The unprecedented epidemic-like scenario of dermatophytosis in India: III. Antifungal resistance and treatment options.

One of the canonical features of the current outbreak of dermatophytosis in India is its unresponsiveness to treatment in majority of cases. Though there appears to be discordance between in vivo and in vitro resistance, demonstration of in vitro resistance of dermatophytes to antifungals by antifungal susceptibility testing is essential as it may help in appropriate management. The practical problem in the interpretation of antifungal susceptibility testing is the absence of clinical breakpoints and epidemiologic cutoff values. In their absence, evaluation of the upper limit of a minimal inhibitory concentration of wild type isolates may be beneficial for managing dermatophytosis and monitoring the emergence of isolates with reduced susceptibility. In the current scenario, most of the cases are unresponsive to standard dosages and duration of treatment recommended until now. This has resulted in many ex-cathedra modalities of treatment that are being pursued without any evidence. There is an urgent need to carry out methodical research to develop an evidence base to formulate a rational management approach in the current scenario.

The unprecedented epidemic-like scenario of dermatophytosis in India: II. Diagnostic methods and taxonomical aspects.

Trichophyton (T.) mentagrophytes now accounts for an overwhelming majority of clinical cases in India, a new "Indian genotype" (T. mentagrophytes ITS genotype VIII) having been isolated from skin samples obtained from cases across a wide geographical distribution in this country. The conventional diagnostic methods, like fungal culture, are, however, inadequate for diagnosing this agent. Thus, molecular methods of diagnosis are necessary for proper characterization of the causative agent. The shift in the predominant agent of dermatophytosis from T. rubrum to T. mentagrophytes, within a relatively short span of time, is without historic parallel. The apparent ease of transmission of a zoophilic fungus among human hosts can also be explained by means of mycological phenomena, like anthropization.

The unprecedented epidemic-like scenario of dermatophytosis in India: I. Epidemiology, risk factors and clinical features.

Dermatophytosis has attained unprecedented dimensions in recent years in India. Its clinical presentation is now multifarious, often with atypical morphology, severe forms and unusually extensive disease in all age groups. We hesitate to call it an epidemic owing to the lack of population-based prevalence surveys. In this part of the review, we discuss the epidemiology and clinical features of this contemporary problem. While the epidemiology is marked by a stark increase in the number of chronic, relapsing and recurrent cases, the clinical distribution is marked by a disproportionate rise in the number of cases with tinea corporis and cruris, cases presenting with the involvement of extensive areas, and tinea faciei.

Evaluation of cervical and anal intraepithelial neoplasia in women attending a sexually transmitted infection clinic.

BACKGROUND: The incidence of anal and cervical cancers and their precursors have increased in the past decades. Women with HIV and sexually transmitted infections are at a higher risk. Cervical human papilloma virus infection may serve as a reservoir and source of anal infection or vice versa. A higher incidence of anal cytological abnormality has been observed in patients with abnormal cervical cytology. OBJECTIVES: This cross sectional study was designed to estimate the prevalence and associations of anal and cervical cytological abnormalities in a cohort of sexually active women using Papanicolaou smears. METHODS: We conducted a single centre study of 35 consecutive HIV positive and 40 HIV negative women attending the sexually transmitted infection clinic. Cervical and anal specimens were obtained for cytology after a detailed history and examination. Chi square test and coefficient of correlation were used for comparison. RESULTS: Cervical dysplasia was observed in 22.6% (17.3% low-grade squamous intraepithelial lesion and 5.3% high grade squamous intraepithelial lesion) and anal dysplasia in 8% study subjects (6.7% low-grade squamous intraepithelial lesion and 1.3% high grade squamous intraepithelial lesion); no association was observed with HIV infection. A higher number of patients with cervical dysplasia (29.4%) were found to have concomitant anal dysplasia (P = 0.002). History of anal intercourse was reported in all patients with anal dysplasia and was higher (P < 0.037) in patients with cervical dysplasia. LIMITATIONS: The limitations included a small sample size, lack of correlation with histological findings and bias due to STI clinic-based recruitment of the study population. CONCLUSION: Cytology may be used to screen for cervical and anal dysplasia in women irrespective of HIV status. Women with cervical dysplasia may be preferentially screened for anal dysplasia and vice versa. Anal intercourse may be a risk factor for anal and cervical dysplasia.