Case report

Atypical manifestations of tinea corporis

Mirjana Ziemer, Florian Seyfarth, Peter Elsner and Uta-Christina Hipler

Department of Dermatology and Allergology, Friedrich Schiller University, Jena, Germany

Summary Tinea corporis classically presents as an erythematous annular plaque with a scaly,
centrifugally advancing border. However, sometimes vesicles and pustules are
observed. Occasionally, even frank bullae appear secondary to severe inflammation.
Diagnostic difficulties arise when atypical manifestations mimic other inflammatory
skin diseases, including atopic or seborrheic dermatitis, subacute cutaneous lupus
erythematosus, or vesicular diseases. We report five cases of atypical tinea corporis,
where the initial clinical diagnosis was different from dermatophytosis. The
differential diagnoses and the diagnostic difficulties related to atypical
manifestations of fungal infections are discussed. Moreover, our cases emphasise
the importance of conventional histological examination, which enables a fast,
correct diagnosis.

Key words: tinea corporis, atypical, vesicular, fulminant, inconspicuous.

Abbreviations: H&E, haematoxylin and esosin; M, Microsporum; PAS, periodic acid–Shiff; T, Trichophyton.

Case reports morphology, the initial differential diagnosis included

subacute cutaneous lupus erythematosus, pustular
Patient 1 psoriasis and subcorneal pustular dermatosis (Sned-
don–Wilkinson-disease).
An 83-year-old man in good general condition presen-
Histological examination showed acanthosis with
ted with a 2-day history of rapidly developing, slightly
overlying parakeratosis and serum crust with collec-
pruritic skin lesions on his trunk. Past medical history
tions of neutrophils. There was a perivascular and
was notable for prostate cancer, diagnosed in 1991. At
interstitial mixed inflammatory infiltrate of lympho-
present, the patient was without signs of metastasis or
cytes, neutrophils and eosinophils. Spores and hyphae
cancer recurrence. He denied any animal exposure.
were identified on haematoxylin and eosin (H&E)
Laboratory data were normal, in particular HIV-1 and
staining and were confirmed in the periodic acid–Schiff
-2 serology was negative.
(PAS) stain. Fungal cultures of skin scrapings were
Examination revealed a symmetric distribution of
positive for Trichophyton (T.) interdigitale.
extensive erythematous papules and small pustules on
Treatment with oral terbinafine 250 mg day)1 and
the chest with accentuation around the breasts, more-
topical clotrimazole cream twice daily resulted in rapid
over, on the upper abdomen (Fig. 1). Some papules
improvement within 1 week. Systemic therapy was
coalesced, forming larger plaques in a serpiginous and
continued for 4 weeks, until resolution of skin lesions
partially annular configuration. On the basis of clinical
was observed. There was no recurrence of infection on
the 6-week follow-up.
Correspondence: Dr. med. Mirjana Ziemer, Department of Dermatology and
Allergology, Friedrich Schiller University, Erfurter Strasse 35, 07743 Jena,
Germany. Patient 2
Tel.: +49 3641 937441. Fax: +49 3641 937423.
E-mail: mirjana.ziemer@derma.uni-jena.de A 65-year-old male patient presented with acutely
All authors have no conflicts of interests.
developing polycyclic erythemato-squamous lesions
with a vesicular border on the lower legs (Fig. 2). The
Accepted for publication 25 April 2007 diameter was in part up to 10 cm. Lesions caused severe

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M. Ziemer et al.
Figure 1 Extensive erythematous, partially annular arranged
papules on the chest and upper abdomen.
Figure 2 Polycyclic, erythemato-squamous lesions with a vesi-
cular border on the lower legs.
pruritus. Clinically, a photoallergic ⁄ phototoxic derma-
titis was suspected.
Histology showed an acanthotic epidermis with
spongiosis and hyperkeratosis. A severe subepidermal
32
Figure 3 Periodic acid–Shiff (PAS) stain displayed hyphae in the
stratum corneum (·200).
oedema displaced the inflammatory infiltrate into the
depth of the dermis. This predominantly perivascular
infiltrate was characterised by lymphocytes, plasma
cells and eosinophilic granulocytes. PAS stain displayed
hyphae in the stratum corneum (Fig. 3).
Mycological native preparation with fluorescence
stain (Blancophor) was positive; however, cultures on
Dermasel agar did not show any growth. Therefore,
identification of the genus of fungus respectively the
way of infection failed.
Terbinafine 250 mg day)1 was administered for
4 weeks completed by an external therapy with cic-
lopiroxolamine cream for 8 weeks. This led to complete
healing of the lesions.
Patient 3
A 26-year-old woman presented with disseminated, but
solitary-standing skin lesions distributed over her
extremities and characterised by drop shaped scaly
papules and tiny tense vesicles (Fig. 4a). After a few
days, the lesion enlarged to small scaly plaques, with an
annular configuration (Fig. 4b). Lesions developed
within 2 weeks. Otherwise the patient was healthy,
except a slight leucocytosis in peripheral blood.
Initially a viral exanthema, in particular herpes
simplex or varicella zoster virus infection, was suspec-
ted. However, when the patient consulted the following
day for disease monitoring, she reported exposure to a
cat at home that suffered from mycosis and was
euthanized. Later the flat was disinfected.
Histology showed an irregularly acanthotic epidermis
with a significant disaggregation of the stratum spino-
sum by severe spongiosis. Stratum granulosum was
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(a)
(b)
Figure 4 Drop shaped scaly papules and tiny tense vesicles dis-
tributed over the extremities (a). After a few days lesions enlarged
to small scaly plaques with an annular configuration (b).
completely absent. The horny layer featured parakera-
tosis and a high number of hyphae and spores,
recognisable already in H&E stain (Fig. 5). This was
confirmed with PAS stain. In the dermis, there was a
perivascular lymphocytic infiltrate.
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Atypical manifestations of tinea corporis
Figure 5 Parakeratosis with a high number of hyphae and
spores, recognisable already in haematoxylin and eosin (H&E) stain
(·400).
Mycological native preparation with Blancophor was
positive, culture on Dermasel agar resulted in Microspo-
rum (M.) canis.
The patient was treated with terbinafine tablets and
ciclopiroxolamine ointment. These led to fast improve-
ment and complete clinical healing after 1 week.
Patient 4
A 90-year-old woman, suffering from dementia,
arterial hypertension, tricuspid insufficiency and atrial
fibrillation presented with very inconspicuous, how-
ever, widespread pale erythematous and slightly
scaling lesions on her trunk (Fig. 6), arms, moreover,
in the big skin folds, the skin of the genitalia and the
face. Lesions were arranged in annular configuration
with pale centre and polycyclic borders. The patient
described severe pruritus and displayed few excoria-
tions especially on the trunk. Symptoms began
10 years ago on the trunk and spread to extremities.
By first glances, the clinical picture reminded eczema
due to exsiccation.
Histology showed an acanthotic epidermis covered
by alternating layers of para- and orthokeratosis. A
few neutrophilic granulocytes were scattered in the
horny layer. The upper dermis presented a very sparse
perivascular lymphocytic infiltrate. The PAS stain
revealed multiple hyphae in the horny layer.
Native preparation was positive, culture on Dermasel
Agar and potato dextrose agar resulted in Trichophyton
rubrum. This diagnosis was confirmed by negative
urease test (Urea indol medium, Biomérieux). Microsc-
opical evaluation after 4 weeks featured long hyphens.
Macroconidia were completely absent. Even microcon-
idia were found in very low quantities.
33
M. Ziemer et al.
Figure 7 Circinate erythematous plaques on the lower extremitis.
The patient was treated with terbinafine (250 mg
orally for 12 days) and topically with clotrimazole.
Later, the topical treatment was substituted by
ciclopiroxolamine cream. Four weeks later, no clinical
sign of tinea corporis remained.
Patient 5
A 72-year-old dement woman presented with gener-
alised erythematous plaques with circinate configur-
ation (Fig. 7) initially with a pronounced border of
close standing tiny pustules accenting the extremities
and the face. This clinical picture already lasted
several months. Moreover, the skin was massively
dry and scaly. Initial clinical diagnosis was that of
subcorneal pustulosis. As subcorneal pustulosis is a
pattern found in several conditions, such as pustular
34
Figure 6 Widespread, however, inconspicuous erythematous-
squamous lesions on the trunk.
psoriasis or linear IgA-dermatosis, a biopsy was
performed.
Histology was surprising, revealing tinea corporis.
The acanthotic and hyperkeratotic epidermis was infil-
trated by neutrophilic granulocytes and an enormous
number of hyphae and spores. The dermis featured an
inflammatory infiltrate of lymphocytes and partially
neutrophilic granulocytes.
Native preparation was positive; culture resulted in
T. interdiditale. Urease test was positive.
The patient was treated with terbinafine orally
(250 mg day)1) and ciclopiroxolamine ointment. After
distinct improvement of the symptoms, she was dis-
charged from the hospital.
Discussion
Tinea corporis classically presents with annular lesions.
Margins are usually well defined, scaly, and often
reddish. Lesions of tinea corporis expand concentrically,
resulting in a polycyclic arrangement. Pruritus is a
commonly associated symptom. Atypical, disseminated
clinical presentations may be seen in immunocompro-
mised patients,1 including those with HIV infection.2,3
Uncommonly, dermatophyte infections may also dem-
onstrate an atypical pattern or simulate other derma-
tological diseases in immunocompetent patients.4
Manifestations of fungal infections include vesiculous
or even bullous tinea, appearing as erythematous
dermatitis characterised by annular lesions with raised
vesicular edges.5,6 Reports in the literature also include
purpuric tinea corporis, presenting as erythematous,
purpuric, scaling lesions on a calf 7 as well as
papulosquamous lesions on the trunk and extremities.4
Further fungal infections may resemble different condi-
tions such as lupus erythematosus,8,9 psoriasis, atopic
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eczema,10,11 nummular eczema, erythema multiforme,12
granuloma annulare, granuloma faciale, lymphocytic
infiltration of the skin,12 pityriasis rosea, seborrheic
dermatitis 11–13 and annular secondary syphilis.
The dermatophytes responsible for atypical manifes-
tations are varied and include T. rubrum, T.interdigitale,
T. mentagrophytes, T. tonsurans, T. verrucosum and
M. canis.4 There are numerous reports of tinea mimick-
ing pustular psoriasis, SweetÕs syndrome, and impetig-
inised herpes.14
In atypical cases, the diagnosis can be missed by false
negative results from culture. In such cases, diagnosis
can easily be verified histologically by the presence of
PAS-positive fungi in stratum corneum or hair follicles.
However, one should be aware of the possibility that
fungi could be overlooked in routine H&E staining.
Spongiotic dermatitis together with neutrophilic gra-
nulocytes in the stratum corneum should be always
suspicious for fungal infection. Thereby, anthropophilic
fungi often result in a less impressive inflammatory
response compared with zoophilic fungi.
We illustrate several unusual manifestations of tinea
corporis. Although our patients had no current signs of
immunosuppression, an immunocompromised state
should be considered and excluded in any patient with
a clinically atypical presentation. Cutaneous dermato-
phyte infections may mimic numerous other dermato-
logical diseases, and it is important to include fungal
infection in the differential diagnoses. The misdiagnosis
or delay in diagnosis of atypical tinea corporis constitute
problems of considerable practical importance for
dermatologists. In our cases, histological examination
was the key in diagnosis, reinforcing our belief that the
skin biopsy is instrumental in establishing a definitive
diagnosis in difficult cases.
References
1 Hironaga M, Okazaki N, Saito K, Watanabe S. Tricho-
phyton mentagrophytes granulomas. Unique systemic
dissemination to lymph nodes, testes, vertebrae, and
brain. Arch Dermatol 1983; 119: 482–90.
 2007 Blackwell Publishing Ltd • Mycoses, 50 (Suppl. 2), 31–35
Atypical manifestations of tinea corporis
2 Lowinger-Seoane M, Torres-Rodriguez JM, Madrenys-
Brunet N, Aregall-Fuste S, Saballs P. Extensive dermato-
phytoses caused by Trichophyton mentagrophytes and
Microsporum canis in a patient with AIDS. Mycopathologia
1992; 120: 143–6.
3 Munoz-Perez MA, Rodriguez-Pichardo A, Camacho F, Rios
JJ. Extensive and deep dermatophytosis caused by Trich-
ophyton mentagrophytes var. interdigitalis in an HIV-1
positive patient. J Eur Acad Dermatol Venereol 2000; 14:
61–63.
4 Graham JH, Barr RJ. Papulosquamous eruptions: useful-
ness of biopsy in establishing diagnosis. Cutis 1977; 20:
629–33.
5 Terragni L, Marelli MA, Oriani A, Cecca E. Tinea corporis
bullosa. Mycoses 1993; 36: 135–7.
6 Veraldi S, Scarabelli G, Oriani A, Vigo GP. Tinea
corporis bullosa anularis. Dermatology 1996; 192:
349–50.
7 Veraldi S, Gorani A, Schmitt E, Gianotti R. Case
report. Tinea corporis purpurea. Mycoses 1999; 42:
587–9.
8 Singh R, Bharu K, Ghazali W, Nor M, Kerian K. Tinea
faciei mimicking lupus erythematosus. Cutis 1994; 53:
297–8.
9 Dauden E, Bartolome B, Pascual M, Fraga J, Garcia-Diez A.
Autoinvolutive photoexacerbated tinea corporis mimick-
ing a subacute cutaneous lupus erythematosus. Acta Derm
Venereol 2001; 81: 141–2.
10 Bohmer U, Gottlober P, Korting HC. Tinea
mammae mimicking atopic eczema. Mycoses 1998; 41:
345–7.
11 Virgili A, Corazza M, Zampino MR. Atypical
features of tinea in newborns. Pediatr Dermatol 1993; 10:
92.
12 Alteras I, Feuerman EJ. Atypical cases of Microsporum
canis infection in the adult. Mycopathologia 1981; 74:
181–5.
13 Alteras I, Feuerman EJ, David M, Segal R. The increasing
role of Microsporum canis in the variety of dermatophytic
manifestations reported from Israel. Mycopathologia 1986;
95: 105–7.
14 Ginter G, Soyer HP. [Unusual clinical manifestations caused
by Trichophyton rubrum–atypical ÔrubrophytosesÕ].
Hautarzt 1989; 40: 364–9.
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