Periocular Tinea Faciei : A Case report
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A 6-year-old boy living in a farming household presented for evaluation of worsening rash on the right eyelid. He had developed an erythematous plaque with a peripheral scale on the right lower eyelid 2 months prior (Figure 1, A). He was initially diagnosed with eyelid eczema and treated with hydrocortisone and moisturizer. The rash worsened and he was subsequently treated with topical erythromycin and systemic cephalexin, amoxicillin-clavulanic acid, clindamycin, and valacyclovir without improvement. At presentation, physical examination was significant for an erythematous plaque with numerous superficial pustules involving the right upper and lower eyelids and loss of eyelashes (Figure 1, B). The constellation of physical examination findings and prior failed therapies was suggestive of a tinea faciei.

Fungal cultures were collected which subsequently grew Trichophyton verrucosum. The patient was treated with a 2-month course of itraconazole 5 mg/kg/day, which resulted in resolution of the eruption (Figure 2). Tinea in the periocular location is often misdiagnosed. In 1 pediatric study, all patients had been treated for at least 1 other condition including eczema, herpes simplex virus, and cellulitis before the correct diagnosis of periocular tinea was made.The diagnosis is commonly made by clinical findings. The presence of peripheral scale, severe inflammation, and pustules are useful clues for tinea infections. Potassium hydroxide preparation and identification of branching septate hyphae can also be a diagnostic tool.

Fungal cultures not only provide diagnostic confirmation, but also elucidate the specific strain and antifungal sensitivities needed to eradicate the infection. It should be noted that fungal cultures may take several days to weeks to result; therefore, empiric therapy is warranted if the index of suspicion is high on clinical presentation alone. The mainstay of treatment for limited tinea infection is topical antifungal agents; however, more extensive disease or any involvement of hair follicles and eyelashes requires the use of oral therapy.Systemic therapy options include oral itraconazole, terbinafine, and griseofulvin.

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