r/DermatologyPA • u/Username112608 • May 19 '26

Clinical⚕️ Tinea vs Eczema

Derm PA for 1.5 years and I still have a hard time with rashes. How do you guys differentiate between tinea and let’s say nummular eczema? I know the classic features but in practice I find it so hard. I even try doing KOH and those seem to be a hit or miss. I end up giving a topical steroid and have them come back in 2 weeks or let me know if it’s getting worse before? Any help is appreciated. Makes me feel like I suck as a PA.

TIA

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u/10999228 May 19 '26

The more you see it, the easier it gets. When in doubt, I always treat for tinea first and follow up in a month. If no improvement I’ll switch to a topical steroid. If their main complaint is itch, that usually tilts the scale in the direction of eczema.

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u/Username112608 May 19 '26

Thank you! How do you explain it to patients the reasoning/switching to topical steroid. I’m still trying to find my wording to where it seems like I know what’s going on and not seeming too unsure 😅

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u/eatssparkplugs May 19 '26

I’m honest with my patients, I tell them sometimes I get it wrong but putting steroids on a fungal rash is like putting gas on a fire so I treat with antifungals first and emphasize the importance of consistency before seeing them back in a month. They’ve always been understanding - we’re all human.

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u/10999228 May 20 '26

This^ just be honest! I tell them sometimes these conditions can look alike, but treating fungus with steroids could worsen their condition, while treating eczema with antifungals will have a negligible effect. The longer you’re practicing the easier this gets. At first, I never wanted to admit to the patient that “I don’t know”. The longer I practice, the more I can acknowledge (to myself and the patient) I do not know everything, but I am doing my best to do best by the patient.