Why has this red, itchy rash worsened despite treatment?

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Authors: 

SMITHA KUPPALLI, MD and BARBARA B. WILSON, MD
University of Virginia

Dr Kuppalli is a dermatology resident and Dr Wilson is associate professor of dermatology at the University of Virginia School of Medicine in Charlottesville.

Kirk Barber, MD, FRCPC--Series Editor: Dr. Barber is a consultant dermatologist at Albert Children's Hospital and clinical associate professor of medicine and community health sciences at the University of Calgary in Alberta.  

tinea faciei Case: A 10-year-old girl is brought for evaluation of an itchy, red, enlarging rash on the left eyelid. When the rash first appeared 4 weeks earlier, she presented to her pediatrician who prescribed a topical combination nystatin and triamcinolone acetonide cream. The mother applied the cream for 2 weeks and noted improvement in the redness initially; however, over the next 2 weeks, the lesion persisted and rapidly enlarged.

The 5-cm, well-demarcated, erythematous, annular, scaly plaque involves the entire left eyelid and extends onto the nasal bridge. Physical examination findings are otherwise normal.

Why did this rash persist and worsen despite treatment?

(Answer on next page.)

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Comments

Submitted by sarahbwren on Sun, 2012-03-25 11:57

I am writing in reference to the March 2012 issue of Consultant for Pediatricians.  I am a Pediatric Nurse Practitioner with many years experience in Pediatric Dermatology.  In reference to the photo quiz on page 71, the lesion was indeed originally Tinea Faciei.  However I believe the proper diagnosis at this time is Tinea Incognito.   Tinea Incognto occurs when a topical steroid is applied to a fungal lesion.  As a result the appearance is altered, often becoming more extensive, less scaly and less raised.  It no longer has the typical appearance of Tinea   It is a diagnosis many practitioners are not familiar with and dont always recognize.

Submitted by hmpeditor on Thu, 2012-04-12 11:24

 
Thank you for your comment regarding our case about tinea faciei. The purpose of
the case was to highlight the original misdiagnosis of tinea faciei and to
discuss pitfalls in treatment. At the time of presentation, the lesion was a
large scaly plaque with an active border classic for a dermatophyte infection.
Tinea incognito refers to steroid modified tinea that is commonly misdiagnosed
due to the reduction in scale and inflammation with treatment.  Tinea incognito
may be considered in this case, however our main emphasis was on the original
diagnosis. 
  
Smitha Kuppalli, MD

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