Tinea Faciei Presenting With an Annular Facial Rash and Persistent Pruritus: A Case Report

Abstract

Tinea faciei is a superficial dermatophyte infection involving the non-bearded facial skin and is often misdiagnosed because its clinical appearance can resemble inflammatory dermatoses such as eczema, seborrheic dermatitis, rosacea, or contact dermatitis. Delayed recognition and inappropriate use of topical corticosteroids may alter the appearance of the infection and contribute to tinea incognito. We report the case of a 28-year-old female who presented with a progressively enlarging itchy facial rash for three weeks. She had initially used a topical corticosteroid-containing cream without significant improvement. Examination revealed an asymmetric annular erythematous plaque over the right cheek with a raised, scaly peripheral border and relative central clearing. Potassium hydroxide examination of skin scrapings demonstrated branching septate fungal hyphae, confirming dermatophytosis. The patient was diagnosed with tinea faciei and treated with topical terbinafine along with discontinuation of the corticosteroid-containing preparation. Marked clinical improvement occurred within two weeks, with complete resolution of the lesion after four weeks. This case highlights the importance of considering tinea faciei in the differential diagnosis of annular facial lesions and emphasizes mycological confirmation when the diagnosis is uncertain or when prior corticosteroid therapy has altered the clinical appearance.

Introduction

Tinea faciei is a dermatophyte infection affecting the facial skin and represents an uncommon but clinically important form of superficial dermatophytosis. It may be caused by anthropophilic dermatophytes such as Trichophyton rubrum or zoophilic organisms such as Microsporum canis. Infection may occur through direct contact with an infected individual or animal or through autoinoculation from another dermatophyte-infected site.

Clinically, tinea faciei commonly presents as an erythematous, scaly, annular or oval lesion with a more active peripheral border and relative central clearing. The eruption may be unilateral or asymmetric and can become more prominent following sun exposure. Because facial dermatophytosis can mimic several inflammatory and infectious conditions, it is frequently misdiagnosed initially.

Common differential diagnoses include seborrheic dermatitis, atopic dermatitis, psoriasis, rosacea, contact dermatitis, perioral dermatitis, and cutaneous lupus erythematosus. Prior treatment with topical corticosteroids may further obscure the characteristic morphology and produce tinea incognito.

Diagnosis can be supported by direct microscopic examination of skin scrapings with potassium hydroxide, while fungal culture or molecular testing may be used when the diagnosis is uncertain, recurrent, extensive, or treatment-resistant. Mild localized disease is generally managed with topical antifungal therapy, whereas systemic antifungal treatment may be considered for extensive or refractory infection.

We report a case of localized tinea faciei initially treated with a topical corticosteroid, in which clinical examination and KOH microscopy established the diagnosis and guided successful antifungal therapy.

Case Report

A 28-year-old female presented to the dermatology outpatient department with an itchy, gradually enlarging lesion over the right cheek for approximately three weeks. The lesion had initially appeared as a small erythematous patch but progressively increased in size and developed peripheral scaling.

The patient reported mild-to-moderate pruritus, particularly after exposure to heat and sunlight. She had no history of fever, facial pain, discharge, or systemic symptoms. There was no previous history of chronic skin disease.

Two weeks before presentation, she had applied an over-the-counter topical cream containing a corticosteroid for the facial rash. Although the redness temporarily decreased, the lesion subsequently enlarged and became more scaly.

There was no history of contact lens use, recent facial procedures, or significant immunosuppressive therapy. She reported regular contact with a domestic cat but no known dermatological illness in household members.

On examination, a solitary, well-demarcated annular erythematous plaque measuring approximately 4 × 3 cm was present over the right cheek. The lesion showed a raised, mildly scaly peripheral border with relative central clearing. Mild excoriation was present because of pruritus.

No lesions were identified over the scalp or beard region. Examination of the nails and interdigital spaces did not reveal obvious fungal infection. There was no regional lymphadenopathy.

Based on the annular morphology, peripheral scaling, asymmetry, and history of worsening after corticosteroid use, tinea faciei was suspected.

Skin scrapings were obtained from the active peripheral margin of the lesion for potassium hydroxide examination. Microscopy demonstrated branching septate fungal hyphae, supporting the diagnosis of dermatophytosis.

The patient was diagnosed with localized tinea faciei.

Management and Outcome

The corticosteroid-containing topical preparation was discontinued immediately.

The patient was started on topical terbinafine applied to the affected area as directed. General measures were advised, including keeping the affected area clean and dry, avoiding sharing towels or cosmetics, avoiding scratching, and maintaining appropriate personal hygiene.

Because of the possibility of dermatophyte transmission or reinfection, the patient was advised to avoid direct contact with potentially infected household items and to seek evaluation if similar lesions developed elsewhere.

No systemic antifungal therapy was required because the infection was localized and responded appropriately to topical treatment.

The patient was reviewed regularly to assess resolution of erythema, scaling, pruritus, and lesion size.

Follow-up

One Week

• Marked reduction in pruritus
• Decreased peripheral scaling
• Reduction in erythema
• No further enlargement of the lesion
• No new facial lesions developed

Two Weeks

• Significant reduction in lesion size
• Peripheral scaling had nearly resolved
• Central clearing became less prominent
• No evidence of secondary bacterial infection

Four Weeks

• Complete clinical resolution of the facial lesion
• No residual scaling or active erythematous border
• Minimal post-inflammatory discoloration remained
• No recurrence reported

Three Months

• Stable facial skin without recurrence
• No new dermatophyte lesions identified
• Patient remained asymptomatic

Discussion

Tinea faciei is an important dermatophyte infection that can be overlooked because facial lesions often have a variable morphology and overlap clinically with several inflammatory dermatoses. Unlike tinea corporis, which typically has a more recognizable annular appearance, facial dermatophytosis may present with subtle erythema, scaling, follicular involvement, or atypical inflammatory changes.

The most characteristic presentation is an asymmetric annular or oval erythematous lesion with a scaly active border and relative central clearing. However, clinical morphology may be altered by previous treatment, particularly corticosteroid use. Steroids can suppress inflammation while allowing fungal proliferation to continue, producing an atypical presentation known as tinea incognito.

A careful history is therefore essential. Clinicians should specifically ask about recent topical corticosteroid use, exposure to infected individuals or animals, occupational exposure, and the presence of dermatophyte infection at other body sites. Examination of the feet, groin, nails, and scalp may help identify a potential source of infection or autoinoculation.

The differential diagnosis of an annular facial lesion is broad and includes seborrheic dermatitis, psoriasis, rosacea, allergic contact dermatitis, atopic dermatitis, perioral dermatitis, and cutaneous lupus erythematosus. Mycological testing is particularly useful when the clinical appearance is atypical or when the patient has already received corticosteroid therapy.

KOH microscopy provides a rapid method for demonstrating fungal elements in skin scrapings. Fungal culture may be useful when the diagnosis remains uncertain or when infection is extensive, recurrent, or resistant to therapy. Molecular techniques are increasingly being investigated for more rapid identification and speciation of dermatophytes.

Treatment depends on the extent and severity of infection. Localized tinea faciei generally responds to topical antifungal therapy, while oral agents such as terbinafine or itraconazole may be considered when topical therapy fails or disease is extensive.

Increasing dermatophyte resistance has become an emerging therapeutic concern. In particular, Trichophyton indotineae has been associated with treatment failure and reduced susceptibility to terbinafine, emphasizing the importance of recognizing persistent or atypical infections and considering appropriate mycological evaluation in refractory cases.

This case demonstrates that recognition of the characteristic peripheral scaling, consideration of dermatophytosis in the differential diagnosis, and confirmation with KOH microscopy can prevent prolonged inappropriate corticosteroid use and facilitate effective treatment.

Prognosis

The prognosis of localized tinea faciei is generally favorable when the diagnosis is established promptly and appropriate antifungal therapy is initiated. Most uncomplicated infections resolve with adequate topical treatment, although recurrence may occur if an untreated dermatophyte infection remains at another body site or if there is continued exposure to an infected contact or animal.

Patients with recurrent, extensive, inflammatory, or treatment-resistant disease require further evaluation to confirm the diagnosis, identify the causative dermatophyte, assess possible sources of reinfection, and guide systemic therapy when indicated.

Conclusion

Tinea faciei should be considered in patients presenting with an asymmetric annular, scaly facial eruption, particularly when the lesion demonstrates peripheral activity or fails to respond to conventional anti-inflammatory treatment. Misdiagnosis and inappropriate corticosteroid use can modify the clinical appearance and delay effective therapy. KOH microscopy provides a simple and rapid method for confirming dermatophytosis, while fungal culture or molecular testing may be useful in atypical or refractory cases. Early recognition, appropriate antifungal therapy, avoidance of unnecessary corticosteroids, and assessment for other sources of dermatophyte infection can result in complete clinical resolution and prevent recurrence.

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