Tinea Trichophytina (Synonym: Ringworm.)
What is tinea trichophytina?
Tinea trichophytina, or ringworm, is a contagious, vegetable-parasitic disease due to the invasion of the cutaneous structures by the vegetable parasite, the trichophyton, or the microsporon Audouinii.
Do the clinical characters of ringworm vary according to the part affected?
Yes, often considerably; thus upon the scalp, upon the general surface, and upon the bearded region, the disease usually presents totally different appearances.
Describe the symptoms of ringworm as it occurs upon non-hairy portions of the body.
Ringworm of the general surface (tinea trichophytina corporis, tinea circinata) appears as one or more small, slightly-elevated, sharply-limited, somewhat scaly, hyperæmic spots, with, rarely, minute papules, vesico-papules, or vesicles, especially at the circumference. The patch spreads in a uniform manner peripherally, is slightly scaly, and tends to clear in the centre, assuming a ring-like appearance. When coming under observation, the patches are usually from one-half to one inch in diameter, the central portion pale or pale red, and the outer portion more or less elevated, hyperæmic and somewhat scaly. As commonly noted one, several or more patches are present. After reaching a certain size they may remain stationary, or in exceptional cases may tend to spontaneous disappearance. At times when close together, several may merge and form a large, irregular, gyrate patch.
Itching, usually slight, may or may not be present.
Exceptionally ringworm appears as a markedly inflammatory pustular circumscribed patch, formerly thought to be a distinct affection and described under the name of conglomerate pustular folliculitis. It consists of a flat carbuncular or kerion-like inflammation, somewhat elevated, and usually a dime to silver dollar in area. The most common seats are the back of the hands and the buttocks. The surface is cribriform, and a purulent secretion may be pressed out from follicular openings.
Describe the symptoms of ringworm when occurring about the thighs and scrotum.
In adults, more especially males, the inner portion of the upper part of the thighs and scrotum (tinea trichophytina cruris, so-called eczema marginatum) may be attacked, and here the affection, favored by heat and moisture, develops rapidly and may soon lose its ordinary clinical appearances, the inflammatory symptoms becoming especially prominent. The whole of this region may become involved, presenting all the symptoms of a true eczema; the border, however, is sharply defined, and usually one or more outlying patches of the ordinary clinical type of the disease may be seen.
Describe the symptoms of ringworm when involving the nails.
In ringworm of the nails (tinea trichophytina unguium) these structures become soft or brittle, yellowish, opaque and thickened the changes taking place mainly about the free borders. Ringworm on other parts usually coexists.
Describe the symptoms of ringworm as it occurs upon the scalp.
Ringworm of the scalp (tinea trichophytina capitis, tinea tonsurans) begins usually in the same manner as that upon the general surface, but, as a rule, much more insidiously. Sooner or later, however, the hair and follicles are invaded by the fungus, and in consequence the hair falls out or becomes brittle and breaks off. The follicles, except in long-standing cases, are slightly elevated and prominent, and the patch may have a puffed or goose-flesh appearance. In addition, there is slight scaliness.
Describe the appearances of a typical patch of ringworm of the scalp.
The patch is rounded, grayish, somewhat scaly, and slightly elevated; the follicles are somewhat prominent; there is more or less alopecia, with here and there broken, gnawed-off-looking hairs, some of which may be broken off just at the outlet of the follicles and more or less surrounded by a whitish or grayish-white dust. This type is produced by the small-spore fungus—microsporon.
Does ringworm of the scalp always present typical appearances?
Not invariably. In some cases the patch or patches may become almost completely bald, and in others a tendency to the formation of pustules, with more or less crust-formation, may be seen. The affection may also appear as small scattered spots or points.
The markedly inflammatory and pustular types are produced by the large-spore fungus—trichophyton.
What is tinea kerion?
Tinea kerion (kerion) is a markedly inflammatory type of ringworm of the scalp involving the deeper tissues, appearing as a more or less bald, rounded, inflammatory, œdematous, boggy, honeycombed tumor, discharging from the follicular openings a mucoid secretion.
Does ringworm of the scalp ever occur in adults?
No. (Extremely rare exceptions.)
Describe the symptoms of ringworm of the bearded region.
Ringworm of the bearded region (tinea trichophytina barbæ, tinea sycosis, parasitic sycosis, barber's itch) begins usually in the same manner as ringworm on other parts, as one or more rounded, slightly scaly, hyperæmic patches. In rare instances the disease may persist as such, with very little tendency to involve the hairs and follicles; but, as a rule, the hairy structures are soon invaded, many of the hairs breaking off, and many falling out. From involvement of the follicles, more or less subcutaneous swelling ensues, the parts assuming a distinctly lumpy and nodular condition. The skin is usually considerably reddened, often having a glossy appearance, and studded with few or numerous pustules. The nodules tend, ordinarily, to break down and discharge, at one or more of the follicular openings, a glairy, glutinous, purulent material, which may dry to thick, adherent crusts.
The disease may be limited to one patch, or a large area, even to the extent of the whole bearded region, becomes involved. The upper lip is rarely invaded. Ringworm of the bearded region is due to the trichophyton.
To what is ringworm due?
To the presence and growth in the cutaneous structures of a vegetable parasite. Although the disease is contagious, individuals differ considerably as to susceptibility. It is much more common in children than in those past the age of puberty, ringworm of the scalp being limited to the former (rare exceptions), and tinea sycosis being a disease of the male adult.
Until recently the ringworm was thought to be due to but one fungus—the trichophyton; it is now known that there are several forms of fungi, the main forms being the small-spored (microsporon Audouini) and the large-spored (trichophyton). Of this latter there are two main subvarieties—endothrix and ectothrix. The small-spored fungus is found as the cause in the majority of scalp cases; the endothrix also commonly invades the scalp integument. The ectothrix variety is usually derived directly or indirectly from domestic animals, and is chiefly responsible for body-ringworm, and for suppurative ringworm, whether upon the bearded region or elsewhere.
What is the pathology of ringworm?
On the general surface the fungus has its seat in the epidermis, especially in the corneous layer; upon the scalp and bearded region the epidermis, hair-shaft, root and follicle are invaded. The inflammatory action may vary considerably in different cases, and at different times in the same case.
The fungus consists of mycelium and spores. In the epidermic scrapings it is never to be found in abundance, and the mycelium predominates, while in affected hairs the spores and chains of spores are almost exclusively seen, and are usually present in great profusion.
How do you examine for the fungus?
The scrapings or hair should be moistened with liquor potassæ, and examined with a power from three hundred diameters upward.
How is ringworm of the general surface to be distinguished from eczema, psoriasis and seborrhœa?
By the growth and characters of the patch, the slight scaliness, the tendency to disappear in the centre, by the history, and, if necessary, by a microscopic examination of the scales.
How is ringworm of the scalp to be distinguished from alopecia areata, favus, eczema, seborrhœa, and psoriasis?
By the peculiar clinical features of ringworm on this region—the slight scaliness, broken hair and hair stumps, with a certain amount of baldness—and in doubtful cases by a microscopical examination of the hairs.
In favus, although the same condition of the hair is noted, the yellow, cup-shaped crusts, and the presence of the atrophic areas in that disease are pathognomonic.
How is ringworm of the bearded region to be distinguished from eczema and sycosis?
By the peculiar lumpiness of the parts, the brittleness of the hair, more or less hair loss, and the history.
The superficial type of ringworm sycosis—those cases in which the disease remains a surface disease—is readily distinguished, as the symptoms are essentially the same as ringworm of non-hairy parts, except that some of the hairs in the areas may become invaded and break off or fall out.
In doubtful cases recourse may be had to microscopical examination.
What is the prognosis of ringworm of these several parts?
When upon the general surface, the disease usually responds rapidly to therapeutical applications; upon the scalp it is always a stubborn affection, and, as a rule, requires several months to a year of energetic treatment to effect a cure. In this latter region the disease will disappear spontaneously as the age of fifteen or sixteen is reached. Tinea sycosis yields in most instances in the course of several weeks or a few months.
Is ringworm of these several parts treated with the same remedies?
As a rule, yes; but the strength must be modified. The scalp will stand strong applications, as will likewise the bearded region; upon non-hairy portions the remedies should be used somewhat weaker. They should be applied twice daily; ointments, if used, being well rubbed in, and lotions thoroughly dabbed on.
How would you treat ringworm of the general surface?
By applications of the milder parasiticides, such as a ten to fifteen per cent. solution of sodium hyposulphite; carbolic acid, five to thirty grains to the ounce of water, or lard; a saturated solution of boric acid; ointments of tar, sulphur and mercury, official strength or weakened with lard; and tincture of iodine, pure or diluted.
When occurring upon the upper and inner part of the thighs (so-called eczema marginatum), the same remedies are to be employed, but usually stronger. Deserving of special mention is a lotion of corrosive sublimate, one to four grains to the ounce; or the same remedy, in the same proportion, may be used in tincture of myrrh or benzoin, and painted on the parts.
How would you treat ringworm of the scalp?
By occasional soap-and-hot-water washing; by extraction of the involved hairs, when practicable; by carbolic acid or boric acid lotions to the whole scalp, so as to limit, as much as possible, the spread of the disease; and by daily (or twice daily) applications to the patches and involved areas of a parasiticide. The following are the most valuable: the oleate of mercury, with lard or lanolin, in varying strength, from ten to twenty per cent.; carbolic acid, with one to three or more parts of glycerine or oil; corrosive sublimate, in solution in alcohol and water, one to four grains to the ounce; sulphur ointment; and citrine ointment, with one or two parts of lard. Chrysarobin is a valuable remedy, but is to be employed with care; it may be prescribed as a rubber plaster, or in a solution of gutta-percha, or as an ointment, ten to fifteen per cent. strength. β-naphthol in ointment form, five to fifteen per cent. strength, is also useful. An excellent application for beginning areas on the scalp is a solution of the red iodide of mercury in iodine tincture, one to three grains to an ounce.
A compound ointment, containing several of the active remedies named, is convenient for dispensary practice, such as:—
℞ β-naphthol, ...................................... ʒss-ʒj
Ol. cadini, ...................................... ʒj
Ungt. sulphuris, ........................ q.s. ad. ℥j. M.
In that form known as tinea kerion mild applications are demanded at first; later the same treatment as in the ordinary type.
How is ringworm of the bearded region to be treated?
On the same general plan and with the same remedies (excepting chrysarobin) as in ringworm of the scalp. Depilation is to be practised as an essential part of the treatment. Special mention may be made of an ointment of oleate of mercury, sulphur ointment, a lotion of sodium hyposulphite (ʒj-℥j), and a lotion of corrosive sublimate (gr. j-iv to ℥j). The x-ray has been used in ringworm of this region with alleged success, pushing it to the production of a mild erythema and depilation. The above methods are, however, usually successful, and are without risk of damage.
How is the certainty of an apparent cure in ringworm of the scalp or bearded region to be determined?
By the continued absence of roughness and of broken hairs and stumps, and by microscopical examination of the new-growing hairs from time to time for several weeks after discontinuance of treatment.
Cure of ringworm of the general surface is usually self-evident.
Is systemic treatment of aid in the cure of ringworm?
It is doubtful, although in children in a depraved state of health the disease is often noted to be especially stubborn, and in such cod-liver oil and similar remedies may at times prove of benefit.