PATIENT PRESENTATION
A previously healthy 64-year-old Caucasian male presented to the outpatient dermatology clinic with a progressive red, pruritic rash on his abdomen and back. Prior to presentation, the patient had used topical steroids intermittently, either prescribed by his primary care physician or on his own. He also mentioned that PUVA therapy sessions had been used in the past, although documentation of the duration and regimen used could not be obtained and there was no improvement.
On physical examination, there was an extensive erythematous eruption with a scaly sharply demarcated serpiginous border on his abdomen and neck.
WHAT IS YOUR DIAGNOSIS?
DIAGNOSIS: TINEA CORPORIS
Tinea corporis, also known as ringworm, is a common, superficial dermatophyte infection of the glabrous skin most commonly caused by Trichophyton, Microsporum and Epidermophyton.1 The fungus is transmitted through direct contact with an infected human or animal.2 The infection is most common among children, the immunocompromised, wrestlers and those who live in warm, humid climates.3,4
CLINICAL PRESENTATION
Tinea corporis classically appears as a pruritic annular erythematous patch or plaque with an advancing scaly border and central clearing most commonly seen on the trunk.1 However, many cases can present less typically, showing papules, pustules and the lack of a scaling border or central clearing.5 These atypical morphologies often represent a form of tinea called tinea incognito. Tinea incognito is tinea corporis when the morphology has been significantly altered due to the use of topical or systemic steroids.6 Besides these atypical forms, others still can present in a more extensive fulminant or widespread pattern covering a large body surface area.7,8,9,10 Trichophyton rubrum, the most common cause of dermatophyte infections in the United States, usually leads to a small, localized lesion; however, there have been several documented cases of extensive infection in both immunocompromised and immunocompetent individuals.9,11-14
Furthermore, in rare cases, Trichophyton tonsurans, a common cause of tinea capitis in the United States, has also been described as causing an extensive, severely inflammatory form of tinea corporis.7 In 2009, Metkar et al described another case of extensive tinea corporis in an immunocompetent neonate and found the common dermatophyte Microsporum gypseum to be the culprit.8 Metkar et al suggested that the possible etiology for the severe presentation may have been correlated to both the preceding use of topical steroids and the neonate’s prematurity.8 Another theory suggests that the extensive nature of some tinea corporis infections may be due to localized immunosuppression induced by the infecting dermatophyte.15
A definitive diagnosis of tinea corporis can be made by microscopically examining skin scrapings taken from the scaling border combined with 1 to 2 drops of potassium hydroxide (KOH). Using this method, the keratin dissolves, allowing the branching fungal hyphae to be visualized.12 In addition, many clinicians use a fungal culture as an adjunct to KOH examination due to its superior specificity. The various dermatophytes can be cultured on agars such as Sabouraud, Mycosel or Dermatophyte Test Medium (DTM) and monitored over the course of 2 weeks.16 Alternatively, the use of confocal microscopy has become available and allows clinicians to immediately visualize the dermatophyte hyphea directly on the patient’s skin after an application of KOH. This method, while limited in use due to the equipment expense, is argued to be a quick, noninvasive method that can decrease false-positive results.17 Another infrequently utilized method of diagnosing tinea corporis is calcofluor staining. The dye binds to the chitin in the fungal cell wall and fluoresces under fluorescent light.18 Lastly, the specific strain of dermatophyte can now be detected via polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). However, because PCR-RFLP is a complicated and expensive test, it is rarely used on a routine basis.16
While biopsies are not usually indicated for tinea corporis, the histologic findings consist of a neutrophilic infiltration of the stratum corneum with compact orthokeratosis and visualization of the fungal hyphae.19
DIFFERENTIAL DIAGNOSIS
When tinea coporis presents in its classic form, other annular lesions must be ruled out, such as pityriasis rosea, granuloma annulare, sarcoidosis, Hansen’s disease, urticaria, subacute cutaneous lupus erythematosis and erythema annulare centrifugum.20 However, due to our patient’s extensive non-classic presentation, disorders such as psoriasis, mycosis fungoides, pityriasis rubra pilaris and subacute cutaneous lupus erythematosus were considered. An outline of the clinical features and histologic characteristics of each diagnosis are outlined in Table 1 (above).
MANAGEMENT
For localized tinea corporis, a topical anti-fungal therapy applied to the affected area 1 to 2 times daily yields a high cure rate within 2 to 4 weeks.2,21 The two main families of topical treatments are the azoles and the allylamines.21 Clotrimazole, miconazole or ketoconazole are common examples of azoles, and terbinafine and naftifine are part of the allylamine family.21 While there are a number of medications used to treat superficial mycoses, McClellan argues in his review that topical terbinafine 1% used 1 to 2 times a day for 2 to 4 weeks should be the first-line treatment of localized tinea corporis due to its high cure rate.22,23 Overall, these topical medications both display a high safety profile due to their minimal systemic absorption, with the most common adverse drug reaction being transient skin irritation.21
However, for more extensive, chronic or recurrent tinea corporis in adults, oral systemic therapies, such as terbinafine (250 mg/day for 2 to 4 weeks), itraconazole (100 mg/day for 15 days), griseofulvin (500 mg/day for 2 to 6 weeks) or fluconazole (50 mg/day to 100 mg/day for 2 to 3 weeks or 150 mg/week to 300 mg/week for 2 to 6 weeks) are preferred over topical therapies.1,21,23,24 In a double-blind comparative study, Faergemann et al compared fluconazole 150 mg once weekly with griseofulvin 500 mg once daily for 4 to 6 weeks for the treatment of tinea corporis and found fluconazole to be more effective.25 When itraconazole and grisofulvin were compared for efficacy, they were found to be equally effective for the treatment of tinea corporis.26 However, relapse rates were significantly higher with griseofulvin than with itraconazole.26 In a study by Lospalluti et al, fluconazole (50 mg and 100 mg daily for 15 days) was compared to itraconazole (100 mg daily for 15 days), and found to be superior in the treatment of dermatomycoses.27 Grisofulvin and terbinafine have been found to have similar efficacies.28,29
As a result of the systemic distribution of these medications, physicians need to take the patient’s general health status into consideration when prescribing them. While the most common side effects are mild and include diarrhea, dyspepsia and headache, more severe side effects are possible.21,30 For example, oral terbinafine and itraconazole should not be prescribed for patients with liver disease due to the risk of hepatotoxicity.21,23 Itraconazole, a potent cytochrome P-450 inhibitor, should be given with caution in diabetics on oral hypoglycemic medications as it can cause disruption of the metabolism of diabetic drugs.31 Therefore, terbinafine should be used in individuals taking several medications, like diabetics or individuals with HIV, to minimize detrimental drug interactions.31 Lastly, the use of itraconazole is contraindicated in patients with current or previous congestive heart failure, due to the drug’s negative inotropic effects.32
In order to prevent further infection after treatment, patients should be educated to keep their skin clean and dry and to bathe daily.33
Our patient was treated with oral terbinafine 250 mg per day for 4 weeks, which resulted in the complete resolution of his extensive tinea corporis.
SUMMARY
Tinea corporis is a common and well-known dermatophyte inflection of the glabrous skin. While it is generally characterized by a localized annular erythematous patch with a scaling border, tinea corporis occasionally appears generalized, covering a large area on the skin. This extensive infection is best diagnosed and treated with a KOH scraping and an oral antifungal agent, respectively. Because extensive tinea corporis is not typical, it is often misdiagnosed and subsequently treated incorrectly. Therefore, in suspicious lesions, a fungal culture in addition to the KOH preparation may increase detection.
Ms. Miniter is with the Loyola Chicago Stritch School of Medicine.
Dr. Khachemoune, the Section Editor of Derm DX, is with the Department of Dermatology, State University of New York, Brooklyn, NY.
Disclosure: The authors have no conflicts of interest or financial disclosure to report.
PATIENT PRESENTATION
A previously healthy 64-year-old Caucasian male presented to the outpatient dermatology clinic with a progressive red, pruritic rash on his abdomen and back. Prior to presentation, the patient had used topical steroids intermittently, either prescribed by his primary care physician or on his own. He also mentioned that PUVA therapy sessions had been used in the past, although documentation of the duration and regimen used could not be obtained and there was no improvement.
On physical examination, there was an extensive erythematous eruption with a scaly sharply demarcated serpiginous border on his abdomen and neck.
WHAT IS YOUR DIAGNOSIS?
DIAGNOSIS: TINEA CORPORIS
Tinea corporis, also known as ringworm, is a common, superficial dermatophyte infection of the glabrous skin most commonly caused by Trichophyton, Microsporum and Epidermophyton.1 The fungus is transmitted through direct contact with an infected human or animal.2 The infection is most common among children, the immunocompromised, wrestlers and those who live in warm, humid climates.3,4
CLINICAL PRESENTATION
Tinea corporis classically appears as a pruritic annular erythematous patch or plaque with an advancing scaly border and central clearing most commonly seen on the trunk.1 However, many cases can present less typically, showing papules, pustules and the lack of a scaling border or central clearing.5 These atypical morphologies often represent a form of tinea called tinea incognito. Tinea incognito is tinea corporis when the morphology has been significantly altered due to the use of topical or systemic steroids.6 Besides these atypical forms, others still can present in a more extensive fulminant or widespread pattern covering a large body surface area.7,8,9,10 Trichophyton rubrum, the most common cause of dermatophyte infections in the United States, usually leads to a small, localized lesion; however, there have been several documented cases of extensive infection in both immunocompromised and immunocompetent individuals.9,11-14
Furthermore, in rare cases, Trichophyton tonsurans, a common cause of tinea capitis in the United States, has also been described as causing an extensive, severely inflammatory form of tinea corporis.7 In 2009, Metkar et al described another case of extensive tinea corporis in an immunocompetent neonate and found the common dermatophyte Microsporum gypseum to be the culprit.8 Metkar et al suggested that the possible etiology for the severe presentation may have been correlated to both the preceding use of topical steroids and the neonate’s prematurity.8 Another theory suggests that the extensive nature of some tinea corporis infections may be due to localized immunosuppression induced by the infecting dermatophyte.15
A definitive diagnosis of tinea corporis can be made by microscopically examining skin scrapings taken from the scaling border combined with 1 to 2 drops of potassium hydroxide (KOH). Using this method, the keratin dissolves, allowing the branching fungal hyphae to be visualized.12 In addition, many clinicians use a fungal culture as an adjunct to KOH examination due to its superior specificity. The various dermatophytes can be cultured on agars such as Sabouraud, Mycosel or Dermatophyte Test Medium (DTM) and monitored over the course of 2 weeks.16 Alternatively, the use of confocal microscopy has become available and allows clinicians to immediately visualize the dermatophyte hyphea directly on the patient’s skin after an application of KOH. This method, while limited in use due to the equipment expense, is argued to be a quick, noninvasive method that can decrease false-positive results.17 Another infrequently utilized method of diagnosing tinea corporis is calcofluor staining. The dye binds to the chitin in the fungal cell wall and fluoresces under fluorescent light.18 Lastly, the specific strain of dermatophyte can now be detected via polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). However, because PCR-RFLP is a complicated and expensive test, it is rarely used on a routine basis.16
While biopsies are not usually indicated for tinea corporis, the histologic findings consist of a neutrophilic infiltration of the stratum corneum with compact orthokeratosis and visualization of the fungal hyphae.19
DIFFERENTIAL DIAGNOSIS
When tinea coporis presents in its classic form, other annular lesions must be ruled out, such as pityriasis rosea, granuloma annulare, sarcoidosis, Hansen’s disease, urticaria, subacute cutaneous lupus erythematosis and erythema annulare centrifugum.20 However, due to our patient’s extensive non-classic presentation, disorders such as psoriasis, mycosis fungoides, pityriasis rubra pilaris and subacute cutaneous lupus erythematosus were considered. An outline of the clinical features and histologic characteristics of each diagnosis are outlined in Table 1 (above).
MANAGEMENT
For localized tinea corporis, a topical anti-fungal therapy applied to the affected area 1 to 2 times daily yields a high cure rate within 2 to 4 weeks.2,21 The two main families of topical treatments are the azoles and the allylamines.21 Clotrimazole, miconazole or ketoconazole are common examples of azoles, and terbinafine and naftifine are part of the allylamine family.21 While there are a number of medications used to treat superficial mycoses, McClellan argues in his review that topical terbinafine 1% used 1 to 2 times a day for 2 to 4 weeks should be the first-line treatment of localized tinea corporis due to its high cure rate.22,23 Overall, these topical medications both display a high safety profile due to their minimal systemic absorption, with the most common adverse drug reaction being transient skin irritation.21
However, for more extensive, chronic or recurrent tinea corporis in adults, oral systemic therapies, such as terbinafine (250 mg/day for 2 to 4 weeks), itraconazole (100 mg/day for 15 days), griseofulvin (500 mg/day for 2 to 6 weeks) or fluconazole (50 mg/day to 100 mg/day for 2 to 3 weeks or 150 mg/week to 300 mg/week for 2 to 6 weeks) are preferred over topical therapies.1,21,23,24 In a double-blind comparative study, Faergemann et al compared fluconazole 150 mg once weekly with griseofulvin 500 mg once daily for 4 to 6 weeks for the treatment of tinea corporis and found fluconazole to be more effective.25 When itraconazole and grisofulvin were compared for efficacy, they were found to be equally effective for the treatment of tinea corporis.26 However, relapse rates were significantly higher with griseofulvin than with itraconazole.26 In a study by Lospalluti et al, fluconazole (50 mg and 100 mg daily for 15 days) was compared to itraconazole (100 mg daily for 15 days), and found to be superior in the treatment of dermatomycoses.27 Grisofulvin and terbinafine have been found to have similar efficacies.28,29
As a result of the systemic distribution of these medications, physicians need to take the patient’s general health status into consideration when prescribing them. While the most common side effects are mild and include diarrhea, dyspepsia and headache, more severe side effects are possible.21,30 For example, oral terbinafine and itraconazole should not be prescribed for patients with liver disease due to the risk of hepatotoxicity.21,23 Itraconazole, a potent cytochrome P-450 inhibitor, should be given with caution in diabetics on oral hypoglycemic medications as it can cause disruption of the metabolism of diabetic drugs.31 Therefore, terbinafine should be used in individuals taking several medications, like diabetics or individuals with HIV, to minimize detrimental drug interactions.31 Lastly, the use of itraconazole is contraindicated in patients with current or previous congestive heart failure, due to the drug’s negative inotropic effects.32
In order to prevent further infection after treatment, patients should be educated to keep their skin clean and dry and to bathe daily.33
Our patient was treated with oral terbinafine 250 mg per day for 4 weeks, which resulted in the complete resolution of his extensive tinea corporis.
SUMMARY
Tinea corporis is a common and well-known dermatophyte inflection of the glabrous skin. While it is generally characterized by a localized annular erythematous patch with a scaling border, tinea corporis occasionally appears generalized, covering a large area on the skin. This extensive infection is best diagnosed and treated with a KOH scraping and an oral antifungal agent, respectively. Because extensive tinea corporis is not typical, it is often misdiagnosed and subsequently treated incorrectly. Therefore, in suspicious lesions, a fungal culture in addition to the KOH preparation may increase detection.
Ms. Miniter is with the Loyola Chicago Stritch School of Medicine.
Dr. Khachemoune, the Section Editor of Derm DX, is with the Department of Dermatology, State University of New York, Brooklyn, NY.
Disclosure: The authors have no conflicts of interest or financial disclosure to report.
PATIENT PRESENTATION
A previously healthy 64-year-old Caucasian male presented to the outpatient dermatology clinic with a progressive red, pruritic rash on his abdomen and back. Prior to presentation, the patient had used topical steroids intermittently, either prescribed by his primary care physician or on his own. He also mentioned that PUVA therapy sessions had been used in the past, although documentation of the duration and regimen used could not be obtained and there was no improvement.
On physical examination, there was an extensive erythematous eruption with a scaly sharply demarcated serpiginous border on his abdomen and neck.
WHAT IS YOUR DIAGNOSIS?
DIAGNOSIS: TINEA CORPORIS
Tinea corporis, also known as ringworm, is a common, superficial dermatophyte infection of the glabrous skin most commonly caused by Trichophyton, Microsporum and Epidermophyton.1 The fungus is transmitted through direct contact with an infected human or animal.2 The infection is most common among children, the immunocompromised, wrestlers and those who live in warm, humid climates.3,4
CLINICAL PRESENTATION
Tinea corporis classically appears as a pruritic annular erythematous patch or plaque with an advancing scaly border and central clearing most commonly seen on the trunk.1 However, many cases can present less typically, showing papules, pustules and the lack of a scaling border or central clearing.5 These atypical morphologies often represent a form of tinea called tinea incognito. Tinea incognito is tinea corporis when the morphology has been significantly altered due to the use of topical or systemic steroids.6 Besides these atypical forms, others still can present in a more extensive fulminant or widespread pattern covering a large body surface area.7,8,9,10 Trichophyton rubrum, the most common cause of dermatophyte infections in the United States, usually leads to a small, localized lesion; however, there have been several documented cases of extensive infection in both immunocompromised and immunocompetent individuals.9,11-14
Furthermore, in rare cases, Trichophyton tonsurans, a common cause of tinea capitis in the United States, has also been described as causing an extensive, severely inflammatory form of tinea corporis.7 In 2009, Metkar et al described another case of extensive tinea corporis in an immunocompetent neonate and found the common dermatophyte Microsporum gypseum to be the culprit.8 Metkar et al suggested that the possible etiology for the severe presentation may have been correlated to both the preceding use of topical steroids and the neonate’s prematurity.8 Another theory suggests that the extensive nature of some tinea corporis infections may be due to localized immunosuppression induced by the infecting dermatophyte.15
A definitive diagnosis of tinea corporis can be made by microscopically examining skin scrapings taken from the scaling border combined with 1 to 2 drops of potassium hydroxide (KOH). Using this method, the keratin dissolves, allowing the branching fungal hyphae to be visualized.12 In addition, many clinicians use a fungal culture as an adjunct to KOH examination due to its superior specificity. The various dermatophytes can be cultured on agars such as Sabouraud, Mycosel or Dermatophyte Test Medium (DTM) and monitored over the course of 2 weeks.16 Alternatively, the use of confocal microscopy has become available and allows clinicians to immediately visualize the dermatophyte hyphea directly on the patient’s skin after an application of KOH. This method, while limited in use due to the equipment expense, is argued to be a quick, noninvasive method that can decrease false-positive results.17 Another infrequently utilized method of diagnosing tinea corporis is calcofluor staining. The dye binds to the chitin in the fungal cell wall and fluoresces under fluorescent light.18 Lastly, the specific strain of dermatophyte can now be detected via polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). However, because PCR-RFLP is a complicated and expensive test, it is rarely used on a routine basis.16
While biopsies are not usually indicated for tinea corporis, the histologic findings consist of a neutrophilic infiltration of the stratum corneum with compact orthokeratosis and visualization of the fungal hyphae.19
DIFFERENTIAL DIAGNOSIS
When tinea coporis presents in its classic form, other annular lesions must be ruled out, such as pityriasis rosea, granuloma annulare, sarcoidosis, Hansen’s disease, urticaria, subacute cutaneous lupus erythematosis and erythema annulare centrifugum.20 However, due to our patient’s extensive non-classic presentation, disorders such as psoriasis, mycosis fungoides, pityriasis rubra pilaris and subacute cutaneous lupus erythematosus were considered. An outline of the clinical features and histologic characteristics of each diagnosis are outlined in Table 1 (above).
MANAGEMENT
For localized tinea corporis, a topical anti-fungal therapy applied to the affected area 1 to 2 times daily yields a high cure rate within 2 to 4 weeks.2,21 The two main families of topical treatments are the azoles and the allylamines.21 Clotrimazole, miconazole or ketoconazole are common examples of azoles, and terbinafine and naftifine are part of the allylamine family.21 While there are a number of medications used to treat superficial mycoses, McClellan argues in his review that topical terbinafine 1% used 1 to 2 times a day for 2 to 4 weeks should be the first-line treatment of localized tinea corporis due to its high cure rate.22,23 Overall, these topical medications both display a high safety profile due to their minimal systemic absorption, with the most common adverse drug reaction being transient skin irritation.21
However, for more extensive, chronic or recurrent tinea corporis in adults, oral systemic therapies, such as terbinafine (250 mg/day for 2 to 4 weeks), itraconazole (100 mg/day for 15 days), griseofulvin (500 mg/day for 2 to 6 weeks) or fluconazole (50 mg/day to 100 mg/day for 2 to 3 weeks or 150 mg/week to 300 mg/week for 2 to 6 weeks) are preferred over topical therapies.1,21,23,24 In a double-blind comparative study, Faergemann et al compared fluconazole 150 mg once weekly with griseofulvin 500 mg once daily for 4 to 6 weeks for the treatment of tinea corporis and found fluconazole to be more effective.25 When itraconazole and grisofulvin were compared for efficacy, they were found to be equally effective for the treatment of tinea corporis.26 However, relapse rates were significantly higher with griseofulvin than with itraconazole.26 In a study by Lospalluti et al, fluconazole (50 mg and 100 mg daily for 15 days) was compared to itraconazole (100 mg daily for 15 days), and found to be superior in the treatment of dermatomycoses.27 Grisofulvin and terbinafine have been found to have similar efficacies.28,29
As a result of the systemic distribution of these medications, physicians need to take the patient’s general health status into consideration when prescribing them. While the most common side effects are mild and include diarrhea, dyspepsia and headache, more severe side effects are possible.21,30 For example, oral terbinafine and itraconazole should not be prescribed for patients with liver disease due to the risk of hepatotoxicity.21,23 Itraconazole, a potent cytochrome P-450 inhibitor, should be given with caution in diabetics on oral hypoglycemic medications as it can cause disruption of the metabolism of diabetic drugs.31 Therefore, terbinafine should be used in individuals taking several medications, like diabetics or individuals with HIV, to minimize detrimental drug interactions.31 Lastly, the use of itraconazole is contraindicated in patients with current or previous congestive heart failure, due to the drug’s negative inotropic effects.32
In order to prevent further infection after treatment, patients should be educated to keep their skin clean and dry and to bathe daily.33
Our patient was treated with oral terbinafine 250 mg per day for 4 weeks, which resulted in the complete resolution of his extensive tinea corporis.
SUMMARY
Tinea corporis is a common and well-known dermatophyte inflection of the glabrous skin. While it is generally characterized by a localized annular erythematous patch with a scaling border, tinea corporis occasionally appears generalized, covering a large area on the skin. This extensive infection is best diagnosed and treated with a KOH scraping and an oral antifungal agent, respectively. Because extensive tinea corporis is not typical, it is often misdiagnosed and subsequently treated incorrectly. Therefore, in suspicious lesions, a fungal culture in addition to the KOH preparation may increase detection.
Ms. Miniter is with the Loyola Chicago Stritch School of Medicine.
Dr. Khachemoune, the Section Editor of Derm DX, is with the Department of Dermatology, State University of New York, Brooklyn, NY.
Disclosure: The authors have no conflicts of interest or financial disclosure to report.
A previously healthy 64-year-old Caucasian male presented to the outpatient dermatology clinic with a progressive red, pruritic rash on his abdomen and back. Prior to presentation, the patient had used topical steroids intermittently, either prescribed by his primary care physician or on his own. He also mentioned that PUVA therapy sessions had been used in the past, although documentation of the duration and regimen used could not be obtained and there was no improvement.
When tinea coporis presents in its classic form, other annular lesions must be ruled out, such as pityriasis rosea, granuloma annulare, sarcoidosis, Hansen’s disease, urticaria, subacute cutaneous lupus erythematosis and erythema annulare centrifugum.20 However, due to our patient’s extensive non-classic presentation, disorders such as psoriasis, mycosis fungoides, pityriasis rubra pilaris and subacute cutaneous lupus erythematosus were considered. An outline of the clinical features and histologic characteristics of each diagnosis are outlined in Table 1 (above).
