AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Tinea faciei is a superficial dermatophyte infection limited to the glabrous skin of the face. In pediatric and female patients, the infection may appear on any surface of the face, including the upper lip and chin. In men, the condition is known as tinea barbae when a dermatophyte infection of bearded areas occurs.

Pathophysiology

Keratinophilic fungi, or dermatophytes, are responsible tinea faciei. Dermatophytes release several enzymes, including keratinases, which allow them to invade the stratum corneum of the epidermis. Infection caused by zoophilic dermatophytes is usually associated with inflammatory reactions that are more severe than those due to anthropophilic fungi.

Frequency

International

Tinea faciei is not an uncommon disease. It occurs worldwide. However, as with other cutaneous fungal infections, it is more common in tropical regions with high temperatures and humidity. Recently, tinea faciei was shown to represent approximately 19% of all superficial fungal infections in the pediatric population with dermatomycoses.

Mortality/Morbidity

Scarring may occur in patients with Trichophyton schoenleinii infection; this is extremely rare.

Sex

Some authors suggest that females may be affected more frequently than males, but the difference is probably semantic. In females, dermatophyte infection of the face is more likely to be diagnosed as tinea faciei, whereas many infections that occur in similar locations in men are diagnosed as tinea barbae. Recent data indicate a female-to-male ratio of 1.06:1.

Age

Tinea faciei may appear in persons of any age, with 2 peaks of disease incidence. One peak involves children, who constitute a large group of patients because of their frequent direct contact with pets. Tinea faciei is commonly noted as a dermatosis that occurs after holidays; it is diagnosed more frequently in children after they spend their holidays in rural areas, where they may come into contact with animals when they play. Several cases are also reported in neonates; these patients may acquire the infection from siblings or contact with pets. The other peak occurs in those aged 20-40 years.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

• The infection is frequently acquired from pets in the home, but it can also be spread from individuals with dermatophyte infection elsewhere on the body.
• Tinea faciei may resemble other dermatoses, such as cutaneous lupus erythematosus, polymorphous light eruption, and allergic contact dermatitis (Meymandi, 2003).

Physical

• Because of the complex anatomy of the face, atypical features are more frequently found on the glabrous skin than the typical patches of tinea corporis.
• Single or multiple erythematous patches without annular structure often resemble other dermatoses; delayed or missed diagnosis may result.
• Lesions are almost always pruritic.
• Typical signs of dermatophyte infection of the glabrous skin, similar to those of tinea corporis, may be present. These signs include annular or serpiginous erythematous scaling patches with an active border composed of papules, vesicles, and/or crusts. The most common locations are the cheeks, followed by the nose, periorbital area, chin, and forehead. Some patients may have multiple lesions present in different areas of the face.
• In as many as 70% of patients with tinea faciei, various other dermatoses are considered.
• • Tinea faciei is the most frequently misdiagnosed entity among cutaneous fungal infections.
  • The atypical clinical features and incognito presentations support the separation of this disease from tinea corporis.
  • Occasionally, tinea faciei may simultaneously occur with other forms of dermatophyte infections, especially tinea capitis and tinea corporis.

Causes

The causative agents vary according to geographic regions.

• Generally, animal reservoirs of zoophilic dermatophytes, especially Microsporum canis, are global among pets and livestock.
• In Asia, Trichophyton mentagrophytes and Trichophyton rubrum are common.
• In contrast, in North America Trichophyton tonsurans is the main pathogen isolated.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Problems to be Considered

Aspergillus infections under applied tape in neonates
Demodex folliculitis
Lupus vulgaris (Occasionally, lupus vulgaris may be in the differential diagnosis of particularly deep-seated annular plaques.)

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• Even in the best mycology laboratories, as many as 30% of culture results may be negative, particularly in chronic infections.
• Mycologic investigation is essential in the diagnosis of tinea faciei. It includes direct microscopic examination for hyphal elements and culturing.
• The collection of the surface scrapings is important for laboratory studies. The material should be obtained from the border of the lesions where the more severe inflammatory reaction occurs and where more fungal elements are present.
• Direct microscopic examination is the easiest mycologic procedure.
• • Scrapings are placed in 10-20% potassium hydroxide (KOH) solution, usually with the addition of dimethyl sulfoxide (DMSO). The latter helps to dissolve background keratinocytes to enable visualization of the fungal elements.
  • After warming the slide for a short time, the specimen is examined with a light microscope.
  • Some authors suggest detection is enhanced with special stains, such as chlorazol black E, Parker blue-black ink, or Swartz-Lamkin stain.
• Culturing allows the identification of the causative pathogen.
• • Culturing is performed routinely with Sabouraud agar and the addition of cycloheximide and chloramphenicol. These substances inhibit the growth of bacteria and other contaminants.
  • After 3-4 weeks of incubation, the final identification is based on morphologic and microscopic findings in the colonies.
• Dermatophytes may be diagnosed by using special media for rapid detection. This media contains a color indicator that changes from yellow to red with the growth of dermatophytes after a few days of incubation.

Histologic Findings

Histologic examination may occasionally be useful for establishing the diagnosis, but it is usually unnecessary. Its pattern is variable, ranging from mild focal spongiosis to a chronic spongiotic psoriasiform dermatitis with a mixed dermal inflammatory infiltrate and fungi in the cornified layer (Meymandi, 2003). Routine histopathologic evaluation with hematoxylin-eosin staining may reveal cutaneous fungal elements, but periodic acid–Schiff (PAS) staining is recommended to facilitate visualization.

Hyphae may be detected in the stratum corneum of the epidermis. Infections with T rubrum or Trichophyton verrucosum may invade hairs and follicles. A mixed cellular inflammatory infiltrate is usually present in the papillary dermis, and neutrophils may extend into the horny layers above.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical Care

Most cases of tinea faciei are curable with topical antifungal agents. If a topical steroid has been applied, fungal folliculitis may be present. Fungal folliculitis requires systemic therapy.

• The frequency of daily application and duration of the treatment depend on the active ingredients of the preparation.
• Topical ciclopirox and terbinafine possess additional anti-inflammatory effects, which are especially important in the therapy for infections caused by zoophilic dermatophytes in which inflammatory reactions are usually prominent.
• Topical azoles are effective.
• Although rare, chronic and/or multiple lesions may require systemic therapy.

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

The 2 classes of antifungal medication most commonly used to treat tinea faciei in practice are azoles and allylamines. Azoles inhibit lanosterol 14-alpha-demethylase, an enzyme that converts lanosterol to ergosterol, an important component of the fungal cell wall. Membrane damage leads to permeability problems and renders the fungus unable to reproduce. Allylamines inhibit squalene epoxidase, an enzyme that converts squalene to ergosterol; this inhibition also leads to the accumulation of toxic levels of squalene in the cell and to cell death. Several antifungal products from both classes are available for topical and systemic administration.

Re-evaluation of the tinea diagnosis is important if clinical improvement is not observed after 4 weeks of therapy.

Drug Category: Antifungal agents

With these agents, the mechanism of action may involve an alteration in cell membrane permeability, DNA or RNA synthesis, or intracellular levels of metabolites that are toxic to the fungal cell.

Drug Name	Clotrimazole (Lotrimin, Mycelex)
Description	Broad-spectrum antifungal agent that inhibits yeast and fungal growth by altering cell membrane permeability. Frequently prescribed for patients with tinea faciei. Available without a prescription as 1% cream, solution or spray, and lotion.
Adult Dose	Gently massage into affected area and surrounding skin areas bid for 3-4 wk
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Not for treatment of systemic fungal infections; avoid contact with the eyes; if irritation or sensitivity develops, discontinue use and initiate appropriate therapy

Drug Name	Miconazole (Femizole-7, Micatin, Absorbine)
Description	Damages fungal cell-wall membrane by inhibiting biosynthesis of ergosterol. Membrane permeability is increased; this effect causes nutrients to leak out. Available as 2% cream, solution or spray, lotion, and powder. Lotion is preferred for use in intertriginous areas. If cream is used, apply sparingly to avoid maceration effects.
Adult Dose	Apply to affected areas bid for 3-4 wk
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Discontinue if sensitivity or chemical irritation occurs; for external use only; avoid contact with eyes

Drug Name	Econazole (Spectazole)
Description	Effective in cutaneous infections. Interferes with RNA and protein synthesis and metabolism. Disrupts fungal cell wall permeability, causing fungal cell death.
Adult Dose	Apply to affected areas qd for 3-4 wk
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Discontinue if sensitivity or irritation develops; for external use only; avoid contact with eyes

Drug Name	Oxiconazole (Oxistat)
Description	Damages fungal cell-wall membrane by inhibiting biosynthesis of ergosterol. Membrane permeability is increased causing nutrients to leak out. Available as a 1% cream or lotion.
Adult Dose	Apply to affected area qd for 3-4 wk
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Discontinue if sensitivity or chemical irritation; for external use only; avoid contact with the eyes

Drug Name	Undecylenic acid (Desenex, Cruex, Fungoid AF, Gordochom)
Description	Nonprescription agent rarely used in the treatment of tinea faciei. Available in cream or solution or spray.
Adult Dose	Apply to affected areas tid for 3-4 wk
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	For external use only

Drug Name	Tolnaftate (Absorbine, Aftate, Breeze, Dr. Scholl's Athlete's Foot)
Description	Nonprescription medication available in 1% cream, solution or spray, and powder.
Adult Dose	Apply to affected areas bid for 3-4 wk
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	For external use only

Drug Name	Haloprogin (Halotex)
Description	Agent for use in the treatment of superficial cutaneous infections. Available in 1% cream and solution or spray.
Adult Dose	Apply to affected areas bid for 3-4 wk
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	For external use only

Drug Name	Ciclopirox (Loprox)
Description	Interferes with synthesis of RNA, DNA, and proteins by inhibiting transport within fungal cells. Available as a 1% cream and lotion for skin.
Adult Dose	Apply to affected areas bid for 3-4 wk
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Avoid contact with eyes and other internal routes

Drug Name	Terbinafine (Lamisil, Daskil)
Description	Member of allylamine family, fungicidal agents that inhibit ergosterol synthesis by means of squalene epoxidase. Result is a decreased ergosterol level and accumulation of squalene, which is toxic to fungal cells.
Adult Dose	250 mg tab PO qd for 1-2 wk Non-prescription cream: Apply to affected area bid for 2 wk
Pediatric Dose	12-20 kg: 62.5 mg/d PO 20-40 kg: 125 mg/d PO >40 kg: 250 mg/d PO for 1-2 wk as in adults Cream: Administer as in adults Consider longer therapy in Microsporum infections
Contraindications	Documented hypersensitivity
Interactions	May decrease cyclosporine effects; toxicity may increase with rifampin and cimetidine
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Discontinue topical use if chemical irritation develops; discontinue oral therapy if hepatobiliary dysfunction, neutropenia, Stevens-Johnson syndrome, or changes in ocular lens or retina develop; pretreatment liver function and repeat LFTs evaluation required with oral treatment > 6 wk; dysgeusia and bone marrow abnormalities rare

Drug Name	Itraconazole (Sporanox)
Description	Fungistatic activity. Synthetic triazole antifungal agent that slows fungal cell growth by inhibiting cytochrome P-450–dependent synthesis of ergosterol, a vital component of fungal cell membranes. Best results are noted 2-3 wk after treatment.
Adult Dose	100 mg PO qd for 2 wk; 200 mg PO qd for 1 wk; not to exceed 400 mg/d; increase in 100-mg increments if no improvement (>200 mg/d in divided doses)
Pediatric Dose	3-5 mg/kg/d PO for 1-2 wk
Contraindications	Documented hypersensitivity
Interactions	Affects metabolism of drugs processed by cytochrome P450-3A enzyme system; antacids may reduce absorption; edema may occur with coadministration of calcium-channel blockers (eg, amlodipine, nifedipine); hypoglycemia may occur with sulfonylureas; high doses may increase tacrolimus and cyclosporine plasma concentrations; rhabdomyolysis may occur with coadministration of HMG-CoA reductase inhibitors (eg, lovastatin, simvastatin); coadministration with cisapride can cause cardiac rhythm abnormalities and death; may increase digoxin levels; coadministration may increase plasma levels of midazolam or triazolam; phenytoin and rifampin may reduce levels (phenytoin metabolism may be altered)
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in hepatic insufficiency

Drug Name	Fluconazole (Diflucan)
Description	Fungistatic activity. Synthetic oral antifungal (ie, broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha-demethylation. This inhibition prevents the conversion of lanosterol to ergosterol, thereby disrupting cellular membranes.
Adult Dose	100 mg PO qd for 1-2 wk
Pediatric Dose	3-6 mg/kg/d PO for 1-2 wk; FDA approved for use in children > 6 mo
Contraindications	Documented hypersensitivity
Interactions	Hydrochlorothiazide may increase levels; levels may decrease with chronic coadministration of rifampin; coadministration may decrease phenytoin clearance; may increase concentrations of theophylline, tolbutamide, glyburide, and glipizide; anticoagulant effects may increase with coadministration; cyclosporine concentrations may increase when administered concurrently; use with cisapride may result in cardiac dysrhythmia
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Adjust dose in renal insufficiency; monitor closely if rashes develop; discontinue if lesions progress; may cause clinical hepatitis, cholestasis, and fulminant hepatic failure (including death) with underlying medical conditions (eg, AIDS, malignancy) or with multiple concomitant medications; not recommended for use in breastfeeding women

Drug Name	Griseofulvin (Fulvicin P/G, Gris-PEG)
Description	Fungistatic activity. Interferes with microtubule impairs fungal cell division. Binds to keratin precursor cells. Keratin is gradually replaced with noninfected tissue, which is highly resistant to fungal invasions.
Adult Dose	500 mg microsize or 330-375 mg ultramicrosize PO qd or divided bid for 3 wk
Pediatric Dose	15-20 mg/kg/d microsize PO or 10-15 mg/kg/d ultramicrosize PO for 3 wk with fatty food or milk
Contraindications	Documented hypersensitivity; hepatic injury
Interactions	May decrease hypoprothrombinemic activity of warfarin; may affect effectiveness of contraceptives; may reduce effects of cyclosporine; may decrease serum salicylate concentrations; barbiturates may decrease serum levels
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	In prolonged therapy, observe patients closely; monitor renal, hepatic, and hematopoietic function regularly; lupus-like syndromes or exacerbation of lupus erythematosus may occur; photosensitivity may also occur (use protective measures against exposure to ultraviolet light or sunlight)

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Deterrence/Prevention:

• The isolation and treatment of infected pets is of great importance.

Prognosis:

• The prognosis for patients with tinea faciei is usually good.
• The lesions respond to topical and oral antifungal treatment within 4-6 weeks.

Patient Education:

• For excellent patient education resources, visit eMedicine's Skin, Hair, and Nails Center. Also, see eMedicine's patient education article Ringworm on Body.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Failure to properly diagnose.
• • Tinea faciei may be misdiagnosed as discoid lupus erythematosus, seborrheic dermatitis, rosacea, or contact dermatitis.
  • Tinea faciei is the most frequently misdiagnosed entity among cutaneous fungal infections. The atypical clinical features and incognito presentations support the separation of this disease from tinea corporis. Occasionally, tinea faciei may simultaneously occur with other forms of dermatophyte infections, especially tinea capitis and tinea corporis.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Multiple lesions on the face caused by Microsporum canis infection in a patient who also has tinea capitis.
	View Full Size Image
Media type:  Photo

Media file 2:  Erythematous scaling lesion on the cheek.
	View Full Size Image
Media type:  Photo

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

• Alteras I, Sandbank M, David M, Segal R. 15-year survey of tinea faciei in the adult. Dermatologica. 1988;177(2):65-9. [Medline].
• Bardazzi F, Raone B, Neri I, Patrizi A. Tinea faciei in a newborn: a new case. Pediatr Dermatol. Nov-Dec 2000;17(6):494-5. [Medline].
• Cirillo-Hyland V, Humphreys T, Elenitsas R. Tinea faciei. J Am Acad Dermatol. Jul 1993;29(1):119-20. [Medline].
• Cohen-Abbo A. Newborn with vesicular rash. Tinea corporis (tinea faciei). Pediatr Infect Dis J. Jul 2000;19(7):661, 676-7. [Medline].
• Daniels J, Pahari A. Tinea faciei. Indian Pediatr. Oct 2004;41(10):1061-2. [Medline].
• Dekio S, Imaoka C, Jidoi J. Corticosteroid-modified tinea faciei simulating rosacea. J Dermatol. Oct 1987;14(5):509-11. [Medline].
• Drake LA, Dinehart SM, Farmer ER, Goltz RW, et al. Guidelines of care for superficial 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. Feb 1996;34(2 Pt 1):282-6. [Medline].
• Gorani A, Oriani A, Cambiaghi S. Seborrheic dermatitis-like tinea faciei. Pediatr Dermatol. May-Jun 2005;22(3):243-4. [Medline].
• Jorquera E, Moreno JC, Camacho F. [Tinea faciei: epidemiology]. Ann Dermatol Venereol. 1992;119(2):101-4. [Medline].
• Lari AR, Akhlaghi L, Falahati M, Alaghehbandan R. Characteristics of dermatophytoses among children in an area south of Tehran, Iran. Mycoses. 2005;48:32-37. [Medline].
• Lee SJ, Choi HJ, Hann SK. Rosacea-like tinea faciei. Int J Dermatol. Jun 1999;38(6):479-80. [Medline].
• Lin RL, Szepietowski JC, Schwartz RA. Tinea faciei, an often deceptive facial eruption. Int J Dermatol. 2004;43:437-440. [Medline].
• Meymandi S, Wiseman MC, Crawford RI. Tinea faciei mimicking cutaneous lupus erythematosus: a histopathologic case report. J Am Acad Dermatol. Feb 2003;48(2 Suppl):S7-8. [Medline].
• Ohta Y, Saitoh N, Tanuma H, Fujimura T, et al. Local cytokine expression in steroid-modified tinea faciei. J Dermatol. Jun 1998;25(6):362-6. [Medline].
• Patel G, Mills C. Tinea faciei due to Microsporum canis abscess formation. Clin Exp Dermatol. Nov 2000;25(8):608-10. [Medline].
• Pustisek N, Skerlev M, Basta-Juzbasic A, et al. Tinea incognito caused by trichophyton mentagrophytes - a case report. Acta Dermatovenerol Croat. 2001;9:283-286. [Medline].
• Romano C, Ghilardi A, Massai L. Eighty-four consecutive cases of tinea faciei in Siena, a retrospective study (1989-2003). Mycoses. Sep 2005;48(5):343-6. [Medline].
• Singh R, Bharu K, Ghazali W, Bharu K, et al. Tinea faciei mimicking lupus erythematosus. Cutis. Jun 1994;53(6):297-8. [Medline].
• Szepietowski J. The contemporary therapy of superficial fungal infections. Terapia i Leki. 2000;28:18-23.
• Szepietowski J. Dermatomycoses and onychomycosis. Medycyna Rodzinna. 1999;2:29-35.
• Szepietowski J. Dermatomycoses in newborns. Mikol Lek. 1997;4:41-5.
• Wilmer A, Wollina U. Oral terbinafine in the treatment of griseofulvin-resistant Tinea capitis et faciei et corporis in a 10-month-old girl. Acta Derm Venereol. Jul 1998;78(4):314. [Medline].

Article Last Updated: Feb 1, 2007