This 60 yo disabled man has had a sic moth history of a mildly pruritic eruption of his upper chest. I expected the KOH prem to be postive, but it was not. He has lots of psychosocial problems (wife an alcoholic, daughter a heroin addict) -- not enough time to properly evaluate; so a biopsy was done. If that is negative for fungal elements I would think about Casal's necklace whigh I have never seen.
Pathology: The biopsy showed a mild superficial spongiotic dermatitis with no evidence offungal elements.
Follow-up: When seen back for suture removal, another KOH prep was done. It was positive for numerous septate hyaline hyphae. The original KOH prep was taken from the advancing scaly border as was the biopsy. Sampling error caused the misdiagnosis. The patient was started on terbinafine 250 mg daily for six weeks. Follow-up photos will be posted when he returns.
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