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Tinea nigra

Tinea nigra
Authors:
Alexandro Bonifaz, MD
Andres Tirado-Sanchez, MD
Section Editor:
Ted Rosen, MD
Deputy Editor:
Abena O Ofori, MD
Literature review current through: Jan 2024.
This topic last updated: Jun 30, 2023.

INTRODUCTION — Tinea nigra is a superficial mycosis caused by the dematiaceous, yeast-like fungus Hortaea werneckii. The infection usually presents as an asymptomatic, hyperpigmented macule or patch on the palm (picture 1A-C). Less commonly, tinea nigra occurs on the soles of the feet or other sites (picture 2A-C). The course of tinea nigra is usually chronic, but the infection resolves rapidly with the appropriate treatment.

The clinical features, diagnosis, and treatment of tinea nigra are discussed here. Other cutaneous fungal infections are reviewed separately.

●(See "Dermatophyte (tinea) infections".)

●(See "Tinea capitis".)

●(See "Tinea versicolor (pityriasis versicolor)".)

MICROBIOLOGY — Tinea nigra is classified as superficial phaeohyphomycosis, a group of fungal infections caused by dematiaceous (pigmented) fungi.

●Hortaea werneckii – The most important causative agent is H. werneckii, a fungus previously assigned to the genera Phaeoannellomyces and Exophiala [1,2]. H. werneckii is a pleoanamorphic fungus that grows as a black yeast and can transform into a mold.

H. werneckii is halotolerant and halophilic (survives and thrives in high salt concentrations), osmotolerant, and grows in aqueous media. The fungus readily adapts to hypersaline conditions ranging from 3 to 30 percent sodium chloride [1-6]. H. werneckii has been isolated in various environments, including coastal areas (beaches and sand), mangrove plants (Aegiceras corniculatum), desalination plants, and desiccated puddles [3,7-9].

●Other causative fungi – Other fungi reported to cause tinea nigra include Cladosporium castellanii (also known as Stenella araguata) [10,11], Phoma hibernica [12], and Cladophialophora saturnica (spp nova) [13]. Tinea nigra caused by Curvularia lunata, a filamentous fungus found in soil and on dead plants, was described in an immunocompetent three-year-old child [14].

EPIDEMIOLOGY AND RISK FACTORS — Tinea nigra is a rare disease for which there are few epidemiologic data.

●Incidence – It is estimated that tinea nigra accounts for less than 1 percent of superficial fungal infections.

●Age and sex – Tinea nigra can occur at any age but is most common in children and young adults. There does not appear to be a sex predilection.

●Geographic distribution – Tinea nigra is most common in individuals who visit or reside in tropical and subtropical climates [1]. It is likely that most patients become infected in aqueous environments (eg, rivers, lakes, and marine areas).

Most reported infections have occurred in Central and South America (Mexico, Panama, Brazil, Colombia, and Venezuela), Asia (Japan, India, Sri Lanka, and Burma), Polynesia, and the African coast [2,15-19]. Tinea nigra is rarely diagnosed in Europe; reported infections are generally acquired outside of Europe [20,21]. Both native and non-native (returning traveler) cases have occurred in the United States. Florida, North Carolina, and South Carolina appear to be the most common states for indigenous infections [22-24].

●Role of hyperhidrosis – Palmar or plantar hyperhidrosis is an important predisposing factor for tinea nigra. In one series, 9 of 22 patients (41 percent) with tinea nigra had hyperhidrosis [2]. The association is probably due to the high salt concentration in sweat, which creates conditions similar to those in the natural niche of the fungus [1,23]. (See 'Microbiology' above.)

PATHOGENESIS

●Acquisition – Tinea nigra develops after direct contact with the fungus in the environment. It is assumed that the infection is not transmitted from person to person.

Minor skin lesions can contribute to infection, which contributes to the palm as a common site. Plantar infections usually occur in people who have walked barefoot in wet or sandy areas (eg, beaches).

The incubation period is not well defined. In a series of 22 patients, the estimated time to the development of visible lesions based on patient recollection was approximately two to four weeks from inoculation [2].

●Sites of infection – On the skin, H. werneckii grows in the form of hyphae and brown spores. The depth of infection is limited to the cornified layer of the epidermis, which is hypertrophied by infection. In rare cases, tinea nigra may occur in association with H. werneckii infection at other sites. For example, H. werneckii peritonitis was reported in a patient on peritoneal dialysis and with tinea nigra on the palm [25].

CLINICAL FEATURES

●Morphology – The most common manifestation is a unilateral, hyperpigmented, irregularly shaped but well-circumscribed macule or patch with fine scales on the palm (picture 1A-C) [1,2,15,16,19,20,26]. The color typically ranges from light to dark brown. Erythema is not usually present. Bilateral involvement is rare and may be due to autoinoculation [2,27].

●Distribution – Although the palm is affected in approximately 80 percent of patients, tinea nigra occasionally occurs on the fingers or in the interdigital spaces (picture 2C) [2,18,19]. Infection on the dorsum of the hand is uncommon. The second most common site is the foot, especially on the soles and, less frequently, in the interdigital spaces (picture 2A-B) [28]. In a series of 22 patients, the soles of the feet were affected in three patients (14 percent), and the palms were affected in the rest [2]. The arms, legs, neck, and trunk are less commonly affected [1,14,26,29].

●Symptoms – Most patients are asymptomatic. Occasionally, patients report pruritus; mild erythema may occur at the site of infection in these patients.

●Course – Without treatment, the course of tinea nigra tends to be chronic. However, spontaneous regression within two to three months has been reported [2,29].

DIAGNOSIS — A strong suspicion of tinea nigra may arise from the physical findings of a newly appeared, brown macule or patch, especially if it is on the palm and occurs in a person who lives in or has visited a tropical or subtropical region.

A dermoscopic examination can help to clinically differentiate tinea nigra from melanocytic lesions. A potassium hydroxide (KOH) preparation is usually made to confirm the diagnosis. Culture can also confirm the diagnosis and identify the causative organism.

Green fluorescence under Wood's lamp examination has also been reported in a patient with interdigital tinea nigra [28].

Dermoscopy — Dermoscopy is helpful in differentiating tinea nigra from melanocytic lesions, such as acral nevi and melanoma. (See "Dermoscopy of pigmented lesions of the palms and soles".)

Typical dermoscopic findings are brown spicules that do not follow the ridges or furrows of the acral dermatoglyphs (skin lines) (picture 3) [1,2,30-36]. However, the occurrence of spicules that follow a parallel ridge pattern has been reported [37,38].

Other findings obtained with super-high magnification dermoscopy include linear shapes with undulated forms corresponding to brown, elongated hyphae and spindle-shaped blastoconidia [39].

Potassium hydroxide preparation — A potassium hydroxide (KOH) preparation can confirm a fungal infection. Scrapes of the affected skin are placed on a glass slide with 10% KOH and examined with a microscope.

In tinea nigra, microscopic examination reveals numerous light brown, fungal elements consisting of septate, variegate, and branched hyphae (picture 4) [1,2,15,16]. Clusters of blastoconidia or chlamydoconidia may also be seen. (See "Office-based dermatologic diagnostic procedures", section on 'Potassium hydroxide preparation'.)

Culture — A superficial scraping of the affected skin (similar to scraping for a KOH preparation) usually provides a sufficient sample for culture. Cultures for identification of H. werneckii are performed on Sabouraud dextrose agar and Sabouraud dextrose agar plus antibiotic media and incubated at 25 to 28°C (77 to 82.4°F). On average, fungal growth can be observed within five to six days [2].

In the initial yeast-like phase, the fungal colonies are smooth, slimy, and olive green to black; in the subsequent mold phase, the fungus appears as filaments with a wooly or velvety appearance (picture 5). In the yeast-like phase, microscopic examination shows abundant budding cells with annellides and characteristic septae (picture 6). In the mold phase, it shows thick, septate hyphae with conidiophores from which sprout numerous arborescent conidia in blastogenic or acropetal formation [1,2,16,20]. Additionally, the cultured fungus can also be identified by a polymerase chain reaction assay [2,40].

Biopsy — Skin biopsy is not usually required for diagnosis. Skin biopsies are generally performed when another diagnosis (eg, melanoma) is suspected.

Characteristic histologic findings of tinea nigra include (picture 7) [1,2,30,41]:

●Hyperkeratosis

●Mild acanthosis

●Numerous hyphae and pigmented spores within the stratum corneum

Inflammation is usually absent; occasionally, perivascular mononuclear cell infiltrates are present in the dermis.

Electron microscopy is not required for diagnosis but shows small fungal colonies with hyphae and blastoconidia within the epidermis [42].

DIFFERENTIAL DIAGNOSIS

●Noninfectious conditions – The differential diagnosis for tinea nigra includes other possible causes of skin (especially acral) pigmentation, such as:

•Melanocytic nevi

•Lentigines

•Melanoma [43,44]

•Dermatitis neglecta (hyperpigmentation of the skin due to inadequate skin cleansing)

•Skin discoloration due to metals in contact with the skin (eg, metal rings)

•Palmar lichen planus (picture 8) [45]

•Phytophotodermatitis (eg, berloque dermatitis (picture 9))

•Fixed drug eruptions (picture 10)

A potassium hydroxide (KOH) preparation, fungal culture, or skin biopsy can be used to differentiate tinea nigra from these disorders. (See "Lichen planus" and "Acquired hyperpigmentation disorders", section on 'Phytophotodermatitis' and "Fixed drug eruption".)

●Other dematiaceous fungal infections – Atypical clinical and KOH preparation findings should raise the possibility of another fungal infection. Superficial infections with other dematiaceous fungi, such as Exophiala mansoni [46], Neoscytalidium dimidiatum (formerly Scytalidium) [47], or Aureobasidium melanogenum [48], may be associated with cutaneous hyperpigmentation and a positive KOH preparation.

For example, a patient with A. melanogenum infection presented with hyperpigmented patches on the face that were less well defined than typical tinea nigra and were accompanied by erythematous papules. A KOH preparation showed dark, septate oval cells with thick septae and septate hyphae. [48]. In such patients, fungal cultures are useful for definitive diagnosis [2].

TREATMENT — No randomized trials have been conducted for the treatment of tinea nigra. Efficacy data are limited to case reports and small case series.

General approach — Topical therapy is the preferred mode of treatment for tinea nigra. Clinical experience and case reports suggest efficacy of both topical antifungal agents and topical keratolytic agents. Systemic therapy is rarely necessary. (See 'Role of systemic antifungal therapy' below.)

Topical antifungal and keratolytic agents — Topical antifungal agents and topical keratolytics are the mainstays of therapy. Selection of a topical treatment is generally based on clinician familiarity with specific agents and treatment availability.

●Topical antifungal drugs – Topical antifungal drugs are the most frequently reported therapies for tinea nigra [14]. Benefit of various antifungal drugs, such as imidazoles (eg, bifonazole [2,49], clotrimazole [27], isoconazole [50,51], ketoconazole [52], miconazole [53], and sertaconazole [54]), terbinafine [50,55], butenafine [56], and ciclopirox [57], is documented in case reports or case series. We usually select an imidazole for topical antifungal treatment.

Topical antifungal agents are typically applied twice daily until clinical resolution. Resolution is expected within two to three weeks.

●Whitfield ointment – Whitfield ointment, which contains 3% salicylic acid (a keratolytic agent) and 6% benzoic acid (a drug with antifungal properties), or similar formulations also appear effective for tinea nigra [2,16].

Whitfield ointment is typically applied twice daily for two to three weeks. In one series, twice-daily treatment with Whitfield ointment was associated with resolution of tinea nigra in 10 of 11 patients [2]. The mean treatment duration was 18 days.

●Other keratolytic agents – Use of other keratolytic agents, such as 3% salicylic acid alone or urea-containing agents, has been suggested [1,58]. However, efficacy data for these therapies are more limited.

Treatment of hyperhidrosis — Hyperhidrosis may be a risk factor for recurrence of tinea nigra. In our experience, concurrent treatment of hyperhidrosis (if present) may be required. (See 'Epidemiology and risk factors' above and "Primary focal hyperhidrosis", section on 'Palmar or plantar hyperhidrosis'.)

Role of systemic antifungal therapy — Systemic therapy is not usually indicated. In practice, use of systemic therapy is rare (ie, generally limited to patients with recurrences associated with severe hyperhidrosis or other predisposing factors and patients who are unable to perform topical treatment).

In one case report, disappearance of tinea nigra occurred with administration of 200 mg of oral itraconazole per day for three weeks [59]. In our experience, 100 mg of itraconazole per day for 15 to 30 days has been sufficient in adults with recurrent tinea nigra. In an in vitro study evaluating the sensitivity of H. werneckii to nine antifungal agents, itraconazole was one of several drugs with low minimal inhibitory concentrations [60].

Other therapies — Some authors have suggested that other approaches might be effective, such as physical scraping of the lesions with a scalpel or curette [16,61]. Resolution with topical thiabendazole is documented in a case report [62]. In our experience, other topical agents, including 1% iodine tincture and 3% sulfur, can also be effective.

PROGNOSIS — Tinea nigra generally responds rapidly to topical therapy. If tinea nigra does not respond to topical treatment, the diagnosis and patient adherence to the treatment regimen should be confirmed. (See 'General approach' above.)

Tinea nigra usually does not recur after treatment. However, continued contact with environmental conditions that favor H. werneckii is a risk factor for reinfection. (See 'Epidemiology and risk factors' above.)

Occasional spontaneous disappearance of tinea nigra has been reported [2,29]. (See 'Clinical features' above.)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Tinea nigra (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Microbiology – Tinea nigra is a rare fungal infection of the skin caused mainly by Hortaea werneckii, a dematiaceous (pigmented) fungus. H. werneckii grows in aqueous environments and can survive in high salt concentrations. (See 'Microbiology' above.)

●Epidemiology and risk factors – Tinea nigra typically occurs in individuals (most often children and young adults) who have visited or live in tropical or subtropical climates. Infection occurs through direct contact with the fungus in the environment. It is likely that most patients become infected in water-rich environments, such as river beaches, lakes, and marine areas. Hyperhidrosis is a risk factor for infection. (See 'Epidemiology and risk factors' above and 'Pathogenesis' above.)

●Clinical features – Tinea nigra usually presents as a unilateral, hyperpigmented, irregularly shaped but well-circumscribed, brown macule or patch with fine scales. The palm is most commonly affected (picture 1A-C). Less commonly, tinea nigra occurs on the feet, elsewhere on the hand, or in other areas of the body (picture 2A-C). The infection is usually asymptomatic. (See 'Clinical features' above.)

●Diagnosis – The diagnosis of tinea nigra is made based upon consistent physical findings and confirmation of fungal infection. A potassium hydroxide (KOH) preparation or fungal culture can be used to confirm fungal infection (picture 4). (See 'Diagnosis' above.)

●Treatment – Tinea nigra responds rapidly to appropriate therapy. We suggest treatment with topical, rather than systemic, agents (Grade 2C). Limited data suggest that topical antifungal agents and topical keratolytic agents are effective treatments. (See 'Treatment' above.)

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