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Ringworm - All you need to know

Last updated date: 14-May-2022

CloudHospital

21 mins read

Ringworm is a common fungal infection that affects the skin; it is also referred to as dermatophytosis, tinea, or dermatophyte infection. It’s characterized by a circular ring-shaped rash, hence the name ringworm. However, it’s not associated with a worm. 

Tinea corporis, commonly known as ringworm, is a superficial dermatophyte infection of the skin that affects all parts of the body except the hands (tinea manuum), feet (tinea pedis), scalp (tinea capitis), bearded areas (tinea barbae), face (tinea faciei), groin (tinea cruris), and nails (onychomycosis or tinea unguium).

Tinea corporis is caused by dermatophytes from one of three genera: Trichophyton (infections of the skin, hair, and nails), Microsporum (infections of the skin and hair), and Epidermophyton (infections of the skin, hair, and nails) (which causes infections on skin and nails).

Dermatophytes are classified as anthropophilic, zoophilic, or geophilic based on whether their major source is human, animal, or dirt. 4,5 Because tinea corporis is a widespread fungal infection and many other annular lesions can resemble it, clinicians must be conversant with its etiology and treatment.

Ringworm can develop in humans as well as animals. Initially, the infection develops in red patches around the affected part of the skin and can spread to other body parts. It can form in the scalp, nails, groin, feet, beard, and other regions. Typically, it’s an infectious condition that can spread from one person to another via direct contact. 

A ringworm is named for the fact that it can create a circular rash (shaped like a ring) that is generally red and itchy. Ringworm may affect anyone. This infection's fungus may survive on the skin, surfaces, and household objects such as clothing, towels, and beds.

 

Epidemiology

Tinea corporis is extremely common all over the world. Dermatophytes are the most common fungi that cause superficial fungal infections. Excessive heat, high relative humidity, and tight clothing have all been linked to more severe and frequent diseases.

Tinea corporis can also be more prevalent in certain demographics, such as children. Tinea capitis and tinea corporis are the most prevalent dermatophytic infections in children under the age of five. Children are also more susceptible to zoophilic illnesses.

Zoophilic infections are spread through contact with animals such as cats and dogs. Patients with weakened immune systems are another vulnerable group. Immunocompromised patients are also more likely to develop Majocchi granuloma, a form of tinea corporis folliculitis that invades the deeper dermal layers rather than the more superficial conventional tinea corporis.

 

Risk Factors of Ringworm 

Ringworm is quite prevalent. Anyone can develop ringworm, but those with weaker immune systems are more vulnerable to infection and may have difficulty fighting off a fungal infection. You are more likely to develop ringworms in your body if;

  • You come into close contact with an infected individual or animal 
  • You reside in a region with a warm climate 
  • You share bedding, towels, or clothes with a fungal infected person 
  • You take part in sports activities that involve skin to skin contact, for instance, wrestling 
  • You put on a restrictive or tight outfit 
  • You have a compromised body immune system 

Persons who use public showers or locker rooms, athletes (especially those who participate in contact sports such as wrestling), those who wear tight shoes and sweat a lot, and people who have close contact with animals are all more prone to come into touch with the fungi that causes ringworm. 

 

Ringworm causes

Typically, ringworm is a contagious fungal infection that occurs due to common mold-like parasites living on the cells within the outer skin layer. Trichophyton, Epidermophyton, and Microsporum are three forms of fungi that can cause ringworm

Ringworm can spread in various ways, including;

  • Person to person: In most cases, ringworm is transmitted through direct skin-to-skin contact with a person infected with the condition. 
  • Animal to human: One may get ringworm by coming into contact with a ringworm-infected animal. The infection can spread when grooming or petting dogs and cats. It is also somewhat popular in cows. 
  • Touching objects: Ringworm may be transmitted by touching or rubbing against items or surfaces that an infected person or animal has recently been in contact with. They can be clothes, sheets, brushes, bedding, and linens, or combs. 
  • Soil to human: Ringworm fungi can likely survive as spores in soil for a long time. Humans and animals can thus contract ringworm after coming into close contact with this soil. Infection can almost certainly only occur after extended contact with contaminated soil.

On the other hand, doctors often identify the ringworms with varying names based on the affected part of the body. They include; 

Ringworm on the scalp: This is also known as tinea capitis; it begins as isolated scaling around the scalp and progresses to scaly and itchy bald patches. It is most prevalent in minors aging between three to seven years. 

Ringworm on the body: This is also known as tinea corporis, which occurs as circular ring-shaped patches on the skin. The symptoms of chronic ringworm infection on the body involve rings that develop, multiply, and fuse. One can also develop pus-filled sores and blisters around the rings. 

Jock itch: This is also known as tinea cruris. It's characterized by a scaly, reddish-brown rash that appears on the inner thighs and has raised borders. It is more popular in adult males. Ring-like rashes may also appear on the buttocks. However, this infection is less likely to occur on or around the penis, vulva, or anus.

Athlete’s foot: Also known as tinea pedis, a popular name for infection on foot. People who frequently go barefoot, especially in public areas where ringworm infection is likely to spread, are often affected. It’s more common in showers, swimming pools, and locker rooms. 

 

Ringworm symptoms 

Ringworm symptoms can vary based on the area it affects. For ringworm on the skin, one is likely to have the following signs and symptoms; 

  • Itching, scaly, or red patches 
  • Raised parts of the skin known as plaques 
  • Ringworm patches that form pustules or blisters 
  • Patches with raised and defined edges 
  • Patches that appear redder on the outer edges or look like a ring 

If you have ringworm in the nails, they tend to thicken, discolor, or crack. This condition is referred to as dermatophytic onychomycosis or tinea unguium. When the infection develops on the scalp, the surrounding hair can fall out or break, resulting in bald patches. Tinea capitis is the medical term for such a condition.

You should consult a physician if you develop a ringworm rash that does not subside even after using antifungal medication. 

 

Symptoms of ringworm by location on the body:

  • Feet (tinea pedis or “athlete’s foot”): The symptoms of ringworm on the feet include red, swollen, peeling, itchy skin between the toes (especially between the pinky toe and the one next to it). The sole and heel of the foot may also be affected. In severe cases, the skin on the feet can blister.
  • Ringworm on scalp (tinea capitis): Ringworm on the scalp usually looks like a scaly, itchy, red, circular bald spot. The bald spot can grow in size and multiple spots might develop if the infection spreads. Ringworm on the scalp is more common in children than it is in adults.
  • Groin (tinea cruris or “jock itch”): Ringworm on the groin looks like scaly, itchy, red spots, usually on the inner sides of the skin folds of the thigh.
  • Beard (tinea barbae): Symptoms of ringworm on the beard include scaly, itchy, red spots on the cheeks, chin, and upper neck. The spots might become crusted over or filled with pus, and the affected hair might fall out.

 

Ringworm on face

Tinea faciei, commonly known as tinea faciale or facial ringworm, is a fungus-caused illness of the skin of the face. The infection often begins as a red or pink patch that gradually gets elevated and itchy, with the center of the patch resembling normal skin.

 

Ringworm dog

Ringworm lesions in dogs often manifest as circular patches of hair loss (alopecia). As the core portion of these circular lesions heals, hair may begin to sprout in the midst of the lesion. Hair shafts that have been damaged are brittle and readily broken.

 

Ringworm in cats

Circular regions of hair loss, broken and stubby hair, peeling or crusty skin, changes in hair or skin color, inflammatory areas of skin, excessive grooming and scratching, infected claws or nail beds, and dandruff are the most obvious and typical clinical symptoms of feline ringworm.

 

Ringworm stages

It’s impossible to notice the ringworm as soon as you get infected by the fungus. In most cases, it could take about two weeks before you begin to see the symptoms. Due to this, medical practitioners categorize ringworms into different stages. 

The basic ringworm stages thus include; 

  • Initial stage or ringworm early stage, which is characterized by red or pink irritating skin patch. In other cases, it can appear scaly and dry, not essentially like the ringworm. 
  • The second stage whereby the lesion begins to grow and enlarge. The middle part of the rash can look like the normal healthy skin and a surrounding scaly region. 

Since ringworm is a highly contagious infection, it’s essential to begin treatment immediately after you notice any sign. Failure to seek treatment causes the ringworm to grow and spread rapidly. 

 

Ringworm Duration 

When the skin comes into contact with dermatophytes, ringworm symptoms normally begin to develop 4 to 14 days later. Antifungal medication will easily resolve a ringworm infection, removing symptoms within a few days. 

Ringworm on the skin, such as tinea pedis (athlete's foot) and tinea cruris (jock itch), usually clears up in two to four weeks when treated using nonprescription antifungal medicine. On the other hand, Tinea capitis (scalp ringworm) is normally treated for one to three months with prescription antifungal medicine. 

 

What is the difference between ringworm and shingles?

Ringworm is an infectious skin condition produced by a fungus, as opposed to the shingles rash, which is caused by a virus. Ringworm infection creates red, itchy, scaly areas on your skin, frequently in many locations at the same time. The areas might blister and ooze, similar to a shingles outbreak. ‏

See more about Shingles

 

What is the difference between ringworm and eczema?

The primary distinction is that ringworm is infectious, but nummular eczema is not. Ringworm appears in one or two areas, as opposed to nummular eczema, which has numerous patches.

See more about Eczema

 

What is the difference between ringworm and cellulitis?

Ringworm can occasionally create a pus-filled lump known as a kerion, which can be mistaken with impetigo or cellulitis (bacterial infections). Infections of the scalp can produce enlarged lymph nodes at the back of the head or neck.

See more about Cellulitis

 

What is the difference between ringworm and impetigo?

Ringworm is a cutaneous fungal illness. The term is derived from the ring-like appearance of the red, raised skin patches that it causes. Ringworm, unlike impetigo, does not create yellow crusting. Ringworm can be contracted by direct touch or by exchanging personal belongings with infected individuals.

See more about Impetigo

 

What is the difference between ringworm and atopic dermatitis?

Eczema, often known as atopic dermatitis, is a skin inflammation. It affects almost 3.5 percent of the population, with children being more vulnerable than adults. When children reach adulthood, they may outgrow this disorder, although it may continue in certain situations. The illness is not infectious.

Ringworm is a fungal infection caused by the tinea fungus. The ailment is known as tinea capitis (rash on the scalp), tinea corporis (rash on the torso), tinea pedis (rash on the feet), tinea cruris (rash in the groin/jock itch), and so on, depending on the location of the skin lesion.

See more about Atopic dermatitis

 

What is the difference between ringworm and skin cancer?

Ringworm is a fungus-caused illness. Ringworm may appear anywhere on your skin.

It creates ring-shaped spots on the majority of the skin. When ringworm grows on the feet (bottoms and sides), palms, nails, crotch, beard region, or scalp, what you see changes.

See more about Skin cancer

 

What is difference between ringworm and hives?

These skin outbreaks, on the other hand, are completely different. In the case of hives, they are caused by an allergic reaction in some cases and by a viral infection in others. Ringworm is caused by a specific form of fungal infection of the skin. ‏

See more about Hives

 

Is ringworm contagious?

Ringworm is a fungal infection of the skin of the face. It is contagious and can be spread from human to human by direct skin to skin contact with an infected person

 

Ringworm Diagnosis 
Ringworm Diagnosis

  • When diagnosing ringworm, the doctor will examine your skin and probably use a black light to see the skin around the infected region. According to the type of ringworm fungus, it can glow or fluoresce in the blacklight occasionally. 
  • The practitioner can rule out the suspected ringworm diagnosis by asking for certain tests. If you have a skin biopsy or a fungal culture, the doctor will obtain a sample of the skin or a ringworm blister discharge. He or she will then send the sample to a lab for fungi presence testing. 
  • For the potassium hydroxide (KOH) test, the physician will scratch a small section of contaminated skin on a slide. He or she will put drops of the liquid potassium hydroxide on the sample. The KOH disintegrates the normal skin cells, allowing the fungal component to be visible under a microscope. 

 

Ringworm Treatment 

The treatment of ringworm usually depends on the location within the body and the severity. In most cases, they can recommend the following; 

The therapy for ringworm is determined by its location on the body and the severity of the illness. Some types of ringworm can be treated with non-prescription (“over-the-counter”) medicines, whereas others require prescription antifungal medication.

 

Medications 

Depending on the seriousness of the ringworm infection, the medical provider can prescribe a variety of medications. Topical drugs, including antifungal creams, gel, ointments, or sprays, can be used to treat jock itch, body ringworm, and athlete's foot.

Oral medications, including griseofulvin (Gris-PEG) or terbinafine, may be recommended for ringworm on the scalp or nails. Antifungal skin creams and over-the-counter (OTC) drugs can also be prescribed. Clotrimazole, terbinafine, miconazole, and other associated ingredients may be present in these products. 

  • Skin ringworm, such as athlete's foot (tinea pedis) and jock itch (tinea cruris), is generally treated with non-prescription antifungal creams, lotions, or powders administered to the skin for 2 to 4 weeks. There are several non-prescription ringworm treatments available, including:
  1. Clotrimazole (Lotrimin, Mycelex)
  2. Miconazole (Aloe Vesta Antifungal, Azolen, Baza Antifungal, Carrington Antifungal, Critic Aid Clear, Cruex Prescription Strength, DermaFungal, Desenex, Fungoid Tincture, Micaderm, Micatin, Micro-Guard, Miranel, Mitrazol, Podactin, Remedy Antifungal, Secura Antifungal)
  3. Terbinafine (Lamisil)
  4. Ketoconazole (Xolegel)

 

  • Ringworm of the scalp (tinea capitis) is often treated with a prescription antifungal drug taken orally for 1 to 3 months. Ringworm on the scalp cannot be treated with creams, lotions, or powders. Prescription antifungal medicines used to treat scalp ringworm include:
  1. Griseofulvin (Grifulvin V, Gris-PEG)
  2. Terbinafine
  3. Itraconazole (Onmel, Sporanox)
  4. Fluconazole (Diflucan)

 

You should contact your healthcare provider if:

  • After utilizing over-the-counter medicines, your infection worsens or does not go away.

You or your kid has scalp ringworm. Ringworm on the scalp must be treated with antifungal medicine prescribed by a doctor. 

 

Ringworm and steroids

Steroid creams should not be used to treat ringworm rashes.

Ringworm patients don't always know what's causing their rash. As a result, patients may use over-the-counter lotions or ointments containing corticosteroids (or “steroids” for short) to their rash.

Steroid creams can assist with some skin issues and can even temporarily alleviate ringworm symptoms such as itching and redness, but they do not eradicate the fungus that causes ringworm. Steroid creams can potentially exacerbate ringworm by weakening the skin's defenses.

Steroid creams, in rare circumstances, allow the fungus that causes ringworm to penetrate deeper into the skin and produce more serious disease.

Steroid creams can cause ringworm infections to spread throughout the body. They can also alter the look of ringworm, making it difficult for healthcare practitioners to identify.

 

Lifestyle changes  

Apart from prescription and over-the-counter medications, the doctor can advise you to treat the infection at home by doing the following;

Applying topical antifungal:

The majority of ringworm cases can be handled at home. Antifungals sold over the counter will destroy the fungus and trigger healing. Apply a small layer of antifungal medicine to the infected area at least two to three times a day or according to directions on the package. This should be after you clean the rash. Spread the medicine a few centimeters beyond the rash's boundary. This is to enable the drug to absorb into the skin.   

Allowing the ringworm to breathe:

It can appear logical to cover ringworm with a bandage to prevent the infection from spreading. Bandaging the rash, on the other hand, traps moisture and delays the healing process. Instead, you should dress in loose, breathable clothing to hasten recovery and prevent the spread of the rash to others. Loose-fitting long-sleeved shirts and trousers are examples of such clothing.

Using antifungal shampoo:

Ringworm may occasionally appear on the scalp. Extreme itchiness, scalp boils, patches of hair loss, and severe dandruff are all signs of a scalp infection. If ringworm develops on the scalp, use an over-the-counter medicated antifungal shampoo to wash your hair. 

These shampoos eliminate bacteria and fungus from the scalp while also reducing inflammation. You can get them at a grocery store or a pharmacy. Look for antifungal active ingredients like ketoconazole, pyrithione zinc, and selenium sulfide in your shampoo. Shampoos can be used according to the instructions on the package. You should, however, note that without oral antibiotics, it's very difficult to get rid of scalp fungus. 

Washing the bedding regularly:

Since ringworm is so infectious, you should consider washing your sheets every day to speed up the healing process. Fungal spores can contaminate the sheets and blankets. Therefore, ringworm can take longer to subside if you sleep on the same beddings every night. Also, the infection can extend to various areas of the body. Infectious bedding can as well affect other people around you.  

When cleaning the bedding and other infected clothing, always use detergents and hot water. This alone can destroy the fungus. You can add borax or bleach to the wash as an extra measure, together with standard laundry detergent. Borax and bleach are both effective at killing fungal spores and can be found in most grocery stores. Follow the package's instructions to ensure safety. 

Changing wet socks and underwear:

If you have ringworm on your feet or in your groin, ensure that you keep them dry. Also, if you excessively sweat during the day, use an antifungal washing bar to bathe with before reapplying the antifungal lotion or powder. When putting on another pair of socks or underwear, ensure the area is fully dry. 

 

Ringworm home remedies

Until researchers develop antifungal treatments, people have continued using home remedies for ringworm for several years. The majority of evidence supporting the use of such remedies is anecdotal. Furthermore, there is no scientific evidence to back up their use against over-the-counter antifungals.

The available home remedies ringworm natural treatments include the following; 

Apple cider vinegar: To treat or manage ringworm infection, other individuals put apple cider vinegar immersed in cotton balls on the infected skin areas at least three times a day. 

Turmeric: This is a spice that you can be mixed with water to form an antifungal paste. Directly put the paste on the skin and let it dry. 

Coconut oil: Apart from cooking, coconut oil is also helpful on the skin since it helps minimize ringworm infections incidences. Apply coconut oil at least once or thrice each day if you wish to try out this treatment.

 

What Happens if Ringworm Infection is Left Untreated?

Untreated ringworm can spread to various parts of the body. An infected person is also at a risk of infecting the people around. Other possible complication areas are scarring, hair loss, and deformities of the nails. 

Ringworm home remedies

The complications of tinea capitis, also known as scalp ringworm, are particularly concerning, as it can result in permanent hair loss. When these risks are taken into account, it's best to handle ringworm as soon as possible. 

 

Differential Diagnosis

Diseases in the differential diagnosis may resemble tinea corporis in appearance. These are also commonly associated with annular lesions. Cases that are resistant to antifungal therapy or have a negative potassium hydroxide microscopic test should be investigated further.

If there is a severe illness, such as significant skin involvement, the doctor must rule out other, more dangerous diseases.

Nummular eczema, erythema annulare centrifugum, tinea versicolor, cutaneous candidiasis, subacute cutaneous lupus erythematosus, pityriasis rosea, contact dermatitis, atopic dermatitis, seborrheic dermatitis, and psoriasis are other frequent illnesses that can appear similarly.

Secondary syphilis, mycosis fungoides, and parapsoriasis are among the serious illnesses that must be checked out.

 

Complications of Ringworm

It’s rare for fungal infections to spread under the skin's surface. Hence, the chance of a chronic illness is relatively low. On the other hand, ringworm is likely to spread from one section of the body to another if it is not treated. 

Bacteria can penetrate the skin and cause an infection in case the skin is broken. Also, ringworm is more likely to spread in people who have HIV or other diseases that impair the immune system. If your immune system is poor, it will be difficult to get rid of the ringworm infection.

Patients with this condition may develop extensive, highly pruritic, erythematous, scaly papules, maculopapules, papulovesicles, or pustules. The dermatitic eruption is most likely an immunologic reaction to the fungal antigen, similar to a delayed-type (type IV) hypersensitivity response. Psoriatic flares caused by tinea corporis have only been described infrequently.

 

Prognosis

With adequate therapy and patient cooperation, the prognosis for localized tinea corporis is favorable. Recurrence may occur if medication is discontinued too soon without full fungus eradication. Reinfection may occur if a reservoir of infection (tinea pedis, tinea capitis, onychomycosis) is present.

 

Ringworm Prevention 

It’s difficult to prevent ringworm infection. A common fungus causes it, and the disease is infectious even before the symptoms develop. You can reduce the ringworm risk by taking the following measure; 

  • Educating yourself and those around you. Be mindful of the possibility of contracting ringworm from infected persons or animals. Inform your children about the infection, including symptoms to look out for and ways of avoiding or preventing infection.  
  • Keeping hands clean: Always ensure that you clean your hands often. Keep common places, such as classrooms, child care centers, locker rooms, or gyms clean. Take a bath immediately after practice or a game if you play contact sports. Also, maintain your uniform and equipment clean. 
  • Keep yourself cool and dry: In a hot, humid environment, avoid wearing heavy clothing for extended periods. Try as much as possible to avoid excess sweating. 
  • Stay away from infected animals: The ringworm infection usually appears as a patch of skin with no hair. If you keep dogs or other pets, have the veterinarian assess them for the infection. 
  • Avoid sharing personal stuff: You should not allow anyone to use your clothes, hairbrushes, towels, athletic equipment, and other personal belongings. Also, avoid borrowing such items. 

 

Ringworm versus Psoriasis 

  • A psoriasis is a form of skin disease that is similar to ringworm. Plaque psoriasis is a skin condition caused by immune dysfunction that results in inflammatory plaques. It takes the form of pink plaques with thick white scales. On the other hand, small isolated plaques may resemble ringworm in appearance. 
  • Psoriasis and ringworm can both cause skin itching and scaling and red patches. On the other hand, ringworm on the limbs or trunk (tinea corporis) typically appears circular with a clearing in the center. It’s always in a secluded place or restricted to just a few lesions.
  • Skin lesions that form due to plaque psoriasis are normally bigger, affect more parts of the skin, and appear in different places, including knees, lower back, and elbows. Also, psoriasis lesions do not have any clearing in the center; instead, they appear normal. 
  • The underlying triggers and causes of these conditions are also different. Ringworm is caused by a fungus, while psoriasis occurs due to a dysfunctional body immune system.

 

Ringworm versus Eczema 

  • Ringworm has a lot in common with nummular eczema, another type of skin disease. Nummular eczema is also referred to as discoid eczema or nummular dermatitis by medical providers. The two conditions are similar in that they both result in round or coin-shaped lesions around the skin. These lesions are usually scaly and itchy. 
  • Ringworm patients usually have fewer ring-like patches compared to those with nummular eczema. Also, unlike ringworm, nummular eczema normally does not have clearing in the middle. Ringworm can be accompanied by pustules, whereas nummular eczema does not. 
  • Occasionally, the two conditions are so similar, and consulting the doctor is the only way to know the difference. If necessary, the doctor will remove skin cell samples and take them to the lab for further analysis.
  • Medical providers address nummular eczema differently, unlike ringworm. They suggest topical steroids to treat ringworm infections, which can both mask and intensify the infection. On the other hand, nummular eczema does not respond to antifungal ointments. 

 

Ringworm and Pregnancy 

If you develop ringworm while pregnant, the doctor will prescribe certain drugs to kill the fungi that cause the ringworm. These medications are not known to harm the infant. Some of the commonly recommended drugs which are safe to use if applied topically are; 

  1. Ciclopirox (Loprox)
  2. Oxiconazole (Oxistat)
  3. Clotrimazole (Lotrimin)
  4. Terbinafine
  5. Naftifine (Naftin)

 

  • Before taking any drugs when pregnant, you should first consult the doctor. Because of the ethical consequences of these studies, most drugs cannot be adequately tested in pregnant women. As a result, telling whether a drug, either topical or oral, would be safe to use is virtually impossible.
  • In case you are breastfeeding, you should also consult the medical provider before taking any drugs. Physicians do not always recommend the use of certain drugs since they have the ability to cause negative side effects. Some of the examples are oral ketoconazole and oral miconazole. 
  • Oral treatments to treat fungal infections are typically not recommended during pregnancy. It’s best to consult a doctor before using any medicine or home remedy to address the illness if you are expectant and have a ringworm infection. This is regardless of the medication option. 

 

Conclusion

Ringworm is a frequent fungus-caused skin condition. Ringworm is known by many different names. The medical names for this condition are "tinea" or "dermatophytosis." Ringworm is sometimes known by other names depending on where it is found on the body. For example, ringworm on the feet is also known as "athlete's foot."

Tinea corporis is distinguished by a well-demarcated, sharply defined, slightly erythematous, annular, a scaly plaque with a raised leading edge, scaling, and center clearing on the body.

It is often characterized by an itchy, scaly rash that is occasionally ring-shaped (learn more about ringworm symptoms). Non-prescription (“over-the-counter”) antifungal creams, lotions, or powders can be used to treat some types of ringworm. Other types of ringworm, on the other hand, necessitate the use of prescription antifungal medication.

The use of topical corticosteroids in the absence of an antifungal drug is not advised for tinea (ringworm) infections. Patients, on the other hand, may have used corticosteroids on their own.

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