Jock Itch, also known as Tinea cruris, is a cutaneous fungal infection, which is associated with a significant amount of distress and therefore, selecting the right kind of treatment from the outset is therefore important, due to the possibility of relapse.
This article provides a synopsis of the current treatment strategies, commonly used antifungal drugs, and the modalities for prevention of re-infection. Jock itch treatment strategies are essentially the same in male and female patients.
Appropriate Diagnosis is Critical Before Treatment
The diagnosis of jock itch relies primarily on the characteristic set of symptoms and skin appearance. Confirmatory diagnosis is made by demonstration of the fungi on the skin surface, following a skin swab collection or skin scrapings, which are then processed by special techniques and examined microscopically under Wood’s light.
Sometimes, confirmation of diagnosis may require a skin biopsy, especially in severe, protracted cases of jock itch. This is a minor surgical procedure, performed in the doctor’s office, where a small skin section is taken, while pain sensations are blocked by the use of anaesthetic drugs applied to the skin. Subsequently, this skin section is processed and analysed by a variety of methods to confirm fungal growth in the skin and to rule out other possible causes of similar skin appearance like atopic dermatitis, ringworm, heat rash, dry skin, erythrasma, eczema or contact dermatitis. Furthermore, concomitant infection with bacteria may require a skin swab culture.
Aims of Treatment
The aims of treatment are:
- The primary intention is to achieve complete cure, through eradication of fungal infection. This is achieved by use of antifungal drugs, in combination with non-drug strategies which prevent fungal growth on the skin.
- The secondary aim is the prevention of reinfection. This is important as reinfection rates of as much as 60% have been observed in some studies(Chang, Young-Xu, Kurth, Orav, & Chan, 2007).
Non-Drug Strategies for Jock Itch Treatment
- Avoid scratching the rash or the affected surfaces as much as possible even in severe and admittedly, this is difficult to achieve owing to the constant pruritic sensations induced by the affected skin areas in the groin. Scratching may provide temporary relief, but serves to inoculate the fungi into adjacent unaffected skin areas and cause odor. Furthermore, fungi embedded under the nails may be a source of auto-inoculation and subsequent re-infection in both men and women.
- Daily bathing is recommended. However affected skin areas in the groin should be washed with mild, non-irritant soap.
- Avoid wearing tight fitting underclothes, especially those made of synthetic fabrics.
- Affected skin area should be kept dry. This is especially important as fungi thrive well in warm moist surfaces. The use of drying agents like skin powders over the affected skin of the penis, scrotum and groin in males is advised. Drying of skin around the vagina is also important for cases of vaginal jock itch in females.
How to Get Rid of Jock Itch: Antifungal Drugs
Based on the numerous antifungal products available, the doctors’ advice is essential when considering the best treatment to choose for curing jock Itch. There are several important considerations when selecting an antifungal drug for use in jock itch.
- Age of patient.
- History of allergic reactions.
- Duration of symptoms.
- Pregnancy status.
- Concomitant use of other medications.
- Availability of formulations as sprays, ointments and creams which are suitable for symptoms in occluded, intertriginous skin areas such as the groin.
- Physico-chemical properties of formulation such as viscosity, acidity and hydrophobic properties.
There are different classes of antifungal drugs available for use in the treatment of jock itch (Ely, Rosenfeld, & Seabury Stone, 2014).
These drugs inhibit the synthesis of ergosterol within fungal cell wall, leading to growth arrest. They are the most widely used drugs in the treatment of moderate to severe job itch.
This is the oldest of the azoles, belonging to the imidazole subclass, based on the two nitrogen atoms in its azole ring chemical structure. It is widely used in a variety of fungal infections. It is available as a 1% lotion, cream and spray for use twice daily over 4 -6 weeks. When used consistently, this cream or spray produces a cure rate of about 55-100%(Chang et al., 2007). Adverse effects include skin itching and redness. This drug is available over the counter .
Econazole is an antifungal drug within the imidazole class, which is useful in treatment of jock itch. It is available as a 1% cream as well as lotion. This is an effective antifungal cream for treating jock itch when oral pills are not desired. Adverse effects include skin redness, itching and contact dermatitis.
Miconazole is suitable for use in the treatment of Jock. It is available as a spray, powder, lotion, cream and ointment. Cure rate is 70-100%(Chang et al., 2007).
Ketaconazole is a broad spectrum antifungal agent, indicated in the treatment of dermatophyte infections, including jock itch. Topical use is preferred while oral treatment is restricted to severe cases.
Itraconazole is a powerful antifungal drug, which is only available in oral or parenteral forms. It is primarily indicated for treatment of systemic fungal infections, but is also used in Tinea cruris infection, where, treatment duration is shorter, as compared to topical agents. A variety of adverse effects like vomiting, abdominal pain, hair loss and photosensitivity may occur with its use.
It is a widely used antifungal which is available both as a cream as well as tablets. Its main indication for use is in the treatment of superficial mycoses caused by Candida species. However, it is also effective in treatment of dermatophytoses such as jock itch and tinea Pedis. Effective cure requires oral usage for up to 6 weeks at a dose of up to 150mg per week. It is one of the strongest medicines available.
Oral fluconazole should be used with caution in pregnancy and is known to be associated with significant drug-drug interactions when used with a wide variety of other medications concomitantly. Thus, its use requires monitoring by a physician, especially for people who are taking other drugs for unrelated medical conditions. Adverse reactions like skin coloration, skin rashes, nausea, dizziness and headaches may occur with fluconazole use.
Allylamines and Benzylamines
These are a newer class of antifungal agents and are largely fungicidal.
They act by inhibiting squalene epoxidase, an important enzyme in the metabolism of fungi. These drugs are currently recommended for first line treatment of jock itch (Moriarty, Hay, & Morris-Jones, 2012).
- Terbinafine and Butenafine
Terbinafine (Lamisil) is indicated in the treatment of Jock Itch and other dermatophyte infections. Lamisil is available as a 1% cream is and well absorbed following topical application. Lamisil cream is used twice daily over a duration of 4-6 weeks, and cure rates of over 90% can be achieved. Adverse effects of Terbinafine include hair loss and skin irritation. Lamisil is currently regarded as one of the strongest and best treatment products for jock itch and especially important for extreme cases of chronic, persistent jock Itch.
Jock itch is very infectious, and therefore, efforts must be made to prevent further infection episodes following successful treatment. Extreme, chronic jock itchmay be associated with symptoms that won’t go away. The following steps will help reduce the risk of re-infection.
- An important consideration therefore, is the need to keep the groin area dry at all times. This is because fungal strains which cause jock itch thrive in moist, warm environments.
- Current underclothes used during or prior to treatment may still contain fungal spores and should be thoroughly washed and ironed before use.
- Efforts should be made to avoid sharing clothes, towels and beddings.
- Since Tinea Pedis, a fungal infection of the feet also known as athlete’s foot, and jock itch may coexist, socks should be worn prior to wearing underwear, to prevent contamination of underwear by fungi from feet.
- Avoid wearing tight fitting clothes, especially those made of synthetic materials.
Home Remedies and Natural Options
There are many remedies which have been proposed for the treatment of jock itch at home. Caution is advised regarding these so-called jock itch home remedies and cures, as currently, majority of them are anecdotal and pseudo-scientific in nature, with little or no scientific support of their efficacies in curing Jock itch. These suggested home based natural treatments include everyday ingredients like lemon, honey, vinegar, onion, bleach, and alcohol.
One notable home natural remedy with possible antifungal property which may be useful is tea tree oil (Homeyer et al., 2015). Tea tree oil has demonstrated potent antifungal activity to a wide variety of fungal species including many of those which cause jock itch. Other natural products with potential activity against jock itch are bergamot oil and Brazillian Copaiba oil (Soares et al., 2013).
Is Jock Itch Curable?
Complete cure is achieved in an overwhelming majority of jock itch cases. However, there are uncommon situations where the jock itch becomes protracted fails to respond to commonly used medications. In such cases, use of more powerful drugs or a combination of several antifungal drugs is usually effective. In rare cases, spontaneous resolution of jock itch without the use of any therapy can be observed.
Complications and Potential Long-Term Effects
Without optimal treatment, complications may arise from long standing cases of jock itch. These complications are usually restricted to the area of skin affected. They include increased skin pigmentation, also called hyperpigmentation, or a reduction on pigmentation known as hypopigmentation.
Bacteria may invade the jock itch affected areas and aggravate the pre-existing skin damage to the groin, thighs and genitals. Secondary complication may cause cellulites, abscess formation or permanent scarring. This is of utmost importance in people with weakened immune systems, who are inherently prone to widespread jock itch. Complications due to side effects of medication are rare.
Chang, C.-H., Young-Xu, Y., Kurth, T., Orav, J. E., & Chan, A. K. (2007). The Safety of Oral Antifungal Treatments for Superficial Dermatophytosis and Onychomycosis: A Meta-analysis. The American Journal of Medicine, 120(9), 791-798.e793. doi: http://dx.doi.org/10.1016/j.amjmed.2007.03.021
Ely, J. W., Rosenfeld, S., & Seabury Stone, M. (2014). Diagnosis and management of tinea infections. Am Fam Physician, 90(10), 702-710.
Homeyer, D. C., Sanchez, C. J., Mende, K., Beckius, M. L., Murray, C. K., Wenke, J. C., & Akers, K. S. (2015). In vitro activity of Melaleuca alternifolia (tea tree) oil on filamentous fungi and toxicity to human cells. Med Mycol, 53(3), 285-294. doi: 10.1093/mmy/myu072
Moriarty, B., Hay, R., & Morris-Jones, R. (2012). The diagnosis and management of tinea (Vol. 345).
Soares, L. A., de Cássia Orlandi Sardi, J., Gullo, F. P., de Souza Pitangui, N., Scorzoni, L., Leite, F. S., . . . Almeida, A. M. F. (2013). Anti dermatophytic therapy – Prospects for the discovery of new drugs from natural products. Brazilian Journal of Microbiology, 44(4), 1035-1041. doi: 10.1590/S1517-83822014005000011