Fungi With Friedman: Recognizing Tinea in Disguise

Sometimes a picture isn't worth a thousand words, Adam Friedman, MD, FAAD, explained in his lecture, "Hang Ten, Not Tinea: An Image-Based Competition to Strengthen Your Management Balance" at the DERM 2025 NP PA CME Conference in Las Vegas, Nevada.¹ His point was simple: sometimes the diagnosis isn't obvious and you need to dig a little deeper.

"Dermatophytoses, which encompass a wide array of clinical cutaneous infections associated with dermatophyte infections, are super common, but are not commonly discussed because they just aren't sexy," Friedman, professor and chair of dermatology and director of translational research at The George Washington University School of Medicine & Health Sciences, said in an interview with Dermatology Times.

First step, he explained, is go beyond the visual examination to truly understand what you are seeing. "Clinical inspection is not going to be enough," he said. "I know we pride ourselves as master diagnosticians, but we have proven time and again in the published literature that clinical inspection is not enough."

To illustrate his point, Friedman shared pictures, some of which were tinea and some were not. Sure enough, conference attendees were just as puzzled as he was when trying to diagnose based on visual examination only. He "really impress upon the audience that simply looking at the photos will not be enough."

With that in mind, Friedman further investigates. "Use my favorite tool of all time, your potassium hydroxide prep," he advised. "I realize there are some limitations with CLIA certification, but this very simple tool can be the distinguisher between calling something a dermatophyte infection or something primary inflammatory."

Not only will such tools help clinicians make the right diagnosis and thus choose the right treatment, but it is necessary to ensure the treatments work well into the future, he told Dermatology Times.

"We need to be able to make the right diagnosis, but also consider the potential for antifungal resistance if we don't treat the right thing or if we're not thoughtful about how we use our antifungals, of which we don't have, unfortunately, a huge amount," Friedman said.

Reference

1. Friedman A. Hang Ten, Not Tinea: An Image-Based Competition to Strengthen Your Management Balance. Presented at the DERM 2025 NP PA CME Conference; July 23-26, 2025; Las Vegas, Nevada.