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Faculty of Medicine




Submitted By :



Intake 2015-2020



Patient’s Details

Name : Apong Anak Long

Age: 35 years old

Sex : Female

Race : Iban

Address : Sibu

Marital status : Married

Date of admission: 18/4/2018

Chief complaint

Patient presented with an itchy patches skin on buttocks (pruritus) since 2 months ago.

History of Presenting Illness

Patient is a 35-year-old gentleman who was presented with an itchy patches skin on
buttocks for further clinical evaluation. The chief complaint of the patient was
pruritus. The lesion on buttocks of the patient was formerly misdiagnosed as psoriasis
vulgaris. Therefore, he was treated with topical corticosteroids. Nevertheless, the
symptoms were not relieved by the application of topical corticosteroids. In addition,
the patient complained of gradual enlargement of the lesion in the last two months.

Systemic Review
General: no loss of appetite or loss of weight
CVS: no chest pain, no shortness of breath, no orthopnea and no paroxysmal
nocturnal dyspnea.
Respiratory: no sore throat, no cough and no flu
Gastrointestinal: no altered bowel movement
Urinary: no dysuria, no increase in frequency, no urgency and no incontinence
MSK: no joint pain, mild body ache
CNS: no headache, no dizziness
Past Medical/ Surgical History
The past medical history was remarkable for diabetes mellitus and psoriasis vulgaris
for the past three years.

Drug History
He admitted that he could manage his blood glucose levels with diet. He was put on
topical calcipotriol and clobetasol propionate to treat psoriasis vulgaris.

Family History
He is the first child in the family. He has 3 other siblings who are married and lives in
Peninsular. His father is a diabetic patient and his mother had hypertension. All the
siblings in the family is healthy as well. There is no family history of other skin

Personal and Social History

Patient is married with two kids. He work as construction worker. He is currently
living with her second daughter. He does not smoke cigarettes and does not consume

Physical Examination

General Examination
On inspection, patient was sitting comfortably on the chair. He was alert, conscious,
oriented to the surrounding and not in pain.
Dermatologic Examination
The physical examination showed an erythematous patch with a slightly raised edge
on the dorsum of the buttocks. There were erythematous, skin coloured papules and
pustules within this lesion. He also had hyperkeratotic plaques and fissures on both
buttocks. In addition, we noticed an erythematous and squamous plaque resembling
psoriasis vulgaris on his lower back.

Systemic Examination

Cardiovascular Examination:

On inspection, the chest move symmetrically with respiration. There was no

chest deformity, no surgical scar, no dilated superficial vein and no visible pulsation.
On palpation, the apex beat was located at the left 5th intercostals space within
the midclavicular line. No heave or thrill noted.
On percussion, normal cardiac dullness was revealed.
On auscultation, there was no murmur of the heart sound and normal dual
Respiratory Examination:

On inspection of the chest, the chest moves symmetrically with respiration,

there was no chest deformity, no use of respiratory accessory muscle, no surgical scar
and no dilated vein.
On palpation, the trachea was centrally located, normal chest expansion, and
normal vocal fremitus at both upper, middle and lower zone.
On percussion, there was normal resonance and normal cardiac and liver dullness.

On auscultation, normal vesicular sound heard.

Abdominal Examination:
On inspection of abdomen, there were no scar, abdominal distension, dilated vein
and visible pulsation.
On palpation, the abdomen was soft, non-tender and no splenomegaly was
detected but the liver can be felt under the right costal margin.
On percussion of the abdomen revealed normal resonance.
On auscultation of the abdomen, normal bowel sounds were heard.

Neurological Examination:
All the cranial nerves were intact and functioning normally. Motor system
examination showed normal muscle power, tone and reflexes.

Provisional diagnosis
Tinea Incognito

Patient is a 35-year-old male who presented with the chief complaint of itchy patches
skin on buttocks. The lesion on buttocks of the patient was formerly misdiagnosed as
psoriasis vulgaris. Therefore, he was treated with topical corticosteroids. Patient
complained of gradual enlargement of the lesion in the last two months.
Upon further examination, it was revealed that there was presence of erythematous
patch with a slightly raised edge on the dorsum of the buttocks.

Based on the history taking and physical examination, patient can be diagnosed as
having Tinea Incognito.

Differential Diagnosis
1. contact dermatitis impetigo
2. psoriasis vulgaris
3. Erythema Migrans

 Full blood count to exclude other infections.
 KOH test
o We scraped active edge of the lesion on the left hand using a scalpel
and we applied 10% potassium hydroxide (KOH) solution to the
sample. KOH preparation was examined microscopically and branched
hyphae of the fungus were detected.
 Diagnosis is basically confirmed through history taking and examination.

1) terbinafine 250 mg once daily
2) topical sertaconazole nitrate twice daily.

Tinea incognito is a fungal infection caused by dermatophytes. It can present with
erythema and minimal scale on the dorsum of the hand. However, chronic tinea
incognito lesions may be scaly and hyperkeratotic. The term ‘tinea incognito’ is used
to describe a dermatophyte infection with altered morphology. Tinea incognito
usually occurs after inappropriate treatment with topical steroids. Wood’s lamp
examination, mycological culture, direct microscopy and molecular techniques like
polymerase chain reaction are the methods to reach a definitive diagnosis [1].
Dermatophyte infections can be managed with antifungal and keratolytic agents [2].


The term tinea incognito describes dermatophytic infections with atypical appearance
due to topical and systemic immunosuppressants such as steroids and
immunomodulators [4]. The lesions are less scaly but more pustular, pruritic,
widespread and erythematous than common dermatophytosis. The active margins may
be lost [5]. In addition to topical immunosuppressive therapy, virulence of pathogen,
individual and environmental factors such as unsanitary conditions may play role in
atypical presentation [4]. Tinea incognito can mimic other skin disorders such as
neurodermatitis, rosacea, lupus erythematosus, contact dermatitis impetigo, lichen
planus, psoriasis vulgaris, erythema migrans and drug eruptions. Systemic antifungal
agents are usually indicated in patients with tinea incognito [6]. The diagnosis of
cutaneous fungal infections may be difficult and tinea manuum can be easily
misdiagnosed as psoriasis vulgaris. In our case, the patient’s past medical history of
psoriasis vulgaris caused a misdiagnosis and delay in the treatment. However,
exacerbation of the lesions during treatment with corticosteroids and active border of
the lesions led us to reevaluate the initial diagnosis.

In conclusion, dermatophyte infections may present with a variety of unusual clinical
features. Dermatophytosis should be kept in mind in differential diagnosis of other
skin diseases especially when there is no response as expected to topical
corticosteroid treatment. A misdiagnosis may lead to chronic and disseminated
lesions. Tinea incognito should be treated with systemic antifungal agents and
treatment should be continued until the lesions disappear.

1. Moriarty B, Hay R, Morris-Jones R. The diagnosis and management of tinea.

BMJ. 2012;345:e4380.
2. 2. Drake LA, Dinehart SM, Farmer ER, Goltz RW, Graham GF, Hardinsky
MK, et al. Guidelines of care for superfi cial mycotic infections of the skin:
Tinea corporis, tinea cruris, tinea faciei, tinea manuum and tinea pedis.
Guidelines/Outcomes Committee. American Academy of Dermatology. J Am
Acad Dermatol. 1996;34:282-6.
3. Sobera JO, Elewski BE. Fungal Diseases. In Bolognia JL, Jorizzo JL, Rapini
RP, eds. Dermatology. Spain: Elsewier, 2003; 1178-1179
4. Segal D, Wells MM, Rahalkar A, Joseph M, Mrkobrada M. A case of tinea
incognito. Dermatol Online J. 2013;19:18175
5. Arenas R, Moreno-Coutiño G, Vera L, Welsh O. Tinea incognito. Clin
Dermatol. 2010;28:137-9.
6. Zisova LG, Dobrev HP, Tchernev G, Semkova K, Aliman AA, Chorleva KI,
et al. Tinea atypica: Report of nine cases. Wien Med Wochenschr.