The great Indian epidemic of superficial dermatophytosis: An appraisal

We would like to admit that if we were purists, it would prove to be a difficult task to choose between the terms “epidemic” and “hyperendemic” to describe the current alarming situation of increased incidence as well as the prevalence of superficial dermatophytosis in India. For both terms, it would be essential to have comparative epidemiological data of the past and the present, and sadly, we are lacking in both. There is a dire need for well-designed studies as well as more solid evidence for various issues pertaining to the dermatophytosis scenario in India.1 It is an indisputable fact that there is an increase in the prevalence of dermatophytosis over the past 4–5 years across the country. Comparison of studies done on superficial fungal infections in cities such as Kolkata, Ahmedabad, and Chennai during different time frames have revealed an increasing trend of dermatophytosis.2,3,4,5,6,7 We, however, need larger epidemiological studies to further bolster our nationwide observation of the alarming increase in its incidence as well as the prevalence.1 Dermatophytosis has undergone a sea change in its clinical pattern in the past few years. The standard treatment recommendations which we have been following from the Western and Indian literature are no longer valid or even realistic8,9,10 Table 1. In a country like India, where there is a paucity of original studies of dermatophytosis and its treatment, it is becoming amply clear that experience-based treatment of dermatophytosis is ruling the roost and is proving to be more effective than the standard guidelines provided in current literature that one often considers most valid and evidence based. While environmental factors, erratic use of topical and oral antifungal agents, increased prevalence of Trichophyton mentagrophytes infections causing inflammatory lesions and probably a growing resistance to antifungal agents may play an important role, one of the most formidable enemies that we have encountered in the recent times is the irrational fixed drug combination (FDC) creams containing a steroid, antifungal, and antibacterial with three to five molecules in the product.1,11Table 1: Treatment schedule of tinea corporisThere are many proponents of topical FDCs containing an antifungal and corticosteroid. An important article highlighting the conclusions of an expert panel meeting on topical treatment of superficial dermatophytoses written after reviewing numerous meta-analyses arrived at some conclusions supporting these combination creams. The authors of this seminal article concluded that adding topical corticosteroid to a topical antifungal agent in the beginning of the therapy can mitigate bothersome inflammation, reduce secondary colonisation with bacteria and enhance the efficacy of the antifungal drug. All the five authors practice in European countries where laws controlling the production and sales of drugs are stringent and are implemented. Therefore, this publication though comprehensive and erudite is not entirely relevant in the Indian context. The authors have specifically mentioned that the corticosteroid may be added in the initial part of the treatment and improper use of the combination creams may lead to both failure of treatment and adverse reactions.12,13 Both points are very relevant for India. Topical corticosteroids used in combination with antifungal agents are very often potent molecules like clobetasol propionate, they are available over the counter and are grossly abused which includes buying over the counter and applying at will for weeks, months and sometimes years.1,11,14,15,16,17,18,19 This leads to chronic, treatment resistant dermatophytosis which is causing a havoc in India. This editorial is aimed at highlighting what seems a significant putative role of these FDCs in the dramatic increase in the number of chronic, recurrent, refractory cases of superficial dermatophytosis that we are encountering for the past 4–5 years. A significant temporal association has also been observed between the free availability of irrational FDCs and the epidemic proportion superficial dermatophytosis has assumed. We have categorized this editorial into an elaboration on changing clinical patterns of tinea corporis and tinea cruris which are the most frequently encountered, the effect of freely available irrational FDC creams, the current drug control policies of the government, which the errant companies are taking advantage of and finally some recommendations based on our own experiences and those of several key opinion leaders from India. Changing Clinical Patterns There is a veritable epidemic of steroid modified tinea in India. Topical antifungals used for this condition are most often in combination with potent topical steroids and antibacterials.1,11 Such formulations account for about 50% of the sales of all topical steroids. The most common combination in India at present is clobetasol propionate, ornidazole, ofloxacin, and terbinafine.1,11 This speaks volumes about the inadequate understanding of the drug control authorities of India who grant permissions to companies manufacturing them. They cost a mere fraction of pure antifungal creams and hence are very popular. They are often bought over the counter, suggested and sold by the pharmacist or prescribed by the general practitioners. Moreover, they are used erratically, often only for symptom control and that too without any instructions or supervision. People often stop using them when the itching and redness are mitigated and begin to apply again when the symptoms reappear. The cutaneous inflammatory response that the skin mounts to resist and limit the fungal infection is majorly suppressed by topical as well as systemic steroids. However, this effect of topical steroids is said to be more profound than with the other routes. Concomitantly, there is local suppression of T-cell mediated immune response to the dermatophyte. It is this “double trouble” that is most likely responsible for the altered patterns seen increasingly in the past few years. This temporary suppression of the host-induced inflammation leads to ineffective elimination of the dermatophyte, and the process becomes chronic and also widespread. At times, the borders of lesions become unclear resulting in ill-defined and bizarre-shaped lesions. The dermatophyte continues its centrifugal march albeit without adequate central clearing. This phenomenon leads to lesions that insidiously increase in size, adopt unusual shapes including tinea pseudoimbricata, eczematous lesions in the center, etc. It is a common observation that severity of changes in the clinical pattern correlates with the duration of the abuse of topical steroids. The following are observations regarding the most common patterns occurring in India, namely, tinea cruris and tinea corporis: the classic description of lesion of tinea corporis or tinea cruris being circinate with an active erythematous well-defined border and central clearing is no longer valid Figure 1. We are seeing an increasing number of atypical presentations, cases that have been vitiated by topical steroids due to the adverse reactions over the treated and surrounding areas and many patients with chronic, recurrent, widespread lesions, many of whom do not respond to standard protocols of therapy. This trend is evident both in private practice as well as in large teaching hospitals. A tertiary care academic department in North India reported a prevalence of about 5%–10% of all new cases, many presenting with recurrent, chronic dermatophytosis with varied clinical presentations.14Figure 1: Scaly patch with an erythematous edgeWe are seeing larger sized and greater number of lesions in individual patients Figure 2a and b. It is now more common to see patients with more than one lesion of tinea in more than one anatomical location. Tinea cruris et corporis is getting more common.Figure 2: (a and b) Large sized, erythematous patches with active border over the gluteal regions and legsWe are seeing more women with active tinea corporis, tinea cruris, and tinea corporis et tinea cruris. These women often present secondary to the index case that is most often a male. Fashion trends are changing, and tight fitting clothing such as figure hugging denims, leggings, and jeggings are increasingly preferred by youngsters who do not pay heed to practical aspects like their nonsuitability to our hot and humid climate. This could explain the increased prevalence of tinea cruris and tinea corporis not only in overweight but also in otherwise hygiene conscious, young, slim women with no other risk factors. A large number of women present with a submammary location of the infection that involves the inframammary fold more than the skin of the breasts. This underscores the role of friction and maceration resulting from moisture of perspiration. We are also seeing more children with dermatophytosis Figure 3. In the past, tinea capitis was considered to be the most common fungal infection occurring in children.10 Tinea cruris and few small lesions of tinea corporis were uncommonly seen in infants and toddlers being handled by mothers and grandmothers suffering from tinea corporis with lesions on the trunk. In contrast, it is not uncommon now, to see children present with large-sized lesions and involvement of multiple sites. This can be explained by the increased spore load in the families by virtue of multiple family members being affected or perhaps an increased virulence and infectivity of the organism. It is also an indicator of the easy transmissibility of the dermatophyte. The role of fomites seems to be highlighted in the case of children because sharing of beds, linen, and clothing is all too common in them. In the author's experience, obese children are afflicted more. We are seeing a similarity between superficial dermatophytosis and scabies in that both show a distinct familial tendency. This underscores the importance of eliciting a careful family history during all visits. The importance of an untreated and undocumented affected family member being a constant source of reinfection that is often mistaken for treatment failure is being widely recognized in India. The practice of sharing the prescription of one family member with others for the purpose of symptom relief is common, which can also lead to clinical resistance.Figure 3: Tinea faciei in a childWe are seeing an increasing number of lesions with multiple concentric circles. It has also been described as “tinea pseudoimbricata” because it is reminiscent of tinea imbricata characterized by multiple concentric rings and has been explained to be occurring due to partial immune response. It has been seen in persons with immune suppression and those applying corticosteroids.20 This has been described in India too, after associating its appearance with the use of topical corticosteroid combinations.21 The authors have suggested that this is included as a of tinea or steroid modified tinea by erratic use of antifungal and topical steroids The of concentric can be explained by the topical corticosteroid local and also its The centrifugal of dermatophytosis is because of the clearing the in the of the lesion and the dermatophyte further at a that is than the of of the to It is that use of would lead to suppression of inflammation and of the dermatophyte which but also in the due to inadequate this it would lead to multiple active borders with clearing in areas where the has been to “tinea one of has used the terms “tinea and “tinea pseudoimbricata” in we the following terms and more at lesions of tinea pseudoimbricata, one that the lesions do not have multiple concentric but very rings and those too are not the which is an important clinical to the of corticosteroid modified tinea is more and to for care Figure and There is also a between the terms “tinea and modified We the “tinea be used only in cases where the is due to its altered most due to topical However, in most cases of superficial dermatophytosis in which topical steroids and their irrational have been it is to the fungal Therefore, modified is a more it is the “tinea is and be “tinea (a and b) in the and mentioned a large number of lesions do not show central clearing. there are the lesions of tinea cruris and tinea corporis [Figure explained in the of tinea pseudoimbricata, the central could be due to inadequate clearing of the to topical steroid and the inflammatory response that the would in those patch a lesion of tinea see lesions, an increasing number of multiple lesions of various the tinea by the of large lesions with and at times a of multiple small lesions with active erythematous borders [Figure lesions show borders [Figure The has been to a virulence of the a inflammatory erythematous and lesions with in the to a large lesions with erythematous borders by of large lesions. Tinea lesion with distinct of dermatophytosis which seems to have been and the more of tinea cruris is There have been of tinea written over in which Indian authors have observed it frequently there have been of the from There has been a paucity of recent literature from India on dermatophytosis one written by the and which the current increase in tinea the of steroid dermatophytosis is observed to be seen more in and more on the than the It is by tinea cruris or tinea cruris et corporis treated by irrational it in it the and While lesions with classic active borders may be seen on the some like areas of ill-defined lesions and are also seen [Figure and b. these patients have lesions on the of the that are by as well as on the and Figure The aspects of the too may be affected [Figure This it essential to the by it from the which too may be affected The be in a that the lesions, often of tinea cruris, do not this to the often in inadequate treatment because of the The untreated lesions become a of a chronic infection to (a and b) Scaly patch over the of The aspects of the too may be patch over the of the number of tinea faciei are being of these patients have an infection of other areas such as tinea corporis or tinea cruris. of these cases of tinea faciei are probably of tinea because it is often difficult to the active borders of these lesions [Figure However, the of the affected is often as has been reported in tinea capitis in children as Tinea tinea are said to be more number of cases of tinea and these have been to be an from the or the and is as of tinea which is the most common of tinea capitis in [Figure of tinea capitis in an are seeing more of of tinea corporis, where there is widespread involvement of with with of these patients are of the have of topical steroid abuse the lesions of dermatophytosis as well as in their The most frequently seen in steroid modified tinea are and [Figure it is the that show the have we seen many dramatic of by topical steroids. They sometimes as as of of FDCs containing and potent steroid molecules such as clobetasol a of them and even with Moreover, it is to see patients to apply the to the to a patients are seen with a of active of the skin with resulting from steroid over the areas over both the also and seen with erythematous tinea corporis and tinea cruris due to the topical steroid fact is the that superficial dermatophytosis on the and there are multiple family members and for effective treatment, member has to a and drugs of their own This is often a to many for who drugs only for one member and with them for other members by taking for which further the Changing of In the recent there seems to be an epidemiological of in India. many studies done across India have Trichophyton to be the most common the prevalence is to the In all these Trichophyton mentagrophytes has as the with an increased prevalence in to what was seen in the A in the of the of has also been studies across the country have Trichophyton mentagrophytes to be the This has been to a in the This change may be responsible for the widespread and inflammatory lesions that mentagrophytes is This change also the we the role of fomites in of In an for on a mentagrophytes for on This fact the importance of of which could be done by in hot at and in as is considered to be the most effective for antifungal resistance to be the most important for the treatment failure of the it is essential for to few about antifungal the of which has to be considered for antifungal and for fungal resistance is into resistance and clinical resistance to of a to an antifungal agent as by in in which the the for that organism. resistance can be or secondary or the resistance without to the drug as is the resistance of to and to or the resistance which after to the antifungal agent is on altered This is by resistance and Clinical resistance is the failure to a fungal infection the of an antifungal agent which may or may not in the resistance for that organism. Clinical resistance may be due to a combination of to the the or the antifungal There have been few of resistance of to and antifungal for the are to than the antibacterial they are by At present, standard guidelines have been by the Clinical and European on for in antifungal of of by and is as the standard of is as the of an antifungal agent that will the of antifungal resistance is with increased do not with clinical response to antifungal The between the in and in resistance in has been by the which that that infections due to respond to therapy in of cases, infections due to resistant respond in of also as are used to and resistance to antifungal agents, as the of They are categorized as and However, now, the have not been for the due to of data on the clinical or epidemiological that it is to not to use the in the of these for this increase in the of to and observed in various studies not that there is an this only the use of adequate or of these drugs or a longer duration of treatment to the clinical response. scenario for antifungal studies across the country to the pattern and any increase in of the of for by the The the observations and in the recent editorial in the regarding the dire need for more studies and a evidence for the and treatment recommendations of the current epidemic of superficial dermatophytosis in The of Topical and Topical steroids of all or in combination with other have for all practical been sold over the counter because of laws to different The of India finally heed to the constant and recommendations of Indian of and in and included most topical steroid molecules as drugs they be sold over the counter and without a valid prescription of a However, the to this effect in the of has not been and all topical steroids to be sold freely in the The in also many irrational and available topical FDCs containing an antifungal, steroid, and antibacterial the have in a in a of India and they to be and sold with It is that no has been to to many irrational A of this of topical drugs is the FDC containing ofloxacin, and other which are and of a topical antifungal, an and a steroid are freely available in the and have become the of Indian The and authorities have also permissions to irrational with a to antifungal resistance such as topical and oral FDCs containing and These permissions as irrational and a the fact that the is to resistance We would like to relevant key from the fact by as as is an increasingly to that across all and cost of care for patients with resistant infections is than care for patients with infections due to longer duration of and use of more All new drugs and their are by to their and efficacy data to the if data pertaining to such FDCs have been at all and if on what and with what understanding of has the them. It is common that often authorities permissions without the or of the a of and in a that with the of the Treatment We are seeing a sea change in the prescription patterns of in private practice as well as in academic The guidelines of do not We are using of oral antifungals for a longer time and these to the patients more. we have observed that even topical antifungal creams need to be for a longer the oral or topical therapy is often with a of lesions or even new lesions in other of of oral as well as topical antifungal drugs are available in India. We have observed that many by companies often do not have efficacy when to of It would be a of of various It is also to see drug companies to to antifungal formulations such as as well as and of and of of a of for and for or for is to be more [Table 1. the antifungal agents such as in a of a for or in a of for to lead to a clinical in patients with However, it is important to and and a one the use of systemic antifungals in a the in patients who are on multiple The recommendations by three of the most of in India in do not relevant in We need treatment guidelines based on Indian experiences that are by our own A large number of for the of of for and are of the drug for or more and have observed clinical response. topical antifungals such as and are to be more to the like probably because they The is that all these changes in pattern of are even if to the of the without a in most patients in the case of private who the of it is to be essential in many it is not practical because it is time and most often the do not have to do While the initial of dermatophytosis not in there is a need for the the treatment with the oral antifungals in case of partial The following are to be by of any antifungal a steroid is highlighting the of these FDCs is on the importance of of and to the of the The topical antifungals be the of the lesion for at clinical We this of applying topical antifungals the a for clinical of tight such as leggings, and jeggings sharing of if and of and only after the and in hot and them. is to In the of the would be too of well after about of if is not patients with tinea cruris to of the tight fitting that the and into it etc. or the by with as to reduce the spore load in the all this is however, it is to the and to enhance the of the We could or use to the to all these The and the We need to and the fact that there is a of and evidence in that we have regarding this epidemic of superficial dermatophytosis in India. The are studies proving the association of topical the and chronic widespread which is a task for We are beginning to the resistance if by antifungal We need to into more aspects and aspects that are to lead to chronic widespread dermatophytosis However, it is clear that the of topical steroids has to be The easy availability of and containing and antifungals has to be Topical steroids and their need to be sold as The will most likely resistance from but the has to be with for we see a in steroid modified tinea and many cases of chronic widespread The in and all authorities need to the of an expert panel of to new They need to the has to and about this The association has also several to the and other in the of and FDCs and formulations are also to many It is that the one of the in manufacturing as well as is responsible for this situation which could have been of The authors that they have all In the the for and other clinical to be reported in the The patients that their and will not be and due will be to their but be