CASE REPORT

Tinea Cruris and Tinea Corporis Masquerading as Tinea

Indecisiva: Case Report and Review of the Literature
Sidharth Sonthalia, Archana Singal, and Shukla Das

Background: Tinea indecisiva is characterized by concentric scaly rings simulating tinea imbricata but caused by dermatophytes
other than Trichophyton concentricum.
Objective: Tinea indecisiva has been rarely reported. We report a unique case and review of the previously reported cases,
pathogenesis, and management.
Methods: An adult Indian man developed extensive tinea cruris and tinea corporis with concentric rings of scaly lesions over
the groin, buttocks, and thighs following the use of oral corticosteroids and antifungal-steroid cream for 3 months. Mycologic and
immunologic studies were performed for diagnosis.
Results: Diagnosis of tinea indecisiva was confirmed on the appearance of ‘‘ring-within-a-ring’’ lesions clinically and isolation
of Trichophyton mentagrophytes var. interdigitale as the etiologic agent on mycologic testing. Intradermal testing with
Trichophyton extract showed fluctuating hypersensitivity responses. Four-week treatment with daily oral terbinafine resulted in
complete resolution.
Conclusion: Tinea indecisiva should be considered in a patient with tinea imbricata–like lesions with local immunosuppression
caused by a non-concentricum dermatophyte.

Contexte: Tinea indecisiva se caracte´ rise par des anneaux squameux, concentriques, simulant tinea imbricata, mais
l’affection est cause´ e par d’autres dermatophytes que Trichophyton concentricum.
Objectif: Rare est la description de Tinea indecisiva dans la documentation; nous faisons e´ tat ici d’un cas unique en son genre
et passons en revue les cas expose´ s ante´ rieurement ainsi que leur pathogene` se et leur prise en charge.
Me´ thode: Un Indien adulte a consulte´ pour des zones e´ tendues d’ecze´ ma margine´ et d’herpe` s circine´ , accompagne´ s
d’anneaux concentriques de le´ sions squameuses touchant les aines, les fesses, et les cuisses, qui sont apparues a` la suite
de la prise de corticoste´ ro¨ıdes oraux et de l’application d’une cre` me associant un antifongique et un ste´ ro¨ıde pendant 3
mois. Des analyses mycologiques et immunologiques ont e´ te´ effectue´ es pour confirmer le diagnostic.
Re´ sultats: Le diagnostic de tinea indecisiva a e´ te´ confirme´ par l’apparence clinique des le´ sions en forme d’« anneau
dans un anneau » et par la mise en e´ vidence de l’agent causal, Trichophyton mentagrophytes, variante interdigitale, a` l’examen
mycologique. Des e´ preuves intradermiques d’extraits de Trichophyton ont re´ ve´ le´ des re´ actions d’hypersensibilite´ de
type variable. La prise quotidienne de terbinafine orale, durant 4 semaines, a permis la disparition comple` te des le´ sions.
Conclusions: Le diagnostic de tinea indecisiva devrait eˆ tre envisage´ chez les patients pre´ sentant des le´ sions ressemblant a`
celles de tinea imbricata, accompagne´ es d’une immunode´ pression locale, mais cause´ es par un dermatophyte de type non
concentricum.

INEA IMBRICATA (TI) caused by Trichophyton

From SKINNOCENCE: The Skin Clinic & Research Centre, Haryana,
India, and Departments of Dermatology and STD and Microbiology,
University College of Medical Sciences and Guru Teg Bahadur
Hospital, University of Delhi, Delhi, India.
Address reprint requests to: Archana Singal, MD, MNAMS, B-14, Law
Apartments, Karkardooma, Delhi-110092, India; e-mail: archanasingal@
hotmail.com.
DOI 10.2310/7750.2014.14057
Ⓒ 2014 Canadian Dermatology Association
T concentricum is a chronic dermatophytosis character-
ized clinically by the presence of multiple annular
concentric plaques that later become lamellar with
abundant thick scales, giving the appearance of tiles or
fish scales.1 TI occurs endemically in certain regions,
especially southern Asia. Although TI is caused exclusively
by T. concentricum, recently, a few cases have been
reported that presented with clinical features simulating
TI but caused by species other than T. concentricum. Such
peculiar cases have been labeled as ‘‘tinea indecisiva’’ and

Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 2 (March/April), 2015: pp 171–176 171
 Sonthalia et al

‘‘tinea pseudoimbricata’’ and tend to occur in patients

with some degree of immunosuppression. 2,3 To the best of
our knowledge, only eight such cases have been published
to date, each occurring in a different clinical setting with
different lesional localization and caused by different
dermatophytic species.2–8 In this report, we describe
another unique case of tinea indecisiva with the following
special characteristics: involvement of the groin, penile
shaft, and buttocks (previous cases have primarily involved
the trunk, limbs, or scalp) and caused by Trichophyton
mentagrophytes var. interdigitale (never described before).
We further present a thorough review of previously
reported cases of this condition, with an emphasis on the
putative pathogenesis.
Figure 1. Erythematous, annular, concentric rings with scattered
pustules studded over the rings and grayish-white scales overlying
Case Report the central relatively clear zone, involving the groin and penile shaft.

An 18-year-old adult Indian male presented with a 3-

month history of persistent itchy rash over the groin, lower dextrose agar (SDA) showed flat, white, downy growth
abdomen, and thighs. He gave a history of intermittent (Figure 4). Lactophenol cotton blue preparation revealed
application of an over-the-counter antifungal-steroid fine septate hyaline branched hyphae with sparse macro-
combination cream (containing miconazole nitrate 2% conidia and clustered microconidia along with well-
and clobetasol dipropionate 0.05%) twice daily, oral developed spiral hyphae and chlamydospores (Figure 5),
levocetirizine 5 mg every night, and oral betamethasone confirming T. mentagrophytes var. interdigitale as the
(2 mg) once a day for the past 3 months, which resulted in etiologic agent. Serologic testing for IgE immunoglobulin
temporary relief of itching and partial resolution of lesions against Trichophyton antigen was strongly positive. A final
followed by progressive worsening. He had not sought a diagnosis of tinea cruris and tinea corporis manifesting as
dermatologic consultation until then and had no history of tinea indecisiva (pseudoimbricata) was made. The patient
having taken any oral antifungal drugs. He had no history was treated with daily oral terbinafine 250 mg for 4 weeks
of diabetes or any other significant medical disorder. A and oral levocetirizine 5 mg for 2 weeks. Oral steroids were
history of high-risk behavior (eg, multiple sex partners and tapered off over the next 6 weeks. The rash completely
intravenous drug abuse) for acquisition of acquired subsided within a month. The patient came for his last
immunodeficiency was not elicited. A family history of follow-up visit around 6 months after the initial episode,
diabetes or recurrent skin infections was absent. and there was no recurrence until then.
His physical and systemic examinations were normal. A
cutaneous examination revealed the presence of wide-
spread erythematous, annular, concentric rings with
scattered pustules studded over the rings and grayish-
white scales overlying the central relatively clear zone,
involving the groin and penile shaft (Figure 1), buttocks
(Figure 2), thighs (Figure 3), and lower abdomen,
clinically mimicking TI. Examination of the palms and
soles, nails, and scalp revealed no abnormality.
Hematologic and biochemical investigations, including
hemography, fasting and postprandial plasma glucose, and
renal and hepatic function tests, were normal. Serology for
human immunodeficiency virus (HIV) was negative.
Microscopic examination of skin scrapings with 10%
potassium hydrox- ide (KOH) revealed thin hyaline hyphae
suggestive of dermatophytic infection. Fungal culture on Figure 2. Similar lesions over the buttocks but with fewer pustules
and marked scaling.
Sabouraud

1 Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 2 (March/April), 2015: pp
 Tinea Indecisiva

Figure 3. Similar lesions over the thighs. Figure 4. Fungal culture on Sabouraud dextrose agar (SDA) showing
flat, white, downy growth.
Discussion
The characteristic clinical picture seen in our patient
simulated features of TI. Tinea imbricata or Tokelau is a
chronic dermatophytosis occurring endemically in certain
regions, such as southern Asia (China and India), the
islands of the South Pacific, and South and Central
America.1 It usually affects glabrous skin and is
exclusively caused by
T. concentricum, a strictly anthropophilic dermatophyte.
The morphology is characteristic, with initial lesions
presenting as squamous annular, erythematous, concentric
plaques that

Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 2 (March/April), 2015: pp 1
Figure 5. Lactophenol cotton blue preparation showing fine septate
hyaline branched hyphae with sparse macroconidia and clustered
microconidia along with well-developed spiral hyphae and chlamy-
dospores, suggestive of Trichophyton mentagrophytes var. interdigitale
(3400 original magnification).

later become lamellar with abundant thick scales adhering

to one side, giving the appearance of tiles, fish scales, or
lace.1 The term imbricata is derived from the Latin
imbrex and refers to the similarity of the rash to
overlapping roof tiles. Cases presenting with clinical
features simulating TI but caused by species other than
T. concentricum have been labeled ‘‘tinea indecisiva’’ by
Batta and colleagues and ‘‘tinea pseudoimbricata’’ by
Lim and Smith.2,3 Until now, only eight such cases have
been reported in the literature (Table 1), of which four
were caused by Trichophyton tonsurans and one each by
Trichophyton rubrum, Microsporum audouinii,
Microsporum gypseum, and T. mentagrophytes var.
menta- grophytes.2–8 This case report is the first in which
a different variant of T. mentagrophytes, that is, T.
mentagrophytes var. interdigitale, was isolated as the
etiologic agent. It is an anthropophilic dermatophyte and
a frequent cause of tinea pedis, tinea manuum, and
onychomycosis. With the exception of the case
reported by Narang and colleagues, in which the scalp
was involved,8 lesions were present over the trunk and/or
limbs in other cases.2–7 The current patient presented
with extensive tinea cruris and tinea corporis primarily
involving the groin, genitalia, and buttocks, manifesting
as tinea indecisiva. Although there were typical

1 Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 2 (March/April), 2015: pp
1
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 2 (March/April), 2015: pp

Table 1. Summary of Reported Cases of Tinea Pseudoimbr icata (Indecisiva), Including the Present Case

Serial Authors and Year of Number of

No. publication Patients Age/Sex Distribution of Lesions Associated Comorbidity and/or Previous Therapy Species Isolated
1 Batta et al, 20022 2 1. NM 1. Arms, legs, and trunk Topical steroids and antifungals 1. Trichophyton mentagrophytes var.
2. NM 2. Legs mentagrophytes
2. Trichophyton tonsurans
2 Lim and Smith, 20033 1 14/F Trunk and limbs Renal transplant patient on oral T. tonsurans
immunosuppressives (tacrolimus and
azathioprine) and topical antifungals
3 Ouchi et al, 20054 1 28/M Neck and trunk Topical steroids for 3 mo T. tonsurans

Sonthalia
4 Poonawalla et al, 20065 1 55/M Extensive involvement of Mycosis fungoides refractory to therapy Trichophyton rubrum
trunk and limbs
5 Hoque and Holden, 20076 1 44/F Trunk and limbs Topical and oral steroids T. tonsurans
6 Poziomczyk et al, 20127 1 21/F Trunk and lower limbs Crusted scabies Microsporum gypseum
7 Narang et al, 20108 1 35/F Scalp HIV-positive patient on antiretroviral Microsporum audouinii
therapy and co-trimoxazole for the last
15 days
8 Sonthalia et al, 2010 1 20/M Groin, penile shaft, lower Topical steroid-antifungal combination T. mentagrophytes var. interdigitale
(present case) abdomen, and lower limbs therapy and oral steroids
HIV 5 human immunodeficiency virus; NM 5 not mentioned.
 Tinea Indecisiva

annular, concentrically placed lesions forming a lamellar postulated

network, as seen in TI, there was prominent postulation
and less scaling in the present case.
The immunologic response to dermatophytes depends
on two factors: the host’s cell-mediated immunity (CMI)
and the species of dermatophyte involved. The host’s CMI
mediated by T-cell reactivity forms the primary defense
against dermatophytes. Although most patients usually
develop specific antifungal antibodies to a particular
dermatophyte after infection, these antibodies are largely
nonprotective. Many characteristic observations from
patients infected with TI indicate that effective CMI does
not develop or is suppressed during the course of
infection. These include the endemicity of TI in specific
geographic locations, indicating inherent susceptibility of
the resident population, acquisition of infection in early
childhood, a lack of spontaneous remissions, and almost
invariable relapses occurring after an initial response to
antifungal therapy. This is in striking contrast to the
infection of a man with the cattle ringworm T.
verrucosum, where lifelong immunity appears to follow
initial infection, indicating the additional role of the
species of dermatophyte involved.9
The formation of concentric rings with the clinical
‘‘ring-within-a-ring’’ appearance and the development of
sequential waves of scaling encountered in TI has been
postulated to arise due to immunologic factors. In a study
by Hay and colleagues conducted in Papua New Guinea,
78% of patients (with TI) investigated had antibody to
T. concentricum and demonstrated either immediate-type
hypersensitivity (52%) or negative responses (46%) to
intradermal trichophytin.9 The majority of patients failed
to develop delayed-type hypersensitivity on both in vivo
skin testing and in vitro assessment by leukocyte migration
inhibition. Based on these findings, the relevance of
negative delayed-type hypersensitivity to the T. concen-
tricum cytoplasmic antigen and T-lymphocyte hyporeac-
tivity of the host, leading to the persistence of the
infection, has been emphasized.9 However, in our case,
the patient did not want to have the trichophytin skin
testing. Moreover, the interpretation of trichophytin is an
investigation with very variable responses. The interpreta-
tion of the immediate- as well as the delayed-type
reactivity and its clinical significance have not been
confidently established.
The principle behind the occurrence of clinically
similar lesions in patients infected with non-concentricum
species of Trichophyton (ie, tinea pseudoimbricata) is at
present speculative. But there is a strong case favoring the
role of local or systemic immunosuppression in its
pathogenesis as well, similar to the phenomenon

Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 2 (March/April), 2015: pp 1
for TI. All of the previously reported cases of tinea
pseudoimbricata had some form of relative immunosup-
pression, the most common being prolonged use of
sequential or cyclical topical steroids with or without oral
steroids in four of the eight reported cases. 2,4,6 Although
the patients reported by Batta and colleagues had used
topical antifungals in addition to topical steroids, no
patient had received oral antifungals.2 Batta and collea-
gues attributed the occurrence of tinea
pseudoimbricata to the combination of two factors: local
immunosuppres- sion due to prolonged topical steroid
use and reinfection due to early discontinuation of topical
antifungals. In the current case too, prolonged
intermittent use of a combination of superpotent topical
steroid and antifungal cream along with oral
corticosteroids resulted in a state of local as well as
systemic immunosuppression. The patients reported by
Lim and Smith, Poonawalla and colleagues, and Narang
and colleagues were also immmu- nosuppressed: a renal
transplant–recipient child on oral immunosuppressives
(tacrolimus plus azathioprine), an adult male with
treatment-refractory mycosis fungoides, and an adult
HIV-positive female with a CD4 count of 99 cells/mL on
antiretroviral therapy, respectively.3,5,8 Although
Poziomczyk and colleagues described their case as
‘‘immu- nocompetent,’’ their patient had apparently not
been more thoroughly evaluated for evidence of
immunosuppression and suffered from concomitant
crusted scabies.7 Crusted scabies characterized by high
mite burdens and extensive cutaneous crusting is known
to occur in individuals who mount a vehement allergic
response to mite infestation, but their strong IgE-driven
T-helper 2 response and other humoral responses are
totally nonprotective, resulting in uncontrolled growth of
the parasite.10 Thus, irrespective of the lesional
distribution and species involved in cases of tinea
indecisiva, the immunopathogenesis of this peculiar
condition is best explained as a simulation of T-cell
hyporeactivity and the lack of delayed-type
hypersensitivity to the dermatophyte, as encountered in
TI.
The differentiation between tinea corporis/cruris
(unaltered by any local or systemic immunomodulators),
tinea indecisiva, and tinea incognito is important. Tinea
corporis and tinea cruris in an immunocompetent
individual typically present with annular lesions with an
erythematous scaly border and central clearing on most
skin surfaces, except the scalp, volar areas, and nails.
Dermatophytic infections are fairly common, especially in
tropical countries, with a higher incidence during the hot,
humid season. Treatment with topical imidazoles or
allylamines for 2 to 4 weeks is often sufficient. Patients
with diabetes are likely to present with extensive
lesions.

1 Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 2 (March/April), 2015: pp
 Sonthalia et al
For extensive tinea corporis/cruris, oral antifungals such as
terbinafine, fluconazole, or itraconazole have to be given
for up to 4 weeks. The overall prognosis is excellent in
unaltered dermatophytic infections. Cases of tinea incog-
nito (also called tinea atypica), best defined as dermato-
phytic infections with altered clinical presentation
following inappropriate use of systemic or topical
corticosteroids or topical calcineurin inhibitors (CNIs), are
on the rise. Easy accessibility of over-the-counter high-
potency topical steroids in some countries and their
inappropriate use by physicians without fungal testing
have contributed to this trend. Immunomodulation by
corticosteroids or CNIs not only leads to pathomorphosis
and misdiagnosis due to simulation of other dermatoses;
the course of infection is also further complicated by
delayed recovery. Although tinea incognito commonly
displays subdued scaling and loss of annular character of
lesions, it may simulate a myriad of other clinical
conditions, such as impetigo, rosacea, dermatitis, lupus
erythematosus, polymorphous light erup- tion, psoriasis,
and widespread folliculitis (Majocchi granuloma–like
presentation), among others.11 Tinea indecisiva, on the
other hand, presents with sequentially appearing
concentric rings and scaling, giving rise to the characteristic
ring-within-a-ring appearance. A high index of clinical
suspicion and direct microscopic examination of skin
scrapings with KOH and fungal culture on SDA are vital for
the diagnosis of both tinea incognito and tinea indecisiva.
Treatment of tinea incognito consists of combined use of
oral and topical antifungals for at least 4 weeks. The
prognosis is good if treatment is complied with and further
abuse of immunosuppressives is halted. Owing to the
paucity of published literature on tinea indecisiva, there is
no current consensus on its standard treatment protocol.
However, 4 weeks of oral terbinafine seems to be the most
effective and sufficient therapy, with an excellent
prognosis.
Conclusion
Any patient presenting with such a ring-within-a-ring
morphology of pustular and/or scaly lesions, that is, TI-
like lesions, should always be investigated with fungal
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 2 (March/April), 2015: pp
cultures for speciation. With indiscriminate use of steroid
creams by patients, at least in the Indian context, more
such cases may surface from time to time. Their early
identification and treatment are all that is required to take
care of this otherwise simple dermatosis.
Acknowledgments
Financial disclosure of authors and reviewers: None
reported.
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