2. pustular, pruritic, extensive, and erythematous and may
mimic other skin diseases (Figure 1). Another clinical form
that can be confused with bacterial infections or prurigo is
trichophytic granuloma (Majocchi granuloma), which is
more commonly found on the legs of women. The fungus
can be inoculated by shaving the legs, and a contributing
factor is the use of corticosteroid creams. It is common to
find tinea pedis or onychomycosis in these cases.
The main differential diagnosis depends on the affected
area. In the face, the lesions may resemble neurodermatitis,
atopic dermatitis, rosacea, seborrheic dermatitis, lupus
erythematosus, or contact dermatitis. A recent study
reported that facial tinea incognito is frequently associated
with tinea pedis or onychomycosis in toenails, or both.8 In
the glabrous skin, the main differential diagnosis is
impetigo, purpura, lichen planus, psoriasis, erythema
migrans, drug eruptions, Sweet neutrophilic dermatosis,
contact dermatitis, discoid lupus, and tuberculoid leprosy.
A 15-year survey from Italy reported 200 cases of tinea
incognito. Of these, 9% had folliculitis, and dermatophytids
were uncommon. The source of infection was human-to-
human transmission. Among elderly patients, the misdiag-
nosis of dermatitis in the legs associated with venous failure,
was reported as a common cause of tinea incognito. Up to
40% in this series required systemic steroids for treatment of
skin and nondermatologic diseases. For this reason, the
authors underlined the importance of looking for nail
alterations, which can indicate onychomycosis, especially
in chronic forms of tinea incognito.
The clinical history is fundamental, because the clinical
appearance may be confusing. The definitive diagnosis must
be attained in a mycology laboratory or by an expert in
dermatomycology using direct examination with potassium
hydroxide, which demonstrates fungal structures. The
species must be also identified by culture. Occasionally,
the diagnosis is made by histopathology with hematoxylin
and eosin and periodic acid-Schiff stains.9,10
The main etiologic agents reported are Trichophyton
rubrum, T mentagrophytes, Epidermophyton floccosum,
Microsporum canis, M. gypseum, T violaceum, and T erinacei.
The first two are most commonly isolated when the face is
involved.11-33 Fluorinated corticosteroids were implicated in a
hospital dermatophytosis outbreak by E floccosum.34
These dermatophytoses usually require systemic treat-
ment with oral antifungal agents. Terbinafine, itraconazole,
and fluconazole have been shown to be superior to treatment
with griseofulvin, because they accumulate in the skin.
Therapy is generally indicated for 2 weeks, but the clinical
and mycologic responses will determine the definite duration
of treatment.35
In renal transplant patients, an uncommon presentation of
atypical tinea is dermatophytic granuloma. The lesions
evolve into chronic dermatophytosis that can clinically
resemble vasculitis.1
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139Tinea incognito