Disseminated tinea incognito due to Trichophyton violaceum in a healthy child

A 13-year-old boy living in a village presented to our clinic with a 1-year history of pruritus involving the face, scalp, trunk, and extremities with nonresponse to topical corticosteroid, including triamcinolone acetonide cream and lotion. Physical examination revealed wide-spread erythematosus, sharply demarcated plaques with scales, and central clearing on the face (Figure 1, 2a), scalp (Figure 3), trunk (Figure 1b and c), and extremities (Figure 1d, e, and f). Posterior cervical and postauricular lymphadenopathy could not be found. There are multiple scattered, irregularly shaped patches of partial alopecia with black dots (Figure 3). Direct microscopy examination of skin lesions revealed abundant dermatophytic hyphae (Figure 4a). Direct microscopy examination of hair also revealed endothrix dermatophytic hyphae and arthrospores (Figure 4b). Fungal culture isolated from different inoculations showed the same dermatophyte. Colonies were waxy, heaped, folded, and deep violet in color. Numerous chlamydospores with no conidia could be detected under slide culture on potato dextrose agar at 28°C. The fungus was defined as Trichophyton violaceum by morphology. The general condition of the child was good. No abnormalities were found during pulmonary and abdominal clinical examinations. The diagnosis of disseminated tinea incognito was confirmed. Tinea incognito is a term used to describe a tinea infection modified by topical corticosteroids (). Topical corticosteroids suppress the local immune response and allow the fungus to grow easily (). As a result, the fungal infection may take on a bizarre appearance in the patient (). Tinea capitis is not usual in tinea incognito (). Oral terbinafine (250mg daily) and topical bifonazole was started. The mycological examination was negative after four weeks of treatment. A follow-up examination six months later showed no recurrence of symptoms. Tinea incognito, especially disseminated tinea incognito, is a great pitfall for physicians (). Therefore, if it's red and scaly, always look for fungus (, ).