significant reduction in apparent oral clearance was observed with increasing age (0.02 L/h/kg per yr) that likely accounts for the lesser degree of accumulation observed in children at steady state (accumulation ratio, 1.5 +/- 0.8 versus 2.3 +/- 0.6, P < 0.01). Adverse events consisted principally of headache (n = 3) and gastrointestinal complaints (altered eating habits n = 3, loss of appetite n = 3, stomachache n = 4, diarrhea n = 2). A reduction in neutrophil count was observed in 5 children and thought to be related to study drug in 2.

CONCLUSIONS

Children require significantly larger weight-normalized doses to approximate the exposure estimates observed in adults. The dosing scheme used in this investigation results in absolute exposure estimates at steady state and a safety profile that are not appreciably different from adults.

Current use of anti-infectives in dermatology

Dermatologic diseases encompass a broad category of pathologic situations. Infection remains a significant aspect of the pathology faced in patient encounters, and it is natural to expect that anti-infectives play a major element in the armamentarium utilized by dermatologists. Aside from the treatment of the classic bacterial and fungal infections, there are now new uses for antiviral agents to help suppress recurrent disease, such as herpes simplex. There is also the novel approach of using anti-infectives, or agents that have been thought to have antimicrobial activity, to treat inflammatory diseases. This review describes anti-infectives, beginning with common antibiotics used to treat bacterial infections. The discussion will then cover the current use of antivirals. Finally, the description of antifungals will be separated, starting with the oral agents and ending with the topical antimycotics. The use of anti-infectives in tropical dermatology has been purposefully left out, and perhaps should be the subject of a separate review. Cutaneous bacterial infections consist chiefly of those microorganisms that colonize the skin, such as species of staphylococcus and streptococcus. Propionibacterium acnes and certain other anaerobes can be involved in folliculitis, pyodermas and in chronic conditions such as hidradenitis suppurativa.

Training Room Management of Medical Conditions: Sports Dermatology

Athletes' skin is subject to a distinct array of physical and environmental stressors. Trauma, the elements, and pathogenic organisms constantly challenge the skin's integrity. This article intends to arm the clinician with a fundamental knowledge of infections, mechanical injuries, and environmental insults common to the skin of athletes. Photographs corresponding to the described entities are included as figures. Because rapid return to play is the ultimate goal after injury or illness, there is a section dedicated to play restrictions as set forth by the National Collegiate Athletic Association. Although the evaluation and management of cutaneous disease is a challenging endeavor, a consistent and systematic approach to this most accessible organ can result in early diagnosis, appropriate treatment, and ultimate performance.

Optimal management of fungal infections of the skin, hair, and nails

Superficial fungal infections are chronic and recurring conditions. Tinea capitis is a scalp infection, primarily affecting prepubescent children. Ringworm infections, such as tinea corporis and tinea cruris, involve the glabrous skin. Tinea nigra is a rare mycotic infection that may be related to travel abroad. Piedra, black or white, is limited to the hair shaft without involvement of the adjacent skin. Pityriasis (tinea) versicolor and seborrheic dermatitis are dermatoses associated with yeasts of the genus Malassezia that affect the lipid-rich areas of the body. The taxonomy of the Malassezia yeasts has been revised to include nine species, eight of which have been recovered from humans. Tinea pedis, an infection of the feet and toes, is one of the most common forms of dermatophytosis. Onychomycosis is a fungal infection affecting the nail bed and nail plate; it may be chronic and can be difficult to treat. In instances where the superficial fungal infection is severe or chronic, an oral antifungal agent should be considered. Terbinafine, itraconazole, and fluconazole are oral antifungals that are effective in the treatment of superficial mycoses.

Tinea faciei, an often deceptive facial eruption

Tinea faciei is a relatively uncommon superficial dermatophyte infection limited to the glabrous skin of the face. It is usually seen in pediatric patients. This fungus can be found worldwide, but has a predilection for tropical humid climates. Although the infecting organisms and treatments are the same as for other superficial fungal infections, it is frequently misdiagnosed clinically and histologically.

Genetic Heterogeneity in the rRNA Gene Locus of Trichophyton tonsurans

Trichophyton tonsurans is the major pediatric pathogen in tinea capitis, causing disparate disease presentations. Little is known about genetic variation, which may ultimately be linked to divergent disease status. This investigation was aimed at identifying genetic variants of T. tonsurans by methods that can facilitate strain discrimination in population-based studies. Ninety-two isolates were acquired from six U.S. microbiology laboratories, and genomic DNA was isolated from mature colonies. The nontranscribed spacer (NTS) was amplified by PCR, and products from isolates with various amplicon sizes were fully sequenced. Nested amplification, targeting a variable internal repeat (VIR) region, allowed assignment of variant type by fragment size. Subvariant type was assigned by a combination of PCR-restriction fragment length polymorphism-based assays. Five variants differing in size (348 to 700 bp) and sequence were identified within the VIR region comprised of several large repeats (104, 140, and 194 bp) arranged in tandem. Seven single-nucleotide polymorphisms (SNPs) were detected across the NTS, with five occurring in the constant regions flanking the VIR region and two occurring in the VIR region. Additionally, a 10-bp insertion and a 14-bp deletion were identified upstream of the VIR region. The combination of SNPs revealed seven haplotype patterns which were stable upon serial passage over 1 year. No sequence variations were identified within the internal transcribed spacer regions. Unique NTS sequences were utilized to develop a duplex PCR assay that discriminated T. tonsurans from other dermatophytes. Of the 92 isolates evaluated, this genotyping scheme distinguished 12 distinct strains, providing evidence of genetic heterogeneity in T. tonsurans.

Tinea corporis, tinea cruris, tinea nigra, and piedra

Tinea infections are among the most common dermatologic conditions throughout the world. To avoid a misdiagnosis, identification of dermatophyte infections requires both a fungal culture on Sabouraud's agar media, and a light microscopic mycologic examination from skin scrapings. Topical antifungals may be sufficient for treatment of tinea corporis and cruris and tinea nigra, and the shaving of hair infected by piedra may also be beneficial. Systemic therapy, however, may be required when the infected areas are large, macerated with a secondary infection, or in immunocompromised individuals. Preventative measures of tinea infections include practicing good personal hygiene; keeping the skin dry and cool at all times; and avoiding sharing towels, clothing, or hair accessories with infected individuals.

New OTC drugs and devices 2002: a selective review

OBJECTIVES

To create a heightened awareness of two consumer issues confronting pharmacists in the self-care arena--consumers' need for accurate information about over-the-counter (OTC) products and consumers' attitudes and beliefs about OTC drugs--and to educate pharmacists about newly introduced nonprescription products, home screening devices, and home accessories.

DATA SOURCES

Recently published clinical and pharmaceutical industry literature and survey results from the National Council on Patient Information and Education.

DATA SYNTHESIS

Although changes have been made to labeling for OTC products to heighten consumers' awareness of the dangers associated with misuse of these products, consumers need the expertise of the pharmacist to guide them toward effective and safe self-care. It remains critical that pharmacists be knowledgeable about the numerous nonprescription products that become available on the U.S. market each year and take the initiative to counsel patients appropriately on the benefits and risks associated with their use.

CONCLUSION

Patients will continue to place an increasing emphasis on self-care. To assist them, pharmacists must remain up-to-date on trends and have an understanding of the nuances of consumers' behavior and thinking in relation to OTC products and their use. The new nonprescription medications and diagnostic screening devices discussed in this review article represent valuable additions to the growing array of self-care products.

Persistent and recurrent tinea corporis in children treated with combination antifungal/ corticosteroid agents

BACKGROUND

Combination antifungal/corticosteroid preparations are widely used by nondermatologists in the treatment of superficial fungal infections in patients of all ages. Over half of the prescriptions written for the most commonly used combination agent clotrimazole 1%/betamethasone diproprionate 0.05% cream (Lotrisone, Schering, Kenilworth, NJ) were prescribed for children younger than 4 years old. Our pediatric dermatology division has recently encountered a series of children with recurrent or persistent tinea corporis, especially tinea faciei, treated initially with combination antifungal/corticosteroid cream.

METHODS

All children evaluated for tinea corporis in a university hospital pediatric dermatology clinic from January through June 2001 were identified from the clinic registry for a retrospective chart review. Response to therapy was confirmed by telephone survey and/or follow-up visits at least 1 month after clearing of infection.

RESULTS

Six children ranging in age from 4 to 11 years were evaluated for tinea corporis in a pediatric dermatology clinic at our institution during the 6-month period. All 6 children were diagnosed clinically by their pediatrician with tinea corporis and initially treated with clotrimazole 1%/betamethasone diproprionate 0.05% cream for 2 to 12 months. In our pediatric dermatology clinic, patients had their diagnosis confirmed with a positive potassium hydroxide preparation and were treated with one of several oral or topical antifungal agents with clearing of all tinea infections.

CONCLUSION

The use of combination clotrimazole 1% cream/betamethasone diproprionate 0.05% cream (Lotrisone) for the treatment of tinea corporis may be associated with persistent/recurrent infection.

Cutaneous fungal infections in the elderly

Fungal infections are common in all age groups, including the elderly. In the elderly patient, unique challenges may exist in the diagnosis and treatment of these diseases. However, proper therapy for these prevalent conditions leads to a better quality of life.

Diseases of the foreskin, penis, and urethra

Diseases of the foreskin, penis, and urethra are uncommon conditions that constitute a small percentage of emergency department visits. However, it is important that the emergency physician recognize and treat these conditions and understand which conditions require urologic consultation. Rapid and proper treatment in the emergency department can alleviate patient discomfort, increase patient satisfaction, and prevent future morbidity.

Superficial fungal infection of the skin. Where and how it appears help determine therapy

Superficial fungal infections of the skin are a common presentation in clinical practice. Any skin surface, the mucous membranes, nail plates, and nail beds can be affected. Tinea pedis is the most common fungal infection and may affect up to 70% of the adult population worldwide. Ubiquitous candidal organisms are found in the oral flora of many healthy persons and result in infection in the presence of certain host factors or immunodeficiency disorders. Onychomycosis has had an increasing incidence worldwide, and it now accounts for almost half of all nail disorders. These and many other infections can have varying presentations as well as features that resemble nonfungal disorders. Therefore, it is important that primary care physicians are familiar with the many cutaneous fungal infections and their differential diagnosis to ensure that appropriate therapy is selected.

From Animal to Man: Tinea Barbae

Dermatophytic fungi cause human infection worldwide. One clinical syndrome--tinea barbae, which closely resembles tinea capitis--is a trichophytosis involving the beard and mustache areas of the face. The fungal agents responsible for tinea barbae (Trichophyton verrucosum and Trichophyton mentagrophytes) are contracted through occupational exposure to animals infected with zoophilic dermatophytes. Tinea barbae may be confused with other facial infections, especially those caused by Staphylococcus aureus or other facial dermatophytes (usually anthrophilic). In an afebrile patient without leucocytosis, a distinctive facial lesion, called a kerion, can be the essential diagnostic finding. Diagnosis requires suspicion based on appropriate exposure. Definitive diagnosis requires a combination of clinical examination, direct microscopic examination using potassium hydroxide, and culture confirmation. Topical treatment is not effective. Oral therapy with an antifungal (eg, terbinafine) or an azole is recommended. This article reviews these factors, as well as germane epidemiologic and prevention measures.

Fungal skin disorders

Fungal skin infections are becoming more common, and primary care physicians must be familiar with the diagnosis and treatment of these disorders. Dermatophyte infections including tinea pedis, corporis and cruris; pityriasis versicolor; and cutaneous candidiasis are the focus of this article. Common presentations of these disorders, the differential diagnosis, and current treatments are stressed. With the newer agents, shorter treatment courses can be used, and oral therapy for widespread, resistant, or recurrent infections is discussed.

Tinea gladiatorum: wrestling's emerging foe

Tinea corporis, or ringworm, has become a common nuisance in competitive wrestling. Although it is a fairly benign infectious skin disease, it has significant effects on the ability of a wrestler to compete because of infection control issues. Very little has been published in the medical literature describing this problem. The majority of the literature has described outbreaks in an isolated group of wrestlers. One must examine ringworm infections in wrestlers as an entity distinct from tinea corporis infections typically seen in the paediatric population, thus the term 'tinea gladiatorum'. Tinea gladiatorum outbreaks have been caused by the dermatophyte, Trichophyton tonsurans. The epidemiology and microbiology point to person-to-person contact as the main source of transmission in wrestlers. The clinical features of tinea gladiatorum may or may not be consistent with those found in the general population. Ancillary tests, including potassium hydroxide preparations and fungal cultures may have to be done to confirm the diagnosis. Treatment guidelines for tinea corporis have failed to produce the desired goals in this particular population. More research studying different treatment regimens in the wrestling environment is needed to define the optimal treatment to return wrestlers to competition quickly without putting other wrestlers at risk for infection. Intuitive hygiene practices have been suggested to prevent spread of the infection, but they have not been substantiated. Anecdotal reports suggest that hygiene practices fall short of producing adequate primary or secondary prevention. Pharmaceutical prophylaxis has been effective, but universal drug prophylaxis carries risks including drug adverse effects and potential drug resistance. The role of potential asymptomatic carriers of dermatophytes has yet to be elucidated in the origin and/or perpetuation of tinea gladiatorum outbreaks. There are many unanswered questions about tinea gladiatorum. Sports medicine professionals must work to define this entity more completely before making recommendations about treatment, prevention and infection control. The ultimate goal is the eradication of tinea infections from the wrestling world. Energy should be focused on primary and secondary prevention, as well as treatment. Without a thorough knowledge of tinea gladiatorum as a distinct disease entity, wrestling has been losing its battle with this formidable opponent.

Effectiveness of treatment of severe tinea pedis with 1% terbinafine cream in members of the Japanese self-defense forces

A clinical study was conducted to determine the efficacy of terbinafine cream in severe cases of tinea pedis. The subjects were 21 men, members of the Japanese Self-Defense Forces who were judged to have severe symptoms of tinea pedis. The description 'severe' was defined as 'considered to require the concurrent internal administration of antifungals for complete cure', or as meeting criterion 5 or 6 for the severity of tinea pedis. A simple surface application of terbinafine cream was given once daily, the subjects' clinical manifestations, mycological cure rates and safety-related changes were observed, and a final assessment was made in the 12th week. In the final assessment, the improvement rate of the cutaneous symptoms was 95.2%, and the fungal eradication and efficacy rates were 81.0%. As for side-effects, one patient complained of local irritation. These results suggested that terbinafine cream is a beneficial topical antifungal cream for severe tinea pedis.

Oral therapy of common superficial fungal infections of the skin

Although superficial fungal infections of the skin often respond to topical agents, systemic therapy is sometimes necessary. This article gives a review of the effectiveness of the oral antifungal agents fluconazole, itraconazole, and terbinafine in the treatment of pityriasis versicolor, tinea corporis/cruris, and tinea pedis. Four hundred milligrams fluconazole as a single dose and 200 mg itraconazole daily for 5 to 7 days were effective in the treatment of pityriasis versicolor; terbinafine taken orally appears to be ineffective in pityriasis versicolor. Tinea corporis and tinea cruris were effectively treated by 50 to 100 mg fluconazole daily or 150 mg once weekly for 2 to 3 weeks, by 100 mg itraconazole daily for 2 weeks or 200 mg daily for 7 days, and by 250 mg terbinafine daily for 1 to 2 weeks. Tinea pedis has been effectively treated with pulse doses of 150 mg fluconazole once weekly, with 100 mg itraconazole daily for 2 weeks or 400 mg daily for 1 week, and with 250 mg terbinafine daily for 2 weeks.

A ten-year survey of Tinea pedis in the central region of the Rio Grande do Sul, Brazil

Tinea pedis in the most common type of dermatophytosis, but can mimic many cutaneous diseases and tend to be chronic. We present a study of the frequency, epidemiology and clinical aspects of tinea pedis in the central region of Rio Grande do Sul during the period 1988-1997.

Common pediatric foot dermatoses

The pediatric foot dermatoses known as tinea pedis, shoe dermatitis, and juvenile plantar dermatosis are seen commonly in clinical practice. A knowledge of the clinical presentations and causes of these disorders can help pediatric and family nurse practitioners identify, diagnose, and treat childhood rashes of the feet. The conventional view in pediatrics is that small children rarely have tinea pedis. However, a 1992 study disputes this claim. Any child who has an atypical or persistent foot rash will need a referral or consultation.

Current and emerging azole antifungal agents

Major developments in research into the azole class of antifungal agents during the 1990s have provided expanded options for the treatment of many opportunistic and endemic fungal infections. Fluconazole and itraconazole have proved to be safer than both amphotericin B and ketoconazole. Despite these advances, serious fungal infections remain difficult to treat, and resistance to the available drugs is emerging. This review describes present and future uses of the currently available azole antifungal agents in the treatment of systemic and superficial fungal infections and provides a brief overview of the current status of in vitro susceptibility testing and the growing problem of clinical resistance to the azoles. Use of the currently available azoles in combination with other antifungal agents with different mechanisms of action is likely to provide enhanced efficacy. Detailed information on some of the second-generation triazoles being developed to provide extended coverage of opportunistic, endemic, and emerging fungal pathogens, as well as those in which resistance to older agents is becoming problematic, is provided.