CASE REPORT

TINEA FACIEI CAUSED BY TRICHOPHYTON RUBRUM MELANOID

TYPE AND PITYRIASIS VERSICOLOR
Ratna Wulandari, Safruddin Amin, Andiati Silviana
Department of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin
Sudirohusodo Hospital Makassar

ABSTRACT
Tinea faciei is a superficial dermatophyte infection limited on the
face. Trichophyton rubrum is one of the most common causative
species due to tinea faciei. In addition dermatophyte group, superficial
fungal infection can caused by Candida and Malassezia. Pityriasis
versicolor is superficial fungal infection caused by genera Malassezia.
A case of tinea facialis caused by Trichophyton rubrum
melanoid type with pityriasis versicolor. Diagnosis base on clinical
features, direct examination with KOH 10% and culture. Patient was
treated with oral ketoconazole and myconazole 2% cream. Clinical and
mycological improvement after 3 weeks treatment.
Keyword :, tinea facialis, Trichophyton rubrum melanoid type, pityriasis
versicolor

Address for correspondence : Ratna Wulandari, dr., Department of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin
Sudirohusodo Hospital Makassar Blok B/18 Jl. Pengayoman kompleks Gladiol Makassar, South Sulawesi, Indonesia dr.ratnawulan@gmail.com

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Ratna Wulandari

tinea faciei caused by trichophyton rubrum melanoid type and pityriasis versicolor

INTRODUCTION

classic yeast form of "spaghetti and

meatball appearance". Wood lamp
examination can give a yellowish
fluorescence of affected skin. (9, 10)

Dermatophytosis is a superficial
fungal infection caused by dermatophyte
fungi in keratin.(1) The term tinea facial
indicate superficial dermatophyte infection
is limited to the face. The clinical diagnosis
of tinea facial is difficult because of the
clinical feature of tinea facial.(2, 3) Clinical
picture often resembles other skin
disorders such as cutaneous lupus
erythematous, psoriasis, acne, rosacea
and other skin disorders erythematous
face. (2-4 )

Most facial tinea respond well to

topical antifungal therapy for 3-4 weeks. (5)
For the PV there are several topical
therapies that can be given. Ointments
Withfield, azole class and alinamin an
effective topical treatment options for PV.
(10)
In the case of fungal infections with
multiple lesions and do not respond to
topical therapy may require systemic
therapy. (10, 11)

Dermatophyte infections, including

tinea facial presence throughout the world,
with a higher prevalence in the tropics.
This disease can occur at any age, more
often in women, and is often caused by
direct contact with infected objects
containing squama, such as towels,
clothing, bedding, bathroom floor and
others . (5) The incidence of tinea facial 34% of all cases of tinea corporis.
Causative agent of tinea facial varies,
depending on the geographical location
and potential reservoir located in the
neighborhood. (5, 6) In the United States,
Trichophyton tonsurans, T.rubrum, and
Microsporum canis is the most common
cause tinea facial. (4, 5)

This paper reports a case of tinea

facial caused by Trichophyton rubrum
melanoid type accompanied by pityriasis
versicolor, providing clinical improvement
with
combination
therapy
oral
ketokonazole and miconazole 2% cream.
CASE REPORTS
A-55-years old male, came to skin
and venereal clinic Sudirohusodo Wahidin
Hospital on July 13, 2012 with complaints
itching and reddish spots on the face.
These patches began to arise since 3
months ago. Initially only a small reddish
spots and became larger . itching getting
worse
when sweating.
History of
treatment, patient applied chinas ointment
to his lesion. Previous history of the same
illness denied. Family history of suffering
from the same disease denied.

In addition to dermatophytes
group, superficial fungal infections can
also be caused by candida and
Malassezia. (7, 8) Pityriasis versicolor (PV)
is a chronic superficial fungal infection
caused by Malassezia. (9, 10) Clinical
Manifestations may be macules or
hyperpigmentation or hypopigmentation
spots and smooth squama on it. Although
there is no racial predilection, but the
infection often strikes people of color of
skin. (9) Diagnosis PV is confirmed by
clinical manifestation and confirmation of
KOH examination. Microscopic picture of

Physical examination on the right

and left lateral facial showed multiple
erythematous plaques with active lesions
well defined edges and scales.
Microscopic examination of skin
scrapings of the lesion by using a solution
of potassium hydroxide (KOH) 10% gave a
positive result with
long branched
hyphae.

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Ratna Wulandari

tinea faciei caused by trichophyton rubrum melanoid type and pityriasis versicolor

Patient diagnosed with tinea facial

and given ketoconazole 200 mg once
daily for 10 days and topical therapy
miconazole 2% cream twice daily.

Final diagnosis is established tinea

faciei caused by Trichophyton rubrum
melanoid type with pityriasis versicolor.
Treatment was continued, and the patient
is recommended to control back.

Culture examination conducted by

specimen scrapings skin lesion on media
Sabouraud's Dextrose Agar (SDA),
incubated at 25 - 30 C. In 21 days
incubation,
macroscopically
downy
surface like velvet coloni,
the center
appear to be some form of radial Umbo.
On the back looks dark brown.
Microscopic examination of the culture
characterized by Lactophenol Cotton Blue
(LCB) got a bunch long and branching
hyphae, microaleuspora little, small, and
located
along
the
hyphae.
Macroaleuspora not found.

On the day 10 of treatment , the

lesions on the body looks improved and
the clinical picture showed macular
hypopigmentation. KOH examination of
skin scrapings showed mycological
improvement.
DISCUSSION
The diagnosis of tinea corporis in
this case is established based on history,
clinical examination and direct microscopic
examination with 10% KOH preparations
using skin scrapings and culture
specimens to determine the species cause
fungal infections. (12, 13)

Control 10 days later, clininical

improvement was shown. And patient had
new complaint white patches on the
chest and back
since 1 week ago.
Physical examination on
anterior et
posterior
trunk
looks
demarcated
hypopigmented macules, lenticuler size,
with thin squama on top of lesions. KOH
examination of skin scrapings hyphae and
arthrospora not obtained, whereas 10%
KOH examination added Parker ink on
skin scrapings was found hyphae with
clustered spores. Wood lamp examination
showed yellowish fluorescence.

From the history was obtained itching,

reddish spots on the face that getting
larger, and itching worse when sweating.
Physical examination found multiple
erythematous plaques with active lesions
well defined edges , and squama. The
literature said the clinical picture of
dermatophyte infections resulting from the
damage to keratin and inflammatory
response from the host. (7) The clinical
features are often atypical facial tinea, with
variations in size, degree of inflammation
and deep fungal infections. Tinea facial is
often preceded by the formation of flat
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macular with scales on top and a raised

edge, but can also evolve with the form
papules, vesicles, and crusting. The
middle of hypopigmentation or brown with
a thin squama. Tinea facial plaques can
be single or multiple. (5)
In this case, microscopic examination of
skin scrapings directly through the use of
10% KOH solution yielded positive results
with the finding sectional long and
branching hyphae. 10% KOH solution
helps digest epithelial tissues so that the
hyphae will appear on microscopic
examination. (7)
Cultures performed with specimens taken
from the lesion scrapings then planted on
SDA media, showed growth of coloni
within 21 days, the colony seemed lined
with downy surface like velvet, the center
appear to be some form of radial Umbo.
On the back looks dark brown.
Microscopic examination of cultures
stained
with
the
LCB
obtained
microaleuspora little, small, and located
along the hyphae. T.rubrum is a common
cause of tinea faciei. (3, 14) T.rubrum colony
morphology can be recognized in six
forms, downy, granular, melanoid, african,
rodhainii, and dysgenic. (15) Colony of T.
rubrum melanoid type of macroscopic form
colonies that accumulate, covered with
fine hairs and produce a dark brown
pigment melanin as in the back. (15, 16) In
the microscopic examination showed
microaleuspora little, small and located
along the lateral hyphae. Macroaleuspora
not found on this type. (15)
In this case , patient also complaint white
spots on the body. Dermatological
examination
showed
hypopigmented
macules, lenticuler size, with thin squama.
Examination of 10% KOH were added
Parker ink on skin scrapings showed
hyphae and clustered spores. Wood
lamp examination showed
positive
results.
Consistent
with
pityriasis

versicolor.
Pityriasis versicolor due to
Microsporum furfur, Malassezia furfur or
Pityrosporum orbiculare. (9) Manifestations
of
macular
hyperpigmentation
or
hypopigmentation often accompanied
squama in seborrheic areas such as body,
arm, neck, and face. Sometimes also
appear as hypopigmented follicular
lesions. (9, 17) In Wood's lamp examination
the lesions will appear golden yellow
fluorescence. (9, 10, 17) Direct microscopic
examination with KOH will look picture
thick short hyphae, and a collection of
spores known with descriptive terms
spaghetty and meatball. (9, 10, 18)
Handling fungal infections are generally
either keep skin clean and dry, take
shower every day, use a clean towel, and
wash clothes with hot water. (19) Drugs that
are ideal for a superficial fungal infection is
a drug that has a broad spectrum of
activity, effective at low concentrations
delivery, fungicidal effect, have a high
affinity for the stratum corneum, is not
irritating and not resistant to fungal
infections. (20) Most cases of tinea facial
cured with topical antifungal. Two classes
of antifungal azole class is often used and
allilamin. Application every day or twice a
day. For the azole class, should be
continued until 3-4 weeks and at least 1
week after the resolution. Because the
price is cheap and quite effective,
miconazole often used as first-line
therapy. (5) For the PV, there are some
topical therapy can be given in the form of
shampoos, lotions, creams and oinment.
Azole group, topical therapies effective for
PV, such as clotrimazole, miconazole,
ketoconazole, and econazole. (9, 10) PV
therapy typically takes 4-6 weeks, it is
associated with a high recurrence of PV.
(10)
In the case of fungal infections with
multiple lesions and do not respond to
topical therapy may require systemic
therapy. (10, 11) Ketoconazole a broad
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tinea faciei caused by trichophyton rubrum melanoid type and pityriasis versicolor

spectrum systemic antifungal that is

fungistatik, with mechanisms inhibit the
enzyme 14--demetilase the formation of
fungal cell membrane ergosterol. (12, 20)
Ketoconazole given at a dose of 200 mg
per day for 2-4 weeks. Oral griseofulvin
given for dermatophyte infections, a dose
of 500 mg per day. (1, 11, 21) But griseofulvin
not effective for pityriasis versicolor. (21) In
our case was given the combination
mikonazole 2% cream and ketoconazole
oral 200 mg / day. Dermatophyte
infections generally occur in areas of high
humidity and heat. Dry and cold
environments play a role in reducing
infections. In addition, reducing contact
with infected animals or individuals that
may help in preventing infection. (7)

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