Persistent Cutaneous Eruption Unresponsive to Antifungal Therapy

Case at a Glance

A 28-year-old healthy male athlete presented with a progressive, widespread cutaneous eruption initially diagnosed as a fungal infection, showing poor response to multiple topical antifungal treatments over 6-7 weeks.

Patient's Story

The patient, a regular gym-goer with good hygiene practices (immediate post-workout showers), first noticed an oval-shaped rash on his body. Initially dismissing it as a transient skin irritation, he did not seek treatment. After two weeks, additional lesions began appearing across his body. Despite close contact with his partner during this period, no transmission occurred. The patient has no history of smoking or alcohol use and maintains an active lifestyle.

Initial Assessment

Physical examination revealed multiple oval-shaped erythematous lesions distributed across the trunk, arms, and legs, sparing the face. The lesions appeared consistent with a superficial fungal infection. The patient's vital signs were stable, and he appeared otherwise healthy. No systemic symptoms were reported initially.

The Diagnostic Journey

The patient initially self-treated with over-the-counter clotrimazole cream, which appeared to halt lesion growth but did not prevent new lesion formation. After one week of self-treatment, he consulted his primary care physician, who clinically diagnosed a fungal infection and prescribed miconazole cream despite the patient's report of clotrimazole ineffectiveness. By week 6, the patient noted intermittent fading and recurrence of lesions, requiring frequent reapplication of medication. New symptoms of pruritus developed after starting miconazole. One episode of acute exacerbation was noted, with lesions becoming intensely erythematous across the chest.

Final Diagnosis

Presumptive superficial fungal infection (tinea corporis) with consideration for alternative diagnoses including pityriasis rosea, eczematous dermatitis, or other inflammatory dermatoses given poor response to antifungal therapy.

Treatment Plan

Sequential topical antifungal therapy was attempted: 1) Clotrimazole cream (self-initiated) - showed minimal improvement, 2) Miconazole cream (physician-prescribed) - required frequent application every 3 days with development of new pruritic symptoms. Patient temporarily discontinued gym activities to prevent potential spread and reduce friction/sweating that might exacerbate the condition.

Outcome and Follow-up

After 6-7 weeks of antifungal treatment with suboptimal response, the patient was advised to continue current therapy while awaiting potential dermatology referral for further evaluation. The persistence and treatment-resistant nature of the eruption, along with the development of new symptoms, suggested the need for mycological confirmation, patch testing, or consideration of alternative diagnoses. Close monitoring was recommended given the possibility of contact dermatitis secondary to prolonged topical medication use.