Imagine this scenario: a client arrives at your clinic and reveals she has a fungal skin infection. What should you do? Don't panic. Instead, get more information and decide on a plan of action.
Fungal infections of the skin and nails are among the most common infections in humans, affecting 20 to 25 percent of the world’s population (Male, 1990). As a massage therapist, you’ll likely encounter a client with a fungal infection over the course of your career. You can prepare yourself by understanding how fungi are spread to humans, the symptoms of fungal infections and how to reduce your risk before you encounter any infections.
Fungi are a group of organisms that are found worldwide, consisting of millions of various types or “species.” Some fungi are large enough to eat, like mushrooms for example, and serve as a food source. Others are too small to see, like yeast. Fungi contribute to the ecosystem by degrading organic material, providing nutrients for plants and animals. Other benefits include fermentation of beer and wine, leavening of bread and the production of antibiotics.
Fungi become pathogenic when their growth is uncontrolled and excessive, causing fungal infections. Some human and animal fungal infections are caused by overgrowth of the microscopic fungi “dermatophytes. These tiny fungi prefer to grow (colonize) on (cutaneous) tissue, such as skin, hair and nails. Other fungi types, such as yeast and nondermatophyte molds (not discussed in this article), prefer mucous membranes or deeper systemic systems, such as blood and organs.
Although not considered part of the normal flora, dermatophytes transfer to living beings from the soil, as well as infected animals, people and objects.These fungi cause common superfi cial fungal infections, such as athlete’s foot, ringworm and jock itch.
Many of the common superficial fungal infections caused by dermatophytes are labeled “tinea.” The infection is further identifi ed by the Latin term for its location on the body. For example, “tinea capitis” and “tinea corporis” refer to superficial fungal infections of the scalp and body, respectively.
Transmission of Fungal Infections
Dermatophytes can transfer to a new “host”—the pathogen’s new place of residence, which is typically human skin—after contact with infected people, animals or objects. The microscopic fungi are most often transferred to the new host by direct touch with infected skin and fur. In addition, people can also acquire pathogens from contact with infected combs, gym floors, clothing and towels.
After dermatophyte transfer, the pathogens immediately encounter the host’s immune defenses. Although the exact mechanisms of attachment (called adherence) and colonization are not clear, the microscopic fungi survive by degrading the protein substance (keratin) within skin, hair or nails and scavenging nutrients. Often, a healthy host’s immune system will destroy the dermatophytes before disease becomes apparent.
If the dermatophytes avoid destruction by the host’s immune factors, however, the pathogens typically remain in superfi cial skin, hair or nails. In rare instances, dermatophytes penetrate deeper tissue, but typically only when the host’s immune defenses are deficient.
Some people are asymptomatic carriers. For these people, dermatophytes inhabit the superfi cial tissue but don’t produce symptoms of fungal disease (Küçükgöz-Güleç, Gümral, Güzel , Khatib, Karaka, Ilkit, 2012). For everyone else, the development (and severity) of infection depends on the type of dermatophyte, environmental factors, the host’s heredity and the host’s level of immunity.
Dermatophyte type. Dermatophytes differ in the host they prefer. Some dermatophytes prefer humans, some prefer animals and some prefer soil. On occasion, the animal dermatophytes transfer to humans from the fur and skin of infected animals. And rarely, soil dermatophytes infect humans and animals, typically through skin cuts. When soil and animal dermatophytes infect human tissue, they can cause greater infl ammation than do human dermatophytes.
Environment. Dermatophytes fl ourish in warm, moist, humid environments. Tinea infections are more prevalent in tropical climates than in cold, northern climates. Although most tinea infections tend to worsen in the summer, toenail fungal infections worsen in winter because your feet spend long periods of time sweating in socks and boots. Showers, dressing rooms and pool floors are also environments where dermatophytes thrive.
Dermatophytes flourish and spread in environments where people and animals are in close contact. Overcrowding provides greater opportunity for skin-to-skin contact with infected people and animals, and contact with infected objects such as clothing, toys and bedding. Inadequate bathing and hygiene also promote pathogen growth (Havlickova, Czaika, Friedrich, 2008). Not surprisingly, environments rife with fungal infections are particularly common among people of lower socioeconomic status.
Heredity. Some people appear genetically predisposed to develop fungal infections. For example, nail fungus seems to run in families (García-Romero, Granados, Vega-Memije, Arenas, 2012) and research links the severity of fungal disease in children to genetics (Abdel-Rahman, Preuett, 2012).
Host Immunity. As noted earlier, dermatophytes proliferate if not kept in check by the host’s immune system. Healthy immune systems typically destroy dermatophytes before widespread disease becomes evident. Children, the elderly and people with stressed immune systems are more likely to develop overt fungal infections. People who are severely immunocompromised are susceptible to tinea fungal infections, as well as to other opportunistic fungi that cause systemic infections, such as blood and pulmonary infections.
Signs and Symptoms of a Tinea Infection
When dermatophytes evade the host’s immune defenses, rash-like signs and symptoms occur from two to 17 days later (Jones, 1993). The appearance of the infection depends on where it occurs on the body.
Trunk, neck and extremities. Superfi cial fungal infections on the trunk, neck and extremities (tinea corporis) present as pink-red, dry patches with scaly, distinct borders. The lesions are often circular and spread outward in a ringlike pattern, leaving the center either “clear” with normal or decreased skin color. Historically, people thought that the ringlike appearance was caused by a cutaneous worm. Although not the case, the label “ringworm” persists.
Groin. When the fungal infection appears on the upper and inner thighs (tinea cruris, pictured right), people often refer to it as “jock itch." Tinea cruris is itchy and bothersome, and typically presents as a small, red, scaly or crusted rash that spreads peripherally. The rash may show partial clearing in areas.
Scalp. Fungal infections of the scalp (tinea capitis) are either noninfl ammatory or inflammatory. Noninflammatory scalp infections present as scaly or flaky gray patches of hair loss. Some people present with broken hairs—resembling “black dots”—close to the scalp. This type of infection is bothersome and itchy. Infl ammatory tinea capitis presents with red, scaly patches of hair loss, broken hairs, pustules, and perhaps a soft, “boggy” mass (kerion). Severe infections may produce fever, pain, and tender neck and head lymph nodes.
Infection can occur within scalp hair, eyelashes and eyebrows. Dermatophytes invade the hair shaft and grow, producing brittle hair. Infl ammation may lead to scarring of the scalp and permanent hair loss.
Face. Superficial fungal infections that occur on the face (tinea faciei) present as red, slightly scaly patches with indistinct borders. The infection is sunsensitive, such that exposure to ultraviolet rays often produces pain. Fungal infections of the beard area (tinea barbae) are uncommon. Men typically present with superficial, crusted, hairless patches, as well as areas of inflamed hair follicles. Tinea barbae may progress to inflamed, painful, deep nodules, and typically occurs on one side of the face or neck.
Hand and foot. Superfi cial fungal infections may occur on one or both hands (tinea manus). The infection typically presents as red, dry, and scaly areas on the palm, sides of the hand and between the fi ngers. Fungal infections that occur on the foot (tinea pedis) are commonly called “athletes’ foot.” This infection presents as moist, cracked white patches between the toes that are itchy and malodorous. Tinea pedis can also appear on the sole of the foot as dull red, scaly patches that progress to the sides of the foot. It can appear on one or both feet.
Nails. The infection presents in various forms, such as a thin, white “film” on the proximal nail or as discoloration on the distal nail with progression toward the cuticle, resulting in a thick, yellow, brittle nail. Nail fungus often spreads to all nails on both feet.
Most Common Tinea; Most Contagious Tinea
In the United States, tinea unguium (nail fungus) is the most common superfi cial fungal infection. Toenails are affected more often than fingernails. Tinea unguium is particularly common among the elderly (Panackal, Halpern, Watson, 2009), perhaps due to declining immunity, poor circulation, inadequate hygiene or constantly moist feet.
Tinea corporis is the second most common superficial fungal infection in the United States, and is spread by physical contact with infected skin or hair. The most common body areas affected are the head, neck and upper extremities. People that develop tinea corporis typically have repeated physical contact with an infected person or animal. Wrestlers and judo participants, for example, are more likely to develop tinea corporis due to skin-to-skin contact, skin abrasion and sweating (Grosset-Janin, Nicolas, Saraux, 2012). Health care workers who have physical contact with infected patients, especially children with tinea capitis, are also at increased risk of tinea infections (Shroba, Olson-Burgess, Preuett, Abdel-Rahman, 2009; Lewis, Lewis, 1997).
Tinea manus is common in the United States and worldwide, and typically coexists with tinea pedis.
Tinea pedis is more prevalent in developed countries and frequently appears in runners and among people serving in the military. Tinea pedis can be acquired from floors of communal showers, baths and pools.
Tinea capitis, although less common in the United States than in underdeveloped nations, is, nonetheless, highly contagious and diffi cult to eliminate. The pathogens pass easily among children at schools or daycares to family members sharing the same living space (Lamb, Rademaker, 2001), and from contaminated objects such as combs, brushes and shaving equipment (Winge, Chryssanthou, Wahlgren, 2009).
Tinea cruris, which occurs in the groin area, is the least common superfi cial fungal infection and is more likely to occur in males than in females. Interestingly, the groin and thighs are affected, yet the scrotum and penis remain unaffected. Tinea cruris often originates from tinea in the feet (tinea pedis) when people are putting on underwear.
Clients Most at Risk to Develop Tinnea
A large variety of clients will visit your practice, so knowing the demographics of people at the most risk for developing tinea infections can help you take better care of yourself:
Diabetics. Foot disease is common in people with diabetes mellitus. Onychomycosis and tinea pedis are common problems, and may be due to various factors related to diabetes.
Pregnant women. Pregnancy taxes the mother’s immune system, increasing the risk of tinea infections.
Children. Children have several risk factors for developing tinea infections, such as an underdeveloped immune system, greater contact with other children and pets, as well as greater opportunity to share combs, hats and scarves.
Elderly. Immune functioning declines with age, placing the elderly at greater risk.
Athletes. Physical stress from prolonged, intense exercise increases risk for tinea infections (Gabriel, Urhausen, Kindermann, 1992; Simpson, Florida-James, Whyte, Guy, 2006). Also, tinea occurs after physical contact and skin abrasion with an opponent’s infected skin (Grosset-Janin, Nicolas, Saraux, 2012).
Immunosuppressed people. Cancer, HIV and organ transplantations require immune suppressing drug treatments, making people with these conditions more susceptible to pathogen-related infections, including tinea.
Health care workers. People that work in hospitals and nursing homes have greater risk of infection due to repeated physical contact with infected patients (Shroba, Olson-Burgess, Preuett, Abdel-Rahman, 2009; Lewis, Lewis, 1997).
People that sweat excessively. Conditions that produce excessive sweating, such as hyperhidrosis and obesity, are known to increase risk of tinea corporis, pedis and manus (Boboschko, Jockenhöfer, Sinkgraven, Rzany, 2005; Khalil, Al Shobaili, Alzolibani, Al Robaee,2011).
Pet-owners. Infected cats, dogs, guinea pigs and rabbits can transmit animal-specifi c dermatophytes to people, causing tinea corporis and tinea capitis (Havlickova, Czaika, Friedrich, 2008; Rabinowitz, Gordon, Odofi n, 2007). Cats are the most common source, but in rare instances people receive infections from horses and cattle. A few animal-specific dermatophytes are highly contagious to humans, and can cause significant scalp inflammation in children (Macura, 1993).
Are We at Risk?
Are massage therapists at significant risk of acquiring superficial fungal infections from infected clients? In the strictest sense, tinea is contagious. Therefore, anyone that has direct contact with infected skin, hair and nails is at risk for developing a fungal infection. The evidence comes from wrestlers, judo participants and hospital staff who touch infected people. Interestingly, the science literature reports no cases of tinea in manual therapy professions, including physical and occupational therapy, athletic training, chiropractic and massage. We aren’t sure, however, whether the absence of cases arises from lack of reporting, low transmission rate or contact with a less risky patient population.
What is clear is that massage therapists who are personally susceptible because they themselves are immunocompromised, work in high-risk environments (hospitals, nursing homes), and work with high-risk patients (infected children, athletes, elderly) face a heightened risk of infection.
Reducing Your Risk
We can decrease our risk by following good hygiene practice. If accidental contact with the skin of an infected client occurs, immediately wash the area of contact with soap and warm water and dry thoroughly with a clean towel. Wash contaminated linens in hot water and dry on high heat because fungi cannot survive laundering in high temperatures (Siegel, Rhinehart, Jackson, Chiarello, et al., 2007). We aren’t sure how long dermatophytes survive in/on lubricants, so when using lubricant from a container, consider using a disposable applicator, such as a tongue depressor. Dip once and dispose of the applicator and any remaining lubricant when finished.
How should massage therapists respond to a client diagnosed with a superfi cial fungal infection? First, be informed. This article provides a primer of what we should know about superfi cial fungal infections, including the symptoms, how they are spread, who is most at risk, and how to reduce our personal risk of infection and spreading infections to others.
Second, decide on a plan of action. In the strictest sense, all superficial fungal infections are contagious, meaning massage would be contraindicated. Reschedule the client until after completion of medical treatment and clearance of the infection. However, if the client has completed prescribed medications and the fungal infection (other than tinea capitis) is small, resolving and covered, massage can be performed on other body areas. Use your best judgment. The massage therapist should be in good health, not pregnant, and practice good hygiene following the massage.
Massage & Skin Conditions: 3 Credit Hours
This online course provides an overview of bacterial, viral and fungal skin conditions and whether massage is indicated or contraindicated
Register now »
Abdel-Rahman SM, Preuett BL (2012). Genetic predictors of susceptibility to cutaneous fungal infections: a pilot genome wide association study to refi ne a candidate gene search. J Dermatol Sci. Aug;67(2):147-52.
Boboschko I, Jockenhöfer S, Sinkgraven R, Rzany B (2005). Hyperhidrosis as risk factor for tinea pedis. Hautarzt. Feb;56(2):151-5.
www.dermnetnz.org/fungal/mycology.html; accessed on January 5, 2013.
Gabriel H, Urhausen A, Kindermann W (1992). Mobilization of circulating leucocyte and lymphocyte subpopulations during and after short, anaerobic exercise. Eur J Appl Physiol Occup Physiol.65(2): 164–70.
García-Romero MT, Granados J, Vega-Memije ME, Arenas R (2012). Analysis of genetic polymorphism of the HLA-B and HLA-DR loci in patients with dermatophytic onychomycosis and in their first-degree relatives. Actas Dermosifi liogr. Jan;103(1):59-62.
Grosset-Janin A, Nicolas X, Saraux A (2012). Sport and infectious risk: A systematic review of the literature over 20 years. Med Mal Infect. Nov;42(11):533-44.
Jones HE (1993). J Am Acad Dermatol. Immune response and host resistance of humans to dermatophyte infection. May;28(5 Pt 1):S12-S18.
Khalil GM, Al Shobaili HA, Alzolibani A, Al Robaee A (2011). Relationship between obesity and other risk factors and skin disease among adult Saudi population. J Egypt Public Health Assoc. 2011;86(3-4):56-62.
Küçükgöz-Güleç U, Gümral R, Güzel AB, Khatib G, Karakas M, Ilkit M. (2012). Asymptomatic groin dermatophyte carriage detected during routine gynaecologic examinations. Mycoses. Sep 24. doi: 10.1111/myc.12012. [Epub ahead of print].
Lewis SM, Lewis BG (1997). Nosocomial transmission of Trichophyton tonsurans tinea corporis in a rehabilitation hospital. Infect Control Hosp Epidemiol. May;18(5):322-5.
Havlickova B, Czaika VA, Friedrich M (2008). Epidemiological trends in skin mycoses worldwide. Mycoses. Sep;51 Suppl 4:2-15.
Lamb SR, Rademaker M (2001). Tinea due to Trichophyton violaceum and Trichophyton soudanense in Hamilton, New Zealand. Australas J Dermatol. Nov;42(4):260-3.
Male O (1990). The signifi cance of mycology in medicine. In: Hawksworth DL (ed.), Frontiers in Mycology. Wallingford: CAB International, 131–56.
Macura AB (1993). Dermatophyte infections. Int J Dermatol. 32: 313–23.
Panackal AA, Halpern EF, Watson AJ (2009). Cutaneous fungal infections in the United States: Analysis of the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), 1995-2004. Int J Dermatol. Jul;48(7):704-12.
Rabinowitz PM, Gordon Z, Odofi n L (2007). Pet-related infections. Am Fam Physician. Nov 1;76(9):1314-22.
Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. (www.cdc; accessed January 1, 2013).
Shroba J, Olson-Burgess C, Preuett B, Abdel-Rahman SM (2009). A large outbreak of Trichophyton tonsurans among health care workers in a pediatric hospital. Am J Infect Control. Feb;37(1):43-8.
Simpson RJ, Florida-James GD, Whyte GP, Guy K (2006). The effects of intensive, moderate and downhill treadmill running on human blood lymphocytes expressing the adhesion/activation molecules CD54 (ICAM-1), CD18 (beta2 integrin) and CD53. Eur J Appl Physiol. 97(1):109–21.
Winge MC, Chryssanthou E, Wahlgren CF (2009). Combs andhair-trimming tools as reservoirs for dermatophytes in juvenile tinea capitis. Acta Derm Venereol.89(5):536-7.