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ORIGINAL ARTICLE
Year : 2017  |  Volume : 18  |  Issue : 3  |  Page : 191-195

Sociodemographic profile and pattern of superficial dermatophytic infections among pediatric population in a tertiary care teaching hospital in Odisha


1 Department of Paediatrics, IMS and SUM Hospital, SOA University, Bhubaneswar, Odisha, India
2 Department of Skin and VD, IMS and SUM Hospital, SOA University, Bhubaneswar, Odisha, India

Date of Web Publication7-Jun-2017

Correspondence Address:
Nibedita Patro
Department of Skin and VD, IMS and SUM Hospital, SOA University, Bhubaneswar - 751 025, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-7250.206047

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  Abstract 

Background: There is a recent rising trend of superficial dermatophytic fungal infections all over the globe. Apart from the causative organisms, there are many modifiable environmental factors contributing to this sudden pandemic. The prevalence of the disease in the pediatric age group needs to be studied more vigorously.
Materials and Methods: All children in the age group of 2–15 years with dermatophytic infections were studied for the pattern of infection and various environmental associations.
Results: Most (102 [51.51%]) of the patients belonged to 11–15 years age group with tinea cruris (99 [50%]) and tinea corporis (94 [47.47%]) type of pattern being the most common. The majority (175 [88.38%]) of the patients belonged to rural and semi-urban locality with improper sanitation system and poor quality of water source in use by the patients.
Conclusion: This study highlights the prevalent pattern of dermatophytic infections in children in our locality.

Keywords: Dermatophytic infection, superficial fungal infection, tinea


How to cite this article:
Dash M, Panda M, Patro N, Mohapatra M. Sociodemographic profile and pattern of superficial dermatophytic infections among pediatric population in a tertiary care teaching hospital in Odisha. Indian J Paediatr Dermatol 2017;18:191-5

How to cite this URL:
Dash M, Panda M, Patro N, Mohapatra M. Sociodemographic profile and pattern of superficial dermatophytic infections among pediatric population in a tertiary care teaching hospital in Odisha. Indian J Paediatr Dermatol [serial online] 2017 [cited 2017 Nov 23];18:191-5. Available from: http://www.ijpd.in/text.asp?2017/18/3/191/206047


  Introduction Top


Infections caused by the pathogenic fungi invading the stratum corneum of skin, hair, or nails are called superficial fungal infections.[1] They are the most common encountered infections in the dermatology outpatient department. Among all the superficial fungal infections, dermatophytic infections have the highest prevalence in the developing countries with significant associated morbidity. Dermatophytic infections are caused by the Trichophyton, Epidermophyton, and Microsporum species. Based on the different body sites involved, the nomenclature varies as tinea capitis, tinea faciei [Figure 1], tinea corporis [Figure 2], tinea cruris, tinea pedis, tinea manuum, and tinea unguium.
Figure 1: Tinea corporis with tinea cruris

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Figure 2: Tinea faciei

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These infections are predominantly seen in hot tropical countries like India. Various climatic factors and socioeconomic and host factors attribute to the increasing incidence of fungal infections among the pediatric population in recent years. Environmental or climatic factors such as the El Nino phenomenon, increased duration of the summer season, increasing humidity, and geographical locations are responsible for the rising incidence of fungal infections. A myriad of host factors contributing to this rising trend are age, race, decreased rate of sebum production, immune status, any disruption in skin barrier, and associated atopic dermatitis.[2] Low socioeconomic status, poor hygiene, overcrowding, improper sanitation, lack of health education and awareness, and poor health-care facilities are the most important predisposing parameters.[3]

The infections are highly contagious in nature with a high rate of skin-to-skin and fomite transmission and recurrences. The increasing prevalence of the superficial fungal infections in the pediatric age group is surely a cause of concern because of its public health importance.


  Materials and Methods Top


A 1-year observational study was undertaken in the Outpatient Department of Pediatrics in collaboration with the Department of Dermatology in a tertiary care teaching hospital from December 2014 to November 2015. The objective of the study was to evaluate the prevalence of superficial dermatophytic infections among pediatric patients, its various clinical patterns, and associated sociodemographic factors.

All children between 2 and 15 years age group and having superficial dermatophytic infections were enrolled in the study after taking informed consent from the parents. Thorough clinical examination of the skin, hair, palms and soles, and nails were undertaken. A pro forma was filled up for each patient including the sociodemographic parameters, history of associated skin disease, other systemic ailment, any treatment undertaken at the time of presentation to the study, clinical pattern of the fungal infection, and basic laboratory investigations. The enrolled patients were subjected to skin scraping, hair plucking, and nail clipping according to site of affection for potassium hydroxide (KOH) mount and fungal culture. Dermatophytic infections positive in KOH test and/or fungal culture were included in the study.


  Results Top


Out of the total 618 children having skin manifestations observed in the study period, 198 children were enrolled in our study having superficial dermatophytic infections diagnosed on the basis of clinical manifestation and relevant investigations, with a prevalence rate of 32%. The majority (51.51%) of cases were in the age group of 11–15 years [Table 1]. Males and females were almost equally affected with slight male preponderance in all age groups with overall male to female ratio being 1.13:1.
Table 1: Sociodemographic distribution and percentage prevalence of dermatophytic infection

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The most common clinical pattern [Table 2] seen was tinea cruris in 99 (50%) children followed by tinea corporis in 94 (47.47%) children. The gray patch (noninflammatory type) was the most common type among tinea capitis patients followed by the kerion (inflammatory) variety. Tinea unguium and tinea pedis were least commonly encountered. A significant number (32 [16.16%]) of patients had multiple area involvement at the time of presentation. A positive family history and/or close contact affection was seen in 166 (83.84%) cases. Most of the patients belonged to semi-urban (97 [48.99%]) and rural (78 [39.39%]) background with poor socioeconomic and hygiene status. A contact history with animals was found in 21 (10.61%) patients, but the direct correlation could not be established.
Table 2: Clinical patterns and site distribution of dermatophytic infections

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There was not much variation in the prevalence of dermatophytic infections according to the seasonal changes from months of December 2014 to November 2015 with slight higher number of patients (85 [42.93%]) clustered in between April and July, followed by 63 (31.82%) patients in between August and November and 50 (25.25%) patients in between December and March. This may possibly be attributed to the El Nino phenomenon showing rising temperature and humidity in the atmosphere.


  Discussion Top


Fungal infections involving the skin can be either superficial or subcutaneous mycosis. Subcutaneous mycoses are caused by fungi occurring in nature that are directly inoculated into the dermis or subcutaneous tissue through any penetrating injury [4] whereas superficial mycoses are infections in which the fungus is restricted to the stratum corneum with little or no tissue reaction.[5] Superficial fungal infections can be caused by dermatophytes as described above and nondermatophytes such as cutaneous candidiasis, pityriasis versicolor, tinea nigra, and black and white piedra.[6] Children are equally susceptible to all types of superficial fungal infections as adults.

The dermatophytic infection classically presents as annular plaques with raised erythematous borders and central clearing. There may be inflammatory papules and pustules with mild scaling at the margin. Dermatophytic infection of the glabrous skin of the trunk, face, and extremities is called tinea corporis.[7] Tinea capitis is the infection of the scalp and hair follicles and is the most common variant affecting children.[2] Clinically, four types are seen, i.e., gray patch, black dot, kerion, and favus. Kerion [Figure 3] is the inflammatory variant presenting as boggy swelling on scalp studded with pustules and broken hairs. It often presents with posterior cervical, retroauricular or occipital lymphadenopathy. The gray patch type is the noninflammatory variant presenting as well-defined patches over scalp with multiple broken stumps of gray lusterless hair and minimal scaling.[2] Black dot variant clinically manifests as multiple patchy alopecia having black dots and diffuse scaling. In tinea cruris, maceration and severity of itching is predominant finding. The infection can invoke a hypersensitivity response at a distant focus known as dermatophytid reactions. Tinea incognito occurs as a result of topical or systemic corticosteroid use in a patient with tinea infection where the typical morphology is altered posing diagnostic challenge. Tinea unguium [Figure 4] occurs as a result of dermatophytic infection of the nail plate. It is seen more commonly in adults. The different clinical types are classified into distal and lateral onychomycosis, proximal subungual onychomycosis, superficial onychomycosis, endonyx onychomycosis, and total dystrophic onychomycosis.[8],[9],[10]
Figure 3: Kerion

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Figure 4: Tinea unguium

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The prevalence of superficial fungal infections in children was found to be 40.57%[11] and 35%[3] in different studies in recent years. Back in 2008, a study in Nigeria [12] found the prevalence rate of dermatophytic infections in children to be 11.3%. These reports show a rising trend of superficial fungal infections in children as also found in our study (32%). The majority (51.51%) of cases in our study were found between 11 and 15 years age group as found by Oke et al.[3] However, in other studies, the majority of cases were found below 10 years of age.[11],[12] The high prevalence of infection in 11–15 years age in our study can be attributed to the crowded hostel or mess type of accommodation in this age group and the highly contagious nature of the disease.

The common clinical patterns seen in our study were that of tinea cruris (50%) and tinea corporis (47.47%) with almost equal prevalence. In previous studies,[3],[11],[12] tinea capitis was found as the most common pattern with 64.87%, 26.9%, and 46.9% prevalence, respectively. The pattern distribution in our study can be associated with the affection of closed and humid areas of the body in children unable to keep proper personal hygiene, mainly in children inhabiting hostels and mess. As found by Ogbu et al. (18.41%),[11] multiple skin fungal infections were found in 16.16% of children in our study.

Most (175 [88.38%]) of our patients belonged to rural and semi-urban locality which may be due to lack of awareness of personal hygiene and also poor health-care facilities prevalent in these areas. Similar findings were seen by George and Altraide.[12] who found that 69.4% of the children belonging to urban slums with poor hygiene and social conditions. A significant proportion of patients (182 [91.92%]) in our study gave a history of improper sanitation system with absence of toilets and water supply to their respective homes. The main source of water for bathing and sanitation was from sources such as, ponds, river, or well [Table 3]. This also attributes to the high prevalence of infection in the rural and semi-urban areas. Again, treatment by quacks and nondermatologists or history of past application of topical steroids and mixed creams seen in 121 (61.11%) patients in our study is a major contributing factor for superficial fungal infections in these localities.
Table 3: Source of water supply used by the patients

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The various treatment options with oral and topical antifungals available are same for children as in adults but with dose adjustments according to body weight and close monitoring on systemic side effects. Apart from treating the child, it is imperative to treat the household close contact to decrease the disease transmission rate. Along with this, proper awareness of the parents regarding health education, sanitation, avoidance of self-medication or treatment by unqualified personnel is highly needed to control the disease burden in the society.


  Conclusion Top


The dermatophytic infections per se are not life-threatening, but the severe extensive forms and unresponsiveness to therapy may indicate underlying immunodeficiency. Furthermore, the worldwide distribution, high transmission rate, associated morbidity, and recent rising trend on recurrences make it highly important to study the prevalent patterns of infection and the modifiable factors predisposing the infection.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Limitation

This study is limited by the fact that the different species were not isolated in culture to comment on the prevalent species in our setup.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

 
  References Top

1.
Odum R. Pathophysiology of dermatophyte infection. J Am Acad Dermatol 2005;5:52-9.  Back to cited text no. 1
    
2.
Grover C, Vohra S. Superficial fungal infections. In: Singal A, Grover C, editors. Comprehensive Approach to Infections in Dermatology. 1st ed. New Delhi, India: Jaypee Brothers Medical Publishers; 2016. p. 85-115.  Back to cited text no. 2
    
3.
Oke OO, Onayemi O, Olasode OA, Omisore AG, Oninla OA. The prevalence and pattern of superficial fungal infections among school children in ile-ife, South-Western Nigeria. Dermatol Res Pract 2014;2014:842917.  Back to cited text no. 3
[PUBMED]    
4.
Kanwar AJ, De D. Superficial fungal infections. In: Valia RG, Valia AR, editors. IADVL Textbook of Dermatology. 3rd ed., Vol. 1. Mumbai, India: Bhalani Publishing House; 2008. p. 252-97.  Back to cited text no. 4
    
5.
Hay RJ, Ashbee HR. Fungal infections. In: Griffiths CE, Barker J, Bleiker T, Chalmers R, Creamer D, editors. Rook's Textbook of Dermatology. 9th ed., Vol. 1. UK: Blackwell Publishing; 2016. p. 32.6-32.70.  Back to cited text no. 5
    
6.
Verma S, Heffernan MP. Superficial fungal infection: Dermatophytosis, onychomycosis, tinea nigra, piedra. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, editors. Fitzpatrick's Dermatology in General Medicine. 7th ed., Vol. 2. USA: McGraw Hill Professional; 2008. p. 1807-31.  Back to cited text no. 6
    
7.
Kelly BP. Superficial fungal infections. Pediatr Rev 2012;33:e22-37.  Back to cited text no. 7
    
8.
Haneke E, Roseeuw D. The scope of onychomycosis: Epidemiology and clinical features. Int J Dermatol 1999;38 Suppl 2:7-12.  Back to cited text no. 8
    
9.
Grover C, Khurana A. Onychomycosis: newer insights in pathogenesis and diagnosis. Indian J Dermatol Venereol Leprol 2012;78:263-70.  Back to cited text no. 9
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10.
Hay RJ, Baran R. Onychomycosis: a proposed revision of the clinical classification. J Am Acad Dermatol 2011;65:1219-27.  Back to cited text no. 10
    
11.
Ogbu CC, Okwelogu IS, Umeh AC. Prevalence of superficial fungal infections among primary school pupils in Awka South local government area of Anambra state. J Mycol Res 2015;2:15-22.  Back to cited text no. 11
    
12.
George IO, Altraide DD. Dermatophyte infections in children: A prospective study from Port Harcourt, Nigeria. Niger Health J 2008;8:52-4.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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