History

Fact Explanation
Severe pustular eruption, deep inflammatory plaques or non- inflammatory superficial patches over the skin of the bearded areas of the face and neck. Tinea barbae is a rare superficial fungal infection caused by dermatophytes. It is caused by organisms of genera Trichophyton, Microsporum and Epidermophyton. Severity of symptoms depends on the causative organisms. [1],[2],[3],[5]
Mild pruritis This is a common symptom. May be due as a response to metabolic products produced by fungus. [4],[5]
Occurs in adult males and male teenagers. Occurs almost exclusively in males because lesions appear in bearded areas of the face and neck. As the beard appears with puberty. It affects adult males and male teenagers. [4], [5]
Contact history Tinea barbae is is a contagious and communicable fungal infection. Therefore contact history with infected family member or sharing razors, towels, pillows or animal contact may be positive in the history. Overcrowding and poor social conditions are risk factors in the history. [4],[5]
History of living in tropical climates. High temperature and humidity provides a better environment on skin surface for pathogenic growth of causative organisms. [1],[2],[3]
History of immunosuppression Protection against fungal infections is provided by cell mediated immunity. Therefore, all diseases leading to cell-mediated immunity disorders such as immunosuppression, AIDS, treating with long term corticosteroids and cytotoxics and malnutrition are possible risk factors in the history. [1],[2]
References
  1. WELLER, Richard P.J.B. HUNTER, John A.A. SAVIN, John A. and DAHL, Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  2. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  3. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 2012,1200-1201.
  4. SIDWELL, R. U. CHAN, I. FRANCIS, N. and BUNKER, C. B. Trichophyton erinacei kerion barbae from a hedgehog with direct osculatory transfer to another person. Clinical and Experimental Dermatology. 10 SEP 2013. [Viewed on 09.04.2013] DOI: 10.1111/ced.12197
  5. BARAN, W. SZEPIETOWSKI, J.C. and . SCHWARTZ, R.A. Tinea barbae, Acta Dermatoven APA. Vol 13, 2004, No 3, 91-94. [Viewed on 09.04.2013] Available from: http://www.zsd.si/ACTA/PUBLIC_HTML/acta-apa-04-3/4.pdf

Examination

Fact Explanation
Single or numerous circular ring like erythematous, well marginated scaly plaques on the skin over the bearded areas of the face and neck. Tinea barbae is a dermatophyte infection. Dermatophyte lesions appear because of delayed type-4 hypersensitivity reaction. [1],[2],[3],[5]
Boggy swelling Due to acute severe inflammation, infiltration with pus and crust formation (Kerion celsi). There may be inflamed nodules with multiple pustules and draining sinuses on its surface. Fungi of animal sources (zoophilic fungi) induce a more intense inflammation than those transmitted from a person. [1],[2],[4],[5]
Hairs are loose or broken and Plucking hairs is easy and painless. Causative dermatophytes invade the stratum corneum and hair cuticle (ectothrix infection), or they invade the interior of the hair shaft (endothrix infection). [1],[2],[5]
Cervical lymphadenopathy There may be regional lymphadenopathy in response to severe infection. [5]
Fever Due to alteration of thermo regulatory center in hypothalamus due to the action of inflammatory mediators. [5]
Single or multiple circulr patches over bearded areas of the face and neck. Fungi coming from human sources (anthrophilic organisms) cause patchy areas with minimal inflammation. Patches can remain stabile for years or may enlarge. [1],[2],[5]
References
  1. WELLER, Richard P.J.B. HUNTER, John A.A. SAVIN, John A. and DAHL, Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  2. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  3. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 2012,1200-1201.
  4. SIDWELL, R. U. CHAN, I. FRANCIS, N. and BUNKER, C. B. Trichophyton erinacei kerion barbae from a hedgehog with direct osculatory transfer to another person. Clinical and Experimental Dermatology. 10 SEP 2013. [Viewed on 09.04.2013] DOI: 10.1111/ced.12197
  5. BARAN, W. SZEPIETOWSKI, J.C. and . SCHWARTZ, R.A. Tinea barbae, Acta Dermatoven APA. Vol 13, 2004, No 3, 91-94. [Viewed on 09.04.2013] Available from: http://www.zsd.si/ACTA/PUBLIC_HTML/acta-apa-04-3/4.pdf

Differential Diagnoses

Fact Explanation
Folliculitis Presentation is with multiple small papules and pustules with an erythematous base that are pierced by a hair in the center. Commonly affects face,scalp, thigh, axilla and groin. [1],[2],[3]
Atopic dermatitis Cardinal feature of atopic eczema is itching and scratching. Their may be a history of atopy and associated asthma. There is a tendency for lichenification. [1],[2],[4]
Allergic contact dermatitis Typical presentation is of pruritic papules and vesicles on an erythematous base. The rash develops at the sites of skin contact with the "allergen", but occasionally spreads outside these limits. Commonly affects neck and beard area due to jewelry. [1],[2],[4]
Irritant contact dermatitis Strong irritants elicit an acute reaction after brief contact and diagnosis is usually obvious. Erythenatous, scaly macules or fissured areas appear on the irritant skin. [1],[2],[4]
Seborrheic dermatitis Erythematous, itchy patches which may become either scaly or exudative and crusted. Commonly involve hair bearing areas such as scalp, forehead, the beard presternal or interscapular areas. [1],[2],[3],[4]
Acne The earliest feature is increased rate of sebum secretion, making the skin look greasy. Blackheads or comedones usually accompany this. Inflamed, erythematous papules develop from blocked follicles. These are tender to touch and may be set deep within the skin. May at times develop pustules. Lesions are confined to face, shoulders, upper chest and back. [1],[2]
Discoid lupus erythematosus Plaques show erythema, scaling, scarring and atrophy, telangiectasia, hypopigmentation and peripharal zone of hyperpigmentation. They are well demarcated and lie mostly on the sun exposed skin. [1],[2],[3],[4]
Rosacea Rosacea is often seen in those who flush easily in response to warmth, spicy food and alcohol. Intermittent flushing is followed by a fixed erythema and telangiectases. Discrete domed inflamed papules and papulopustules and rarely plaques or nodules develop. Predominantly affects cheeks and fore head. Rosacea, unlike acne, has no comedone or seborrhoea. [1],[2],[4]
References
  1. WELLER, Richard P.J.B. HUNTER, John A.A. SAVIN, John A. and DAHL, Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 79-103, 162-176, 211, 222, 248-252.
  2. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43, 156, 105-127,149-161.
  3. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 2012,1200-1201.
  4. BARAN, W. SZEPIETOWSKI, J.C. and . SCHWARTZ, R.A. Tinea barbae, Acta Dermatoven APA. Vol 13, 2004, No 3, 91-94. [Viewed on 09.04.2013] Available from: http://www.zsd.si/ACTA/PUBLIC_HTML/acta-apa-04-3/4.pdf

Investigations - for Diagnosis

Fact Explanation
Woods light examination Uses ultraviolet light to observe skin closely. It reveals some of the epidermophytes with green fluorescence. But some causative fungus does not fluoresce. [1],[2],[3],[4]
Light microscopic examination The skin scrapings should be taken from the scaly margin of a lesion, with a small curette or a scalpel blade. Broken hair should be plucked with tweezers. The specimens are cleared with potassium hydroxide. Branching hyphae and spores can easily be seen. Hyphae may also be seen within a cleared hair shaft, or spores may be noted around it. [1],[2],[3],4]
Culture Culture should be carried out in a mycology or bacteriology laboratory. Transport medium is not necessary, and specimens can be sent in folded black paper and dry petri dish. The report may take as long as a month: microscopy is much quicker. [1],[2],[3],[4]
References
  1. WELLER, Richard P.J.B. HUNTER, John A.A. SAVIN, John A. and DAHL, Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  2. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  3. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 2012,1200-1201.
  4. BARAN, W. SZEPIETOWSKI, J.C. and . SCHWARTZ, R.A. Tinea barbae, Acta Dermatoven APA. Vol 13, 2004, No 3, 91-94. [Viewed on 09.04.2013] Available from: http://www.zsd.si/ACTA/PUBLIC_HTML/acta-apa-04-3/4.pdf

Management - General Measures

Fact Explanation
Educate the patient Tinea barbae is a superficial fungal infection which can be treated successfully. [1],[2],[3],[4]
Advise regarding hygiene Tinea barbae is a contagious and communicable fungal infection. Therefore advise not to share razors, towels, pillows and to avoid animal contact. [1],[2],[3]
Shaving or dipilation When hairs are involved, shaving or depilation should be considered. Warm compresses can be used to remove crusts and debris as a nonspecific treatment. [1],[2],[3],[4]
References
  1. WELLER, Richard P.J.B. HUNTER, John A.A. SAVIN, John A. and DAHL, Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  2. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  3. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 2012,1200-1201.
  4. BARAN, W. SZEPIETOWSKI, J.C. and . SCHWARTZ, R.A. Tinea barbae, Acta Dermatoven APA. Vol 13, 2004, No 3, 91-94. [Viewed on 09.04.2013] Available from: http://www.zsd.si/ACTA/PUBLIC_HTML/acta-apa-04-3/4.pdf

Management - Specific Treatments

Fact Explanation
Local imidazole preparations An imidazole containing preparation (such as miconazole, econazole and clotrimazole) should be used twice daily for a 3-4 week period is usually adequate. Imidazoles interfere with fungal oxidative enzymes to cause lethal accumulation of hydrogen peroxide. They also reduce the formation of ergosterol, an important constituent of fungal cell wall which thus becomes permeable to intracellular constituents. However topical therapy alone not adequate for tinea barbae. [1],[2],[3],[4],[5]
Terbinafin Has now largely superseded griseofulvin. It acts by inhibiting fungal squalane epoxidase and does not interact with cytochrome p-450 system. It is fungicidal and therefore cures chronic dermatophyte infections more quickly and more reliably than griseofulvin. 250mg daily given for2-6 weeks. [1],[2],[3],[4],[5]
Griseofulvin Was for many years drug of choice for chronic dermatophyte infections, but is now largely reserved for treatment of tinea capitis and tinea barbae. Griseofulvin prevents fungal growth by inhibiting mitosis. The therapeutic efficacy of griseofulvin depends on its capacity to bind to keratin. [1],[2],[3],[4],[5]
Itraconazole Is now preferred to ketoconazole , which may cause liver damage, it is also a reasonable alternative to terbinafin. Fungistactic rather than fungicidal, it interferes with the cytochrome P-450 system, so a review of any other medication being taken is needed before a prescription is issued. 100mg daily given for 2-6 weeks. [1],[2],[3],[4],[5]
Ketoconazole This drug should be reserved for patients with severe and resistant disease because of the possibility of serious hepatotoxicity and occurrence of other side effects, including rashes. Thrombocytopenia and gastrointestinal disturbances are also likely. 200mg daily given for 2-6weeks . [1],[2],[3],[4],[5]
References
  1. WELLER, Richard P.J.B. HUNTER, John A.A. SAVIN, John A. and DAHL, Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  2. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  3. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 2012,1200-1201.
  4. BENNET, P.N. and BROWN, M.J. CLINICAL PHARMACOLOGY. 9th Ed. CHURCHILL LIVINGSTONE. 2003, 263-267.
  5. BARAN, W. SZEPIETOWSKI, J.C. and . SCHWARTZ, R.A. Tinea barbae, Acta Dermatoven APA. Vol 13, 2004, No 3, 91-94. [Viewed on 09.04.2013] Available from: http://www.zsd.si/ACTA/PUBLIC_HTML/acta-apa-04-3/4.pdf