Tinea Faciei
Douglas J. Pravda, DO, Michael M. Pugliese, MD
\s=b\ A 62-year-old man had a long-
standing fungal infection of the face. The
eruption had been treated as a photosen-
sitivity disorder for 22 years. A literature
review revealed only 35 reported cases
classified as tinea faciei, most of which
also were misdiagnosed originally. Perti-
nent clinical findings include facila ery-
thema, pruritus, and scaling patches with
arcuate or annular borders. The most
common organisms isolated were Tricho-
phyton rubrum or T mentagrophytes.
To our knowledge, this unique case
represents the longest duration of Tinea
faciei.
(Arch Dermatol 114:250-252, 1978)
Tinea faciei is a dermatophyte
infection
monly reported
of the face. Uncom¬
in this anatomic loca¬
tion, it has the ability to masquerade
as a number of other dermatoses. In
the literature and texts of derma¬
tology and mycology, tinea faciei
generally is not considered to be a
unique entity, but is included inciden¬
tally under headings of tinea corporis,
tinea capitis, or tinea barbae. Because
superficial fungal infections of the
face have not been emphasized, there
is a low index of suspicion, and often
an incorrect diagnosis is made.
In 1960, Shanon and Raubitschek1
reported the cases of four patients
Accepted for publication March 8, 1977.
From the Department of Dermatology, US
Public Health Service Hospital, Staten Island,
NY.
Reprint requests to Department of Dermatol-
ogy, US Public Health Service Hospital, Staten
Island, NY 10304 (Dr Pravda).
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with tinea of the face that clinically
simulated discoid lupus erythemato¬
sus. Gilgor and co-workers2 reported
14 cases of "tinea faciale" in 1971.
Over half of the conditions of their
patients were misdiagnosed origi¬
nally, with most of them described as
sunlight-related disorders. During the
same year, Shapiro and Cohen3
reported four additional cases that
mimicked other diseases. Thirteen
more individual case reports have
been found in the literature, and most
of these also originally were misdiag¬
nosed.418
In all of the previously reported
cases, the recurrence of disease varied
from several months to 11 years
before the correct diagnosis was
made. The present case, with symp¬
toms and mismanagement for 22
years, appears to be the longest yet
recorded in the literature.
REPORT OF A CASE
A 62-year-old man was first seen in the
dermatology clinic at the Staten Island
(NY) Public Health Service Hospital in
August 1974 because of a persistent facial
eruption of 22 years' duration. The rash
was usually asymptomatic, but was asso¬
ciated occasionally with a slight burning
sensation. Although the eruption always
was present, it worsened during the
months.
summer
The patient was first seen by a dermatol¬
ogist for this problem in 1952. A biopsy
specimen was obtained and was inter¬
preted as a sunlight-induced reaction.
Treatment with topical steroids and sun¬
screens was of no benefit. He was seen
subsequently by a number of physicians,
who concurred with the original diagnosis,
and the eruption was treated in a similar
fashion. There had been no other dermato-
logic complaints, and his medical history,
other than seasonal hay-fever symptoms,
was noncontributory.
On examination the patient displayed a
facia] eruption of erythematous macules,
papules, and plaques, a few of which had
arcuate borders (Fig 1). Atrophy was not
noted, but telangectasia and minimal
scaling were present. All areas of the face
and upper neck were involved (Fig 2).
Examination of the skin, mucosa, hair, and
nails revealed only dystrophy of both great
toe nails. Results of a general physical
examination were normal. Routine labora¬
tory test results were all negative or within
normal limits. In addition, antinuclear
antibody and anti-DNA antibody tests
were negative, and IgE level and serum
immunoelectrophoresis results were within
the normal range.
Intradermal skin testing was performed
with trichophytin, candidin, mumps vac¬
cine, purified protein derivative (PPD),
and streptokinase-streptodornase. At 48
hours, only the mumps test was positive.
Interestingly, the trichophytin test re¬
sulted in an immediate 40-mm wheal and
flare, but the skin showed no response in 48
hours.
A skin biopsy specimen of a facial lesion
demonstrated a mild dermal dermatitis
with hematoxylin-eosin. Fungal hyphae
were demonstrated with PAS. Scrapings
from both the facial lesions and the toe
nails were positive; cultures from both
areas subsequently grew Trichophyton
rubrum.
The eruption was treated orally with
micronized griseofulvin, 500 mg twice
daily. Within four weeks, the facial lesions
resolved, and the medicine was discontin¬
ued. No recurrence has been noted during
the subsequent nine months.
COMMENT
With regard to accuracy of clinical
diagnosis, our case demonstrates the
 Fig 1— Diffuse facial eruption consisting or erythematous macules,
papules, and plaques. Note minimal amount of scale.

Fig 2.—Prominent annular lesion involving neck.

Table 2—Organisms Isolated From 34 Patients With

Tinea Faciei
Table 1— Initial Clinical Impression of 36 Cases of Organism No. of Patients
Tinea Faciei Trichophyton species
7 rubrum 13
Original Diagnosis No. of Patients T mentagrophytes 10
Tinea 11 T tonsurans 3
Photosensitive disorders T verrucosum 1
Total 27
Lupus erythematosus (DLE and SLE) 13
Polymorphous light eruption 4 Microsporum species
Dermatomyositis 2 M cants
"Xeroderma pigmentosum incipiens" 1 M gypseum
Total 20 Total
Miscellaneous Miscellaneous
Pyoderma Contaminant (KOH positive)
Contact dermatitis No growth (KOH positive)
Total Total

difficulty in the recognition of tinea
faciei. Of the total number of cases
reviewed (including the present case
report), 25 of 36 (69%) at first were
diagnosed incorrectly (Table 1). Of
these 25 patients, 20 (80%) were
believed to have had a photosensi¬
tivity disorder. Since the total number
of patients is small, it is difficult to
estimate the frequency of the most
helpful clinical findings. However, of
those mentioned, erythema, pruritus,
and scaling were among the most
common. The combination of raised
lesions with annular or arcuate bor¬
ders is a particularly helpful clue.
Sensitivity to sunlight also was men¬
tioned in about one third of the
cases.
Superficial fungal infections histo¬
logically may appear as a dermal
dermatitis, and clinically can resemble
such diseases as lupus erythemato-
sus,16 dermatomyositis,1'' acne rosa-
cea,7 contact dermatitis, lupus vulgar¬
'
is,17 or polymorphous light eruption.2
These facts, along with a history of
photoaggravation and, at times, the
concomitant presence of solar-induced
skin damage, account for the common
error in diagnosis. Since the treat¬
ment of these disorders often involves
medications with potentially haz¬
ardous side effects, tinea faciei must
be included in the differential diagno¬
sis.
A variety of organisms have been
isolated from patients with this
disease (Table 2). Of those pathogens
that have been proved by culture, 27 of
31 (87%) have been of the Tricho¬
phyton species, with T rubrum and T
mentagrophyt.es being the most com¬
mon. Of the few cases in the literature
where cultures were reported as nega¬
tive, the initial scrapings revealed
fungal hyphae. Therefore, either po¬
tassium hydroxide preparations or
'"
fungal culture should be positive in all
cases.
In the immunologically competent
host, delayed hypersensitivity or cell-
mediated immunity follows an initial
encounter with a pathogenic fungus,
and is the mechanism responsible for
the development of resistance. Our
patient's skin test reactivity to tricho¬
phytin corresponds to that of other
patients with chronic superficial fun¬
gal infections, ie, an immediate wheal
and flare but a negative 48-hour
delayed reaction. The positive imme¬
diate skin test, which indicates the
presence of humoral or serum anti¬
body to trichophytin, correlates
strongly with persistent infection. It
is this immediate response, in con¬
junction with a negative delayed reac¬
tion, that seems to be associated with

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 chronic fungal susceptibility.18
The incidence of chronic fungal
infections has been reported to be
higher in atopic individuals,19 who also
can display an impaired immunity to
multiple antigens.1921 Our patient,
who was known to be atopic, demon¬
strated this pattern by his lack of
reaction to candidin, PPD, and strep-
tokinase, as well as to trichophytin.
He falls into the group of approxi¬
mately 80% of those chronically
infected patients whose immune sys-
ternsrespond inappropriately to der¬
matophyte antigens. Further study
may clarify the status of the remain¬
ing 20% who, by present clinical and
laboratory criteria, apparently have
normal immune reactivity yet suffer
from chronic fungal involvement.22
In conclusion, tinea faciei rep¬
resents an unusual fungal infection
that often is not considered by clini¬
cians. The ease of diagnosis and the
response to treatment warrants that
it be included in the differential
nosis of sun-sensitive, chronic facial
eruptions. This patient also demon¬
strated the impaired immunologie
reactivity that has been described in
individuals with chronic dermato¬
phyte infections.
The cost of the color reproduction was paid for
by Westwood Pharmaceuticals Inc.
James P. Fields, MD, provided the histopatho¬
logical diagnosis, gave advice, and assisted in the
diag- preparation of this communication.

1. Shanon J, Raubitschek F: Tinea faciei simu-
lating chronic discoid lupus erythematosus. Arch
Dermatol 82:268-271, 1960.
2. Gilgor RS, Tindell JP, Elson M: Lupus-
erythematosus-like tinea of the face (tinea
facile). JAMA 215:2091-2094, 1971.
3. Shapiro L, Cohen HJ: Tinea faciei simu-
lating other dermatoses. JAMA 215:2106-2107,
1971.
4. Drouhet E, Robin J: Mycose cutanee simu-
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Dermatol Syphiligr 76:502-504, 1969.
5. Sirkis L, Tosi MJ: Mycose cutanee dela face
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et al: Trichophytie de menton simulant acne
une
rosacee. Bull Fr Dermatol Syphiligr 75:581\x=req-\
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