History

Fact Explanation
Multiple concentric rings of papules with scales over the body surface Tinea imbricata is a superficial dermatophyte fungal infection. It is caused by fungi of human sources (anthrophilic organisms). The commonest causative organism is Trichophyton concentricum. [1],[4],[6],[7],[8]
Pruritus Most of patients complain of pruritus, It may range from mild to intense itching. [1],[2],[3],[6]
Contact history Tinea imbricata is a contagious and communicable fungal infection. Therefore contact history with infected family member of sharing clothes, towels, bed linen may be positive. Overcrowding and poor social conditions are other risk factors. [2],[3]
History of immune suppression Protection against fungal infection is mediated by the cell mediated immunity (CMI). Long term steroid therapy, Cushing syndrome, malnutrition and HIV infection may be positive in the history. [2],[3],[6],[7]
History of living in endemic regions. Tinea imbricata is endemic in some islands of the South Pacific (Polynesia), South-East Asia, Central and South America, and Mexico. High humidity and warmth provide a favorable environment for the growth of causative fungal organisms. [7]
References
  1. RAO, A.G. Datta, N. Tinea corporis due to Trichophyton mentagrophytes and Trichophyton tonsurans mimicking tinea imbricata. Indian J Dermatol Venereol Leprol [Online] 2013;79:554. [Viewed on 2014.05.21] Available from: http://www.ijdvl.com/text.asp?2013/79/4/554/113109
  2. 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.
  3. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  4. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 2012,1200-1201.
  5. QADIM, H.H. GOLFOROUSHAN, F. AZIMI, H. and Goldust, M. Factors leading to dermatophytosis. Annals of parasitology. 2013;59(2):99-102. [Viewed on 21.05.2014]
  6. NARANG, Kirti. PAHWA, Manish and RAMESH, V. Tinea Capitis in the form of Concentric Rings in an HIV Positive Adult on Antiretroviral Treatment. Indian J Dermatol. 2012 Jul-Aug; 57(4): 288–290. [Viewed on 21.05.2014] doi: 10.4103/0019-5154.97672 Available from:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3401845/
  7. MOUSAVI, Seyyed Amin Ayatollahi. SARDOIP, Sammira salari. SHAMSADINI, Sadollah. A First case of tinea imbricata from Iran. Jundishpur Journal of microbiology (2009);2920:71-74. [Viewed on 21.05.2014] Available from:http://www.jjmicrobiol.com/5726.pdf
  8. MARKS JR, James G. and MILLER Jeffery. Lookilgbill& Marks’ Principles of Dermatology. 4th Ed. Elesvier. 2006,125-128.

Examination

Fact Explanation
Multiple erythematous scaly circular ring like papule involving the skin of extensor surface of arm, trunk and limbs. Tinea imbricata is a superficial, dermatophyte fungal infection. Dermatophyte lesions appear because of delayed or type-4 hypersensitivity reaction to the Trichophyton concentricum cytoplasmic antigen. [1],[2],[3],[4],[5]
Small vesicles and pustules may be seen within the lesions. Small vesicles and pustules may be seen within the lesions, specially in the advancing margin due to the acute inflammation. Fungi from human sources (anthrophilic organisms) cause lesions with minimal inflammation. [4],[5]
Erythema most pronounced at the periphery Due to acute inflammation in advancing margin, erythema most pronounced at the periphery. The lesions expand slowly and healed areas have a typical ring like pattern. [4],[5]
References
  1. RAO, A.G. Datta, N. Tinea corporis due to Trichophyton mentagrophytes and Trichophyton tonsurans mimicking tinea imbricata. Indian J Dermatol Venereol Leprol [Online] 2013;79:554. [Viewed on 2014.05.21] Available from: http://www.ijdvl.com/text.asp?2013/79/4/554/113109
  2. NARANG, Kirti. PAHWA, Manish and RAMESH, V. Tinea Capitis in the form of Concentric Rings in an HIV Positive Adult on Antiretroviral Treatment. Indian J Dermatol. 2012 Jul-Aug; 57(4): 288–290. [Viewed on 21.05.2014] doi: 10.4103/0019-5154.97672 Available from:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3401845/
  3. MOUSAVI, Seyyed Amin Ayatollahi. SARDOIP, Sammira salari. SHAMSADINI, Sadollah. A First case of tinea imbricata from Iran. Jundishpur Journal of microbiology (2009);2920:71-74. [Viewed on 21.05.2014] Available from:http://www.jjmicrobiol.com/5726.pdf
  4. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  5. 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.

Differential Diagnoses

Fact Explanation
Tinea corporis Typically, the lesions appear as an scaly, erythematous, plaque that may rapidly enlarge and worsen. Scale, crust, papules, vesicles, and bullae may develop, as a result of the inflammation, especially in the advancing border.[1],[2],[3],[4]
Discoid (nummular) eczema This common pattern of eczema classically affects the limbs of middle-aged males. The lesions are multiple, coin shaped, vesicular or crusted highly itchy plaques. [1],[2],[3]
Plaque psoriasis The lesions are well demarcated and range from a few millimeters to many centimeters in diameter. The lesions are pink or red with large centrally adhered silvery white, polygonal scales. Symmetrical sites on elbows,knees, lower back and scalp are sites of predilection. [1],[2],[3]
Pityriasis rosea Most patients develop one plaque before the others, It is larger (2-5 cm diameter) than later lesions, and is rounder, redder and more scaly. After several days many smaller plaques appear, mainly on the trunk, but some also on neck and extremities. [1],[2],[3]
Candidiasis A moist glazed area of erythema and maceration appears in a body fold; the edges show soggy scaling, and outlying satellite papulopustules. These changes are most common under the breasts and the arm pits and groin. [1],[2]
Seborrhoic 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]
Discoid Lupus Erythematosus Plaques show erythema, scaling, scarring and atrophy, telangiectasia, hypopigmentation and peripheral zone of hyperpigmentation. They are well demarcated and lie mostly on sun exposed skin. [1],[3]
Tinea versicolor Depigmented macules with fine scaling develop over the skin commonly involving upper trunk. [1],[2]
Erythrasma Presents with symptom free macular wrinkled slightly scaly pink, brown or macerated white areas, most often found in armpits or groins or between toes. [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, 54-70, 71-72, 97-100,131-134, 221, 252-256, 303, 237, 248-252, 325.
  2. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 17, 37-43, 114-118,128-142, 241, 265-266, 277.
  3. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 2012,1200-1201, 1236-1240,1240-1243, 1244,1245.
  4. MARKS JR, James G. and MILLER Jeffery. Lookilgbill& Marks’ Principles of Dermatology. 4thEd. Elesvier. 2006,125-128.

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 fluorescence. [1],[2],[3]
Light microscopic examination The skin scrapings should be taken from the scaly margin of a lesion, with a small curette or a scalpel blade. The specimens are cleared in pottassium hydroxide. Branching hyphae and spores can easily be seen. [1],[2],[3]
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]
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.

Investigations - Followup

Fact Explanation
Periodic monitoring These patients are given systemic anti fungals. Periodically assessment of response to therapy and side effects must be monitored because of the possibility of serious hepatotoxicity and occurrence of other side effects, including Thrombocytopenia. Therefore periodically Liver functions and full blood count assessment is important.[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.

Management - General Measures

Fact Explanation
Educate the patient Tinea imbricata is a superficial fungal infection which can be treated successfully. [1],[2],[3],[4]
Advise regarding hygiene Tinea imbricata is a contagious and communicable fungal infection. Therefore advise not to share clothes, towels, bedlinen etc. Advise regarding importance of daily bathing and wearing clean,dry clothes. [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. MARKS JR, James G. and MILLER Jeffery. Lookilgbill& Marks’ Principles of Dermatology. 4thEd. Elesvier. 2006,125-128.

Management - Specific Treatments

Fact Explanation
Local imidazole preparations An imidazole containing preparation (such as miconazole, econazole and clotrimazole) used twise daily for 3-4 week period. 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. Usually topical treatment alone inadequate. Therefore systemic drugs needs to be considered from the beginning. [1],[2],[3],[4],[5]
Terbinafin Has now largely superseded griseofulvin. It acts by inhibiting fungal squalaneepoxidase and does not interact with cytochrome p-450 system. It is fungicidal and so cures chronic dermatophyte infections more quickly and more reliably than griseofulvin. 250mg daily given for2-6 weeks. [1],[2],[3],[4]
Itraconazole Is now preferred to Ketoconazole , which occasionally damages the liver, and is a reasonable alternative to terbinafin if this is contraindicated. Fungistactic rather than fungicidal, it interferes with cytochrome P-450 system, so a review of any other medication being taken is needed before a prescription is issued. [1],[2],[3],[4]
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. 200mg daily given for 2-6weeks. [1],[2],[3],[4]
Griseofulvin Was for many years drug of choice for chronic dermatophyte infections, but is now largely reserved for treatment of Tinea capitis. Griseofulvin prevents fungal growth by inhibiting mitosis. The therapeutic efficacy of griseofulvin depends on its capacity to bind to keratin. [1],[2],[3],[4]
References
  1. BENNET, P.N. and BROWN, M.J. CLINICAL PHARMACOLOGY. 9th Ed. CHURCHILL LIVINGSTONE. 2003, 263-267.
  2. KATZUNG, Bertram G. MASTERS, Susan B. and TREVOR, Anthony J. Basic and Clinical Pharmacology. 12th Ed. Tata McGraw-Hill. 2012, 849-860.
  3. 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.
  4. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  5. MARKS JR, James G. and MILLER Jeffery. Lookilgbill& Marks’ Principles of Dermatology. 4thEd. Elesvier. 2006,125-128.