Dermoscopy - a simple and rapid in vivo diagnostic technique for tinea incognito

AnBrasDermatol.2019;94(5):612---614

Anais

Brasileiros

de

Dermatologia

IMAGES

IN

DERMATOLOGY

Dermoscopy

--- a

simple

and

rapid

in

vivo

diagnostic

technique

for

tinea

incognito

夽,夽夽

Sidharth

Sonthalia

_,

_Balachandra

_S.

_Ankad

_,

_Mohamad

_Goldust

_,

Abhijeet

Kumar

Jha

a_{DepartmentofDermatology,Venereology,andTrichology,SKINNOCENCE:TheSkinClinic&ResearchCenter,Gurugram,India}

b_{DepartmentofDermatology&STD,S.NijalingappaMedicalCollege,Bagalkot,India} c_{DepartmentofDermatology&STD,MazandaranUniversityofMedicalSciences,Sari,Iran} d_{DepartmentofDermatology&STD,PatnaMedicalCollege&Hospital,Patna,India}

Received12August2018;accepted26November2018

KEYWORDS Dermoscopy; Hair; Tinea; Weightsand measures; Dermatoscopy; Corticosteroidabuse; Dermatophytosis; Cruris; Corporis;

Tineaofvellushair;

Morse-codehairs; Bar-codehairs; Comma-shapedhairs; Corkscrew-shaped hairs; Blackdots; Brokenhairs; Deformablehairs; Translucenthairs

Abstract Tineaincognito resultingfrom corticosteroid abuseis becomingvery commonin thetropics.Itsdiagnosisistrickyowingtoitsconfusingmorphology,aswellaspracticaland technical issuesassociated with mycologicaltests. Dermoscopyhasnow evolvedasanovel diagnostictoolfordiagnosingtineaincognitoinsuchchallengingsituations,sincethetypicalhair changessuchasMorse-codehairs,deformablehairs,translucenthairs,commaandcorkscrew hairs,andperifollicularscalingmaybeseendespitesteroiduse,irrespectiveofmycological results.

©2019SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.Thisisan openaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

夽 _{Howtocitethisarticle:SonthaliaS,AnkadBS,GoldustM,JhaAK.Dermoscopy---asimpleandrapidinvivodiagnostictechniquefor}

tineaincognito.AnBrasDermatol.2019;94:612---4.

夽夽_{StudyconductedattheSKINNOCENCE:TheSkinClinic&ResearchCenter,Gurugram,India.} ∗_{Correspondingauthor.}

E-mail:[email protected](S.Sonthalia). https://doi.org/10.1016/j.abd.2019.09.017

0365-0596/©2019SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.ThisisanopenaccessarticleundertheCC BYlicense(http://creativecommons.org/licenses/by/4.0/).

Dermoscopy---asimpleandrapidinvivodiagnostictechniquefortineaincognito 613

Figure 1 Clinical image of tinea incognito lesion over the rightaxillaofayoung male---minimallyraisederythematous plaquewithill-definedborders,shinysurfacewithperipherally scattered,mildlyscalypapules.Onsetfourmonthspreviously; historyofintermittentapplicationofsteroid-antifungalcream andoralitraconazoleintake.

Topical corticosteroid abuse not only renders thera-peutic management challenging, it is contributing to the growingepidemic of antifungaltherapeutic failure.1,2 _The

utility ofdermoscopy in rapiddiagnosis of tineacapitisis well-established.3_{However,dermoscopicdiagnosisoftinea}

corporis,especiallytheincognitovariant,hasbeensparingly reported.4

A22-year-oldmedicalundergraduatestudentpresented with four-month-old itchy pinkish-red lesions in the right axilla.Thelesionhadill-definedborders,andashinysurface withperipherallyscattered,mildlyscalypapules(Fig.1).He hadbeenself-medicatingwithclobetasol-miconazolecream andoralitraconazole200mg/day,intermittently.Polarized dermoscopyrevealedpatchyerythema,perifollicularscales andcasts,blackdots,brokenhairs,bentdeformablehairs, Morse-codehairs,commaandcork-screwhairs,and translu-centhairs;additionally,dottedvesselsandtelangiectasias were present (Fig. 2). These dermoscopic changes typify thetineaofnon-glabrousskin.2---5 _{Skinscrapingsweresent}

for fungal culture and showed septate branching hyphae on 10% KOH microscopy.Oral terbinafine 250mg/day and topicalciclopiroxolamine1%cream forsixweeksresulted incomplete resolution. Trichophytonmentagrophytesvar. interdigitalewasconfirmedonculture.

Altered morphology, logistic issues associated with in-house light-based microscopy, and time delay of fungal

Figure2 Polarizeddermoscopicimageofthelesionrevealed patchyerythema,perifollicularscales(greenarrow),andcasts (redarrow), black dots,broken hairs, andcomma and cork-screw hairs (blue arrows). The entire field is filled with translucentanddeformable hairswithbends(yellowarrows), and Morse-code hairs showing horizontal skip white bands. Additionally,dottedvessels(greencircle)andscattered telang-iectasias (green arrows) were seen. The larger red blotches representexcoriation-induced,driedupblood-crusts(Dermlite 4,×20).

cultureresultswarrantarapidofficetoollikedermoscopyto diagnosetineaincognito.1,2_{Fungalinvasionofthehairleads}

todeformation and cracking that present as translucent, deformablehairs,commaandcorkscrewhairs,and Morse-codehairsthatshowhorizontalskipwhitebands(localized invasion).3---5 _{Dermoscopyserves asanoninvasiveand}

sim-ple method that allows speedy in vivo diagnosis of tinea incognito.

Funding

Nonedeclared.

Author’s

contribution

Sidharth Sonthalia: Approval of the final version of the manuscript;conception and planning of thestudy; elabo-rationandwriting ofthemanuscript;obtaining, analyzing and interpreting the data; intellectual participation in propaedeuticand/ortherapeuticconductofthecases stud-ied;criticalreviewoftheliterature;criticalreviewofthe manuscript.

Balachandra S. Ankad: Approvalof the final version of themanuscript;elaborationandwritingofthemanuscript; critical review of the literature; critical review of the manuscript.

MohamadGoldust:Approval of thefinal versionof the manuscript;criticalreviewoftheliterature;criticalreview ofthemanuscript.

AbhijeetKumarJha:Approvalofthefinalversionofthe manuscript;criticalreviewofthemanuscript.

614 SonthaliaSetal.

Conflicts

of

interest

Nonedeclared.

References

1.VermaS,MadhuR.ThegreatIndianepidemicofsuperficial der-matophytosis:anappraisal.IndianJDermatol.2017;62:227---36.

2.Navarrete-DechentC,BajajS,MarghoobAA,MarchettiMA.Rapid diagnosis of tinea incognito using handheld reflectance con-focal microscopy: a paradigm shift in dermatology? Mycoses. 2015;58:383---6.

3.ElghblawiE.Idiosyncraticfindingsintrichoscopyoftineacapitis: comma,zigzaghairs,corkscrew,andMorsecode-likehair.IntJ Trichol.2016;8:180---3.

4.GómezMoyanoE,CrespoErchigaV,MartínezPilarL, Martinez GarcíaS.Correlationbetweendermoscopyanddirectmicroscopy ofMorse codehairs intinea incognito.J AmAcad Dermatol. 2016;74:e7---8.

5.Gómez-MoyanoE,CrespoErchigaV,MartínezPilarL, Martínez García S, Martín González T, Godoy Diaz DJ, et al. Using dermoscopy to detect tinea of vellus hair. Br J Dermatol. 2016;174:636---8.