ATHLETES FOOT (TENIA PEDIS)

A Project work submitted to

Hemwati Nandan Bahyguna Garhwal University, Srinagar (U.K.)

In Partial Fulfillment of the Requirement for the Bachelor of Physiotherapy

DR. P. NANDITA, PT
MPT (Sports) By

Under the guidance of

Aprana Agarwal
Department of Physiotherapy

Shri Guru Ram Rai Institute of Medical Health & Sciences, Patel Nagar, Dehradun- 248001 (2006-2010)

DECLARATION BY THE CANDIDATE

hereby

declare

that

the

project

entitled

Atheletes Foot (Tinea Pedis) embodies the work done by me at Shri Ram Rai Institute of Medical Health and Sciences, Patel Nagar Dehradun. This work in part or full has not been submitted to any other university.

(Aprana Agarwal) (BPT IV year)

CERTIFICATE BY THE GUIDE

This is to certify that the project work entitled Athletes Foot (Tinea Pedis) submitted by Aprana Agarwal in partial fulfillment of the requirements for the award of degree of Bachelor of Physiotherapy of the Hemwati Nandan Bahuguna University, Srinagar (Garhwal), is a bonafide work carried out by her under my supervision and guidance during the academic year 2006-2010. Neither this project nor the part of it has been submitted for any degree or diploma.

(Signature of Guide) Dr. P. Nandita, PT M.P.T. (Sports) Place: Date:

ENDORSEMENT BY THE HEAD OF THE DEPARTMENT This is to certify that the project entitled Athletes Foot (Tinea Pedis) bonafied project work done by Aprana Agarwal under the guidance of Dr. P. Nandita PT, MPT (Sports) in the partial fulfillment of requirement Physiotherapy. for the degree of bachelor of

(Seal and Signature of HOI) DR. TARANG SRIVASTAVA, PT M.P.T. (Ortho) Head of Department of Physiotherapy SGRRIMHS of SMI Hospital Patel Nagar, Dehradun (U.K.) Place: Date:

CERTIFICATE BY THE EXAMINER This is to certify that the project entitled Athletes Foot (Tinea Pedis) submitted by Aprana Agarwal in partial fulfillment of the requirements for the award of degree of bachelor of Physiotherapy of Hemwati Nandan Bahuguna Garhwal University, Srinagar (Garhwal) has been thoroughly examined and approved by us.

Accepted/Not accepted
(Sign. of Internal Examiner) Place: Date: (Sign. Of External Examiner)

Copyright DECLARATION BY THE CANDIDATE I hereby declare that HNB Garhwal University, Srinagar (Uttrakhand) shall have the rights to preserve, use and disseminate this project in print or electronic format for academic/research purpose.

Date: Place: Dehradun

Aprana Agarwal (BPT IV year)

HNB Garhwal University, Srinagar Garhwal (Uttrakhand)

DEDICATED TO

Acknowledgement It gives me immense pleasure and satisfaction to place on record my sincere thanks and appreciation with respect and regards for an adorable person, Dr. P. Nandita PT, NPT (Sports), Department of Physiotherapy, SGRR Institute of Medical Health and Sciences, Dehradun (U.K.), as it was her blessings, guidance, valuable suggestions and constant encouragement which helped me to greatly ease the task of completing this project a reality. I seek to express my indebted to the all teaching and nonteaching members of the department for their support and assistance in any way during the work. I would like to thanks Chirman Shri Mahant Devendra Das Ji Maharaj for providing al the facilities to carry out the project work. I also want to express my thanks to Principal Dr. J.B. Gogoi for their support during the work. Words fall short to express my gratitude to my father, mother, brothers and friends whose inspiration, everlasting moral support and love always elevated my confidence during the work.

CONTENTS Declaration by the Candidate Certificate (Guide) Endorsement by the HOD Certificate (Examiner) Copyright Dedication Acknowledgement Chapters 1. Introduction 2. Anatomy 3. Pathogen 4. Pathogenesis 5. Aetiology 6. Types of Tinea Pedis 7. Clinical Features 8. Risk Factors 9. Investigations 10. Differential Diagnosis 11. Diagnosis 12. Treatment 13. Discussion 14. Conclusion 15. References Page No. ii iii iv v vi vii viii 1

INTRODUCTION OF TINEA PEDIS

Athletes foot (also plus ringworm of the foot and Tinea Pedis) is a fungal infection of the skin that causes scaling, flaking and itch of affected areas. Although the condition typically affects the feet, it can spread to other areas of the body including the grain. In fact, its so common that most people will have at least one episode at lead once in their lives. Its less often found in women and children under age 12. Because the fungi grow well in worm, damp areas, they flourish in and around swimming pools, showers and locker rooms. Tinea Pedis got its common name because the infection was common among athletes who often used these areasCarol A Tarkington Synonyms :- Tinea Pedies, foot ringworm, Ringworm, Athletes foot Tinea Pedis is used the most common form of ringworm in the UK and USA and is usually caused by anthropophilie fungi such as Trichophyton rubrum, T. mentagrophytes and Epidermophyton flouovem (Davidson). These three species of fungi are together responsible for the vast majority of cases of tinea pedis through out the world. Trichophyton rubrum is the mostcommon pathogen associatd with chronic tinea pedis, while other fungal pathogens have also been associated with the disorder. The factors affecting the transmission of these dermatophytic pathogens are dependent on the source of inflation which is usually either human (anthropophillic), animal (zoophilic) or Soil (geophilic). Athletes foot spread into the American English vocabulary in a 1928 issue of literary digest: Athlete foot.. is a popular name for

ringworm of the foot, from which more than ten million persons in the United States are now suffering. The association of athletes and this variety of ringworm had to wait until the twentieth century, when Americans, including athletes finally began to take a serious interest in hygiene. Occasional baths had been the limits of American cleanliness in previous centuries. Now, not only did athletes have running water in their locker rooms (itself a term of the first dude of the 20th Century), they had communal showers. Floors in the locker room environment are usually wet, making ideal conditions for lurking fungi. In fact, medical authorities say, the association with athletes is unfounded. Most people already carry the fungi, one recent estimate is that 70 percent of the population may be affected to one degree or another. The little organisms thrives in moist and airless environments like that created by wet feet in shoes. If the skin between the toes is kept healthy and dry, we rarely have problems with athletes foot. How do you catch tinea pedis People often caqtch tinea pedis by walking barefoot where there are fragments of skin or nail shed by an influted person. This most commonly occurs around swimming pools and public showers. It can also be picked up in showers at home. If tinea pedis is not treated or is particularly bad sometimes the nails can also become influted. This causes them to become chalky and thickened. Athletes foot can be treated but it can be tenacious and different to clear up completely. Athletes foot can be prevented by good hygiene, and is treated by a number of pharmaceutical and other treatments.

ANATOMY OF FOOT & SKIN

FOOT: The foot is the region of the lower limb distal to the ankle joint. It is subdivided into the ankle, the meta-travels & the digits. There are five digits consisting of the medially positioned great toe (digit I) and four more laterally placed digit, ending laterally with the little toe (digitV) The foot has a superior surface (dorsum of foot) and an inferior surface (soles). BONES: There are three groups of bones in the foot: The seven tarsal bones which from the skeletal framework for the ankle. Meta farsals ( I to V) which are the bones of the metatarsus. The phalanges which are the bones of the toes-each toe has three phalanges, except for the great toe, which has twoo Proximal Group:It contains Talus: It is the superior bone of the foot. It articulates with the tibia & fibula to form the ankle it. o Callaneus: it is largest of tarsal bone. It articulate with one of the distol group of tarsal bones. o Intermediate: o Navicular: It is boat shaped. This bone articulates behind with the talus and articulates in front & on the lateral side with the distol group of tarsal bones. o Distal Group:o Cuboid: Articulates behind with the caleaneus & in front with the base of lateral two metatarsals. o Cuneiform: Lateral, medial & intermediate cuneiform bone articulates with naucular bone & in front with bases of medial three metatarsal. o Metatarsals: There are five metatarsals in the foot, numbered I to V from medial to lateral.

Each metatarsal has a head at the distal end, an elongate shaft in the middle & a pronimal base. The head of each metatarsals articulates with the pronimal phalamn of a toe and the base articulates with one or more of the distal group of tarsal bones. Plantar surface of the head of metatarsal I also articulates with two lesamoid bones. PHALANGES: Are the bones of the toes. Each toe has three phalanges (Pronimal, middle and distal) except for great toe which has only two (proximal & distal) I. Appendix of skin: a. Nails are hardened keratin plates on the dorsal surface of the lips of fingers & toes. b. Hairs c. Sweat glands d. Sebaceous gland Function of skin: Protection Sensory Regulation of body temp Absorption Sevelion Regulation of pH Synthesis Repair alive II. Superfival fascia: It is general coating of the body beneath the skin, made up of loose areola tissue with varying amounts of fat. III. Deep fascia: is a fibrous sheet which invents the body beneath the superfavial fascia. It is devoid of fat & is usually inelastic & touch. SKIN It is the general covering of the entire internal surface of the body. The colour of the skin is determined by at least five pigments present at different levels and places of the skin. There are1. Melanin: brown in clour. 2. Melanoid : resembles melanin

3. Carotene : yellow to orange in colour 4. Hemoglobin : Purple 5. Oxyhalmoglobin : Red Thickness : The thickness of skin various from about 0.5 to 3 mm. Structure of Skin: Skin is composed of two distinct layers, epidermis & dermis. (A)Epidermis: It is the superficial, a vascular layer of stratified squamous epithelium. It is ectodermal in origin and gives rise to the appendages of the skin, namely hair, nails, sweat glands and sebaceous gland. *Structurally, the epidermis is made up of Superficial cornfield zone. A deep germinative zone The cornfield zone includes three strata of cells namely Stratum corneum Lucidum granulosum The Germinative zone inclues two strata Stratum Spinosum basale (Stratum germinatium or malpighion layer) of a single layer of columnar cells). (B)Dermis or Corium: It is the deep, vascular layer of the skin, derived from mesoderm, it is made up of connective tissue mined with blood vessels, lymphaties and nerves. The connective tissue is arranged into a superfivial papinary layer and a deep reticular layer. Synovial shealb in the ankle region:The tendons that cross the ankle joint are all deflated to some degree from a straipht course, and must therefore be hold down by retinacula and enclosed in synowal shealths. Plantas fascia: or aponeurosis is compound of densely con-paited collegen fibres oriented mainly lorfiludinally, but also transversely. It have three parts= (1) Central Part:- It is attached to the medial process of the caleaneal tuberovity. It becomes broader and somewhat timers as it diverges towards the metatarsal heads.

(2) Lacteal part:- It forms a stronger band, sometimes containing nurell fibers. (3) Medial part:- It is continuous pronumally with the plen retin acleem. Foxial Compartment of the foot: There are four main compartments of the plants aspect of the foot (Jones 1949) (Fog 115.7). Medial Compartment Central Compartment Lateral Compartment Interossous Compartment Muscular of the sole of foot: It have been divided into four layers: Plants muscular of foot (first layer) Abductor nalluis: Abdwlion of xallure Flenor degelorum breuis: flexes the lesser tol Abdutos digiti mimimi: it is more a plenor of the little toe metatarso phalangeal joint than an abduetor. Pto Second layer: Intermsus numerals Flexon diglorum layers Flexon halluis layer Hlenos dijitorum ouessorius Lumbrual muscles: Entension of the interphalangeal joint of toes there are four muscle numbered from medal to lateral: Planfor third layer : Hlexor Halluis breuis: flexes the pronemal phalamx of the halluse Addiction halluis: partly flexes the pronemal phalamx of the halluse but also stabeleres the metaforsal heads. Flenon digiti mimimi breuis : flenes the M7PJt of little toe Plantas fourth layer: Dassal Interossei: Flex M7PJt & entend the JPJt of lesse toes the hallum & little toe have their own abdutos. Plantar interossei: Adduit the 3 & 4, J toes, flex the M7PJy & extend the JPJt.

 Tibialis pusterion Peroneur lonyus

PATHOGENS There are three species of fungi: 1. Trichophyton Rubrum 2. Trichophyton mentagropfytes 3. Epidermophyron flousoum There are together responsible for the vast majority of cases of tinea pedis through out the world.
1.

T. rubrum: A recent study showed that T. rubrum accounted for over 76% of all dermatophite infections including tinea pedis and may account for over 213 of all tinea pedis infections. It appears in two forms: a. The first is typically white and fluffy in appearance with several aerial hypae and is called the downy form. b. The second is granular form, however & flat and has no acuial hyphae. T.Rubrum not always, wine colored on the bottom.

2. T. mentaqrophytes: is morphologically and characteristically similar to T. rubrum. Both have a downy or granular appearance and are sometimes indistinguishable under the microscope. T. Mentaqrophytes species can be pale yellow on the underside. 3. Epidermophyton flouosum: is an anthrophilic fungus found worldwide and has been ineriminated in several types of tinea inflections. Colonies of this fungus are flat and grainy and range in colour from yellow to brown.

PATHOGENESIS
T. Rubrum, T. Mentagrophytes, Epidermophyton flououm most commonly cause tinea pedis, with T. rubrum being the most common cause world wide. Trihopyton tonsurans has also been implicated in children. Nondermatophyte causes include seytalidim dimidiatum, scytalidium hyalinum an merely, candida species. Using enymes called keratinases, dermatophyte fungi include the superfinial keratin of the skin and the infection remains limited to this layer. Dermatophyte cell walls also contains manners that may reduce keratinoyte proliferation, hesulting in a decreased rate of sloughing and a chronic state of infection. Temperature and serum factors, such as beta globulins and ferritin, appear to have a growth inhibitory effect on dermatophytes; however this patho genesis is not completely understood. Sebum also is inhibitory,thus partly explaining the propensity for dermatophte inflation of the feet, which have no sebaueous glands. Host factors such as breaks in the skin and maceration of the skin may aid in dermatophate incasion. The cutaneous presentation of tinea pedis is also dependent on the hosts immune system and the infecting dermatophyte.

AETIOLOGY
Athletes foot is caused by a fungal infection of either one, or both of your feet. All have bacteria and fungi on skin, most of which are harmless. However, in some conditions, these organisms can multiply and cause skin to become infected. Athlete foot is caused by a group of fungi dermatophytes. These fungi are parasitic, which means they feed off other organisms to stay alive. Feet provide a warm, dark and humid environment, which are the ideal conditions needed for dermatophyte to grow. Mostly athletes foot is caused by one of two of types of fungus. Truchophton mentagrophytes:- Often cause toe web or vericular infection. Trichophyton rubrum:- often causes moccasin type inflections. This condition lasts for a long time (Chronic) and is difficult to treat. Athlete foot when come in contact with the fungus, it begins to grow on skin. Fungi commonly grow on or in the top layer of human skin and may or may not cause infections. Athlete foot is easily spread (containers):- we get it by touching the affected area of a person who have it. More commonly, pick up the fungi; from damp, contaminated surfaces, such as the floors in public showers or locker rooms. Although athletes foot is contagious, some people are likely to get it (susceptible) than others. Susceptibility may increase with age. Experts dont know why some people are more likely to get it. After athletes foot, people are more likely to get it again. After coming in contact with the fungi that cause athlete foot have the channel of spreading the fungi to others, whether you get the infection or not. Additional causes include irritant or contact dermatitis, allergic rashes from shoes or other creams, dyshidrotic eczema (skin allergy rash), psoriasis, keratodermie blenorrhagium, yeast inflections and bacterial infections.

TYPES OF TINEA PEDIS (FIGURES)

Depending on the pathogen and anatomical distribution, tinea pedis may present in a given patient as one of several syndromes. Typically, three variants are seen and include the interdigital, Bilateral moccasin and vericobullous forms of the disease.
(1) Interdigital

Tinea Pedis:- It is the most common form and usually manifests in the inter space of the fourth and fifth digits and may spread to the undervide of the toes (figure 1) (4,8) Patient complains of itching and burning sensations on the feet auompainted by malodor. T. melagrophytes are mainly isolated with this. There are generally two types of interdigital tinea pedis:a.

Moccasin type tinea pedis: It is a more severe, prolonged form of tinea pedis that covers the bottom and lateral aspects of the foot. Its appearance is that of a slipper or moccasin covering the foot. T. rubrum is most commonly associated with this 2A gif shows xyperkerototc skin on the medial

(2) Vesiculabullous

tinea pedis: Comprises pustules or vesicles on the instep and adjunct planter surfaces of the feet and is less common.

CLINICAL FEATURES Chronic kyperkeratotic refers to patehy fine dry scaling on the sole of the feet. Moccasin tinea is entensive hyperkeratotic tinea: in which skin of the entire sole, heal and sides of the foot is dry but not inflamed. Athletes foot is most peeling irritable skin between the toes, most often in the cleft between the fourth & fifth does. Clusters of blisters or pustules on the sides of the feet or insteps (more likely with T interdigitale) Round dry patches on the top of the foot (ringworm like tinea corporals) Ringworm Jock itch Dryness Itching Burning Scaling Gauked skin Nail infection

RISK FACTORS Risk of getting athlete foot increase if, by mayo clinic staff. Are a man Frequently wear damp socks re light filling shoes. Wear closed shoes, especially if they are plastic lined. Share mats, rugs, bed linens, clothes, shoes with someone who has a fungal infection. Sweat a lot. Develop a menor skin or nail injury. Frequently visit public areas where the infection can spread such as locker rooms, saunad, swimming pools, communal baths & showers. Have a weakened immune system.

Reference: Nov. 22, 2008 1998-2010 Mayo foundation for medical education & research (MEMER) Mayo Clinic, :Mayo Clinic.com.

INVESTIGATION Physician can perform a simple test called a KOH, or potassium hydroxide for microscope fungal-examination, in the office or laboratory to confirm the presence of a fungal infection. This test is performed using small flakes of skin that are examined under the microscope. Many dermatologists perform this test in their office with results available within minutes. Rarely, a small piece of skin may be removed and sent for biopsy to help confirm the diagnosis.

DIFFERENTIAL DIAGNOSIS
Psoriasis Contact dermatitis Dyshidrotic ecrema Scabis Pithed kerololysis Eczema Erythema Diabetes Gout Ingrown toe nail Clelluclies Phleliutes Asteomy eliteb Paronyehia Pseudogoul Psoriasis : It is a non-infectious, chronic inflammatory disease of the skin, characterized by well defined erythematous plagues with slvery scale. Contact Dermatitis:- Inflammation of skin caused by numerous condition including contact with skin irritants. Marked by itching and redness. Scabis:- A contagious infection of the skin with he itch mite, sarcoptes scabiei. It typically presents as an intensely prurtic rash, composed of scaly papules and secondarily infected lesion distributed in the webs between the fingers. Eczema :- It is an itchy red rash may result from various causes including allergies, irritating chemicals, drys or rubbing the skin, sun exposure. Dyshedrotic & Pompholyx Erythema:- Reddening of the skin. It is a common but non specifc sign of skin urrelalion, injury or inflammation. Clelluclies :- A spreading bacterial infection of the skin, caused by strephocoual or staphylocoual infections, result in severe information with eryhema, warmth and localized edema.

Phlebitis: Inflammation of vein caused by chemical or mechanical irritation of veins by thrombosis, indwelling catheter or venous infections vein may be painful, tender, red or swollen. Paronyehia:Bacterial infection of the posterior nail folds.

Irgrown nail:Causes severe pain in the distal nail folds with associated erythema, edema and tenderness. Gout:Monosodium urate bustal deposition secondary to hypercurillmia Severe pain, redness and swelling occurring in one joint usually of the lower intermity, and mainly MJP joint of great toe (Podagra). Pseudogout:Calcium pyrophosphate deposition disease can affect the toe, but the knee is most common. Osteomyelitis:- Infection of the bone by micro-organism it is also used for infection of the bone by pyogenic organism. Diabetes

DIAGNOSIS
Diagnosis of tenia pedis is based on history and clinical appearance of the feet in addition to direct microscopy of a potassium hydroxide (KOX) preparation. Cultures or histological examinations are rarely required. A woods lamp is not usually helpful in diagnosing tinea Pedis but can be used to rule out other diagnosis like infection with Malasseria furfur (1) or ertthrasma. Malasseria furfur and corynebaiterium minutissimum both fluoresce under ultraviolet light while other common dermatophytes do not. KOX preparations are simple, inexpensive, efficient and widely used. KOX preparation has an excellent positive predictive value. Occasionally, false negative results may be obtained, especially if treatment has already begun.

DIAGNOSTIC TEST INCLUDE: A CBC Sedimentation rate Chemistry Panel VDRL test X-ray of foot If peripheral pulses are diminished, Doppler studies and angiography should be considered. If there is diffuse swelling and erythema: venography may need to be done. If there are neurologic findings: nerve condition velocity studies and EMGs (electromyograms) may be helpful.

PESTS CONTROL
A Project work submitted to

RAM LUBHAI SAHANI GOVT. MAHILA MAHA VIDHYALAYA (PILIBHIT)

In Partial Fulfillment of the Requirement for the Bachelor of Science (ZOOLOGY)

MAHIMA SAXENA
B.Sc. (Final) Zoology

By

Affiliated to M.J.P. Rohilkhand University, Bareilly