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Infections and infestations Skin and nail

Fungal skin infection - body and groin

Last revised in July 2023

Fungal infection of the skin (also known as ringworm or tinea) is caused by dermatophytes.

Fungal skin infection - body and groin: Summary

  • Fungal infections of the body and groin are also known as 'tinea corporis', and 'tinea cruris', respectively, and describe superficial skin infections predominantly caused by dermatophytes such as Trichophyton rubrum.
    • Fungal groin infection is usually caused by autoinoculation from infection of the hands, feet, or nails.
  • Risk factors for developing infection include hot, humid environments; wearing tight-fitting clothing; obesity; and hyperhidrosis.
  • The diagnosis of suspected fungal infection of the body and groin should be made based on clinical features:
    • There may be scaly, itchy skin.
    • There may be single or multiple red or pink, flat or slightly raised annular (ring-shaped) patches of varying sizes which enlarge outwards on the body. Typically, lesions have an active red, scaly advancing edge and a clear central area.
    • There may be groin involvement of the inguinal folds and proximal medial thighs. The typical scaly edge of lesions may be lost in moist flexures.
  • Assessment of suspected fungal infection of the body and groin should include:
    • Asking about the nature, site, and duration of any symptoms; previous treatments; family or close contacts affected; and any co-morbidities.
    • Examining the person to assess the pattern, extent, and severity of infection and for any associated inflammation or fungal infection at other sites.
    • Arranging for skin sampling for fungal microscopy and culture, if there is severe or extensive disease in adults, or the diagnosis is uncertain.
  • Initial management of fungal infection of the body and groin should include:
    • Advice on self-care strategies and sources of information.
    • Advice on treatment with a topical antifungal cream such as terbinafine or an imidazole if there is mild, non-extensive disease in children and adults.
    • Prescribing a short-term mildly-potent topical corticosteroid such as hydrocortisone cream in addition if there is associated marked inflammation.
    • Considering prescribing an oral antifungal such as terbinafine first-line if an adult has severe or extensive disease, depending on fungal microscopy or culture results and/or clinical judgement. Alternative options are oral itraconazole or oral griseofulvin, if terbinafine is not tolerated or contraindicated.
    • Managing concomitant fungal nail, foot, or hand infection, if present, to reduce the risk of reinfection.
  • If there are persistent signs of infection following topical antifungal treatment in adults:
    • Any underlying cause of treatment failure should be managed, such as non-adherence to self-care advice or the treatment regimen; reinfection from close contacts; or tinea incognito resulting from inappropriate use of topical corticosteroids.
    • Skin sampling for fungal microscopy and culture should be arranged.
    • Depending on microscopy or culture results and/or clinical judgement, oral antifungal treatment should be prescribed.
  • Referral to a dermatology specialist should be arranged, the urgency depending on clinical judgement, if:
    • There is severe or extensive disease, or topical antifungal treatment is unsuccessful in a child.
    • The diagnosis is uncertain.
    • Treatment in primary care is unsuccessful, or there are frequent recurrences.
    • The person is immunocompromised, depending on clinical judgement.

Have I got the right topic?

From age 1 month onwards.

This CKS topic covers the diagnosis and management of fungal skin infections of the body (tinea corporis) and groin (tinea cruris).

This CKS topic does not cover other fungal infections of the skin or nails.

There are separate CKS topics on Candida - skin, Fungal nail infection, Fungal skin infection - foot, and Fungal skin infection - scalp.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

July 2023 — reviewed. A literature search was conducted in June 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to the recommendations have been made. 

Previous changes

July 2022 — minor update. Added drug interaction between clotrimazole and tacrolimus.

May 2018 — reviewed. A literature search was conducted in March 2018 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone restructuring. New nodes on Definition, Risk factors, Prevalence, Complications, and Prognosis have been added to the Background information section. The management recommendations have been updated in line with the current literature. The Prescribing Information section has been updated and expanded in line with current CKS style.

September 2014 — minor update. Text amended in the Prescribing information section on terbinafine, to state that a baseline liver function test is required before starting treatment with terbinafine.

January 2014 — minor update. Text amended to include information from the manufacturer regarding how much clotrimazole to apply to the skin.

December 2013 — minor update. Text amended to reflect that the European Medicines Agency’s (EMA) Committee for Medicinal Products for Human Use (CHMP) has suspended the marketing authorisation for oral ketoconazole, and it should not be prescribed for the treatment of fungal infections.

August 2013 — reviewed. A literature search was conducted in July 2013 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to clinical recommendations have been made. Prescribing information has been added to support the prescribing of topical and oral antifungal treatments.

August 2013 — minor update. Nizoral® (ketoconazole 2%) cream is no longer licensed for use in children.

August 2013 — minor update. Text amended to reflect recent guidance from the European Medicines Agency (EMA) regarding the use of oral ketoconazole.

November 2012 — minor update. The links to the electronic medicines website (www.medicines.org.uk) have been updated.

February 2012 — minor typographical error corrected. 

August 2010 — minor update. Sulconazole 1% cream (Exelderm®) has been discontinued. The prescription has been removed. 

June 2009 — minor update. Econazole 1% plus hydrocortisone 1% cream (Econacort®) has been discontinued. The prescription has been removed. 

January to May 2009 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. Together with the CKS topics on Fungal skin infection - foot and Fungal skin infection - scalp, this CKS topic replaces the former topic on Fungal skin infections.

September 2008 — minor update. Correction to the Changes section. 

August 2008 — minor update. Text amended to state that nystatin cream and ointment discontinued.

April 2008 — minor update. Text amended to reflect the most recent Medicines and Healthcare products Regulatory Agency (MHRA) guidance on oral ketoconazole.

March 2008 — minor update. New text inserted regarding rare cases of changes in international normalized ratio (INR) when warfarin and oral terbinafine have been given concomitantly. Issued in March 2008.

October to December 2005 — written. Validated in March 2006 and issued in May 2006.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 June 2023.

HTAs (Health Technology Assessments)

No new HTAs since 1 June 2023.

Economic appraisals

No new economic appraisals relevant to England since 1 June 2023.

Systematic reviews and meta-analyses

No new systematic reviews since 1 June 2023.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 June 2023.

New policies

No new national policies or guidelines since 1 June 2023.

New safety alerts

No new safety alerts since 1 June 2023.

Changes in product availability

No changes in product availability since 1 June 2023.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Be aware of when to suspect fungal infection of the body and groin and exclude similar conditions.
  • Offer appropriate treatment in primary care.
  • Arrange referral to secondary care if appropriate.
  • Provide advice and information to people with fungal infection of the body and groin.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Fungal infections of the body and groin are also known as 'tinea corporis' or 'ringworm', and 'tinea cruris' respectively.
    • They describe superficial skin infections predominantly caused by dermatophytes.
      • Fungal body infection is usually caused by the dermatophyte Trichophyton rubrum or Trichophyton interdigitale.
      • Fungal groin infection is usually caused by autoinoculation from dermatophyte infection of the hands, feet, or nails caused by Trichophyton rubrum, Trichophyton interdigitale, or, more rarely, Epidermophyton floccosum.
    • Infection is usually transmitted by:
      • Direct contact with an infected person (anthropophilic spread from human to human).
      • Direct contact with an infected animal (zoophilic spread from animals to humans, for example from dogs, cats, guinea pigs, and cattle).
      • Indirect contact with fomites (objects or materials which carry infection, such as clothing, towels, or bed linen).
      • Contact with the soil (geophilic infections, rare).

[Kovitwanichkanont, 2019; Leung, 2020; Perry, 2021; BMJ Best Practice, 2022; Pippin, 2023]   

What are the risk factors?

  • Risk factors for developing fungal infection of the body and groin include:
    • Hot, humid climates or working in high-temperature environments.
    • Wearing tight-fitting clothing.
    • Obesity — see the CKS topic on Obesity for more information.
    • Hyperhidrosis — see the CKS topic on Hyperhidrosis for more information.
    • Immunocompromised states — may lead to severe, resistant or extensive disease.

[Kovitwanichkanont, 2019; Leung, 2020; Perry, 2021; BMJ Best Practice, 2022; Pippin, 2023; Yee, 2023]

How common is it?

Opinions in expert reviews estimate the lifetime risk of acquiring fungal infections of the body and groin to be between 10-20% [Leung, 2020]:

  • Fungal infection of the body is most commonly seen in children and young adults [BMJ Best Practice, 2022].
  • Fungal skin infection is more common in men than in women [PCDS, 2023].
  • Fungal infection of the groin is more common in adolescents and young adult men [BMJ Best Practice, 2022].

What are the complications?

  • Possible complications of fungal infection of the body and groin include:
    • Secondary bacterial infection — immunocompromised people are at increased risk.
    • Majocchi granuloma formation — where the dermatophyte invades via the hair follicle and can penetrate much deeper into the dermis and subcutaneous layers of the skin.
    • Fungal infection of the hand (tinea manuum) — this may develop as a result of scratching of the affected area and typically affects the dominant hand.
    • Tinea incognito — inappropriate use of topical corticosteroids can lead to extensive spread of fungal infection, and a change in the morphology of lesions.
      • There may be bizarre-shaped lesions; loss or modification of the active erythematous edge; loss of central clearing with eczematous areas within lesions; and the appearance of double edges or multiple rings reflecting periods of active inflammation and partial remission. This may lead to difficulty in the diagnosis of fungal skin infection.

[Verma, 2017; BMJ Best Practice, 2022; Pippin, 2023; Yee, 2023]

What is the prognosis?

CKS found limited evidence in the literature on the prognosis of fungal infections of the body and groin.

Diagnosis of fungal skin infection - body and groin

When should I suspect fungal infection of the body and groin?

The diagnosis of suspected fungal infection of the body and groin should be made based on clinical features.

  • The affected areas may have a history of scaly, itchy skin.
  • On examination of the body, there may be:
    • Single or multiple red or pink, flat or slightly raised annular (ring-shaped) patches of varying sizes (usually 1–5 cm), which enlarge outwards.
      • Typically, lesions have an active red, scaly advancing edge and a clear central area (so-called 'central clearing').
      • They are usually asymmetrical in distribution.
      • There may be larger lesions and coalescence of lesions.
    • More rarely, numerous overlapping concentric circles (tinea imbricate) or herpetiform subcorneal vesicles or pustules (bullous tinea corporis).
  • On examination of the groin(s), there may be:
    • Involvement most commonly affecting the inguinal folds and proximal medial thighs. The perianal skin, buttocks, and above the waistline may also be affected. In men, the penis and scrotum are often spared.
    • Skin lesions which are commonly red to red-brown, flat or slightly raised plaques with active borders (there may be pustules or vesicles within lesions).
    • Uniform scale without central clearing, and the typical scaly edge may be lost in moist flexures.

Basis for recommendation

These recommendations are based on the British Medical Journal (BMJ) Best Practice guide Dermatophyte infections [BMJ Best Practice, 2022], expert opinion in Fungal skin infections [Perry, 2021], Tinea Cruris [Pippin, 2023], Tinea Corporis [Yee, 2023] and expert opinion in the narrative reviews Superficial fungal infections [Kovitwanichkanont, 2019] and Tinea corporis: an updated review [Leung, 2020].

How should I assess suspected fungal infection of the body and groin?

If fungal infection of the body and groin is suspected on the basis of clinical features:

  • Ask the person about:
    • The nature, site, and duration of any symptoms, such as itchy, flaky skin on the body and or groin(s).
    • Any previous treatments, including over-the-counter preparations.
    • Any family or close contacts affected.
    • Any co-morbidities such as underlying causes of immunosuppression.
  • Examine the person to assess:
  • Be aware that diagnostic tests are not usually needed in primary care, but arrange for skin sampling for fungal microscopy and culture, to confirm the diagnosis and identify the underlying cause, if:
    • There is severe or extensive disease in adults.
    • The diagnosis is uncertain or there is an atypical appearance.
  • Be aware that Wood's light examination is not needed to aid diagnosis in primary care.

Taking skin samples

  • When taking skin samples for fungal microscopy and culture:
    • Wipe off any creams from the skin before sampling.
    • Scrape skin from the advancing edge of the lesion(s) with a blunt scalpel blade to collect skin scale. Sampling the edge of lesions may provide a higher yield of dermatophyte.
    • Collect at least 5 mm2 of skin flakes into folded dark paper squares secured with a paper clip. Alternatively, commercially available packs are available. Label the sample clearly.
    • Keep the samples at room temperature and do not refrigerate (dermatophytes are inhibited at low temperatures, and humidity facilitates the growth of contaminants).
    • Ensure clinical details provided on the microbiology request form include any treatment used, animal contacts, and overseas travel.
    • Inform the person that microscopy results (to identify hyphae or spores) should be available within 1–2 days; culture results (to identify the causative organism) within 2–3 weeks.
    • Be aware that testing for antifungal susceptibilities is not required.

Consider arranging a skin swab for bacterial and fungal microscopy and culture if the skin is very pustular or macerated.

[UKHSA, 2017; Kovitwanichkanont, 2019; Leung, 2020; Perry, 2021; BMJ Best Practice, 2022; Pippin, 2023]

Basis for recommendation

These recommendations are based on the UK Health Security publication Fungal skin and nail infections: Diagnosis and laboratory investigation [UKHSA, 2017], the British Medical Journal (BMJ) Best Practice guide Dermatophyte infections [BMJ Best Practice, 2022], expert opinion in Fungal skin infections [Perry, 2021], Tinea Cruris [Pippin, 2023], Tinea Corporis  [Yee, 2023] and expert opinion in the narrative reviews Superficial fungal infections [Kovitwanichkanont, 2019], Tinea corporis: an updated review  [Leung, 2020] and Steroid modified tinea [Verma, 2017].

What else might it be?

  • Other conditions that may present similarly to fungal infection of the body include:
    • Discoid eczema — itchy plaques of papules or vesicles tend to occur symmetrically on the limbs. Less likely to have active lesion border with central clearing; lesions may be lichenified if chronic. If atopic eczema, there may be a personal or family history of atopy. See the CKS topic on Eczema - atopic for more information.
    • Pityriasis rosea — multiple circular or oval pink-red or fawn-coloured slightly scaly lesions, typically in a symmetrical distribution affecting the trunk and proximal limbs. A larger herald patch usually precedes the onset of the generalized rash. See the CKS topic on Pityriasis rosea for more information.
    • Pityriasis versicolor — well-demarcated multiple round or oval macules of variable colours most commonly on the back, chest, and upper arms. The surface may have a fine scale. May be more noticeable in the summer months if patches fail to tan. Lesions may fluoresce a bright yellow-green or gold colour on Wood lamp examination. See the CKS topic on Pityriasis versicolor for more information.
    • Psoriasis — chronic plaque psoriasis typically presents as monomorphic, erythematous plaques covered by adherent silvery-white scale, usually on the scalp, trunk, buttocks, periumbilical area, and extensor surfaces (such as forearms, shins, elbows, and knees). Psoriasis may be associated with nail pitting. See the CKS topic on Psoriasis for more information.
    • Granuloma annulare — single or multiple rings of small, smooth, red or flesh-coloured papules; no scale, there may be vesicles or pustules. Often on the dorsum of the hands or feet.
    • Erythema multiforme — acute onset target lesions with no scale; may be associated with oral lesions.
    • Subacute cutaneous lupus — multiple annular lesions, typically on sun-exposed areas.
  • Other conditions that may present similarly to fungal infection of the groin include:
    • Intertrigo — superficial skin inflammation occurring on two closely-opposed skin surfaces, such as the skin folds. May be due to mechanical causes (such as moisture, friction, or heat), and may have secondary bacterial or candidal infection. The rash is usually uniformly red without central clearing or scale. Candidal infection usually involves the scrotum and may have satellite lesions. See the CKS topic on Candida - skin for more information.
    • Erythrasma — typically small, red-brown macules that may coalesce into larger patches with sharp borders; may be slight scaling. Fluoresces a bright coral-red on Wood lamp examination due to the causative organism Corynebacterium minutissimum.
    • Flexural psoriasis — typically affects areas such as the groin, genital area, axillae, inframammary folds, abdominal folds, sacral and gluteal cleft. Lesions are often well-defined, red and glazed in appearance, and there may be little or no scaling. There may be additional plaque psoriasis on the extensor surfaces of the knees, elbows, and scalp, with nail pitting. See the CKS topic on Psoriasis for more information.
    • Seborrhoeic dermatitis — greasy scale on an erythematous base, typically involving the scalp, nasolabial folds, hairline, eyebrows, postauricular folds, and upper chest. See the CKS topic on Seborrhoeic dermatitis for more information.

Basis for recommendation

This information is based on the British Medical Journal (BMJ) Best Practice guide Dermatophyte infections [BMJ Best Practice, 2022], expert opinion in Fungal skin infections [Perry, 2021], Tinea Cruris [Pippin, 2023], Tinea Corporis [Yee, 2023] and expert opinion in the narrative reviews Superficial fungal infections [Kovitwanichkanont, 2019] and Tinea corporis: an updated review [Leung, 2020].

Management

Scenario: Management of fungal skin infection - body and groin

From age 1 month onwards.

How should I initially manage fungal infections of the body and groin?

  • Advise on self-care management strategies:
    • Wear loose-fitting clothes made of cotton or material designed to keep moisture away from the skin.
    • Maintain good hygiene by washing affected skin areas daily.
    • After washing dry thoroughly, especially in the skin folds.
    • Avoid scratching affected skin, as this may spread the infection to other sites.
    • Do not share towels, and wash them frequently, to reduce the risk of transmission.
    • Wash clothes and bed linen frequently to eradicate fungal spores.
    • If a child is affected, it is not necessary to exclude them from school or nursery.
  • Provide information on sources of advice and support, such as:
  • Advise treatment with a topical antifungal cream if there is mild, non-extensive disease in children and adults.
    • Options include terbinafine cream or an imidazole such as clotrimazole, miconazole, or econazole cream (available over-the-counter for specific age groups).
    • Advise that treatment with a topical antifungal cream may be repeated in the future if there is a good response to topical treatment and there are recurrent episodes of mild, non-extensive disease.
  • Consider prescribing a mildly-potent topical corticosteroid in addition if there is associated marked inflammation, such as:
    • Hydrocortisone 1% cream, applied once daily for a maximum of 7 days.
    • Advise that a topical corticosteroid preparation should not be used alone on skin lesions.
    • Advise that topical corticosteroid preparations should be completely avoided if there are signs of complications such as tinea incognito.
  • If an adult has severe or extensive disease, consider prescribing oral antifungal treatment if there is:
    • A positive skin sample fungal microscopy or culture result.
    • A strong clinical suspicion of fungal skin infection before mycology results are back, depending on clinical judgement.
    • A negative mycology result, but clinical features are very suggestive of infection.
      • Arrange for repeat skin sampling, and start oral antifungal treatment.
  • If oral antifungal treatment is offered in primary care:
    • Consider prescribing terbinafine first-line.
    • Consider prescribing oral itraconazole or oral griseofulvin if terbinafine is not tolerated or is contraindicated.
  • If a child has severe or extensive disease, arrange referral to a paediatric dermatologist.
  • If there is concomitant suspected fungal nail, foot, or hand infection, manage appropriately. See the CKS topics on Fungal nail infection and Fungal skin infection - foot for more information.
  • Advise the person to arrange for follow-up if there is an inadequate response to initial treatment.

Basis for recommendation

These recommendations are based on the UK Health Security Agency publications Fungal skin and nail infections: Diagnosis and laboratory investigation [UKHSA, 2017] and Health protection in schools and other childcare facilities [UKHSA, 2023], the British Medical Journal (BMJ) Best Practice guide Dermatophyte infections [BMJ Best Practice, 2022],  a Cochrane systematic review Topical antifungal treatments for tinea cruris and tinea corporis (Review) [El-Gohary, 2014], a meta-analysis Efficacy of topical antifungals in the treatment of dermatophytosis: a mixed-treatment comparison meta-analysis involving 14 treatments  [Rotta, 2013], randomized trials Efficacy of oral terbinafine versus itraconazole in treatment of dermatophytic infection of skin - A prospective, randomized comparative study [Bhatia, 2019], Efficacy of Terbinafine and Itraconazole in different Doses and in Combination in the Treatment of Tinea Infection [Singh, 2020], expert opinion in Fungal skin infections [Perry, 2021], Tinea Cruris [Pippin, 2023], Tinea Corporis  [Yee, 2023], expert opinion in the narrative reviews Superficial fungal infections [Kovitwanichkanont, 2019], Tinea corporis: an updated review  [Leung, 2020] Steroid modified tinea [Verma, 2017] and the manufacturer's summary of product characteristics for Daktacort Cream [EMC, 2021a].

Offering topical antifungal treatment
  • Expert opinion in the UK Health Security Agency [UKHSA, 2017] publication supports the use of topical terbinafine first-line for fungal skin infection, and states that one week duration of this treatment is as effective as four weeks' duration of an azole.
Management of severe or extensive disease in children
  • The recommendation to arrange dermatology referral for children with severe or extensive disease is pragmatic, based on what CKS considers to be good clinical practice. It is also supported by the expert opinion of previous external reviewers of this CKS topic.

When should I follow up and refer?

Arrange for the person to be reviewed if there is an inadequate response to initial management.

  • If there are persistent signs of infection following topical antifungal treatment in adults:
    • Consider and, if possible, manage any underlying cause of treatment failure. This may include:
      • Non-adherence to self-care advice or the treatment regimen.
      • Inappropriate use of topical corticosteroids leading to tinea incognito.
      • Drug-resistant or multiple organisms. Drug resistance to terbinafine, itraconazole and griseofulvin has been reported.
      • Drug interactions or adverse effects.
      • Reinfection from close contacts or recurrence of infection.
      • An immunocompromised host.
      • An alternative diagnosis.
    • Arrange for skin sampling for fungal microscopy and culture, and consider prescribing oral antifungal treatment if there is:
      • A positive skin sample fungal microscopy or culture result.
      • A strong clinical suspicion of fungal infection before fungal microscopy and culture results are back, depending on clinical judgement.
      • A negative mycology result, but clinical features are very suggestive of infection. Arrange for repeat skin sampling, and start oral antifungal treatment.
  • Arrange referral to a dermatology specialist, the urgency depending on clinical judgement, if:
    • There is severe or extensive disease, or topical antifungal treatment is unsuccessful in a child.
    • The diagnosis is uncertain.
    • Treatment in primary care is unsuccessful or there are frequent recurrences.
    • The person is immunocompromised, depending on clinical judgement.

Basis for recommendation

These recommendations are based on the UK Health Security Agency publication Fungal skin and nail infections: Diagnosis and laboratory investigation [UKHSA, 2017] , the British Medical Journal (BMJ) Best Practice guide Dermatophyte infections [BMJ Best Practice, 2022],  expert opinion in Fungal skin infections [Perry, 2021], Tinea Cruris [Pippin, 2023], Tinea Corporis  [Yee, 2023], expert opinion in the narrative reviews Superficial fungal infections [Kovitwanichkanont, 2019], Tinea corporis: an updated review  [Leung, 2020] Steroid modified tinea [Verma, 2017] and the commentary The Spread of Resistant Tinea and the Ingredients of a Perfect Storm [Hay, 2022].

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

Topical antifungals

Application

The following application regimens are recommended for the treatment of fungal infection of the body and groin:

  • Terbinafine 1% cream (children above 12 years of age)
    • Apply thinly to the affected area once or twice a day for up to 1–2 weeks.
  • Clotrimazole 1% cream
    • Apply to the affected area 2–3 times a day and continue for at least 4 weeks. A strip of cream about half a centimetre long is enough to treat an area about the size of the hand.
  • Miconazole 2% cream
    • Apply to the affected area twice a day continuing for 10 days after all skin lesions are healed.
  • Econazole 1% cream
    • Apply to the affected area twice a day and continue until all skin lesions are healed.

  [EMC, 2020a; EMC, 2021a; EMC, 2022a; BNF, 2023; BNFC, 2023; EMC, 2023]

Contraindications and cautions

  • Terbinafine 1% cream is licensed for the treatment of fungal infection of the body and groin above the age of 12 years.
  • Clotrimazole 1% cream, miconazole 2% cream, and econazole 1% cream are licensed for the treatment of fungal skin infections in children and adults.
    • Advise the person to avoid contact with the eyes and mucous membranes during use.

[EMC, 2022a; BNF, 2023; EMC, 2023]

Adverse effects

  • Possible adverse effects with topical antifungals are uncommon and may include erythema, hypersensitivity reactions, itching, mild burning sensation, occasional local irritation.

[BNF, 2023; BNFC, 2023]

Drug interactions

  • Topical terbinafine cream — there are no known significant drug interactions.
  • There is an interaction between topical clotrimazole and tacrolimus with an increase in plasma tacrolimus levels with concurrent prescribing.
  • Topical miconazole and econazole cream — oral miconazole and econazole are known to interact with oral anticoagulants, but due to the limited systemic availability of topical preparations, clinically relevant drug interactions are rare. The manufacturer advises, however, that caution should be exercised and the anticoagulant effect should be monitored during concurrent use with an oral anticoagulant.

 [Preston, 2019; EMC, 2020a; EMC, 2021a; EMC, 2022a; EMC, 2023]

Oral terbinafine

Dosing schedule

  • For adults, prescribe terbinafine 250 mg once daily:
    • For 4 weeks for fungal infection of the body.
    • For 2–4 weeks for fungal infection of the groin.

[EMC, 2020b; BNF, 2023]

Contraindications and cautions

Do not prescribe terbinafine to people with:

  • Hepatic impairment — the manufacturer recommends that terbinafine should not be prescribed in people with chronic or active hepatic disease. It recommends for other people, liver function tests (LFTs) should be performed. Hepatotoxicity may occur in people with and without pre-existing hepatic disease, therefore periodic monitoring of LFTs (after 4–6 weeks of treatment) is recommended. Terbinafine should be stopped immediately if LFTs are deranged.
  • Severe renal impairment.

Prescribe terbinafine with caution to people with:

  • Autoimmune disease — risk of lupus erythematosus-like effect.
  • Psoriasis — increased risk of exacerbation of psoriasis.
  • Renal impairment — the BNF recommends that half the normal dose of terbinafine should be used if estimated glomerular filtration rate (eGFR) is less than 50 mL/min/1.73 m2 and there is no suitable alternative. However, the manufacturer does not recommend using terbinafine in these people, as it has not been adequately studied.

[EMC, 2020b; BNF, 2023]

Adverse effects

Adverse effects of terbinafine include:

  • Gastrointestinal — abdominal distension, dyspepsia, nausea, abdominal pain, diarrhoea, feeling of fullness (very common); pancreatitis (unknown frequency).
  • Nervous system — headache (common); taste disturbance (uncommon). Dizziness, paraesthesia, and hypoaesthesia (rare).
  • Skin and subcutaneous tissue — rash, urticarial (very common). Very rarely Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema multiforme, skin eruption, dermatitis exfoliative, dermatitis bullous, photosensitivity reaction, and alopecia.
  • Other adverse effects include:
    • Anaphylaxis.
    • Arthralgia, myalgia, decreased appetite.
    • Hepatic dysfunction, jaundice, hepatitis, cholestasis — people taking terbinafine tablets should be warned to report immediately any signs and symptoms of unexplained persistent nausea, decreased appetite, fatigue, vomiting, right upper abdominal pain, jaundice, dark urine, or pale faeces. If these symptoms develop, terbinafine treatment should be stopped, and liver function tests (LFTs) should be immediately performed.
    • Malaise, neutropenia, agranulocytosis, thrombocytopenia, vertigo.

[EMC, 2020b; BNF, 2023]

Drug interactions

Possible drug interactions with terbinafine include:

  • Codeine — the analgesic effect may be reduced or abolished by terbinafine. Monitor for analgesic efficacy.
  • Rifampicin — levels of terbinafine are reduced. Dose increases of terbinafine may be necessary.
  • Tamoxifen — avoid concurrent use. Metabolism to an active metabolite of tamoxifen may be inhibited by terbinafine.
  • Terbinafine levels may be increased by the following drugs if taken concomitantly:
    • Amiodarone.
    • Fluconazole, ketoconazole.
  • Terbinafine may increase levels of the following drugs if taken concomitantly, thereby increasing or prolonging their effects, including adverse effects:
    • Anti-arrhythmics (flecainide, mexiletine, and propafenone).
    • Aripiprazole, risperidone.
    • Beta-blockers (carvedilol, metoprolol, nebivolol, propranolol, and timolol).
    • Dextromethorphan.
    • Monoamine oxidase inhibitors Type B (MAOIs-B, such as selegiline).
    • Selective serotonin reuptake inhibitors (sertraline, paroxetine).
    • Tramadol — terbinafine may increase levels of tramadol, but not the active metabolite, which causes an increase in adverse effects, but not in analgesic effect.
    • Tricyclic antidepressants (amitriptyline, imipramine, nortriptyline).

[Preston, 2019; EMC, 2020b; BNF, 2023]

Oral itraconazole

Dosing schedule

  • For adults, prescribe itraconazole 100 mg once daily for 15 days, alternatively 200 mg once daily for 7 days.

[EMC, 2022b; BNF, 2023]

Contraindications and cautions

Do not prescribe itraconazole to people with:

  • Acute porphyria.
  • Ventricular dysfunction or a history of heart failure — itraconazole has been shown to have a negative inotropic effect.

Prescribe itraconazole with caution in people:

  • At high risk of heart failure, including people on treatment with negative inotropic drugs (such as calcium-channel blockers).
  • Who are immunocompromised (for example people with AIDS, on chemotherapy, have neutropenia, or previous organ transplants).
  • With acute liver disease or a history of hepatotoxicity with other drugs — consider monitoring liver function tests (LFTs). Advise immediate LFTs if symptoms of possible liver toxicity develop, such as anorexia, nausea, vomiting, fatigue, abdominal pain, or dark urine.
  • With renal impairment.
  • Taking drugs such as astemizole, pimozide, quinidine, or terfenadine that may prolong the QT interval, as there is a risk of cardiac arrhythmias.

[EMC, 2022b; BNF, 2023]

Adverse effects

Adverse effects of itraconazole include:

  • Gastrointestinal — nausea, abdominal pain (common); vomiting, diarrhoea, constipation, dyspepsia, taste disturbance, flatulence (uncommon). Rarely pancreatitis.
  • Hepatobiliary — hyperbilirubinaemia (uncommon). Rarely hepatotoxicity (including acute liver failure).
  • Nervous system — headache, dizziness, paraesthesia (uncommon).
  • Skin and subcutaneous tissue — rash (common); alopecia, urticaria, pruritus (uncommon).
  • Other — arthralgia, myalgia, heart failure, erectile dysfunction, menstrual disorders, oedema, tinnitus, visual disturbance.

[EMC, 2022b; BNF, 2023]

Drug interactions

Itraconazole is metabolized by the cytochrome p450 3A4 (isoenzyme CYP34A) and it interacts with a number of liver enzyme-inducing and liver enzyme-inhibiting drugs.

  • Itraconazole levels may be reduced by the following drugs:
    • Carbamazepine, phenobarbital, phenytoin — monitor itraconazole efficacy and increase dose if necessary.
    • Rifampicin, rifabutin — monitor itraconazole efficacy and increase dose if necessary.
    • St John’s wort — avoid concurrent use.
  • Itraconazole levels may be increased by the following drugs:
    • HIV protease inhibitors (ritonavir, indinavir) — monitor for adverse effects.
    • Clarithromycin and erythromycin — monitor for adverse effects.
  • Itraconazole may increase levels of the following drugs:
    • Aliskiren — monitor for adverse effects.
    • Aripiprazole, quetiapine, risperidone — dose reductions may be necessary.
    • Quetiapine — concurrent use with itraconazole is contraindicated. If considered necessary, monitor for adverse effects and adjust dose.
    • Phospodiesterase-5 inhibitors (avanafil, sildenafil, vardenafil) — avoid concurrent use with avanafil; reduce dose of sildenafil or vardenafil.
    • Benzodiazepines (alprazolam, triazolam, midazolam) — dose reductions may be required.
    • Calcium-channel blockers (amlodipine, verapamil) — monitor for adverse effects.
    • Colchicine — dose adjustment may be necessary.
    • Corticosteroids (budesonide, dexamethasone) — avoid concurrent use.
    • Digoxin — monitor the effects of digoxin; digoxin dose may need to be reduced by 50–75%.
    • Disopyramide — avoid concurrent use.
    • Domperidone — possible increased risk of ventricular arrhythmias. Avoid concurrent use.
    • Eplerenone — concurrent use is contraindicated.
    • Ergot alkaloids (such as ergotamine and ergometrine) — increased risk of ergotism. Concurrent use is contraindicated.
    • Ivabradine — concurrent use is contraindicated.
    • Mizolastine — monitor for adverse effects.
    • Oral anticoagulants (warfarin, apixaban, dabigatran). — Monitor for adverse effects and adjust doses if required.
    • Pimozide — increased risk of QT interval prolongation. Concurrent use is contraindicated.
    • Quinidine — increased risk of torsades de pointes. Concurrent use is contraindicated, but if considered necessary, monitor for adverse effects and reduce dose if required.
    • Ranolazine — increased risk of QT interval prolongation. Concurrent use is contraindicated.
    • Reboxetine — monitor for adverse effects and adjust dose if required.
    • Solifenacin — restrict dose of solifenacin to 5 mg daily.
    • Statins (lovastatin, simvastatin) — avoid concurrent use.

  [Preston, 2019; EMC, 2022b; BNF, 2023] 

Oral griseofulvin

Dosing schedule

  • For adults, prescribe griseofulvin 500 mg daily. If necessary, increase to 1000 mg daily for severe infections for at least four weeks; reduce the dose when treatment response occurs.
    • The daily dose may be taken once daily or in divided doses. Treatment should be continued for at least two weeks after lesions have healed.

[EMC, 2021b; BNF, 2023]

Contraindications and cautions

  • Do not prescribe griseofulvin to people with:
    • Acute porphyria.
    • Severe liver disease.
    • Systemic lupus erythematosus — increased risk of exacerbation.

[EMC, 2021b; BNF, 2023]

Adverse effects

  • Possible adverse effects of griseofulvin include:
    • Gastrointestinal — such as nausea, vomiting, diarrhoea, abdominal pain, dyspepsia, and anorexia.
      • Advise the person to take griseofulvin after a high-fat meal to increase systemic absorption and reduce the risk of adverse effects.
    • Hepatobiliary — alteration in liver function tests (LFTs), intrahepatic cholestasis, and hepatitis.
    • Neuropsychiatric — headache, dizziness, confusion, taste disturbance, impaired co-ordination and hearing, peripheral neuropathy, sleep disturbances, agitation, and irritability.
      • Advise the person that griseofulvin may enhance the effects of alcohol and impair the performance of skilled tasks, such as driving.
    • Skin — rashes such as erythema multiforme, toxic epidermal necrolysis, photosensitivity, bullous reactions (including Lyell's syndrome), urticarial reactions.
    • Other — fatigue, leucopenia, neutropenia, anaemia (usually resolve on stopping treatment).

[EMC, 2021b; BNF, 2023]

Drug interactions

Possible drug interactions with griseofulvin include:

  • Alcohol — concurrent use of alcohol and griseofulvin may cause a disulfiram-like reaction (flushing, tachycardia). Warn people about the possibility of this reaction.
  • Oral contraceptives — the efficacy of oral contraceptives may be reduced with concurrent griseofulvin use. The clinical significance of this effect is unknown.
    • The Faculty of Sexual and Reproductive Healthcare (FSRH) recommends avoiding the use of combined oral contraceptives (COCs) and progestogen-only contraceptives (POPs), the progestogen-only implant, and ulipristal acetate, and using an alternative method of contraception when using griseofulvin, and within 28 days of stopping treatment.
      • If a woman wishes to use the COC when taking griseofulvin, consider an increased ethinylestradiol dose (at least 50 micrograms) during treatment and for a further 28 days after stopping griseofulvin, with a continuous or tricycling regimen plus a pill-free interval of four days.
      • See the CKS topic on Contraception - assessment for more information.
  • Warfarin — griseofulvin potentially decreases the efficacy of warfarin. Monitor the international normalized ratio (INR), and adjust the anticoagulant dose accordingly. 
  • Phenobarbital — may result in a decreased plasma level of griseofulvin, leading to a reduction in efficacy.
  • Primidone — may result in a decreased plasma level of griseofulvin, leading to a reduction in efficacy.

[Preston, 2019; EMC, 2021b; BNF, 2023]

Supporting evidence

This CKS topic is largely based on the UK Health Security Agency (UKHSA) publications  Fungal skin and nail infections: Diagnosis and laboratory investigation [UKHSA, 2017] and Health protection in schools and other childcare facilities [UKHSA, 2023], the British Medical Journal (BMJ) Best Practice guide Dermatophyte infections [BMJ Best Practice, 2022],  a Cochrane systematic review Topical antifungal treatments for tinea cruris and tinea corporis (Review) [El-Gohary, 2014], a meta-analysis Efficacy of topical antifungals in the treatment of dermatophytosis: a mixed-treatment comparison meta-analysis involving 14 treatments  [Rotta, 2013], expert opinion in Fungal skin infections [Perry, 2021], Tinea Cruris [Pippin, 2023], Tinea Corporis  [Yee, 2023] and expert opinion in the narrative reviews Superficial fungal infections [Kovitwanichkanont, 2019], Tinea corporis: an updated review  [Leung, 2020] Steroid modified tinea [Verma, 2017]. The rationale for the individual recommendations is discussed in the relevant basis for recommendation sections.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines and systematic reviews on primary care management of fungal skin infections of the body and groin.

Search dates

March 2018 - June 2023

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for EBSCO Medline.

  • (MH "Dermatomycoses+")
  • AB ( ((fungal* or mould* or mold or molds or candida* or tinea or trichophyton* or dermatophyt* or myco* or dermatomyco*) N3 (skin or body or groin or dermat* or corporis or cruris)) ) OR AB ( ((fungal* or mould* or mold or molds or candida* or tinea or trichophyton* or dermatophyt* or myco* or dermatomyco*) N3 (skin or body or groin or dermat* or corporis or cruris)) )

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • Bhatia A, Kanish B, Badyal DK, Kate P, Choudhary S. (2019) Efficacy of oral terbinafine versus itraconazole in treatment of dermatophytic infection of skin - A prospective, randomized comparative study. Indian Journal of Pharmacology 51(2), 116-119. [Free Full-text]
  • BMJ Best Practice (2022) Dermatophyte infections. BMJ Publishing Group. https://bestpractice.bmj.com
  • BNF (2023) British National Formulary. National Institute for Health and Care Excellence. https://bnf.nice.org.uk
  • BNFC (2023) British National Formulary for Children. National Institute for Health and Care Excellence. https://bnfc.nice.org.uk
  • DermNet NZ (2020) Tinea corporis (Body ringworm). DermNet NZ. EPub. [Free Full-text]
  • El-Gohary, M., van Zuuren, E.J., Fedorowicz, Z., et al. (2014) Topical antifungal treatments for tinea cruris and tinea corporis. Issue 8. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
  • EMC (2020a) SPC for Daktarin 2% Cream. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2020b) SPC for Terbinafine 250mg tablets. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2021a) SPC for Daktacort Cream. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2021b) SPC for Griseofulvin 125mg tablets. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2022a) SPC for Canesten Antifungal Cream. Electronic Medicines Compendium. Datapharm Communications Ltd. [Free Full-text]
  • EMC (2022b) SPC for Itraconazole 10mg/ml Sugar Free Oral Solution. Electronic Medicines Compendium. Datapharm Communications Ltd. [Free Full-text]
  • EMC (2023) SPC for Lamisil 1% w/w Cream. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • Hay RJ. (2022) The Spread of Resistant Tinea and the Ingredients of a Perfect Storm. Dermatology 238(1), 80-81. [Free Full-text]
  • Kovitwanichkanont, T. and Chong, A.H. (2019) Superficial fungal infections. Australian Journal of General Practice 48(10), 706-711. [Free Full-text]
  • Leung A.K.C., Lam, J.M., Leong, Leong, K.F. and Hon, K.L. (2020) Tinea corporis: an updated review. Drugs Context. 9, 5-6. [Abstract] [Free Full-text]
  • PCDS (2023) Tinea corporis (body), cruris (groin) and incognito (steroid exacerbated). Primary Care Dermatology Society. EPub. [Free Full-text]
  • Perry, M. (2021) Fungal skin infections. Journal of prescribing practice. EPub. [Free Full-text]
  • Pippin M.M., Madden M.L. and Das M. (2023) Tinea Cruris. In: StatPearls [Internet]. StatPearls Publishing. https://www.statpearls.com [Free Full-text]
  • Preston, C. (2019) Stockley's Drug Interactions. Medicines Complete. Pharmaceutical Press.
  • Rotta, I., Ziegelmann, P.K., Otuki, M.F., et al. (2013) Efficacy of Topical Antifungals in the Treatment of Dermatophytosis: A Mixed-Treatment Comparison Meta-analysis Involving 14 Treatments. JAMA Dermatology 149(3), 341-349. [Abstract]
  • Singh, S.K., Subba, N. and Tilak, R. (2020) Efficacy of Terbinafine and Itraconazole in Different Doses and in Combination in the Treatment of Tinea Infection: A Randomized Controlled Parallel Group Open Labeled Trial with Clinico-Mycological Correlation. Indian Journal of Dermatology 65(4), 284-289. [Abstract] [Free Full-text]
  • UKHSA (2017) Fungal skin and nail infections: Diagnosis and laboratory investigation. UK Health Security Agency. http://www.gov.uk [Free Full-text]
  • UKHSA (2023) Health protection in schools and other childcare facilities. UK Health Security Agency. https://www.gov.uk [Free Full-text]
  • Verma, S. (2017) Steroid modified tinea. BMJ 356, 1-4. [Abstract]
  • Yee, G. and Al Aboud, M. (2023) Tinea Corporis. In: StatPearls [Internet]. StatPearls Publishing. https://www.statpearls.com [Free Full-text]
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