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| ORIGINAL ARTICLE |
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| Ahead of print publication |
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Clinicomycological profile of cutaneous dermatophytosis: A cross-sectional study from western India
Yuvraj Singh1, Amit Bahuguna2, Saurabh Mahajan3, Aradhana Sood4, Arun K Yadav3
1 Department of Dermatology, Command Hospital (WC), Panchkula, Haryana, India
2 Department of Dermatology, Base Hospital and ACMS, Delhi, India
3 Department of PSM, AFMC, Pune, Maharashtra, India
4 Department of Dermatology, Base Hospital, Lucknow, Uttar Pradesh, India
| Date of Submission | 13-May-2022 |
| Date of Decision | 19-May-2022 |
| Date of Acceptance | 20-May-2022 |
| Date of Web Publication | 03-Jan-2023 |
Correspondence Address:
Arun K Yadav,
Associate Professor Department of Community Medicine, AFMC, Pune - 411 040, Maharashtra
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/mjdrdypu.mjdrdypu_209_22
Introduction: The prevalence of cutaneous mycoses has been on the rise worldwide with an increased incidence of recurrent and recalcitrant infections. This study was conducted to assess the clinical patterns and etiological agents of dermatophytosis, at a tertiary care hospital in western India. Material and method: One hundred clinically diagnosed cases of dermatophytosis attending the OPD of a tertiary care hospital were included in this cross-sectional study. Thorough history taking and detailed clinical examination were done for each patient. For studying the mycological profile, direct microscopy for fungal elements in KOH and fungal culture on Sabouraud dextrose agar (SDA) was done for each patient. The growth on SDA plates was further mounted on lactophenol cotton blue mounts for species identification. Results: Our study found a male preponderance, and the majority of infections (36%) were in the 21–30 years age group. The most common clinical pattern was the mixed type of infections followed by T. corporis. Direct microscopy for fungal elements was positive in 71% but the culture positivity was only 35%. The most common species isolated in our study was T. mentagrophytes (62.8%). Conclusion: The present study highlights the bearing of factors like socioeconomic status and occupation on the clinical profile of dermatophytosis and reveals a changing trend in the etiological agent of dermatophyte species in this part of western India.
Keywords: Dermatophytosis, fungal culture, trichophyton mentagrophyte
How to cite this URL:
Singh Y, Bahuguna A, Mahajan S, Sood A, Yadav AK. Clinicomycological profile of cutaneous dermatophytosis: A cross-sectional study from western India. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2023 Mar 24]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=366868 |
| Introduction | |  |
Superficial mycoses are among the most frequent forms of human infections, affecting more than 20%–25% of the world's population.[1] Though ubiquitous in nature, dermatophytoses exhibit a regional variation in distribution, incidence, epidemiology, and target hosts. Geographic location, climate, overcrowding, immigration, environmental hygiene culture, and socioeconomic conditions have been incriminated as major factors for these variations.[2] In India, dermatophyte infection has been reported from all regions with a slightly increased prevalence in the southern and northeastern parts of the country due to favorable environmental conditions for the growth of the organisms.[3],[4] Worldwide, in the mid-20th century, Trichophyton rubrum was the predominant pathogen causing dermatophytosis. During the last 35 years, the frequency of isolation of T. rubrum has shown a continuous increase while a progressive decline has been seen in the prevalence of T. violaceum, M. canis, and even more of E. floccosum.[5] Various studies conducted in India show that T. rubrum is the most common species causing dermatophytosis followed by T. mentagrophytes.[6],[7] However, recent studies show that culture positivity of T. mentagrophytes has exceeded T. rubrum.[8] We conducted this study to assess the prevalence and clinical types and to identify etiological agents of dermatophytosis in western India.
| Methods | | |
A hospital-based cross-sectional study was carried out at a tertiary care hospital in western India during the period 01 Jan 2016 to 30 Jun 2017. Inclusion criteria included all patients who have been clinically diagnosed with dermatophyte infection. Patients on any oral or topical antifungal/antifungal-steroid combination drugs at the time of presentation or anytime during the last 06 weeks and those having only onychomycosis were excluded from the study. Patients with tinea capitis who had any history of oral antifungal treatment in the past were also excluded from the study.
A thorough history, detailed clinical examination, and clinical photographs were recorded for each patient. The history for comorbidities like diabetes, HIV, hypertension, obesity, tuberculosis, and coronary artery disease was taken. There was no test done for assessment of any of the comorbidity. Demographic data were obtained and the patients were classified into various socioeconomic strata as per the modified BG Prasad scale (Per capita per month) May 2016.[9] Depending on the type of dermatophytosis, skin scales, crusts, or easily pluckable hairs were obtained for microscopy and fungal culture. The sample size was calculated assuming the proportion of clinical patterns varying from 6% to 60%, 95% confidence interval, and 10% error of margin, the highest calculated sample size was 94. However, a total of 97 skin and 03 hair samples were taken. Direct examination for fungal elements of the skin scales and hair samples was done by 10% and 20% KOH mounts, respectively. The preparation was examined under low (10×) and high (40×) power magnification for the presence of fungal elements. The study was given institute ethical clearance and written informed consent was taken from the patient.
All samples were also inoculated onto plates of Sabouraud dextrose agar (SDA) with chloramphenicol and cycloheximide for culture. The plates were then incubated for 4–6 weeks at 25°C –30°C aerobically and examined weekly for any fungal growth and were discarded only if no growth was observed after 6 weeks.
Fungal growth on SDA plates was further mounted on lactophenol cotton blue mounts and Cornmeal agar/Potato dextrose agar slide cultures for species identification. Dermatophyte species were identified based on colony morphology, pigment production, and microscopic examination.
The results were tabulated and data analysis was performed using SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. Appropriate statistics were used. The P value of less than 0.05 was taken as significant.
| Results | | |
The study population comprised 58% males and 42% females. The age of the patients ranged from 12 years to 72 years (mean ± SD = 31.2 + 14.04 years) and the majority (36%) were in the third decade of life as shown in [Figure 1]. As per the modified BG Prasad scale, 54% of the cases belonged to the lower and lower-middle class of the society [Figure 2]. Amongst the study population, the majority (26%) were labourers. Farmers and government salaried persons constituted 9% each, whereas 20% had miscellaneous occupations [Figure 3]. Overall, 44% of the patients were involved in occupations/activities, which predisposed them to excessive sweating. History of dermatophyte infection was present in 45% of the patients and family history of dermatophytosis was present in 29% of cases. The most common comorbidity was diabetes (n = 12), followed by HIV (n = 10), hypertension (n = 8), obesity (n = 6), tuberculosis (n = 2), and coronary artery disease (n = 2). Of the patients with diabetes mellitus, KOH was found to be positive in 75% and culture in 58% with T. mentagrophytes being the predominant fungal species seen in 5 out of 7 isolates (71%). However, this was not statistically significant (P-value = 0.083). Concomitant HIV infection was seen in 10% of our study group with 70% of these having a mixed pattern of infection. KOH positivity was seen in 90%, while culture was positive in 60% of this group with T. mentagrophytes being the most common pathogen (83%). Though the KOH and culture positivity rates were higher in patients with HIV, this difference was not statistically significant (P-value -0.095).
Out of 100 patients, 34% of patients had mixed infection with multiple sites of involvement; T. corporis (29%) was the most common type of infection followed by T. cruris (24%), T. manuum, T. pedis, T. faciei, and T. capitis (3% each), and T. barbae (1%). Mixed pattern of infection was seen in 34 of the 100 patients (34%). T. corporis et cruris was the most common pattern in mixed infections found in 17 out of 34 patients (50%), followed by T. corporis et faciei and T. corporis et cruris at faciei (8.8% each). Three cases of T. capitis were seen in children.
Direct microscopy was positive in 71% of our patients; however, fungal culture positivity was seen in only 35% of patients. Among the total of 35 culture positive samples, 22 (62.8%) grew T. mentagrophytes and Microsporum Canis was cultured in 2 (5.7%) samples [Table 1].
A 100% KOH positivity was seen in cases of T. Capitis, faciei, and barbae. Among patients with mixed infections, 82.35% of T. corporis et cruris pattern showed KOH positivity compared to 55.17% of T. corporis and 54.17% of T. crurispattern. Maximum culture positivity was in seen in mixed infection of T. corporis et cruris pattern (70.69%) followed by T. pedis (66.67%), while T. manuum, T. capitis, and T. faciei showed 50% culture positivity [Table 2]. | Table 2: Clinical type, KOH mount, fungal culture and isolate correlation
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Out of 12 patients with T. corporis et cruris having positive cultures, T. mentagrophytes was isolated in 10 (83.33%) and T. rubrum grew in 2 (16.67%) samples. Out of 6 positive cultures in cases of T. corporis, T. mentagrophytes was isolated from 3 samples (50%) and one each of T. rubrum, M. gypseum, and M. canis [Table 2].
The higher percentage of KOH positivity (75%) and culture positivity (58%) was observed in patients having diabetes, with T. mentagrophytes being the predominant fungal species. Similarly, a higher total percentage of KOH positivity (90%) and culture positivity (60%) was noted in HIV patients too. However, none of these associations were found to be statistically significant (P-values >0.05).
| Discussion | | |
Our study demonstrated a male preponderance, with the male to female ratio being 58:42. Studies conducted by Noronha et al.[10] and Mahajan et al.[11] also demonstrated male preponderance. This could be due to the greater involvement of men in strenuous activity causing excessive perspiration, which may cause a higher prevalence in men.
Although all age groups can be affected, 36% of patients in our study were in the age group of 21 to 30 years followed by those in the 31 to 40 years age group accounting for 21% of the patients. This may represent the fact that this group of patients is much more prone to infection due to greater mobility, the potential for contact with other patients, and increased physical activity. This finding was in concordance with the studies conducted by Noronha et al.[10] and Mahajan et al.[11] However, Abida Malik et al.[12] have reported a higher incidence in the age group of 11–20 years in their study.
The socioeconomic distribution of our study population showed that 54% of patients were from the lower class (9%) and lower middle class (45%). These findings were in concordance with those of Noronha et al.[10] and of Ranganathan et al.[13] who reported that 61.5% and 69.2%, respectively, of the infected people were from low-income group. Poor hygienic conditions, sharing of fomites and clothes, lack of proper nutrition, poor sanitation, overcrowding, and delay in seeking treatment, which are seen among the patients of low socioeconomic groups, may be the factors that promote this increased incidence of dermatophyte infections in this socioeconomic group.[10]
Forty-five percent of our patients had a positive history of dermatophytosis. This could be explained by poor hygiene, low income, and lack of knowledge about the factors predisposing to dermatophytes. In recent times, incomplete treatment and poor compliance have contributed to emerging resistance.
A total of 29% gave a history of similar complaints in the family/close contacts. This is in concordance with the studies by Bindu and Pavithran[14] and Lyngdoh et al.[15] This confirms that dermatophyte infections are transmitted from person to person by sharing common household clothes and fomites.
In our study, in diabetic patients, there was higher culture positivity (58%), yet it was not statistically significant. Had similar findings. No correlation was found between dermatophytosis and duration or type of diabetes and its complications, blood sugar levels, or levels of glycosylated hemoglobin.[15] Our finding on concomitant HIV infection was consistent with the study done by Rodwell et al.[16] in which they found that HIV is not an independent risk factor for dermatophyte infections.
Our findings on mixed infection are in concordance with the study by Noronha et al.[10] This finding may indicate chronicity of the infection, either due to delay in seeking treatment on time or emerging antifungal resistance, resulting in auto-infection from one region of the body to the other.
Overall (including mixed infections), T. corporis was the single most common pattern of infection seen in 61 patients, followed by T. cruris in 50 patients, T. faciei in 11 patients, T. manuum and T. pedis in 6 patients each, T. barbae in 4 patients, and T. capitis in 3 patients. This was in concordance with the study done by Bindu and Pavithran,[14] in which T. corporis (54.6%) was the most common clinical type followed by T. cruris (38.6%). However, Karmakar et al.[17] have reported that T. cruris as the most common clinical type in their study. Less aeration due to tight clothing, maceration, and a high rate of sweating in the groin and waist region make this site more vulnerable to dermatophytosis.
All three cases of T. capitis in our study were seen in children. This finding is in agreement with that of Bennassar and Grimalt[18] who have shown T. capitis is primarily affecting pre-pubertal children.[18] They have an immature immune system and enhanced exposure to subclinical infection carriers in the school and at home. Also, before puberty, they lack the effective fungistatic activity of sebum.[19]
In our study, 71% of the patients were found to have positive direct microscopy. In the studies by Abida Malik et al.[12] and Mahajan et al.,[11] fungal elements could be identified in 79.6% and 61.2% of cases, respectively, by KOH preparation. Karmakar et al.[17] have reported higher fungus identification by KOH mount in 86% of cases.
Microbiological confirmation by culture on Sabouraud agar was obtained in 35% of the patients in our study. This percentage positivity was comparable with the studies by Noronha et al.,[10] Karmakar et al.,[17] Bindu and Pavithran,[14] and Singh et al.[20] This low rate of culture positivity could reflect the fastidious needs of the organisms. T. mentagrophytes was the most common species identified on culture in 62.8% of patients. This was followed by T. rubrum, which was positive in 22.8% of patients.
Most of the other studies from India have reported T. rubrum as the most common isolate.[12],[21] Also, this finding was in variance with the previous studies done in the same geographic area.[22] However, this finding of our study is consistent with the recent studies by Noronha et al.,[10] Bhatia et al.,[23] and Mahajan et al.,[11] which showed T. mentagrophytes to be the most common isolated species. This may be explained by the fact that T. rubrum is generally linked to chronic dermatophytosis[24] and most of the patients in our study had a short duration of illness varying from a few days to 2-3 weeks. Also, T. rubrum is a slow-growing organism and other dermatophyte species might overgrow or mask the growth of T. rubrum while attempting its isolation.[23] The higher isolation rate of T. mentagrophytes observed in this study may be due to changing trends in the prevalence of dermatophyte species in this part of the country and in consistent with the recent epidemiological transformation of dermatophytes in India.[25] Trichophyton mentagrophytes emerging as the codominant pathogen with an increased prevalence in various regions of India may be the reason for the change in clinical trends where we are finding more inflammatory lesions, large and multiple lesions, genital tinea and even erythrodermic variants of tinea corporis.
The other isolates seen in our study were M. gypseum and M. canis (8.6% and 5.7% respectively). We did not isolate any species of T. tonsurans, T. violaceum, T. verrucosum, or E. floccosum. This observation is consistent with the changing trend in the epidemiology of dermatophytosis with a progressive decline in etiological role of T.violaceum and E. floccosum.[5] The species of dermatophyte isolated was also related to the anatomical site of infection. In T. corporis and cruris, T.mentagrophytes was the most common organism followed by T. rubrum. In tinea capitis, M. canis and M. gypsium were more common. T. rubrum was more commonly seen in cases with T. pedis.
Direct microscopy was positive in 71% cases and culture was positive in 35% of our study. This shows that direct microscopy by KOH mount is a useful screening technique in the laboratory diagnosis of dermatophytosis. Only 29% of samples were both KOH and culture positive, while 23% were both KOH and culture negative. 42% were KOH positive and culture negative and 6% were KOH negative and culture positive. This outlines the limitations of culture in the diagnosis of dermatophytosis. However, a well-designed study with adequate power may be conducted to refute or confirm the findings of the study.
| Conclusion | | |
The study found important socioeconomic correlates of the dermatophyte. The mixed infections were common. T. corporis was the single most common pattern of infection. T. mentagrophytes was the most common species rather than T. rubrum. The study points toward a trend in epidemiological transformation of dermatophyte infections in India and the significance of direct microscopy with or without culture as an important diagnostic tool in dermatophytosis.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]
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