Tinea incognito in children: 54 cases

Tinea Incognito

Tinea incognito (TI), or incognita, are superficial fungal dermatophyte infections that are changed in shape, most frequently because of topical, systemic steroids use and other immunosuppressants. There are different clinical presentations depending on host factors and the species of dermatophyte causing the disorder. Diagnosis can be challenging and might need combined methods. Once diagnosed the treatment is the usual antifungals, either topical or systemic or combined depending on the site, extent, and host factors.

Atypical and Unpredictable Superficial Mycosis Presentations: A Narrative Review

While typically exhibiting characteristic features, fungal infections can sometimes present in an unusual context, having improbable localization (eyelid, face, or joint); mimicking other skin diseases such as eczema, psoriasis, or mycosis fungoides; and appearing with unexpected color, shape, or distribution. The emergence of such a challenging clinical picture is attributed to the complex interplay of host characteristics (hygiene and aging population), environment (climate change), advances in medical procedures, and agent factors (fungal resistance and species emergence). We aim to provide a better understanding of unusual epidemiological contexts and atypical manifestations of fungal superficial diseases, knowing that there is no pre-established clinical guide for these conditions. Thus, a literature examination was performed to provide a comprehensive analysis on rare and atypical superficial mycosis as well as an update on certain fungal clinical manifestations and their significance. The research and standard data extraction were performed using PubMed, Medline, Scopus, and EMBASE databases, and a total of 222 articles were identified. This review covers published research findings for the past six months.

Facial pruritic skin rash in a Nigerian boy with atopic dermatitis

We present the case of a 4-year-old boy with annular, pruritic macules on the face who did not respond to the application of topical immunosuppressive therapy for atopic dermatitis. In this case report, we emphasize how pruritic annular macules that are not responsive to immunosuppressants should always be suspected of being tinea incognita.

Case Report and Literature Review of Impetigo-Like Tinea Faciei

Impetigo, commonly caused by bacteria, is characterized by lesions of pustules, bullae or golden yellow crusts; it is seldom caused by fungi. Here, we report one case of a 17-year-old female patient with a 1-month history of erythematous pustules on her left cheek. She was clinically diagnosed with “impetigo”, but did not respond to 1 week of treatment with topical mupirocin cream (antibacterial agent). We then saw that a fungal colony grew on the culture, which was identified as T. mentagrophytes based on the morphological and molecular characteristics. The patient was then diagnosed with tinea faciei and was topically treated with 0.2% ketoconazole cream twice per day for 7 days. Through a literature review, we found another 18 cases of impetigo-like tinea faciei with similar clinical manifestations and pathogenic characteristics. Among these, the most common causative agent was T. mentagrophytes complex, which frequently occurs in children and adolescents and exhibits no gender preferences. Systemic and topical antifungals such as terbinafine or itraconazole are effective for impetigo-like tinea faciei caused by T. mentagrophytes complex. However, prolonged course of impetigo in more than 50% cases highlights the importance of mycological examination when dealing with apparent antibiotic-resistant impetigo cases in clinical settings.

Tinea corporis: an updated review

Background

Tinea corporis is a common fungal infection that mimics many other annular lesions. Physicians must familiarize themselves with this condition and its treatment.

Objective

This article aimed to provide a narrative updated review on the evaluation, diagnosis, and treatment of tinea corporis.

Methods

A PubMed search was performed with Clinical Queries using the key term ‘tinea corporis.’ The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies, and reviews. The search was restricted to the English language. The information retrieved from the mentioned search was used in the compilation of the present article.

Results

Tinea corporis typically presents as a well-demarcated, sharply circumscribed, oval or circular, mildly erythematous, scaly patch or plaque with a raised leading edge. Mild pruritus is common. The diagnosis is often clinical but can be difficult with prior use of medications, such as calcineurin inhibitors or corticosteroids. Dermoscopy is a useful and non-invasive diagnostic tool. If necessary, the diagnosis can be confirmed by microscopic examination of potassium hydroxide wet-mount preparations of skin scrapings from the active border of the lesion. Fungal culture is the gold standard to diagnose dermatophytosis especially if the diagnosis is in doubt and results of other tests are inconclusive or the infection is widespread, severe, or resistant to treatment. The standard treatment of tinea corporis is with topical antifungals. Systemic antifungal treatment is indicated if the lesion is multiple, extensive, deep, recurrent, chronic, or unresponsive to topical antifungal treatment, or if the patient is immunodeficient.

Conclusion

The diagnosis of tinea corporis is usually clinical and should pose no problem to the physician provided the lesion is typical. However, many clinical variants of tinea corporis exist, rendering the diagnosis difficult especially with prior use of medications, such as calcineurin inhibitors or corticosteroids. As such, physicians must be familiar with this condition so that an accurate diagnosis can be made and appropriate treatment initiated.

Diagnosis and Management of Cutaneous Tinea Infections

GENERAL PURPOSE

To provide information about the epidemiology, clinical features, and management of cutaneous tinea infections.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After completing this continuing education activity, you should be better able to:1. Summarize the epidemiology related to cutaneous tinea infections.2. Describe the clinical features of cutaneous tinea infections.3. Identify features related to the diagnosis and management of cutaneous tinea infections.

ABSTRACT

Dermatophyte or tinea infection refers to a group of superficial fungal infections of the hair, skin, and nails. Tinea infections are most commonly caused by fungi of the genus Trichophyton, Microsporum, or Epidermophyton. Cutaneous manifestations of tinea infections are seen worldwide and classified based on the affected body site. The diagnosis of these conditions is complicated by morphologic variations in presentation and overlap with other common infectious and noninfectious entities. As a result, diagnosis and appropriate management of these conditions are essential to avoid patient morbidity. This case-based review summarizes the epidemiology, relevant clinical features, microbiology, and management considerations for commonly encountered tinea infections.

Tinea Incognito — Incorrect Initial Diagnosis. Case Series Presentation with Emphasis on the Mycological Examination

Tinea incognito defines a modified clinical aspect of a tinea following an immunosuppressive therapy, mostly with potent topical steroids. Its diagnosis may be delayed by its delusive appearance, especially in small children and young adults. We present a series of 2 cases of Tinea incognito developed at different ages and incorrectly diagnosed initially, where the clinical diagnosis was followed by mycological examination and positive therapeutic test with antifungal medication, helping to avoid unnecessary laboratory investigations and to prevent further complications.

Human Infections with Microsporum gypseum Complex (Nannizzia gypsea) in Slovenia

Microsporum gypseum complex is a group of geophillic dermatophytes with a worldwide distribution and is a rare cause of dermatomycoses in humans. The infection most commonly presents as tinea corporis, with some geographical and occupational variations. We studied M. gypseum complex infections in patients examined in the Mycological Laboratory of the Department of Dermatovenereology, University Medical Centre Ljubljana, during the period 2000-2015. Diagnosis was confirmed by mycological examination. Skin scales were examined by direct microscopy and cultivated on Sabouraud glucose agar. A total of 226 patients were identified, representing 1.5% of all dermatophyte infections during the study period. Tinea corporis was diagnosed in majority of patients, followed by tinea manus, tinea faciei, tinea inguinalis and tinea pedis. Tinea capitis was observed in three and onychomycosis in two patients only. Infection was disseminated on different parts of the body in nine patients. In 39% of patients, infection was diagnosed in children younger than 9 years. Face and scalp infection was more often observed in children. The incidence was the highest during July and October. Contacts with soil and domestic animals were often reported. Data on the prevalence and clinical characteristics of M. gypseum complex infection in other countries are reviewed.

Tinea Incognita following the Use of an Antipsoriatic Gel

Tinea incognita is a dermatophyte infection of the skin whose clinical presentation has been modified by the misuse of steroids or, as has been described recently, calcineurin inhibitors. We report a case of pustular psoriasis treated with an antipsoriatic cream, composed of topical steroids and a vitamin D3 derivative, which gave rise to a tinea incognita. Our case underlines that clinical features of fungal infection can be modified by the increasing use of self-prescribed topical therapies, usually applied to treat incorrectly 'self-diagnosed' diseases. Moreover, we suggest that a mycological examination should be performed in every atypical presentation of skin lesion, and to rule out tinea pedis, in any disease of the feet that requires topical application of steroids.

Tinea incognito in Korea and its risk factors: nine-year multicenter survey

Tinea incognito (TI) is a dermatophytic infection which has lost its typical clinical appearance because of improper use of steroids or calcineurin inhibitors. The incidence of TI is increasing nowadays. We conducted retrospective review on 283 patients with TI from 25 dermatology training hospitals in Korea from 2002-2010 to investigate the demographical, clinical, and mycological characteristics of TI, and to determine the associated risk factors. More than half (59.3%) patients were previously treated by non-dermatologists or self-treated. The mean duration of TI was 15.0 ± 25.3 months. The most common clinical manifestations were eczema-like lesion, psoriasis-like, and lupus erythematosus-like lesion. The trunk and face were frequently involved, and 91 patients (32.2%) also had coexisting fungal infections. Among 67 isolated strains, Trichophyton rubrum was the most frequently detected (73.1%). This is the largest study of TI reported to date and the first investigational report concerning TI in Korea. We suggest that doctors should consider TI when a patient has intractable eczema-like lesions accompanied by tinea pedis/unguium. Furthermore, there should be a policy change, which would make over-the-counter high-potency topical steroids less accessible in some countries, including Korea.