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.

A prospective study of the epidemiological and clinical patterns of recurrent dermatophytosis at a tertiary care hospital in India.

BACKGROUND: Recurrent and clinically unresponsive dermatophytosis is being increasingly encountered in our country. It runs a protracted course with exacerbations and remissions. However, there is little information regarding the extent of the problem and the characteristics of recurrent dermatophytosis in published literature. AIMS: We sought to determine the prevalence, risk factors and clinical patterns of recurrent dermatophytosis in our institution. We also investigated the causative dermatophyte species and antifungal susceptibility patterns in these species. METHODS: One hundred and fifty patients with recurrent dermatophytosis attending the outpatient department of the Postgraduate Institute of Medical Education and Research, Chandigarh, India were enrolled in the study conducted from January 2015 to December 2015. A detailed history was obtained in all patients, who were then subjected to a clinical examination and investigations including a wet preparation for direct microscopic examination, fungal culture and antifungal susceptibility tests. RESULTS: Recurrent dermatophytosis was seen in 9.3% of all patients with dermatophytosis in our study. Trichophyton mentagrophytes was the most common species identified (36 patients, 40%) samples followed by T. rubrum (29 patients, 32.2%). In-vitro antifungal susceptibility testing showed that the range of minimum inhibitory concentrations (MIC) on was lowest for itraconazole (0.015-1), followed by terbinafine (0.015-16), fluconazole (0.03-32) and griseofulvin (0.5-128) in increasing order. LIMITATION: A limitation of this study was the absence of a suitable control group (eg. patients with first episode of typical tinea). CONCLUSION: Recurrence of dermatophytosis was not explainable on the basis of a high (MIC) alone. Misuse of topical corticosteroids, a high number of familial contacts, poor compliance to treatment over periods of years, and various host factors, seem to have all contributed to this outbreak of dermatophytosis in India.

End of the road for terbinafine? Results of a pragmatic prospective cohort study of 500 patients.

BACKGROUND: There is a general impression among dermatologists in India that terbinafine has been losing its effectiveness in dermatophytoses over the past few years, but there are no recent data to support this. AIMS: To determine the effectiveness of terbinafine in tinea corporis, tinea cruris and tinea faciei with a pragmatic prospective cohort study. METHODS: A sample size of 361 patients was calculated taking a 5% margin of error and a 95% confidence level. Five hundred patients with tinea corporis, tinea cruris and tinea faciei confirmed by potassium hydroxide microscopy received oral terbinafine (5mg/kg/day) and topical terbinafine 1% applied twice daily for 4 weeks. Patients were evaluated at 2 and 4 weeks. Cure was defined as total clearance of lesions and negative microscopy. RESULTS: Patients who came for follow-up at 2 and 4 weeks numbered 357 and 362 respectively. Ten patients were cured at 2 weeks (cure rate 2%, 95% confidence interval 1.0-3.7%, intention-to-treat analysis) and 153 patients were cured at 4 weeks (cure rate 30.6%, 95% confidence interval 26.7-34.8%). LIMITATIONS: Culture and antifungal susceptibility testing were not performed since this was a pragmatic study. There was also no follow up after completion of treatment to check for relapses, but the poor response makes this less relevant. CONCLUSION: The effectiveness of terbinafine in dermatophytosis was abysmal in this study.

Clinico-mycological study of dermatophytic infections and their sensitivity to antifungal drugs in a tertiary care center.

BACKGROUND: Worldwide, dermatophytic infections are running a chronic course either due to ineffective treatment or emerging drug resistance. In the past three decades, there has been an increase in incidence and non-responsiveness to conventional antifungals, which suggests that there is a need of antifungal sensitivity testing. AIMS: This study was aimed at identifying clinico-mycological pattern of dermatophytic infections in patients attending thedermatology outpatient department of a tertiary care hospital, and to obtain the sensitivity pattern of isolates against six commonly used oral antifungals (fluconazole, terbinafine, itraconazole, ketoconazole, griseofulvin and voriconazole). METHODS: Patients with suspected dermatophytoses attending the outpatient department of Sir Sunderlal Hospital, Varanasi, were enrolled in the study. A detailed history, clinical examination and sample collection for mycological examinations was done. In vitro antifungal sensitivity testing was done on species isolated from culture as per the Clinical and Laboratory Standard Institute M38-A standards, with broth microdilution method. RESULTS: There were 256 patients recruited in the study, with a male: female ratio of 3:1. The most commonly affected age group was 20-40 years (52.4%). Tinea corporis et cruris was the most common type observed (27.2%). Potassium hydroxide positivity was seen in 211 samples (79.6%) and culture positivity was found in 139 samples (52.4%). The most common species identified was Trichophyton mentagrophytes (75.9%). Sensitivity testing was done on fifty isolates of T. mentagrophytes. Minimum inhibitory concentrations of itraconazole, ketoconazole, terbinafine and voriconazole were comparable, while griseofulvin showed the highest minimum inhibitory concentration. Itraconazole was found to be the most effective drug, followed by ketoconazole, terbinafine and fluconazole. Griseofulvin was the least effective drug among the tested antifungals. LIMITATIONS: This is a hospital-based study, and may not reflect the true pattern in the community. Sensitivity pattern of only one species T. mentagrophytes was carried out. CONCLUSION: Inadequate and irregular use of antifungal drugs has led to the emergence of resistant strains, which cause poor treatment outcomes. Thus, it is very important to test for antifungal sensitivity to check for resistance to antifungals.

Clinico-epidemiological study of tinea incognito with microbiological correlation.

BACKGROUND: Tinea incognito is a dermatophytic infection with a clinical presentation that is modified due to previous treatment with topical or systemic steroids, as well as topical immunomodulators. It tends to mimic other dermatological conditions. AIMS: To evaluate the various clinical manifestations, sites, predisposing factors and causative agents of tinea incognito. METHODS: A prospective observational study was done on one hundred clinically suspected cases of tinea incognito, with a history of topical or systemic steroid use for a period of at least six weeks. They were subject to direct microscopy and fungal culture, and re-evaluated at the end of the third and sixth week. RESULTS: Eczema-like conditions were the most common clinical manifestation, followed by inflammatory, autoimmune and infective conditions. The face was the most commonly affected site. Direct microscopy was positive in 85% of cases, and fungal culture was positive in 63% of cases. Trichophyton rubrum was the most common species isolated. Pharmacists were responsible for 78% of tinea incognito cases, and betamethasone dipropionate was the most common drug used. LIMITATIONS: As this was a hospital outpatient-based study, cases with severe systemic problems could have attended other departments. Cases involving the hair and nails were negligible. CONCLUSIONS: Tinea incognito is a commonly encountered, yet poorly reported entity in the study population. An increased level of awareness and vigilance on the sale of steroid containing compounds will help control this dermatological condition.

Epidemiological survey of dermatophytosis in Tehran, Iran, from 2000 to 2005.

BACKGROUND: Cutaneous fungal infections are common in Tehran, Iran, and causative organisms include dermatophytes, yeasts and non-dermatophyte molds. The prevalence of superficial mycosis infections has risen to such a level that skin mycoses now affect more than 20-25% of the world's population, making them the most frequent form of infection. AIMS: Our aim was to determine the prevalence of superficial cutaneous fungal infections especially dermatophytosis in our Medical Mycology Laboratory in the Pasteur Institute of Iran, Tehran. METHODS: A total of 17,573 specimens were collected from clinically suspected tinea corporis, tinea cruris, tinea capitis, tinea faciei, tinea pedis, tinea manuum and finger and toe onychomycosis from 2000 to 2005. Patients were referred to our laboratory for direct examination, fungal culture and identification. The incidence of each species was thus calculated. RESULTS: Dermatophytes remain the most commonly isolated fungal organisms, except from clinically suspected finger onychomycosis, in which case Candida species comprise >7% of the isolates. Epidermophyton floccosum remains the most prevalent fungal pathogen and increased incidence of this species was observed in tinea cruris. Trichophyton tonsurans continues to increase in incidence. CONCLUSION: This study identifies the epidemiologic trends and the predominant organisms causing dermatophytosis in Tehran, Iran. These data can be used to ascertain the past and present trends in incidence, predict the adequacy of our current pharmacologic repertoire and provide insight into future developments. Consideration of the current epidemiologic trends in the incidence of cutaneous fungal pathogens is of key importance to investigational effort, diagnosis and treatment.

A clinical and mycological study of onychomycosis in HIV infection.

BACKGROUND: Onychomycosis is one of the early manifestations of HIV infection with a prevalence of 15-40%. Multiple nail involvement, isolation of both common and rare species and resistance to treatment are the characteristics of onychomycosis in HIV. AIM: To study the epidemiology, clinical manifestations of onychomycosis in HIV-infected individuals and to identify the various causative fungi microbiologically. METHODS: A total of 250 HIV infected patients, diagnosed by ELISA, were screened for nail involvement; of which 60 patients i.e, 40 males and 20 females, who had clinically suspected untreated fungal infection were included in this study. RESULTS: Of the 60 respondents, 34 (56.66%) were from the 31-40 years age group. Amongst the 40 males, there were 20 manual laborers and 14 farmers; while 18 of 20 females were housewives. Toenail involvement was seen in 38 patients (63.33%), fingernail in 12 patients (20%) while 10 (16.66%) patients had involvement of both. Twenty eight (46.66%) patients gave history of some trauma, 6 (10%) had diabetes mellitus and only 1 patient (1.66%) had history of peripheral vascular disease. Nineteen (31.66%) patients had associated tinea pedis, 5 (8.33%) had tinea manuum, 10 (16.66%) had tinea corporis and 7 (11.66%) had tinea cruris. Twenty one (35%) respondents had distal and lateral superficial onychomycosis (DLSO), 5 (8.33%) had proximal subungual onychomycosis (PSO), 1 (1.66%) had superficial white onychomycosis (SWO), while 33 (55%) had total dystrophic onychomycosis (TDO). Fungal elements were demonstrated by KOH mount in 49 patients (81.66%) and growth was seen in 32 (53.33%) cultures. Dermatophytes were isolated in 13 (21.66%) and nondermatophytic molds (NDM) in 19 (31.66%). Out of the 13 positive dermatophyte cultures, Trichophyton rubrum was isolated on 11 and Trichophyton mentagrophytes on 2 cultures. Of the 19 non-dermatophytic cultures, Aspergillus niger was isolated on 3 and Candida spp. on 12 while Cladosporium spp, Scytalidium hyalinum, Penicillium spp. and Gymnoascus dankaliensis on 1 each. CONCLUSIONS: Total dystrophic onychomycosis was the most common clinical type and NDM were the predominant causative organisms.

Clinico-mycological profile of dermatophytosis in a reference centre for leprosy and dermatological diseases in Addis Ababa.

To assess the clinical and fungal species spectrum of dermatophyte infection in a reference centre in Addis Ababa, 539 dermatological patients with signs of dermatophytosis were investigated. Seventy-one percent were female and 29% male, aged 2-66 years (median 9). Four hundred-fifteen (77%) had at least one skin lesion. Tinea capitis was diagnosed in 138/155 males (89%) as compared to 214/384 females (40%) (p < 0.05). T. capitis was diagnosed in 69% of the 374 children. Fingernails were affected in 132/145 (91%) of onychomycosis, 118 (90%) of these patients were females and 14 males (p < 0.05). Tinea corporis was observed in 45, and other types of tinea in 12 patients. Thirty-six percent of all patients had also other skin lesions, mostly impetigo. Of 490 cultured samples 364 (74%) grew dermatophytes: Trichophyton violaceum in 84%, Trichophyton verrucosum in 9.6%, Trichophyton tonsurans in 1.4% and T. rubrum in 0.5%. Additionally, 15 isolates were identified as white variants of T. violaceum, in 3 cases confirmed by sequencing of the rDNA ITS 2 region. T. capitis in young males and T. unguium of fingernails in females were the most common manifestations of dermatophytosis in Addis Ababa, usually caused by T.violaceum.

Dermatófitos isolados em pacientes do Hospital "Lauro de Souza Lima" Bauru - SP / Isolated dermatophytes in patients at Hospital Lauro de Souza Lima - Bauru - SP

Os autores analisaram 160 amostras de pacientes do hospital Lauro de Souza Lima, Bauru, Estado de Säo Paulo, com o intuito de pesquisa de dermatófitos, na tentativa de estabelecerem os agentes etiológicos e dermatofitoses mais incidentes na regiäo. Fizeram também uma correlaçäo da incidência de dermatófitos nas diversas formas clínicas de hanseniase. Concluiram que o Trichophyton rubrum é o dermatófito mais incidente e o tipo clínico de hanseníase mais incidente é o virchoviano

[Pathology in the Republic of Vanuatu]. / La pathologie en République du Vanuatu.

The archipelago of Vanuatu is located in the South-West Pacific at 2,000 km, East of Australia. The so-called "current" pathology is similar to the one met in Europe. Because of its geographical location, a tropical pathology is to be found with a prevalence of Malaria, intestinal nematodoses and filariases ( Wuchereria bancrofti). Leprosy , dengue, ciguatera, eosinophilic meningitis as well as Tokeleau bring its originality to this pathology.