A 15-day old male infant from Lu He of Jiangsu Province came to our clinic due to erythema and papules on the face for two days. Erythema, papules and vesicles appeared from the 13th day, and gradually extended. The infant was delivered at full term and breast-fed. The general condition of the infant was good, and no abnormalities were found. Dermatological examinations showed round erythema with a diameter of 1.5 cm at the nasal root, with papules and scales. On the right cheek and beneath the left eye, there were annular erythema, papules and scales, approximately 1×1 cm2 in size. The margin was demarcated with vesicles along the rim. The central lesions were subsided ().
The clinical photos of patients.
The mother was 27 years old. At the third month of pregnancy, her neck developed itching erythema and scale, but she did not take any medication because of concern of side effects of medication on fetus development. Later, new lesions gradually developed on her back and abdomen. She came to our clinic with the infant. Physical examinations showed multiple irregular lesions on the chest and abdomen with red papules on the rim with the center resolved and hyperpigmented (). On her head, there were erythema and sticky scales with small pustules. The hair broke off on the surface of the scalp, leaving the appearance of a black dot, and was easily removed (). The father was 30 years old and had several red papules and erythema on his abdomen. The lesions were irregular, scaly and centrally resolved.
Specimens were taken from the edge of the infant's facial lesions with a cotton swap. A potassium hydroxide (KOH) wet mount showed hyaline septate hyphae (). The sample was inoculated on Sabouraud dextrose agar containing 0.5% cycloheximide and 1% chloramphenicol (SCAA) at 25°C. Colonies started to grow at day 5, initially appearing as a grey, flat and powdery colony without red pigment. At day 10, the center of the colony developed white short fluffy hyphae on the surface with red pigmentation on the edge, which became darker within 3 weeks. The reverse was also dark red (). Microscopic examination showed that microconidia were produced in abundance, most forming loosely clustered branches, sessile, clavate, cylindrical or balloon-shaped. Neither macroconidia nor chlamydospore was observed ().
The results of the laboratory examination.
The skin samples were taken from the edge of the mother's lesions. A KOH test showed abundant branched and septate hyphae (). Hair samples were also taken for direct KOH examination, which revealed that chain-like spores were inside of the hairs (). Branched septate hyphae were also detected in the scales from the head. All the samples were cultured on SCAA as described above and the pathogen was identified as T. tonsurans. Skin samples taken from the edge of the father's lesions on the abdomen has a negative result on microscopic examination, but the SCAA culture was positive and revealed T. tonsurans infection.
The infant was given topical 1% amorolfine cream. The lesions were resolved in two weeks. The infant's mother was also given 1% amorolfine cream for topical use on her abdomen. The lesions were cured in two weeks. Meanwhile, a 2% ketoconazole shampoo was prescribed for her hair washing. One month later, her hairs and scales were still positive by microscopic examination. Six months after delivery, the mother was given oral terbinafine 250 mg/d for 4 weeks, and all lesions were cured after three months. The father's lesions disappeared after topical use of 1% amorolfine cream for two weeks. No relapse from any family member was observed during one year follow-up.