around the base of the foot and often with extension in between the toes Coincident onychomycosis is common and presents with toe nail thickening and subungual debris Tinea manuum is the name for dermatophyte infection of the palms and is characterized by an extremely dry and sometimes fissured appearance that can mimic hand dermatitis Often, patients with tinea manuum will have tinea pedis as well and present with both feet and one hand infected FIGURE 66.11 Tinea corporis (ringworm) Note the annular appearance, central clearing, and “active” scaly border that demonstrate hyphae on potassium hydroxide examination (Reprinted with permission from Goodheart HP Goodheart’s Photoguide of Common Skin Disorders 2nd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2003.) FIGURE 66.12 Tinea capitis Alopecia with the “black dot” sign of broken hairs (Reprinted with permission from Fleisher GR, Ludwig S, Baskin MN Atlas of Pediatric Emergency Medicine Philadelphia, PA: Lippincott Williams & Wilkins; 2004.) In North America, tinea capitis is most commonly caused by infection with Trichophyton tonsurans or Microsporum canis Infection can manifest as scaling patches of alopecia, areas of distinct alopecia with broken hairs that manifest as “black dots” ( Fig 66.12 ), diffuse scaling with little alopecia, or an acute boggy plaque (kerion) ( Fig 66.13 ) Tinea capitis and other dermatophyte infections of hair-bearing areas (eyebrow, beard, etc.) usually require systemic therapy because these are deeper infections of the hair shaft and follicle Four to weeks of griseofulvin (children over years) or to weeks of terbinafine (children over years) are commonly used therapies In children under years, oral fluconazole can be used, but topical therapy with an azole (e.g., clotrimazole) or an allylamine (e.g., terbinafine) may be effective if the hairs are fine FIGURE 66.13 Tinea capitis with kerion Note the boggy swelling from inflammation (Reprinted with permission from Fleisher GR, Ludwig S, Baskin MN Atlas of Pediatric Emergency Medicine Philadelphia, PA: Lippincott Williams & Wilkins; 2004.) Dermatophytes can be cultured by sending skin scrapings on a sterile tooth brush or in a sterile urine cup to the laboratory Of note, some labs standardly perform a more broad fungal culture instead of a dermatophytespecific culture Incidental, nonpathologic soil molds can grow on broader fungal cultures and the results must be interpreted with caution Topical therapy for dermatophyte infections with azole agents such as clotrimazole or allylamines such as terbinafine is usually effective In hair-bearing areas (scalp, beard, eyebrow) and nail infections, oral antifungals are usually needed to penetrate the hair follicle or nail Tinea manuum and severe tinea pedis may also require oral antifungals due to the thickness of the stratum corneum Candida Infections ... broken hairs (Reprinted with permission from Fleisher GR, Ludwig S, Baskin MN Atlas of Pediatric Emergency Medicine Philadelphia, PA: Lippincott Williams & Wilkins; 2004.) In North America, tinea... inflammation (Reprinted with permission from Fleisher GR, Ludwig S, Baskin MN Atlas of Pediatric Emergency Medicine Philadelphia, PA: Lippincott Williams & Wilkins; 2004.) Dermatophytes can be