Tinea inkognito

Tinea incognito is a condition that occurs after a fungal infection of the skin has been incorrectly
treated with a steroid cream. These creams, while appropriate for treating certain conditions such
as eczema or psoriasis, can worsen fungal infections. Patients could experience symptoms such
as itchiness, redness, or an increase in the size of the initial lesion. Treatment of tinea incognito
varies according to the symptoms experienced, but could include a topical antifungal ointment or
an antifungal pill taken by mouth.
A number of different fungi, including those in the classes Epidermophyton, Trichophyton, and
Microsporum, can infect the superficial regions of the body. As a collective, they are known as
the dermatophytic infections, and can cause a variety of conditions including those commonly
known as athlete's foot, jock itch, cradle cap, and ringworm. Sometimes these fungal infections
are misdiagnosed, and instead of being treated with an antifungal cream or spray, they are
treated with skin creams that include anti-inflammatory substances referred to as steroids.
Many times the incorrect treatment of the dermatophytic infections with steroid creams does not
cause any symptoms. In some cases, however, it causes the condition known as tinea incognito.
Patients report symptoms such as pain or itchiness at the location of the fungal infection. The
skin itself can become redder, can develop a purple color, or could become raised above the
natural contour. Occasionally, the condition can infect hair follicles, causing a painful condition
known asfolliculitis.
Ad
Making the diagnosis of tinea incognito can be difficult. Patients typically were initially
misdiagnosed with having conditions such as psoriasis or eczema, instead of receiving the
correct diagnosis of having a superficial fungal infection. After a worsening of their symptoms due
to application of a steroid cream occurs, alert doctors could recognize that an initial misdiagnosis
might have occurred. Confirming the diagnosis of having a dermatophytic infection can be done
by scraping off a sample of the affected skin and examining it under the microscope.
The treatment of tinea incognito depends on the symptoms experienced. Some patients with
minor symptoms respond well to antifungal creams applied to the skin. More complicated cases,
however, could require treatment with antifungal medications that are taken in pill form. This is
especially true if the condition has progressed to folliculitis. The medications taken by mouth
typically have more side effects and require more follow-up visits as compared to the antifungal
medications applied directly to the skin.

ir,
Tinea incognito represents cutaneous fungal infection whose clinical morphology has been modified
by the use of systemic or topical steroids and other immunosuppressive agents (13). The clinical
manifestation can successfully mimic a large number of other dermatoses, thus leading to
misdiagnosis, sometimes with severe consequences.

CASE REPORT
A 68-year-old woman who had had pemphigus foliaceus for 13 years, presented for initiation of
more aggressive therapy due to gradual continuous clinical worsening in the last 3 months despite
potent topical steroid and long-standing systemic therapy with prednisolone 50 mg/day for one
year. At the time of presentation desmoglein-1 antibodies were detectable to a low grade using

enzyme-linked immunosorbent assay (ELISA). Clinical examination revealed a bizarre pattern of

non-pruritic, brownish circinate plaques, covered with white-greyish greasy scales, which affected
excessive areas of the body, with accentuation in the facial, lower torso and buttock areas (Fig. 1).
There were no signs of tinea pedis or nail involvement. Histological and immunohistochemical
examination revealed no evidence of active pemphigus foliaceus. However, periodic acid-Schiff
(PAS) stain, fungal culture and polymerase chain reaction (PCR) analysis showed
abundant Trichophyton rubrum, leading to the diagnosis tinea incognito. The patient commenced
oral treatment with itraconazole 100 mg/day for 4 weeks, in addition to local therapy with
ciclopiroxolamine cream once a day with cessation of all topical steroids. In order to decrease the
need for systemic corticosteroids and to maintain complete remission of the bullous autoimmune
disease with minimum adverse effects, we began maintenance treatment with azathioprine by
concurrently tapering the prednisolone daily dosage under 7.5 mg. A follow-up examination 6
months later showed complete resolution of the fungal infection with no recurrence of pemphigus
foliaceus.

Fig. 1. Bizarre pattern of non-pruritic, brownish circinate plaques, covered with white-greyish greasy
scales affecting excessive areas of the body, with accentuation in the facial, lower torso and buttock
areas.

DISCUSSION
Tinea incognito, first described in 1968 by Ive and Marks (1, 2), is a dermatophytic infection in
which topical or systemic steroids, administered as a result of dermatological misdiagnosis or preexisting pathologies, have modified its clinical appearance. Compared with untreated tinea
corporis, tinea incognito usually displays a less raised margin, is less scaly, presents as more
pustular, is more extensive and irritable, and can thereby mimic other skin diseases (e.g.
pemphigus foliaceus), as described in this case report. In a large retrospective study Romano et al.
(4) analysed causative agents, clinical aspects, and sources of infection of 200 cases of tinea
incognito. Tinea incognito was found to be due mainly to
different Trichophyton and Microsporum species and clinically presented as lupus erythematosus-,
eczema- and rosacea-like on the face and impetigo- and eczema-like on trunk and limbs (4).
Furthermore, there have been reports of tinea incognito resembling purpura, seborrhoeic
dermatitis, lichen planus, contact dermatitis, psoriasis and erythema migrans (1, 46).
Beside these non-systemic infections usually caused by topical application of steroids, systemic
immunosuppression can result in the formation of deep subcutaneous abscesses and secondary
granuloma formation, known as Majocchis granuloma, which, for example, can mimic Kaposis
sarcoma (79). Taken together, the great diversity in the clinical picture of tinea incognito can
delay proper diagnosis and treatment, as described in this case, where its occurrence was first
misinterpreted as a relapse of immunosuppressive-treated pemphigus foliaceus. Once recognized,
tinea incognito usually requires systemic treatment with oral antifungal agents. Terbinafine,
itraconazole and fluconazole have been shown to be superior to griseofulvin as they accumulate in
the skin (10). In our case combined therapy with itraconazole and ciclopiroxolamine for 4 weeks
was successful in clearing the fungal infection.
Recent reports and the case presented here demonstrate the need carefully to monitor
immunosuppressed patients and to perform frequent skin examinations, as these patients are
susceptible to additional clinically atypical superinfections, such as tinea incognito.

REFERENCES
1. Ive FA, Marks R. Tinea incognito. BMJ 1968; 3: 149152.
2. Marks R. Tinea incognito. Int J Dermatol 1978; 17: 301302.
3. Burkhart CG. Tinea incognito. Arch Dermatol 1981; 117: 606607.
4. Romano C, Maritati E, Gianni C. Tinea incognito in Italy: a 15-year survey. Mycoses 2006; 49:
383387.
5. Agostini G, Knopfel B, Difonzo EM. [Universal dermatophytosis (tinea incognito) caused by
Trichophyton rubrum]. Hautarzt 1995; 46: 190193 (in German).
6. Feder HM, Jr. Tinea incognito misdiagnosed as erythema migrans. N Engl J Med 2000; 343: 69.
7. Novick NL, Tapia L, Bottone EJ. Invasive trichophyton rubrum infection in an
immunocompromised host. Case report and review of the literature. Am J Med 1987; 82: 321
325.
8. Faergemann J, Gisslen H, Dahlberg E, Westin J, Roupe G. Trichophyton rubrum abscesses in
immunocompromised patients. A case report. Acta Derm Venereol 1989; 69: 244247.
9. Grossman ME, Pappert AS, Garzon MC, Silvers DN. Invasive Trichophyton rubrum infection in
the immunocompromised host: report of three cases. J Am Acad Dermatol 1995; 33: 315318.
10. Hay R, Moore M. Mycology. In: Champion R, Burton J, Burns D, Breathnach S, editors.
Textbook of dermatology, 6th edn. Oxford: Blackwell Science; 1998: p. 12771377.