A Challenging Case of Recalcitrant Facial and Disseminated Rash in a Patient with Autoimmune Comorbidities

Correct Answer: B. Tinea faciei

Tinea faciei is the most likely diagnosis, given the positive KOH findings of septate hyphae. The patient most likely was exposed to tinea faciei from her cat, who she reported had an unknown skin infection. Tinea faciei can be spread by direct contact with an infected person or animal¹.

Lupus erythematous was originally considered, given the past medical history of flares. However, the current treatment regimen failed to alleviate her symptoms. Demodex folliculitis and seborrheic dermatitis involving other body parts outside of the head are both rare and less likely.

Treatment and management. Given the widespread infection, the patient was prescribed oral terbinafine 250 mg taken daily for 2 weeks, and her topical steroid was discontinued. Prior treatment of clotrimazole (dosage and duration was unknown) did not eliminate the dermatophyte.

Due to the possibility of lupus erythematous, skin biopsy was performed on the abdomen and wrist. Histopathology revealed no evidence of lupus erythematous; spongiosis of epidermis and parakeratosis was seen and the biopsy was positive for fungal elements after staining with Periodic acid–Schiff (PAS).

Outcome and follow-up. The patient adhered to her treatment regimen when assessed in a follow-up visit 6 weeks later and did not experience adverse effects or unanticipated events.

Discussion. Tinea faciei is a dermatophyte infection of the face that typically presents as flat, scaly macules or patches with raised borders and an annular configuration. Diagnosing tinea faciei can be difficult because up to 70% of lesions are misdiagnosed as lupus erythematosus, seborrheic dermatitis, rosacea, or granuloma annulare.^1,2 The clinical presentation can become further complicated when treated with corticosteroids, as seen in our patient. Topical steroid use alters the characteristic clinical appearance of the lesion, making it resemble other skin disorders—a phenomenon known as tinea incognito.³ Additionally, topical steroids can spread the infection to hair follicles, including the eyebrows, as was observed in our patient (Figure 1).

A retrospective cohort analysis of 200 cases of tinea incognito in Italy found that the disease frequently mirrored lupus, eczema, or rosacea on the face, as well as eczema-like lesions on the trunk and limbs.⁴ This overlap in clinical appearance may obfuscate the diagnosis, prolonging favorable clinical outcomes. In our patient, past clotrimazole treatment may have removed the dermatophyte from the stratum corneum but left fungal spores in the hair follicles potentially extending the rash symptoms.⁵  Although tinea faciei is typically easy to treat, its ability to mimic other skin disorders can result in delayed diagnosis and prolonged disease. Oral terbinafine is the first-line treatment for extensive tinea infections due to its tolerability, high cure rate, and low cost.⁶

The histopathologic features of lupus erythematosus and tinea infections differ significantly, providing diagnostic clarity when necessary. On histology, cutaneous lupus can show liquefactive vacuolar degeneration of basal cells, thickened basement membranes, dermal mucin deposition, perivascular infiltrates of lymphocytes, histiocytes, and plasma cells, follicular plugging, and telangiectasia.⁷ In contrast, dermatophyte infections may exhibit compact orthokeratosis, epidermal spongiosis with mononuclear cell and neutrophil infiltration, and fungal hyphae in the cornified layers.⁸ While a biopsy is valuable for diagnosing cutaneous lupus erythematosus when suspicion is high, its sensitivity may be limited in detecting hyphae, making KOH preparation, as shown in Figure 4 with branching, septate hyphae in clusters and chains, a preferable initial test in suspected fungal infections due to its cost-effectiveness, non-invasiveness, and rapid results⁶.

Hematoxylin and eosin staining may lack the sensitivity needed to detect fungal hyphae, potentially delaying diagnosis. Therefore, PAS staining is recommended to confirm the presence of hyphae.⁸ While demodex folliculitis may clinically resemble tinea faciei, the application of a KOH stain would detect demodex mites. Furthermore, demodex folliculitis seldom causes symptoms outside of the face.

This case highlights the diagnostic challenge of tinea faciei. Differential diagnoses may include cutaneous lupus erythematous, demodex folliculitis, and seborrheic dermatitis. Early recognition is crucial to prevent mismanagement, such as the continued use of a topical steroid for tinea. Physicians should consider fungal infection in atypical facial lesions unresponsive to therapies as part of their differential.

AUTHORS:
Nabeel Ahmad MD, MSed¹ • Preeti Tekchandani PA² • Thomas N. Helm MD²

AFFILIATIONS:
¹University of Houston College of Medicine, Houston, TX
²Department of Dermatology, Penn State College of Medicine, Hershey, PA

CITATION:
Ahmad N, Tekchandani P, Helm TN. A C\challenging case of recalcitrant facial and disseminated rash in a patient with autoimmune comorbidities. Consultant. Published online November 19, 2025. doi:10.25270/con.2025.11.000003
Received June 29, 2025. Accepted Sep. 4, 2025.

DISCLOSURES:
The authors report no relevant financial relationships.

ACKNOWLEDGEMENTS:
None.

CORRESPONDENCE:
Thomas N. Helm MD, Penn State College of Medicine, 700 HMC Crescent Rd. Hershey, PA 17033 (thelm3@pennstatehealth.psu.edu)

References

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2. Nakamura S, Yamada T, Umemoto N, et al. Cheek and periorbital peculiar discoid lupus erythematosus: rare clinical presentation mimicking tinea faciei, cutaneous granulomatous disease or blepharitis. Case Rep Dermatol. 2015;7(1):56-60. doi:10.1159/000381208
3. Santamore WP, Constantinescu M, Vinten-Johansen J, Johnston WE, Little WC. Alterations in left ventricular compliance due to changes in right ventricular volume, pressure and compliance. Cardiovasc Res. Nov 1988;22(11):768-76. doi:10.1093/cvr/22.11.768
4. Romano C, Maritati E, Gianni C. Tinea incognito in Italy: a 15-year survey. Mycoses. Sep 2006;49(5):383-7. doi:10.1111/j.1439-0507.2006.01251.x
5. Sun PL, Lin YC, Wu YH, Kao PH, Ju YM, Fan YC. Tinea folliculorum complicating tinea of the glabrous skin: an important yet neglected entity. Med Mycol. Jul 01 2018;56(5):521-530. doi:10.1093/mmy/myx086
6. Ely JW, Rosenfeld S, Seabury Stone M. Diagnosis and management of tinea infections. Am Fam Physician. Nov 15 2014;90(10):702-10.
7. Hood AF, Farmer ER. Histopathology of cutaneous lupus erythematosus. Clin Dermatol. 1985;3(3):36-48. doi:10.1016/0738-081x(85)90076-8
8. Park YW, Kim DY, Yoon SY, et al. 'Clues' for the histological diagnosis of tinea: how reliable are they? Ann Dermatol. Apr 2014;26(2):286-8. doi:10.5021/ad.2014.26.2.286

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