Ringworm

Ringworm also known as “tinea” or “dermatophytosis”, is a common fungal skin infection that is caused by a fungus. It’s called “ringworm” because it can cause a circular rash (shaped like a ring) that is usually red, scaly and itchy. There are approximately 40 different species of fungi can cause ringworm; the scientific names for the types of fungi that cause ringworm are Trichophyton, Microsporum, and Epidermophyton ¹. No worm is involved. Anyone can get ringworm. The fungi that cause this infection can live on skin, surfaces, and on household items such as clothing, towels, and bedding.

Ringworm rash is itchy and is highly contagious being easily spread by touching an infected person or animal. Ringworm can also be spread by touching objects or surfaces that had contact with the infection. If infected, people often begin itching four to fourteen days after contact. The rash may be scaly, reddened, and circular. Ringworm on the scalp usually makes a bald patch of scaly skin.

Ringworm can affect skin on almost any part of your body as well as fingernails and toenails. Ringworm goes by different names depending on which body part it affects. Ringworm on your body is called tinea corporis. This type of ringworm affects your arms, legs, torso and face.

Areas of the body that can be affected by ringworm include:

• Feet (tinea pedis, commonly called “athlete’s foot”)
• Groin, inner thighs, or buttocks (tinea cruris, commonly called “jock itch”)
• Scalp (tinea capitis)
• Face (tinea faciei)
• Beard (tinea barbae)
• Hands (tinea manuum)
• Toenails or fingernails (tinea unguium, also called “onychomycosis”)
• Other parts of the body such as arms or legs (tinea corporis)

Sometimes, the name gives a different meaning:

• Tinea versicolor is more accurately called pityriasis versicolor. This is a common yeast infection on the trunk.
• Tinea incognito refers to a tinea infection in which the clinical appearance has changed because of inappropriate treatment, usually a topical steroid cream. It is also known as steroid-modified tinea ².
• Tinea nigra is a mold infection (not a dermatophyte). It affects the palms or soles, which appear brown (on white skin) or black (on dark skin).

The symptoms of ringworm often depend on which part of the body is infected, but they generally include:

• Itchy skin
• Ring-shaped rash
• Red, scaly, cracked skin
• Hair loss

Symptoms typically appear between 4 and 14 days after the skin comes in contact with the fungi that cause ringworm.

Symptoms of ringworm by location on the body:

• Ringworm on the feet (tinea pedis or “athlete’s foot”): The symptoms of ringworm on the feet include red, swollen, peeling, itchy skin between the toes (especially between the pinky toe and the one next to it). The sole and heel of the foot may also be affected. In severe cases, the skin on the feet can blister.
• Ringworm on the scalp (tinea capitis): Ringworm on the scalp usually looks like a scaly, itchy, red, circular bald spot. The bald spot can grow in size and multiple spots might develop if the infection spreads. Ringworm on the scalp is more common in children than it is in adults.
• Ringworm on the groin (tinea cruris or “jock itch”): Ringworm on the groin looks like scaly, itchy, red spots, usually on the inner sides of the skin folds of the thigh.
• Ringworm on the beard (tinea barbae): Symptoms of ringworm on the beard include scaly, itchy, red spots on the cheeks, chin, and upper neck. The spots might become crusted over or filled with pus, and the affected hair might fall out.
• Fungal nail infections also known as “onychomycosis”. Fungal nail infections may cause nails to become discolored, thick, fragile, or cracked. The nail may also become separated from the nail bed. Fungal toenail infections are more common than fungal fingernail infections ³.

Your doctor might suspect you have ringworm by looking at your affected skin and asking questions about your symptoms. Your doctor will generally take a small skin scraping or nail sample to examine under a microscope or send to a laboratory for further testing.

Ringworm is treated with antifungal medication available either over the counter or as a prescription. Mild ringworm often responds to antifungal medications applied to the skin. For more-severe infections, you may need to take prescription-strength oral antifungal medication for several weeks.

Most ringworm infections improve with antifungal treatment, but treatment failure may occur. Common reasons for treatment failure may include incorrect diagnosis and inadequate treatment.

Figure 1. Ringworm rash

Figure 2. Ringworm (tineas) throughout the body

Footnote: From top to bottom, left to right: fungal infections of (A) ringworm on the scalp (tinea capitis); (B) ringworm on the face (tinea faciei); (C) ringworm on the arm (tinea corporis); (D) close-up of ringworm; (E) ringworm on the torso with concentric rings (tinea corporis); (F) ringworm on the groin (tinea cruris); (G) ringworm on between the toe webbing (tinea pedis); (H) ringworm on the foot (tinea pedis / “moccasin” type); and (I) ringworm in the nails (onycomycosis).

Figure 3. Ringworm on face

Figure 4. Ringworm on neck

Figure 5. Ringworm on body (tinea corporis)

Figure 6. Ringworm on hands

Footnote: (A) Tinea manuum clinical examination shows diffuse white scaling involving the palmar surface and the volar aspect of the fingers of both hands. (B) Polarized light dermoscopy reveals white scaling mainly located in the creases. Direct microscopic examination of 10% potassium hydroxide (KOH) preparation of the scales scraped from the palmar surface showed septate branching hyphae. Cultures of specimens on conventional Sabouraud’s dextrose agar medium showed Trichophyton rubrum growth after three weeks, thus confirming the diagnosis of tinea manuum.

Figure 7. Ringworm on leg

Figure 8. Ringworm on foot

Is ringworm contagious?

Yes. Ringworm is a highly contagious fungal skin infection that is spread easily and through close contact with an infected person, animal or object.

Many different kinds of animals can transmit ringworm to people. Dogs and cats, especially kittens or puppies, can have ringworm that can be passed to people. Cows, goats, pigs, and horses can also pass ringworm to people.

Animals, like people, get infected through touching an infected animal’s skin or hair or by touching things that are infected with the fungus, like blankets and towels.

Adult animals, especially long-haired cats, do not always show signs of ringworm infection. Puppies and kittens most often have patches that are hairless, circular, or irregularly shaped areas of scaling, crusting, and redness that may or may not be itchy. The area may not be completely hairless, and instead have brittle, broken hairs. If the claws are affected, they may have a whitish, opaque appearance with shredding of the claw’s surface. If you suspect your pet has ringworm, make sure it is seen by a veterinarian.

Ringworm is also fairly common in show lambs, and is referred to as “club lamb fungus” ⁷. Lambs usually have circular, hairless areas with thick scabs on their head and face.

How does ringworm spread?

The fungi (Trichophyton, Microsporum, and Epidermophyton) that cause ringworm can live on your skin and in the environment. There are three main ways that ringworm can spread:

1. From a person who has ringworm. People can get ringworm after contact with someone who has the infection. To avoid spreading the infection, people with ringworm shouldn’t share clothing, towels, combs, or other personal items with other people.
2. From an animal that has ringworm. People can get ringworm after touching an animal that has ringworm. Many different kinds of animals can spread ringworm to people, including dogs and cats, especially kittens and puppies. Other animals, like cows, goats, pigs, and horses can also spread ringworm to people.
3. From the environment. The fungi that cause ringworm can live on surfaces, particularly in damp areas like locker rooms and public showers. For that reason, it’s a good idea not to walk barefoot in these places.

Who gets ringworm?

Ringworm is very common. Anyone can get ringworm, but people who have weakened immune systems may be especially at risk for infection and may have problems fighting off a ringworm infection ⁸. People who use public showers or locker rooms, athletes (particularly those who are involved in contact sports such as wrestling), people who wear tight shoes and have excessive sweating, and people who have close contact with animals may also be more likely to come in contact with the fungi that cause ringworm ⁹, ¹⁰, ¹¹.

My cats and dogs have ringworm and I’m worried about ringworm in my house. What should I do?

Ringworm can easily transfer from animals to humans ¹². You can take the following steps to protect yourself and your pet:

For people

• DO
  • Wash your hands with soap and running water after playing with or petting your pet.
  • Wear gloves and long sleeves if you must handle animals with ringworm, and always wash your hands after handling the animal.
  • Vacuum the areas of the home that the infected pet commonly visits. This will help to remove infected fur or flakes of skin.
  • Disinfect areas the pet has spent time in, including surfaces and bedding.
    • The spores of this fungus can be killed with common disinfectants like diluted chlorine bleach (mix 2 ml of 2.2% household bleach for every 1 liter of water to make a 0.005% solution. Brands vary strength, so check the label. If the concentration is higher, use less bleach, and if the concentration is lower, use more bleach), benzalkonium chloride, or strong detergents.
    • Never mix cleaning products. This may cause harmful gases.
• DON’T handle animals with ringworm if your immune system is weak in any way (if you have HIV and AIDS, are undergoing cancer treatment, or are taking medications that suppress your immune system, for example).

For pets

• If you suspect that your pet has ringworm, make sure it is seen by a veterinarian so treatment can be started.
• If one of your pets has ringworm, make sure you have every pet in the household checked by a veterinarian for ringworm infection.
• Your veterinarian may test some fur for the fungus. Treating animals for ringworm can help them clear the infection sooner and prevent spreading the infection to other people and animals.
• Your veterinarian may prescribe antifungal shampoos or creams, dips, or antifungal pills. During this time, the pet should be handled as little as possible until the infection is cleared.

Ringworm causes

Ringworm also called “tinea” or “dermatophytosis,” is a common infection of the epidermis (skin, hair, or nails) caused by dermatophyte fungi (the fungal organisms that cause tinea) ¹³. There are approximately 40 different species of fungi can cause ringworm; the scientific names for the types of fungi that cause ringworm are Trichophyton (abbreviated as “T”), Microsporum (“M”), and Epidermophyton (“E”) ¹. Dermatophytes (the fungal organisms that cause tinea) have the ability to invade keratinized tissue (skin, hair and nails). Infection is normally restricted to the outermost layer of the skin (epidermis).

People can acquire ringworm through direct skin contact with people and animals who are infected. People can also acquire ringworm by sharing personal items (e.g., towels, clothing, bedding) or through contact with surfaces found in moist areas (e.g., shower stalls, locker room floors, pool areas). Ringworm can also spread from one part of the body to another.

Dermatophytes are grouped into three general categories based on their natural environment: anthropophilic (live exclusively on humans), zoophilic (live on an animal host), and geophilic (live in the soil) ¹⁴. The majority of human infections are caused by anthropophilic dermatophytes; however, dermatophytes from all three groups have been associated with human disease. For example, pets with ringworm can transmit the infection to their owners, and stray cats carrying dermatophytes are considered to be a vector for infection in several eastern and southern European countries ¹⁵.

Anthropophilic dermatophytes are so well adapted to living on human skin that they provoke a minimal inflammatory reaction. Zoophilic or geophilic dermatophytes will often provoke a more vigorous inflammatory reaction when they attempt to invade human skin.

Anthropophilic dermatophytes (live exclusively on humans) include:

• Trichophyton rubrum
• Trichophyton interdigitale
• Trichophyton tonsurans (very common in the USA)
• Microsporum audouinii
• Trichophyton violaceum
• Microsporum ferrugineum
• Trichophyton schoenleinii
• Trichophyton megninii
• Trichophyton soudanense
• Trichophyton yaoundei

Zoophilic dermatophytes (live on an animal host) include:

• Microsporum canis (originating from cats and dogs)
• Trichophyton equinum (originating from horses)
• Trichophyton erinacei (originating from hedgehogs and other animals)
• Trichophyton verrucosum (originating from cattle)
• Microsporum nanum (originating from pigs)
• Microsporum distortum (a variant of M. canis).

Geophilic dermatophytes (live in the soil) include:

• Nannizzia gypsea
• Microsporum fulvum.

Although dermatophytes are found throughout the world, the most prevalent strains and the most common sites of infection vary by region ¹⁵, ¹. Hot, humid climates and overcrowding predispose populations to skin diseases, including tinea infections ¹⁶. Developing countries have high rates of tinea capitis, while developed countries have high rates of tinea pedis and onychomycosis ¹⁵.

Low socioeconomic conditions are strongly linked to higher prevalence rates for skin infections, including tinea infections. A review of 18 studies representing large geographical areas determined that tinea capitis is present in up to 19.7% of the general population in developing countries ¹⁶. A recent study found tinea capitis present in more than 30% of children at certain grade levels in some urban areas of the United States ¹⁷.

High prevalence rates of tinea pedis and onychomycosis have been linked to increased urbanization, community showers, sports, and the use of occlusive footwear ¹⁵, ¹, ¹⁸. These factors are thought to contribute to the high prevalence of tinea pedis in certain occupational groups, including marathon runners (22%–31% prevalence), miners (21%–72.9% prevalence), and soldiers (16.4%–58% prevalence) ¹⁵. Several of these studies also found high rates of onychomycosis presenting with tinea pedis. Although tropical and subtropical climates have a higher overall prevalence of skin mycoses, tinea pedis and onychomycosis are rare in India and rural Africa ¹⁸.

Ringworm prevention

• Keep your skin clean and dry.
• Wear shoes that allow air to circulate freely around your feet.
• Don’t walk barefoot in areas like locker rooms or public showers.
• Clip your fingernails and toenails short and keep them clean.
• Change your socks and underwear at least once a day.
• Don’t share clothing, towels, sheets, or other personal items with someone who has ringworm.
• Wash your hands with soap and running water after playing with pets. If you suspect that your pet has ringworm, take it to see a veterinarian. If your pet has ringworm, follow the steps below to prevent spreading the infection.
• If you’re an athlete involved in close contact sports, shower immediately after your practice session or match, and keep all of your sports gear and uniform clean. Don’t share sports gear (helmet, etc.) with other players.

Ringworm signs and symptoms

Ringworm typically begins as a flat, discolored patch, which may appear red in lighter complexions and brown in darker complexions. The patch has a ring-like or circular shape with a raised, scaly border.

Ringworm has different names based on where it appears on your body and it can appear just about anywhere.

Symptoms of ringworm by location on the body:

• Ringworm on the feet (tinea pedis or “athlete’s foot”): The symptoms of ringworm on the feet include red, swollen, peeling, itchy skin between the toes (especially between the pinky toe and the one next to it). The sole and heel of the foot may also be affected. In severe cases, the skin on the feet can blister.
• Ringworm on the scalp (tinea capitis): Ringworm on the scalp usually looks like a scaly, itchy, red, circular bald spot. The bald spot can grow in size and multiple spots might develop if the infection spreads. Ringworm on the scalp is more common in children than it is in adults.
• Ringworm on the face (tinea faciei): Ringworm on the face does not include infection of the beard and moustache area, which is called tinea barbae. Tinea faciei resembles tinea corporis (ringworm). It may be acute (sudden onset and rapid spread) or chronic (slow extension of a mild, barely inflamed, rash). There are round or oval red scaly patches, often less red and scaly in the middle or healed in the middle. It is frequently aggravated by sun exposure. It may also present as a kerion (fungal abscess). Tinea faciei is uncommon and often misdiagnosed at first.
  
• Ringworm on the body (tinea corporis): Ringworm on the body (tinea corporis) is a superficial fungal infection of the skin that can affect any part of the body, excluding the hands and feet, scalp, face and beard, groin, and nails. Ringworm on the body (tinea corporis) is most commonly seen in children and young adults, however all age groups can be infected including newborns. Ringworm on the body (tinea corporis) initially presents as a solitary circular red patch with a raised scaly leading edge. A lesion spreads out from the centre forming a ring-shape with central hypopigmentation and a peripheral scaly red rim (ringworm). The border can be papular or pustular. Itch is common. With time, multiple lesions can develop which may coalesce to form a polycyclic pattern. The distribution of lesions is typically asymmetrical.
  
• Ringworm on the groin (tinea cruris or “jock itch”): Ringworm on the groin looks like scaly, itchy, red spots, usually on the inner sides of the skin folds of the thigh.
• Ringworm on the beard (tinea barbae): Symptoms of ringworm on the beard include scaly, itchy, red spots on the cheeks, chin, and upper neck. The spots might become crusted over or filled with pus, and the affected hair might fall out.
• Fungal nail infections also known as “onychomycosis”. Fungal nail infections may cause nails to become discolored, thick, fragile, or cracked. The nail may also become separated from the nail bed. Fungal toenail infections are more common than fungal fingernail infections ³.

Ringworm diagnosis

Ringworm may be difficult to distinguish from other skin conditions ¹⁹. Physical examination with the help of dermatoscopy and clinical history alone may not be enough to diagnose ringworm. Doctors often use a diagnostic test to confirm suspected ringworm, especially before prescribing antifungal treatment. Clinicians should generally confirm the diagnosis of scalp fungus (tinea capitis) using a laboratory test ¹³.

The presence of a dermatophyte infection is confirmed by:

• Microscopy and culture of skin scrapings
• Histopathological examination of skin or nail biopsy using periodic acid-Schiff (PAS) stains to reveal fungal elements
• Specific antigen tests using molecular biology techniques such as polymerase chain reaction (PCR).

Potassium hydroxide preparation

Doctors often use a potassium hydroxide (KOH) preparation of skin scrapings or nail clippings to confirm a diagnosis of ringworm. This test can provide rapid results, but the test’s accuracy depends on clinician experience and technique ²⁰.

Fungal culture

Fungal culture can be used to diagnose ringworm. Fungal culture is more specific than potassium hydroxide (KOH) stain, but results may take several weeks ²¹, ²².

Note: Antifungal-resistant fungal nail infections (onychomycosis) is a growing problem ²³, ²⁴, ²⁵ Therefore, antifungal susceptibility testing may be considered based on the fungus or fungi identified and the patient’s clinical course.12,16,17

Histopathologic examination with a periodic acid-Schiff stain

Histopathologic examination of nail clippings with a periodic acid-Schiff (PAS) stain is a method for confirming the diagnosis for patients with suspected onychomycosis, a fungal nail infection most often caused by dermatophytes.

Polymerase chain reaction (PCR)

Footnote: Ringworm of the scalp appears as round patches where the hair has broken off at or just above the scalp. These bald-looking patches slowly grow larger.

Figure 10. Close up view of the scalp with ringworm

Footnote: Close up view of the scalp with ringworm that can look scaly and silvery with patches of broken hair. You may also see small black dots if the hair has broken off right at the scalp.

Figure 11. Kerion

Footnote: Kerion appears as soft, raised swellings that drain pus and cause thick, yellow crusting on the scalp. With kerion, the hair falls out or can be easily pulled out. Kerion may be caused by an overly vigorous reaction to the fungus and can lead to scarring and permanent hair loss.

Ringworm on scalp causes

Ringworm of the scalp is caused by a common fungus. The fungus attacks the outer layer of skin on the scalp and the hair. This causes those hairs to break. The condition can be spread in the following ways:

• Human to human. Ringworm often spreads through direct skin-to-skin contact with an infected person.
• Animal to human. You can contract ringworm by touching an animal with ringworm. Ringworm can spread while petting or grooming dogs or cats with ringworm. Ringworm is fairly common in kittens, puppies, cows, goats, pigs and horses.
• Object to human. It’s possible for ringworm to spread by contact with objects or surfaces that an infected person or animal has recently touched. This includes items such as clothing, towels, bedding, combs and brushes.

Risk factors for ringworm of the scalp

Risk factors for ringworm of the scalp include:

• Age. Ringworm of the scalp is most common in toddlers and school-age children.
• Exposure to other children. Outbreaks of ringworm are common in schools and child care centers where the infection easily spreads with close contact.
• Exposure to pets. A pet, such as a cat or a dog, can have the infection without showing any signs. Children can get the infection by touching the animal.

Ringworm on scalp prevention

Ringworm of the scalp is difficult to prevent. The fungus that causes it is common, and the condition is contagious even before symptoms appear. Take these steps to reduce the risk of ringworm:

• Educate yourself and others. Be aware of the risk of ringworm from infected people or pets. Tell children about ringworm, what to watch for and how to avoid the infection.
• Shampoo regularly. Be sure to wash your child’s scalp regularly, especially after haircuts. Some scalp conditioning products, such as coconut oil and pomades with selenium, might help prevent ringworm of the scalp.
• Keep skin clean and dry. Be sure children wash their hands, including after playing with pets. Keep shared areas clean, especially in schools, child care centers, gyms and locker rooms.
• Avoid infected animals. The infection often looks like a patch of skin where fur is missing. If you have pets or other animals that commonly carry ringworm, ask your veterinarian to check them for the infection.
• Avoid sharing personal items. Teach children not to let others use their clothing, towels, hairbrushes, sports gear or other personal items.

Ringworm on scalp signs and symptoms

Signs and symptoms of ringworm of the scalp may include:

• One or more round, scaly or inflamed patches where the hair has broken off at or near the scalp
• Patches that slowly get bigger and have small, black dots where the hair has broken off
• Brittle or fragile hair that can be easily broken or pulled out
• Tender or painful areas on the scalp due to severe inflammation called kerion. Kerion appears as soft, raised swellings that drain pus and cause thick, yellow crusting on the scalp. With kerion, the hair falls out or can be easily pulled out. Kerion may be caused by an overly vigorous reaction to the fungus and can lead to scarring and permanent hair loss.

Ringworm on scalp diagnosis

Your doctor will likely be able to diagnose ringworm of the scalp by looking at the affected skin and asking certain questions. To confirm the diagnosis, your doctor may take a sample of hair or skin to be tested in a lab. Testing a sample of hair or skin can show if a fungus is present.

Ringworm on scalp treatment

Treatment for ringworm of the scalp requires a prescription-strength oral antifungal medication to be taken by mouth. The first-choice medication is usually griseofulvin (Gris-Peg). Alternatives might be used if griseofulvin isn’t working or your child is allergic to it. These include terbinafine, itraconazole (Spoanox, Tolsura) and fluconazole (Diflucan). You or your child might need to take one of these medications for six weeks or more until the hair regrows. Typically, with successful treatment, the bald spots will grow hair again and the skin will heal without scarring.

Your doctor might recommend that you or your child also wash you or your child’s hair with a prescription-strength medicated shampoo such as selenium sulfide shampoos ²⁶, ²⁸. The shampoo removes fungus spores and helps prevent spreading the infection to others or to other areas of your body.

There is no need to shave the head or cut the hair as part of the treatment.

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