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Tinea Cruris and Tinea Corporis Masquerading as Tinea Indecisiva

Article  in  Journal of Cutaneous Medicine and Surgery · October 2014

DOI: 10.2310/7750.2014.14057 · Source: PubMed

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 CASE REPORT

Tinea Cruris and Tinea Corporis Masquerading as Tinea

Indecisiva: Case Report and Review of the Literature
Sidharth Sonthalia, Archana Singal, and Shukla Das

Background: Tinea indecisiva is characterized by concentric scaly rings simulating tinea imbricata but caused by dermatophytes
other than Trichophyton concentricum.
Objective: Tinea indecisiva has been rarely reported. We report a unique case and review of the previously reported cases,
pathogenesis, and management.
Methods: An adult Indian man developed extensive tinea cruris and tinea corporis with concentric rings of scaly lesions over the
groin, buttocks, and thighs following the use of oral corticosteroids and antifungal-steroid cream for 3 months. Mycologic and
immunologic studies were performed for diagnosis.
Results: Diagnosis of tinea indecisiva was confirmed on the appearance of ‘‘ring-within-a-ring’’ lesions clinically and isolation of
Trichophyton mentagrophytes var. interdigitale as the etiologic agent on mycologic testing. Intradermal testing with Trichophyton
extract showed fluctuating hypersensitivity responses. Four-week treatment with daily oral terbinafine resulted in complete
resolution.
Conclusion: Tinea indecisiva should be considered in a patient with tinea imbricata–like lesions with local immunosuppression
caused by a non-concentricum dermatophyte.

Contexte: Tinea indecisiva se caractérise par des anneaux squameux, concentriques, simulant tinea imbricata, mais l’affection
est causée par d’autres dermatophytes que Trichophyton concentricum.
Objectif: Rare est la description de Tinea indecisiva dans la documentation; nous faisons état ici d’un cas unique en son genre et
passons en revue les cas exposés antérieurement ainsi que leur pathogenèse et leur prise en charge.
Méthode: Un Indien adulte a consulté pour des zones étendues d’eczéma marginé et d’herpès circiné, accompagnés d’anneaux
concentriques de lésions squameuses touchant les aines, les fesses, et les cuisses, qui sont apparues à la suite de la prise de
corticostéroı̈des oraux et de l’application d’une crème associant un antifongique et un stéroı̈de pendant 3 mois. Des analyses
mycologiques et immunologiques ont été effectuées pour confirmer le diagnostic.
Résultats: Le diagnostic de tinea indecisiva a été confirmé par l’apparence clinique des lésions en forme d’« anneau dans un
anneau » et par la mise en évidence de l’agent causal, Trichophyton mentagrophytes, variante interdigitale, à l’examen mycologique.
Des épreuves intradermiques d’extraits de Trichophyton ont révélé des réactions d’hypersensibilité de type variable. La prise
quotidienne de terbinafine orale, durant 4 semaines, a permis la disparition complète des lésions.
Conclusions: Le diagnostic de tinea indecisiva devrait être envisagé chez les patients présentant des lésions ressemblant à celles
de tinea imbricata, accompagnées d’une immunodépression locale, mais causées par un dermatophyte de type non concentricum.

INEA IMBRICATA (TI) caused by Trichophyton

From SKINNOCENCE: The Skin Clinic & Research Centre, Haryana,
India, and Departments of Dermatology and STD and Microbiology,
University College of Medical Sciences and Guru Teg Bahadur Hospital,
University of Delhi, Delhi, India.
Address reprint requests to: Archana Singal, MD, MNAMS, B-14, Law
Apartments, Karkardooma, Delhi-110092, India; e-mail: archanasingal@
hotmail.com.
DOI 10.2310/7750.2014.14057
# 2014 Canadian Dermatology Association
T concentricum is a chronic dermatophytosis character-
ized clinically by the presence of multiple annular
concentric plaques that later become lamellar with
abundant thick scales, giving the appearance of tiles or
fish scales.1 TI occurs endemically in certain regions,
especially southern Asia. Although TI is caused exclusively
by T. concentricum, recently, a few cases have been
reported that presented with clinical features simulating
TI but caused by species other than T. concentricum. Such
peculiar cases have been labeled as ‘‘tinea indecisiva’’ and

Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 2 (March/April), 2015: pp 171–176 171
 Sonthalia et al

‘‘tinea pseudoimbricata’’ and tend to occur in patients

with some degree of immunosuppression.2,3 To the best of
our knowledge, only eight such cases have been published
to date, each occurring in a different clinical setting with
different lesional localization and caused by different
dermatophytic species.2–8 In this report, we describe
another unique case of tinea indecisiva with the following
special characteristics: involvement of the groin, penile
shaft, and buttocks (previous cases have primarily involved
the trunk, limbs, or scalp) and caused by Trichophyton
mentagrophytes var. interdigitale (never described before).
We further present a thorough review of previously
reported cases of this condition, with an emphasis on the
putative pathogenesis.
Figure 1. Erythematous, annular, concentric rings with scattered
pustules studded over the rings and grayish-white scales overlying the
Case Report central relatively clear zone, involving the groin and penile shaft.

An 18-year-old adult Indian male presented with a 3- dextrose agar (SDA) showed flat, white, downy growth
month history of persistent itchy rash over the groin, lower (Figure 4). Lactophenol cotton blue preparation revealed
abdomen, and thighs. He gave a history of intermittent fine septate hyaline branched hyphae with sparse macro-
application of an over-the-counter antifungal-steroid conidia and clustered microconidia along with well-
combination cream (containing miconazole nitrate 2% developed spiral hyphae and chlamydospores (Figure 5),
and clobetasol dipropionate 0.05%) twice daily, oral confirming T. mentagrophytes var. interdigitale as the
levocetirizine 5 mg every night, and oral betamethasone etiologic agent. Serologic testing for IgE immunoglobulin
(2 mg) once a day for the past 3 months, which resulted in against Trichophyton antigen was strongly positive. A final
temporary relief of itching and partial resolution of lesions diagnosis of tinea cruris and tinea corporis manifesting as
followed by progressive worsening. He had not sought a
tinea indecisiva (pseudoimbricata) was made. The patient
dermatologic consultation until then and had no history of
was treated with daily oral terbinafine 250 mg for 4 weeks
having taken any oral antifungal drugs. He had no history
and oral levocetirizine 5 mg for 2 weeks. Oral steroids were
of diabetes or any other significant medical disorder. A
tapered off over the next 6 weeks. The rash completely
history of high-risk behavior (eg, multiple sex partners and
subsided within a month. The patient came for his last
intravenous drug abuse) for acquisition of acquired
follow-up visit around 6 months after the initial episode,
immunodeficiency was not elicited. A family history of
and there was no recurrence until then.
diabetes or recurrent skin infections was absent.
His physical and systemic examinations were normal. A
cutaneous examination revealed the presence of wide-
spread erythematous, annular, concentric rings with
scattered pustules studded over the rings and grayish-
white scales overlying the central relatively clear zone,
involving the groin and penile shaft (Figure 1), buttocks
(Figure 2), thighs (Figure 3), and lower abdomen,
clinically mimicking TI. Examination of the palms and
soles, nails, and scalp revealed no abnormality. Hematologic
and biochemical investigations, including hemography,
fasting and postprandial plasma glucose, and renal and
hepatic function tests, were normal. Serology for human
immunodeficiency virus (HIV) was negative. Microscopic
examination of skin scrapings with 10% potassium hydrox-
ide (KOH) revealed thin hyaline hyphae suggestive of Figure 2. Similar lesions over the buttocks but with fewer pustules
dermatophytic infection. Fungal culture on Sabouraud and marked scaling.

172 Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 2 (March/April), 2015: pp 171–176
 Tinea Indecisiva
Figure 3. Similar lesions over the thighs.
Discussion
The characteristic clinical picture seen in our patient
simulated features of TI. Tinea imbricata or Tokelau is a
chronic dermatophytosis occurring endemically in certain
regions, such as southern Asia (China and India), the islands
of the South Pacific, and South and Central America.1 It
usually affects glabrous skin and is exclusively caused by
T. concentricum, a strictly anthropophilic dermatophyte. The
morphology is characteristic, with initial lesions presenting
as squamous annular, erythematous, concentric plaques that
Figure 4. Fungal culture on Sabouraud dextrose agar (SDA) showing
flat, white, downy growth.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 2 (March/April), 2015: pp 171–176 173
Figure 5. Lactophenol cotton blue preparation showing fine septate
hyaline branched hyphae with sparse macroconidia and clustered
microconidia along with well-developed spiral hyphae and chlamy-
dospores, suggestive of Trichophyton mentagrophytes var. interdigitale
(3400 original magnification).
later become lamellar with abundant thick scales adhering to
one side, giving the appearance of tiles, fish scales, or lace.1
The term imbricata is derived from the Latin imbrex and
refers to the similarity of the rash to overlapping roof tiles.
Cases presenting with clinical features simulating TI but
caused by species other than T. concentricum have been
labeled ‘‘tinea indecisiva’’ by Batta and colleagues and ‘‘tinea
pseudoimbricata’’ by Lim and Smith.2,3 Until now, only
eight such cases have been reported in the literature (Table
1), of which four were caused by Trichophyton tonsurans and
one each by Trichophyton rubrum, Microsporum audouinii,
Microsporum gypseum, and T. mentagrophytes var. menta-
grophytes.2–8 This case report is the first in which a different
variant of T. mentagrophytes, that is, T. mentagrophytes var.
interdigitale, was isolated as the etiologic agent. It is an
anthropophilic dermatophyte and a frequent cause of tinea
pedis, tinea manuum, and onychomycosis. With the
exception of the case reported by Narang and colleagues,
in which the scalp was involved,8 lesions were present over
the trunk and/or limbs in other cases.2–7 The current patient
presented with extensive tinea cruris and tinea corporis
primarily involving the groin, genitalia, and buttocks,
manifesting as tinea indecisiva. Although there were typical
 174
Table 1. Summary of Reported Cases of Tinea Pseudoimbricata (Indecisiva), Including the Present Case

Serial Authors and Year of Number of

No. publication Patients Age/Sex Distribution of Lesions Associated Comorbidity and/or Previous Therapy Species Isolated
1 Batta et al, 20022 2 1. NM 1. Arms, legs, and trunk Topical steroids and antifungals 1. Trichophyton mentagrophytes var.
2. NM 2. Legs mentagrophytes
2. Trichophyton tonsurans
2 Lim and Smith, 20033 1 14/F Trunk and limbs Renal transplant patient on oral T. tonsurans
immunosuppressives (tacrolimus and
azathioprine) and topical antifungals
3 Ouchi et al, 20054 1 28/M Neck and trunk Topical steroids for 3 mo T. tonsurans
4 Poonawalla et al, 20065 1 55/M Extensive involvement of Mycosis fungoides refractory to therapy Trichophyton rubrum
trunk and limbs
Sonthalia et al

5 Hoque and Holden, 20076 1 44/F Trunk and limbs Topical and oral steroids T. tonsurans
6 Poziomczyk et al, 20127 1 21/F Trunk and lower limbs Crusted scabies Microsporum gypseum
7 Narang et al, 20108 1 35/F Scalp HIV-positive patient on antiretroviral Microsporum audouinii
therapy and co-trimoxazole for the last
15 days
8 Sonthalia et al, 2010 1 20/M Groin, penile shaft, lower Topical steroid-antifungal combination T. mentagrophytes var. interdigitale
(present case) abdomen, and lower limbs therapy and oral steroids
HIV 5 human immunodeficiency virus; NM 5 not mentioned.

Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 2 (March/April), 2015: pp 171–176
 Tinea Indecisiva
annular, concentrically placed lesions forming a lamellar
network, as seen in TI, there was prominent postulation and
less scaling in the present case.
The immunologic response to dermatophytes depends
on two factors: the host’s cell-mediated immunity (CMI)
and the species of dermatophyte involved. The host’s CMI
mediated by T-cell reactivity forms the primary defense
against dermatophytes. Although most patients usually
develop specific antifungal antibodies to a particular
dermatophyte after infection, these antibodies are largely
nonprotective. Many characteristic observations from
patients infected with TI indicate that effective CMI does
not develop or is suppressed during the course of infection.
These include the endemicity of TI in specific geographic
locations, indicating inherent susceptibility of the resident
population, acquisition of infection in early childhood, a
lack of spontaneous remissions, and almost invariable
relapses occurring after an initial response to antifungal
therapy. This is in striking contrast to the infection of a man
with the cattle ringworm T. verrucosum, where lifelong
immunity appears to follow initial infection, indicating the
additional role of the species of dermatophyte involved.9
The formation of concentric rings with the clinical
‘‘ring-within-a-ring’’ appearance and the development of
sequential waves of scaling encountered in TI has been
postulated to arise due to immunologic factors. In a study
by Hay and colleagues conducted in Papua New Guinea,
78% of patients (with TI) investigated had antibody to
T. concentricum and demonstrated either immediate-type
hypersensitivity (52%) or negative responses (46%) to
intradermal trichophytin.9 The majority of patients failed
to develop delayed-type hypersensitivity on both in vivo
skin testing and in vitro assessment by leukocyte migration
inhibition. Based on these findings, the relevance of
negative delayed-type hypersensitivity to the T. concen-
tricum cytoplasmic antigen and T-lymphocyte hyporeac-
tivity of the host, leading to the persistence of the
infection, has been emphasized.9 However, in our case,
the patient did not want to have the trichophytin skin
testing. Moreover, the interpretation of trichophytin is an
investigation with very variable responses. The interpreta-
tion of the immediate- as well as the delayed-type
reactivity and its clinical significance have not been
confidently established.
The principle behind the occurrence of clinically
similar lesions in patients infected with non-concentricum
species of Trichophyton (ie, tinea pseudoimbricata) is at
present speculative. But there is a strong case favoring the
role of local or systemic immunosuppression in its
pathogenesis as well, similar to the phenomenon postulated
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 2 (March/April), 2015: pp 171–176 175
for TI. All of the previously reported cases of tinea
pseudoimbricata had some form of relative immunosup-
pression, the most common being prolonged use of
sequential or cyclical topical steroids with or without oral
steroids in four of the eight reported cases.2,4,6 Although
the patients reported by Batta and colleagues had used
topical antifungals in addition to topical steroids, no
patient had received oral antifungals.2 Batta and collea-
gues attributed the occurrence of tinea pseudoimbricata
to the combination of two factors: local immunosuppres-
sion due to prolonged topical steroid use and reinfection
due to early discontinuation of topical antifungals. In the
current case too, prolonged intermittent use of a
combination of superpotent topical steroid and antifungal
cream along with oral corticosteroids resulted in a state of
local as well as systemic immunosuppression. The
patients reported by Lim and Smith, Poonawalla and
colleagues, and Narang and colleagues were also immmu-
nosuppressed: a renal transplant–recipient child on oral
immunosuppressives (tacrolimus plus azathioprine), an
adult male with treatment-refractory mycosis fungoides,
and an adult HIV-positive female with a CD4 count of 99
cells/mL on antiretroviral therapy, respectively.3,5,8 Although
Poziomczyk and colleagues described their case as ‘‘immu-
nocompetent,’’ their patient had apparently not been more
thoroughly evaluated for evidence of immunosuppression
and suffered from concomitant crusted scabies.7 Crusted
scabies characterized by high mite burdens and extensive
cutaneous crusting is known to occur in individuals who
mount a vehement allergic response to mite infestation, but
their strong IgE-driven T-helper 2 response and other
humoral responses are totally nonprotective, resulting in
uncontrolled growth of the parasite.10 Thus, irrespective of
the lesional distribution and species involved in cases of
tinea indecisiva, the immunopathogenesis of this peculiar
condition is best explained as a simulation of T-cell
hyporeactivity and the lack of delayed-type hypersensitivity
to the dermatophyte, as encountered in TI.
The differentiation between tinea corporis/cruris
(unaltered by any local or systemic immunomodulators),
tinea indecisiva, and tinea incognito is important. Tinea
corporis and tinea cruris in an immunocompetent
individual typically present with annular lesions with an
erythematous scaly border and central clearing on most
skin surfaces, except the scalp, volar areas, and nails.
Dermatophytic infections are fairly common, especially in
tropical countries, with a higher incidence during the hot,
humid season. Treatment with topical imidazoles or
allylamines for 2 to 4 weeks is often sufficient. Patients
with diabetes are likely to present with extensive lesions.
 Sonthalia et al
For extensive tinea corporis/cruris, oral antifungals such as
terbinafine, fluconazole, or itraconazole have to be given
for up to 4 weeks. The overall prognosis is excellent in
unaltered dermatophytic infections. Cases of tinea incog-
nito (also called tinea atypica), best defined as dermato-
phytic infections with altered clinical presentation following
inappropriate use of systemic or topical corticosteroids or
topical calcineurin inhibitors (CNIs), are on the rise. Easy
accessibility of over-the-counter high-potency topical
steroids in some countries and their inappropriate use by
physicians without fungal testing have contributed to this
trend. Immunomodulation by corticosteroids or CNIs not
only leads to pathomorphosis and misdiagnosis due to
simulation of other dermatoses; the course of infection is
also further complicated by delayed recovery. Although
tinea incognito commonly displays subdued scaling and loss
of annular character of lesions, it may simulate a myriad of
other clinical conditions, such as impetigo, rosacea,
dermatitis, lupus erythematosus, polymorphous light erup-
tion, psoriasis, and widespread folliculitis (Majocchi
granuloma–like presentation), among others.11 Tinea
indecisiva, on the other hand, presents with sequentially
appearing concentric rings and scaling, giving rise to the
characteristic ring-within-a-ring appearance. A high index
of clinical suspicion and direct microscopic examination of
skin scrapings with KOH and fungal culture on SDA are
vital for the diagnosis of both tinea incognito and tinea
indecisiva. Treatment of tinea incognito consists of
combined use of oral and topical antifungals for at least 4
weeks. The prognosis is good if treatment is complied with
and further abuse of immunosuppressives is halted. Owing
to the paucity of published literature on tinea indecisiva,
there is no current consensus on its standard treatment
protocol. However, 4 weeks of oral terbinafine seems to be
the most effective and sufficient therapy, with an excellent
prognosis.
Conclusion
Any patient presenting with such a ring-within-a-ring
morphology of pustular and/or scaly lesions, that is, TI-
like lesions, should always be investigated with fungal
176 Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 2 (March/April), 2015: pp 171–176
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cultures for speciation. With indiscriminate use of steroid
creams by patients, at least in the Indian context, more
such cases may surface from time to time. Their early
identification and treatment are all that is required to take
care of this otherwise simple dermatosis.
Acknowledgments
Financial disclosure of authors and reviewers: None
reported.
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