Tinea Faciei misdiagnosed as case of Lupus Erythematosus

presented by

Khalifa Shaquie MD, PhD,

Baghdad, Iraq

on July 14, 2005

Professor of Dermatology, College of Medicine, University of Baghdad, Baghdad, Iraq

Abstract A 47-year-old woman was referred as a case of lupus erythematosus. On examination, she had butterfly rash of face with raised borders which was very suggestive of tinea faciei.
F.M., 47-year-old woman
4 years
Face and buttock

History of 4 years of rash that appeared on face. It was treated as rosacea or lupus erythematosus with little transient benefit. She was mainly complained because of the cosmetic appearance of the rash. No systemic complaints. Investigations were negative

Physical Examination

There was diffuse erythematous rash in a butterfly distribution involving most of the face. The nasolabial folds were spared. The rash extended to the neck in some areas and also to the sides of face with well defined borders that covered with few pustules. The rash was slightly scaly. On further examination of skin, it showed extensive tinea cruris extending to the buttocks. No systemic complaints and findings


Laboratory Data

Systemic investigations were negative. Skin scrape from active borders on face mounted in KOH showed numerous hyphae. Scrape from old lesion on face was negative.



Diagnosis Tinea faciei
Reasons Presented

Tinea faciei is not an uncommon problem in Iraq as a result of malpractice or misdiagnosis


How often you see tinea faciei in your country? In any chronic red rash of the face, tinea should be excluded especially in countries where tinea of the skin and animals is a common problem


Gilgar RS.Tindall JP,ElsonM.Lupus erythematosus-like tinea of the face (tinea faciale).JAMA 1971;215:2091-4

Comments from Faculty and Members

David Elpern M.D., Williamstown, MA, USA on July 14, 2005

This is an important presentation since we see these patients a few times a year. It underscores the importance of a KOH prep. The advancing scaly border is a salient finding. Also, examining the rest of the patient as was done here.
How was she treated? I find systemic therapy works best here and still favor griseofulvin.

Julian Manzur M.D., Havana, Cuba on July 15, 2005

Infections by dermatophytes are very common in our country and tinea faciale is not rare, sometimes misdiagnosed and treated with topical steroids.
Lesions are generally annular (ring shaped) with an asymmetric distribution. I think these are very helpful hints. As you say is very important to practice KOH

Henry Foong FRCP, Ipoh, Malaysia on July 16, 2005

I agree that this is not an uncommon condition in our practice. Just about a month ago, I saw 2 cases of tinea faciale and I think a high index of suspicion is important not to miss this condition. Other clues include unilateral involvement, distinct border with an annular margin, sometimes with ear involvement, and history of advancing scaly lesion. KOH examination would be most helpful to confirm clinical suspicion. I almost invariably put these patients on oral antifungals as these patients may not tolerate the topicals well and may result in poor compliance and lower cure rates. The following 2 patients below illustrate the typical features. The 2nd patient was earlier seen by another practitioner who used some topicals which had caused some undesirable effects.

Khaled El-hoshy M.D., Troy, Michigan, USA on July 18, 2005

Three weeks ago, I saw a 14 yr old boy with 6 months hx of facial scaly erythematous rash; on topical steroids. Two weeks of lamisil 250 mg qd did the miracle. Tinea Incognito is a well earned name!

Ibrahim Misk M.D., Amman, Jordan, on July 18, 2005

A very nice case for discussion with colleagues with an open mind.

Azad Kassim M.D., Hasa, Saudi Arabia on July 19, 2005

Actually, in countries where cutaneous fungal infection is common, one can see such cases infrequently and might be confused and misdiagnosed as cases of rosacea, seborrheic dermatitis and lupus erythematosus. Our dear colleague, Professor Sharquie wants to raise an issue that in any suspicious case with long standing red scaly patches on face, tinea faciei should be put in mind, and side lab. direct KOH smear is a must and solve a lot of queries when it is timely performed.

Benjamin Barankin M.D., Department of Dermatology, University of Alberta, Edmonton, Canada on July 20, 2005

Thank you for presenting this very interesting case. This case is a great reminder of the power of the KOH, an open mind, and the visual & deductive wisdom of dermatologists.

Sushil Ratti M.D., Ipoh, Malaysia on July 29, 2005

This condition requires high index of suspicion especially when the clinical signs are totally masked by the misuse of topical steroids. My maxin is any scaly lesion which does not have a specific diagnosis is to be considered for skin scrapping and quite often with appropriate treatment you will get a very grateful patient.The microscope forms a very important tool in our daily practice.

Janjua Shahbaz M.D., Lalamusa, Pakistan on July 29, 2005

A wonderful case presentation indeed. All varieties of dermatophyte infection are commonly seen in our practice in Pakistan. Most of the time these present as tinea incognito due to liberal and prolonged use of topical steroids either as self medication or prescribed by the general practioners due to lack of awareness and misdiagnosis. To address this problem, refresher courses in basic dermatology should be planned for the general practitioners.

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