Tinea Incognito Hidden under Apparently Treatment-resistant Pemphigus Foliaceus
Emmanuella Guenova, Wolfram Hoetzenecker, Martin Schaller, Martin Rcken and Gerhard Fierlbeck Department of Dermatology, Eberhard Karl University, Liebermeisterstrasse 25, D-72076 Tuebingen, Germany. E-mail: emmanuella.guenova@med.uni-tuebingen.de Accepted October 30, 2007.
Sir, cream once a day with cessation of all topical steroids.
Tinea incognito represents cutaneous fungal infection In order to decrease the need for systemic corticoste- whose clinical morphology has been modified by the roids and to maintain complete remission of the bullous use of systemic or topical steroids and other immuno autoimmune disease with minimum adverse effects, suppressive agents (13). The clinical manifestation can we began maintenance treatment with azathioprine by successfully mimic a large number of other dermatoses, concurrently tapering the prednisolone daily dosage thus leading to misdiagnosis, sometimes with severe under 7.5 mg. A follow-up examination 6 months later consequences. showed complete resolution of the fungal infection with no recurrence of pemphigus foliaceus. CASE REPORT DISCUSSION A 68-year-old woman who had had pemphigus fo- liaceus for 13 years, presented for initiation of more Tinea incognito, first described in 1968 by Ive and aggressive therapy due to gradual continuous clinical Marks (1, 2), is a dermatophytic infection in which worsening in the last 3 months despite potent topical topical or systemic steroids, administered as a result of steroid and long-standing systemic therapy with dermatological misdiagnosis or pre-existing patholo- prednisolone 50 mg/day for one year. At the time of gies, have modified its clinical appearance. Compared presentation desmoglein-1 antibodies were detectable with untreated tinea corporis, tinea incognito usually to a low grade using enzyme-linked immunosorbent displays a less raised margin, is less scaly, presents assay (ELISA). Clinical examination revealed a bizarre as more pustular, is more extensive and irritable, and pattern of non-pruritic, brownish circinate plaques, can thereby mimic other skin diseases (e.g. pemphigus covered with white-greyish greasy scales, which af- foliaceus), as described in this case report. In a large fected excessive areas of the body, with accentuation retrospective study Romano et al. (4) analysed causa- in the facial, lower torso and buttock areas (Fig. 1). tive agents, clinical aspects, and sources of infection There were no signs of tinea pedis or nail involvement. of 200 cases of tinea incognito. Tinea incognito was Histological and immunohistochemical examination found to be due mainly to different Trichophyton and revealed no evidence of active pemphigus foliaceus. Microsporum species and clinically presented as lupus However, periodic acid-Schiff (PAS) stain, fungal erythematosus-, eczema- and rosacea-like on the face culture and polymerase chain reaction (PCR) analysis and impetigo- and eczema-like on trunk and limbs (4). showed abundant Trichophyton rubrum, leading to the Furthermore, there have been reports of tinea incognito diagnosis tinea incognito. The patient commenced oral resembling purpura, seborrhoeic dermatitis, lichen treatment with itraconazole 100 mg/day for 4 weeks, planus, contact dermatitis, psoriasis and erythema in addition to local therapy with ciclopiroxolamine migrans (1, 46).
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.
doi: 10.2340/00015555-0398 Letters to the Editor 277
Beside these non-systemic infections usually caused REFERENCES
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