Fungal infections
- Confirmed by
- A KOH mount — minutes, at the bedside
- Commonest reason it returns
- Treatment stopped when it looked better
- Typical course length
- Weeks, not days — and longer than it looks necessary
Superficial fungal infection — tinea, commonly called ringworm — produces itchy, scaly patches with a raised advancing edge and relative clearing in the centre. It spreads outward, and it spreads between people and through shared clothing, towels and bedding.
In India over the last decade these infections have become markedly harder to treat. Wider areas, longer courses, more recurrence. Two things explain most of it: easy availability of combination creams containing potent steroids, and incomplete courses of treatment.
Where it appears
- Tinea corporis — body, trunk and limbs
- Tinea cruris — groin and inner thighs, very common in hot humid months
- Tinea pedis — feet and between the toes
- Tinea capitis — scalp, mostly in children; always needs oral treatment
- Onychomycosis — nails; thickened, discoloured, crumbling. Needs months of treatment
- Pityriasis versicolor — pale or light brown flat patches on the chest and back. A different organism and a different treatment
How it is confirmed
A KOH mount takes a few minutes. A scraping from the edge of the patch is examined under the microscope, and fungal filaments are either there or they are not. It is cheap, it is quick, and skipping it is why so many rashes are treated for months with the wrong cream.
Where the infection has been altered by steroid use, or has failed appropriate treatment, a fungal culture identifies the species and guides which oral agent to use.
Treatment
Topical
A plain antifungal — never a combination containing a steroid — applied to the patch and a margin of normal skin beyond its edge, continued for a period after it looks clear.
Oral
Terbinafine or itraconazole for widespread, recurrent, scalp or nail disease. Course length depends on the site and extent, and liver function may be checked depending on the agent and duration.
The part that actually prevents recurrence
- Treat everyone in the household who is affected, at the same time
- Hot-wash clothing, towels and bedlinen; dry in sunlight where possible
- Loose cotton clothing; change out of damp clothes promptly
- Dry carefully in the groin, under the arms and between the toes
- Do not share towels, combs or footwear
- Complete the full course even after it looks clear
Combination creams
Creams mixing an antifungal, an antibiotic and a potent steroid are sold widely and used for almost any itchy rash. They relieve itching within a day, which is why people trust them, and they allow fungus to spread wider and deeper while changing its appearance so the diagnosis is missed. If you have one at home, bring it rather than discarding it — knowing exactly what was used changes the treatment plan.
What else it could be
These are the conditions this is most often mistaken for. Treating the wrong one is the commonest reason a problem drags on for months.
| Often mistaken for | How it's told apart |
|---|---|
| Eczema | Itchy and scaly, but without the raised advancing edge and central clearing. Steroid creams help eczema and make fungus spread. |
| Psoriasis | Sharply defined, silvery scale, usually symmetrical on elbows, knees and scalp rather than spreading outward in rings. |
| Pityriasis rosea | A single larger patch followed days later by a shower of smaller oval patches along the rib lines. Self-limiting. |
| Granuloma annulare | A ring of firm bumps with no scale at all. Not an infection, and antifungals do nothing. |
| Steroid-modified fungal infection (tinea incognito) | A fungal infection whose appearance has been altered by steroid cream — the edge is lost and it looks like eczema. Extremely common in India. |
Common questions
Why does my ringworm keep coming back?
Three reasons, in order of frequency: treatment was stopped as soon as it looked better rather than completing the full course, a combination cream containing a steroid was used, or close contacts and clothing were not treated at the same time. Resistant strains exist and are a real problem in India, but they are diagnosed after the first three are ruled out.
Are over-the-counter combination creams a problem?
Yes, and this is the single biggest driver of difficult fungal infections in India. Creams combining an antifungal with a potent steroid give rapid relief from itching while allowing the fungus to spread more widely and deeply. The result is a larger, harder-to-treat infection with altered appearance. If you are using one, bring the tube.
How long does treatment take?
Longer than most people expect and longer than it looks necessary. Skin infections typically need several weeks of treatment, continued for a period after the rash has cleared. Nail infections take months. Stopping early is the commonest cause of recurrence.
Do I need tablets, or will a cream do?
Limited, recently started infections often respond to a cream alone. Widespread disease, scalp or nail involvement, and anything that has already failed topical treatment usually needs oral antifungals with the appropriate monitoring.
Can this be treated online?
A straightforward, clearly typical case can be. But confirming fungus needs a KOH mount, and if the appearance has been altered by steroid cream the diagnosis genuinely cannot be made from a photograph. In those cases you will be advised to be seen in person.
This page is general information and does not replace a consultation. Whether any treatment described here is right for you depends on examination, history and other medicines, and that assessment needs a doctor.