Ringworm
What is Ringworm?
Dermatophytosis, also called ringworm or tinea, is a superficial and keratinized (any tissue with a high keratin content like the epidermis) fungal infection of the skin, hair and nails. The skin infections on the body may appear like red, enlarged, raised rings. If the nails are affected, they will look thick, discolored and will finally crumble and fall off. Statistics show that ringworm affects about 20% of the adult population worldwide. Ringworm usually gets worse in summer. The symptoms sometimes reduce during the winter. Besides humans, this disease affects animals such as pet dogs and cats. It can be transmitted between animals and humans (zoonotic disease).
The disease process in Dermatophytosis is unique for two reasons: Firstly, no living tissue is invaded. The keratinized tissue is simply colonized by the fungi. However, the presence of the fungus and its metabolic products usually induces an allergic and inflammatory response in the patient. Ringworm occurs in adults and children of both sexes and as well as all races.
Symptoms of Ringworm
The symptoms of Ringworm or Dermatophytosis vary depending on the kind of fungus causing it. Some of the symptoms are:
01) Small, spreading bumps (papules) progressing to inflamed, pus-filled lesions, patchy hair loss with scaling – Tinea capitis
02) Lesions in the bearded area as folliculitis (damage of hair follicles by friction) – Tinea barbae
03) Dry/scaly or moist/crusty, flat skin lesions in affected area (except scalp, bearded skin, feet). As they enlarge, the centers heal and produce a classic ring-shaped appearance – Tinea corporis
04) Raised, sharply defined and itchy red lesions in the groins, buttocks, inner thighs and external genitalia – Tinea cruris
05) Gradual thickening, discoloration and crumbling of the nails and especially toe nails. Eventually, the nail may be completely destroyed – Tinea unguium
06) Extremely itchy, scaly and painful blisters between toes – Tinea pedis
07) Mild, superficial infection of the torso with tan, pink, white or brown macules (flat patches) lesions - Tinea versicolor.
Diagnosis of Ringworm
Diagnosis must first check for other possible causes of the symptoms including eczema, psoriasis and contact dermatitis. After this elimination process, other tests are carried out.
Woods ultraviolet lamp: This examination is used in some cases as certain species of ringworm will show clearly under fluorescent light.
Microscopic examination: Microscopy and culture are the most commonly used methods. Using a blunt scalpel, tweezers or a bone curette, some skin-scrapings, nail scrapings and epilated samples are taken for microscopic examination. Keratin debris beneath the free edge of the nail is also collected. Skin and nail specimens are scraped directly onto special black cards which make it easier to see how much material has been collected as the laboratory needs sufficient quantity of specimen to perform both microscopy and culture.
The culture is called KOH (potassium hydroxide) preparation. Culture of the affected area may help identify the infecting organism. Microscopy results take 24 hours but culture may take several weeks for accurate diagnosis. Direct microscopic examination is usually performed using clearing reagents like KOH or Amman’s chloral-lactophenol. Stains or fluorochromes like Congo red or Calcofluor white are also employed. Culture is often more reliable as compared to microscopy and permits the accurate identification of the species of fungus involved. Subcultures on culture medium which stimulate conidiation for some species and the production of pigments are sometimes necessary. Conidiation is where filamentous fungi asexually form spores.
Caution: Repeat collections should always be considered in cases of definite suspicion of Dermatophytosis with negative laboratory results, or this could result in misdiagnosis.
Causes of Ringworm
Dermatophytes: Dermatophytosis (tinea or ringworm) of the scalp, glabrous skin, and nails is caused by a closely related group of fungi known as dermatophytes. These dermatophytes have the ability to utilize keratin as a source of nutrition, i.e. they have a unique enzymatic capacity (keratinase). The usual dermatophytes causing Ringworm are genera Trichophyton and Microsporum.
Contact with infected person: Transmission of the disease can occur directly through contact with infected lesions of another person. It can also occur indirectly through contact with articles such as shoes, towels or shower stalls used by an infected person. Contact sports like wrestling put a person more at risk from this disease.
Weather: Living in hot and humid climatic conditions is conducive to getting this disease.
Clothing: Wearing tight clothes during warm weather conditions encourages fungal growth.
Other diseases: Other skin disorders like psoriasis in the skin folds can cause fungal infections and ringworm. Also, diabetes or any infections that adversely affect the immune system can also cause ringworm.
Contact with pets: Frequent contact with infected pet animals can cause fungal infection and ringworm in a person, as this disease is easily transmitted between humans and animals.
Medications: Immunosuppressive medications being taken after organ transplantation can be another cause of tinea or ringworm.
Types of Ringworm
Ringworm (tinea or Dermatophytosis) can be categorized by the location of the affected area of the body. The various types are:
a) Tinea faciei is infection on the facial skin
b) Tinea barbae is infection under the facial hair or beard
c) Tinea corporis is infection on the arms, legs and trunk
d) Tinea pedis (athlete’s foot) is infection on the feet
e) Tinea unguium is infection of the fingernails and toenails
f) Tinea cruris (jock itch) is infection in the groin area
g) Tinea manuum is infection on the hands and palms
h) Tinea capitis is infection on the scalp.
Treatment of Ringworm
Most cases of ringworm resolve with treatment, without leaving behind any scars or other residual effects. But sometimes it recurs, especially if the person is frequently exposed to probable infections of dermatophyte fungi, like in the case of wrestlers. As the treatment may take several weeks and sometimes as long as 3 months, there are several measures one needs to take for effective treatment of ringworm.
Low sugar diet: Fungi thrive on sugar so limited amount sugar, including fruits, must be consumed.
Medicated wash: The affected area must be washed with chlorhexiderm with 1% concentration daily before applying medicated cream or lotion.
Topicals: Uncomplicated single cutaneous lesions can be adequately treated with topical antifungal creams or lotions. Over the counter (OTC) anti-fungal creams like Nystatin or creams containing clotrimazole, miconazole or terbinafine can be applied once or twice a day. Selenium sulfide lotion is also used for treatment.
Shampoos: Anti-fungal shampoos like 
those containing ketoconazole can be used, but as they are not as effective as creams or lotions, they have to be used in conjunction with other prescribed treatment.
Sulfur dip: The patient can dip the affected part of the body in a solution of Lime Sulfur with 2% concentration and pat-dry with a towel (not rub). This should be done once a week till symptoms last.
Caution: Care should be taken not to get the solution in and around eyes or nose.
Pharmacotherapy: Chronic or widespread Dermatophytosis, nail infections, or those involving the sole of the foot usually also require systemic therapy. Anti-fungal oral medications like Griseofulvin, Terbinafine, Itraconazole Fluconazole, and Ketoconazole are prescribed for 3 to 4 weeks.
Steroids: Corticosteroids are used in the treatment of severely inflamed or potentially scarring lesions like those of the scalp.
Combination therapy: A combination of systemic (oral) antifungal and systemic corticosteroid therapy is required if the inflamed lesions are draining purulent (pus) substance.
Living with Ringworm
Ringworm (tinea or Dermatophytosis) adversely affects the quality of life of the person as long as the infection persists. It is not a life-threatening disease, but an ailment, if treated on time, can subside within a few months. But while the symptoms last, they case discomfort due to constant itching and pain. Also, the skin is sore and red, thus marring the appearance of the person. Thirdly, if it affects the eyes or nails it can hamper the day-to-day activities of the patient as long as the symptoms last. This can cause irritation and loss of self-esteem for a while.
Prevention of Ringworm
There are various ways in which the infection of Dermatophytosis (Ringworm or tinea) can be prevented by preventing conditions conducive to fungal growth:
1) Keep the skin dry as moistness and warmth favor fungi
2) Wear loose fitting underclothes as tight clothes plus moistness are favorable conditions for fungi
3) Socks should be changed daily and reusing should be avoided
4) Open-toed footwear can help keep feet dry
5) Maintain good personal hygiene, especially of the hands, feet and genitals
6) Keep immunosuppressive medication needed for other ailments to the minimum
7) Avoid sharing clothing or equipment such as hats, helmets or gym mats without sanitizing them between users if infection is suspected
Showering after exercise and changing into clean dry clothing can prevent accumulation of moisture on the skin.
