Will the Real Tinea Please Stand Up …

1. The patient’s original lesion is dark brown, macular, and ovoid. An additional 15 to 20 oval, papulosquamous lesions are seen elsewhere on her trunk. These are widely scattered, hyperpigmented, and have scaly centers. The long axes of her oval back lesions are parallel with natural lines of cleavage in the skin.

Diagnosis: Pityriasis rosea, which is commonly seen in patients ages 10 to 35 and is about twice as likely to occur in women as in men.

The so-called herald patch appears initially, in a majority of cases, as a salmon-pink patch that can become as large as 5 to 10 cm, on the trunk or arms. The smaller oval lesions begin to appear within a week or two, averaging 1 to 2 cm in diameter; most display the characteristic “centripetal” scaling, clearly sparing the lesions’ periphery and serving as an essentially pathognomic finding.

On darker-skinned patients, the lesions (including the herald patch) will tend to be brown to black. The examiner must then look for the other characteristic aspects of PR, including the oval (as opposed to round) shape, the long axes of which will often parallel the skin tension lines on the back to produce what is termed the “Christmas tree pattern.”

For more information on this case, see “All of Her Friends Say She Has Ringworm.” Clin Rev. 2013;23(2).

For the next photograph, proceed to the next page >>

2. A man has had an asymptomatic rash for several weeks. Prior to its appearance, he was diagnosed with strep throat and treated with amoxicillin. The rash is quite striking: brightly erythematous, with annular margins on which the skin is red. But just behind the advancing margin is a parallel band of scaling.

Diagnosis: Erythema annulare centrifugum (EAC), one of the so-called “reactive erythemas,” which have several potential causes including streptococcal infections. The clinical picture and classic histologic pattern seen on biopsy effectively ruled out the other items in the differential diagnosis. EAC lesions can be large, appear in multiples, and spare only palms and soles. EAC is most often idiopathic. However, there are many reported triggers, including drugs (eg, gold, antimalarials, penicillin, and aspirin), infections (such as strep and dermatophytosis), and malignancies.

For more information on this case, see “Is A Common Illness The Cause of This Man's Rash?” Clin Rev. 2011;21(12).

For the next photograph, proceed to the next page >>

3. For two months, an 8-year-old girl has had a mildly tender and markedly pruritic rash on her right lower leg. Physical exam reveals concentric annular lesions on the affected leg. The central areas demonstrate a bruised appearance that does not resolve with diascopy.

Image courtesy of Robert Brodell, MD; reprinted from The Journal of Family Practice (2014;63:395-396).

Diagnosis: Tinea corporis was confirmed by the results of a potassium hydroxide (KOH) preparation showing septate hyphae. A periodic acid-Schiff (PAS) stain performed on the previous biopsy specimen revealed septate hyphae in the stratum corneum that were not apparent on the original hematoxylin and eosin (H&E) stained sections.

Dermatophyte infections of the skin are known as tinea corporis or “ringworm.” Ringworm fungi belong to 3 genera, Microsporum, Trichophyton, and Epidermophyton. These infections occur at any age and are more common in warmer climates.¹ The classic lesion is an annular scaly patch, sometimes with the concentric rings, as seen in our patient. The bruising was almost certainly caused by rubbing and scratching.

1. Shrum JP, Millikan LE, Bataineh O. Superficial fungal infections in the tropics. Dermatol Clin. 1994;12:687-693.

For more information on this case, see “Young girl with lower leg rash.” J Fam Pract. 2014;63(7):395-396.

For the next photograph, proceed to the next page >>

4. For three months (since the long, cold winter), this man has had very itchy lesions on his legs that he often scratches vigorously. He is not atopic and has no new pets, but he does admit to being “addicted” to sitting in his new hot tub. Examination of the patient’s legs, particularly his calves, shows discrete and confluent round, scaly plaques of a striking reddish orange hue.

Diagnosis: Nummular eczema (NE), an extremely common condition, especially in older men with dry skin made drier by bathing habits, swimming, or use of hot tubs. But many cases appear without these conditions, causing much conjecture about potential triggers, such as contact versus irritant dermatitis. Indeed, the multiplicity of topical medications applied by this patient was probably making things worse, as is often the case. NE typically manifests acutely, but can persist for months. If need be, a 4-mm punch biopsy will rule out the other suspects in the differential diagnosis.

For more information on this case, see “Family Thinks Man has Worms.” Clin Rev. 2010;20(8):6.

1. The patient’s original lesion is dark brown, macular, and ovoid. An additional 15 to 20 oval, papulosquamous lesions are seen elsewhere on her trunk. These are widely scattered, hyperpigmented, and have scaly centers. The long axes of her oval back lesions are parallel with natural lines of cleavage in the skin.

Diagnosis: Pityriasis rosea, which is commonly seen in patients ages 10 to 35 and is about twice as likely to occur in women as in men.

The so-called herald patch appears initially, in a majority of cases, as a salmon-pink patch that can become as large as 5 to 10 cm, on the trunk or arms. The smaller oval lesions begin to appear within a week or two, averaging 1 to 2 cm in diameter; most display the characteristic “centripetal” scaling, clearly sparing the lesions’ periphery and serving as an essentially pathognomic finding.

On darker-skinned patients, the lesions (including the herald patch) will tend to be brown to black. The examiner must then look for the other characteristic aspects of PR, including the oval (as opposed to round) shape, the long axes of which will often parallel the skin tension lines on the back to produce what is termed the “Christmas tree pattern.”

For more information on this case, see “All of Her Friends Say She Has Ringworm.” Clin Rev. 2013;23(2).

For the next photograph, proceed to the next page >>

2. A man has had an asymptomatic rash for several weeks. Prior to its appearance, he was diagnosed with strep throat and treated with amoxicillin. The rash is quite striking: brightly erythematous, with annular margins on which the skin is red. But just behind the advancing margin is a parallel band of scaling.

Diagnosis: Erythema annulare centrifugum (EAC), one of the so-called “reactive erythemas,” which have several potential causes including streptococcal infections. The clinical picture and classic histologic pattern seen on biopsy effectively ruled out the other items in the differential diagnosis. EAC lesions can be large, appear in multiples, and spare only palms and soles. EAC is most often idiopathic. However, there are many reported triggers, including drugs (eg, gold, antimalarials, penicillin, and aspirin), infections (such as strep and dermatophytosis), and malignancies.

For more information on this case, see “Is A Common Illness The Cause of This Man's Rash?” Clin Rev. 2011;21(12).

For the next photograph, proceed to the next page >>

3. For two months, an 8-year-old girl has had a mildly tender and markedly pruritic rash on her right lower leg. Physical exam reveals concentric annular lesions on the affected leg. The central areas demonstrate a bruised appearance that does not resolve with diascopy.

Image courtesy of Robert Brodell, MD; reprinted from The Journal of Family Practice (2014;63:395-396).

Diagnosis: Tinea corporis was confirmed by the results of a potassium hydroxide (KOH) preparation showing septate hyphae. A periodic acid-Schiff (PAS) stain performed on the previous biopsy specimen revealed septate hyphae in the stratum corneum that were not apparent on the original hematoxylin and eosin (H&E) stained sections.

Dermatophyte infections of the skin are known as tinea corporis or “ringworm.” Ringworm fungi belong to 3 genera, Microsporum, Trichophyton, and Epidermophyton. These infections occur at any age and are more common in warmer climates.¹ The classic lesion is an annular scaly patch, sometimes with the concentric rings, as seen in our patient. The bruising was almost certainly caused by rubbing and scratching.

1. Shrum JP, Millikan LE, Bataineh O. Superficial fungal infections in the tropics. Dermatol Clin. 1994;12:687-693.

For more information on this case, see “Young girl with lower leg rash.” J Fam Pract. 2014;63(7):395-396.

For the next photograph, proceed to the next page >>

4. For three months (since the long, cold winter), this man has had very itchy lesions on his legs that he often scratches vigorously. He is not atopic and has no new pets, but he does admit to being “addicted” to sitting in his new hot tub. Examination of the patient’s legs, particularly his calves, shows discrete and confluent round, scaly plaques of a striking reddish orange hue.

Diagnosis: Nummular eczema (NE), an extremely common condition, especially in older men with dry skin made drier by bathing habits, swimming, or use of hot tubs. But many cases appear without these conditions, causing much conjecture about potential triggers, such as contact versus irritant dermatitis. Indeed, the multiplicity of topical medications applied by this patient was probably making things worse, as is often the case. NE typically manifests acutely, but can persist for months. If need be, a 4-mm punch biopsy will rule out the other suspects in the differential diagnosis.

For more information on this case, see “Family Thinks Man has Worms.” Clin Rev. 2010;20(8):6.

1. The patient’s original lesion is dark brown, macular, and ovoid. An additional 15 to 20 oval, papulosquamous lesions are seen elsewhere on her trunk. These are widely scattered, hyperpigmented, and have scaly centers. The long axes of her oval back lesions are parallel with natural lines of cleavage in the skin.

Diagnosis: Pityriasis rosea, which is commonly seen in patients ages 10 to 35 and is about twice as likely to occur in women as in men.

The so-called herald patch appears initially, in a majority of cases, as a salmon-pink patch that can become as large as 5 to 10 cm, on the trunk or arms. The smaller oval lesions begin to appear within a week or two, averaging 1 to 2 cm in diameter; most display the characteristic “centripetal” scaling, clearly sparing the lesions’ periphery and serving as an essentially pathognomic finding.

On darker-skinned patients, the lesions (including the herald patch) will tend to be brown to black. The examiner must then look for the other characteristic aspects of PR, including the oval (as opposed to round) shape, the long axes of which will often parallel the skin tension lines on the back to produce what is termed the “Christmas tree pattern.”

For more information on this case, see “All of Her Friends Say She Has Ringworm.” Clin Rev. 2013;23(2).

For the next photograph, proceed to the next page >>

2. A man has had an asymptomatic rash for several weeks. Prior to its appearance, he was diagnosed with strep throat and treated with amoxicillin. The rash is quite striking: brightly erythematous, with annular margins on which the skin is red. But just behind the advancing margin is a parallel band of scaling.

Diagnosis: Erythema annulare centrifugum (EAC), one of the so-called “reactive erythemas,” which have several potential causes including streptococcal infections. The clinical picture and classic histologic pattern seen on biopsy effectively ruled out the other items in the differential diagnosis. EAC lesions can be large, appear in multiples, and spare only palms and soles. EAC is most often idiopathic. However, there are many reported triggers, including drugs (eg, gold, antimalarials, penicillin, and aspirin), infections (such as strep and dermatophytosis), and malignancies.

For more information on this case, see “Is A Common Illness The Cause of This Man's Rash?” Clin Rev. 2011;21(12).

For the next photograph, proceed to the next page >>

3. For two months, an 8-year-old girl has had a mildly tender and markedly pruritic rash on her right lower leg. Physical exam reveals concentric annular lesions on the affected leg. The central areas demonstrate a bruised appearance that does not resolve with diascopy.

Image courtesy of Robert Brodell, MD; reprinted from The Journal of Family Practice (2014;63:395-396).

Diagnosis: Tinea corporis was confirmed by the results of a potassium hydroxide (KOH) preparation showing septate hyphae. A periodic acid-Schiff (PAS) stain performed on the previous biopsy specimen revealed septate hyphae in the stratum corneum that were not apparent on the original hematoxylin and eosin (H&E) stained sections.

Dermatophyte infections of the skin are known as tinea corporis or “ringworm.” Ringworm fungi belong to 3 genera, Microsporum, Trichophyton, and Epidermophyton. These infections occur at any age and are more common in warmer climates.¹ The classic lesion is an annular scaly patch, sometimes with the concentric rings, as seen in our patient. The bruising was almost certainly caused by rubbing and scratching.

1. Shrum JP, Millikan LE, Bataineh O. Superficial fungal infections in the tropics. Dermatol Clin. 1994;12:687-693.

For more information on this case, see “Young girl with lower leg rash.” J Fam Pract. 2014;63(7):395-396.

For the next photograph, proceed to the next page >>

4. For three months (since the long, cold winter), this man has had very itchy lesions on his legs that he often scratches vigorously. He is not atopic and has no new pets, but he does admit to being “addicted” to sitting in his new hot tub. Examination of the patient’s legs, particularly his calves, shows discrete and confluent round, scaly plaques of a striking reddish orange hue.

Diagnosis: Nummular eczema (NE), an extremely common condition, especially in older men with dry skin made drier by bathing habits, swimming, or use of hot tubs. But many cases appear without these conditions, causing much conjecture about potential triggers, such as contact versus irritant dermatitis. Indeed, the multiplicity of topical medications applied by this patient was probably making things worse, as is often the case. NE typically manifests acutely, but can persist for months. If need be, a 4-mm punch biopsy will rule out the other suspects in the differential diagnosis.

For more information on this case, see “Family Thinks Man has Worms.” Clin Rev. 2010;20(8):6.