Case Report

DERMATOMEDICAL FACULTY OF SYIAH KUALA UNIVERSITY

Dr. ZAINOEL ABIDIN GENERAL HOSPITAL

TINEA FACIALIS

By :

AULIA RAHMATUN NUFUS RAIHANUN NISA DINUR

SRI RIZKI

Supervisor : NANDA EARLIA

DERMATO-VENEREOLOGY DEPARTEMENT

MEDICAL FACULTY OF SYIAH KUALA UNIVERSITYDr. ZAINOEL ABIDIN GENERAL HOSPITAL

BANDA ACEH JANUARY 2014

VENEREOLOGY DEPARTEMENT MEDICAL FACULTY OF SYIAH KUALA UNIVERSITY

Dr. ZAINOEL ABIDIN GENERAL HOSPITAL

ii

PREFACE

All praise be to Allah, the Lord of the world and peace and prayers be upon

Muhammad, his family and companions and all those who follow in their footsteps

until the last day.

In finishing this case report entitled Tinea Corporis, the authors really give they

regard and thanks to dr. Nanda Earlia, Sp. KK who has given guidance and help.

Finally, the authors realize there are unintended errors in writing this case

report. The authors really allow all readers to give their suggestion to improve this

content in order to be made as one of the good examples for the next case report.

Banda Aceh, January 2014

Authors

iii

CONTENTS

Page

CONTRIBUTORS .......................................................................................... i

PREFACE ......................................................................................................... ii

CONTENTS ...................................................................................................... iii

1. Introduction ................................................................................................... 1

2. Case Report ................................................................................................... 3

2.1 Anamnesis ............................................................................................... 3

2.2 Status of Dermatology ............................................................................ 5

2.3 Clinical Test ........................................................................................... 5

2.4 Differential Diagnosis ............................................................................ 6

2.5 Resume ................................................................................................... 6

2.6 Diagnosis ................................................................................................ 7

2.7 Management ........................................................................................... 7

2.8 Education ................................................................................................ 7

2.9 Prognosis ................................................................................................. 7

3. Discussion ..................................................................................................... 8

REFERANCE ................................................................................................... 14

ATTACHMENT ................................................................................................ 15

1

INTRODUCTION

Tinea corporis is a superficial dermatophyte infection of the glabrous skin

most commonly caused by species of the genera trichophyton and mycrosporum.

When the face is affected, it is called tinea faciale whom 3%-4% of tinea corporis.

The infection as generally restricted to the stratum corneum of the epidermis. The

clinical symptoms are the result of the fungal metabolites acting as toxins and

allergens. This form of ringworm is characterized by one or more circular, sharply

cirscumscribed, slightly erithematous, dry, scaly, usually hypopigmented patches.

An advancing scalling edge is usually prominent. Progressive central clearing

procedures annular outline that give them the name “ringworm”. Lesions may

wider to form rings many centrimeters in diameter. In some case concentric

circles or polycyclic lesion form, making intricate patterns.1,2

The diagnosis is relatively easily made by finding the fungus under the

microscope in skin scrapings. In addition, skin scrapings can be cultured on a

suitable medium. Growth of the fungus on the culture medium is apparent within

a week or two at most and, in most instances, is identifiable to the genus level by

the gross and microscopic appearance of the culture. In this case report, patient

diagnosed tinea corporis based on history and physical examination. The patient

with complaints the appearance of rash followed by itching on the the face, upper

back, palmars and plantars since two month ago. At first, the patient found red

spots that felt very itchy on the upper back area, the rash was getting wider and

spreaded to the face, palmars and plantars area. Itching is increasing at the time of

using pads and when the groin area is moist.3,4

Dermatophyte infection are the most common skin fungal infection are age,

sex, genetics, racial factors, lifestyle, drug therapy, metabolic endocrine disorder

such as diabetes mellitus, contact with animals and environmental factors are

involved in these infection. Accordingly, accurate diagnosis, approprite treatment

of these infections health seeking behaviours and hygiene reduce their

transmission and complications. In some study, dermatophyte infection were more

prevalent in men and the moat frequent areas of involvement were the scalp, groin

and trunk. Most of them aged 20-29 years.5

2

In this case the patient has metabolic endocrine disorder skin infection

accure in 20% to 50% of diabetic patients more often in those with type 2 diabetic

and often associated with poor glicemyc control. Poor microcirculation, peripheral

vascular disease, peripheral neuropathy and decreased immune response have

been implicated in the increased susceptibility to cutaneous infection. This is our

reason to pick up tinea facialis for the case report.5

3

CASE REPORT

Identity of patient

Name : Mr. R

Sex : Male

Age : 56 years old

Weigth : 62 kg

Job : Selling Vegetables

Address : Tungkop, Aceh Besar

Phone number : 085277466610

Registration number : 87-06-35

Examination date : December 31th 2013

History

The Chief Complain:

Rash followed by itching on the face, upper back, palmars and plantars since two

month ago.

History of present illness:

The patient came to the hospital complaint the appearance of rash followed by

itching on the face, upper back, palmars and plantars since two month ago. At

first, the patient found red spots that felt very itchy on the upper back area, the

rash was getting wider and spreaded to the face, palmars and plantars area. Then,

about one month ago the appearance of rash following itching on the upper back

was disappeared. Itching is felt everytime not induced with environment

temperature, but itching is increasing at the time of using pads and when the groin

area is moist.

History of previous illness:

The patient had the same complaint before since two month ago. Patient

were also informed having a history of diabetic since twelve year ago.

4

History of Family disease:

None of his family had this kind of disease.

History of Treatment:

Since the patient have complaint he was getting treatment from a doctor and take

medication regularly but not healed.

5

Status of Dermatology

Clinical Test

1. KOH examination

Procedure :

a) Place the material to be examination onto a clean glass slide

b) Add a drop of 10% KOH to the material and mix

c) Pace a cover glass over the preparation

d) Allow the KOH preparation to sit at room temperature until the material has

been cleared. The slide may be warmed to speed the clearing process. Slide

that are initially negative for fungi may be re-examined the following day.

On facial and palmars dextra and sinistra region, found erythematous patches and hypopigmentation with circumpscripta boundary, irregular and polycyclic edges, there are papules and scales on the edge of lesions, multiple lesions, plaque size, there are central healings, disseminated arrangement, and generalized distribution.

Figure 1. Dermatological Status

6

e) Observe the preparation by brightfield or phase-contrast microscopy. The

illumination on a brightfield or phase-contrast microscope should be

carefully adjusted using the K holder method. Hyaline fungi will be difficult

to see if the illumination is improperly adjusted. Refer to the table in the

examination of specimen for interpretation of positive result.

Figure 2. Microscopic examination of skin scrapings (scales) with 10% potassium

hydroxide (KOH) showed long, septate and branching hyphae.

Differential Diagnosis

1. Tinea facialis

2. Seborrheic dermatitis

3. Cutaneus candidiasis

4. Granulloma anulare

5. Morbus Hansen type pausibasiler

Resume

A 56 years old man came to the hospital complaint the appearance of rash

followed by itching on the face, upper back, palmars and plantars since two month

ago. On dermatological status was found hypopigmented patches with advancing

red, vesiculated border and central scaling and pruritic. On microscopic

examination of skin scrapings (scales) with 10% potassium hydroxide (KOH)

showed long, septate and branching hyphae and wood’s lamp examination did not

found fluoresce, or shine under the ultraviolet light.

7

Diagnosis

Tinea facialis

Management

Systemic Medication :

1. Ketoconazole 200 mg tab once daily for 2 to 3 weeks

Topical Medication :

1. Ketoconazole salp once daily at night for 2 to 4 weeks

2. Myconazole cream once daily in the morning for 2 to 4 weeks.

Education

1. Taking medicine regularly

2. Do not scratch the rash to prevent the secondary infection

3. Change clothes when the body is sweating

4. Wearing loose clothing and materials that easily absorb sweat

5. Dry off after a shower and sweating

Prognosis

Quo ad vitam : dubia ad bonam

Quo ad functionam : dubia ad bonam

Quo ad sanactionam : dubia ad bonam

8

DISCUSSION

Superficial fungal infection which are confined to the stratum corneum,

hair and nail can be subdivided into infections that induced an inflammatory

response such as those caused by the dermatophytes. They are the group of

taxonomically related fungi. Their ability to form molecular attachments to

keratin and use it as a source of nutrients allows them to colonize keratinized

tissues, including the stratum corneum of the epidermis, hair , nails and the horny

tissues of the animal. Superficial infection caused by a dermatophyte is termed

dermatophytosis, wheres dermatomycosis refers to a fungal infection by any

fungi.6

Nomerous way of classifying superficial fungi exist, including habitat and

pattern of infection : 1) Geophilic (earth-loving) organism originate in the soil and

only sporadically infect humans usually by direct contact with the soil. 2)

Zoophilic (Animal-Loving) species are usually found on animals, but also

transmitted to humans. 3) Anthropophilic (man-loving) species have adapted to

humans as hosts are transmitted from person to person via direct contact or

fomites. An estimated 20-25 % of the world`s population has some form of fungal

infection usually an anthropophili, Trichophyton infection making fungal

infections the comman type of infection worldwide. They are classified in three

genera: mycrosporum, trichophyton, epidermophyton. 1,6

The infections caused by dermatophytes are commonly referred to as

“ tinea” or “ring-worm” infections due to the characteristic ringed lesions. Based

on the site of infection the tinea infections are referred to as tinea capitis (scalp),

tinea corporis or tinea circinata (non-hairy, glaborous region of the body), tinea

pedis (“Athletes’ foot”; foot), tinea ungium (“onychomycosis”; nail), tinea

mannum (hands), tinea barbae (“Barbers’ itch”; bearded region of face and neck),

tinea incognito (steroid modified), tinea imbricata (modified form of tinea

corporis), tinea gladiatorium (common among wrestlers’) and tinea cruris

(“Jocks’ itch”; groin). 7,8

9

Tabel 1.Some of Clinical Features of Dermatophytes Infection.4

Skin Disease Location of lesions

Clinical Features Fungi Most Frequently Responsible

Tinea corporis (ringworm)

Nonhairy, smooth skin.

Circular patches with advancing red, vesiculated border and central scaling. Pruritic.

T. rubrum, E.floccosum

Tinea pedis (athlete`s foot)

Interdigitalis spaces on feet of persons wearing shoes.

Acute: itching, red vesicular. Chroni: itching, scaling, fissures

T. rubrum, T. mentagrophytes, E.floccosum

Tinea cruris (jork itch)

Groin. Eritematous scaling lesion in intertridiginous area. Pruritic.

T. rubrum, T. mentagrophytes, E.floccosum

Tinea capitis Scalp hair. Endothrix: fungus inside hair shaft. Ectothrix: fungus on surface of hair.

Circular bald patches with short hair stubs or broken hair within hair follicles. Kerion rare. Microsporum-infected hairs fluoresce.

T. mentagrophytes, M.canis

Tinea barbae Beard hair. Edematous, erythematous lesion. T. mentagrophytes

Tinea Unguium (onychomycosi)

Nail. Nails thickened or crumbling distally;discolored;lusterless. Usually associated with tinea pedis.

T. rubrum, T. mentagrophytes, E.floccosum

Dermatophytid (id reaction)

Usually sides and flexor aspects fingers. Palm. Anysite on body.

Pruritic vesicular to bullous lesions. Most commonly associated with tinea pedis.

No fungi present in lesion. May become secondarily infected with bacteria.

According to the World Health Organization (WHO) survey on the

incidence of dermatophytic infection, about 20% the people worldwide present

with cutaneous infections. The disease does not spare people of any age. Among

the tinea infections the most predominant type of infection is tinea corporis or

tinea circinata followed by tinea cruris, tinea pedis and Onychomycosis. Tinea

corporis accounts for about 70% of the dermatophytic infection. 8

Tinea corporis is a superficial dermatophyte infection of the glabrous skin

most commonly caused by species of the genera trichophyton and mycrosporum.

When the face is affected, it is called tinea faciale whom 3%-4% of tinea corporis.

The infection as generally restricted to the stratum corneum of the epidermis. The

clinical symptoms are the result of the fungal metabolites acting as toxins and

allergens. This form of ringworm is characterized by one or more circular, sharply

10

cirscumscribed, slightly erithematous, dry, scaly, usually hypopigmented patches.

An advancing scalling edge is usually prominent. Progressive central clearing

procedures annular outline that give them the name “ringworm”. Lesions may

wider to form rings many centrimeters in diameter. In some case concentric

circles or polycyclic lesion form, making intricate patterns.1,2

In this case report, patient diagnosed tinea facialis based on history and

physical examination. The patient with complaints the appearance of rash

followed by itching on the the face, upper back, palmars and plantars since two

month ago. At first, the patient found red spots that felt very itchy on the upper

back area, the rash was getting wider and spreaded to the face, palmars and

plantars area. Itching is increasing at the time of using pads and when the groin

area is moist.4

In this case, microscopic examination of skin scrapings specimen using 10

% KOH solution showed long, septate and branching hyphae. This is accordance

with the literature that diagnosis of dermatophyte infection can be confirmed by

microscopic examination or culture. Although microscopic examination of KOH

treated samples of scale does not allow for speciation or characterization of

susceptibility profile, it is used or underused as a quick and inexpensive bedsite

tool to provide evidence of dermatophytosis. Direct microscopic examination of

skin scrapings specimens using 10 % KOH will show septate hyphae and squared

or rounded, irregularly arranged arthroconidia. All superficial dermatophytes

appear identical when visualized in this manner. Because KOH examination may

yield false-negative results in up 15 % of cases. Patients suspected of having

dermatophytosis on clinical impression should be treated. Curtures should always

be taken. In the experience, the number of culture-positive cases when the KOH

was negative ranges from 5 to 15 %.2,6

Differential diagnose are tinea facialis, seborrheic dermatitis, cutaneous

candidiasis, granulloma anulare and morbus Hansen. Seborrheic dermatitis is a

common chronic papulo squamous dermatosis that is usually easily recognized. It

affects infants and adults and is often associated with increased sebum production

(seborrhea) of the scalp and the sebaceous follicle rich area. The sites of

11

predilection are face, ears, scalp, and upper part of the trunk. The affected skin is

pink, edematous, and covered with yellow-brown scales and crusts. In all patient

with seborrheic dermatitis is called seborrheic stage, whice is often combined

with a grey white or yellow res skin discoloration, prominent follicular openings

and mild to severe pityriasiform scales. Several form can be distinguished.6

Cutaneous candidiasis has a predilection for colonizing moist, macerated

folds of skin. Intertrigo is the most common clinical presentation on glabrous skin.

Usual locations for intertrigo include the genitocrural, axilary, gluteal, interdigital,

and inframammary areas and between folds of skin on the abdominal wall.

Cutaneous candidiasis appears as pruritic, erytematous, macerated skin in

intertriginous areas with satellite vesicopustules. These pustules break open,

leaving an erythematous base with collarette of easily detachable necrotic

epidermis. Cutaneous candidiasis diagnosed by the typical appearance of skin

lesions and the presence of satellite vesicopustules. Of all the clinical symptoms

found such lesions form.6

Based on the shape of lesion Granuloma annulare starts as a ring of small,

firm, flesh-colored or red papules. As the condition progresses, there is some

central involution, and the ring of papules slowly increases from 0.5 to 5.0 cm in

diameter. The lesions may be isolated or coalesce into plaques. They are found on

the lateral or dorsal surfaces of the hands and feet. Tinea facialis have different

form of lesions so differential diagnose can be removed .3

Morbus Hansen is painless skin patch accompanied by loss of sensation but

not itchiness.6

Therapy in this case are oral ketoconazole 200 mg once daily for 2 to 3

weeks and ketoconazole 2% cream applied once daily at night for 2 to 4 weeks

and miconazole cream once daily in the morning for 2 to 4 weeks. This is

accordance with literature that systemic antifungal therapy is indicated if the

lesions are extensive or fails to topical treatment, recurrent or chronic, or if the

skin condition gets worse. Ketoconazole and miconazole is an antifungal azole

class, broad-spectrum imidazole group, fungistatic and can be given to patients

who do not respond to topical therapy. Mechanism of action of this drug to inhibit

ergosterol biosynthesis enzyme cytochrome P-450, C-14-α-dimethylase

12

responsible transform lanosterol to ergosterol resulting in fungal cell walls

become permeable and the destruction of the fungus occurs. Imidazole group is

quite effective either as lotions, solutions, or creams for lesions of limited size in

accessible areas.2,9

Based of the the number of nitrogen atoms the azoles derivatives are

classified into 2 groups as imidazoles and triazoles. Imidazoles include miconazol,

clotrimazole, ketoconazole, econazole, bifonazole, tioconazole and oxiconazole.

In general the imidazoles exhibit side effects such as anorexia, constipation,

headache, hepatitis, pruritis, exhanthema and inhibition of synthesis of steroid

hormone. Triazoles include fluconazole, voriconazole, itraconazole, posaconazole,

teraconazole and ravuconazole. In comparison to the imidazole, the triazoles

exhibit lesser degree of side effects which includes nausea, dizziness and

gastrointertinal upset.8

Table 2. Treatment of Dermatophytes6

Disease Topical Treatment Systemic Treatment Tinea capitis Only as adjuvant

Selenium sulfide Zinc pyrithione Povidone iodine Ketokenazole

Griseofulvin, 20-25 mg/kg/day Fluconazole,6 mg/kg/day Itraconazole,3-5 mg/kg/day Terbinafine,3-6 mg/kg/day

Tinea barbae Only as adjuvant Topical antifungal

Griseofulvin 1g/day Itraconazole 200 mg/day Terbinafine 250 mg/day Fluconazole 200 mg/day

Tinea corporis/kruris

Allylamines Imidazoles Tolnaffate Butenafine Ciclopirox

Adults: Fluconazol 150 mg/week Itraconazole 100 mg/day Terbinafin 250 mg/day Griseovulvin 500 mg/day Children: Griseovulvin 10-20 mg/kg/day Itraconazole 5 mg/kg/day Terbinafrin 3-6 mg/kg/day

Tinea pedis/ manum

Allylamine Azole Ciclopirox Benzylamine Tolnaftate Undecenoic acid

Adults: Terbinafine 250 mg/day Itraconazole 200 mg twice/day Fluconazole 150 mg/week Children: Itraconazole 5 mg/kg/day

Onychomycosis Ciclopirox Amorolfine

Terbinafine 250 mg/day Itraconazole 200 mg/day Fluconazole 150-300 mg once/week

13

Based literature for systemic treatment, the imidazole preparations have the

advantage of being broad have the adventage of being broad spectrum antibiotic

and effective againts candida spp. and some case, bacteria. In vitro ketoconazole

and the azoles in general have about the same susceptibility pattern as

griseofulvin. Infections that failed to respond to griseofulvin treatment have

sometimes responded to ketoconazole. Actual development of griseofulvin

resistance has been noted in some dermatophytes.2

Non medicamentosa management and prevention of relapse of disease is

very important, such as reducing the predisposing factors, namely temperature,

humidity and occlusion by advocating wearing loose clothing and materials that

easily absorb sweat, dry off after a shower and sweating, and washing the clothes

that contaminated.9,10

The prognosis in normal patients tinea facialis resolves spontaneously after

a few months. The less tendency toward chronicity than in tinea pedis and tinea

cruris. The treatment aids in the resolution of lesion and effects a clinical cure.

Reinfection of the same area may occur within a few weeks to months if the

patient is again exposed to infectious material. In some patients lesions of tinea

facialis reappear at regular interval.2

14

REFERENCE

1. James WD, Berger TG, Elston DM. Disease Resulting From Fungi and

Yeasts In Andreaw`s Disease of the skin clinical Dermatology. 10 th ed.

Saunders Elsevier: 2006.p. 297-331.

2. Rippon JW. Characteristics of Fungi. 3th ed. Saunders Compony:1988. p.

121-53.

3. Smith MD, Downie JB, DiCostanzo D. 2010. Granuloma annulare. Int J

Dermatol : 326-33.

4. Mitchell TG. Medical Mycology In Jawetz, Melnick and adelberg`s Medical

Microbiology. 24th ed. Mc Graw Hill Companies: 2007. p. 621-57.

5. Rassai S, Feily A, Sina N, Derakhshanmehr F. Some Epidemiological

Aspects of Dermatophyte Infections in Southwest iran. Acta

Dermatovenerol Croat. 2011. p.13-15

6. Schieke AM, Garg A. Fungal Infection In Goldsmith AG, Stephen IK,

Barbara AG, Ami SP, David JL. Fitzpatrick’s Dermatologiy in General

Medicine. 8th ed. New York: McGraw Hill: 2012.p. 2277-328.

7. Hay RJ, Moore M. Mycology In Rook Textbook of Dermatology. 7th ed.

Blackwell Science. 2007.p. 1277-376.

8. Lakshmipathy, Deepika. 2010. Review on Dermatomycosis: Pathogenesis

and Treatment. Biomolecules and Genetics, School of Biosciences and

Technology. VIT University, Vellore. Vol.2. No.7. 726-731

9. Risdianto A, Dirmawati K, and Safruddin A. 2013. Case Report: Tinea

Corporis and Tinea Cruris Caused By Trichopyton Mentagrophytes Type

Granular In Asthma Bronchiale Patient. Vol.2. No.2. 31-38.

10. Hand JW, Wroble RR. Prevention of Tinea Corporis in Collegiate

Wrestlers. J of Atlhletic Training. 1999. Vol: 34. p.350-52.

15

ATTACHMENT

Table 3. Several things which found and the relationship with some theory

Case Literature Author

Anamnesis The patient found red spots that felt very itchy on the upper back area, the rash was getting wider and spreaded to the face, palmars and plantars area.

Patient diagnosed tinea fasialis based on history and physical examination. The patient with complaints the appearance of rash followed by itching on the the face, upper back, palmars and plantars since two month ago. At first, the patient found red spots that felt very itchy on the upper back area, the rash was getting wider and spreaded to the face, palmars and plantars area. Itching is increasing at the time of using pads and when the groin area is moist.

There are similarities between the case and the theory which states that tinea facialis symptom.

Status of

dermatology

On facial and palmars dextra and sinistra region, found erythematous patches and hypopigmentation with circumpscripta boundary, irregular and polycyclic edges,

This form is characterized by one or more circular, sharply cirscumscribed, slightly erithematous, dry, scaly, usually hypopigmented patches. An advancing scalling edge is usually

There are similarities between the case and the theory which states that tinea facialis description.

16

there are papules and scales on the edge of lesions, multiple lesions, plaque size, there are central healings, disseminated arrangement, and generalized distribution.

prominent. Progressive central clearing procedures annular outline that give them the name “ringworm”. Lesions may wider to form rings many centrimeters in diameter. In some case concentric circles or polycyclic lesion form, making intricate patterns.

Clinical test Microscopic examination of skin scrapings (scales) with 10% potassium hydroxide (KOH) showed long, septate and branching hyphae.

Direct microscopic examination of skin scrapings specimens using 10 % KOH will show septate hyphae and squared or rounded, irregularly arranged arthroconidia.

There are similarities between the case and the theory which states that tinea facialis description.

Therapy Therapy in this case are oral ketoconazole 200 mg once daily for 2 to 3 weeks and ketoconazole 2% cream applied once at night for 2 to 4 weeks and than miconazole cream once daily in the morning.

Ketoconazole and miconazole is an antifungal azole class, broad-spectrum imidazole group, fungistatic and can be given to patients who do not respond to topical therapy.

There are similarities between the case and the theory which states that tinea facialis treatment.

17

Table 4. Differantial diagnosis

Tinea facialis One or more circular, sharply cirscumscribed, slightly erithematous, dry, scaly, usually hypopigmented patches. An advancing scalling edge is usually prominent. Progressive central clearing procedures annular outline that give them the name “ringworm”. Lesions may wider to form rings many centrimeters in diameter. In some case concentric circles or polycyclic lesion form, making intricate patterns.

Seborrheic

dermatitic

a common chronic papulosquamous dermatosis that is usually easily recognized. It affects infants and adults and is often associated with increased sebum production (seborrhea) of the scalp and the sebaceous follicle rich area. The sites of predilection are face, ears, scalp, and upper part of the trunk.

18

Cutaneous

candidiasis

a predilection for colonizing moist, macerated folds of skin. Intertrigo is the most common clinical presentation on glabrous skin. Usual locations for intertrigo include the genitocrural, axilary, gluteal, interdigital, and inframammary areas and between folds of skin on the abdominal wall. Cutaneous candidiasis appears as pruritic, erytematous, macerated skin in intertriginous areas with satellite vesicopustules.

Granulloma

anulare

Based on the shape of lesion Granuloma annulare starts as a ring of small, firm, flesh-colored or red papules. As the condition progresses, there is some central involution, and the ring of papules slowly increases from 0.5 to 5.0 cm in diameter. The lesions may be isolated or coalesce into plaques. They are found on the lateral or dorsal surfaces of the hands and feet.

19

Morbus Hansen Painless skin patch accompanied by loss of sensation but not itchiness.