Should a patient with widespread tinea incognito (ringworm infection) around the surgery site be treated for the fungal infection before undergoing a hernia operation?

Treatment of Tinea Incognito Before Hernia Surgery

Yes, widespread tinea incognito around the surgical site should be treated with systemic antifungals for 2-4 weeks before elective hernia repair to reduce the risk of devastating mesh infection and potential mesh explantation.

Rationale for Pre-operative Treatment

The primary concern is mesh infection, which occurs in approximately 1.9-5% of hernia repairs and frequently requires complete mesh removal (72.7% of infected cases), creating a long-term surgical problem 1, 2. While superficial skin infections don't directly increase mesh infection rates, any active skin infection at the surgical site represents a bacterial and fungal reservoir that can contaminate the operative field 1, 2.

Key Risk Factors for Mesh Infection

The following factors significantly increase mesh infection risk and should inform your decision:

• Emergency operations (RR = 2.46) 1
• Postoperative surgical site infection (OR 2.9) 1
• Onlay mesh position (OR 3.51) - most vulnerable to superficial contamination 1
• ASA score ≥3 (RR = 1.40) 1

Treatment Protocol Before Surgery

Systemic Antifungal Therapy

• Initiate oral antifungals immediately upon diagnosis of tinea incognito 3, 4
• Treatment duration: 2-4 weeks minimum for tinea corporis (body/trunk infections), which is the typical location for groin/abdominal wall involvement 5
• Griseofulvin dosing: 500 mg daily (or 250 mg twice daily) for adults; 10 mg/kg daily for pediatric patients 5
• Alternative agents: Terbinafine or itraconazole may be used, particularly if the patient has been on immunosuppressive therapy 6, 4

Critical Adjunctive Measures

• Discontinue all topical or systemic corticosteroids immediately, as these are the primary cause of tinea incognito and will prevent treatment success 3, 6, 4
• Apply topical azole antifungals (clotrimazole, miconazole, or ketoconazole cream) twice daily to affected areas 7
• Keep the area dry and clean with thorough drying after washing 7
• Implement hygiene measures: use boiling water for laundry, iron clothing before wearing, avoid sharing linens and towels 4

Timing of Surgery

Delay elective hernia repair until:

• Clinical resolution of skin lesions is achieved (typically 2-4 weeks) 5
• The patient has completed at least the minimum treatment course 5
• Skin integrity is restored at the surgical site 1

Verification of Treatment Success

• Clinical examination showing resolution of erythema, scaling, and lesions 3, 4
• Consider repeat KOH preparation or fungal culture if clinical response is uncertain, though this is not mandatory if clinical resolution is clear 5, 4

Special Considerations for Mesh Placement

If surgery cannot be delayed (urgent/emergency setting):

• Avoid onlay (subcutaneous) mesh placement, as this position has the highest infection risk (OR 3.51) 1
• Prefer retromuscular or preperitoneal placement, which are more resistant to superficial contamination 1, 2
• Consider biological mesh in contaminated fields, though this is more expensive and less durable 1
• Administer perioperative antibiotics covering skin flora (Staphylococcus and Enterococcus species) 1

Common Pitfalls to Avoid

• Do not proceed with elective surgery with active skin infection, as the consequences of mesh infection (removal, recurrence, prolonged morbidity) far outweigh the inconvenience of delaying surgery 1, 2
• Do not rely on topical antifungals alone for widespread tinea incognito; systemic therapy is required 3, 4
• Do not continue immunosuppressive medications during antifungal treatment if medically feasible 6, 4
• Do not place drains routinely, as drainage increases SSI risk and should be avoided or minimized 1, 8

Expected Outcomes

With appropriate pre-operative treatment:

• Tinea incognito typically resolves completely with 2-4 weeks of systemic antifungals 5, 4
• Mesh infection risk returns to baseline once skin integrity is restored 1
• Surgical outcomes are not compromised by the delay in elective cases 1

The cost of delaying surgery (2-4 weeks) is negligible compared to the $1,300-$5,000 added cost per mesh infection, plus the morbidity of potential mesh explantation and hernia recurrence 8, 1.