Correspondence Address:
Pretty Mathew
Department of Dermatology, Government Medical College, Kannur, Pariyaram Medical College Post, Kannur 670503, Kerala
India

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Dear Editor,

A 40-year-old diabetic woman, with history of chronic iridocyclitis on long term oral prednisolone and azathioprine, presented with generalised redness, scaling, and itching for the past two months. Lesions first appeared as discrete, pruritic annular scaly lesions over flexor aspect of bilateral forearms 5 months back, for which she took irregular treatment. Gradually similar lesions appeared over face, leg and later involved the whole body. No history of recent change in medication was noted.

On examination, there was generalised erythema and scaling involving more than 90% of body surface area with some lesions over lower limb and back of trunk showing active borders [Figure 1]A–D. Finger nails showed distal onycholysis and subungual hyperkeratosis and toe nails had onychodystrophy and subungual hyperkeratosis [Figure 2]. Palms, soles, mucosa and hair were normal.{Figure 1} {Figure 2}

Scraping mounted in 10% potassium hydroxide (KOH) from the active border of the skin lesion showed refractile, long, branching, and septate hyphal filaments [Figure 4]A. Routine investigations including complete blood count, erythrocyte sedimentation rate, urine microscopy, serum electrolytes, liver and renal function tests, and peripheral smear were within normal limits. Viral markers were negative. Skin biopsy was taken from scaly lesions on right leg. Scrapings from skin and nail were sent for fungal culture.

Skin biopsy showed neutrophil collections in stratum corneum [[Figure 3]A]. Periodic acid-schiff (PAS) stain revealed PAS-positive hyphae in the stratum corneum, there by confirming a diagnosis of dermatophytosis [[Figure 3]B]. Gomori Methenamine Silver stain showed many fungal hyphae in keratin layer [[Figure 3]C].{Figure 3}

Fungal culture of skin and nail scraping in Sabouraud’s dextrose agar showed cottony white colonies and lactophenol cotton blue staining of smear from culture showed septate hyphae with tear shaped conidia arranged singly along sides of hyphae which was characteristic of Trichophyton rubrum [[Figure 4]B and C]. Involvement of nails may be a clue to the diagnosis of T. rubrum.[1]{Figure 4}

Correlation of the clinical, histopathologic and microbiological findings established a diagnosis of erythroderma secondary to dermatophytosis. Erythroderma secondary to other causes like eczema and psoriasis was ruled out by the presence of lesions with active borders and by history of similar lesions in the family members. She was advised to maintain a good personal hygiene and started on itraconazole capsule 100 mg twice daily along with topical clotrimazole. Blood sugars were controlled. After two weeks of treatment patient improved symptomatically with reduction in erythema and scaling.

Dermatophytes usually cause infections limited to the stratum corneum or keratinized adnexal structures. Erythrodermic variants are also seen rarely. There is an unprecedented epidemic-like scenario of tinea infections in India. Dermatophytes can cause extensive and invasive infection in immunocompromised hosts.[2] Environmental factors, a growing resistance to antifungal agents, irrational use of topical and oral antifungal drugs and more importantly use of fixed drug combination creams containing a steroid, antifungal, and antibacterial play an important role.[3]

Alterations in skin barrier function induced by extensive dermatophytosis may have resulted in erythroderma, via sweat dysfunction in our patient.[4] Irregular treatment and immunosuppression may also have accentuated it. The possibility of secondary dermatophytic infection in a pre-existing erythrodermic patient was excluded considering the dramatic improvement following a short course of antifungal therapy.

This case proves the possibility of life-threatening complications like erythroderma in a common dermatophyte infection following improper and irregular treatment in an immunocompromised setting. It also highlights the importance of simple bedside investigations like KOH mount, which helped in early diagnosis of the condition.

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