'Tinea indecisiva' may mimic the concentric rings of tinea imbricata

A clinico mycological study of tinea pseudoimbricata

Introduction:

Tinea pseudoimbricata is a variant of dermatophytosis characterized morphologically by concentric scaly rings resembling tinea imbricata with an culture isolate other than Trichophyton concentricum. To date, no large case report series is available.

Aim:

To study the clinical profile and the fungus isolated in patients with tinea pseudoimbricata.

Materials and Methods:

In this case series, all the patients with tinea imbricata with an isolate other than Trichophyton concentricum were subjected to a detailed history and clinical examination. Scrapings of the scales were investigated with potassium hydroxide examination and culture in Sabouraud Dextrose Agar enriched with cycloheximide and chloramphenicol. The results obtained were tabulated and analyzed.

Results:

A total of 42 patients fulfilling the above culture criteria were included in the present study. A majority were in the age group of 21–40 years (54.70%) with a male preponderance (M:F = 2:1). All the patients had abused steroids for more than 4 weeks and had multiple site involvement. Trichophyton tonsurans (42.8%) was the predominant isolate cultured, followed by Trichophyton mentagrophytes.

Conclusion:

Hence, as per our study, tinea pseudoimbricata is encountered more often nowadays due to the misuse of topical steroids and to diagnose tinea pseudoimbricata culture is mandatory. The morphology of concentric rings is not restricted to Trichophyton concentricum, but can occur with other species depending on the clinical scenario.

A Case of Tinea Pseudoimbricata Due to Trichophyton tonsurans Induced by Topical Steroid Application

Tinea imbricata and tinea pseudoimbricata are variant types of tinea corporis characterized by annual-ring-shaped erythema. Although the skin lesions manifest similar symptoms, these two diseases are classified based on causative fungi. The former is caused by Trichophyton concentricum, an anthropophilic dermatophyte, and the latter is caused by dermatophytes other than T. concentricum, commonly zoophilic fungi such as Trichophyton mentagrophytes complex. Here, we report a 27-year-old Japanese male diagnosed with tinea pseudoimbricata attributed to Trichophyton tonsurans, an anthropophilic dermatophyte. We suspected that application of steroid ointment caused the annular pattern of his skin lesions. After three months use of topical luliconazole cream, treatment was finished. We also summarize the knowledge about tinea pseudoimbricata through previous reports with bibliographical consideration.

Tinea Pseudoimbricata as a Unique Manifestation of Steroid Abuse: A Clinico-Mycological and Dermoscopic Study from a Tertiary Care Hospital

Background:

Tinea pseudoimbricata, characterized by concentric scaly rings simulating Tinea imbricata is caused by dermatophytes other than Trichophyton concentricum. It is reported to occur in patients with steroid abuse and in immunocompromised individuals.

Aim:

To study the clinico-mycological profile and dermoscopic features of T. pseudoimbricata in immunocompetent patients.

Methods:

We have evaluated 14 consecutive, clinically diagnosed patients of T. pseudoimbricata with positive 10% potassium hydroxide (KOH) examination and culture, seen over a period of 6 months. Dermoscopy was performed in all patients. The demographic, clinical, and mycological features of each patient were recorded on a predesigned proforma.

Results:

There were seven male and seven female patients with a mean age of 27.6 years and a mean disease duration of 3.8 months. All patients gave a history of application of potent or super-potent topical steroid with or without oral/injectable steroid for varying duration. Culture isolates were Trichophyton mentagrophytes complex and Trichophyton rubrum in 11 and 3 patients, respectively. Dermoscopic analysis showed features of steroid abuse in majority of the patients.

Limitation:

A small sample size was the limitation of our study.

Conclusion:

T. pseudoimbricata is a special subset of Tinea incognito caused by injudicious and inappropriate use of topical steroid. The typical appearance should alert the dermatologists regarding the possible abuse of steroids. Most common species isolated on culture was T. mentagrophytes complex.

Tinea Imbricata: An Overview

BACKGROUND

Tinea imbricata is a chronic superficial mycosis caused mainly by Trichophyton concentricum. The condition mainly affects individuals living in primitive and isolated environment in developing countries and is rarely seen in developed countries. Physicians in nonendemic areas might not be aware of this fungal infection.

OBJECTIVE

To familiarize physicians with the clinical manifestations, diagnosis, and treatment of tinea imbricata.

METHODS

A PubMed search was completed in Clinical Queries using the key terms "Tinea imbricata" and "Trichophyton concentricum". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, reviews, and case reports. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

The typical initial lesions of tinea imbricata consist of multiple, brownish red, scaly, pruritic papules. The papules then spread centrifugally to form annular and/or concentric rings that can extend to form serpinginous or polycyclic plaques with or without erythema. With time, multiple overlapping lesions develop, and the plaques become lamellar with abundant thick scales adhering to the interior of the lesion, giving rise to the appearance of overlapping roof tiles, lace, or fish scales. Lamellar detachment of the scales is common. The diagnosis is mainly clinical, based on the characteristic skin lesions. If necessary, the diagnosis can be confirmed by potassium hydroxide wet-mount examination of skin scrapings of the active border of the lesion which typically shows short septate hyphae, numerous chlamydoconidia, and no arthroconidia. Currently, oral terbinafine is the drug of choice for the treatment of tinea imbricata. Combined therapy of an oral antifungal agent with a topical antifungal and keratolytic agent may increase the cure rate.

CONCLUSION

In most cases, a spot diagnosis of tinea imbricata can be made based on the characteristic skin lesions consisting of scaly, concentric annular rings and overlapping plaques that are pruritic. Due to popularity of international travel, physicians involved in patient care should be aware of this fungal infection previously restricted to limited geographical areas.

Mycosis Fungoides with Tinea Pseudoimbricata Owing to Trichophyton Rubrum Infection

Background:

Dermatophytes can mimic or possibly trigger mycosis fungoides (MF).

Objectives:

To present the case of a 55-year-old male referred for MF refractory to therapy who instead had extensive tinea pseudoimbricata (concentric, annular lesions secondary to Trichophyton rubrum).

Methods:

Case report with biopsy and cultures.

Results:

Oral antifungal therapy dramatically improved his lesions, and only a few MF lesions persisted after treatment.

Conclusions:

Concurrent tinea may confound the treatment and diagnosis of MF.

Tinea Imbricata in an Italian Child and Review of the Literature

Tinea imbricata is a chronic superficial mycosis caused by Trichophyton concentricum. It is characterized by widespread, annular, concentric, squamous lesions. Tinea imbricata is endemic in three geographical areas: Southwest Pacific, Southeast Asia, and Central and South America. Tinea imbricata in travelers returning from endemic areas is exceptionally rare. We report a case of tinea imbricata in an Italian child who acquired the infection during a trip to Solomon Islands. Three cultures were positive for T. concentricum. The patient was successfully treated with griseofulvin and terbinafine cream.

Tinea Cruris and Tinea Corporis Masquerading as Tinea Indecisiva: Case Report and Review of the Literature

Background

Tinea indecisiva is characterized by concentric scaly rings simulating tinea imbricata but caused by dermatophytes other than Trichophyton concentricum.

Objective

Tinea indecisiva has been rarely reported. We report a unique case and review of the previously reported cases, pathogenesis, and management.

Methods

An adult Indian man developed extensive tinea cruris and tinea corporis with concentric rings of scaly lesions over the groin, buttocks, and thighs following the use of oral corticosteroids and antifungal-steroid cream for 3 months. Mycologic and immunologic studies were performed for diagnosis.

Results

Diagnosis of tinea indecisiva was confirmed on the appearance of “ring-within-a-ring”; lesions clinically and isolation of Trichophyton mentagrophytes var. interdigitale as the etiologic agent on mycologic testing. Intradermal testing with Trichophyton extract showed fluctuating hypersensitivity responses. Four-week treatment with daily oral terbinafine resulted in complete resolution.

Conclusion

Tinea indecisiva should be considered in a patient with tinea imbricata-like lesions with local immunosuppression caused by a non-concentricum dermatophyte.

Trichophyton Tonsurans Infection Manifesting as Multiple Concentric Annular Erythemas

We report a case of dermatophytosis in a Judo wrestler caused by Trichophyton tonsurans (T. tonsurans) with clinical features that mimicked the concentric rings of tinea imbricata. Tinea imbricata is a unique dermatophytosis caused by Trichophyton concentricum (T. concentricum), observed endemically in subtropical to torrid zones and characterized by impressive concentric rings. We found three similar cases of the dermatophytosis in the literature that were reported as tinea pseudoimbricata or tinea indecisiva. All of these cases were associated with systemic or local immunosuppression, perhaps simulating the mechanism of tinea imbricata, which is known to involve the lack of delayed type hypersensitivity to T. concentricum. These cases imply that iatrogenic immunosuppression may perhaps play an important role in the development of the unique clinical features mimicking tinea imbricata. Furthermore, three of the four cases, including the presented case, were caused by T. tonsurans. It may be necessary to consider T. tonsurans infection when multiple concentric erythemas are encountered.

Tinea capitis in the form of concentric rings in an HIV positive adult on antiretroviral treatment

Dermatophyte infection may present in the form of concentric rings caused by Trichophyton concentricum, known as Tinea Imbricata. In immunosuppressed patients, there are reports of lesions in the form of concentric rings caused by dermatophytes other than Trichophyton concentricum too, mostly by Trichophyton tonsurans, known as Tinea indesiciva or Tinea pseudoimbricata. We report a case of tinea capitis in a HIV-positive adult woman on antiretroviral therapy, who presented with concentric rings of papules and pustules with slight scaling on the scalp along with diffuse thinning of hair. Both Potassium hydroxide mount and culture showed the presence of Dermatophytes. Tinea capitis is considered rare in adults, but new cases are being reported in immunocompromised as well as in immunocompetent patients. The pertinent features of this case are: HIV-positive adult female on antiretroviral therapy, presenting with tinea capitis in the form of concentric rings; culture from the lesion grew Microsporum audouinii; responding to oral Terbinafine.

Tinea imbricata in the Americas

PURPOSE OF REVIEW

The aim is to provide an overview on tinea imbricata, or Tokelau, a superficial mycosis caused by Trichophyton concentricum, a strictly anthropophilic dermatophyte with a well-defined geographic distribution and predisposing factors that include genetic, racial and immunologic susceptibility patterns and a specific environment.

RECENT FINDINGS

This review covers the most interesting aspects of the infrequent disease tinea imbricata, including the historical background, the epidemiologic aspects, highlighting the genetic and racial patterns of susceptibility to the acquisition of the disease, and the immunologic aspects that help to explain its clinical behavior. We also present a clinical description of the disease, the differential diagnosis and how currently some other emerging diseases such as syphilis in immunocompromised patients can mimic tinea imbricata. The therapeutic options are still griseofulvin and nowadays terbinafine, but the access to the treatments in the endemic zones and the changes in habits of the affected population make control and prevention of the disease difficult.

SUMMARY

Tinea imbricata, or Tokelau, remains an infrequent superficial mycosis restricted to endemic zones in the South Pacific islands (Polynesia and Melanesia), South Asia and some specific areas of South America. Migration phenomena and global changes in the climate may modify the incidence and characteristics of the disease.

Tinea pseudoimbricata por M. gypseum associada à escabiose crostosa

Tinea pseudoimbricata é relacionada ao T. tonsurans e ao T. rubrum e a escabiose crostosa é uma dermatose altamente contagiosa, ocasionada pela proliferação excessiva do S. scabiei var. hominis. Descrevemos uma paciente com 21 anos, soronegativa para HIV, apresentando ambas doenças dermatológicas. O encontro simultâneo destas dermatoses em pacientes imunocompetentes é muito raro.

Concentric rings: an unusual presentation of tinea corporis caused by Microsporum gypseum

A case of tinea corporis with the unusual presentation of concentric erythematous rings on the abdomen is reported. The pathogen was identified as Microsporum gypseum. While a number of unusual lesions have been described in M. gypseum infections, we are unaware of any reports on concentric rings.

Tinea imbricata or Tokelau

Tinea imbricata (TI) or Tokelau is a superficial mycosis caused by Trichophyton concentricum, an anthropophilic dermatophyte. It is endemic in some islands of the South Pacific (Polynesia), South-East Asia, Central and South America, and Mexico, and is most often seen in individuals living in primitive and isolated conditions. The skin lesions are characteristically concentric and lamellar (imbricata: in Latin, tiled) plaques of scale. Predisposing conditions include humidity, inheritance, and immunologic factors. The diagnosis is usually made on clinical grounds, supported by skin scrapings and culture. Tokelau is a chronic and highly relapsing disease and, although no first-line treatment exists, best results are obtained with oral griseofulvin and terbinafine and a topical combination of keratolytic ointments, such as Whitfield's. TI is a disease model that allows the correlation of a series of environmental, genetic, immunologic, and therapeutic conditions.