Leprosy Masquerading as Tinea Faciale

Abstract

A male in his 40s presented to the dermatology department of Post Graduate Institute of Medical Education and Research, Chandigarh, in December 2019 with a non-pruritic, large annular plaque of size 20 × 25 cm over face for 6 months ([Fig. 1A–C]). He had been treated for tinea faciale for ∼3 to 4 months, with no improvement. On examination, a well-defined annular plaque with elevated erythematous border and scaling was observed. There was appendageal loss overlying the lesion, but no regional or peripheral nerve thickening was observed. Potassium hydroxide examination and slit skin smear were negative. Histopathological examination showed epithelioid cell granulomas with peripheral lymphocytes in the dermis along the nerve bundles and Langhans giant cells; however, no acid-fast bacilli were seen ([Fig. 2A, B]). He was diagnosed with borderline tuberculoid Hansen and was prescribed WHO multidrug therapy multibacillary regimen with monthly follow-ups, leading to complete resolution of the lesion. Leprosy can have a polymorphous presentation and there are reports of leprosy lesions mimicking psoriasis, pityriasis versicolor, granuloma annulare, leishmaniasis, sarcoidosis, syphilis, and vitiligo. Both leprosy and tinea faciale may present as annular lesions and at times it is difficult to differentiate between the two clinically. The differentiating features that help in diagnosis are tinea faciale lesions which are annular, pruritic, with preserved appendages and sensations. Whereas the lesions of borderline tuberculoid leprosy are non-pruritic/asymptomatic, hypopigmented, or erythematous plaques (more infiltrated), with loss of appendages and regional/peripheral nerve thickening. With the current epidemic-like situation of dermatophytosis, awareness regarding these atypical presentations is important in countries where leprosy is still prevalent for early diagnosis and treatment to prevent disabilities.