BMJ 2017;356:j973 doi: 10.1136/bmj.

j973 (Published 2017 March 08) Page 1 of 4

Practice

PRACTICE

10-MINUTE CONSULTATION

Steroid modified tinea

Shyam Verma consultant dermatologist
Nirvan Skin Clinic, Makarpura Road, Vadodara 390009, India

A 24 year old man complains of a severely itchy rash in the drugs. These conditions suppress the immune response and
groin which had spread to his thighs and penis over two months may lead to extensive tinea.2-7
(fig 1⇓). He had bought and applied a cream from a pharmacy
which had helped a bit at first; it contained clobetasol, ofloxacin, Examine skin lesions
terbinafine, and ornidazole.
The classic appearance of tinea is suppressed due to the
Tinea is a superficial fungal infection caused by dermatophytes.
anti-inflammatory effect of topical steroids. Lesions lose their
The lesions are typically annular with an erythematous scaly
active erythematous edges and often attain bizarre shapes,
advancing edge with or without central clearing. Itching is
become widespread, or mimic other diseases such as eczema.3-10
common. Tinea is simple to diagnose and treat with oral and
These changed clinical presentations are commonly called tinea
topical antifungal agents.1
incognito. This may be inaccurate, however, because many
However, topical corticosteroids or steroid-containing antifungal lesions do maintain an annular configuration with perceptible
creams are commonly used, particularly in developing countries edges, but these are modified (figs 1-3⇓).
with lax drug laws allowing advertising and unregulated sale
Use of topical steroids, especially when erratic, leads to periods
of these creams.2-6 Steroids may alleviate itching and redness
of active inflammation and apparent remission with the
but do not eliminate the fungus from the surface of the skin.3 7
appearance of multiple rings and inadequate clearing of the
This leads to spread of lesions after initial symptom relief, a
fungus. This gives a scaly eczematous appearance in the centre
modified clinical picture, and treatment failure, and contributes
of the rings, which otherwise would be clear.7 10
to antifungal resistance.2-8
Look for signs of overuse of topical steroids such as striae,
Tinea is more common in a warm and humid climate,
hypopigmentation, telangiectasias, hypertrichosis, acneiform
particularly in tropical and subtropical regions of the world.2 9
lesions, or follicultis.6 7
What you should cover Examine other sites for fungal infection, such as beneath the
Take a history breasts in women, soles of the feet, and nails. Scaly, ill-defined
lesions of tinea pedis or yellow crumbling nails of tinea unguium
Ask about: may be easily missed and can cause recurrence of lesions
• Characteristics of the lesion, such as site and pattern of elsewhere.
first presentation, duration, spread over the body, and
itching.
What you should do
• Excessive sweating, wearing tight undergarments and
denims, personal hygiene. Steroid-modified tinea may mimic various forms of eczema
such as nummular eczema, atopic dermatitis, contact dermatitis,
• Treatment taken so far: check any over-the-counter creams and seborrhoeic dermatitis and conditions such as rosacea and
that the patient has bought and note their active ingredients. psoriasis. You may confirm the diagnosis of tinea by examining
• Fungal infection in family members. Overcrowding in a skin scraping in 10% potassium hydroxide under a microscope
homes and sharing of clothes, bed linen, towels, etc, may for hyphae and spores of dermatophytes. Fungal culture may
predispose to recurrent infection. be requested if testing is available.
• Co-existing conditions such as HIV infection, diabetes, The mainstay of treatment is oral and topical antifungal agents
malignancy, connective tissue disorders, or treatment with as used for dermatophytosis.1 Patients treated with steroids
immunosuppressive drugs such as steroids or anticancer occassionally require higher than standard recommended doses

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This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.
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BMJ 2017;356:j973 doi: 10.1136/bmj.j973 (Published 2017 March 08) Page 2 of 4

PRACTICE

What you need to know

• Do not use corticosteroid-antifungal-antibacterial creams to treat superficial fungal infections as they cause recurrence, widespread
lesions, and may promote resistance
• Ask patients about use of steroid creams if tinea not responding to treatment or where symptoms suggest tinea but lesions are modified,
such as with double edges, multiple rings, and eczematous areas within the lesion
• Confirm diagnosis with examination of skin scrapings in 10% potassium hydroxide when possible. Treat with oral or topical antifungal
agents and give advice on personal hygiene

of oral antifungals for a longer period, albeit with due Provenance and peer review: Not commissioned; externally peer
precautions.2 Ask the patient to apply an adequate quantity of reviewed.
topical antifungal agent to 1 cm beyond the edge of the lesion
and to continue treatment for at least two weeks after complete 1 Sahoo AK, Mahajan R. Management of tinea corporis, tinea cruris, and tinea pedis: a
comprehensive review. Indian Dermatol Online J 2016;356:77-86. doi:10.4103/2229-5178.
resolution. Advise complete avoidance of steroid creams. 178099 pmid:27057486.
2 Dogra S, Uprety S. The menace of chronic and recurrent dermatophytosis in India: Is the
Adherence to treatment is essential for complete resolution. problem deeper than we perceive?Indian Dermatol Online J 2016;356:73-6. doi:10.4103/
Review the patient within two weeks after starting treatment. 2229-5178.178100 pmid:27057485.
Consider referral to a dermatologist if the lesions are extensive, 3 Kim WJ, Kim TW, Mun JH, et al. Tinea incognito in Korea and its risk factors: nine-year
multicenter survey. J Korean Med Sci 2013;356:145-51. doi:10.3346/jkms.2013.28.1.
clinically confusing, recur after treatment, or there is no 145 pmid:23341725.
improvement after two weeks. 4 Ansar A, Farshchian M, Nazeri H, Ghiasian SA. Clinico-epidemiological and mycological
aspects of tinea incognito in Iran: a 16-year study. Med Mycol J 2011;356:25-32. doi:10.
Advise maintaining personal hygiene and avoidance of tight 3314/jjmm.52.25 pmid:21441710.
5 Romano C, Maritati E, Gianni C. Tinea incognito in Italy: a 15-year survey. Mycoses
fitting clothes. 2006;356:383-7. doi:10.1111/j.1439-0507.2006.01251.x pmid:16922789.
Patients are often distressed by non-resolution of lesions despite 6 Verma SB. Topical corticosteroid misuse in India is harmful and out of control. BMJ
2015;356:h6079. doi:10.1136/bmj.h6079 pmid:26608450.
treatment. Explain to them the role of steroids in recurrence and 7 Hay R, Ashbee H. Fungal infections. In: Griffiths C, Blieker T, Chalmers R, Creamer D,
spread of lesions. If patients have co-existing conditions such eds. Rook’s Textbook of Dermatology. 9th ed. Wiley Blackwell, 2016: 32-50.
8 Lahiri K, Coondoo A. Topical steroid damaged/dependent face (TSDF): an entity of
as diabetes, explain how they delay resolution and cause cutaneous pharmacodependence. Indian J Dermatol 2016;356:265-72. doi:10.4103/0019-
recurrence and ensure patients are taking appropriate treatment 5154.182417 pmid:27293246.
9 Havlickova B, Czaika VA, Friedrich M. Epidemiological trends in skin mycoses worldwide.
for the condition. Mycoses 2008;356(Suppl 4):2-15. doi:10.1111/j.1439-0507.2008.01606.x pmid:18783559.
10 Verma S, Hay RJ. Topical steroid-induced tinea pseudoimbricata: a striking form of tinea
incognito. Int J Dermatol 2015;356:e192-3. doi:10.1111/ijd.12734 pmid:25601089.
Competing interests: I have read and understood BMJ policy on
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declaration of interests and have no relevant interests to declare.
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BMJ 2017;356:j973 doi: 10.1136/bmj.j973 (Published 2017 March 08) Page 3 of 4

PRACTICE

How patients were involved in the creation of this article

At least six patients with fungal skin infection presenting at a dermatology clinic in India read this article. Their main concern was why
steroid-antifungal-antibacterial creams are freely available, recommended by friendly pharmacists, and prescribed by doctors when they
may be harmful. They also said that doctors must ask patients to re-attend even if lesions are improving to ensure complete resolution. In
response, I have emphasised that steroid creams must not be prescribed for fungal skin infections and doctors must explain to patients the
need to adhere to treatment and follow-up.

Education into practice

• Do you routinely ask patients with tinea about the use of steroid-containing creams either prescribed or bought over-the-counter?

Figures

Fig 1 Extensive tinea cruris and tinea corporis with erythematous, eczematous, and scaly lesions in groin, both thighs, and
penis

Fig 2 Widespread tinea corporis with multiple large annular lesions. Lesions on thigh have steroid-induced hypopigmentation.
Visible steroid-induced striae on the right medial thigh. Multiple eczematous circles seen in some lesions

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BMJ 2017;356:j973 doi: 10.1136/bmj.j973 (Published 2017 March 08) Page 4 of 4

PRACTICE

Fig 3 Classic double edges of steroid modified tinea. Eczematous circular lesions with ill defined borders seen within the
main lesion

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