Periocular Rash FREE

A healthy 5-year-old boy presented with a 3-month history of an erythematous rash around his left eye (Figure). He initially received a diagnosis of eczema and was treated with pimecrolimus, 1% cream. The dermatitis did not respond, and he was further treated for presumed superimposed impetigo with oral erythromycin estolate and topical mupirocin calcium ointment. The eruption continued to progress. Physical examination revealed a large annular erythematous scaling plaque with papules and pustules surrounding the left eye with associated upper eyelid swelling. Visual acuity was unaffected, the globes were not proptotic, canthi were normal, conjunctivae were noninflamed, pupils were reactive and responsive to light, and extraocular eye movements were intact.

A . Culture papule to rule out orbital cellulitis
B . Obtain potassium hydroxide (KOH) preparation
C . Treat with oral griseofulvin
D. Treat with topical hydrocortisone cream

Periocular tinea

B. Obtain potassium hydroxide (KOH) preparation

The key clinical feature in this case is making the diagnosis of the cause of periocular tinea in this child. Treatment often requires a high degree of clinical suspicion for tinea.¹

Fungi in the genera Microsporum, Trichophyton, and Epidermophyton cause dermatophytosis and are called dermatophytes. Microsporum and Trichophyton are both human and animal pathogens, whereas Epidermophyton is a human pathogen only. Dermatophytes are pathogenic members of the keratin-digesting soil fungi. In humans, they generally grow in keratinized tissues such as hair, nails, and the outer layer of skin. Infections are referred to as “tinea” infections and are named with reference to the area of the body involved.

The diagnosis of periocular tinea is often missed. While some cases can cause a significant inflammatory response, leading to the clinical appearance of a cellulitis,^2- 4 not all periocular tinea incites a strong inflammatory response. The diagnosis should be considered in less dramatic presentations that lack periorbital edema and red, tender, swollen eyelids.

Periocular tinea has a highly pleomorphic appearance that mimics other conditions, especially when partially or inappropriately treated. Key features that should arouse suspicion for tinea include the presence of scaling, exacerbation with the use of topical corticosteroids, and the loss of eyelashes or eyebrows. KOH preparations made with scrapings at multiple sites within the affected area can confirm the diagnosis. If desired, fungal cultures can also be sent to the laboratory but are not routinely done if the KOH preparation is positive for fungal elements. In a review of 10 children with periocular tinea, all had been previously diagnosed and treated for at least 1 other condition prior to their diagnosis of tinea. Of these, only 7 had a KOH preparation and/or culture positive for fungal elements.¹

Treatment with oral griseofulvin is effective and analogous to treating tinea capitis, which requires oral medication for organism clearance. Alternative systemic antifungals include oral terbinafine, itraconazole, and ketoconazole, but griseofulvin has fewer toxicities, fewer concerning potential drug interactions, and does not require monitoring of hepatic function for healthy children.¹ Topical antifungals are a useful adjunctive therapy. To prevent relapses, topical therapy should be continued for a minimum of 2 weeks after the eruption clears clinically. If domestic animals are a potential source of infection, the animals may need to be examined by a veterinarian.

This patient's pediatrician added hydrocortisone cream, 2.5%, which resulted in acute worsening of the eruption. A general dermatologist made the diagnosis of rosacea and prescribed metronidazole benzoate cream, which did not lead to improvement. Because of strong clinical suspicion for tinea at presentation to the final specialist, a KOH slide was prepared that demonstrated rare septated hyphae consistent with a fungal infection. The patient was treated with oral griseofulvin and topical econazole nitrate cream. At his follow-up visit 7 weeks later, the child's condition had significantly improved, and only minimal erythema remained on the left eyelid and cheek. He completed the 8-week course of griseofulvin and continued the econazole cream for 2 weeks after the infection appeared completely clear. He had no relapse.