A male in his 40s presented to the dermatology department of Post Graduate Institute
of Medical Education and Research, Chandigarh, in December 2019 with a non-pruritic,
large annular plaque of size 20 × 25 cm over face for 6 months ([Fig. 1A–C]). He had been treated for tinea faciale for ∼3 to 4 months, with no improvement.
On examination, a well-defined annular plaque with elevated erythematous border and
scaling was observed. There was appendageal loss overlying the lesion, but no regional
or peripheral nerve thickening was observed. Potassium hydroxide examination and slit
skin smear were negative. Histopathological examination showed epithelioid cell granulomas
with peripheral lymphocytes in the dermis along the nerve bundles and Langhans giant
cells; however, no acid-fast bacilli were seen ([Fig. 2A, B]). He was diagnosed with borderline tuberculoid Hansen and was prescribed WHO multidrug
therapy multibacillary regimen with monthly follow-ups, leading to complete resolution
of the lesion. Leprosy can have a polymorphous presentation and there are reports
of leprosy lesions mimicking psoriasis, pityriasis versicolor, granuloma annulare,
leishmaniasis, sarcoidosis, syphilis, and vitiligo. Both leprosy and tinea faciale
may present as annular lesions and at times it is difficult to differentiate between
the two clinically. The differentiating features that help in diagnosis are tinea
faciale lesions which are annular, pruritic, with preserved appendages and sensations.
Whereas the lesions of borderline tuberculoid leprosy are non-pruritic/asymptomatic,
hypopigmented, or erythematous plaques (more infiltrated), with loss of appendages
and regional/peripheral nerve thickening. With the current epidemic-like situation
of dermatophytosis, awareness regarding these atypical presentations is important
in countries where leprosy is still prevalent for early diagnosis and treatment to
prevent disabilities.
Fig. 1 Well-defined erythematous annular plaque with mild scaling on the left lateral side
of the face (A); anterior side of the face (B); and lesion on the right lateral side of the face (C).
Fig. 2 Histopathology showing multiple well-circumscribed epithelioid cell granulomas in
perivascular and periadnexal locations in the dermis (black arrow). (A and B) (A: hematoxylin and eosin 40x, B: hematoxylin and eosin 200x;).
