Fungal Infections

February 25, 2012

Several Conditions Mimic Nail Fungus in Children

Several Conditions Mimic Nail Fungus in Children

Feb 2012

By: JEFFREY EISENBERG, Family Practice News Digital Network

As a pediatric dermatologist, Dr. Robert A. Silverman is all too familiar with this scenario: A child is referred to him with a diagnosis of nail fungus, and the parents are frustrated that the oral antifungal agents did not work.

What bothers him the most is not the antifungals, but that the patients didn’t need them to begin with because the child didn’t have a fungal infection, he said at the annual Hawaii Dermatology Seminar, sponsored by Skin Disease Education Foundation (SDEF). Several conditions of the nail in children can easily be mistaken for fungal infections.

Dr. Silverman of the department of pediatrics at Georgetown University Medical Center in Washington discussed how to distinguish fungal disease mimics from other pediatric nail conditions in children.

Onychomycosis, the most common nail infection in adults, is not all that common in children, Dr. Silverman said. Studies have shown the prevalence in children to be less than 3% in developed countries, although it is increased among children who have Down syndrome and HIV, or children from households with moccasintype Trichophyton rubrum. Clinical variants are similar to those that occur in adults, such as white superficial onychomycosis, distal lateral subungual onychomycosis, proximal subungual onychomycosis, and endonyx onychomycosis.

Other conditions that may be mistaken for fungal infections include:

• Psoriasis. Nail findings in patients who have psoriasis can be misinterpreted as fungal disease. Telltale signs of psoriasis in the nails, however, are large, irregular pits and the oil spot sign.

• Subungual tumors. These include subungual exostosis and onychomatricoma. These benign growths push on the skin surface, leading to separation of the nail. “Some people think fungus when it’s really a tumor of the underlying bone,” Dr. Silverman said.

• Pachyonychia congenitaThough often confused with fungal disease, this condition, which involves a single thickened toenail, is somewhat rare. “If someone came in with a thick toenail, I’d culture him or her,” Dr. Silverman said. “If the culture is negative, then you have to start thinking of these other conditions.”

• Alopecia areata. Children may have nail signs of alopecia areata before hair loss occurs. In alopecia areata, the nail surface is studded to near confluence with tiny pits, also known as Scotch plaid nails. Also, the nail will have lost its luster and has a sandpaperlike texture.

“If you see what looks like alopecia areata of the nail, but don’t see any hair findings, you ought to scrape the nail to rule out fungus, because fungus can look like alopecia areata of the nails,” Dr. Silverman said. “And, of course, then you would want to treat it.”

Treatment for fungal infections requires the use of an oral agent for 6-12 weeks, so Dr. Silverman emphasized the importance of obtaining a culture. “If you’re going to treat someone for that length of time, it makes sense to know exactly what you’re treating,” he said.

Also, Dr. Silverman said, any time he sees that a child’s parent appears to have a fungal infection, he considers that to be a red flag when trying to diagnose the patient.




October 29, 2008

Jock Itch Tinea Cruris

Jock Itch Tinea Cruris

Jock itch, also known as tinea cruris, is a fungal infection of the skin in the groin. The warm, moist environment is the perfect place for the fungus to grow. Anything that enhances that environment puts the person at risk of getting jock itch. Therefore, wearing sweaty, wet clothing in the summer time or wearing several layers of clothing in the wintertime causes an increased incidence of jock itch. Men are affected more often than women.

The Jock Itch Fungus
The fungus that most commonly causes jock itch is called Trichophyton rubrum. It also causes fungal infections of the toes and body. Under the microscope, this fungus looks like translucent, branching, rod-shaped filaments or hyphae. The width of the hyphae is uniform throughout which helps distinguish it from hair, which tapers at the end.

Some hyphae appear to have bubbles within their walls, also distinguishing them from hair. Under most conditions these fungi inhabit only the dead skin cells of the epidermis.

Jock Itch Appearance
The rash of jock itch starts in the groin fold usually on both sides. If the rash advances, it usually advances down the inner thigh. The advancing edge is redder and more raised than areas that have been infected longer. The advancing edge is usually scaly and very easily distinguished or well demarcated. The skin within the border turns a reddish-brown and loses much of its scale. Jock itch caused by T. rubrum does not involve the scrotum or penis. If those areas are involved, the most likely agent is Candida albicans, the same type of yeast that causes vaginal yeast infections.

Rashes Similar to Jock Itch
There are other rashes of the groin that can cause symptoms similar to jock itch. The first is called
intertrigo which is a red, macerated rash at the groin fold not caused by a fungus. It is seen many times in obese patients and caused by moist skin rubbing against moist skin. The skin cracks and breaks down in lines called fissures, which can be very painful. These fissures can get secondarily infected with fungi or bacteria. The edge of the rash usually does not advance until much later in the life of the rash.

The other condition that mimics tinea cruris is called erythrasma. This is a bacterial infection that affects the groin and advances down the inner thigh similar to tinea cruris. However, the rash of erythrasma is flat and more brown than red throughout the affected area. It also does not have any scale or blisters.

Jock Itch Diagnosis
The best way to diagnose tinea cruris is to look for hyphae under the microscope, a
KOH test. The skin is scraped with a scalpel or glass slide causing dead skin cells to fall off onto a glass slide. A few drops of Potassium hydroxide (KOH) are added to the slide and the slide is heated for a short time. The KOH dissolves the material binding the skin cells together releasing the hyphae, but it does not distort the cell or the hyphae. Special stains such as Chlorazol Fungal Stain, Swartz Lamkins Fungal Stain, or Parker’s blue ink can be used to help visualize the hyphae better.

Jock Itch Treatment
Jock itch is best treated with topical creams or ointments since the fungus only affects the top layer of skin. Many of the antifungal medications require a prescription, but there are three that can be bought over-the-counter (OTC). The OTC antifungals are tolnaftate (Tinactin), clotrimazole (Lotrimin), and miconazole (Micatin). Creams used to treat jock itch should be applied twice a day for at least two weeks. Application can be stopped after the rash has been gone for one week. Creams should be applied to the rash and also at least two finger widths beyond the rash. Many people with jock itch also have athlete’s foot and these same creams can be applied to the feet. However, treatment of athlete’s foot can take up to four weeks. If the rash is very red and itchy, especially if it has blisters at the edge, a topical steroid such as hydrocortisone can be applied also. Steroids should not be used in the groin alone without consulting a health care provider since steroids alone can make the rash of jock itch much worse.

Jock Itch Prevention
To prevent jock itch from occurring or re-occurring, several measures may be taken.

  • Wear loose fitting clothing made of cotton or synthetic materials designed to wick moisture away from the surface.
  • Avoid sharing clothing and towels or washcloths.
  • Allow the groin to dry completely after showering before covering with clothes.
  • Antifungal powders or sprays may be used once a day to prevent infection.


Jock Itch

Game over! It was a hard-fought match, and you’ve just won in the final seconds. Now, as you bask in the afterglow of sweet victory, you think about all the great things you’re going to get from your sweaty efforts – admiring glances, bragging rights, a medal, a trophy, maybe even a mention in the local paper. But suddenly, your celebration is interrupted. Something’s not quite right. You’re feeling a little itchy and uncomfortable in a strange area due south. And it’s starting to burn. Yes, it’s something else you got for your athletic efforts, something you really didn’t expect and really didn’t want – jock itch.

What Is Jock Itch?
Jock itch is a pretty common fungal infection of the groin and upper thighs. It’s part of a group of fungal skin infections called tinea (pronounced: tih-nee-uh), and it’s related to athlete’s foot and ringworm (by the way, ringworm isn’t really a worm – it’s a fungus). The medical name for all of these types of fungal infections is a tinea infection, and the medical name for jock itch is tinea cruris (pronounced: tih-nee-uh krur-us).

Jock itch, like other tinea infections, is caused by several types of mold-like fungi called dermatophytes (pronounced: dur-mah-tuh-fites). All of us have microscopic fungi and bacteria living on our bodies, and dermatophytes are among them. Dermatophytes live on the dead tissues of your skin, hair, and nails and thrive in warm, moist areas like the insides of the thighs. So, when your groin area gets sweaty and isn’t dried properly, it provides a perfect environment for the fungi to multiply and thrive.

Who Gets Jock Itch?
You don’t have to be a jock to get an itch in your groin area. Jock itch is so named because mostly athletes or “jocks” get it, but it can affect anyone who tends to sweat a lot. It most often affects guys, but girls can get it, too. Certain factors can make jock itch more likely to develop, like lots of sweating while playing sports, hot and humid weather, friction from wearing tight clothes for extended periods (like bathing suits), sharing clothes with others, diabetes mellitus, or obesity.

What Are the Signs and Symptoms?
Jock itch is usually less severe than other tinea infections, but can it last for weeks or months without treatment. Symptoms of jock itch include:

  • a circular, red, raised rash with elevated edges
  • itching, chafing, or burning in the groin, thigh, or anal area
  • skin redness in the groin, thigh, or anal area
  • flaking, peeling, or cracking skin

How Do I Get Rid of It?
Jock itch usually responds to self-care, and using over-the-counter antifungal creams and sprays will probably clear it up, though prescription antifungal creams are sometimes required. Be sure to:

  • Wash, then dry the area using a clean towel.
  • Apply the antifungal cream, powder, or spray as directed on the label.
  • Change your clothes, especially your underwear, every day.

It’s important to continue this treatment for 2 weeks, even if symptoms disappear, to prevent the infection from recurring. If these steps don’t work, it’s a good idea to see a doctor. Sometimes, a doctor may need to prescribe a stronger antifungal cream, spray, or pill.

Can I Prevent Jock Itch?
Good hygiene is the most important thing that helps prevent jock itch. Keep the area as dry as possible by always using a clean towel after showering or swimming (also remember to avoid sharing towels). If you play sports and wear an athletic supporter, make sure you wash it as often as possible.

Jock itch is pretty common, but can be avoided through proper care and attention. Be sure to keep your groin area clean and dry, especially after strenuous and sweaty activity. If you do get jock itch, remember that it almost always goes away on its own.

Updated and reviewed by: Eliot N. Mostow, MD
Date reviewed: May 2004
Originally reviewed by:
Patrice Hyde, MD


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