Clinics in Dermatology (2010)
28,
137–139
Tinea incognito Roberto Arenas, MD a, , Gabriela Moreno-Coutiño, MD a , Lucio Vera, DrSc b , Oliverio Welsh, MD b ⁎
a
Mycology Section, Department of Dermatology, Dr. Manuel Gea Gonzalez General Hospital, Calzada de Tlalpan 4800, 14080 México, DF, México b Department of Dermatology, Dr. Jose Eleuterio Gonzalez University Hospital, Monterrey, México “
”
Tinea incognito was first described 50 years ago. It is a dermatophytic infection with a clinical Abstract Tinea Abstract presentation modified by previous treatment with topical or systemic corticosteroids, as well as by the topical application of immunomodulators such as pimecrolimus and tacrolimus. Tinea incognito usually resembles resem bles neuro neuroderma dermatiti titis, s, atopi atopicc derma dermatiti titis, s, rosace rosacea, a, seborr seborrheic heic derma dermatiti titis, s, lupus eryth erythemat ematosus, osus, or contact conta ct derma dermatiti titis, s, and the diagn diagnosis osis is freque frequently ntly missed or delay delayed. ed. © 2010 Published by Elsevier Inc.
Introduction Tinea corporis is clinically defined as patches of scaly erythe ery thema ma wit with h a sli slight ghtly ly ele elevat vated ed bor border der.. Thi Thiss pic pictur turee is representative of most lesions affecting glabrous skin. One of the dia diagno gnosti sticc cha challe llenge ngess in tin tinea ea cor corpor poris is and tin tinea ea capitis is identifying those cases that have been previously mistr mi streat eated ed by sel self-m f-medi edicat cation ion or seco seconda ndary ry to the use of topical and systemic immunosuppressants, such as steroids and immunomodulators. The term tinea incognito was originally described in 1968 by Ive and Marks in 14 patients with a dermatophytic infection that had an atypical clinical presentation caused by previous treatment with steroids. This occurred in the 1960s after the introduction of these drugs for the topical treatment of div divers ersee derm dermato atolog logic ic dis disease eases. s. Sin Since ce the then, n, oth other er cas cases es hav havee been described with the topical application of pimecrolimus
⁎ Corresponding
author. Tel.: + 55 4000 3058; fax: +55 4000 3058.
[email protected] (R. (R. Aren Arenas). as). E-mail address:
[email protected] 0738-081X/$ – see front matter © 2010 Published by Elsevier Inc. doi:10.1016/j.clindermatol.2009.12.011 doi: 10.1016/j.clindermatol.2009.12.011
and tac tacrol rolimu imus, s, alt althou hough gh top topica icall or sys system temic ic use of corticosteroids continues to be the most common cause. Over-the-counter access to steroids and other immunosuppressants in some countries, as well as the increase in medications containing steroids, makes tinea incognito more likely, and therefore, the diagnosis is frequently missed or delayed. These drugs suppress the normal cutaneous immune response to dermatophytes, thus enhancing the development of fungal superficial infections. 1-6 Some physi physicians cians,, parti particularl cularly y nonde nondermato rmatologis logists, ts, prescribe scr ibe com combin binati ations ons of ste steroi roids ds and ant antifu ifunga ngals, ls, suc such h as betamethasone and clotrimazole, in which the betamethasone hass a do ha domi minan nantt eff effect ect ov over er th thee ant antifu ifung ngal al age agent nt,, th thus us 7 exacerbating superficial dermatophytosis. As wi with th oth other er der dermat matoph ophyto ytosis sis,, the these se inf infect ection ionss may involve patients of any age or sex. All areas may be affected, but the face and arms are more prevalent; the feet are rarely affe af fect cted ed by th this is co cond ndit itio ion, n, be beca caus usee ti tine neaa pe pedi diss is an exceptionally missed diagnosis. Clinically, these lesions have a less raised margin and are less scaly than common dermatophytosis. They tend to be
138
R. Arenas et al.
Fig. 1
Tinea incognito on the upper part of the back.
pustular, pruritic, extensive, and erythematous and may mimic other skin diseases (Figure 1). Another clinical form that can be confused with bacterial infections or prurigo is trichophytic granuloma (Majocchi granuloma), which is more commonly found on the legs of women. The fungus can be inoculated by shaving the legs, and a contributing factor is the use of corticosteroid creams. It is common to find tinea pedis or onychomycosis in these cases. The main differential diagnosis depends on the affected area. In the face, the lesions may resemble neurodermatitis, atopic dermatitis, rosacea, seborrheic dermatitis, lupus erythematosus, or contact dermatitis. A recent study reported that facial tinea incognito is frequently associated with tinea pedis or onychomycosis in toenails, or both. 8 In the glabrous skin, the main differential diagnosis is impetigo, purpura, lichen planus, psoriasis, erythema migrans, drug eruptions, Sweet neutrophilic dermatosis, contact dermatitis, discoid lupus, and tuberculoid leprosy. A 15-year survey from Italy reported 200 cases of tinea incognito. Of these, 9% had folliculitis, and dermatophytids were uncommon. The source of infection was human-tohuman transmission. Among elderly patients, the misdiagnosis of dermatitis in the legs associated with venous failure, was reported as a common cause of tinea incognito. Up to 40% in this series required systemic steroids for treatment of skin and nondermatologic diseases. For this reason, the authors underlined the importance of looking for nail alterations, which can indicate onychomycosis, especially in chronic forms of tinea incognito. The clinical history is fundamental, because the clinical appearance may be confusing. The definitive diagnosis must be attained in a mycology laboratory or by an expert in dermatomycology using direct examination with potassium hydroxide, which demonstrates fungal structures. The species must be also identified by culture. Occasionally, the diagnosis is made by histopathology with hematoxylin and eosin and periodic acid-Schiff stains.9,10
The main etiologic agents reported are Trichophyton rubrum, T mentagrophytes, Epidermophyton floccosum, Microsporum canis, M. gypseum, T violaceum, and T erinacei. The first two are most commonly isolated when the face is involved. 11-33 Fluorinated corticosteroids were implicated in a hospital dermatophytosis outbreak by E floccosum.34 These dermatophytoses usually require systemic treatment with oral antifungal agents. Terbinafine, itraconazole, and fluconazole have been shown to be superior to treatment with griseofulvin, because they accumulate in the skin. Therapy is generally indicated for 2 weeks, but the clinical and mycologic responses will determine the definite duration of treatment.35 In renal transplant patients, an uncommon presentation of atypical tinea is dermatophytic granuloma. The lesions evolve into chronic dermatophytosis that can clinically resemble vasculitis.1
References 1. Arenas R. Atlas dermatología. Diagnóstico y tratamiento. 3rd ed. Mexico: Mc Graw-Hill; 2005. p. 387-91. 2. Ive FA, Marks R. Tinea incognito. Br Med J 1968;3:149-52. 3. Solomon BA, Glass AT, Rabbin PE. Tinea incognito and “over-thecounter ” topical potent topical steroids. Cutis 1996;58:295-6. 4. Crawford KM, Bostrom P, Russ B, Boyd J. Pimecrolimus-induced tinea incognito. Skinmed 2004;3:352-3. 5. Siddalah N, Erickson O, Miller G, Elston DM. Tacrolimus-induced tinea incognito. Cutis 2004;73:237-8. 6. Grau-Salvat C, Pont Sanjuan V, Sànchez-Carazo JL, Vilata-Corell JJ, Aliaga-Boniche A. Tiña inflamatoria diseminada: presentación inusual. Rev Iberam Micol 1998;15:100-2. 7. Fisher DA. Adverse effects of topical corticosteroid use. West J Med 1995;162:123-6. 8. Nenoff P, Mügge C, Herrmann J, Keller U. Tinea faciei incognito due to Trichophyton rubrum as a result of autoinoculation from onychomycosis. Mycoses 2007;50(suppl 2):20-5. 9. Romano C, Maritati E, Gianni C. Tinea incognito in Italy: a 15-year survey. Mycoses 2006;49:383-7. 10. Odom RB, James WD, Berger TG. Andrew's diseases of the skin. Clinical dermatology. 9th ed. Philadelphia: W.B. Saunders; 2000. p. 369-70. 11. Whittle CH. Tinea incognito. Br Med J 1968;3:498. 12. Serarslan G. Pustular psoriasis-like tinea incognito due to Trichophyton rubrum . Mycoses 2007;50:523-4. 13. Rallis E, Koumantaki-Mathioudaki E. Pimecrolimus induced tinea incognito masquerading as intertriginous psoriasis. Mycoses 2008;51: 71-3. 14. Ghislanzoni M. Tinea incognito due to Trichophyton rubrum responsive to topical therapy with isoconazole plus corticosteroid cream. Mycoses 2008;51(suppl 4):39-41. 15. Belhadjali H, Aounallah A, Youssef M, Gorcii M, Babba H, Zili J. Tinea faciei, underrecognized because clinically misleading [in French]. Presse Med 2009;38:1230-4. 16. Lange M, Jasiel-Walikowska E, Nowicki R, Bykowska B. Tinea incognito due to Trichophyton mentagrophytes . Mycoses 2009 doi: 10.1111/j.1439-0507.2009.01730.x [E-pub]. 17. Sánchez-Castellanos ME, Mayorga-Rodríguez JA, Sandoval-Tress C, Hernández-Torres M. Tinea incognito due to Trichophyton mentagro phytes. Mycoses 2007;50:85-7. 18. McGinness J, Wilson B. Tinea incognito masquerading as granulomatous periorificial dermatitis. Cutis 2006;77:293-6.
Tinea incognito 19. Wacker J, Durani BK, Hartschuh W. Bizarre annular lesion emerging as tinea incognito. Mycoses 2004;47:447-9. 20. Al Aboud K, Al Hawsawi K, Alfadley A. Tinea incognito on the hand causing a facial dermatophytid reaction. Acta Derm Venereol 2003; 83:59. 21. Faegermann J, Fredriksson T, Herczka O, Krupicka P, Björklund KN, Sjövist M. Tinea incognito as a source of an “epidemic” of Tricho phyton violaceum infections in a dermatologic ward. Int J Dermatol 1983;22:39-40. 22. Burkhart CG. Tinea incognito. Arch Dermatol 1981;117:606-7. 23. Marks R. Tinea Incognito. Int J Dermatol 1978;17:301-2. 24. Elgart ML. Tinea incognito: an update on Majocchi granuloma. Dermatol Clin 1996;14:51-5. 25. Bose SK. Tinea incognito mimicking red face and red ear. J Dermatol 1995;22:706-7. 26. Singhi S, Singh G, Pandey SS. Mycologic examination in tinea incognito. Int J Dermatol 1991;30:376-7. 27. Romano C, Asta F, Massai L. Tinea incognito due to Microsporum gypseum in three children. Pediatr Dermatol 2000;17:41-4. 28. Cerroni L. Tinea incognito. N Engl J Med 2000;343:1499. 29. Feder Jr HM. Tinea incognito misdiagnosed as erythema migrans. N Engl J Med 2000;343:69.
139 30. Nakagawa T, Nakashima K, Takaiwa T, Negayama K. Trichosporon cutaneum ( Trichosporon asahii ) infection mimicking hand eczema in a patient wit h leukemia. J Am Acad Dermatol 2000;42:929-31. 31. Gorani A, Schiera A, Oriani A. Case report. Rosacea-like tinea incognito. Mycoses 2002;45:135-7. 32. Pustisek N, Skeriev M, Basta-Juzbasic A, Lipozencic J, Marinovic B, Bukvic-Mokos Z. Tinea incognito caused by trichophyton mentagrophytes —a case report. Acta Dermatovenereol Croat 2001; 9:283-6. 33. Jacobs JA, Kolbach DN, Vermeulen AH, Smeets MH, Neuman HA. Tinea incognito due to Trichophyton rubrum after local steroid therapy. Clin Infect Dis 2001;33:142-4. 34. Burry JN. Fluorinated corticosteroids and dermatophytosis. Br Med J 1975;3:40. 35. Guenova E, Hoetzencker W, Schaller M, Röcken M, Fierbeck G. Tinea incognito hidden under apparently treatment-resistant pemphigus foliaceus. Acta Derm Venereol 2008;88:276-7. 36. Arenas R, Vázquez del Mercado E, Molina de Soschin D, RuizEsmenjaud J. Superficial mycoses in renal transplanted patients. Report of 5 cases and details of one of them with trichophytic granuloma, tinea cruris and onychomycosis treated with oral terbinafine. Dermatol Klin 2003;5:195-9.
