Tinea genitalis profunda, a diagnostic challenge: a case report and literature review Maruša Selan1, Bor Hrvatin Stančič1,2, Mateja Dolenc-Voljč1,2 ✉ 1Department of Dermatovenereology, Ljubljana University Medical Center, Ljubljana, Slovenia. 2Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia. 71 2023;32:71-74 doi: 10.15570/actaapa.2023.14 Introduction In the last decade, an increase in dermatophytosis and changing epidemiology has been observed in humans due to several rea- sons: migration of populations, socioeconomic conditions, in- ternational travel, climate and environmental changes, lifestyle, overcrowded living conditions, changes in human interaction with animals, and aging of the population with various comor- bidities (1, 2). Fungal skin infections present a significant public health concern worldwide. According to a recent survey on the prevalence of the most common skin diseases in Europe, fungal skin diseases were the most common skin conditions in the popu- lation aged 18 and older (3). Tinea genitalis (syn. genital tinea, pubogenital tinea, genital dermatophytosis) is a relatively new entity of dermatophyte infec- tion, observed mainly in young adults. By definition, it is localized on the mons pubis and labia in women, and on the penile shaft in men, with the possibility of expansion into the groin and scrotum (4). It can occur with or without concomitant tinea inguinalis or tinea corporis. According to recent epidemiological observations, it has been described as a “lifestyle disease” (4) and potentially sexually transmitted infection (5). We present a 35-year-old patient, an immigrant woman, with severe tinea genitalis, and we review previous reports on this rare type of tinea with new clinical and epidemiological observations, and diagnostic and treatment recommendations. Case report A 35-year-old female patient was referred to our department from the general emergency medical service due to an extensive in- flammatory erythematous plaque in the pubic and genital area and erythematous annular macules on the trunk and face. She reported experiencing genital lesions for approximately 2 months. She arrived in Slovenia with her family from Afghanistan 10 days before referral to our department. Prior to admission, she visited the emergency medical service twice, where she received systemic antibiotics, topical antibiot- ics, and antimycotic treatment. According to anamnestic data, her husband had several annular macules on his trunk. Due to extensive painful inflammatory plaques in the pubic and genital area that impaired her gait, the patient was admitted to our department. At admission, she was subfebrile (37.7 °C) and had swollen and painful inguinal lymph nodes. An extensive livid erythematous plaque with numerous papules and pustules and purulent discharge was present in the pubic area as well as the labia majora (Fig. 1). Abstract Tinea genitalis is a relatively new entity of dermatophyte infection, observed mainly in young adults. By definition, it is localized on the mons pubis and on the labia in women, and on the penile shaft in men. It has been described as a “lifestyle disease” and potentially sexually transmitted disease. We report the case of a 35-year-old patient, an immigrant woman, with tinea genitalis profunda, presenting with painful deep infiltrative papules and plaques, purulent inflammation, and signs of secondary impetigi- nization. Concomitantly, tinea corporis, tinea faciei, tinea colli, and tinea capitis were diagnosed. Her skin lesions developed over an approximately 2-month period. The zoophilic dermatophyte Trichophyton mentagrophytes was cultivated from the pubogenital lesions, as well as Escherichia coli and Klebsiella pneumoniae. The patient was treated systemically with terbinafine, antibiotics, and short-term corticosteroid, and topically with antimycotic and antibiotic cream. During almost 3 weeks of hospitalization, sat- isfactory improvement was achieved. A literature review with new clinical and epidemiological observations is presented for this rare type of tinea, which poses a diagnostic and treatment challenge. Keywords: tinea genitalis, dermatophytosis, Trichophyton mentagrophytes, zoophilic dermatophyte, immigration Acta Dermatovenerologica Alpina, Pannonica et Adriatica Acta Dermatovenerol APA Received: 1 May 2023 | Returned for modification: 24 May 2023 | Accepted: 5 June 2023 ✉ Corresponding author: mateja.dolenc-voljc@mf.uni-lj.si Figure 1 | Extensive erythematous plaque with numerous papules and pustules and purulent discharge on the mons pubis (tinea genitalis profunda) and annular erythematous macules on the thighs and abdomen (tinea corporis). 72 Acta Dermatovenerol APA | 2023;32:71-74M. Selan et al. Evidence of hair shaving on the pubic region was present. Nu- merous annular erythematous macules with scaly margins were present on the trunk (Fig. 2), both thighs, the neck, the face, and the scalp. A total of 14 extragenital lesions were observed. Laboratory tests showed elevated CRP (87 mg/l, reference range up to 5 mg/l) and leukocytosis (14.6 × 109/l, reference range 4–10 × 109/l), elevated alkaline phosphatase (1.83 µkat/l, normal < 1.74 μkat/), AST (1.29 µkat/l, reference range up to 0.52 μkat/l ), ALT (1.39 µkat/l, reference range up to 0.77 µkat/l), and gamma- GT (2.11 µkat/l, reference range up to 0.92 µkat/l). Concurrent in- fection with COVID-19, hepatitis, and tuberculosis was excluded. Direct microscopic examination revealed hyphae, and the zoophilic dermatophyte Trichophyton mentagrophytes grew in a culture of skin scrapings from several lesions, including the pubogenital region. PCR was performed from the culture and confirmed Trichophyton sp. Due to evident secondary bacterial in- fection in the pubic area, we performed a pustule swab in which ESBL-producing Escherichia coli and Klebsiella pneumoniae were isolated. We introduced terbinafine orally at a 250 mg daily dose. Due to severe inflammation, simultaneous application of peroral methyl- prednisolone was initiated for a period of 2 weeks at an initial 16 mg daily dose. Concurrent systemic antibiotic therapy with amoxicillin / clavulanic acid was administered first and was later changed to piperacillin / tazobactam intravenously, according to the antibiogram. Due to severe pain, the patient also needed anal- gesics. Topically, terbinafine cream was applied to all lesions, and additionally antibiotic gentamicin cream to pubogenital lesions. Significant improvement of all skin lesions was observed dur- ing hospitalization (Figs. 3, 4), with a decrease in pain and lab- oratory inflammatory parameters. The patient was able to walk normally and was discharged from the department after 19 days. Unfortunately, she was lost to follow-up. Discussion Tinea genitalis profunda was diagnosed in our patient, along with tinea capitis, tinea faciei, tinea colli, and tinea corporis. The causa- tive pathogen was the zoophilic dermatophyte T. mentagrophytes, as in many other reports on tinea genitals published in recent years. Dermatophytosis of the pubogenital region can be caused by anthropophilic, zoophilic, and geophilic dermatophytes. In the past, anthropophilic dermatophytes were the most common caus- ative pathogens and were mainly reported in males (6–10). The source of infection was attributed to autoinoculation from tinea pedis and toenail onychomycosis (11). In the last decade, tinea genitalis caused by zoophilic dermato- phytes has increasingly been reported with the dimensions of epi- demic outbreaks (12). The most common causative dermatophyte has been T. mentagrophytes (12–19), followed by Microsporum canis (4, 20). Other zoophilic dermatophytes—T. benhamiae (ear- lier known as Arthroderma benchamiae) (4, 12, 21), T. verrucosum (22), and T. erinacei (23)—have rarely been diagnosed. The zoo- philic type of tinea genitalis has also often been observed in fe- males. Table 1 presents an overview of previous reports on tinea genitalis with causative pathogens, sex distribution, and possible sources of infection. Due to changes in the taxonomy and nomenclature of the T. mentagrophytes complex in 2017 (24), the causative dermato- phytes of tinea genitalis reported in the literature should be inter- preted with caution. T. interdigitale was the term used for a zoo- philic strain before 2017, which is now named T. mentagrophytes. With implementation of genotyping as the most reliable method for differentiation between zoophilic and anthropophilic strains within the T. mentagrophytes complex, some zoophilic dermatophytes have been found to have a high possibility of hu- man-to-human transmission, such as genotypes VII and VIII (11). T. mentagrophytes genotype VII was recently recognized as a causative pathogen of highly inflammatory, painful, and persis- Figure 2 | Erythematous scaly macules on the trunk (tinea corporis). Figure 3 | Improvement of tinea genitalis after treatment. Figure 4 | Improvement of tinea corporis after treatment. 73 Acta Dermatovenerol APA | 2023;32:71-74 Tinea genitalis tent infections, mostly of the pubogenital region. Sexual trans- mission of infection was assumed in the majority of patients after having had contact with a sex worker in Thailand (12). Interest- ingly, the same genotype of T. mentagrophytes was also diagnosed in a patient with tinea barbae after a journey to Thailand (25). T. mentagrophytes genotype Thailand Type 1 has recently been rec- ognized as a cause of severe inflammatory and abscessing derma- tophytosis in patients with tinea genitalis and tinea barbae (26). In contrast, T. mentagrophytes genotype VIII has been diagnosed in rural areas in India so far and was found to be associated with mild-to-moderate inflammation in the genital area (27). Unfortu- nately, genotyping was not performed in our patient. In the last decade, more attention has also been paid to geo- philic dermatophytes. Genital infection due to Nannizzia gypsea (earlier known as Microsporum gypseum) was seen only in males and was confined to the scrotum. It has mainly been reported from China (28). The manner of transmission remained unexplained; however, sweating and gyms were suspected. There was no his- tory of sexual transmission. It was also reported on the scrotum in a young immunosuppressed male patient (29). Scrotal tinea caused by N. incurvata was recently reported in two young other- wise healthy men with no history of soil or pet contact (30). Geo- philic dermatophytes were only observed in a male on the scrotal skin, with a unique presentation, such as pseudomembranous- like dermatitis, whitish crusts, and grayish-yellow scales (11, 28). Clinically, a variety of lesions can occur in tinea genitalis, from superficial erythematous macules, follicular papules and pus- tules, and painful nodules to deeper inflammatory plaques with ulcerations, seropurulent discharge, and fistulas, resulting in scarring alopecia (18). Topical application of corticosteroids can obscure the clinical picture and thus complicate the diagnosis, allowing lesions to spread more rapidly with the image of tinea incognito (11, 31). Epidemic outbreaks of tinea genitalis have been observed in India due to improper use of topical corticosteroids (31). Double-edged tinea can occur on the pubic region after ap- plication of topical corticosteroids (32). A special entity of deep tinea is Majocchi granuloma, defined as a deep folliculitis caused by a dermatophyte, with the most common causative agent originally being T. rubrum. In tinea geni- talis, it is most commonly present in young women in areas where they shave their hair (13). Tinea genitalis can also present with the kerion celsi type of inflammation (14, 15, 18). Regional lymphad- enopathy, leukocytosis, and fever may be present, as was also ob- served in our patient. Tinea genitalis is often diagnosed with a significant delay, leading to improper treatment, more severe and deep inflamma- tory lesions, secondary bacterial infections, increased morbidity, and permanent alopecia. Patients with limited healthcare access, as was the case in our immigrant patient, are especially vulner- able to diagnostic delay and a more severe course of the disease. Awareness about this rare type of tinea is low and is often mis- interpreted as bacterial folliculitis or furunculosis. Differential diagnosis also includes contact dermatitis, inverse psoriasis (13), candidiasis, and hidradenitis suppurativa. Rarely, mycobacterial infection and actinomycosis can be considered (18). Many predisposing factors should be considered in tinea genitalis: owning pets (which are a source of zoophilic dermato- phytes), shaving the genital area, traveling to tropical countries, and heterosexual sexual intercourse (4). Dermatophytosis is more common in tropical countries due to warm and humid climates (5, 11). Shaving or waxing pubic hair is an important promoting fac- tor, which allows deep invasion of the pathogen due to its contin- uous spread along the hair structures (5, 12, 14). It also promotes sexual transmission and autoinoculation from extragenital tinea (12), which was probably the transmission pathway in our patient. Additional risk factors include diabetes, immune deficiency, HIV infection, and atopic dermatitis (5, 7). New pathways of dermatophyte transmission have been ob- served in tinea genitalis. T. mentagrophytes, although a zoophilic dermatophyte, has developed a greater ability for human-to-hu- man transmission (18). It has been speculated that the newly rec- ognized zoophilic strain, the so-called “Thai variant,” has a higher virulence. Based on this, tinea genitalis has been proposed as a potentially sexually transmitted infection since 2015 (5, 12). Indi- Table 1 | Tinea genitalis due to various dermatophytes and possible sources of infection. Ref. Patients Dermatophytes Possible infection sources 4 11 M, 19 F M. canis, T. interdigitale*, A. benhamiae, T. verrucosum, T. rubrum, T. tonsurans Various: contact with cats, mice, rats; travel to Egypt, Mongolia 5 5 M, 2 F T. interdigitale* Sexual transmission in Southeast Asia 12 26 M, 17 F T. mentagrophytes genotype VII 86% T. benhamiae 4.7% Negative culture 9.3% Various: sexual transmission, contact with animals, gyms? 13 1 F T. mentagrophytes Unknown 14 1 F T. mentagrophytes Tinea manuum? 15 1 F T. mentagrophytes Unknown 16 1 F T. mentagrophytes Dog 17 1 F T. mentagrophytes Contact with various animals 18 1 F T. mentagrophytes Hotel wellness facilities? 19 1 F T. interdigitale* Sexual transmission 20 17 M M. canis 58.8% E. floccosum 29.4% T. interdigitale* 11.8% Various: contact with animals, autoinoculation 21 1 M, 1 F T. benhamiae Sexual transmission (M), guinea pig (F) 22 1 F T. verrucosum Cat 23 1 F T. erinacei Unknown, spa facilities? 27 174 M, 102 F T. mentagrophytes genotype VIII 99.3% T. rubrum 0.7% Various: autoinoculation, sexual transmission, sharing clothes 28 28 M N. gypsea 48.6% T. rubrum 25.7% E. floccosum 5.7% Unknown, gyms? M = male, F = female, M = Microsporum, T = Trichophyton, A = Arthroderma, E = Epidermophyton, N = Nannizzia. *T. interdigiale was defined as a zoophilic dermatophyte according to nomenclature before 2017. 74 Acta Dermatovenerol APA | 2023;32:71-74M. Selan et al. References 1. Begum J, Mir NA, Lingaraju MC, Buyamayum B, Dev K. Recent advances in the diagnosis of dermatophytosis. J Basic Microbiol. 2020;60:293–303. 2. Segal E, Elad D. Human and zoonotic dermatophytoses: epidemiological as- pects. Front Microbiol. 2021;12:713532. 3. Richard MA, Paul C, Nijsten T, Gisondi P, Salavastru C, Taieb C, et al. Prevalence of most common skin diseases in Europe: a population-based study. J Eur Acad Dermatol Venereol. 2022;36:1088–96. 4. Ginter-Hanselmayer G, Nenoff P, Kurrat W, Propst E, Durrant-Finn U, Uhrlaß S, et al. Tinea in the genital area: a diagnostic and therapeutic challenge. Hautarzt. 2016;67:689–99. German. 5. Luchsinger I, Bosshard PP, Kasper RS, Reinhardt D, Lautenschlager S. 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Diagnosis must be confirmed by mycological examination, in- cluding microscopy, cultivation, and PCR analysis (6). The exact method of differentiation between dermatophytes depends more on the genotype rather than phenotypic characteristics (11). In re- cent years, molecular techniques such as RT-PCR, multiplex PCR, PCR-ELISA, nested PCR, and PCR-RFLP have significantly evolved. In cases of clinical suspicion and negative mycological examina- tion, PCR and histopathological examination with PAS stain of the skin is needed (1). Regarding treatment, systemic antifungal therapy is required for tinea genitalis, with terbinafine being the drug of choice. Ter- binafine 250 mg daily for at least 1 month is recommended but should be extended to 6 weeks or even longer in more severe and recalcitrant cases (11). On average, 7 weeks of systemic treatment was needed in tinea genitalis caused by T. mentagrophytes (12). In cases with a poor treatment response, either itraconazole or flu- conazole can be considered (25). Alternatively, griseofulvin 250 to 500 mg twice daily for 4 to 6 weeks is recommended if resistance to terbinafine is suspected (11). Topical azoles are preferred over allylamines because of their broad-spectrum antifungal activity (11, 12). Topical corticosteroids should be discontinued immediately and can only be considered in severe inflammatory dermatophytosis in the 1st week of treat- ment (18, 33). In cases of extensive and painful inflammatory plaques, in our experience, short-term and low-dose systemic corticosteroid therapy seems justified in combination with systemic antifungal therapy. In some reported cases with severe inflammation, sys- temic prednisone was administered for 6 to 21 days (5). Conclusions Tinea genitalis has been observed with increasing frequency in recent years, as well as changing epidemiology, diversity of pos- sible sources of infection, and new patterns of transmission. This type of tinea should be included in the differential diagnosis of superficial and deep inflammatory lesions in the genital and pu- bic area. Early diagnosis is essential to prevent the development of extensive painful inflammatory plaques that require long-term systemic antifungal treatment, the occurrence of secondary bac- terial infection, and persistent alopecia. The goal of this case report is to raise awareness about this type of tinea and the new observation that patients with limited healthcare access, including migrating populations, are especial- ly vulnerable to diagnostic delay and increased morbidity from this infection.