Pimecrolimus-induced tinea incognito

A 6-year-old boy was brought to his primary care provider by his mother, who complained of a pruritic rash near his right eye. The eruption was described as a small, erythematous, slightly scaly plaque at the lateral margin of the right eyelid. The child was in good health and took no medications. The diagnosis of eczema was made; the patient was treated with pimecrolimus cream b.i.d. to the affected area. After 2-3 days of treatment, the itching and erythema completely resolved; however, a rough and scaly plaque persisted. After 1-2 weeks of treatment, the itching gradually returned, and the lesion began to increase in size. Multiple, similar lesions appeared several centimeters from the initially affected area. Pimecrolimus was discontinued; topical nystatin/triamcinolone ointment was prescribed. The eruption continued to spread, and the patient was referred to dermatology for further evaluation. The patient presented to the dermatology clinic with multiple annular, scaly papules and plaques with central clearing. Excoriations and mild inflammation were noted around all affected areas (Figure). A potassium hydroxide examination of the lesions revealed numerous hyphae. The nystatin/triamcinolone ointment was discontinued; oral griseofulvin was prescribed. The eruption improved dramatically after 3 weeks and eventually cleared completely after 5 weeks of treatment. Topical 2% ketoconazole cream was applied b.i.d. for the final 2 weeks of treatment.