• Fungal or tinea infections of the skin are common, with tinea corporis (ringworm) and tinea cruris (jock itch) affecting 10 to 20% of the general population at some point in their lifetime.
  • Outbreaks often occur in athletes that have skin to skin contact. It is common in wrestlers & is known as tinea corporis gladiatorum.
  • Men are more often affected than women.
  • Superficial fungal infections of the skin are caused by three dermatophytes; Trichophyton, Epidermophyton and Microsporum which use the keratin layer of the epidermis as their source of nutrition.
  • Predisposing factors can contribute to dermatophyte infections including:
    • conditions that increase moisture such as occlusive clothing or shoes and warm, humid climates
    • impaired immunity states (e.g., diabetes, HIV infection, chemotherapy)
    • genetic predisposition can also increase susceptibility to dermatophyte infection
  • Tinea infection is classified by location on the body, not by the causative organism.
  • Tinea infections are contagious and are spread by skin-to-skin contact with infected humans or animals (most commonly dogs, cats, guinea pigs, horses), by contact with surfaces that have been in contact with infected humans or animals, and less often by prolonged contact with dirt that harbors tinea organisms.

For more information and photos, go to:

Skinsight.com
DermNet NZ

  • Presents as a small, round, red spot on the neck, trunk or limbs- usually on smooth, hairless areas.
  • Gradually expands outward in a circular pattern
  • Patch has well-defined borders with central clearing 
  • Edges are bumpy or scaling
  • Prominent itching +/- burning 
  • Lesion is typically from 1 to 5 cm in diameter
  • Outbreaks common in close-contact sports

Rule out the following conditions which can resemble tinea corporis. With the exception of seborrheic dematitis, these conditions do not respond to topical antifungal treatment.

  • Bacterial infections such as impetigo - pustules with honey-colored crusts or fluid-filled blisters.
  • Seborrheic dermatitis - appears as yellow or white, greasy, flaky scales on scalp and may extend down to face and upper chest in the form of circular scaly pink patches. In some cases can also affect skinfolds in groin. May respond to self-care treatment. More severe cases should be referred to the patient's primary care provider.
  • Nummular (discoid) eczema - appears as small round plaques of small papules and blisters, usually on arms, neck and legs. Very itchy, can may persist for months.
  • Psoriasis - presents as red spots covered with thick silver scales, with no central clearing. Refer to patient's primary care provider.
  • Pityriasis rosea - is a viral rash that lasts 6 to 12 weeks, beginning with a "herald" patch: a small, scaly, pink-coloured lesion on the trunk. It starts as a single patch which may be mistaken for tinea corporis. Often preceded by an upper respiratory tract infection. Self-limiting condition.
  • Allergic contact dermatitis - itchy rash caused by reaction to a substance that has come in contact with the skin, usually confined to the area exposed to the allergen.
  • Lichen Simplex - an area of thickened skin with small bumps and/or scaling caused by chronic rubbing or scratching due to itchiness. Does not respond to antifungals. Refer to patient's primary care provider.
  • Lupus erythematosus - may present as an itchy or painful rash most commonly on face but can also occur on the chest and back. Refer to patient's primary care provider.
  • Lyme disease - may resemble ringworm without scales at the site of a tick bite. It has a typical bull's-eye appearance starting around the bite and spreading outward. Refer to patient's primary care provider.
  • Tinea capitis - infection of the scalp involving skin surrounding the hair shaft. It is most common in children and if left untreated, can cause scarring and permanent hair loss. Topical treatment does not work; systemic antifungals are required. Refer to patient's primary care provider.
  • Tinea incognito - occurs when a fungal infection is inappropriately treated with steroids, causing the lesion to become less grouped, and the scaly border vanishes.

Most patients with typical signs and symptoms of tinea corporis (ringworm) do not require further investigation, however an assessment by the patient's primary care provider should be recommended in the following situations:

  • If the lesions are:
    • Extensive (diameter > 5 cm and/or multiple lesions).
    • Severely inflamed
    • Weeping or purulent
    • Painful
    • Disabling
    • On the scalp
  • Previous tinea corporis infection which did not fully resolve, despite appropriate treatment. Refer for evaluation and possible systemic treatment.
  • No improvement after 1 week of pharmacologic treatment. Refer for an evaluation.
  • Patient has uncontrolled or advanced diabetes or is immunocompromised due to disease state or drug treatment.
  • Patient has symptoms of systemic illness (e.g. fever, fatigue, swollen lymph glands).
  • Unable to confirm patient self-diagnosis of tinea corporis. Further evaluation is required. (See Differential Diagnosis above).

Treatment is recommended to alleviate symptoms, reduce risk of bacterial infection and limit the spread to other areas of the body or to other individuals. 

1. Non-pharmacologic treatment for tinea corporis:

  • Skin should be kept dry to help stop infection from spreading.
  • Avoid rubbing or scratching lesions.
  • Use a hair dryer on cool setting to dry the affected area.
  • Wear loose fitting, cotton clothing or moisture absorbing synthetics.
  • Launder items used by infected person separately and often.
  • Have pets examined by a veterinarian to make sure that they are not carrying a fungal infection. Be sure to have the animal treated if it is a carrier.
  • Use of non-medicated powders may help absorb moisture. Do not use cornstarch or powders that contain cornstarch as these may provide nourishment for the tinea organism.
2. Over-the-counter drug options for treating tinea corporis:
  • OTC anti-fungal agents are available in a variety of dosage forms; creams, lotions, gels, solutions, sprays and powders. Generally, creams and lotions are most effective because they can be massaged into the affected area, increasing contact time of the medication.
  • Solutions may be easier to apply to hairy areas. Sprays and powders can be useful as adjunctive treatment, especially for oozing lesions and as preventative agents.
  • Available agents: 
    • Tolnaftate 1% available in solution, gel, powder, cream, spray
    • Clotrimazole 1% available in cream
    • Miconazole 2% available in cream, powder, spray
      *azoles are generally more effective than tolnaftate
  • OTC anti-fungal treatments have been shown to be effective in treating and curing tinea infections of the skin, but they may require a longer duration of treatment than prescription agents.
  • Directions for application of creams and solutions should include:
    • Instructions to clean and dry the area first, and to apply product to visible lesions as well as 2cm surrounding the area of visible infection. This will help treat fungus which is in the process of spreading.
    • Massage cream into area TWICE a day for 4 weeks. Products should continue to be used for 1 week after symptoms resolve to help prevent recurrent infection.
  • Pregnancy / Lactation
    • Clotrimazole and miconazole are the agents of choice in pregnancy and breastfeeding.
    • Tolnaftate has not been thoroughly studied in pregnancy and lactation.
    • In general, systemic absorption of topical antifungals through intact skin is not expected, therefore, negligible amounts of drug would be expected to cross into breast milk and reach the nursing infant.
    • If treatment is required to a large area of skin in pregnancy, patients should be referred.

3. Prescription drug options for treating tinea corporis:

Terbinafine 1% Cream and Terbinafine 1% Spray

  • Terbinafine has a broad spectrum of anti-fungal activity. It is fungicidal to dermatophytes via interference with fungal sterol biosynthesis.
    • Directions for application of cream & spray should include:
      • Instructions to clean and dry the area first, and to apply product to visible lesions as well as 2cm surrounding the area of visible infection. This will help treat fungus which is in the process of spreading.
      • Children > 12 years old and Adults: Massage cream into area ONCE a day for 1 week only
    • Symptoms continue to improve for up to 4 weeks after treatment. [therefore, no need to apply for a longer duration]. Two weeks of treatment provided slightly better results than one week but may not be clinically significant.
    • Less than 5% is absorbed after topical application. Half-life is 14-35 hours in the stratum corneum.
    • Pregnancy: There are only limited clinical studies; current recommendations are to avoid during pregnancy. However, it is not expected to increase the risk of birth defects.
    • Clotrimazole and miconazole are the agents of choice in pregnancy, but application to large areas should be avoided & patients should be referred. 
    • Lactation: With topically applied cream and spray treatment, the small amounts absorbed through the skin are unlikely to affect the infant. Terbinafine should not be applied to the breast. Avoid contact between infant and treated skin area as safety of terbinafine has not been established in children.
    • Pediatrics: Topical terbinafine has not been studied in children <12, so should not be recommended.

Ketoconazole 2% Cream
  • Ketoconazole is fungicidal to tinea dermatophytes by interfering with fungal sterol biosynthesis.
    • Directions for application of cream should include:
      • Instructions to clean and dry the area first, and to apply product to visible lesions as well as 2cm surrounding the area of visible infection. This will help treat fungus which is in the process of spreading.
      • Children > 12 years old and Adults: Massage cream into area ONCE to TWICE a day for 3 to 4 weeks. Products should continue to be used for 1 week after symptoms resolve to help prevent recurrent infection.
    • Treatment should meet, but not exceed recommended duration as safety for longer periods has not been established.
    • Systemic absorption is minimal to undetectable.
  • Pregnancy: Adverse effects are noted in animal studies with oral ketoconazole. Systemic absorption is very low suggesting that ketoconazole is unlikely to have adverse effects but there is no data to confirm safety.
  • Clotrimazole and miconazole are the agents of choice in pregnancy but application to large areas should be avoided & patients should be referred. 
  • Lactation: The effect on a nursing infant is unknown, but does not appear to be clinically significant. The American Academy of Pediatrics classifies ketoconazole as compatible with breastfeeding. 
  • Pediatrics: Safety and efficacy has not been established in children. Topical ketoconazole has been used without unusual adverse effect in a limited number of children.

Steroid or combination steroid/anti-fungal products should not be recommended. The itch caused by tinea infections subsides fairly soon after topical antifungal treatment begins. Extended treatment with these products may unnecessarily expose patients to steroid side effects.

Topical nystatin is ineffective.

  • Discuss and recommend appropriate non-pharmacologic measures.
  • Improvement of symptoms such as itching and burning should occur within a few days.
  • The patient should be instructed to avoid direct skin contact or sharing clothing or personal items with others restrict activities such as wrestling or swimming.
  • Ensure treatment is used for the recommended duration & for 1 week after symptoms resolve.  (Exception: Terbinafine- which only requires 1 week of treatment) 
  • Ensure the topical product is applied to the entire area including 2cm of the surrounding area. 
  • If no improvement after 1 week of topical treatment, patient should see their primary care provider. 
  • If symptoms worsen, contact the patient's primary care provider.

Assess Benefit

  • Follow-up in 7 days to assess initial effect.
  • Refer to patient's primary care provider if:
    • Symptoms not improving
    • New lesions have appeared, or affected area is spreading
    • Pain, swelling or more redness has occurred
    • Patient has signs of systemic illness- fever, fatigue, malaise, etc.
    • Severe sensitivity to medication
  • If symptoms are improving, advise patient to continue treatment for recommended duration &  for 1 week after symptoms resolve. (Exception: Terbinafine- which only requires 1 week of treatment) 

Assess Adverse Effects

  • Minor redness, itching or stinging does not usually require discontinuation.
  • If symptoms persist or are severe, may indicate contact dermatitis reaction to components of cream. Advise patient to stop therapy and refer to patient's primary care provider.

Detailed information on contraindications, cautions, adverse effects and interactions is available in individual drug monographs in the CPS (e-CPS), Lexi-Comp, AHFS, www.drugs.com or other reliable drug monograph references. For comprehensive drug comparisons, see RxFiles charts (www.rxfiles.ca). This information should be routinely consulted before prescribing.

OTC Products

Ingredient

Brands

Dosage / Directions

Tolnaftate 1%

Tinactin
Generics

Apply TWICE daily for 4 weeks.

Recommend using for ONE week after symptoms resolve to prevent recurrence.

Clotrimazole 1%

Canesten
Generics

Miconazole 2%

Micatin
Monistat
Generics

Prescription Products

Ingredient

Brands

DIN

Dosage / Directions

Terbinafine 1% cream

Lamisil cream

02031094

Adults and children ≥12:

Apply ONCE daily for 7 days. Improvements persist for up to 4 weeks

Terbinafine 1% spray

Lamisil spray

02238703

Ketoconazole 2% cream

Ketoderm

02245662

Adults and children ≥12:

Apply ONCE or TWICE daily for 3-4 weeks.

Recommend using for ONE week after symptoms resolve to prevent recurrence.

Maximum duration 4 weeks. 

  • pseudoDIN: 00951101
    • Max of 4 claims per 365 days per patient
    • All "tineas" use the same pseudoDIN and thus have a max of 4 claims per 365 days per patient altogether.

  • May prescribe sufficient quantity to treat ONE episode of tinea corporis.
    • You may prescribe an OTC product, however, they are not eligible for billing the assessment fee. 
    • Terbinafine: ONCE daily for 7 days only (long duration of action of up to 4 weeks, longer treatment not needed)
    • Ketoconazole: ONCE or TWICE daily for 3-4 weeks. Continue for an additional week after full resolution.
    • For help prescribing the proper quantity of topicals using finger-tip units, see: http://dermnetnz.org/treatments/fingertip-units.html

  • Only products with an official indication from Health Canada for tinea corporis are considered for these guidelines. Only the active ingredients in the "products" section are approved for pharmacist prescribing.
  • Drugs in Pregnancy and Lactation, 6th edition: Gerald G Briggs BPharm, Roger K Freeman MD, Sumner J Yaffe MD By Lippincott Williams & Wilkins Publishers (November 2001) Dynamed Database, Cochrane Database Syst Rev 2014 Aug 4;(8):CD009992
  • Haaf M. Use of anti-infective agents during lactation, Part 3: Antivirals, antifungals, and urinary antiseptics. Journal of human lactation 2001;17:160-6
  • Miller P. Dermatological Conditions: Fungal Skin Infections. CTMA. In: RxTx [Internet]. Canadian Pharmacists Association. Available from: http://www.e-therapeutics.ca. (In Saskatchewan available through www.shirp.ca.)
  • Mallen A. Athlete’s foot. CTMA. In: RxTx [Internet]. Canadian Pharmacists Association. Available from: http://www.e-therapeutics.ca. (In Saskatchewan available through www.shirp.ca.)
  • Stone S. Antifungal treatment chart. In: RxFiles. Available at www.rxfiles.ca by subscription. (In Saskatchewan available through www.shirp.ca.)
  • Tinea corporis. In: DynaMed. Available at https://dynamed.ebscohost.com/ by subscription. (In Saskatchewan available through www.shirp.ca.
  • Goldstein A, Goldstein B. Dermatophyte (tinea) infections. In: UpToDate. Available at www.uptodate.com by subscription.
  • Fungal skin or nail infections.In: C-Health. chealth.canoe.ca. (Free access)
  • Ringworm In: Mayo Clinic. www.mayoclinic.org. (Free access)
  • )Ringworm or tinea. In Bluebook – Guidelines for the control of infectious diseases http://ideas.health.vic.gov.au/bluebook/ringworm.asp (Free access)

No part of this work may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the copyright holder. For copyright permission requests, please contact druginfo@usask.ca.

Prepared by medSask, Your Medication Information Service
Reviewed by Dr. P. Fourie, Family Physician and Dr. Yvonne Shevchuk, Professor, College of Pharmacy & Nutrition
 Sponsored by the Saskatchewan College of Pharmacy Professionals
Posted May 2010. Updated May 2017