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 Table of Contents  
SPECIAL ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 1  |  Page : 112-117

Epidemic of difficult-to-treat tinea in India: Current scenario, culprits, and curbing strategies


1 Department of Dermatology, Venereology and Leprosy, Yenepoya Medical College, Mangalore, Karnataka, India
2 Department of Dermatology, Venereology and Leprosy, Father Muller Medical College, Mangalore, Karnataka, India

Date of Web Publication12-Jun-2019

Correspondence Address:
Dr. Manjunath M Shenoy
Department of Dermatology, Venereology and Leprosy, Yenepoya Medical College, Deralakatte, Mangalore - 575 018, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_72_19

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  Abstract 


Dermatophytes cause superficial skin infections of skin, nail, and hair known as dermatophytosis. It is commonly called as “ring worm” infection. There has been an emergence of an epidemic of recurrent and chronic dermatophytosis in India. Several reasons have been implicated that are related to the agent, host, and the treatment. Topical steroid misuse has been considered as an important contributor that has led to the persistence and atypicality of the infection. This article emphasizes on the salient features of the current dermatophyte epidemic to sensitize all physicians who treat the infections.

Keywords: Chronic dermatophytosis, recurrent dermatophytosis, tinea, topical steroid misuse


How to cite this article:
Shenoy MM, Jayaraman J. Epidemic of difficult-to-treat tinea in India: Current scenario, culprits, and curbing strategies. Arch Med Health Sci 2019;7:112-7

How to cite this URL:
Shenoy MM, Jayaraman J. Epidemic of difficult-to-treat tinea in India: Current scenario, culprits, and curbing strategies. Arch Med Health Sci [serial online] 2019 [cited 2019 Aug 23];7:112-7. Available from: http://www.amhsjournal.org/text.asp?2019/7/1/112/260024




  Introduction Top


Dermatophytes are fungi that metabolize keratin to produce superficial skin infections of skin, nail, and hair known as dermatophytosis. It is commonly called as “ring worm” infection due to the round, itchy, and inflammatory patches seen in the common form of the disease. The lesions may sometimes become widespread and may have a significant impact on social, psychological, and occupational health compromising the quality of life.[1] It is a contagious disease that spreads by direct or indirect contact. Until a few years ago, it had been a disease treated with ease using antifungal agents. In the recent past, there has been a failure of treatment with conventional therapy and emergence of an epidemic of recurrent and chronic dermatophytosis in India.[2],[3]

Dermatologists across the country are sensitized to this aspect, but the disease is not managed by dermatologists alone. Many patients are first reported to the family practitioners, physicians, and pediatricians. This article hence intended to bring awareness among all our colleagues. In India, practitioners of alternate medicine and unqualified quacks also manage these patients with allopathic medications who have inadequate knowledge of these drugs. This has also been a hindrance in tackling epidemics of this magnitude.


  Epidemiology Top


The prevalence of the dermatophytosis depends on the host and environmental factors such as temperature, humidity, demographic factors of patient, occupation, genetic predisposition, and socioeconomical status.[4] Dermatophytes evolve along with the change in geography and socioeconomic conditions. These keratinophilic fungi have the ability to invade hair, nails, and the skin of the living host.

Conventionally, dermatophytes are classified as asexual or imperfect (anamorphic) molds belonging to three genera, namely Trichophyton, Microsporum, and Epidermophyton. There are about 40 species of dermatophytes under these three genera.[5] The taxonomy of dermatophytes is an evolving area and the use of molecular techniques to study the relatedness of species has led to confusion and conflicts in the literature. Dermatophytes are found in three different ecological sources, namely humans, animals, and soil, based on which they are classified into geophilic, zoophilic, and anthropophilic species.[6] There is geographic variation in the dominance of infecting agents. Most of the infections are generally mild and are treated with common antifungal agents.

The prevalence of superficial mycotic infection worldwide according to the World Health Organization in 2015 has been found to be 20%–25%.[7] In the past 7–8 years, there has been an escalation in difficult to treat, recurrent as well as chronic dermatophytosis in India. In a study conducted in Sikkim, India, about 60.4% of patients gave a history of recurrent dermatophytosis.[8] These changes may be contributed to a complex interplay of host, agent, and environmental factors.

In India, common species noted are Trichophyton rubrum, followed by Trichophyton mentagrophytes and Microsporum gypseum. There have been reports of an increase in T. mentagrophytes as a leading causative agent in many studies from India.[9],[10],[11] The recent worldwide trends have been summarized in a review article published by Hayette MP et al.; it has been briefly depicted in [Table 1].[12]
Table 1: Epidemiology of dermatophytosis in the world

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  Current Scenario in the World and India Top


Dermatophytosis was always common but was never considered as a major public health hazard in India. It rarely causes major complications. Published literature on dermatophytosis in the past highlighted the clinical and epidemiological trends but rarely focused on the chronic and recurrent infections since it was a rare occurrence. Treatment failure was also uncommon.

The current epidemic of dermatophytosis in India has many characteristic features due to which it has been among the common topic of discussion in most conferences. A fresh literature from India has been emerging focusing the changing clinic-epidemiological and therapeutic aspects. Major aspects have been enlisted here.

  1. Overall increased frequency of dermatophyte infection across the country
  2. Increased incidence of recurrent and chronic infections[13]


    • Recurrent dermatophytosis is defined as reoccurrence of the signs and symptoms within few weeks of apparent cure
    • Chronic dermatophytosis refers to the persistence of the infection despite treatment for over 6 months–1 year.


  3. Deviation in the clinical patterns with extensive and morphologically atypical lesions
  4. Increased trends of potent topical steroid misuse to treat the disease
  5. Failure of systemic antifungal agents with lack of adequate response[14]
  6. Emergence of T. mentagrophytes as the dominant or codominant pathogen.


Most infections that are reported at higher frequency primarily infect the glabrous skin (tinea corporis, cruris, and faciei). Tinea capitis, onychomycosis, tinea pedis, and tinea manuum have not been a major part of the current epidemic in India.


  Pathogenesis Top


Infection starts after contact with spores or conidia. Dermatophytes growing in a vertebrate host normally form only arthrospores (arthroconidia) or asexual spores that develop within the hyphae. Invasion of the epidermis by dermatophytes begins with adherence between arthroconidia and keratinocytes followed by penetration through and between cells and the development of a host response. In laboratory culture medium, they can also produce microconidia, macroconidia, and asexual spores that develop outside the hyphae.

Growth of dermatophytes is associated with the development of areas of inflammation. Geophilic and zoophilic dermatophytes generally produce more inflammatory lesions than anthropophilic dermatophytes.[15] The amount of inflammation exhibited by the host is determined by the cell-mediated immunity which place a major role in curtailing the infection.

Host factors such as site of infection, barrier function, age, obesity, immunosuppressive state, use of topical steroids, or other immunosuppressive medications may affect the spread of infection and clinical presentation. Anatomical variations such as the presence of skin folds, sebaceous glands, variable thickness of the stratum corneum, and presence of vellus hair follicle involvement may also determine the progress and persistence of infection.

In the Indian scenario, presence of hot and humid climate, low socioeconomic status, overcrowding, sharing of infected clothes and footwear, poor hygiene, and migration of population may be predisposing recurrence of dermatophytosis.


  Diagnostic Challenges Top


Dermatophytosis is classified according to the site of involvement. Salient features of the various forms of dermatophytosis have been depicted in [Table 2]. Most nonhairy infections are characteristically show ring like (annular) reddish scaly lesions with active, spreading, and inflammatory borders [Figure 1]. Hairy areas often show more inflammation often due to the invading fungus which are frequently zoophilic in origin.[16] Extensive disease, atypical presentations, and extension of the disease into the scalp and face are common. The appearance of the lesions at the site of the rings, drawstrings, wrist bands and body threads worn for cultural and religious reasons has been seen indicating these articles may serve as reservoir of the infection [Figure 2]. Most infections are diagnosed based on the clinical manifestations. Rarely laboratory diagnosis using mycological examination is carried out to confirm the diagnosis.
Table 2: Salient features of dermatophytosis

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Figure 1: Tinea corporis; annular and polycyclic erythematous scaly plaques with active borders

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Figure 2: Tinea corporis occurring at the site of the wrist band

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The diagnostic difficulty has been posed in the recent past with the emergence of atypical dermatophytosis.[17] Majority of such presentation can be attributable to the usage of over-the-counter steroid containing creams.[18] These creams can give quick relief in the symptom but eventually leading to atypical presentation, persistence, and widespread infection. Rampant use of such creams has immensely contributed to the current epidemic.

Atypical tinea presents with clinical appearances ranging from eczematous, psoriasis-like, pustular lesions, pseudoimbricata (concentric rings), and rosacea-like lesions which are resilient to treatment [Figure 3], [Figure 4], [Figure 5].[17] Topical steroid misuse has been the main culprit for the atypical presentations. Many cases are also associated with cutaneous adverse effects of steroid abuse such as striae, atrophy of skin, acneiform eruptions, and rosacea [Figure 6] and [Figure 7].[19],[20] Understanding the impact of topical steroids in the current epidemic is crucial and can be considered as a gap in the research. Topical steroid abuse shall be considered as one of the major health tragedies in India. These drugs impede the cutaneous inflammatory response that the skin mounts to resist and limit the fungal infection. Concomitantly, there is local suppression of T-cell-mediated immune response to the dermatophytes. Tinea “incognito” refers to the steroid modified tinea that has lost the inflammatory signs with masked margins [Figure 7].
Figure 3: Psoriasis-like atypical tinea

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Figure 4: Annular lesion of tinea corporis with pustules

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Figure 5: Tinea pseudo imbricata due to topical steroid misuse

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Figure 6: Tinea incognito

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Figure 7: Cutaneous atrophy with striae due to steroid misuse

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Laboratory diagnosis relies primarily on the conventional diagnostic techniques, namely direct microscopy and mycological culture. Currently, there has been a major shift in the epidemiology with T. mentagrophytes emerging as the dominant pathogen overtaking the T. rubrum. This has also been attributed to various host and environmental factors. T. mentagrophytes has many subspecies, and detection of it is of great epidemiological importance. Molecular biological techniques are adapted to detect the fungus to the subspecies level.[21],[22] In India, there are very few centers offering those services.


  Therapeutic Challenges Top


Antifungal therapy can be administered as topical or oral formulations. Topical therapy alone can cure localized lesions, but such an occurrence in the current epidemic is rare. Topical antifungal therapy is safe for pregnant, lactating women, infants, and small children.[23] It is important to mention once again that topical antifungal alone without any antibiotics or steroids shall be used to manage dermatophytosis,

Systemic antifungals commonly used for the treatment of dermatophytosis include griseofulvin, terbinafine, itraconazole, and fluconazole. Textbooks and published literature describes the conventional doses and duration of therapy which has been summarized with modifications in [Table 3]. This therapy is often inadequate in the current scenario, and we require fresh management guidelines.
Table 3: Conventional therapy of dermatophytosis

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If not contraindicated, systemic antifungals have become necessary in virtually all cases of dermatophytosis. There have been reports of failure of systemic therapy, especially with terbinafine indicating there may be a possible antifungal resistance.[24] A few Indian studies have reported mutation in squalene epoxidase enzyme leading to drug resistance in terbinafine.[25],[26]

Apart from treatment, prevention of recurrences, reinfection and spread to family members and contacts is important. This can be made possible by an elaborate counseling of every patient. Various aspects of counseling have been summarized in [Table 4]. Important aspects include hygiene, avoiding the steroid-containing creams, and treating all contacts. It is very common to notice that many family members are simultaneously affected in the current scenario, which causes economic burden too.[27]
Table 4: Counseling of patients with dermatophytosis

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  Conclusion Top


Superficial mycosis that was amenable to minimal interventions has grown into a bothersome health problem accountable to epidemic in India. Atypical presentations, poor therapy response, chronic disease, and recurrent infections are the hallmark of this epidemic. Many factors related to the fungus, host, environment, and drug are responsible for it, but topical steroid abuse is a leading cause of it. Apart from a negative impact on the quality of life, tinea epidemic in India has caused economic burden to the affected family. Physicians treating the infections should be aware of all these aspects and comprehensively treat the infections with pharmacological therapy and counseling.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Sharma R, Adhikari L, Sharma RL. Recurrent dermatophytosis: A rising problem in Sikkim, a Himalayan state of India. Indian J Pathol Microbiol 2017;60:541-5.  Back to cited text no. 8
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Sentamilselvi G, Kamalam A, Ajithadas K, Janaki C, Thambiah AS. Scenario of chronic dermatophytosis: An Indian study. Mycopathologia 1997;140:129-35.  Back to cited text no. 13
    
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Majid I, Sheikh G, Kanth F, Hakak R. Relapse after oral terbinafine therapy in dermatophytosis: A clinical and mycological study. Indian J Dermatol 2016;61:529-33.  Back to cited text no. 14
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de Hoog GS, Dukik K, Monod M, Packeu A, Stubbe D, Hendrickx M, et al. Toward a novel multilocus phylogenetic taxonomy for the dermatophytes. Mycopathologia 2017;182:5-31.  Back to cited text no. 15
    
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Verma S, Hay RJ. Topical steroid-induced tinea pseudoimbricata: A striking form of tinea incognito. Int J Dermatol 2015;54:e192-3.  Back to cited text no. 18
    
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Meena S, Gupta LK, Khare AK, Balai M, Mittal A, Mehta S, et al. Topical corticosteroids abuse: A clinical study of cutaneous adverse effects. Indian J Dermatol 2017;62:675.  Back to cited text no. 19
    
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Verrier J, Monod M. Diagnosis of dermatophytosis using molecular biology. Mycopathologia 2017;182:193-202.  Back to cited text no. 21
    
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Singh S, Shukla P. End of the road for terbinafine? Results of a pragmatic prospective cohort study of 500 patients. Indian J Dermatol Venereol Leprol 2018;84:554-7.  Back to cited text no. 24
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Rudramurthy SM, Shankarnarayan SA, Dogra S, Shaw D, Mushtaq K, Paul RA, et al. Mutation in the squalene epoxidase gene of Trichophyton interdigitale and Trichophyton rubrum associated with allylamine resistance. Antimicrob Agents Chemother 2018;62. pii: e02522-17.  Back to cited text no. 25
    
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27.
Singh S, Verma P, Chandra U, Tiwary NK. Risk factors for chronic and chronic-relapsing tinea corporis, tinea cruris and tinea faciei: Results of a case–control study. Indian J Dermatol Venereol Leprol 2019;85:197-200.  Back to cited text no. 27
[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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