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Year : 2015  |  Volume : 33  |  Issue : 5  |  Page : 134--136

Epidemiological and clinical pattern of dermatomycoses in rural India

A Lakshmanan1, P Ganeshkumar2, S Raam Mohan3, M Hemamalini4, R Madhavan4,  
1 Department of Microbiology, Employee State Insurance Corporation Medical College and Post-graduate Institute of Medical Science and Research, Chennai, India
2 Department of Community Medicine, Employee State Insurance Corporation Medical College and Post-graduate Institute of Medical Science and Research, Chennai, India
3 Department of Microbiology, Chengalpet Medical College, Chengalpet, Tamil Nadu, India
4 Department of Microbiology, Sri Ramaswamy Memorial Medical College Hospital and Research Centre, Sri Ramaswamy Memorial University, Kattankulathur, India

Correspondence Address:
P Ganeshkumar
Department of Community Medicine, Employee State Insurance Corporation Medical College and Post-graduate Institute of Medical Science and Research, Chennai
India

Abstract

Superficial fungal infections are most common in tropical and subtropical countries. In this study, 297 suspected superficial fungal infection cases were identified among 15,950 patients screened. The collected samples (skin, nail, and hair) were subjected to direct microscopy with potassium hydroxide and cultured on Sabourauds dextrose agar to identify the fungal species. The prevalence of superficial fungal infection was 27.6% (82/297), dermatophytosis was 75.6% (62/82), and non-dermatophytosis was 24.4% (20/82). Among the isolated dermatophytes, Trichophyton rubrum was the commonest species (79%) and Candida (60%) the commonest non-dermatophytic species. Tinea corporis was the commonest (78%) clinical presentation.

How to cite this article:
Lakshmanan A, Ganeshkumar P, Mohan S R, Hemamalini M, Madhavan R. Epidemiological and clinical pattern of dermatomycoses in rural India.Indian J Med Microbiol 2015;33:134-136

How to cite this URL:
Lakshmanan A, Ganeshkumar P, Mohan S R, Hemamalini M, Madhavan R. Epidemiological and clinical pattern of dermatomycoses in rural India. Indian J Med Microbiol [serial online] 2015 [cited 2019 Aug 20 ];33:134-136
Available from: http://www.ijmm.org/text.asp?2015/33/5/134/150922

Full Text

 Introduction



Superficial fungal infections are the most common fungal infections. According to World Health Organization (WHO), the prevalence rate of superficial mycotic infection worldwide has been found to be 20-25%. [1] Its prevalence varies in different countries. [2],[3] It is more prevalent in tropical and subtropical countries like India where the heat and humidity is high for most part of the year. [4] Dermatophytosis is the most important group of superficial fungal infections caused by dermatophytes, which is a group of fungi that are capable of growing by invading the keratin of skin, hair, and nail for obtaining nutrients. There are several reports on intracontinental variability of the global incidence because of the change in climatic condition across the world. [3]  Over the past decades, non-dermatophytes, as agents of superficial fungal infection in humans, produce lesions that are clinically similar to those caused by dermatophytic infections. [4],[5] The present study was undertaken with a view to find out the clinical pattern of dermatophytes and non-dermatophytes and to identify the commonest pathogen.

 Materials and Methods



This hospital-based cross-sectional study was conducted covering around 123 villages of a rural block of Tamil Nadu state, India, where our tertiary healthcare center is located. The study was conducted for a year, between June 2011 and May 2012. In our tertiary healthcare center, a total of 15,950 patients who attended the dermatology outpatient department were screened for superficial fungal infection.

A superficial fungal infection is suspected when a lesion has central clearing, with advancing, red, scaly, elevated border, which may result in vesicles on the border of the affected area. A corporis is suspected when there is a circular plaque with demarcated border, and cruris is suspected when there is an erythematous plaque, often bilateral with pruritis. Tinea pedis is suspected when there are white macerated areas in the webs, and chronic, dry, scaly hyperkeratosis of the sole and heel. Tinea manuum is suspected when there is erythema, mild scaling when the dorsum is involved, and it appears in the palm as chronic, dry, scaly hyperkeratosis. A nail infection is suspected when there is distal hyperkeratosis, when chalky and dull yellow debris is found under the nail if it is separated from its bed, and the nail plate is brittle.

With the above said criteria, 297 participants were suspected to have superficial fungal infections. Samples from skin, nail, and hair were collected from suspected patients of all age group and both sexes who had not been treated earlier for the fungal infection. The skin scrapings were collected from the active edges of the lesion with a blunt scalpel after cleaning it thoroughly with 70% alcohol. The infected nails were clipped, and hair was epilated and processed as per standard mycological techniques. Samples were collected from the same site for 3 consecutive days and processed to rule out contaminants. These clinical samples (infected skin, nails, and hair) were collected in small black papers for easy visualization and absorption of moisture. Samples were also sent for histopathological study, whenever necessary, to rule out contamination. A detailed history of the selected patients was taken regarding duration of illness, involvement of other sites, and history of similar episodes in the family members and immunocompromised condition were collected along with the demographic details. The 297 samples were subjected to direct microscopy in 10% potassium hydroxide (KOH) for skin samples and 40% KOH for nail samples. The samples were cultured in Sabourauds dextrose agar tubes into two sets, one group with chloramphenicol and other with cycloheximide (to prevent growth with saprophytic fungi and bacteria); and incubated at 37 and 25°C; respectively. The cultures were examined for presence of growth, colony morphology, and pigment production. Slide cultures were prepared for identification of specific fungal species.

 Results



A total of 15,950 patients were screened during the study period of 1 year, of which only 297 were clinically diagnosed to have superficial fungal infection. Clinically, tinea corporis 78% (215/297) was the commonest superficial fungal infection, followed by tinea cruris 10% (28/297), tinea manuum 2.5% (7/297), tinea faciei 1.8% (5/297), tinea pedis 0.7% (2/297), onychomycosis 6.7% (20/297), and piedra 0.6% (2/297) [Table 1].{Table 1}

Among the 297 patients, 167 (56%) were male and 130 (44%) were female. The predominant age group affected was 22-45 years. Of the 297 suspected cases of superficial fungal infections, 160 (50.5%) were confirmed by KOH microscopic examination, 82 were both KOH and culture positive, and 55 were negative to both microscopy and culture. Thus, the prevalence of fungal infection was 27.6%.

On the basis of culture characteristics, out of 82 culture positive samples, 62 (75.6%) grew dermatophytes and 20 (24.4%) grew non-dermatophytes. Among the isolated dermatophytes, Trichophyton rubrum was the commonest (79%), followed by T. mentagrophytes (14.5%), Microsporum canis (3.2%), and M. gypseum (3.2%) [Table 1]. Among the isolated non-dermatophytes, Candida was the commonest species (60%). Clinically, all non-dermatophytic infections affected the nails (onychomycosis) [Table 2].{Table 2}

 Discussion



A total of 297 cases were clinically diagnosed to have superficial fungal infection, which is common in those aged 30-45 years, as this is the age of maximum outdoor activity. In this study, the prevalence of dermatomycoses was 27.6%. Skin is the commonest site of superficial infection, followed by nail and hair. Tinea corporis (78.1%) was the commonest clinical presentation, followed by tinea cruris (10.1%), tinea manuum (2.5%), tinea faciei (1.8%), and tinea pedis (0.7%). Similar findings were observed in the study by Mishra et al., [6] and Goldstein et al. [7] This study showed an increase in the number of non-dermatophytes, which are now being widely reported. As reported in a study conducted by Patel et al., [8] dermatophytes commonly isolated were T. rubrum, followed by T mentagrophytes, M. canis, and M. gypseum; this is similar to the study conducted by Patel et al., [8] in Gujarat. Epidermophyton floccosum (31.4%) was the commonest dermatophyte isolated in Iran [9] and also noted in the findings of the study by  Muhsin et al., in Iraq. [10] M. canis was commonly isolated in the study conducted by  Fortuño et al., in Spain [11] and in the study conducted by  Mangiaterra et al., in Argentina. [12] T. tonsurans was commonly isolated in the United States which was observed by  Weitzman et al.[13] T. mentagrophytes was common among dermatophytes in Poland as reported by  Nowicki [14] and in Jordan by  Abu-Elteen et al.[15]

The distribution of the dermatophytosis and their etiological agents varies with geographical location, the trends of people living in communities, and the socioeconomic conditions. In our study, the percentage of non-dermatophytic fungus isolated was 24.4%. The commonest non-dermatophyte isolated was Candida, followed by Aspergillus, Alternaria, Curvularia, and Fusarium. In a study by  Grover et al., [16] the percentage of non-dermatophytes was 34%. Non-dermatophytes are being increasingly reported to cause infection of nail .

Tenia corporis is the commonest clinical presentation of superficial fungal infection. Dermatophytes is the commonest isolate causing superficial fungal infection, and in that T. rubrum is the commonest species. Besides dermatophytes, non-dermatophytic fungi are also emerging as important cause of superficial mycosis, where candidiasis is the commonest species of non-dermatophytes affecting nails.

Because therapeutic options are different for different fungal species and intrinsic resistance is common among Candida species, identification of species is vital to curtail the drug resistance among the fungus.

Direct microscopy, along with culture, needs to be included in the fungal infections identified clinically, especially where molecular diagnostics are not available.

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