Due to the continual contact with polluted water while travelling and the monsoon's humid atmosphere, skin and fungus illnesses grow quickly during the monsoon. The diagnosis and treatment of different monsoon skin disorders are penned down in this article. 

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Monsoon and skin problems

Since humidity promotes the development of bacteria and fungus, often being soaked in the rain or wearing wet clothing and shoes for an extended period of time might result in the same germs and fungi developing on your skin. Ironically, monsoon is also a period when skin tends to dry up owing to dehydration since frequent perspiration causes a significant loss of water content.

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Skin disorders in monsoon 

Dermatophyte infections:

Dermatophyte infections are prevalent globally, and dermatophytes are the most frequent cause of fungal infections of the skin, hair, and nails. The clinical symptoms of these illnesses include tinea pedis, tinea corporis, tinea cruris, and tinea capitis.

The most common clinical subtypes of dermatophyte infections include the epidermis, hair, and nails :

1. Epidermis

• Tinea corporis: Infection of body surfaces other than the feet, groin, face, scalp hair, or beard hair.
• Tinea pedis: Infection of the foot.
• Tinea cruris: Infection of the groin, proximal inner thighs, or buttocks.
• Tinea faciei: Infection of the face.
• Tinea manuum: Infection of the hand.

2. Hair

• Tinea capitis: Infection of scalp hair.
• Tinea barbae: Infection of beard hair.

3. Nails

• Dermatophyte onychomycosis (tinea unguium)

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Athlete’s foot (Tinea pedis)

Tinea pedis, popularly known as athlete's foot, is an infection of the foot caused by dermatophytes. Itchy, flaky, white blisters and fissures occur between and under the toes. It is a non-lethal yet communicable fungal illness. Trichophyton rubrum, Trichophyton interdigitale (formerly Trichophyton mentagrophytes), and epidermophyton floccosum are common causes.

Tinea pedis interdigitalis shows as pruritic erosions or scales between the toes, particularly in the third and fourth digital interspaces. Associated interdigital cracks may result in discomfort.

Treatment

For the majority of patients, topical antifungal medication is the treatment of choice. Systemic antifungal medications are generally reserved for individuals who do not respond to topical treatment.

Initial therapy: Azoles, allylamines, butenafine, ciclopirox, tolnaftate, and amorolfine are effective topical medications for tinea pedis. Nystatin used topically is ineffective against dermatophyte infections. In general, antifungal topical therapy is administered once or twice daily for four weeks. Shorter treatment courses may be successful; one week of terbinafine 1% cream used for interdigital tinea pedis resulted in a good cure rate.

Refractory disease: Patients with confirmed tinea pedis who do not respond to topical treatment may be given oral antifungal medication. Examine the potential reasons for therapy failure.

In most cases, terbinafine, itraconazole, or fluconazole is used to treat adults. Typical therapy regimens for adults include:

• Terbinafine: 250 mg per day for two weeks.
• Itraconazole: 200 mg twice daily for one week.
• Fluconazole: 150 mg once weekly for two to six weeks.

Prevention

Using socks with wick-away material, desiccating foot powders, treating hyperhidrosis if there is a history of damp feet, treating shoes with antifungal powder, and avoiding occlusive footwear may assist to decrease recurrences.

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Jock itch (Tinea cruris)

Tinea cruris, popularly known as jock itch, is an infection of the crural fold caused by dermatophytes. Tinea cruris is much more prevalent in men than in women. Frequently, infection is caused by the spread of dermatophyte infection from tinea pedis. Excessive perspiration, obesity, diabetes, and immunodeficiency are risk factors.

Clinical features

Tinea cruris is often characterised by an erythematous or hyperpigmented area on the proximal medial thigh. The infection spreads centrifugally, with partial centre clearance and a strongly delineated, slightly raised, erythematous or hyperpigmented perimeter.

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Eczema (Atopic dermatitis) 

As a result of increased humidity during the monsoon, skin tends to lose its capacity to retain moisture and develop eczema. Typically, skin is very dry, itchy, red, and blistering. Atopic dermatitis is a persistent, pruritic, inflammatory skin condition that affects both children and adults. Atopic dermatitis is characterised by skin dryness, erythema, oozing and crusting, and lichenification. Pruritus is a defining characteristic of the disorder and accounts for a significant portion of the disease burden for patients and their families.

The optimum therapy of atopic dermatitis needs a multifaceted strategy that includes the removal of aggravating factors, the restoration of skin barrier function and hydration, patient education, and pharmaceutical treatment of skin inflammation.

Topical treatments 

The topical anti-inflammatory treatment of pruritus with topical corticosteroids or topical calcineurin inhibitors is successful. Crisaborole, a topical phosphodiesterase 4 (PDE4) inhibitor licensed for the treatment of mild to moderate atopic dermatitis in patients aged 3 months, looks helpful in reducing itching. Inhibition of PDE4 increases intracellular cyclic adenosine monophosphate, which decreases pruritogenic cytokine production.

If alternative treatments fail, topical doxepin, a tricyclic antidepressant with strong H1- and H2-blocking capabilities, may be employed. Low-potency corticosteroid cream or ointment (e.g., desonide 0.05%, hydrocortisone 2.5%) is recommended for people with mild atopic dermatitis. For two to four weeks, topical corticosteroids are used once or twice every day. In combination with topical corticosteroids, emollients should be generously applied numerous times a day. Emollients may be used either before or after the application of topical corticosteroids.

For individuals with moderate illness, corticosteroids of moderate to high potency are prescribed (eg, fluocinolone 0.025 per cent, triamcinolone 0.1 per cent, betamethasone dipropionate 0.05 per cent). In individuals with acute flares, super high- or high-potency topical corticosteroids such as Clobetasol propionate may be administered for up to two weeks before being replaced with lower-potency formulations until the lesions clear.

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Scabies

There is no way to avoid coming into touch with polluted water during the rainy season. This results in scabies, a water-related infectious illness caused by parasitic mites. Invisible to human sight, these mites cause agony via acute itching and skin rashes.

Clinical manifestation

The classic manifestation of scabies is a very itchy rash with a distinct distribution. Common areas of involvement include the sides and webs of the fingers and wrists, as well as the axillae, areolae, and genitalia. A rare type of scabies, crusted scabies is characterized by thick scale, crusts, and fissures. It is largely related to impaired cellular immunity and a severe mite load. Microscopic inspection reveals the presence of scabies mites, eggs, or excrement to confirm the diagnosis of scabies.

Treatment

The treatment of scabies involves the application of a scabicidal agent (e.g., permethrin, lindane, or ivermectin) and an antibiotic agent if a secondary infection has occurred.

Pharmaceutical treatment 

To eliminate S scabiei mites, a scabicidal treatment, such as permethrin, lindane, or ivermectin, is provided, along with an antibiotic agent if a secondary infection has occurred. Moxidectin and afoxolaner are intriguing novel medicines that are developing. Botanical oils have also been used, however, these may cause allergic contact dermatitis. Despite the emergence of resistance, permethrin continues to be very effective.

Treatment should be administered to the infected individual as well as household members and sexual partners, especially those who have had extended direct skin-to-skin contact with the infected individual:

• All individuals should be treated simultaneously to avoid re-infestation.
• Bedding, clothes, and towels used by infected individuals or close contacts three days before to treatment must be decontaminated by washing in hot water and drying in a hot dryer, dry-cleaning, or sealing in a plastic bag for at least 72 hours. Scabies mites cannot live more than two to three days away from human skin.
• It is not suggested to use pesticide sprays or fumigants.

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Impetigo 

Impetigo is a common epidermal infection that is extremely infectious and often caused by gram-positive bacteria. It manifests most typically as erythematous plaques with a yellow crust, which may be irritating or painful. The lesions are extremely infectious and readily transmissible. Typically, diagnosis is based only on symptoms and clinical presentations. The treatment consists of topical and oral antibiotics as well as symptomatic care. Streptococcus pyogenes and Staphylococcus aureus are chiefly responsible for this acute, highly infectious infection of the superficial layers of the epidermis. Existing skin lesions (such as cuts, abrasions, insect bites, and chickenpox) may potentially lead to secondary skin infections.

Treatment

It is possible to treat impetigo with topical antibiotics alone or in combination with systemic antibiotics. Coverage for antibiotics should include both S. aureus and S. pyogenes (i.e. GABHS). Antibiotics reduce the length of disease and the spread of lesions, although untreated impetigo is often self-limiting.

Localised, simple, nonbullous impetigo is best treated with topical therapy alone. Before using a topical antibiotic medication, the crust should be removed using soap and water. Mupirocin, retapamulin, and fusidic acid are the preferred therapies.

All cases of bullous impetigo and non-bullous impetigo with more than five lesions, deep tissue involvement, systemic symptoms of infection, lymphadenopathy, or oral lesions should be treated with systemic antibiotics. The therapy of choice is beta-lactamase-resistant antibiotics such as cephalosporins, amoxicillin-clavulanate, and dicloxacillin. Cephalexin is widely used. If a culture indicates a streptococcal infection, oral penicillin is the primary treatment. Clindamycin or doxycycline are the chosen therapies in regions with a high incidence of MRSA or if MRSA is detected in cultures.

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This is the next article of our monsoon series. To read the earlier articles of the series, click here: Managing dengue fever: What you should know; Malaria in monsoon: Recent updates; Leptospirosis: A commonly misdiagnosed disease; Know cholera: Diagnosis and treatment approach; Chikungunya: An overview of diagnosis and treatment; Typhoid Treatment in OPD: Recent Updates

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Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Monish Raut is a practising super specialist from New Delhi.