American Journal of Dermatology and Venereology 2015, 4(2): 15-17 DOI: 10.5923/j.ajdv.20150402.02

America’s First Case of Tinea Pseudoimbricata

Lisa Mask-Bull M. D.1,*, Ravi Patel Msiii2, Michelle B. Tarbox M. D.3

1Resident of Dermatology, Texas Tech University Health Sciences Center, Department of Dermatology, Lubbock, USA 2Medical student at Texas Tech University Health Sciences Center School of Medicine, Odessa, USA 3Assistant professor of Dermatology, Texas Tech University Health Sciences Center, Department of Dermatology, Lubbock, USA

Abstract Tinea imbricata is a variant of classically caused by the Trichophyton concentricum that is clinically characterized by scaly concentric rings. There have been recent reports of immunosuppressed patients presenting with dermatologic findings consistent with tinea imbricata but caused by other than Tricophyton concentricum. These cases, described by the terms ‘tinea pseudoimbricata’ or ‘tinea indecisiva’, have never been reported to develop in the United States. Patients with tinea pseudoimbricata are usually systemically immunosuppressed and only a handful of cases have occurred following topical immunosuppression. We encountered a young man in West Texas with tinea pseudoimbricata secondary to Tricophyton tonsurans that occurred following prolonged use of topical corticosteroids. Our case adds to the five previously described cases of tinea pseudoimbricata secondary to Tricophyton tonsurans and serves as the first example of tinea pseudoimbricata development in North America. Keywords Tinea pseudoimbricata, Tinea imbricata, Trichophyton concentricum, Trichophyton tonsurans

1. Introduction Tinea imbricata is a geographically restricted exclusively caused by Trichophyton concentricum. Infection results in a characteristic clinical appearance of annular concentric scaly plaques [1]. Tinea imbricata is endemic to the South Pacific islands and Southeast Asia; it may less commonly present in Central America [1, 2]. While Trichophyton concentricum remains to be the sole culprit behind Tinea imbricata, there have been cases caused by other species that mimic the classic clinical presentation. To describe these situations, the terms ‘tinea pseudoimbricata’ and ‘tinea indecisiva’ have been adopted. Although a wide range of species can cause tinea Figure 1. Pre-treatment examination shows concentric erythematous pseudoimbricata, there have only been five documented annular scaly plaques on the left lateral neck cases caused by Trichophyton tonsurans. More importantly, A 21-year-old male from Dallas presented with a there have been no reported cases of tinea pseudoimbricata 12-month history of a persistent scaly eruption on his lateral North of Mexico. To our knowledge, we describe the first neck. In an attempt to treat the rash, he had been applying cases of tinea pseudoimbricata in North America. L’abidjanaise cream twice daily for a duration of 3 months. Furthermore, the causative agent of tinea pseudoimbricata Clobetasol Propionate 0.05% was included among the listed in this case (Trichophyton tonsurans) adds to the five ingredients of this medication, which the patient had previously reported cases. Finally, we explore the role of purchased online. Because the patient noticed a change in his topical immunosuppression in the development of tinea rash with use of this agent, he presented to Dermatology for pseudoimbricata. evaluation. He denied use of additional agents to treat the rash and lacked history of any prior medication or supplemental use. He denied any history of 2. Patient Presentation immunosuppressive conditions such as HIV, hepatitis or tuberculosis. The patient was of Sudanese descent but was * Corresponding author: [email protected] (Lisa Mask-Bull M. D.) born in the United States and had no history of travel. Skin Published online at http://journal.sapub.org/ajdv examination of the lateral neck demonstrated concentric Copyright © 2015 Scientific & Academic Publishing. All Rights Reserved erythematous annular plaques with overlying tightly

16 Lisa Mask-Bull M. D. et al.: America’s First Case of Tinea Pseudoimbricata

adherent peripheral scale (figure 1). of these cases reported usage of topical immunosuppressants KOH findings and fungal culture were consistent with only, whereas one case reported only the use of oral Trichophyton tonsurans (figure 2). Oral Terbinafine was immunosuppression and another reported the use of both recommended. Following 2 pulsed doses of Terbinafine the topical and oral steroids [4-8]. erythema and scale resolved, and residual post inflammatory Immunosuppression plays a central role in the hyperpigmentation was present on exam (figure 3). development of both tinea pseudoimbricata and tinea imbricata [1]. This is supported by the notion that despite sufficient exposure, only certain individuals acquire tinea imbricata [1]. A previous study conducted in Papua New Guinea showed that 52% of individuals with tinea imbricata (35/68) failed to develop a delayed-type hypersensitivity reaction despite demonstrating normal immediate type hypersensitivity responses. This implies that individuals with tinea imbricata have deficient cellular immunity [1]. Similarly, immune dysregulation plays a crucial role in the Figure 2. KOH demonstrating hyphal elements development of tinea pseudoimbricata since the vast majority of cases have been reported in patients with underlying systemic immunosuppressive conditions, or less commonly in the setting of topical immunosuppression. In fact, it is this shared relationship of immunosuppression that is thought to explain the identical clinical appearance between tinea imbricata and tinea pseudoimbricata. As detailed by Verma et al, the ring effect seen in these two entities can be explained by the fact that although host reaction occurs in response to actively metabolizing fungal cells, these are only partially inhibited as a result of immunosuppression or topical steroid usage [3]. When local immune responses decline below a key threshold, the fungal genes are switched on again and instigate another zone of host-induced inflammatory response [3]. This process may repeat multiple times, resulting in concentric rings of scaling Figure 3. Post-treatment examination shows concentric hyperpigmented and inflammation that reflect the alternating activation and patches deactivation of defense mechanisms [3]. Furthermore, as demonstrated in our case, the dermatologic features may be subtle since the number of 3. Discussion concentric rings typically varies with duration of infection, In our case, a diagnosis of tinea pseudoimbricata was with fewer concentric rings seen in earlier infections [1]. The appropriate since dermatologic findings consistent with tinea morphologic appearance further varies based on anatomic imbricata were present, but subsequent culture revealed a location and corresponding skin thickness of involvement causative agent other than Trichophyton concentricum. [1]. Providers should be aware of this potentially subtle Tinea pseudoimbricata has not yet been reported to develop presentation and maintain a low clinical suspicion for in the United States. Our patient, a Texas native with no diagnosis, especially since detection of pseudoimbricata may history of travel, may represent the first encountered case of lead to identification of serious underlying tinea pseudoimbricata North of Mexico. We believe it is immunosuppressive conditions. important to alert regional providers of this situation since detection of pseudoimbricata is not purely of academic 4. Conclusions importance. Tinea pseudoimbricata is most commonly caused by This case demonstrates the importance of suspecting an Trichophyton rubrum and Trichophyton mentagrophytes [3]. alternate diagnosis when a tinea imbricata like presentation The causative agent in this case, Trichophyton tonsurans, is is encountered outside of endemic areas. Concentric annular an anthropophilic dermatophyte that typically causes tinea scaly plaques are not pathognomonic of causative infection corporis and [2]. To the best of our knowledge, by Trichophyton concentricum. Culture should be there have only been five previously reported cases of tinea consistently performed in such situations, since detection of pseudoimbricata caused by Trichophyton tonsurans. Of responsible fungi allows for selection of appropriate therapy. these reported cases, all arose from outside the United States Furthermore, the clinical presentation of tinea and most involved some form of immunosuppression. Two pseudoimbricata can be subtle. Since the number of

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concentric rings varies with duration of infection (with fewer [4] Ouchi, T., Nagao, K., Hata, Y., Otuka, T., Inazumi, T., 2005, concentric rings seen in earlier infections) and since the Trichophyton tonsurans infection manifesting as multiple concentric annular erythemas, J Dermatol, 32(7), 565-8. morphologic appearance further varies based on anatomical location. The provider should therefore remain vigilant [5] Batta, K., Ramlogan, D., Smith A.G., Garrido, M.C., Moss, especially since diagnosis of pseudoimbricata may even lead C., 2002, ‘Tinea indecisica’ may mimic the concentric rings to detection of serious underlying immunosuppressive of tinea imbricata, Br J Dermatol, 147(2), 384. conditions. And while Trichophyton tonsurans is an [6] Lim, S.P., Smith A.G., 2003, “Tinea pseudoimbricata”: tinea increasingly common culprit of North American cases of corporis in a renal transplant recipient mimicking the tinea corporis, it may rarely present as multiple concentric concentric rings of tinea imbricata, Clin Exp Dermatol, 28(3), plaques in patients with local immunosuppressive therapy 332-3. [9, 10]. Finally as demonstrated by our patient, it is [7] Hoque, S.R., Holden, C.A., 2007, Trichophyton tonsurans important that Dermatologists are made aware that legitimate infection mimicking tinea imbricata, Clin Exp Dermatol, formulations of high potency topical corticosteroids may be 32(3), 345-6. illicitly obtained. [8] Rao, A.G., Datta, N., 2013, Tinea corporis due to Trichophyton mentagophytes and Trichophyton tonsurans mimicking tinea imbricata, Indian J Dermatol Venereol Leprol, 79(4), 554. REFERENCES [9] Foster, K.W., Ghannoum, M.A., Elewski, B.E., 2004, Epidemiologic surveillance of cutaneous fungal infection in [1] Satter, E.K., 2009, Tinea Imbricata, Cutis, 83(4), 188-91. the United States from 1999 to 2002, J Am Acad Dermatol, 50(5), 748-52. [2] Bonifaz, A., Vazquez-gonzalez, D., 2011, Tinea imbricata in the Americas, Curr Opin Infect Dis, 24(2), 106-11. [10] Tucker, P.L.Y., 2013, Epidemiologic trends in pediatric tinea capititis: a population-based study from Kaiser Permanente [3] Verma, S., Hay, R.J., 2015, Topical steroid-induced tinea Northern California, J Am Acad Dermatol, 69(6), 916-21. pseudoimbricata: a striking form of tinea incognito, Int J Dermatol, 54(5), e192-3.