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ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 4  |  Page : 243-248

Clinical and mycological features of recurrent dermatophytosis: A hospital-based observational cross-sectional study


1 Department of Dermatology, Venereology and Leprosy, GSL Medical College, Rajahmahendravaram, Kolalapudi, Andhra Pradesh, India
2 Department of DVL, GSL Medical College, Rajahmahendravaram, Andhra Pradesh, India
3 Department of DVL, NRI Institute of Medical Sciences, Visakhapatnam, Andhra Pradesh, India

Date of Submission03-Jun-2021
Date of Decision15-Jun-2021
Date of Acceptance16-Jun-2021
Date of Web Publication22-Mar-2022

Correspondence Address:
Dr. Seetharam Anjaneyulu
Department of Dermatology, Venereology and Leprosy, GSL Medical College, Rajahmahendravaram, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrntruhs.jdrntruhs_70_21

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  Abstract 


Background: Dermatophytosis has changed its facets. The prevalence, clinical features, and causative organisms are changing leading to recurrent, recalcitrant, and chronic dermatophytosis. The misuse of potent topical steroids is further aggravating the problem. The risk factors, clinical features, and mycological nature of recurrent dermatophytosis are sparsely documented.
Objectives: To know the epidemiological and clinical features, and to identify the organisms causing recurrent dermatophytosis.
Materials and Methods: Patients attending to our OPD with dermatophytic infections from December 2017 to June 2019 were scrutinized and those, who had recurrence within 6 weeks after treating with 4 weeks of systemic antifungal treatment were recruited into our study. Demographic data and clinical patterns were documented after informed consent. KOH smears were taken, and the scrapings were cultured in Sabouraud's dextrose agar with 0.05% chloramphenicol and 0.5% cycloheximide.
Results: Ninety-six patients were recruited to the study after following the inclusion and exclusion criteria. The most common age group was 21–30 years, and males were slightly more. A total of 66.7% (64/96) had used topical corticosteroids or steroid combinations. KOH positivity was seen in 67.7%, and the culture was positive in 58.3% of cases. The most common organism isolated in culture was the Trichophyton rubrum (27.1%), followed by Trichophyton mentagrophytes (22.9%). Recurrences were early in those who used topical potent corticosteroids like clobetasol.
Limitation: Minimum inhibitory concentrations (MIC) levels of the antifungal drugs were not done to know the relation between MIC levels and recurrence.
Conclusion: Recurrent dermatophytosis is increasing and presenting with modified clinical patterns. Topical steroid use, mainly with potent clobetasol or its combinations, seems to be the main culprit for recurrences.

Keywords: Clinical features, dermatophytosis, epidemiological, mycological features


How to cite this article:
Praveen S, Saka S, Subhashini K, Venkataramana G, Sathvika G, Ramanamurty P, Anjaneyulu S. Clinical and mycological features of recurrent dermatophytosis: A hospital-based observational cross-sectional study. J NTR Univ Health Sci 2021;10:243-8

How to cite this URL:
Praveen S, Saka S, Subhashini K, Venkataramana G, Sathvika G, Ramanamurty P, Anjaneyulu S. Clinical and mycological features of recurrent dermatophytosis: A hospital-based observational cross-sectional study. J NTR Univ Health Sci [serial online] 2021 [cited 2022 Dec 2];10:243-8. Available from: https://www.jdrntruhs.org/text.asp?2021/10/4/243/339825




  Introduction Top


Dermatophytosis is increasing all over the world, especially in tropical countries, and India is no exception.[1] The prevalence, atypical clinical features, altered causative species, and chronicity are becoming more common.[2],[3] Recurrences after adequate antifungal treatment are also reported.[2],[4] Recurrences occurring within 6 weeks after adequate treatment are considered recurrent dermatophytosis, and those persisting more than 6 months are referred to as chronic dermatophytosis.[4],[5],[6] The epidemiology, clinical features, and mycological features of this recurrent dermatophytosis are rarely reported. Hence, we studied the features in recurrent dermatophytosis, attending to our OPD over a period of one and half years.


  Materials And Methods Top


This is a hospital-based-observational cross-sectional study. All the patients with dermatophyte infections attending to our OPD from December 2017 to June 2019 were scrutinized. Patients, who developed dermatophyte infection within 6 weeks of adequate antifungal treatment were included in the study. Patients with naïve infection, infection of hair and nail, and patients who did not complete 4 weeks of systemic antifungal treatment were excluded. The institutional ethics committee has approved the study (GSLMC/RC: 416-EC/416-10/17).

A total of 1,956 clinically suspected dermatophytosis cases were observed during the study period. Of this, 96 were of recurrent dermatophytosis based on inclusion and exclusion criteria [Figure 1]. Informed consent was taken from all the patients. A detailed history was taken. All the demographic data and the epidemiological factors associated with these infections were noted. A digital photograph was taken after their consent. Skin scrapings from the edges of the lesions were inoculated into freshly prepared 10% KOH mount and into a test tube containing Sabouraud's dextrose agar with 0.05% chloramphenicol and 0.5% cycloheximide. The culture media were kept at 28°C for a maximum of 4 weeks with regular examination for growth of fungi. Identification was done based on the microscopic and topography of fungal colonies and pigmentation on the surface and reverse was examined, and the species were further identified by lactophenol cotton blue mount.
Figure 1: Flow chart of the study protocol

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  Results Top


The demographic and morphological features were shown in [Table 1]. The most common age group was 21–30 years (24/96, 25%), and males were slightly more (50 M, 46 F; M:F: 1.08:1.0). Family history was observed in one-third of the cases, and 66.7% (64/96) had used topical corticosteroids or steroid combinations. Use of tight clothes and sharing of linen-like towels, bedsheets were seen in 56.2% and 46.8%, respectively. Comorbidities such as diabetes (15.6%), hypertension (10.4%), and hypothyroidism (8.3%) were seen. The eczematous type [Figure 2] and the pseudo-imbricata [Figure 3] were seen in 26% each, followed by pustular (17.7%), classical (15.6%), and psoriasiform (14.6%) [Figure 4]. The most common clinical form was tinea corporis (29.2%), followed by tinea cruris (27.1%). KOH positivity was seen in 67.7%, and the culture was positive in 58.3%. The most common organism isolated in culture was the Trichophyton rubrum (27.1%) [Figure 5]a and [Figure 5]b, followed by Trichophyton mentagrophytes (22.9%) [Figure 6]a and [Figure 6]b. Among the studied individuals, 46.8% had both culture and KOH-positive. In 11.5%, KOH was negative, but the culture was positive, and in 20.9%, KOH was positive, but the culture was negative [Table 1].
Table 1: Demographic, clinical, and mycological features of 96 cases with recurrent dermatophytosis

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Figure 2: Eczematous pattern of recurrent dermatophytosis along with healed hyperpigmentation

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Figure 3: Tinea pseudoimbricata

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Figure 4: Psoriasiform pattern

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Figure 5: (a and b): White granular colonies with central folding and deep red reverse, suggesting Trichophyton rubrum

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Figure 6: (a and b): White cottony colonies with raised central tufts and reddish-brown reverse, suggesting Trichophyton mentagrophytes

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  Discussion Top


Recurrent dermatophytosis is increasing all over the world. We observed 4.9% cases of recurrent dermatophytosis among all dermatophytosis cases during this period. Pathania et al.[4] reported in 9.3% in their study from northern India. In addition to the humidity factors in the environment, poor personal hygiene, use of topical steroids could be the causes of these recurrent infections. Sharma et al.[7] reported recurrences in 34.3% of cases of their study. This difference could be because of the differences in the inclusion criteria.

Recurrent dermatophytosis was seen mostly in the age group of 21–30 years in our study (25%). Parameswari et al.[8] reported in the same age group, but Pathania et al.[4] reported a mean age of 32.5 years. However, in the majority of the studies, recurrent dermatophytosis was predominantly in the adult age group. It may be due to more physical activity, excessive sweating, and tight clothing leading to the growth of dermatophytes. This age group of people socializes with different people, hence enabling the spread of dermatophytosis.

We observed recurrent dermatophytosis more in males (57.2%), similar to Pathania et al.[4] (63%) and Gupta et al. (75%).[9] This predominance in males could be due to increased outdoor activity and more sweating. Verma et al.[5] mentioned that dermatophytosis is rising in women, leading to the reversal of the men: women ratio. Family members were affected in 33.3% of cases in our study and 50% of cases had more than two members involved in the family. Some studies reported up to 72% of the family members, with 44.4% were having more than two affected members in the family.[4] This could be because of overcrowding in the house and many members sharing the same room and linen. The students were seen more frequently in our study (23%) similar to Kucheria et al.[10] Nearly 66.7% of the study participants had used topical steroids or steroids combined with antibiotic, antifungal creams previously. Thus, the overcrowding in the houses, tight clothing, sharing of clothes, and usage of topical steroids or steroid combinations could be the causes for recurrence in these cases.

In our study, morphologically, the eczematous (25%) and the pseudo-imbricata (25%) patterns were more frequent, followed by pustular (17%) and psoriasiform (15%). Mostly tinea corporis (29.1%) was seen involving the waist, abdomen, back, thighs, and legs followed by tinea cruris (27%) and in 27% of the cases, a combination of two or more than two types was seen. Pathania et al.[4] reported a combination of lesions in 64.6%, followed by tinea cruris (18%) and tinea corporis (17.3%). Verma et al.[5] presented varied morphological presentations such as double-edged tinea, rings in-ring appearance, in addition to the annular, eczematous, pustular, cockade, and psoriasiform patterns.

All 96 patients received systemic antifungals, either terbinafine 250 mg once daily, or itraconazole 100 mg BID, or griseofulvin 500 mg once daily for 4 weeks. In all, lesions cleared completely by 4 weeks and recurred within 2 weeks (18.8%), 4 weeks (45.8%), and in the remaining by 6 weeks. Recurrences were earlier with griseofulvin and terbinafine, compared to itraconazole. Topical steroids (Clobetasol, betamethasone, fluocinolone, mometasone) were used by 66.7%, either before starting antifungal therapy or on recurrence soon after 4 weeks. In these patients, 4 weeks of therapy may not be adequate and longer periods of treatment may be necessary. These were the patients, in whom recurrences were early also within 2–4 weeks, and the use of clobetasol-containing creams (52%) caused the recurrence early within 2 weeks. The dermatophytes are cleared from the skin through Th1/Th17-dependent cell-mediated immunity.[11] In acute dermatophytosis, it is the Th1 that helps in clearance, and with the topical steroids and the immune-deficient people, there is a tilt towards the Th2 cytokines which may predispose to recurrences and chronicity.[12] The mechanisms to this shift are not known clearly. Hence, a thorough history of the use of topical steroids should be enquired and adequately treated. In addition to topical steroids, damp houses, overcrowding, tight clothes, sharing of linen can contribute to recurrences. In our study, 56.2% were using tight clothes and 46.8% were sharing the towels, wearing clothes, or bed linen. Pathania et al.[4] reported that 69% shared the towels and 18% shared their clothes, and 85% washed the clothes together.

In our study, the KOH was positive in 67.7% of patients, whereas other studies reported KOH positivity from 32.4% to 94.1%.[13],[14],[15],[16] These differences could be because of differences in sample collection, processing, and the skill to identify the fungal filaments in the smear. Culture identifies the specific species, and we could culture the fungus in 58.3% of the study participants, and other studies have isolated fungus in 37%–51% of their cases.[13],[14],[17] Comparably, Pathania et al.,[4] have also reported positive cultures in 60% of their cases, and they also included only recurrent cases in their study. The culture yield is slightly high in recurrent cases as they might be lodging more viable fungi. In 11 cases, KOH was negative, but the culture was positive. This could be because of the inactive sporulating phase, difficult to identify with normal microscopy, but culture can grow.[7],[8],[18],[19] Similarly, in 20.9% of cases, KOH was positive, but the culture was negative. Similar reports were there earlier from Sikkim and Meghalaya.[7],[13] As Sharma et al.[7] stated, this could be because of the nonviability of fungus before inoculation.

Many studies from India of late have found Trichophyton mentagrophytes as the causative organism.[20],[21],[22],[23],[24] This shift to a zoophilic fungus was because of extensive misuse of potent topical steroids like clobetasol and betamethasone in addition to inadequate space and cultural attitudes.[24] Verma et al.[24] further mentioned that it could be because of anthropization, which means the dermatophyte adapts to human skin. However, in our study, Trichophyton rubrum was isolated in 27.1% of the patients, followed by T.mentagrophytes (22.9%), similar to Laksmanan et al.[1] There were no significant specific differences in the clinical patterns in relation to fungal species, but T.mentagrophytes caused more inflammatory lesions.

In our 96 cases of recurrent dermatophytosis, 46.8% of the cases had used oral terbinafine, 34.3% used itraconazole, and 18.7% used griseofulvin for the treatment of their fungal infection before recurrence. Majid et al.[25] reported a 22% recurrence rate after terbinafine use, and Ahmed et al.[26] reported recurrences in 38.75% of cases after terbinafine and in 20% of the cases after itraconazole. Recurrences are seen with all the three commonly used drugs; however, most of them could be because of clinical failure rather than mycological resistance. It is surprising that even after the use of 4 weeks of treatment, the recurrences are seen, and most of them used topical steroids before that. Sunil et al.[27] had reported an increase in dermatophyte fungal width after topical corticosteroid usage leading to chronicity and recurrences. Recurrence after topical steroid therapy was reported by Vineetha et al., and Narang et al., and Verma et al.[28],[29],[30] In such cases, a longer duration of treatment may be necessary. The main limitation of this study was we did not estimate the MIC levels of the antifungal drugs, to know the relation between MIC levels and recurrence.


  Conclusion Top


Recurrent dermatophytosis is seen with all the commonly treated drugs such as terbinafine, itraconazole, and griseofulvin. Topical steroid use, mainly with potent clobetasol, or its combinations seems to be the main culprit for recurrences, nonresponsiveness/clinical failure, and chronicity. General measures such as proper hygiene, avoiding tight clothing, not sharing towels or linen, and a prolonged course of systemic antifungals may be needed to prevent recurrences. More randomized studies with a longer duration of treatment are needed to be done.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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