Ringworm/Body Ringworm/Scalp Ringworm

What Is Ringworm? What Is Body Ringworm? What Is Scalp Ringworm?

We use the term ringworm or tinea when referring to several types of contagious fungal infections of the top layer of the skin and scalp, as well as the nails. We call it ringworm because the itchy, red rash has a ring-like appearance. There is no connection between ringworm and worms.

Dermatologists (skin specialist doctors) say that approximately 10% to 20% of us will develop one or more fungal infections in our lifetime.

According to Medilexicon's medical dictionary, tinea (ringworm) is "A fungus infection (dermatophytosis) of the keratin component of hair, skin, or nails. Genera of fungi causing such infection are Microsporum, Trichophyton, and Epidermophyton."

We classify ringworm according to which part of the body is affected. The most common ones are: Tinea captis (scalp ringworm), Tinea corporis (skin or body ringworm), Tinea cruris (groin infection), Onychomycosis (Fungal nail infection), Tinea pedis (athlete's foot).

Scalp ringworm - much more common among young children than children who have reached puberty. Adults can be affected, but this is rare. When a human enters puberty the glands in the scalp change, resulting in a scalp that is less attractive to fungi.

• Scalp ringworm is more common among children who live in urban environments, as well as Afro-Caribbean children, according to the National Health Service (NHS), UK. Experts say that there is a higher incidence in urban environments because people are closer together, giving the fungus more opportunities to spread to other people.
• Body (skin) ringworm - this can affect babies, children and adults. Health authorities are unsure how many people are affected because most patients self-treat with OTC (over-the-counter, non-prescription) medications and never see their doctor about it.
• Groin infections - also known as jock itch. This is much more common among young men. As most patients self medicate, it is also difficult to know how common it really is.

What causes ringworm?

Ringworm is caused by fungi (singular: fungus). Fungi are similar to plants, with one big difference - plants can turn sunlight into food (photosynthesis) while fungi can't. Fungi need to break down living tissue in order to feed themselves - this includes living human tissue.
A dermatophyte is any fungus that infects our skin, hair or nails. Keratin, a protein which can be found in our nails, hair, as well as the outer surfaces of our skin, attract dermatophytes. Dermatophytes only attack our skin, scalp, hair and nails because those are the only parts of the body with enough keratin to attract them.

Dermatophytes are microscopic spores which can survive on the surface of the skin for months. They can survive equally well in towels, combs, the soil and other household objects - they are incredibly resilient.

Dermatophyte spores spread in four main ways:

• Human-to-human - if an infected person touches another person.
• Animal-to-human - if an infected animal is touched or touches a human. Pet dogs and cats may be infected and can pass it on to humans who pet (stroke) them. Cattle, pigs, horses and rabbits are also carriers. 
• Object-to-human - infected people and animals may deposit fungi spores on objects and surfaces when they touch them. If they touch things other people commonly touch, such as towels, bed linen, combs, brushes, door handles, and even clothing, another person who touches those objects may become infected.

Although children invariably show symptoms when they become infected, many adults don't. The older you get, the more likely it is that your immune system will protect you - but you may still be a carrier and pass the spores onto others.

People with athlete's foot may then go on to develop a groin infection. It happens when the patient scratches his/her infected feet and then transfers the spores to the groin when going to the toilet or dressing.

What are the risk factors for ring-worm?

A risk factor is anything that is likely to increase the chances of something happening. The following risk factors either increase your chances of developing ringworm, or will most likely make the symptoms worse:

• Age - very young and very old people are much more likely to develop ringworm than other people.
• Diabetes type 1 - this is the diabetes caused by the destruction of beta cells, the body does not produce insulin.
• Obesity
• Weakened immune systems - patients with HIV/AIDS are more likely to get ringworm.
• Some medical treatments - medications that lower the immune system, such as steroids (long-term), chemotherapy, and immunosuppressants (common among transplant recipients), have a significantly higher risk of developing ringworm compared to other people.
• Previous fungal infections - especially if they occurred repeatedly.
• Arteriosclerosis - this is when the arteries harden.
• Vascular problems - especially if the patient's veins have difficulty in moving blood back to the heart.
• Housing conditions - people who live in damp, humid, crowded conditions have a considerably higher risk.
• Close proximity to infected people/animals - you are more likely to touch an infected animal or person, or touch places he/she/it has touched, and become infected yourself, compared to other people.
• Hyperhidrosis - this is when the patient tends to sweat excessively.
• Contact sports - such as rugby, wrestling, or judo. Any sport where human-to-human contact is the main part of the activity. If sports changing rooms are crowded and you do not wear slippers or sandals when walking about inside them, the risk of infection is greater.
• Tight clothing - fungi love humid and dark places. Tight clothing restricts ventilation, making conditions ideal for the fungus to thrive.

What are the symptoms of ringworm?

Symptoms of scalp ringworm

• Small patches of scaly skin appear on the scalp
• Patches may feel tender
• Patches may be inflamed
• Patches may be painful
• Hair on the patches breaks away
• Some hair near the patches breaks away
• Kerion - this is a large inflamed lesion or sore which forms on the scalp. It may ooze pus. The patient may have a temperature and have swollen glands (nymph nodes). This is uncommon and is a more serious case of scalp ringworm.

Symptoms of body (skin) ringworm

• Rash - with a ring-like appearance. The skin may be red and inflamed around the outside of the ring, but look fine in the middle of it.
• More rings - they may multiply and grow.
• Merging rings - when there are enough of them they will merge together.
• Rings are raised - when you touch them they may feel slightly raised.
• Itchiness - especially under the rash.

Symptoms of a groin infection

• Itchiness - especially in and around the area of the groin.
• Redness - the affected area becomes red, it may sometimes feel like burning.
• Inner thighs - the skin in this area may become flaky and scaly.
• Movement worsens things - if you walk, run, or exercise the symptoms get worse.
• Tight clothing - tight clothing makes your symptoms worse, compared to loose clothing.

When should I see a doctor?

If you develop body or groin ringworm most doctors say you should wait a few days, even a couple of weeks as most cases resolve themselves with self-medication and home treatments. A qualified pharmacist should be able to help you find the right remedies. If, on the other hand, you have a medical condition or are receiving medical treatment such as long-term steroids, or chemotherapy, you should see your GP (general practitioner, primary care physician) straight away.

If your child develops scalp ringworm you should seek medical advice immediately. Anti-fungal creams you buy at the pharmacy do not work because they do not penetrate the entire scalp. Anti-fungal tablets are used for treating pediatric scalp ringworm, and they can only be obtained with a doctor's prescription (in most countries).

Diagnosing ring worm

Body ringworm and groin ringworm diagnosis

A good doctor should be able to diagnose ringworm or groin infection after examining the affected area and asking the patient about his/her medical history and symptoms. The doctor should be able to determine whether or not the skin problem is being caused by some other disorder, such as psoriasis or atopic dermatitis. Further testing is not usually needed, unless symptoms are particularly severe.

If symptoms have not improved after treatment the doctor may remove a small piece of infected skin and send it to the lab to be analyzed. The sample will be examined under a microscope - this will make it possible to identify whether fungi are present, and if so, what type they are.

Scalp ringworm diagnosis

Generally, a physical examination as all that is required to diagnose scalp ringworm. However, being able to identify the specific fungi helps, because some anti-fungal medications are better targeted at specific types of fungi. In other words, if the doctor can identify the type of fungi he is able to prescribe a more specific medication. Therefore, after diagnosing scalp ringworm the doctor will most likely remove a sample of scalp and send it to the lab.

Unfortunately, scalp ringworm lab tests take a long time to come back, approximately a couple of weeks. In the UK most doctors will prescribe terbinafine straight away and then review his/her choice of medication after checking the lab results.

Treatment for ringworm?

Scalp ringworm treatment

The most common treatment for scalp ringworm are oral anti-fungals (tablets). Examples include, Terbinafine (Lamisil) and griseofulvin (Grisovin). However, the choice of medication will depend on the type of fungi involved, as well as patient preference.

Terbinafine (Lamisil) - taken once daily for four weeks. Side effects are generally mild and do not last long, they may include:

• Diarrhea
• Skin reactions (rash)
• Indigestion
• Nausea
• Sense of taste affected - rare

If you have a history of liver disease you should not take terbinafine.

Griseofulvin (Grisovin) - taken once or twice daily for about two months. Side effects, which usually go away fairly quickly, may include:

• Vomiting
• Nausea
• Headache
• Indigestion
• Diarrhea (mild)

Griseofulvin must NOT be taken by pregnant women or women planning to become pregnant as there is a risk of birth defects. Women should not try to become pregnant for at least one month after treatment has stopped. Men should wait until six months after treatment has stopped before trying to get a female partner pregnant.

Patients taking combined or progestogen-only oral contraceptives and take griseofulvin should use a barrier form of contraception, such as a condom, because griseofulvin interferes with the contraceptive's efficacy.

Griseofulvin may affect your ability to drive safely, or operate heavy machinery.

Griseofulvin makes the effects of alcohol more pronounced.

Anti-fungal shampoos - they can help prevent the spread of ringworm and may speed up recovery, but they do not cure it. Examples of anti-fungal shampoos include selenium sulphide. They should be used about twice a week.

Shaving a child's head - all this will do is give him/her a head with no hair. There is absolutely no evidence that this reduces ringworm infection, or accelerates recovery time.

Skin ringworm and groin infections treatment

The majority of cases may be treated with OTC (over-the-counter, no prescription required) anti-fungal creams. Those that contain terbinafine have been proven to be effective, according to studies. A qualified pharmacist should be able to help you.

Apply the cream to the affected areas once daily for two weeks. Read instructions carefully - anti-fungal creams do not all have the same instructions.

If your symptoms do not change after the two weeks, see your doctor.

If symptoms are severe, of if they cover a large area of the body and do not respond to OTC medications, the doctor may prescribe a prescription-strength topical medication. A topical medication is one that you apply to the skin, such as a lotion, cream or ointment.

The most common topical medications prescribed in the USA are:

• Butenafine (Mentax)
• Ciclopirox (Loprox)
• Econazole
• Miconazole (Monistat-Derm)
• Oxiconazole (Oxistat)
• Terbinafine (Lamisil)

The doctor may prescribe an oral medication (taken by mouth). These may include:

• Itraconazole (Sporanox)
• Fluconazole (Diflucan)
• Ketoconazole (Nizoral)
• Terbinafine (Lamisil)

These oral medications may have some side effects, including stomach upset, rash, or abnormal liver function. If you are taking medications for ulcer disease or GERD (gastroesophageal reflux disease), the oral antifungal may not work so well. Oral medications for ringworm may make the drug-thinning blood warfarin less effective.

Caring for your skin - skin ringworm and groin infections

• Wash the skin gently
• Dry the skin thoroughly, but gently. Pat the skin with a towel in tender areas, don't rub. Make sure folds and areas between the toes are dried thoroughly.
• Change your underwear more often than usual (groin infection)
• Athlete's foot and groin infection - always treat both areas at the same time. Groin infections are often caused by infection that started with athlete's foot, and sometimes vice-versa. Put your socks on before your underwear if you have athlete's foot.

Prevention of ringworm

If somebody has ringworm in the house:

• Pets - if the pet is found to be the source of the infection you will need to take it to the vet. One of the signs of ringworm may be patches of missing fur.
• Wash your hands regularly. Get an antibacterial and anti-fungal soap, or one that contains tea tree oil, which contains terpinen-4-ol.
• Check yourself - everyone in the house should check themselves for signs of ringworm.
• Do not share combs, hairbrushes, clothing, bed lining, towels, or shoes/slippers/sandals.
• The patient should not scratch the affected areas as this increases the risk of spreading the infection. This is easier said than done, especially if one of the symptoms includes itchiness.
• Clothing - remember that tight and thick clothing make the fungi's environment ideal. Wear light loose clothing, especially if the weather is warm.
• Sweating - try to avoid excessive sweating.
• Avoid walking around the house with bare feet.
• Wash clothes in hot water with fungicidal soap if there is ringworm in the house.

Complications of ringworm

Fungal infection very rarely spreads below the surface of the skin. The risk of any serious illness is very small. If complications do occur, they may include:

• Spreading - the infection may spread from one part of the body to another - this is the most common complication.
• Bacterial infections - if the skin is broken bacteria may get in and cause an infection. In such cases the patient may need an antibiotic.
• Weakened immune systems - people with HIV, and other conditions that weaken the immune system are much more likely to experience spreading of ringworm. It is much more difficult to get rid of the infection if your immune system is weak. 
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