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Abstract A middle-aged man presented to clinic in South India with a 1-year history of a widespread rash involving his whole body. There was no pre-existing skin condition. It appeared to be a possible inflammatory dermatosis and he was prescribed fixed-dose combination topical agents, including topical steroids (clobetasol propionate), topical antibiotics (gentamicin and neomycin), and a combination of an oral antifungal (terbinafine) and topical antifungals (clotrimazole and miconazole). On examination, there were numerous large, scaly plaques coalescing to an erythrodermic morphology. He was reviewed by two dermatologists, who commenced him on a reducing course of prednisolone. Due to nonresponse he was then started on ciclosporin 2.5 mg kg−1 per day. However, the condition continued to worsen. A skin biopsy was taken; this demonstrated hyperkeratosis with multiple fungal filaments consistent with extensive dermatophytosis. Over the past decade, there has been a significant increase in recalcitrant dermatophytosis seen in India. A recent multicentre study notes that the inaccessibility of adequate antifungal susceptibility testing results in excessively long treatment durations with poorly selected drugs and experimentation in medication dosage and frequency, which in turn contribute to drug resistance and the emergence of new strains (Ebert A, Monod M, Salamin K et al. Alarming India-wide phenomenon of antifungal resistance in dermatophytes: a multicentre study. Mycoses 2020; 63: 717–28). Trichophyton indotineae (previously known as Trichophyton mentagrophytes genotype VIII) is a newly identified dermatophyte species and has outpaced Trichophyton rubrum as the major causative agent of tinea cruris, tinea corporis and tinea faciei in India (Uhrlaß S, Verma SB, Gräser Y et al. Trichophyton indotineae – an emerging pathogen causing recalcitrant dermatophytoses in India and worldwide – a multidimensional perspective. J Fungi 2022; 8: 757). It has since spread to many countries globally. It is particularly problematic due to its resistance to terbinafine as a result of point mutations within the squalene epoxidase gene. Clinically, T. indotineae infections are extensive, involving multiple sites with symptoms of pain, pruritis and localized burning. Infection characteristically follows a chronic and relapsing clinical course, with an average duration of 9 months. The drug of choice is itraconazole 100 mg twice daily for 4–8 weeks, with fluconazole and griseofulvin as second-line options. Adequate hygiene measures are crucial to avert transmission and reinfection. This case highlights the issue of recalcitrant dermatophytosis in the subcontinent, emphasizing the need for improved antifungal susceptibility testing and judicious use of medications to curb drug resistance.
Damani et al. (Fri,) studied this question.