Larger-sized lesions and more number of lesions in individual patients are being observed now with increasing frequency (Fig. 14.2). It is now more common to see patients with more than one lesion of tinea in more than one anatomical location. Tinea cruris et corporis is getting more common.

More women patients with active tinea corporis, tinea cruris, et corporis et cruris are being encountered now. These women very often present secondary to the index case that is most often male. A large number of women present with a submammary location of the disease that involves the inframammary fold more than the skin of the breasts. This underscores the role of friction and maceration resulting from moisture of perspiration. We are also seeing more children afflicted by dermatophytosis (Fig. 14.3). In the author’s experience, obese children are afflicted more. Sharing of bed linen and towels is fairly common in this group of patients.

Dermatologists are observing an increasing number of lesions with multiple concentric circles (Fig. 14.4). It has also been described as tinea pseudoimbricata because it is reminiscent of tinea imbricata which is characterized by multiple concentric rings and has been explained to be occurring due to partial immune response. It has been seen in persons with immune suppression and those applying corticosteroids [4]. This has been described in India too after associating its appearance with the use of topical corticosteroid combinations [5]. The authors have suggested that this be included as a manifestation of tinea incognita induced by topical steroids. The formation of concentric circles can be explained by the local TCS-induced immunosuppression and also its anti-inflammatory effect. The centrifugal spread of dermatophytosis is because of the cell-mediated immunity clearing the fungus in the center of the lesion and the dermatophyte moving further out at a rate that is faster than the rate of shedding of the outer corneocytes in order to survive [6]. It is felt that the use of TCS, especially intermittently used, would lead to suppression of inflammation and therefore promote survival of the dermatophyte which spreads centrifugally but also remains in the center due to inadequate clearance. If this happens repeatedly, it would lead to multiple active borders with intermittent clearing in areas where the organism has been cleared circles concentrically leading to “tinea pseudoimbricata.” Though we have used the term tinea incognito and tinea pseudoimbricata in our report, I feel the need to propose two easier and more accurate terms. Looking carefully at lesions of tinea pseudoimbricata, one observes that the lesions of tinea incognito do not always have multiple concentric rings but very commonly have two lesions, and in those too, the rings are not always complete. Therefore, I propose the term double-edged tinea which is an important clinical pointer to diagnosis of corticosteroid modified tinea (Fig. 14.5). There is also a difference between the terms “tinea incognito” and “steroid-modified tinea.” Though we ourselves have used it in the past, the term tinea incognito should be used only in cases where the disease is rendered unrecognizable due to its altered appearance, most commonly due to topical corticosteroids [7]. However it is possible to recognize tinea in most cases of topical steroid abuse where topical steroids and their irrational combinations have been used. Therefore “steroid-modified tinea” is a more inappropriate term [7]. And finally an appeal has also been made as an afterthought that grammatically the phrase “tinea incognito” is incorrect and should actually be “tinea incognita” [7].

As mentioned earlier a large number of lesions do not show central clearing. Instead there are eczematized areas, often circular, within the circinate lesions (Fig. 14.6). As explained in the pathogenesis of tinea pseudoimbricata, the central eczematization could be due to inadequate clearing of the dermatophytes owing to topical steroid application.

We see arciform lesions and an increasing number of two annular lesions showing confluence, dumbbell-shaped tinea (Fig. 14.7a, b). Sometimes a curious clustering of multiple small annular lesions with active erythematous scaly borders is seen, often in areas prone to friction (Fig. 14.7c). Some lesions show pustular borders (Fig. 14.7d). This phenomenon has been attributed to a probable higher virulence of the organism promoting a higher inflammatory response.