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LETTER TO EDITOR
Year : 2020  |  Volume : 21  |  Issue : 1  |  Page : 78-80

Atypical manifestations of genital dermatophytosis in a male toddler


1 Department of Dermatology and STD, Shree Guru Gobind Singh Tricentenary Medical College, Hospital and Research Institute, Gurugram, India
2 Bhojani Clinic, Matunga, Mumbai, Maharashtra, India

Date of Submission25-Oct-2019
Date of Acceptance01-Dec-2019
Date of Web Publication24-Dec-2019

Correspondence Address:
Dr Shikhar Ganjoo
Department of Dermatology and STD, Shree Guru Gobind Singh Tricentenary Medical College, Hospital and Research Institute, Gurugram
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_108_19

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How to cite this article:
Ganjoo S, Vasani R. Atypical manifestations of genital dermatophytosis in a male toddler. Indian J Paediatr Dermatol 2020;21:78-80

How to cite this URL:
Ganjoo S, Vasani R. Atypical manifestations of genital dermatophytosis in a male toddler. Indian J Paediatr Dermatol [serial online] 2020 [cited 2020 Feb 19];21:78-80. Available from: http://www.ijpd.in/text.asp?2020/21/1/78/273830



Sir,

A 2-year-old male child presented with an asymptomatic red raised lesion over the penis and scrotum for 3 days. It started as a red, minimally raised lesion over the penile shaft and the scrotum [Figure 1]a – clicked by the parent on a mobile] over which topical fluticasone with 2% mupirocin ointment was applied twice daily for 2 days. A noticeable aggravation of lesions with increase in the redness and swelling occurred after the application. There was no antecedent history of an insect bite or any oral medication. He was completely immunized for age and had no significant past history.
Figure 1: (a) A well-defined erythematous plaque on the scrotum and erythematous papule on the dorsum of the penile shaft. (b) A nontender erythematous, edematous plaque with microvesiculation and pustulation in the periphery present over the penile shaft. There is a well-defined erythematous edematous plaque on the scrotum as well. (c) Lesion on the penile shaft with an increase in size with appearance of annularity and scaling on the plaques

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On examination, there was a nontender erythematous, edematous plaque with microvesiculation and pustulation in the periphery present over the penile shaft. There was a well-defined erythematous edematous plaque on the scrotum as well [Figure 1]b. Rest of the cutaneous examination including the palms, soles, scalp, and nails was normal. Considering the urticated morphology of the lesions, a differential diagnosis of insect bite reaction and nodular scabies was thought of. However, in the absence of symptoms and other suggestive lesions or a positive family history, the diagnosis of scabies was ruled out. With a working diagnosis of an insect bite reaction, the child was administered prednisolone syrup 0.33 mg/kg on day 1 and 0.15 mg/kg on day 2 of presentation. On follow-up on the 3rd day, the number of lesions on the penile shaft increased with the appearance of annularity and scaling on the plaques [Figure 1]c. The mother admitted to having tinea corporis of the buttocks and groin and therefore was given oral itraconazole 100 mg with topical eberconazole twice daily. Considering the background of dermatophytosis in mother, aggravation of lesions after oral and topical steroids, a diagnosis of inflammatory tinea corporis was considered. A potassium hydroxide mount was done which was negative. The parents could not afford a fungal culture and did not consent for a skin biopsy. In spite of a negative mount, it was thought prudent to institute an empirical course of antifungal medication in view of the on-going epidemic of superficial dermatophytosis with atypical presentations in India.

Fluconazole was administered in the dose of 6 mg/kg body weight on alternate days along with topical eberconazole twice daily. After 7 days of treatment, the patient showed increase in the number as well as the size of the lesions which now assumed a psoriasiform appearance [Figure 2]a. In view of the nonresponse to treatment, the dose of fluconazole was hiked to a daily regimen instead of alternate days. Within 2 days of the increased dose, there were positive signs of improvement of lesions and the lesions were completely cleared after 2 weeks [Figure 2]b. The oral and topical antifungals were continued 2 and 4 weeks beyond the clinical improvement, respectively. Follow-up at the end of 2 months revealed no recurrence. The mother too reported progressive clearing of the lesions and a satisfactory response immediately after beginning the treatment with itraconazole with no recurrence at the end of 2 months.
Figure 2: (a) The lesions on the penis and scrotum increasing in number and assuming a psoriasiform appearance. (b) Complete clearance of lesions with 2 weeks of oral and topical antifungal treatment with few areas showing postinflammatory hyperpigmentation

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The initial urticated presentation of the lesions mimicking an insect bite reaction, progressing to a psoriasiform appearance during the course of the disease, exemplifies the atypical and deceptive appearance that superficial dermatophytosis can assume in this epidemic-like situation. A change in the pathogenetic species to Trichophyton mentagrophytes compounded by the widespread menace of topical steroid abuse is the factor responsible for such atypical presentations.[1] Although a culture was not possible in this case, a primary inflammatory response induced by the causative fungus and the local immunosuppression induced by the topical steroid combination cream are the likely reasons for this unusual presentation.

Traditional learning has always described relatively common sparing of penile and scrotal skin in patients of tinea cruris. Reduced barrier function in the scrotal skin leads to spread in antifungal factors such as capric acid, which renders that area resistant to dermatophytes.[2] Decreased eccrine sweat secretion leading to less hydration of the penile skin is also suggested.[3] In the current scenario, there is increasing evidence of genital involvement primarily as well as an extension of preexisting tinea corporis and cruris demonstrated in adults.[4] Primary genital involvement in the pediatric age group as in our case is a rare presentation. In our patient, the aggravation of the lesions in the form of appearance of new lesions and increase in the size of the existing lesions after starting the oral and topical antifungal can be explained by the rebound of local immunity after withdrawal of the immunosuppressive effect of the local and systemic steroid akin to immune recovery reaction. Continuing the escalated dose of fluconazole with the topical antifungal leading to complete resolution of lesions with no relapse till date emphasizes the need to use a higher dose for an optimal duration beyond the clinical resolution, especially against the backdrop of steroid use. The importance of screening close contacts cannot be over-emphasized.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nenoff P, Verma SB, Vasani R, Burmester A, Hipler UC, Wittig F, et al. The current Indian epidemic of superficial dermatophytosis due to trichophyton mentagrophytes-a molecular study. Mycoses 2019;62:336-56.  Back to cited text no. 1
    
2.
Romano C, Ghilardi A, Papini M. Nine male cases of tinea genitalis. Mycoses 2005;48:202-4.  Back to cited text no. 2
    
3.
Smith JG, Fisher RW, Blank H. The epidermal barrier: A comparison between scrotal andabdominal skin. J Invest Dermatol 1961;36:337-41.  Back to cited text no. 3
    
4.
Verma SB, Vasani R. Male genital dermatophytosis – Clinical features and the effects of the misuse of topical steroids and steroid combinations – An alarming problem in India. Mycoses 2016;59:606-14.  Back to cited text no. 4
    


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  [Figure 1], [Figure 2]



 

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