British Journal of Dermatology (1979) 100, 147.

Concomitant erythrasma and dermatophytosis of thegroin

OTTO L. A. SCHLAPPNER,* GERALD A.ROSENBLUM,*GEOFFREY ROWDENj AND TERRENCE M.PHILLIPSj

* Department of Dermatology, The Montreal General Hospital and McGill University, Montreal, Canada, andt Department of Pathology, Georgetown University Medical School, Washington, D.C. 20007, U.S.A.

Accepted for publication 15 May 1978

SUMMARY

Four patients are reported with concomitant erythrasma and trichophyton riibrum dermatophytosisof the groin. The recognition and diagnosis of these associated infections is emphasized.

Studies have shown the association of erythrasma and dermatophytes in the toe webs (Temple &Boardman, 1962; English & Turvey, 1968), but a relationship of these two organisms in the groin hasnot been established. In a review of the literattire there is one incidental reference to both erythrasmaand fungal infections of the groin (Burns et al, 1967).

METHOD

Sixty patients in whom clinical examinations suggested tinea cruris or erythrasma were studied. Allexaminations were performed in daylight and with a Wood's light. Particular attention was given toexamination of the axillae, the infra-mammary folds, the groins, the peri-anal area and the toe webs.Only sites fluorescing a coral red colour were sampled. Tinea cruris was diagnosed on the basis ofclinical appearance, a positive potassium hydroxide wet mount for fungus, as well as positive Sabor-aud's cultures. Patients were also specifically examined to rule out pityriasis versicolor.

Erythrasma was diagnosed clinically on the criteria of well-defined, dry, pink-reddish to brown,finely scaling patches on the inner thighs with or without involvement of the crural folds, and coralred fluorescence in Wood's light. Corynebacteria were demonstrated on direct phase contrast micro-scopy of skin specimens stained by the Gram and PAS methods. In one patient, skin scrapings wereplanted on Sarkany's modification of Tissue Culture Medium 199 (Sarkany, Taplin & Blank, 1961;Noble & Sommerville, 1974). In the same patient, electronmicroscopy and fluorescence microscopywere also performed. For the fluorescence microscopy human derived fluorescein-tagged antiserumwas used to identify the corynebacteria in the tissue (Bering, Hoechst Pharmaceuticals).

Correspondence: Dr OX.A,Schlappner, Division of Dermatology, Department of Medicine, The Universityof British Columbia, 865 West 10th Avenue, Vancouver, British Columbia, Canada V5Z 1L7.

0007-0963/79/&200-0147 $02.00 C' 1979 British Association of Dermatologists

147

148 O.L.A.Schlappner et ai

FIGURE I. Photograph of Patient 2. Right groin showing well-defined patch of wrinkled, scaling,brown skin. Appearance similar to that of Patients i, 3 and 4.

FIGURE 2. Photograph ofPAS Stained skin scraping from groin of Patient i, showing fungal hyphaeand corynebacteria (Leitz Orthoplan Microscope, mercury light 490 Peak HBO 200) ( x 5740).

Erythrasma and dermatophytosis of the groin 149

?*• .

FIGURE 3, Area closely adjacent to site shown in Fig. 2, demonstrating numerous corynebacteria inthe skin scraping ( x 5740).

TABLE I

Patient no.

Age

Racial originSexSite of erythrasma and 7". rubrum

infectionOther sites of T. rubrum infection

Previous duration of infection (years)

I

27

CaucasianMale

GroinsSoles and

toewebs ofone foot

2

2

23NegroFemale

GroinsToewebs of

one foot

6

3

18

CaucasianMale

GroinsDorsal aspect ofhands and one

sole9/12

4

31Oriental (Chinese)

Male

GroinsNone

8

RESULTS

The four patients who met the criteria for concomitatit erythrasma and tinea cruris had bilateral,irregular, dry, reddish brown, well-defined, scaly patches on the inner thighs extending into thecrural folds (Fig. i). In some patients T. rubrum infections of the toe webs, soles and hands werepresent as shown in Table i. In Patient i the corynebacteria were also identified by culture, byelectron-microscopy (Montes et al., 1965), and by fluorescence microscopy, which showed coryne-bacteria within the stratum corneum.

150 O.L.A.Schlappner et al

Complete blood count, automated reagin test, urinalysis and multiphasic biochemical serum screen-ing were normal in all four patients. In all but one we prescribed a 7-14 day course of oral erythro-mycin to clear the corynebacterial infection. Then we used topical tolnaftate or clotrimazole along withoral griseofulvin to treat the remaining fungal infection. In Patient 3, treatment with griseofulvin andclotrimazole cream led to resolution of both infeaions in 3 weeks (Clayton & Connor, 1973)-

Follow-upOn follow-up there was no recurrence of the erythrasma. However, in Patient 4, the fungal infectionrecurred after 5 months and was successfully treated with clotrimazole cream.

DISCUSSION

The patients studied had had crural intertrigo for 9 months or more (Table i). Erythrasma had notbeen diagnosed on previous examinations, and treatments for fungal infection had never quiteeradicated their crural intertrigo.

It is of note that there are numerous reports of concomitant erythrasma and dermatophyte infectionsof the toe webs (English et al, 1968; Somerville et al, 1970). The frequent co-existence of fungus anderythrasma of the toe webs was not particularly emphasized until Temple & Boardman's study (t962)even though as early as 1931 Gougerot reported the association of erythrasma and fungal infections(Gougerot, 1930-1931). It is well known that each infection on its own commonly affects the groin, yetthey have not been noted as being co-existent in the groin except as incidentally reported by Burns ctal. (1967). Interestingly the clinical appearance of the double infection in our patients was reallysuggestive of either a fungal infection or of erythrasma (Fig. i). In addition to Wood's light examina-tion we found the phase contrast microscope most helpful in showing the corynebacteria in Gramand PAS stained fresh skin specimens (Figs 2 and 3).

What relationship the two organisms have to each other is not known. Most authors studyingerythrasma believe that keratin or glandular secretions are the sources of nutrient (Burns et al., 1967;Marples, 1965). In our patients we could not determine which pathogen was the primary invader. It isconceivable that the combination of organisms created a micro-environment suitable for each other'sgrowth.

With this report we wish to point to the co-existence of erythrasma and dermatophytes in intertrigi-nous areas other than the toe webs. Increased clinical awareness may prove this double infection to befairly common. Further studies may also reveal an occasional association of Corynebacterium minutim-mum and dermatophytes in yet other body folds.

ACKNOWLEDGMENTS

We gratefully acknowledge the assistance of Dr L.Kapica and the Department of Microbiology andImmunology of McGill University; Dr G.K.Richards, Microbiologist-in-Chief, The MontrealGeneral Hospital, Mr J.Fotheringham, and Mr H.Artinian of the Audiovisual Department of TheMontreal General Hospital.

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skin. Archives of Dermatology, 96, 436.CLAYTON, Y . M . & CONNOR, B.L. (r973) Comparison of Clotrimazole cream, Whitfield's ointment and Nystatin

ointment for the topical treatment of ringworm infections, pityriasis versicolor, erythrasma and candidiasis.British Journal of Dermatology, 89, 297.

Erythasma and dermatophytosis of the groin 151

ENGLISH, M . P . & TURVEV, J. (1968) Studies in the epidemiology of tinea pedis. IX. Tinea pcdis and erythrasmain new patients at a chiropody clinic. British Medical Journal, iv, 228.

GouGEROT, H. (1930-1931) Les complexes des plis. Archives de la Clinique de St Louis, No. 11 Monde Med., pp.777.

MARPLES, M.J . (1965) The Ecology of Human Skiti, pp. 675. Charles C. Thomas, Springfield, Illinois.MONIES, L.R., MCBRIDE, M.D., JOHNSON, W.P., OWENS, D . W . & KNOX, J . M . (1965) Ultrastructural study of

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hospital for the mentally subnormal. British Journal of Dermatology, 82, 355.TEMPLE, D . E . & BOARDMAN, C.R. (1962) The incidence of erythrasma in the toewebs. Archives of Dermatology,

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