Tinea Faciei

Dermatophyte infection of the non-bearded skin of the face. It is less common than tinea at other sites, and is often missed or misdiagnosed because it lacks the typical appearance.

• Organisms: Trichophyton rubrum, T. mentagrophytes, T. tonsurans, Microsporum canis (from cats, dogs and rabbits) and T. verrucosum (from cattle).
• Infection arises from other sites (autoinoculation from the feet, nails, groin or scalp), from animals, from household contacts, or from contact sports.
• It is commonest in children and in adults who use topical steroids or immunosuppressants, which suppress inflammation and alter its appearance (tinea incognito). Sun exposure often makes it worse.
• Diagnosis is frequently delayed by weeks to months.

• A red, scaly, well demarcated patch or ring with a slightly raised edge, central clearing and mild to moderate itch. Lesions are often asymmetrical and photosensitive.
• Steroid use produces a less scaly, more diffuse patch with papules, pustules and an indistinct edge.
• Zoophilic infection is more inflammatory, with vesicles and pustules.
• Differential diagnosis: seborrhoeic dermatitis, discoid and subacute cutaneous lupus erythematosus, rosacea, perioral dermatitis, contact dermatitis, atopic dermatitis, polymorphic light eruption, psoriasis, impetigo, granuloma annulare, erythema migrans and cutaneous lymphoma.
• Complications: scarring if inflamed, secondary bacterial infection, post-inflammatory pigmentation, relapse and spread to the scalp or beard.

• Scrapings from the active edge in potassium hydroxide 10 to 20% show hyphae. Send for culture for 2 to 4 weeks. Polymerase chain reaction testing is useful where available.
• Wood lamp: green fluorescence for M. canis.
• Examine scalp, feet, nails, groin and pets, and ask about animal contact, topical steroid or calcineurin inhibitor use.
• Biopsy with periodic acid Schiff staining if the diagnosis is uncertain or the lesion has not responded.

• Stop topical steroids and calcineurin inhibitors on the lesion.
• Topical therapy for limited disease:
  • Terbinafine 1% cream once or twice daily for 1 to 2 weeks.
  • Clotrimazole 1%, miconazole 2% or econazole 1% cream twice daily for 2 to 4 weeks.
  • Continue for 1 week after clearing.
• Oral therapy for extensive, inflammatory, steroid modified or recurrent disease, or when involvement of hair follicles is suspected:
  • Terbinafine 250 mg orally daily for 2 weeks (child under 20 kg 62.5 mg, 20 to 40 kg 125 mg).
  • Itraconazole 100 mg orally daily for 2 weeks, or 200 mg daily for 1 week (capsules with food).
  • Fluconazole 150 to 200 mg orally once weekly for 2 to 4 weeks (child 6 mg/kg once weekly).
  • Griseofulvin microsize 10 to 20 mg/kg per day (adult 500 mg to 1 g) for 4 weeks if other agents are unsuitable.
  • Check liver function if the course is longer than 4 weeks.
• Treat coexisting tinea at other sites, treat infected animals through a veterinarian, and wash towels and pillowcases at 60 C.
• Apply sunscreen to reduce photosensitivity and pigmentation.
• Special groups:
  • Pregnancy: use topical clotrimazole or miconazole and avoid oral therapy.
  • Children: use topical therapy, with weight based oral therapy for extensive disease.
  • Renal or hepatic impairment: avoid terbinafine in creatinine clearance below 50 mL/min or active liver disease.
  • Immunosuppression: treat for longer and use oral therapy early.
• Treatment failure: repeat culture, review for steroid use, exclude lupus, rosacea and dermatitis, and consider biopsy.
• Follow up: review at 2 to 4 weeks. Refer to dermatology if the diagnosis is uncertain or there is no response.