Tinea faciei (TF) is a type of superficial dermatophyte infection affecting the glabrous skin of the face (excluding the beard and moustache area in men). It can mimic several other dermatoses which involve the face and pose a diagnostic challenge [1]. Among fungal infections affecting the skin, TF is the most frequently misdiagnosed condition due to its variable morphological presentation. Approximately, 70% of patients having TF are wrongly diagnosed with other dermatoses [2, 3]. In this article, the case of TF simulating cutaneous lupus erythematosus is presented; wet mount and fungal culture enabled correct diagnosis and treatment, and avoided any unnecessary investigatory work up.
A 30-year-old male with itchy skin lesions in a typical butterfly pattern over the face of 1 month duration, was referred to our dermatology clinic by a general physician with a provisional diagnosis of cutaneous lupus erythematosus. There was a history of photosensitivity. He denied any history of treatment (topical or oral) before or after the appearance of lesions. Clinical examination revealed a large erythematous scaly plaque covering the nose and both cheeks in a typical butterfly distribution (figs. 1 A–C). The erythematous plaque had a well-defined raised erythematous border with central clearing. The rest of the dermatological examination including mucosae, nails and hair was non-contributory. A thorough review of systems was unremarkable. 10% potassium hydroxide (KOH) wet mount from the scrapings of the affected skin revealed fungal hyphae (fig. 1 D). Fungal culture from the skin scrapings taken from the edge of the plaque confirmed Trichophyton rubrum species establishing the diagnosis of tinea faciei. He was treated with itraconazole 200 mg/day along with topical Luliconazole cream to be applied twice a day. At 4 weeks’ follow-up, there was complete clearance of the lesions.
Tinea faciei can simulate several dermatoses including rosacea, cutaneous lupus erythematosus, polymorphous light eruption, allergic contact dermatitis, actinic keratosis, lymphocytic infiltrate of Jessner, psoriasis, impetigo, granuloma faciale, seborrheic dermatitis, granuloma annulare, among others [1, 3, 4]. Table 1 presents characteristic features of these entities. Trichophyton rubrum and Trichophyton mentagrophytes are the most common dermatophytes involved in the etiology of tinea faciei [5, 6]. Like cutaneous lupus erythematosus (CLE), the photo-aggravation of TF is well known and is likely a contributing factor for causing diagnostic dilemma [4]. The spectrum of clinical features of TF includes smooth, scaly and itchy circinate or annular lesions, erythematous plaques with a raised border, erythematous papules, macular erythema, as well as exacerbation following exposure to sun [3, 4]. Thus, mycological examination becomes imperative to confirm the diagnosis of fungal infection.
Not only clinical but also histopathological changes similar to other dermatoses like chronic dermatitis, acute contact dermatitis, erythema multiforme, vasculitis, granuloma faciale, CLE and folliculitis can be induced by T. rubrum [4, 5]. Such histological similarities and differences are presented in table 2.
The subject gets further complicated that the case of TF histologically mimicking cutaneous lupus as well as TF coexisting with discoid lupus erythematosus (DLE) have been reported [5, 6]. Conversely, Nakamura et al. have reported a case of DLE over the face which simulated TF. In their case, diagnosis was confirmed by histopathology and direct immunofluorescence test [7]. From ongoing discussion, it is evident that TF is a clinical and histopathological mimicker. However, in the present case, due to the typical morphology of the plaque with a raised border and central clearing, lack of application of topical steroids by the patient, positive KOH wet mount and identification of dermatophyte by culture, and complete clearance of lesions following antifungal therapy, confirmed our diagnosis and obviated the need for further investigations.
A robust consideration for the diagnosis of TF in a patient having erythematous lesions over the face should be made. It is wise to perform KOH examination and/or fungal culture when suspecting TF before going for further investigations.
Funding
No external funding.
Ethical approval
Not applicable.
Conflict of interest
The author declares no conflict of interest.
References
1. Malhotra S., Malhotra S.K., Aggarwal Y.: Tinea faciei caused by Trichophyton mentagrophytes in a 20-day-old neonate. Indian Dermatol Online J 2015, 6 (Suppl 1), S43-46.
2.
Lin R.L., Szepietowski J.C., Schwartz R.A.: Tinea faciei, an often deceptive facial eruption. Int J Dermatol 2004, 43, 437-440.
3.
Şener S.: Tinea faciei presenting butterfly erythema in a boy. Eur J Gen Med 2007, 4, 141-142.
4.
Hay R.J., Ashbee H.R.: Mycology. In: Rook’s Textbook of Dermatology. 8th ed. T. Burns, S. Breathnach, N. Cox, C. Griffiths, editors. Wiley-Blackwell, UK 2010, 36.18-36.50.
5.
Meymandi S., Wiseman M.C., Crawford R.I.: Tinea faciei mimicking cutaneous lupus erythematosus: a histopathologic case report. J Am Acad Dermatol 2003, 48 (2 suppl), S7-S8.
6.
Safer L.F., Lang P.G., Demetree J.W., Jones H.E.: Tinea faciei coexistent with discoid lupus erythematosus. Arch Dermatol 1981, 117, 121-122.
7.
Nakamura S., Yamada T., Umemoto N., Nakamura T., Wakatabi K., Iida E., et al.: Cheek and periorbital peculiar discoid lupus erythematosus: rare clinical presentation mimicking tinea faciei, cutaneous granulomatous disease or blepharitis. Case Rep Dermatol 2015, 7, 56-60.
