Table 4.

Clinical features

Type of tinea infection	Clinical features
Tinea corporis	Annular, erythematous, and pruritic patches or plaques with scaly and active raised borders, and central clearing as the infection advances [36, 37] Pustules may appear along the border of the patch or plaque Multiple areas can be affected with coalescing plaques
Tinea cruris	Annular, erythematous, and pruritic patches or plaques with scaly and active raised borders, and central clearing as the infection advances [36, 37] Always involves the crural fold Infection may spread to the thighs, genital, pubic, perineal, and perianal skin Penis and scrotum in men and labia majora in women are commonly spared [249, 250] Often presents with pruritus Pain may be a prominent feature if maceration or a secondary bacterial infection are present [250, 251]
Tinea capitis, endothrix	A type of non-inflammatory tinea capitis Characterized microscopically by arthroconidia within the hair shaft Typically caused by T. tonsurans, T. violaceum, and/or T. soudanese infections. Hair breakage occurs at the level of the scalp, resulting in the appearance of ‘black dots’, which are representative of the broken, distal ends of hairs Does not fluoresce under Wood’s lamp [6, 75]
Tinea capitis, ectothrix	A type of non-inflammatory tinea capitis characterized microscopically by arthroconidia outside of the hair shaft, occurring at the mid-follicular level. Hyphae then grow towards the bulb of the hair Typically caused by T. verrucosum, M. canis, M. audouinii, Nannizzia nana, and N. gypsea Often present as scaly patch(es) with accompanying inflammation Hair loss occurs, with breakage of the hair above the level of the scalp by at least 2–3 mm Does fluoresce under Wood’s lamp [6, 74]
Tinea capitis, favus	A type of inflammatory tinea capitis characterized microscopically by hyphae and air spaces within hair shafts Almost uniquely caused by T. schoenleinii Begins as erythema surrounding a hair follicle, that progresses to the classic presentation of a scutulum lesion The scutulum (plural scutula) is a concave yellow crust containing fungal hyphae, neutrophils, and epidermal cells that appears on the scalp and cover areas of severe alopecia. Scutula may coalesce to form plaques, which may lead to secondary bacterial infections [94, 252] If left untreated, inflammation may lead to scarring [252]
Tinea capitis, kerion	An inflammatory-type presentation of tinea capitis, most often caused by zoophilic dermatophytes [253] Usually presents as a solitary, painful, boggy plaque on the occipital scalp Begins as a folliculitis and a scaly lesion containing short hairs. It then progresses to an erythematous, tender, inflamed boggy plaque, that is covered with pustules producing a copious purulent discharge [254] Patients often experience fever and cervical lymphadenopathy Major and minor features:  Major features: tenderness to palpation, alopecia within the lesion, numerous pustules and purulent drainage, and scaling  Minor features: a dermatophytid reaction, a type of secondary immunologic reaction caused by dermatophytosis resulting in eczematous scaly patches or plaques at a site distinct from the main infection [255], regional lymphadenopathy (namely cervical), short hairs on dermoscopy, boggy plaques, clear demarcation of borders, overlying erythema, and pruritus [253]
Tinea pedis, interdigital	Mainly caused by T. rubrum May present with scaling, erythema, maceration, or fissuring, particularly in the fourth interdigital space [112] Generally spares the dorsal foot, but may spread to adjacent plantar surfaces Typically pruritic and may be foul smelling [112] Further subcategorized into dermatophytosis simplex, a dry phenotype with mild peeling scale, and wet tinea pedis, which presents with wet, macerated interdigital spaces [106]
Tinea pedis, hyperkeratotic (‘moccasin-type’)	Typically caused by T. rubrum Named for its distribution Entire plantar surfaces and lateral feet are typically involved bilaterally, while the dorsal feet remain clear [112] Presents on a spectrum, from slight scaling to diffuse hyperkeratosis, with chronic erythema of the plantar surface Occasionally, thick scales and fissures develop along with papules along the line of erythema of the foot [106]
Tinea pedis, vesiculobullous (inflammatory)	More commonly caused by T. mentagrophytes Typically involves the medial foot, foot arches, and the sides of the toes Characterized by tense vesicles, pustules, or bullae May be accompanied by burning pain and intense pruritus that may impact ambulation While bullae often contain clear fluid, purulence may ensue with bacterial superinfection, particularly with Staphylococcus aureus or group A Streptococcus infection [106, 112]
Tinea pedis, rare ulcerative form	Rare Most often caused by T. interdigitale Presents with ulcers and vesicular lesions that spread rapidly and are prone to bacterial superinfection [112] There may be maceration involving the interdigital spaces and the plantar surface of the foot [112] Immunocompromised patients are at greatest risk [256]
Tinea manuum	Typically presents as scaling and erythema of the palm, dorsum, and/or interdigital spaces of one or both hands [257] May resemble tinea corporis with an erythematous plaque and an active border [134] 80% of patients with tinea manuum have co-occurring tinea pedis [2, 239] but tinea manuum may also present independently Clinical features often similar to those of moccasin-type tinea pedis [112] Two feet-one hand syndrome describes involvement of unilateral tinea manuum and bilateral tinea pedis, often with co-occurring onychomycosis, a characteristic distribution that likely results from direct hand-to-foot contact while scratching affected feet [239, 258–260]
Tinea barbae, noninflammatory	Affects the hair and hair follicles of beards and mustaches in adult and adolescent males Caused by anthropophilic (humans as primary host) organisms, such as T. tonsurans and T. rubrum Flat, scaly plaques with central clearing, vesicles and pustules may be present at the active border [261] May be difficult to distinguish from tinea faciei [261]
Tinea barbae, inflammatory	Affects the hair and hair follicles of beards and mustaches in adult and adolescent males Caused by zoophilic (animals as primary host) organisms, such as T. mentagrophytes and T. verrucosum [262] Kerion lesion develops, with erythema, boggy, tender, weeping nodule or plaque. Pustules and draining sinuses may be present [263, 264] Hair easily plucked and appears brittle Hair loss occurs within the infected areas Pain and pruritus usually mild or non-existent Usually unilateral Constitutional symptoms, including fever, may be present Superinfection of kerion with bacterial organisms may occur May result in alopecia and scar formation if left untreated [262]
Tinea faciei	The most frequently misdiagnosed superficial fungal infection [265] Affects the glabrous skin of the face Erythematous, annular plaques with scaly borders [70] Begins with scaly papules that extend outward in a ring, with the central area becoming hypoor hyper-pigmented [70, 265] Pustules may be present [265]
Tinea incognito	Classically refers to tinea corporis, cruris, or faciei modified by a topical steroid cream applied due to misdiagnosis of dermatophyte infection as another dermatosis, commonly eczema or psoriasis [104, 105, 266] Also known as ‘steroid-modified tinea’ May also be caused by other anti-inflammatory creams, such as tacrolimus ointment, or systemic glucocorticoids [104] Raised margins and scale typically associated with dermatophytosis may be subtle, making diagnosis challenging May present with inflammatory papules and pustules [267] Affected area may become extensive with unusually shaped borders due to suppression of the local immune response and allowing the fungus to grow [267] Secondary changes caused by long-term steroid use may be present, such as skin atrophy, purpura, or telangiectasia