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Tinea Incognito

1-year-old male child had a past medical history of


mild atopic dermatitis in the first months of life,
successfully treated with intermittent topical steroid
therapy. Because of the reappearance of similar lesions in
the recent period, he was treated with antibiotics and oral
steroids by the general practitioner. Despite such therapy,
skin eruption worsened and expanded, and the patient
was then referred to our institution. Initial evaluation revealed a child in good general condition with sharply
demarcated, scaly erythematous patches on the upper trunk,
shoulders, and back (Figure 1); small pustules were also
evident. Remaining physical examination was negative.
The patient was apyretic. Laboratory tests showed no
alterations of white blood cells count, lymphocyte
subpopulations, erythrocyte sedimentation rate, and Creactive protein. Pustular psoriasis was suspected, and
topical corticosteroid therapy was undertaken. Despite
treatment, skin lesions progressed; a diagnostic skin
biopsy was then performed, revealing dermatophytic
fungal hyphae of Trichophyton mentagrophytes species.
Such findings suggested a primary diagnosis of tinea
incognito (TI), worsened by steroid therapy and
mimicking pustular psoriasis. Oral fluconazole (6 mg/kg/
d) and topical miconazole were then started. After
4 weeks, complete resolution of skin erythema and

pustules was observed on trunk and back (Figure 2;


available at www.jpeds.com).
TI is a dermatophytosis with atypical features because
of the absence of classic appearance of cutaneous tinea
(ringworm), usually caused by prolonged use of steroids.1
Mistreatment of tinea infection with topical corticosteroid
therapy may lead to a variety of skin presentations, including
lichenoid, rosacea-like, eczema-like, and psoriasis-like TI.2
The mechanism by which dermatophytes lead to pustular
lesion development in psoriasis-like TI is poorly understood.
It is known that dermatophytes are able to stimulate
production of interleukin 8 by human keratinocytes3 which,
in turn, induces neutrophil chemotaxis. Local neutrophil
activation may contribute to the development of pustules.4
Two published cases of TI characterized by pustular
inflammatory skin lesions are similar to our patient.5,6 The
presentation of pustular psoriasis-like TI may cause
potential confusion in the initial diagnosis, which includes
juvenile-type pustular psoriasis, subcorneal pustular
dermatosis, and impetigo (Figures 3 and 4; available at
www.jpeds.com). Skin swab and/or skin punch biopsy are
advisable to detect fungal hyphae in all psoriasis-like
clinical pictures unresponsive to steroid therapy; correct
diagnosis of TI allows, in turn, onset of appropriate
antimicotic treatment and skin lesions healing. n
Giulia Paloni, MD
Institute for Maternal and Child Health
IRCCS Burlo Garofolo
Trieste, Italy

Enrico Valerio, MD
Department of Pediatrics Salus Pueri
University of Padova
Padua, Italy

Irene Berti, MD
Institute for Maternal and Child Health
IRCCS Burlo Garofolo
Trieste, Italy

Mario Cutrone, MD
Figure 1. A, Clinical picture at admission: sharply demarcated, scaly erythematous patches on the upper trunk,
B, shoulders, and back.

Pediatric Dermatology Department


Ospedale dellAngelo
Venice, Italy

References available at www.jpeds.com

J Pediatr 2015;-:---.
0022-3476/$ - see front matter. Copyright 2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jpeds.2015.08.062

THE JOURNAL OF PEDIATRICS

www.jpeds.com

References
1. Romano C, Asta F, Massai L. Tinea incognito due to Microsporum gypseum in three children. Pediatr Dermatol 2000;17:41-4.
2. Gorani A, Schiera A, Oriani A. Case report. Rosacea-like tinea incognito.
Mycoses 2002;45:135-7.
3. Tani K, Adachi M, Nakamura Y, Kano R, Makimura K, Hasegawa A, et al.
The effect of dermatophytes on cytokine production by human
keratinocytes. Arch Dermatol Res 2007;299:381-7.

Vol. -, No. 4. Davies RR, Zaini F. Drugs affecting Trichophyton rubrum-induced


neutrophil chemotaxis in vitro. Clin Exp Dermatol 1988;13:228-31.
5. Kawakami Y, Oyama N, Sakai E, Nishiyama K, Suzutani T, Yamamoto T.
Childhood tinea incognito caused by Trichophyton mentagrophytes var.
interdigitale mimicking pustular psoriasis. Pediatr Dermatol 2011;28:
738-9.
6. Serarslan G. Pustular psoriasis-like tinea incognito due to Trichophyton
rubrum. Mycoses 2007;50:523-4.

Figure 2. A, Resolution of skin erythema and pustules on trunk and B, back after 4 weeks of antimicotic therapy.
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Paloni et al

- 2015

REDISCOVERING THE PHYSICAL EXAM

Figure 3. Juvenile-type pustular psoriasis.

Figure 4. Diffuse impetigo.


Tinea Incognito

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