Dermatology Online Journal

Sycosiform tinea barbae caused by Trichophyton rubrum
Marcus Henrique de S B Xavier MD, Daniel M Torturella MD, Fernanda Valente S Rehfeldt MD, Cristina M G Rodrigues Alvariño MD, Neide Kalil Gaspar PhD, Mayra C Rochael PhD, Flávia de Souza Cunha.
Dermatology Online Journal 14 (11): 10

Universidade Federal Fluminense, Hospital Universitário Antônio Pedro - Serviço de Dermatologia. Niterói, Rio de Janeiro - Brasil. marcus_hx@hotmail.com

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Abstract

Tinea barbae is an uncommon superficial dermatophyte infection of the beard and moustache areas. It was more frequently observed in the past, before single-use razors became available. In most cases, the zoophilic ectothrix Trichophyton mentagrophytes and Trichophyton verrucosum are responsible for this type of infection. Its clinical presentation is variable; it can mimic many other skin disorders such as sycosis, iododerma, contact dermatitis, perioral dermatitis, and actinomycosis. We report a case of tinea barbae caused by an uncommon agent Trichophyton rubrum, misdiagnosed as sycosis, and review the approach and management of the disease.

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Clinical synopsis

A 69-year-old Brazilian retired man from the Rio de Janeiro metropolitan area presented with a 4-week history of an asymptomatic red plaque with pustules and some hair loss on his left moustache region (Fig. 1).

His illness had begun as a small pustule that enlarged in size after trauma. The patient had taken an oral antibiotic (Cephalexin / Cyprofloxacin ) and had applied a topical antibiotic (Mupirocin) without any improvement. The man's general condition was good and his past medical history was not significant. He denied contact with animals and used his own razor for shaving.

Figure 1	Figure 2

On physical examination, the patient exhibited a 3 x 3 cm non-tender erythematous plaque, with follicular pustules and partial hair loss (Figs. 1 & 2).

Skin smears from follicular pustules were obtained for microscopic examination and culture. Smears obtained for KOH preparation and also stained with Gram's stain did not show any evidence of a microorganism. The bacterial culture was negative.

Biopsy specimens from the patient were obtained for histological examination. The biopsy shows a chronic deep folliculitis. An intrafollicular and perifollicular mixed infiltrate is noted with an area showing a ruptured follicule (Fig. 3 - H&E stain, x40). Hair shaft disruption by neutrophils, lymphocytes, histiocytes, and plasma cells that have spread into the dermis is also shown (Figure 4 - H&E stain, x100).

Figure 3	Figure 4

Based on the clinical appearance, the presence of folliculitis on histological examination, and the non-response to antibacterial therapy, we decided to start oral Griseofulvin 500 mg microsized once a day while awaiting the fungal culture result.

After 24 days, the fungal culture performed at 25°C using Sabouraud Dextrose agar showed a downy colony with a white surface. The reverse of the colony was dark brown with a paler cream border. The microscopy showed small tear-shaped, clevate microconidia arranged along the sides of the hyphae, compatible with Trichophyton rubrum (Fig. 5).

Figure 5	Figure 6

The diagnosis of tinea barbae caused by T. rubrum was confirmed and the treatment was completed in six weeks. After the treatment, the patient was completely cleared and there was no recurrence, scar, or cicatricial alopecia upon follow-up after six months (Fig. 6).

Discussion

Tinea barbae, also known as ringworm of the beard, is an uncommon superficial dermatophyte infection of the beard and moustache areas with invasion of coarse hairs [1]. Therefore, it is a disease nearly exclusively found in adult males. The presence of this kind of lesion on the same areas in women and children are classified as tinea faciei.

The infection is most common in tropical countries where weather is characterized by high temperatures and humidity [2]. Tinea barbae was observed more frequently in the past before single-use razors became available; infection was frequently transmitted by barbers who used unsanitary razors [3]. The chronic use of topical corticosteroids has been incriminated as a risk factor for the disease [4].

Today, this source of infection has nearly been eliminated, but the disease is still seen among rural inhabitants; animals (cattle, horses, cats, dogs) constitute the source of infection. In most cases, the zoophilic ectothrix dermatophytes Trichophyton mentagrophytes and Trichophyton verrucosum are responsible for this type of infection. Microsporum canis and Trichophyton mentagrophytes varerinacei may cause tinea barbea but these are rare [2, 3]. A deeply abcessing tinea barbae due to a zoophilic strain of Trichophyton interdigitale, probably acquired from a cat, has been reported [5].

Although rare, anthropophilic dermatophyte infections of beard skin may be caused by Trichophyton rubrum and Trichophyton violaceum, especially in endemic regions. In addition, there have been reports of infection caused by autoinoculation from onychomycosis [6] and tinea pedis [7]. According to Szepietowski JC et al. autoinoculation from infected nails is not such a rare phenomenon. They stress the importance of careful examination of the skin and its appendages to uncover the source [6].

Tinea barbae begins on the bearded area of the face and neck. The condition is classified clinically into two types: inflammatory and non-inflammatory, depending on the type of fungus and patient's immune response [2]. Deep and inflammatory tinea barbae is the most common clinical presentation. The characteristic lesion is an inflammatory nodule with multiple follicular pustules and draining sinuses on the surface. Usually, hairs are loose or broken; abscesses, kerion-like plaques, bacterial superinfections and regional lymphadenopathy may develop [6]. This variety of tinea barbea may cause scarring alopecia and reports have implicated T. rubrum species [8, 9].

A second type of tinea barbae is superficial, less inflammatory, and similar to tinea corporis or bacterial folliculitis [10]. The characteristic lesion is an erythematous plaque with an active border composed of papules. This may be annular in shape; vesicles and crusts are common [6]. Alopecia may be present in the center of the lesion, but it is reversible, as in our case. A chronic variant of tinea barbae similar to sycosis can occur.

Tinea barbae is usually diagnosed by clinical characteristics and verified with laboratory tests. Useful laboratory tests include potassium hydroxide test (direct microscope examination), fungal culture, Wood's light examination, and biopsy. Direct microscopic examination is the most important diagnostic test and allows fungal element visualization. The material can be collected from infected hair and pustules [11]. Fungal culture is performed on agar (Mycosel and Micobiotic) with the addition of cycloheximide to identify the causative fungus. Wood's light examination shows fluorescence when M. Canis infection is the cause of tinea barbae.

Like tinea capitis, tinea barbae should be treated with oral therapy. Systemic anti-fungal medications are able to penetrate the infected hair shaft whereas topical therapies cannot [11].

Griseofulvin is the only agent that U.S. Food and Drug Administration (FDA) has labeled for the treatment of tinea capitis. However, the treatment needs to be longer and the adverse effects are more common than for terbinafine and itraconazole [12]. When using griseofulvin the suggested dosing is 500 mg-1000 mg daily for six to twelve weeks, taken with a meal. It is contraindicated in patients with porphyria or hepatocellular failure. Common adverse effects include: nausea, vomiting, pain, excessive thirst, diarrhea, photosensitivity, headache, and dizziness. It is a CYP3A4 enzyme inducer and can potentially reduce drug levels of antiarrhythmics agents, anticoagulants, and anticonvulsivants [13].

Terbinafine 250 mg, once daily for 4 weeks, is the treatment of choice according to some authors [2]. It may be taken in a fasted or fed state without affecting absorption. Serum transaminase tests are suggested prior to beginning drug therapy and at 4 weeks if prolonged treatment is required. This medication is not recommended for patients with existing liver disease [14]. Common adverse events include diarrhea, dyspepsia, nausea, skin eruptions, pruritus, and headache. It has been reported to precipitate or exacerbate cutaneous and systemic lupus erythematosus [15]. It is metabolized through the CYP2D6 enzymes and thus can increase the serum concentration of tricyclic antidepressants, selective serotonin reuptake inhibitors, beta-blockers, and monoamine oxidase inhibitors.

Itraconazole 200mg/day for four to six weeks or given as pulse therapy at 400mg (divided into two doses) is also effective. It must be taken with a meal or acidic/cola beverage to ensure adequate absorption. Maeda et al. reported a case of tinea barbae due to Trichophyton verrucosum treated with itraconazole 100mg/day for two months [16]. As with terbinafine, liver function monitoring should be considered. The drug is prohibited in patients showing ventricular dysfunction such as current or past congestive heart failure [17]. Common adverse events include diarrhea, dyspepsia, nausea, gas, appetite elevation, constipation, cutaneous eruptions, headache, and dizziness. It is metabolized through the CYP3A4 enzymes and thus can increase the serum concentration of warfarin, carbamazepine, calcium channel blockers, tryciclic antidepressants, benzodiazepines and diabetic drugs [13].

Fluconazole treatment is not well documented for tinea barbae, but data from tinea capitis studies indicate that a dose of 150 mg once per week for up to six weeks also may be effective [18].

Compared with griseofulvin, ketoconazole is no more effective and has the potential for adverse hepatic effects and drug interactions [11].

Antifungal shampoos are used as adjuvant therapies to decrease shedding of infectious fungal elements. Ketoconazole 2 percent shampoo or selenium sulfide 2.5 percent shampoo should be used at least three times weekly [19]. Shaving or hair depilation is recommended and warm compresses should be used to remove crusts and debris. Elimination of the source of infection, such as treatment of infected animals and other sites of fungal infection (tinea pedis or onychomycosis), are important. A recent case of tinea barbae caused by Trichophyton rubrum was likely acquired via infected fingernails [20].

Acknowledgments: The authors appreciate the language review by Lilian Bonilha Morais.

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