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What Is Your Diagnosis? Tinea Corporis
The Diagnosis: Tinea Corporis
Although contact dermatitis from the metal on the back of the watch was suspected, many modern wrist watches are made with stainless steel rather than nickel, which is a common contact allergen; therefore, other diagnoses were considered in the differential including irritant contact dermatitis, psoriasis, and tinea infection. A potassium hydroxide (KOH) preparation was performed to rule out tinea infection. Unexpectedly, the KOH preparation was positive for fungal hyphae, confirming a diagnosis of tinea corporis. The patient was treated with clotrimazole cream 1% twice daily for 3 weeks during which time the rash completely resolved.
We present this case to stress the importance of performing KOH preparations even when the likelihood of tinea infection seems remote. At our institution, we teach our residents, “If it’s scaly, scrape it.” This adage has served us well. Tinea corporis may be mistaken for many other skin diseases, including eczema, psoriasis, and seborrheic dermatitis.1 A KOH preparation often is a helpful tool in confirming the diagnosis and should be performed when a dermatophyte infection is suspected. The KOH preparation is the most sensitive diagnostic test used to confirm dermatophyte infection, with 90% of infections showing positive results.2,3
Tinea infections may occur anywhere on the body, but areas that are prone to excessive heat and/or moisture are particularly susceptible.4 Dermatophyte infections typically present as annular, scaly, pruritic patches or plaques often with central clearing and an active border.1 In our patient, the lesion showed characteristics that were suggestive of a dermatophyte infection but was somewhat atypical in appearance, as it lacked central clearing (Figure). The 3 genera of dermatophytes—Trichophyton, Microsporum, and Epidermophyton—are common causes of fungal infections.2 The pathogenesis of dermatophytosis is the synthesis of keratinases that digest keratin and sustain the presence of the fungi. Local factors such as sweating and occlusion facilitate the activity of these organisms.2 In our case, the pathogenesis was believed to be due to the entrapment of moisture behind the patient’s watch, creating a favorable environment for fungal growth.
- Ely JW, Rosenfeld S, Seabury SM. Diagnosis and management of tinea infections. Am Fam Physician. 2014:90:702-710.
- Wolff K, Saavedra AP, Fitzpatrick TB. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology. 7th ed. New York, NY: McGraw-Hill Medical; 2013.
- Levitt JO, Levitt BH, Akhavan A, et al. The sensitivity and specificity of potassium hydroxide smear and fungal culture relative to clinical assessment in the evaluation of tinea pedis: a pooled analysis (published online ahead of print June 22, 2010). Dermatol Res Pract. doi:10.1155/2010/764843.
- Gupta AK, Chaudhry M, Elewski B. Tinea corporis, tinea cruris, tinea nigra and piedra. Dermatol Clin. 2003;21:395-400.
The Diagnosis: Tinea Corporis
Although contact dermatitis from the metal on the back of the watch was suspected, many modern wrist watches are made with stainless steel rather than nickel, which is a common contact allergen; therefore, other diagnoses were considered in the differential including irritant contact dermatitis, psoriasis, and tinea infection. A potassium hydroxide (KOH) preparation was performed to rule out tinea infection. Unexpectedly, the KOH preparation was positive for fungal hyphae, confirming a diagnosis of tinea corporis. The patient was treated with clotrimazole cream 1% twice daily for 3 weeks during which time the rash completely resolved.
We present this case to stress the importance of performing KOH preparations even when the likelihood of tinea infection seems remote. At our institution, we teach our residents, “If it’s scaly, scrape it.” This adage has served us well. Tinea corporis may be mistaken for many other skin diseases, including eczema, psoriasis, and seborrheic dermatitis.1 A KOH preparation often is a helpful tool in confirming the diagnosis and should be performed when a dermatophyte infection is suspected. The KOH preparation is the most sensitive diagnostic test used to confirm dermatophyte infection, with 90% of infections showing positive results.2,3
Tinea infections may occur anywhere on the body, but areas that are prone to excessive heat and/or moisture are particularly susceptible.4 Dermatophyte infections typically present as annular, scaly, pruritic patches or plaques often with central clearing and an active border.1 In our patient, the lesion showed characteristics that were suggestive of a dermatophyte infection but was somewhat atypical in appearance, as it lacked central clearing (Figure). The 3 genera of dermatophytes—Trichophyton, Microsporum, and Epidermophyton—are common causes of fungal infections.2 The pathogenesis of dermatophytosis is the synthesis of keratinases that digest keratin and sustain the presence of the fungi. Local factors such as sweating and occlusion facilitate the activity of these organisms.2 In our case, the pathogenesis was believed to be due to the entrapment of moisture behind the patient’s watch, creating a favorable environment for fungal growth.
The Diagnosis: Tinea Corporis
Although contact dermatitis from the metal on the back of the watch was suspected, many modern wrist watches are made with stainless steel rather than nickel, which is a common contact allergen; therefore, other diagnoses were considered in the differential including irritant contact dermatitis, psoriasis, and tinea infection. A potassium hydroxide (KOH) preparation was performed to rule out tinea infection. Unexpectedly, the KOH preparation was positive for fungal hyphae, confirming a diagnosis of tinea corporis. The patient was treated with clotrimazole cream 1% twice daily for 3 weeks during which time the rash completely resolved.
We present this case to stress the importance of performing KOH preparations even when the likelihood of tinea infection seems remote. At our institution, we teach our residents, “If it’s scaly, scrape it.” This adage has served us well. Tinea corporis may be mistaken for many other skin diseases, including eczema, psoriasis, and seborrheic dermatitis.1 A KOH preparation often is a helpful tool in confirming the diagnosis and should be performed when a dermatophyte infection is suspected. The KOH preparation is the most sensitive diagnostic test used to confirm dermatophyte infection, with 90% of infections showing positive results.2,3
Tinea infections may occur anywhere on the body, but areas that are prone to excessive heat and/or moisture are particularly susceptible.4 Dermatophyte infections typically present as annular, scaly, pruritic patches or plaques often with central clearing and an active border.1 In our patient, the lesion showed characteristics that were suggestive of a dermatophyte infection but was somewhat atypical in appearance, as it lacked central clearing (Figure). The 3 genera of dermatophytes—Trichophyton, Microsporum, and Epidermophyton—are common causes of fungal infections.2 The pathogenesis of dermatophytosis is the synthesis of keratinases that digest keratin and sustain the presence of the fungi. Local factors such as sweating and occlusion facilitate the activity of these organisms.2 In our case, the pathogenesis was believed to be due to the entrapment of moisture behind the patient’s watch, creating a favorable environment for fungal growth.
- Ely JW, Rosenfeld S, Seabury SM. Diagnosis and management of tinea infections. Am Fam Physician. 2014:90:702-710.
- Wolff K, Saavedra AP, Fitzpatrick TB. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology. 7th ed. New York, NY: McGraw-Hill Medical; 2013.
- Levitt JO, Levitt BH, Akhavan A, et al. The sensitivity and specificity of potassium hydroxide smear and fungal culture relative to clinical assessment in the evaluation of tinea pedis: a pooled analysis (published online ahead of print June 22, 2010). Dermatol Res Pract. doi:10.1155/2010/764843.
- Gupta AK, Chaudhry M, Elewski B. Tinea corporis, tinea cruris, tinea nigra and piedra. Dermatol Clin. 2003;21:395-400.
- Ely JW, Rosenfeld S, Seabury SM. Diagnosis and management of tinea infections. Am Fam Physician. 2014:90:702-710.
- Wolff K, Saavedra AP, Fitzpatrick TB. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology. 7th ed. New York, NY: McGraw-Hill Medical; 2013.
- Levitt JO, Levitt BH, Akhavan A, et al. The sensitivity and specificity of potassium hydroxide smear and fungal culture relative to clinical assessment in the evaluation of tinea pedis: a pooled analysis (published online ahead of print June 22, 2010). Dermatol Res Pract. doi:10.1155/2010/764843.
- Gupta AK, Chaudhry M, Elewski B. Tinea corporis, tinea cruris, tinea nigra and piedra. Dermatol Clin. 2003;21:395-400.
An 81-year-old woman presented with a 2-cm erythematous, scaly, pruritic rash on the left dorsal wrist localized to the skin under her watch. The patient first noticed the lesion 2 months prior. She moved the watch to the right wrist a few days prior to presentation and no symptoms developed in that location. No other areas of the skin were affected. She had no known allergies and was otherwise in good health.
Thickened Velvety Plaques in a 75-Year-Old Woman
The Diagnosis: Tripe Palms and Acanthosis Nigricans
A shave biopsy specimen from the left palm showed slight epidermal hyperplasia with substantial papillomatosis and compact orthokeratosis. The complete blood cell count, thyrotropin level, uric acid level, liver function tests, mammogram, Papanicolaou test, and chest radiograph were unremarkable. A basic metabolic panel showed mildly elevated blood glucose at 111 mg/dL (reference range, 70-99 mg/dL) and hemoglobin A1c at 6.3% (reference range, <6.0%). Full-body computed tomography, endoscopy, and colonoscopy initially were normal. One year later after presenting with tripe palms, the patient had a bowel obstruction secondary to omental carcinomatosis from a primary ovarian tumor.
The term tripe in tripe palms refers to the resemblance to the edible lining of the bovine foregut. It originated in 1963 from a patient's own description of the rugose velvety texture of the palms.1 In the literature, tripe palms also is called acanthosis palmaris, acanthosis nigricans of the palms, palmar hyperkeratosis, palmar keratoderma, and pachydermatoglyphy. It is a rare cutaneous finding. Tripe palms is associated with other cutaneous paraneoplastic syndromes such as malignant acanthosis nigricans (72% of cases) and Leser-Trélat sign (10% of cases). It affects more men than women (63% vs 37%) and is almost exclusively seen in adults (median age, 62 years).1
The clinical appearance of tripe palms includes hypertrophy of the palms and often the soles with papillations producing a velvety or honeycomb appearance. In addition, the dermatoglyphics are pronounced. The histologic findings typically show hyperkeratosis and acanthosis. Other features that can be seen include dermal mucinosis and increased mast cells in the dermis. To differentiate tripe palms from other keratodermas, substantial papillations can be seen with less diffuse hyperkeratosis.1
Tripe palms has been associated with an underlying malignancy in more than 90% of published cases. In two-thirds of cases, tripe palms either appears before or concurrent with the diagnosis of cancer.2 It is rarely reported as an idiopathic finding or associated with nonneoplastic disorders. Malignancies most commonly associated are adenocarcinomas, especially of the stomach (27%) and lungs (22%). Other neoplasms, such as in our patient, include those of the genitourinary tract and breast. In a patient with tripe palms in the absence of acanthosis nigricans, the most common neoplasm is of the lung, especially when clubbing of the nails also is present.2 Thus, after a diagnosis of tripe palms is established, a thorough investigation for an underlying malignancy is the next most important step to direct specific therapy.
1. Cohen PR, Grossman ME, Silvers DN, et al. Tripe palms and cancer. Clin Dermatol. 1993;11:165-173.
2. Moore RL, Devere TS. Epidermal manifestations of internal malignancy. Dermatol Clin. 2008;26:17-29.
The Diagnosis: Tripe Palms and Acanthosis Nigricans
A shave biopsy specimen from the left palm showed slight epidermal hyperplasia with substantial papillomatosis and compact orthokeratosis. The complete blood cell count, thyrotropin level, uric acid level, liver function tests, mammogram, Papanicolaou test, and chest radiograph were unremarkable. A basic metabolic panel showed mildly elevated blood glucose at 111 mg/dL (reference range, 70-99 mg/dL) and hemoglobin A1c at 6.3% (reference range, <6.0%). Full-body computed tomography, endoscopy, and colonoscopy initially were normal. One year later after presenting with tripe palms, the patient had a bowel obstruction secondary to omental carcinomatosis from a primary ovarian tumor.
The term tripe in tripe palms refers to the resemblance to the edible lining of the bovine foregut. It originated in 1963 from a patient's own description of the rugose velvety texture of the palms.1 In the literature, tripe palms also is called acanthosis palmaris, acanthosis nigricans of the palms, palmar hyperkeratosis, palmar keratoderma, and pachydermatoglyphy. It is a rare cutaneous finding. Tripe palms is associated with other cutaneous paraneoplastic syndromes such as malignant acanthosis nigricans (72% of cases) and Leser-Trélat sign (10% of cases). It affects more men than women (63% vs 37%) and is almost exclusively seen in adults (median age, 62 years).1
The clinical appearance of tripe palms includes hypertrophy of the palms and often the soles with papillations producing a velvety or honeycomb appearance. In addition, the dermatoglyphics are pronounced. The histologic findings typically show hyperkeratosis and acanthosis. Other features that can be seen include dermal mucinosis and increased mast cells in the dermis. To differentiate tripe palms from other keratodermas, substantial papillations can be seen with less diffuse hyperkeratosis.1
Tripe palms has been associated with an underlying malignancy in more than 90% of published cases. In two-thirds of cases, tripe palms either appears before or concurrent with the diagnosis of cancer.2 It is rarely reported as an idiopathic finding or associated with nonneoplastic disorders. Malignancies most commonly associated are adenocarcinomas, especially of the stomach (27%) and lungs (22%). Other neoplasms, such as in our patient, include those of the genitourinary tract and breast. In a patient with tripe palms in the absence of acanthosis nigricans, the most common neoplasm is of the lung, especially when clubbing of the nails also is present.2 Thus, after a diagnosis of tripe palms is established, a thorough investigation for an underlying malignancy is the next most important step to direct specific therapy.
The Diagnosis: Tripe Palms and Acanthosis Nigricans
A shave biopsy specimen from the left palm showed slight epidermal hyperplasia with substantial papillomatosis and compact orthokeratosis. The complete blood cell count, thyrotropin level, uric acid level, liver function tests, mammogram, Papanicolaou test, and chest radiograph were unremarkable. A basic metabolic panel showed mildly elevated blood glucose at 111 mg/dL (reference range, 70-99 mg/dL) and hemoglobin A1c at 6.3% (reference range, <6.0%). Full-body computed tomography, endoscopy, and colonoscopy initially were normal. One year later after presenting with tripe palms, the patient had a bowel obstruction secondary to omental carcinomatosis from a primary ovarian tumor.
The term tripe in tripe palms refers to the resemblance to the edible lining of the bovine foregut. It originated in 1963 from a patient's own description of the rugose velvety texture of the palms.1 In the literature, tripe palms also is called acanthosis palmaris, acanthosis nigricans of the palms, palmar hyperkeratosis, palmar keratoderma, and pachydermatoglyphy. It is a rare cutaneous finding. Tripe palms is associated with other cutaneous paraneoplastic syndromes such as malignant acanthosis nigricans (72% of cases) and Leser-Trélat sign (10% of cases). It affects more men than women (63% vs 37%) and is almost exclusively seen in adults (median age, 62 years).1
The clinical appearance of tripe palms includes hypertrophy of the palms and often the soles with papillations producing a velvety or honeycomb appearance. In addition, the dermatoglyphics are pronounced. The histologic findings typically show hyperkeratosis and acanthosis. Other features that can be seen include dermal mucinosis and increased mast cells in the dermis. To differentiate tripe palms from other keratodermas, substantial papillations can be seen with less diffuse hyperkeratosis.1
Tripe palms has been associated with an underlying malignancy in more than 90% of published cases. In two-thirds of cases, tripe palms either appears before or concurrent with the diagnosis of cancer.2 It is rarely reported as an idiopathic finding or associated with nonneoplastic disorders. Malignancies most commonly associated are adenocarcinomas, especially of the stomach (27%) and lungs (22%). Other neoplasms, such as in our patient, include those of the genitourinary tract and breast. In a patient with tripe palms in the absence of acanthosis nigricans, the most common neoplasm is of the lung, especially when clubbing of the nails also is present.2 Thus, after a diagnosis of tripe palms is established, a thorough investigation for an underlying malignancy is the next most important step to direct specific therapy.
1. Cohen PR, Grossman ME, Silvers DN, et al. Tripe palms and cancer. Clin Dermatol. 1993;11:165-173.
2. Moore RL, Devere TS. Epidermal manifestations of internal malignancy. Dermatol Clin. 2008;26:17-29.
1. Cohen PR, Grossman ME, Silvers DN, et al. Tripe palms and cancer. Clin Dermatol. 1993;11:165-173.
2. Moore RL, Devere TS. Epidermal manifestations of internal malignancy. Dermatol Clin. 2008;26:17-29.
A 75-year-old woman presented with progressive, velvety, thick skin involving the bilateral axillae, inner thighs, palms, and buccal mucosa. She also reported weight loss of approximately 25 pounds over the last 12 months. Her medical history was notable for metabolic syndrome, allergic rhinitis, and colon polyps. She denied a family history of malignancy. On physical examination, she was a healthy-appearing overweight woman. The palmar surface of the bilateral hands was thickened and velvety with exaggerated dermatoglyphics. She had similarly thickened, velvety, gray-brown plaques on the bilateral axillae and proximal aspects of the inner thighs. The buccal mucosa had a thickened rugose texture.
