Ringworm

The symptoms of ringworm depend upon the location of the body invaded by the fungi but they broadly include:

• Itchy or scaly patches that are red, brown, or grey, or raised areas of skin called plaques
• Patches that develop blisters or pustules
• Patches that resemble a ring with a deeper color on the outside
• Patches with defined and raised edges
• Overlapping rings
• Hair loss

Depending upon the site of infections, a person may experience the following clinical manifestations:

1. Feet (tinea pedis or athlete’s foot)
   It is the most common type of tinea infection. It usually occurs in men and young adults but can also affect children, women, and older people. It is characterized by:
   • Red, swollen, peeling, and itchy skin between the toes
   • Whitening of the skin between the toes
   • Scaling of the feet
   • Blisters on the foot
2. Scalp (tinea capitis)
   This type of infection involves the skin and hair and usually affects children more than adults. Symptoms include:
   • Hair loss
   • Dry scaly areas on the scalp
   • Itching on the scalp
   • Bald patches on the scalp
3. Beard (tinea barbae)
   This infection affects the beard and mustache areas of the face and usually affects only adult men. The infections can be recognized by the following symptoms:
   • Presence of lumps around the hairs
   • Easily pulling out of the hairs
   • Presence of bald patches and itchy red spots on the cheeks, chin, and around the neck
   • Fatigue
   • Swollen lymph nodes
4. Body (tinea corporis)
   This type of fungal infection can affect any part of the body except the hands, feet, scalp, face, beard, groin, and nails. The typical symptoms of tinea corporis include:
   • Pink to red round patches on the skin
   • Itching
5. Nails (tinea unguium)
   Also known as onychomycosis, it is the fungal infection of the fingernails or toenails. Onychomycosis affects toenails more often than fingernails and is most common among persons who have tinea pedis. It is more common in older adults and in persons with vascular disease, diabetes mellitus, and trauma to the nails. The nails of a person infected with tinea unguium are:
   • Discolored
   • Thick
   • Fragile
   • Cracked
6. Hands (tinea manuum)
   This refers to the fungal infection of the hands and involves the following changes:
   • A ring-shaped, scaly rash
   • Itchiness
   • Clear, scaly, or bumpy center of the ring rash
   • Slightly raised rings
   • A round patch of itchy skin
7. Groin (tinea cruris)
   This type of fungal infection often affects the skin of the genitals and can spread to the upper inner thighs. The symptoms include:
   • Rash that can be painful or painless
   • Burning sensation in the groin area
   • Continuous itching

The causative organism behind ringworm infection is a fungus. Approximately 40 different species of fungi are known to cause ringworm. Some of the common species that cause ringworm include:

• Trichophyton
• Microsporum
• Epidermophyton

Once the fungi attach to the outer layer of the skin, they trigger an allergic reaction causing certain blood cells like eosinophils and chemicals called histamines to rush to the infected site. This results in the characteristic itching sensation. Scratching the area can cause further damage to the skin, allowing the infection to spread deeper and wider.

A person can contract ringworm mainly from the following sources:

• Humans: This is called anthropophilic transmission, involving parasites that prefer humans over animals. This is the most common form of transmission.
• Animals: Known as zoophilic infection, this occurs when animals become the preferred source of food for the fungus. The infected animal can then infect a human.
• Soil: Ringworm-causing fungi can also be the earth-loving variety that leads to geophilic ringworm infection.

Your risk of getting ringworm increases if you:

• Live in a tropical area
• Spend time in hot, humid weather
• Sweat heavily
• Wrestle, play football, or participate in another contact sport
• Live in close contact with an infected person or animal
• Share towels, clothes, razors, and other personal items with an infected person
• Are obese
• Have diabetes
• Wear tight clothing
• Have a weakened immune system
• Use public showers or locker rooms

Note: Ringworm can easily transfer from animals to humans. You can contract the infection by touching the skin and belongings of an infected animal.

To confirm a ringworm infection, your healthcare provider can perform the following tests:

• Physical examination: Ringworm is characterized by specific lesions that are examined by the doctor. The severity and stage of the infection can also be assessed by examining the lesions under black light.
• Microscopy: In this method, scrapings of the lesions are placed in potassium hydroxide (KOH) solution and examined under a microscope. This method is highly specific and cost-effective.
• Fungal culture: This is the most reliable method to diagnose ringworm, wherein scrapings taken from the infected area are allowed to grow in an artificial medium. This method is more specific than other tests but requires more time.
• Polymerase chain reaction (PCR): If KOH and fungal culture clinical evaluations are inconclusive, a PCR test for fungal deoxyribonucleic acid (DNA) identification can be performed.
• Wood’s lamp examination: In this test, the skin is examined under ultraviolet (UV) light using a Wood lamp in a dark room. The fungal infection is confirmed through the color changes of the skin under UV rays.

Proper preventive measures help the patient in speedy recovery. One can prevent the ringworm infection by practicing the following measures:

• Maintaining good hygiene by regular bathing.
• Wearing fresh socks and undergarments daily.
• Avoiding tight clothes.
• Drying off the upper body followed by drying the lower body (feet) after taking a shower.
• Regularly trimming and cleaning nails.
• Washing infected clothes in hot water with an antifungal agent.
• Taking a shower after playing sports that involve skin-to-skin contact.
• Avoiding sharing personal items of infected people such as clothes, towels, hair brushes, and combs.
• Wearing shoes or slippers in locker rooms and public showers.
• Disinfecting exercise machines regularly.
• Wearing gloves while handling infected pets.
• Disinfecting surfaces and pet bedding.
• Wearing loose shoes to allow air to circulate.
• Avoiding sharing of sports gear such as helmets with other players.

Ringworm is a fungal infection and can be treated by antifungal creams, lotions, sprays, tablets, and shampoos. The treatment provided to the patient depends on the severity of the disease and the affected body part, such as hair, skin, and nails. Some ringworm infections can be treated with over-the-counter medications, while more severe forms require prescription medications. The following treatments can be administered based on the need and severity of the disease:

Topical antifungal medications

These are available in the form of creams, gels, lotions, powders, and shampoos. Shampoos are used for fungal infections of the scalp and are generally instructed to be applied twice a week initially. Topical antifungal formulations such as creams, lotions, gels, and sprays are meant to be applied to the affected area of the skin. Antifungal nail paints are also available for fungal infections of the nails. Some of the medications used for ringworm include:

• Terbinafine (cream or solution)
• Butenafine (cream)
• Clotrimazole (cream, solution, or lotion)
• Econazole (cream)
• Ketoconazole (cream or shampoo)
• Miconazole (cream, spray, lotion, or powder)
• Oxiconazole (cream or lotion)
• Ciclopirox (cream, lotion, or nail lacquer)
• Tolnaftate (cream, solution, or powder)
• Selenium sulfide (shampoo)
• Naftifine (cream or gel)
• Sulconazole (cream or lotion)

Onychomycosis mostly does not respond to topical therapy; however, ciclopirox nail lacquer applied daily for a year is occasionally beneficial. Itraconazole and terbinafine both accumulate in the nail plate and can be used to treat onychomycosis.

Oral antifungal medications

Oral antifungal agents are prescribed in cases of severe infection, failed topical treatment, or for immunocompromised patients. These are available in the form of tablets and capsules. Some common examples include:

• Terbinafine
• Griseofulvin
• Itraconazole
• Fluconazole

Surgical care

Surgical treatment is usually not indicated except for the drainage of superficial vesicles, bullae, pustules, or deep abscesses.

Note: Relapse of tinea cruris and tinea pedis is common and should be treated early with creams to avoid the development of more extensive disease.

1. Hygiene

Ringworm is a highly contagious disease. Hence, maintaining good hygiene is necessary to prevent the spread of the infection to other parts of the body, to other people, and to pets. Practicing cleanliness also ensures faster recovery. The following measures can be taken to adopt a fungus-free environment:

• Wash your hands with soap and water after applying medication to the affected area.
• Shower daily and after playing any sports.
• Wash the belongings of the patients such as towels, clothes, and bedding in hot water.
• Wear washed clothes every day.
• Keep your body and clothes clean and dry.
• Disinfect your shoes regularly.
• Take measures to reduce sweat.

2. Duration of treatment

Generally, antifungal medications show improvement in the lesions quickly, and patients may discontinue taking or applying medicines. Take the medications as per the recommendations of your doctor to avoid recurrence of the infection.

3. Consult veterinarian

Ringworm can be spread from your pets, such as dogs and cats, to humans or vice versa. All the preventive measures taken by the patient and family members should be followed for the pets too. If a pet is showing any symptoms of ringworm, consult a veterinarian.

4. Keep in touch with your dermatologist

Most ringworm infections often start to show improvement with the first treatment within 1 to 2 weeks. If infections persist and are not responding to the treatment, follow up with your doctor.

5. Eat right

Diet alone cannot treat fungal infections, but some foods help in speedy recovery through their anti-inflammatory properties, such as:

• Protein-rich foods like meats, pulses, and beans
• Foods rich in omega-3 fatty acids, including nuts, seeds, and fish
• Green vegetables
• Yogurt
• Garlic in the form of food

Avoid excess sugar and processed foods, as high sugar serves as a medium for the growth of fungi that may delay your recovery and healing process.

As ringworm is a superficial fungal infection, complications are rare. However, because it is highly contagious, leaving it untreated can lead to several complications by spreading to other parts of the body. Some of the possible complications include:

• Dark spots on the skin known as post-inflammatory hyperpigmentation (PIH).
• Hair loss.
• Nail deformities, such as changes in the shape of the nails.
• Deep infections, such as Majocchi’s granuloma, in which fungi invade deeper skin layers.
• Secondary bacterial infections, if bacteria penetrate broken skin.
• Kerion, a type of abscess filled with pus.

Interface Dermatitis (ID) Reaction

Fungal reactions can trigger an interface dermatitis (ID) reaction. It is characterized by an itchy rash with small, water-filled blisters, usually seen on the sides of the fingers. The ID reaction is thought to be an allergic or autoimmune response in which the immune system begins to attack and target the skin.

Some of the alternative therapies that can be easily applied at home include:

• Tea Tree Oil: Tea tree oil is an essential oil extracted from a tree found in Australia. Studies have shown that tea tree oil has antibacterial and antifungal properties, making it commonly used to treat ringworm. It is applied directly to the affected area of the skin. Note: People with sensitive skin should dilute tea tree oil in a medium such as coconut oil.
• Coconut Oil: Also known as the “tree of life,” coconut oil is one of the most popular and widely available home remedies for ringworm infections. Studies suggest that various fatty acids present in coconut oil possess antifungal properties. It can be applied directly to the skin and scalp, providing a convenient way to treat ringworm of the scalp due to its ease of application.
• Aloe Vera: Aloe vera has been used for many years for its skin care properties and also possesses antifungal properties according to various studies. The gel can be applied to the affected skin 3 to 4 times daily and provides symptomatic relief from itching due to its cooling properties.
• Garlic (Lehsun): Garlic has shown properties against various species of Candida. It can be applied in the form of a paste made by blending crushed garlic cloves with coconut oil. Note: Do not reapply and rinse off immediately if you experience stinging, swelling, or redness after applying the paste.
• Turmeric (Haldi): Turmeric is known for its excellent anti-inflammatory properties. Mix about half a teaspoon of turmeric powder with coconut oil and apply it to the infected skin.
• Epsom Salt: Studies have shown that Epsom salt acts as an antifungal agent. It should be mixed with warm water and applied to the skin.
• Eucalyptus Oil: The anti-inflammatory effect of eucalyptus oil helps inhibit the growth of fungus. It should be applied to the skin mixed with warm water.
• Apple Cider Vinegar: Apple cider vinegar is known to have antifungal properties against some fungi. It should be wiped on the infected area to treat ringworm. Watch the video to learn more about the benefits of apple cider vinegar.