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Not all that is red, itchy, and scaly on the feet or groin is fungal.  Be sure to consider other causes such as contact dermatitis, eczema, and bacteria.  Take a KOH preparation from the scaly advancing border of a groin rash or from scaling on the feet adjacent to (but not within) an area of maceration, or the roof of a vesicle on the foot to confirm the diagnosis. Branching hyphae should be visible (figure 9).

Fungus lives where it is wet, warm, and dark.  The groin and foot are ideal locations for growing fungus.  Control of the milieu is important to controlling tinea.   Potent medications are not a substitute for simple preventative measures to make the fungus less welcome.

Web spaces and groins should be thoroughly dried after gently showering, followed by applying simple antifungal powders containing tolnaftate or miconazole.  Shoes should fit well and socks should be frequently changed. If possible, two sets of routine footwear should be maintained; one for odd days, one for even days.  In this fashion, the shoes will dry out on the "off day".  Sweating of the feet can be treated with antiperspirants such as aluminum chloride solution (e.g. DrySol, Xerac AC, or Certain Dri) applied at bedtime.  Boxer shorts are preferable to briefs... especially if wearing BDUs.

If tinea develops, remember to use the preventive steps outlined previously in addition to the treatment plan.  These actions will make the treatment much more effective, provide more rapid relief, and allow for better results over the long run.

Wet, very macerated tinea of the web spaces is best treated with antifungal lotions such as miconazole or clotrimazole after astringent compresses with Burow's solution (see Impetigo above) or dilute vinegar.  These areas are frequently overgrown with a potpourri of gram negative bacteria (figure 10).  The concurrent use of a drug such as oral ciprofloxacin accelerates recovery.

Typical web space tinea is treated with a cream or solution vehicle antifungal drug.  Miconazole or clotrimazole are effective.  Nizoral, Spectazole, Naftin, or Lamasil cream is also effective but quite a bit more expensive.  At least 3 weeks of treatment are required.

Chronic, hyperkeratotic, cracked and peeling "moccasin foot" tinea is treated with keratolytics such as Whitfield's ointment, 10% salicylic acid in petrolatum or 12% ammonium lactate lotion (Lachydrin).  Antifungal creams are also effective but are quite a bit more expensive.  Localized vesicular plantar tinea can be treated with cream.  Extensive vesicular tinea of the feet requires the addition of astringent soaks (see above) and strong consideration of oral antifungal therapy (see below).

Not all itchy perineums and groins are caused by tinea.  Strongly consider the diagnosis of Candida if "satellite pustules" and extensive maceration are present, especially in females.  The differential diagnosis frequently includes contact dermatitis (occupational and non-occupational), seborrheic dermatitis, and psoriasis.  Take a history and look for diagnostic hints.  Remember, in temperate climates Tinea and Candida rarely involve the scrotum.

Contact dermatitis as an overlay to another diagnosis on the genital and crural skin occurs more often than is appreciated.  Patients with itchy groins are desperate to stop the itch and will try anything topical;  topical benzocaine, deodorants, rubbing alcohol, strong antibacterial soaps, and Ben Gay to name a few.  Insist that all applications be ceased except the ones that you prescribe.  Wet and weepy groins need astringent solution compresses and ventilation to facilitate drying.

If the diagnosis is tinea cruris, begin with twice a day antifungal cream once if the area is not weeping.  Treat for at least 3 weeks.   Remember that nystatin powder, cream or lotion, while effective for Candida, will not work against the dermatophyte fungi which cause tinea.  If the tinea is very macerated, strongly consider using oral antifungal therapy (see below) as well as astringent solution compresses.

The diagnosis of Tinea of the nails (tinea unguium) needs to be confirmed before you even consider treatment.  Not all distorted nails are due to fungal infection.  If you are not sure of the diagnosis, refer to dermatology.