ORIGINAL ARTICLE

Dermatology

http://dx.doi.org/10.3346/jkms.2013.28.1.145 • J Korean Med Sci 2013; 28: 145-151

Tinea Incognito in Korea and Its Risk Factors: Nine-Year

Multicenter Survey
Won-Jeong Kim,1,2 Tae-Wook Kim,1,2 Je-Ho Mun,1,2 Tinea incognito (TI) is a dermatophytic infection which has lost its typical clinical
Margaret Song,1,2 Hoon-Soo Kim,1,2 appearance because of improper use of steroids or calcineurin inhibitors. The
Hyun-Chang Ko,1,2 Byung-Soo Kim,1,2 incidence of TI is increasing nowadays. We conducted retrospective review on 283
Chun Wook Park,3 Seok-Jong Lee,4 patients with TI from 25 dermatology training hospitals in Korea from 2002–2010
Mu Hyoung Lee,5 Kyu Suk Lee,6 Young Chul Kye,7 to investigate the demographical, clinical, and mycological characteristics of TI,
Kee Suck Suh,8 Hyun Chung,9 Ai Young Lee,10 and to determine the associated risk factors. More than half (59.3%) patients were
Ki Ho Kim,11 Sook Kyung Lee,12 previously treated by non-dermatologists or self-treated. The mean duration of TI
Kyoung Chan Park,13 Jun Young Lee,14 was 15.0 ± 25.3 months. The most common clinical manifestations were eczema-
Jee Ho Choi,15 Eun-So Lee,16 Kwang Hoon Lee,17
like lesion, psoriasis-like, and lupus erythematosus-like lesion. The trunk and face
Eung Ho Choi,18 Jong Keun Seo,19
were frequently involved, and 91 patients (32.2%) also had coexisting fungal
Gwang Seong Choi,20 Hai Jin Park,21
Seok Kweon Yun,22 Seong Jun Seo,23
infections. Among 67 isolated strains, Trichophyton rubrum was the most
Tae Young Yoon,24 Kwang Ho Kim,25 Hee Joon Yu,26 frequently detected (73.1%). This is the largest study of TI reported to date and the
Young Suck Ro,27 and Moon-Bum Kim1,2 first investigational report concerning TI in Korea. We suggest that doctors should
consider TI when a patient has intractable eczema-like lesions accompanied by
1
Department of Dermatology, Pusan National University tinea pedis/unguium. Furthermore, there should be a policy change, which would
School of Medicine, Busan; 2Biomedical Research Institute, make over-the-counter high-potency topical steroids less accessible in some
Pusan National University Hospital, Busan; 3Department of countries, including Korea.
Dermatology, Kangnam Sacred Heart Hospital, Hallym
University College of Medicine, Seoul; 4Kyungpook National
University School of Medicine, Daegu; 5Kyung Hee University Key Words:  Calcineurin Inhibitor; Dermatophytoses; Korea; Steroid; Tinea; Tinea
College of Medicine, Seoul; 6 Keimyung University School of Incognito
Medicine, Daegu; 7Korea University College of Medicine,
Seoul; 8Kosin University College of Medicine, Busan; 9 The
Catholic University of Daegu College of Medicine, Daegu;
10
Dongguk University Ilsan Hospital, Dongguk University
College of Medicine, Goyang; 11Dong-A University College of
Medicine, Busan; 12Maryknoll Medical Center, Busan; 13Seoul
National University Bundang Hostpital, Seongnam; 14 Seoul
St. Mary’s Hospital, The Catholic University of Korea College
of Medicine, Seoul; 15Asan Medical Center, University of Ulsan
College of Medicine, Seoul; 16Ajou University School of
Medicine, Suwon; 17Severance Hospital, Yonsei University
College of Medicine, Seoul; 18Wonju Christian Hospital, Yonsei
University Wonju College of Medicine, Wonju; 19Busan Paik
Hospital, Inje University College of Medicine, Busan; 20Inha
University College of Medicine, Incheon; 21Ilsan Paik Hospital,
Inje University College of Medicine, Goyang; 22Chonbuk
National University Medical School, Jeonju; 23Chung-Ang
University College of Medicine, Seoul; 24Chungbuk National
University School of Medicine, Cheongju; 25Hallym University
College of Medicine, Anyang; 26Guri Hospital, Hanyang
University College of Medicine, Guri; 27Hanyang University
College of Medicine, Seoul, Korea

Received: 4 September 2012

Accepted: 31 October 2012

Address for Correspondence:

Moon-Bum Kim, MD
Department of Dermatology, Pusan National University School of Medicine,
179 Gudeok-ro, Seo-gu, Busan 602-739, Korea
Tel: +82.51-240-7338, Fax: +82.51-245-9467
E-mail: [email protected]

This work was subsidized by a research grant from the Janssen Award in 2010.

© 2013 The Korean Academy of Medical Sciences. pISSN 1011-8934

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0)
which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. eISSN 1598-6357
 Kim W-J, et al.  •  Tinea Incognito in Korea and Its Risk Factors

INTRODUCTION However, there has been no published large-scale study on TI

in Korea, as yet. For this reason, we investigated the demo-
Tinea incognito (TI) is the term given to a dermatophyte infec- graphics and past medical histories of TI patients, and clinical
tion, which has been modified in appearance by improper use and mycological characteristics of TI in Korea.
of steroids or calcineurin inhibitors (1, 2). Since it was first de-
scribed by Ive and Marks in 1968 (3), a few case reports and a MATERIALS AND METHODS
number of review articles have been published on TI in English
journals (1, 2, 4-6). Though typical dermatophytic infection on Patients
most skin surfaces except scalp, volar areas and nails usually In the period from 2002 to 2010, cases of TI were collected ret-
present as annular lesions with erythematous scaly border and rospectively from dermatologic departments of 25 general hos-
central clearing. Therefore, dermatophytic infection may be pitals in Korea, which had a dermatology training program. We
confused with other skin disorders such as granuloma annu- defined 4 criteria for diagnosis of TI: 1) loss of typical clinical
lare, discoid lupus erythematosus, pityriasis rosea, erythema appearance of tinea (Fig. 1A); 2) previous history of corticoste-
annulare centrifugum, erythema migrans, or other dermato- roid (topical or systemic) or calcineurin inhibitor application to
logical lesions (7). Most textbooks or review articles state that present lesions; 3) positive for at least 1 mycological evaluation
mycological confirmation with laboratory testing before the (KOH examination, mycologic culture, or skin biopsy with D-
start of antifungal therapy is recommended because the clinical PAS stain); and 4) improvement after antifungal treatment. To
diagnosis of fungal presence could be inaccurate (8). However, be enrolled in this study, all patients had to satisfy all the 4 diag-
this is not easy to do in practice because of time pressure, inad- nostic criteria listed above. Only the cases confined to dorsum
equate access to equipment, lack of experience, low reproduc- of hands and feet were included to avoid confusion with tinea
ibility, and so on (8, 9). Misdiagnosed dermatophytic disorders pedis and tinea manus.
could be treated improperly with steroids. As some high-poten-
cy topical steroids are easily accessible as over-the-counter Ethics statement
(OTC) products and non-dermatologists can also prescribe The study protocol was approved by Institutional Review Boards
topical steroids freely without any fungal examination, the inci- or Ethics Committees of Pusan National University Hospital and
dence of TI seems to be gradually increasing in Korea (10). informed consent was obtained.

A B C

D E F G

Fig. 1. Various features of tinea incognito (A-G). Vitiligo-like (A; pre-treatment, B; after 4 weeks of application of topical pimecrolimus, C; 6 weeks after topical antifungal treat-
ment), contact dermatitis-like (D), nonspecific eczema-like (E), seborrheic dermatitis-like (F), and lupus erythematosus-like (G) lesions.

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Kim W-J, et al.  •  Tinea Incognito in Korea and Its Risk Factors

Demographics, past histories, and clinical characteristics patients with TI under 10 and over 80 yr old. Sixty-five patients
Clinical data including charts and clinical photos from 25 hos- (23.0%) had coexisting diseases at first clinic visit such as hyper-
pitals were systematically and retrospectively reviewed. Demo- tension in 37 (13.1%), diabetes in 23 (8.1%), and hepatitis in 7
graphic information included age, gender, coexisting diseases, (2.5%). Five patients had underlying malignancy (1.8%), 2 patients
and other dermatologic diseases. Past medical histories includ- suffered from angina, and 2 patients had asthma. In addition,
ed the duration of TI, how the patients obtained the topical ste- 1 patient had adrenal insufficiency, 1 patient had myasthenia
roid or calcineurin inhibitor, and treatment modality. After divid- gravis, 1 had depression, and 1 had epilepsy. Sixteen patients
ing the patients into 3 groups (dermatologist-treated, non-der- (5.7%) had coexisting dermatologic diseases including 5 pa-
matologist-treated, and self-treated TI groups), the duration of tients with atopic dermatitis (1.8%), 4 patients with psoriasis
TI and treatment modality were compared among the 3 groups. (1.4%), 3 with systemic lupus erythematosus (1.1%), and 2 with
Regarding the clinical characteristics of TI, the distribution, the
most likely clinical feature, and coexisting fungal infections were
Table 1. Demographics and past histories of 283 cases of tinea incognito in Korea
investigated. during 2002-2010
Parameters No. (%)
Mycological data
No. of patients 283 (100.0)
The KOH examination (20% potassium hydroxide) was per- Male: Female, No. (%) 158:125 (55.7:44.3)
formed to check for the presence of fungi. Mycological culture Mean age (yr) 44.6 ± 22.3 (range 3-94)
was performed on Sabouraud dextrose agar with chloramphe- Age distribution, No. (%)
0-10 24 (8.5)
nicol and cycloheximide. After incubation at 25°C for at least 11-20 25 (8.8)
3 weeks, dermatophytes were identified by means of gross mor- 21-30 31 (11.0)
phology, light microscopy, and/or biopsy with PAS stain (11). 31-40 38 (13.4)
41-50 40 (14.1)
51-60 41 (14.5)
Statistical analysis 61-70 44 (15.5)
Pearson’s chi-square test was used to compare the frequency of 71-80 33 (11.7)
81-90 6 (2.1)
treatment modalities and one-way ANOVA was used to com- > 90 1 (0.4)
pare the duration of TI among dermatologist-treated, non-der- Coexisting disease, No. (%) 65 (23.0)
matologist-treated, and self-treated TI patients group. A P value Hypertension 37 (13.1)
Diabetes 23 (8.1)
of less than 0.05 was considered statistically significant. Hepatitis 7 (2.5)
Malignancy 5 (1.8)
RESULTS Angina 2 (0.7)
Asthma 2 (0.7)
Others 4 (1.4)
Demographics Coexisting dermatologic diseases, No. (%) 16 (5.7)
After thorough review, 283 patients fulfilled the diagnostic cri- Atopic dermatitis 5 (1.8)
Psoriasis 4 (1.4)
teria of TI in this study. The mean age was 44.0 ± 22.5 yr (range Systemic lupus erythematosus 3 (1.1)
3-94) and 125 patients (44.3%) were female. Table 1 shows the Seborrheic dermatitis 2 (0.7)
age distribution of TI patients with a slightly lower frequency of Others (rosacea, bullous pemphigoid) 2 (0.7)

Table 2. Mean duration of the disease and previous treatment modalities according to past physician’s specialty
Disease status Dermatologists Non-dermatologists Self-treatment † Total P value*
Mean duration of the disease (mo ± SD) 16.4 ± 25.8 15.7 ± 28.1 9.0 ± 11.1 15.0 ± 25.3 0.234
Treatment modalities, No. (%)
Topical steroid only 90 (31.8) 112 (39.6) 44 (15.5) 246 (86.9) < 0.001
Systemic steroid only - - - - -
Topical and systemic steroid 9 (3.2) 9 (3.2) - 18 (6.4) 0.175
Topical steroid and topical calcineurin inhibitor 8 (2.8) 1 (0.4) - 9 (3.2) 0.010
Topical steroid and systemic antibiotics 2 (0.7) 2 (0.7) - 4 (1.4) 0.692
Steroid intralesional injection 1 (0.4) - - 1 (0.4) 0.224
Topical steroid and steroid intralesional injection 1 (0.4) - - 1 (0.4) 0.474
Systemic steroid and topical calcineurin inhibitor 1 (0.4) - - 1 (0.4) 0.474
Systemic steroid and topical antibiotics 1 (0.4) - - 1 (0.4) 0.474
Topical calcineurin inhibitor only 2 (0.7) - - 2 (0.7) 0.224
Total, N (%) 115 (40.6) 124 (43.8) 44 (15.5) 283 (100.0)
*P value < 0.05 considered statistically significant; using one-way ANOVA test in mean duration and Pearson’s chi-square test in treatment modalities; † For children younger
than 12, self-treatment group also include treatment by parents or others.

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 Kim W-J, et al.  •  Tinea Incognito in Korea and Its Risk Factors

seborrheic dermatitis (0.7%). There was 1 patient with rosacea, injection, or a combination of aforementioned agents. Overall,
and 1 patient with bullous pemphigoid. most of TI patients were treated with topical steroids only (86.9%),
and other treatment modalities included topical and systemic
Past medical histories steroids (6.4%), topical steroid and topical calcineurin inhibitor
The mean duration of TI in the study patients was 15.0 ± 25.3 (1.4%), and topical calcineurin inhibitor (0.7%), etc. There were
months. While mean duration of self-treated TI patients was no significant differences in treatment modalities according to
9.0 ± 11.1 months, that of TI patients treated by dermatologists past physician’s specialty (P > 0.05).
and non-dermatologists was 16.4 ± 25.8 and 15.7 ± 28.1 months,
respectively. There was no statistical significance among the 3 Clinical characteristics
groups (P = 0.234) (Table 2). Overall, the trunk (30.4%) is the most commonly affected area
  Before coming to the teaching hospital, 40.6% of TI patients of TI followed by the face (24.4%), foot (13.8%), multiple involve-
received treatment from a dermatologist, 43.8% from non-der- ments (13.8%), the groin (9.9%), and hand (7.8%) (Table 3). The
matologists, and another 15.5% were self-treated. While all of clinical features were variable, but regardless of distribution,
self-treated patients used topical steroids only, people treated over more than three-quarters of all study patients showed ec-
by dermatologists or non-dermatologists used various treatment zema-like (82.0%) lesions which included nonspecific eczema,
modalities such as topical/systemic steroids, topical/systemic contact dermatitis, seborrheic dermatitis, and atopic dermatitis.
antibiotics, topical calcineurin inhibitor, steroid intralesional Less often, TI mimicked psoriasis (6.0%), lupus erythematosus

Table 3. Clinical and mycological characteristics of 283 cases of tinea incognito in Korea during 2002-2010
TI distribution Face Trunk Groin Hand* Foot* Multiple Total
Clinical manifestation, No. (%) 69 (24.4) 86 (30.4) 28 (9.9) 22 (7.8) 39 (13.8) 39 (13.8) 283 (100.0)
Eczema-like 53 (76.8) 68 (79.1) 25 (89.3) 22 (100.0) 37 (94.9) 27 (69.2) 232 (82.0)
Nonspecific eczema 30 (43.5) 54 (62.8) 25 (89.3) 19 (86.4) 35 (89.7) 23 (59.0) 186 (65.7)
Contact dermatitis 16 (23.2) 8 (9.3) - 3 (13.6) 1 (2.6) 4 (10.3) 32 (11.3)
Atopic dermatitis 3 (4.3) 1 (1.2) - - 1 (2.6) - 5 (1.8)
Seborrheic dermatitis 3 (4.3) 1 (1.2) - - - - 4 (1.4)
Diaper dermatitis - 2 (2.3) - - - - 2 (0.7)
Intertrigo - 1 (1.2) - - - - 1 (0.4)
Nummular dermatitis 1 (1.4) - - - - - 1 (0.4)
Stasis dermatitis - 1 (1.2) - - - - 1 (0.4)
Psoriasis-like 1 (1.4) 9 (10.5) 1 (3.6) - - 6 (15.4) 17 (6.0)
Lupus erythematosus-like 6 (8.7) - - - - 1 (2.6) 7 (2.5)
Impetigo-like 2 (2.9) 2 (2.3) - - - - 4 (1.4)
Urticaria-like 1 (1.4) 1 (1.2) 1 (3.6) - - - 3 (1.1)
Folliculitis-like 1 (1.4) - - - - 1 (2.6) 2 (0.7)
Lichen simplex chronicus-like - 1 (1.2) - - - 1 (2.6) 2 (0.7)
Vitiligo-like 2 (2.9) - - - - - 2 (0.7)
Xerosis-like - - - - 2 (5.1) - 2 (0.7)
Others 3 (4.3) 5 (5.8) 1 (3.6) - - 3 (7.7) 12 (4.2)
The percentage of children 8 (28.6) 10 (35.7) 1 (3.6) 2 (7.1) 4 (14.3) 3 (10.7) 28 (100.0)
(age < 12, N = 28)
Combined fungal disease ‡ 12 (4.2) 24 (8.5) 11 (3.9) 6 (2.1) 19 (6.7) 19 (6.7) 91 (32.2)
T. pedis 4 (33.3) 16 (66.7) 9 (81.8) 3 (50.0) - 7 (36.8) 39 (42.9)
T. unguium 1 (8.3) 5 (20.8) - 3 (50.0) 12 (63.2) 8 (42.1) 29 (31.9)
T. pedis et unguium 7 (58.3) 3 (12.5) 2 (18.2) - 7 (36.8)§ 4 (21.1) 23 (25.3)
KOH † 69 (24.4) 86 (30.4) 28 (9.9) 22 (7.8) 39 (13.8) 39 (13.8) 283 (100.0)
Positive 59 (85.5) 80 (93.0) 28 (100.0) 20 (90.9) 38 (97.4) 35 (89.7) 260 (91.9)
Negative 10 (14.5) 6 (7.0) - 2 (9.1) 1 (2.6) 4 (10.3) 23 (8.1)
Biopsy with D-PAS stain 21 (7.4) 15 (5.3) 1 (0.4) 3 (1.1) 1 (0.4) 8 (2.8) 49 (17.3)
Positive (fungal hyphae or spores) 19 (90.5) 12 (80.0) 1 (100.0) 2 (66.7) 1 (100.0) 7 (87.5) 42 (85.7)
Negative 2 (9.5) 3 (20.0) - 1 (33.3) - 1 (12.5) 7 (14.3)
Culture 19 (6.7) 15 (5.3) 5 (1.8) 3 (1.1) 6 (2.1) 19 (6.7) 67 (23.7)
Trichophyton rubrum 10 (52.6) 11 (73.3) 4 (80.0) 3 (100.0) 5 (83.3) 16 (84.2) 49 (73.1)
Trichophyton mentagrophytes 3 (15.8) - - - 1 (16.7) 2 (10.5) 6 (9.0)
Trichophyton tonsurans 1 (5.3) 1 (6.7) - - - - 2 (3.0)
Trichophyton verrucosum - 1 (6.7) 1 (20.0) - - - 2 (3.0)
Microsporum canis 3 (15.8) 2 (13.3) - - - 1 (5.3) 6 (9.0)
Microsporum gypseum 2 (10.5) - - - - - 2 (3.0)
*TI involves hand and foot but confined to dorsal aspects; † KOH, potassium hydroxide examination; ‡ Combined fungal disease: fungal disease which involves distant areas with
present TI; § Tinea unguium with tinea corporis.

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Kim W-J, et al.  •  Tinea Incognito in Korea and Its Risk Factors

(2.5%), impetigo (1.4%), urticaria (1.2%), folliculitis (0.7%), and the use of topical calcineurin inhibitors has been increasing
other dermatological lesions (Table 3). According to the anatom- gradually in many dermatologic diseases such as atopic derma-
ical distribution, facial TI presented as eczema-like (76.8%), lu- titis, seborrheic dermatitis, intertriginous psoriasis, contact der-
pus erythematosus-like (8.7%), impetigo-like (2.9%), and vitili- matitis and other dermatological lesions (12), the number of
go-like (2.9%) lesions. Trunk TI presented as eczema-like (79.1%) cases of modified tinea has also increased (7, 13, 14). Thus, we
and psoriasis-like (10.5%) lesions, and almost all of groin, hand, propose that TI be defined as certain dermatophytoses which
and foot TI resembled eczema. When TI involved multiple sites, have lost their usual clinical manifestation because of erroneous
it appeared similar to eczema (69.2%), psoriasis (15.4%), follic- use of systemic/topical corticosteroids or topical calcineurin
ulitis (2.6%), and other dermatological lesions (Table 3). In chil- inhibitor, as in 1 recent article (2). In addition, we think that TI,
dren, TI was most likely to be found in the facial area (11.6%), which involves the hand or the foot, should be confined to the
and the trunk (11.6%), and least likely to be found in the groin dorsal surface, because tinea pedis and tinea manus cannot be
(3.6%). definitively differentiated from TI involving the palm or the sole.
  In 91 cases (32.2%), other fungal diseases such as tinea pedis It has been suggested that the use of immunosuppressants de-
(42.9%), tinea unguium (31.9%), tinea pedis et unguium, or tin- creases the fungus-induced local inflammation, and this may al-
ea unguium/tinea corporis (25.3%) were diagnosed apart from low the fungus to grow slowly with less erythema or scaling caus-
TI sites (Table 3). According to anatomical distribution, TI of ing a “modification” of the typical manifestation of tinea (7).
the trunk, groin, or hand was commonly seen with tinea pedis   While TI seems to be common in dermatology practices cur-
(> 50.0%), TI involving foot or multiple areas usually accompa- rently, only a few numbers of large scale studies have been re-
nied tinea unguium, and facial TI was strongly associated with ported (1, 2, 4). These studies were done in Italy, Spain, and Iran.
tinea pedis et unguium. Our study in Korea was designed to be the largest scale study
on TI. While previous case reports of TI in Korean literature (10,
Mycological data 15-21) (Table 4) showed female predominance, this study showed
Direct microscopic examination was performed in all cases and relatively equal gender distribution and relatively uniform age
260 cases (91.9%) were positive. Of 49 biopsied specimens, 42 distribution (mean: 44.0 ± 22.5 yr) were found except for patients
(85.7%) showed fungal hyphae and/or spores by D-PAS stain. over 80 yr. A recent article regarding TI in Italy (1) also reported
Sixty-seven cases (23.7%) were cultured in our study and Tricho- equal gender distribution and similar mean age (42 yr), and an-
phyton rubrum was the most frequently detected dermatophyte other article in Iran (4) also revealed equal gender distribution
(49/67, 73.%), regardless of TI distribution. Trichophyton men- with slightly younger mean age (32.6 yr). Based on these data,
tagrophytes (6/67, 9.0%) and Microsporum canis (6/67, 9.0%) we can postulate that TI is common in middle-aged persons
were the second-most frequently detected causative agents, and with little difference in gender. Moreover, 65 (23.0%) patients in
T. tonsurans, T. verrucosum and M. gypseum were also isolated our study had coexisting non-dermatologic diseases such as
in a few cases. While only 1 or 2 species of dermatophytes were hypertension, diabetes, hepatitis, malignancy, and so on, and
found in groin, hand, and foot TI, various kinds of fungi were 16 (5.7%) patients had coexisting dermatologic disorders requir-
identified in face or trunk TI (Table 3). ing systemic steroids or other immunosuppressants. This was
lower than the previous Italian report in that 40% of patients
DISCUSSION with TI had non-dermatological pathologies which required
treatment with systemic steroids (1). Though the percentage of
Tinea incognito had been defined as tinea modified by the im- the patients in this study who received immunosuppressive
proper use of systemic or topical corticosteroids. However, as therapy was lower than in the Italian report, the possibility of TI
Table 4. Previous reports of tinea incognito in Korean literatures
Case Report S/A Clinical manifestation Site Previous treatment Dermatophyte isolated
1 Yang et al. (15) F/47 Eczema-like Face, trunk, extremities Topical steroids T. mentagrophytes
2 Kang et al. (16) F/64 Eczema-like Face Topical steroids T. mentagrophytes
3 Kim et al. (17) F/70 Contact dermatitis-like Face, scalp Topical steroids T. rubrum
4 Choi et al. (10) M/8 Atopic dermatitis-like Face Topical calcineurin inhibitor T. mentagrophytes
5 Han et al. (18) M/49 Atopic dermatitis-like Face Topical and systemic steroid T. rubrum
6 Park et al. (19) F/40 Eczema-like Face Topical steroid and T. mentagrophytes
systemic antibiotics
7 Hwang et al. (20) F/15 Eczema-like Leg Topical steroid and T. rubrum
topical calcineurin inhibitor
8 Lee et al. (21) F/23 Insect bite-like Arm Topical steroids T. mentagrophytes
S/A, sex and age (years).

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 Kim W-J, et al.  •  Tinea Incognito in Korea and Its Risk Factors

should be kept in mind whenever the patient with skin lesions Table 5. Suggested risk factors of tinea incognito
is on immunosuppressant medications. 1. Long-lasting erythematous scaly skin lesions
  There have been no published data regarding TI according 2. Unresponsive to steroids or calcineurin inhibitor treatment
to past treating physician’s specialty or treatment modalities, 3. Truncal or facial lesion
4. Combined tinea pedis/unguium
as yet. Based on our study, over half of the patients were either
5. Under immunosuppressant treatment or medications
treated by non-dermatologists (124/283, 43.8%) or self-treated
(44/283, 15.5%). TI was thought to be associated with easy ac-
cess to high-potency OTC topical steroids such as betametha- eczema-like features were quite high, TI of the face, trunk, or
sone valerate by patients and with lack of understanding of tin- multiple areas showed more variable features. Therefore, not
ea by non-dermatologists. Therefore, there should be swift poli- only eczema-like lesions but also other recalcitrant skin mani-
cy changes to limit OTC access of high-potency steroids to pa- festations resembling psoriasis, lupus erythematosus, impetigo,
tients in Korea. This would limit inappropriate tinea treatment urticaria, etc., should also be carefully evaluated to rule out TI
by patients. Furthermore, to reduce the number of cases of TI especially when skin diseases involve the face, the trunk, or mul-
caused by non-dermatologists, education regarding skin dis- tiple areas (Table 5).
eases including fungal infections could be provided by Korean   Moreover, one-third of our study population (32.2%) had
Dermatologic Associations. combined fungal diseases, which involved distant areas from
  Surprisingly, about 40% of the patients were treated by der- present TI, and most of them had dermatophytic infection on
matologists in this study. Even though tinea can mimic many their feet regardless of affected areas, including tinea pedis and
other skin disorders and there could be selection bias, this ratio tinea unguium. Therefore, in patients with refractory skin dis-
seems to be too high. This may mean a lack of mycological eval- ease especially resembling eczema and also with concomitant
uation and carelessness of dermatologists when diagnosing tin- tinea pedis or tinea unguium, TI should be ruled out because
ea infection. It is important for dermatologists to consider fun- these coexisting fungal infections could be an autoinoculation
gal infection in the differential diagnosis of skin disorders, and source of superficial dermatophytic infection in another body
increase the use of laboratory tests for mycological evaluation. part at any time.
In practice, the medical cost for mycological examinations is   As many previous studies confirmed (1, 23-25), Trichophyton
very low in Korea. However, the patient load is high and doctors rubrum (T. rubrum) was also the most frequently identified der-
are pressed for time. This could be the prime reason for misdi- matophyte. T. rubrum is one of the anthropophilic dermato-
agnosis of fungal infections (22). Therefore, we think that if phy- phytes and the most common pathogen in tinea corporis, tinea
sicians were better paid for mycological evaluations there might cruris, tinea manus, tinea pedis, and tinea unguium (26). Since
be more active mycological examinations and fewer misdiag- TI affecting the trunk, groin, hands, and feet accounted for al-
noses of fungal infections. most 60% of T1 in our study, it would not be surprising that T.
  On the aspect of distribution, the trunk was the most com- rubrum was the most commonly isolated dermatophyte. More-
monly involved site of TI and the face was another commonly over, the high prevalence of combined tinea pedis and tinea un-
involved area, as reported in other original articles (1, 4) and guium might also have contributed to the high isolation rate of
previous Korean literatures. Another recent study regarding 54 T. rubrum. Anthropophilic dermatophytes have adapted to hu-
childhood TI cases also reported similar results with highest mans and elicit a mild to non-inflammatory host response unlike
incidence in the trunk and face (2), and our study backed it up zoophilic and geophilic infections (26). This mild inflammatory
with the same results. From these findings, we can postulate response might be the cause of the long duration of TI because
that the most common sites of TI are trunk and face regardless topical corticosteroids or topical calcineurin inhibitor could al-
of age. leviate the inflammation, which could be the main mechanism
  The clinical features of TI were reported to be variable, and of disguising the typical manifestation of tinea.
the most prevalent features seen are eczema-like disorders such   In summary, our research was the largest study of TI in Korea
as nonspecific eczema, contact dermatitis, and atopic dermati- to date. We investigated the characteristics of TI according to
tis (1, 4, 7), and previous Korean reports about TI also in accor- the primary physician’s specialty though the clinical and myco-
dance with it. Similarly, 232 TI patients in this study showed logical results were similar to previous studies. From this study,
quite various clinical features such as eczema-like, psoriasis- we can suggest that long-lasting erythematous scaly skin lesions
like, lupus erythematosus-like, and etc. Specifically, nearly all unresponsive to steroids or calcineurin inhibitor as the most
cases of hand and foot TI showed eczema-like features. There- important risk factors of TI. Not only truncal or facial involve-
fore, when dealing with recalcitrant eczematous lesions on the ment, but also combined tinea pedis/unguium or the history of
hand or foot, mycological examination should always be con- immunosuppressant treatment could also be a good clue in di-
sidered. Compared to TI of groin, and hand and foot, where the agnostic approach of TI. Moreover, we can suggest several things

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Kim W-J, et al.  •  Tinea Incognito in Korea and Its Risk Factors

to reduce the incidence of TI based on our results. First, reform of guidelines among dermatologists. Br J Dermatol 2006; 155: 1080-2.
of OTC sales system of high-potency topical steroids is needed 10. Choi YL, Kim JA, Rho NK, Lee DY, Lee JH, Yang JM, Lee ES, Kim WS. A
so that they are not as easily available to the public in some coun- case of tinea incognito induced by 1% pimecrolimus (Elidel) cream. Ko-
rean J Dermatol 2006; 44: 731-3.
tries including Korea. Second, non-dermatologists need to be
11. Hsiao YP, Lin HS, Wu TW, Shih HC, Wei SJ, Wang YL, Lin KL, Chiou HL,
informed and educated that superficial dermatophytic infection
Yang JH. A comparative study of KOH test, PAS staining and fungal cul-
could appear in a variety of forms. Care by experienced derma-
ture in diagnosis of onychomycosis in Taiwan. J Dermatol Sci 2007; 45:
tologists could also be needed especially when dealing with
138-40.
long-lasting erythematous scaly skin lesions, which have prov- 12. Wollina U, Hansel G, Koch A, Abdel-Naser MB. Topical pimecrolimus
en to be unresponsive to steroids or calcineurin inhibitor treat- for skin disease other than atopic dermatitis. Expert Opin Pharmacother
ment. Finally, we recommend dermatologists not to neglect TI 2006; 7: 1967-75.
as a possibility in cases of recalcitrant variable skin lesions, not 13. Crawford KM, Bostrom P, Russ B, Boyd J. Pimecrolimus-induced tinea
hesitating to do active mycological examinations, which would incognito. Skinmed 2004; 3: 352-3.
give them some critical clues in diagnosis of TI, and doing care- 14. Siddaiah N, Erickson Q, Miller G, Elston DM. Tacrolimus-induced tinea
ful clinical examinations when finding combined tinea pedis or incognito. Cutis 2004; 73: 237-8.
tinea unguium. 15. Yang CW, Lee BG, Lee MH, Kim NI. A case of tinea incognito. Korean J
Dermatol 1989; 27: 79-82.
16. Kang HY, Son HC, Lim YS, Cho YW, Han JY. A case of tinea incognito on
ACKNOWLEDGMENTS
the face due to Trichophyton mentagrophytes. Korean J Dermatol 2000;
38: 1124-6.
The authors have no conflicts of interest to disclose.
17. Kim KJ, Jee MS, Choi JH, Sung KJ, Moon KC, Koh JK. A case of tinea in-
cognito presented as folliculitis. Korean J Dermatol 2001; 39: 1328-30.
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