Tinea Infection of the Lips

A 51-year-old woman presented with concern for painful, cracking, and peeling lips. She had had no previous history of these symptoms. She reported that she had been using an over-the-counter hydrocortisone cream that seemed to help at first, but her lips had worsened over the last 2 days.

History. She had no history of herpes labialis, trauma, or itching. Other than hydrocortisone, she had not taken any new or different medications.

She had her lips augmented 6 weeks prior to this visit by a cosmetic dermatology provider. She stated that the provider had used the hyaluronic acid dermal filler that had been used on her several times before without incident. The woman noted, however, that the results only last 3 to 4 months, when the expected time is 6 to 12 months, according to the provider and product manufacturer. She said she has been told that she is an unusually fast “absorber” of the product, and she wondered whether this is related to her allergies.

The patient reported a history of severe year-round environmental allergies. She had been taking loratadine, triamcinolone nasal spray, and azelastine ophthalmic daily for years with good effect, although she complained of having puffy eyes almost daily. She also stated that she had been treated frequently for sinus infections and had been taking antibiotics on-and-off for 2 years; she had just finished a regimen of cephalexin a few days prior.

Physical examination. The patient was afebrile, and her vital signs were stable. Physical examination revealed pink, mildly edematous upper eyelids and sparse lashes but no discharge. Her vision was unchanged at 20/20 in both eyes. Nasal examination showed boggy and pale anterior turbinates with clear discharge. The oral cavity had slightly erythematous buccal mucosa. Her lips were moderately erythematous, edematous, and slightly cracked, with peeling around the vermilion border and several tiny vesicles on the upper and lower lips. In addition, tiny, coalesced, erythematous, raised lesions were noted outside of the vermilion border, and they were slightly tender to palpation. No white patches were noted on the tonsillar pillars, tonsils, or the tongue, and her teeth appeared healthy. No lymphadenopathy was noted.

Diagnostic tests. A culture of the vesicular fluid was obtained and sent for laboratory evaluation. Potassium hydroxide (KOH) examination of skin gently scraped from the patient’s lips showed the segmented hyphae and arthrospores characteristic of dermatophyte infections.

Differential diagnosis. The differential diagnoses in this patient’s case include allergic reaction to a hyaluronic acid product, contact dermatitis, bacterial infection, oral candidiasis, trauma, and eczematous inflammation.¹ Although possible, hyaluronic acid allergy was unlikely in this patient, because she had had several previous treatments over several years that did not produce these symptoms. Contact dermatitis would manifest with some itching after use of a new product, which the patient denied; moreover, the hydrocortisone cream she used likely would have been an effective treatment. Bacterial infection was a possibility, since a needle had pierced the skin during her lip augmentation. Oral candidiasis or dermatophyte infection also were possible, given that the patient recently had been on antibiotics. Trauma and eczematous inflammation were not likely in that the patient reported no injury or trauma, and the problem was acute.

Discussion. When diagnosing a dermatophyte infection, the borders of active lesions are the best areas to obtain samples, because these areas have the highest yields.^1,2 Vesicles appear at the active border when intense inflammation is present. Tinea is caused by 3 types of fungi that invade only keratinized tissues, hair, nails, and stratum corneum: Trichophyton, Microsporum, and Epidermophyton.³ It is usually not necessary to culture dermatophyte skin infections, because the same oral or topical medications are effective against all of them; however, cultures are necessary for hair and nail infection.¹

When performing a skin scraping for diagnosis of a fungal infection, use a scalpel blade to gently scrape the lesion near the active border, and collect the scrapings on a glass slide. Place several drops of 10% to 20% of KOH solution on the slide, and cover it with a coverslip. Next, examine the specimen under a microscope to determine the presence of hyphae and/or arthrospores that indicate a positive result for dermatophytes.⁴

The 4 oral medications indicated for the treatment of dermatophyte infections are fluconazole, griseofulvin, itraconazole (which is not approved for use in pediatric patients in the United States), and terbinafine. Three topical preparations indicated for tinea treatment are the allylamines, the imidazoles, and the hydroxypyridinones.

Outcome of the case. Based of the results of KOH testing of the specimen, the patient received a diagnosis of tinea infection of the lips, likely secondary to chronic and recent antibiotic use. She was instructed to apply a topical antifungal cream (clotrimazole) to her lips, to take 150 mg oral fluconazole once a week for 4 weeks, and to follow up in 2 weeks for reassessment. At the 2-week follow-up visit, only slight erythema of the lips remained, and she had no edema, pain, or lesions. She was instructed to continue the medications as directed for an additional 2 weeks and to follow up again at that time. At her final appointment, there were no signs or symptoms of infection, and she was discharged.

References:

1. Tinea of the body (tinea corporis) and face (tinea faciei). In: Habif TP, Campbell JL Jr, Chapman MS, Dinulos JGH, Zug KA. Skin Disease: Diagnosis and Treatment. 3rd ed. Philadelphia, PA: Elsevier Saunders; 2011:275.
2. Goldstein AO, Goldstein BG. Dermatophyte (tinea) infections. UpToDate. http://www.uptodate.com/contents/dermatophyte-tinea-infections. Accessed December 8, 2015.
3. Fungal diseases. In: Bolognia JL, Schaffer JV, Duncan KO, Ko CJ. Dermatology Essentials. Philadelphia, PA: Elsevier Saunders; 2014:613-633.
4. Monroe JR. Performing in-office KOH prep tests. Consultant for Pediatricians. 2013;12(9):412-414.