Trichophyton rubrum-Syndrom und Tinea incognita unter immunsuppressiver Behandlung mit Leflunomid und Fumarsäureestern bei Patienten mit rheumatoider Arthritis und Psoriasis vulgaris

Zusammenfassung

Ein 70-jähriger Patient mit rheumatoider Arthritis (Anti-CCP-Antikörper positiv), Nikotinabusus und Arteriosklerose wurde immunsuppressiv mit Leflunomid 20 mg und Prednisolon 50 mg täglich behandelt. Am Körperstamm traten großflächige, ekzematisierte, randbetonte, zentrifugal wachsende erythrosquamöse Läsionen auf. Die Haut der rechten Hand und beider Füße war trocken, schuppend und atrophisch. Außerdem bestanden gelbbraune Onychodystrophien aller Fingernägel der rechten Hand sowie aller Zehennägel. Das Blankophor^®-Präparat aus Hautschuppen war positiv, kulturell und mit PCR ließ sich Trichophyton (T.) rubrum nachweisen. Die ausgeprägte Tinea corporis wurde mit einer Antimykotika- und Glukokortikoid-haltigen Creme behandelt, wegen der Tinea unguium kam Terbinafin zur Anwendung.

Ein 68-jähriger Psoriatiker erhielt bereits seit 1979 Fumarsäureester zur systemischen antipsoriatischen Therapie. Seit einigen Monaten entwickelten sich an Flanken, Rücken, gluteal, an den Waden, prätibial und an den Oberschenkeln blass-rote erythrosquamöse Plaques im Sinne einer Tinea corporis incognita. Das Nativpräparat war positiv, kulturell und mit PCR gelang aus insgesamt 6 Lokalisationen der Nachweis von T. rubrum. Da eine systemische antimykotische Behandlung abgelehnt wurde, kam Terbinafin-Creme im Wechsel mit Clotrimazol- + Betamethason-Creme zur Anwendung.

Die großflächige und generalisierte Tinea corporis mit Onychomykose erfüllte bei beiden Patienten die Kriterien eines sog. T. rubrum-Syndroms. Dieses, aber auch die Tinea incognita, entwickeln sich in der Regel infolge einer Autoinokulation von einer vorbestehenden Tinea pedis et unguium. Disponierender Faktor für das T. rubrum-Syndrom, aber auch für die Tinea incognita, ist nicht selten eine immunsupprimierende Therapie, hier durch Glukokortikoide, Leflunomid sowie Fumarsäureester.

Abstract

A 70-year-old patient with rheumatoid arthritis (anti-CCP antibodies positive), nicotine abuse, and arteriosclerosis received an immunsuppressive therapy by leflunomide 20 mg and prednisolone 50 mg, both daily. The trunk showed extensive areas of eczematization with edge emphatic rubefaction and centrifugal growing lesions. The skin of the right hand and of both feet was dry, scaling, and atrophic. Moreover, yellow brown and hypertrophic onychodystrophy of all fingernails of the right hand and all toe nails of both feet were apparently. The Blankophor^® preparation was positive, by cultivation and with PCR Trichophyton (T.) rubrum was detected from skin scrapings. The pronounced tinea corporis was treated topically with a combined antifungal and glucocorticoid containing cream, for the tinea unguium and tinea corporis terbinafine was started.

A 68-year-old psoriatic patient received already since 1979 fumaric acid esters for systemic antipsoriatic therapy. Over the last few months, at the flanks, the back, in the gluteal area, both lower legs, and at the thighs he developed pale red plaques which could be interpreted as tinea corporis incognita. The native preparation of skin scrapings was positive, and again by culture and by PCR it was possible to detect T. rubrum. Because the oral antifungal therapy was rejected topical antifungal treatment using terbinafine cream and clotrimazole plus betamethasone containing cream was started.

The extensive area and generalized tinea corporis and onychomycosis fulfilled the criteria of a so called T. rubrum syndrome. Both the dermatomycosis in the patient with rheumatoid arthritis, and the tinea incognita of the psoriatic patient have been developed after an autoinoculation from a prior existing tinea pedis and tinea unguium. An immunosuppressive treatment – here by glucocorticoids, leflunomide, and fumaric acid esters – represents a disposing factor both for the T. rubrum syndrome, and also for the tinea incognita.

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