By Gary M. White, MD

Deep dermatophytosis (DD) is an infection of the skin and deeper tissues by dermatophytes. DD is an AR inherited disorder caused by deficiencies in CARD9 (caspase recruitment domain 9) protein.


For the inherited disease, onset of symptoms is from 2-21 years of age. Red scaly annular plaques typical of tinea corporis occur. Nail dystrophy from onycholysis will occur. What makes this syndrome different is the nodular, ulcerative lesions with deep involvement to e.g. bone and even brain. Lymphadenopathy is common. The condition may worsen during adolescence and death is common.


Patients with human immunodeficiency virus and patients who are receiving immunosuppressive therapy may develop deep dermatophytosis infection. These should be excluded and DD diagnosed only in "otherwise healthy individuals".


Genetic counseling is important. For the fungal infection, terbinafine is recommended as first line therapy with posaconazole as a second agent [JAMA Derm 2015;151;192].


Deep dermatophytosis in patients with inherited CARD9 deficiency. N Engl J Med. 2013 Oct 31;369(18):1704-14

Prednisolone 25 mg/day and tacrolimus 3 mg/day for myasthenia gravis probably predisposed to these lesions. Acta Derm Venereol 2013;93;358.


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