Summary

Diagnosing and managing cases of fungal infections are becoming harder as unusual presentations are becoming more common. An Indian Expert Forum Consensus Group has, therefore, put together guidelines on the latest diagnosis and management of dermatophytosis in India.

The current prevalence of dermatophytosis in India lies between 36.6% to 78.4% and can be regarded as significantly high. Unusually large lesions, prolonged chronicity, ring within ring lesions, more than one site lesions, altered presentations due to steroid usage make diagnosis difficult. 

Secondary bacterial infection may co-exist, and present as foul smelling and macerated lesions and should therefore be treated with topical or systemic antibiotics. Specific management pearls for managing dermatophytosis (Tinea corporis, cruris and pedis) in India were also created. Factors such as infection site, dryness or sebum-rich nature of the site, earlier treatment, and the patients age were some of the important factors that the experts highlighted.

Managing dermatophytosis

Generally, complying with the treating physician advice and adherence to the prescribed regime was stressed. Patients should be advised:

• not to wear tight clothing and share bed linen, clothes, or towels
• to wash all clothing including underwear, caps and socks regularly, sun-dry and iron them before use

Obesity and excessive sweating encourage fungal infection re-occurrence. Patients should also be advised:

• weight loss, frequent changes of clothing, usage of absorbent powders, and anti-perspiration deodorants
• medicated powders to prevent Tinea pedis
• footwear that is not occlusive and avoid using slippers in public washrooms

Managing Trichophyton rubrum syndrome

Diagnosis

1. The predisposing host environmental factors should be identified.
2. Diagnosis can be established clinically if two or more non-contagious sites, hands, feet, nails, are involved with absence of deeper lesions or via investigation if KOH positivity is found from all sites, and culture positivity from at least one site.
3. Concomitant HIV infection, or the use of immunosuppressive drugs may suggest other diagnosis and should be checked for.

Treatment

One or more antifungals may need to be used for up to 3 months. Some possible combinations include:

• Itraconazole 200 mg/ day, for 4–6 weeks or till there is complete clinical resolution and depending on the clinical response, itraconazole 200 mg twice a day × 7 days/month, for 3–5 months can also be used
• Terbinafine 250 mg/day can also be combined with itraconazole 200 mg/day for 4–6 weeks or longer
• Topical terbinafine/amorolfine for longer periods or topical luliconazole/sertaconazole once/twice a day for 6 weeks can also be considered

Other steps to take

• Fomites should be considered and household contacts also treated
• If there are facilities, fungal cultures and antifungal susceptibility tests should be considered
• Onychomycosis if suspected should be treated accordingly
• Topical drugs should be used in the proper quantity and manner, and patient should be compliant with continuous therapy till the infection clears completely

Priorities for future research

The experts also identified:

• the maintenance of a registry
• herd immunity measurement
• correlating skin levels of drug with blood levels
• therapy response with various dose schedules especially in cases of recalcitrant, relapse, immunocompromised states or patients with comorbidities, as useful for better treatment results

Management outcomes can be improved with:

• Better and more accurate diagnostic tests, faster turnaround time, and the prognostic values of body surface area (BSA) can integrate antifungal therapy in real time
• Direct infection causing species identification and their antifungal resistance from clinical specimen
• Enhanced risk prediction models using genetic risk factors to target scrutiny and prevention
• Ensuring maximal antifungal effect urgently by combination therapy, and monitoring drug therapy
• New immunomodulatory agents that minimise immune-mediated damage to maximise antifungal effects
• Collaborative Indian dermatophytosis management programs with international support