Fungal infection - How does it look like on your back?

An obese 52 year old single mother has been my patient for a couple of years. She comes regularly for a follow-up of her hypertension ( high blood pressure). Her condition is under control with her present medication.  And she is not a diabetic.

On one or two occasions she complained of itchiness on her arms. Upon examination, I diagnosed it as a fungal infection (tinea corporis) and prescribed her an anti-fungal regimen and after some weeks the lesions had cleared.

Last week she came for her review and at the same time she said she had been coughing for the last two weeks or so and had difficulty breathing when her coughs were bad. As per my practice, I wanted to listen to (auscultate) her chest. Whilst most local primary care doctors would just put their stethoscope on the back with the clothes on, my medical trainers had always insisted that we asked the patient to lift up their clothes and examine it that way. Observe the chest movement of the right and left side before auscultation.And that is what I always practice.

I auscultated the lung from the back and found that the lady had an abnormal breath sounds on her left lung and diagnosed it as bronchitis.

But there was something else I observed on her upper back. It was a large area of fungal infection which looked migratory and active in the lower middle of her back with visible scratch marks around it. I asked her whether she knew about this or has she got any itchiness over this area. She replied yes, and she had been asking her only child, a son to apply some kind of an over-the-counter cream on it. I asked her whether she knew what the area looked like and of course she did not know because it was on her back. Her son just described it but she really could not visualise it. As it is very itchy she even had some kind of heat treatment on the back to relieve it.

Migrating fungal infection on the back

I asked her permission to take a photograph of the lesions and show it to her. She was surprised to see the picture. The skin infection is fungal and she needed the right cream to treat it. I have a feeling she had been applying a steroid cream which temporarily relieved her itchiness but actually made the infection worse through extension as the fungus thrives on steroid!

Her problem is further compounded by her heavy attire and tight hair scarf (hijab) which is relatively inappropriate in our hot weather. The excessive sweating promotes fungal growth. I advised her to use cotton material and not to cover her head at home and maybe use the normal scarf for the time being while her back condition is being treated.

So concerned was she about her modesty that she had never admitted her skin problem on her back. Moreover she thought it was simple itchiness as she could not see it. Inappropriate therapy had worsened the condition and her heavy clothing did not help at all.

I am prescribing her a local anti-fungal regimen failing which I might have to resort to an oral therapy. Had I not asked her to lift up her blouse for her chest examination, I would not have seen this treatable skin disease. Left untreated the disease would eventually burn itself out but in the meantime she could get other skin infection due to the constant scratchings and the discomfort of itchiness could disturb her sleep and affect her quality of life.