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ORIGINAL ARTICLE
Year : 2018  |  Volume : 19  |  Issue : 4  |  Page : 326-330

Clinicomycological study of dermatophytoses in children: Presenting at a tertiary care center


1 Department of Dermatology, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
2 Department of Dermatology, Maharani Laxmi Bai Medical College, Jhansi, Uttar Pradesh, India

Date of Web Publication28-Sep-2018

Correspondence Address:
Dr. Madhur Kant Rastogi
F-124, Doctor's Campus, Shri Ram Murti Smarak Institute of Medical Sciences, Bhojipura, Bareilly - 243 202, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_98_17

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  Abstract 


Background: Superficial tinea infections are some of the most common dermatological conditions in children. Recently, few studies done showed abrupt increase in dermatophytic infection in adults; however, similar recent studies describing clinicoepidemiological pattern in pediatric population are lacking. Aims and Objectives: The aims and objectives of this study are to identify the epidemiological profile of the dermatophytoses among pediatric population. Materials and Methods: Pediatric patients with suspected tinea infections presenting in the Department of Dermatology at a tertiary care medical college hospital in Northern India from April 2016 to 2017 were evaluated for inclusion in this study. Samples were collected in two parts; if first part was found to be potassium hydroxide (KOH) positive for septate hyphae, the second part was sent for fungal culture subsequently. Statistical Analysis Used: SPSS version 20 was used for statistical analysis. Results: Out of 235 patients, 152 were male and 83 were female. Only 200/235 (85.1%) KOH positive enrolled patients yielded positive fungal culture. Most common species identified on culture was Trichophyton mentagrophytes, followed by Trichophyton rubrum, and Trichophyton violaceum. Trunk was the most common site affected in 29.4% patients, palms and soles were least affected. Conclusion: More number of patients applied topical steroid for a longer period of time in patients with extensive disease as compared to limited disease. The present study provides evidence that dermatophytosis in pediatric patients is following the pattern of adult dermatophytosis clinically and microbiologically now.

Keywords: Dermatophytoses, pediatric, Trichophyton


How to cite this article:
Mishra N, Rastogi MK, Gahalaut P, Yadav S, Srivastava N, Aggarwal A. Clinicomycological study of dermatophytoses in children: Presenting at a tertiary care center. Indian J Paediatr Dermatol 2018;19:326-30

How to cite this URL:
Mishra N, Rastogi MK, Gahalaut P, Yadav S, Srivastava N, Aggarwal A. Clinicomycological study of dermatophytoses in children: Presenting at a tertiary care center. Indian J Paediatr Dermatol [serial online] 2018 [cited 2020 Feb 25];19:326-30. Available from: http://www.ijpd.in/text.asp?2018/19/4/326/242420




  Introduction Top


Skin ailments are common in children.[1] Children are particularly susceptible to dermatophytic infections because of their poor personal hygiene habits and poor environmental sanitation.[2] Superficial tinea infections are some of the most common dermatological conditions in children.[3] Hence, it gives negative impact on health and well-being of children.

India is a large subcontinent with varied topography, tropical, and subtropical climate which is conductive for acquisition and management of mycotic infection. Hot and humid climate in the tropical and subtropical countries like India makes dermatophytoses or ringworm infection as a very common superficial fungal infection.[4] They can spread by direct contact from other people (anthropophilic organisms), animals (zoophilic organisms), and soil (geophilic organisms), as well as indirectly from fomites.[5]

Prospective epidemiological surveys carried out in outpatient clinics form an important aid in understanding the spectrum of superficial fungal infections among children. Recently, few studies done showed abrupt increase in dermatophytic infection in adults; however, similar recent studies describing clinicoepidemiological pattern in pediatric population are lacking. The aim of the present study was to identify the epidemiomycological profile of the dermatophytoses among pediatric population.


  Materials and Methods Top


Sample collection

Pediatric patients with suspected tinea infections presenting in the Department of Dermatology at a tertiary care medical college hospital in Northern India from April 2016 to April 2017 were evaluated for inclusion in this study. Patients were included in the study after taking an informed and written consent. The study was started after obtaining approval from the ethical committee of medical college. All the children were subjected to potassium hydroxide (KOH) examination. Skin lesions of the primary site (site with largest lesion) were sampled for KOH examination from the erythematous, peripheral, actively growing margins of the lesions. Skin was decontaminated with 70% alcohol to remove surface bacterial contamination. Oral and written consent was obtained from the parents or guardians. At the time of enrollment a detailed predesigned proforma was filled in which detailed history in relation to age, sex, duration of illness, duration and type of prior application, sites of involvement, and body surface area (BSA) was noted, similar complaints in the family and contact with them were elicited and recorded.

Surface area was calculated using rule of nine.[6] Only one single anatomical site involvement was considered as localized disease while more than one anatomical site involvement was considered as extensive disease. Largest lesion was considered as primary site. Samples were collected in two parts if first part was found to be KOH positive for septate hyphae then second part was sent for fungal culture subsequently.

Isolation of dermatophytes:

  • The samples were cultured under sterile conditions on the Sabouraud's Dextrose Agar (Himedia, India) and Sabouraud's Dextrose Agar-containing Cycloheximide (0.05%) and chloramphenicol (0.004%) (Himedia, India). The colonies on the slants were examined for their morphology, texture and pigmentation (front and reverse) etc., up to 21 days. If growth came, earlier fungus was reported on the same day. The confirmation was done by microscopic examination of the stained preparations.


Identification by microscopy:

  • Colony of each isolate was stained in Lactophenol Cotton Blue (Himedia, India) and observed under low (×10 lens) as well as high power (×40 lens) of light microscope.



  Results Top


In the present study, clinically diagnosed and KOH positive pediatric patients of dermatophytosis aged <18 years of age and presenting in the Department of Dermatology of a tertiary care referral medical college hospital from October 2016 to March 2017 were enrolled. A total of 340 pediatric patients suggestive of tinea were included in this study, 281/340 patients gave consent for inclusion in this study. Out of them, 235 patients were KOH positive; hence, fungal culture was done on these patients only. A total of 235 patients were included in the study on the basis of inclusion criteria after taking written and informed consent.

Out of 235 patients, 152 were male, and 83 were female. Mean age of presentation was 7.7 ± 4.74 years with a range from 1 to 17 years. Mean duration of disease was 8.05 ± 3.57 weeks with a range of 2–32 weeks, out of this only single child was having chronic dermatophytoses whose duration of disease was 32 weeks. Mean BSA involved was 7% with a range of 1%–25%.

Majority of children were aged <9 years of age (46.3%) as per [Table 1].
Table 1: Age group

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171/235 patients had only one site (limited disease) involvement while 64/235 patients more than 1 site (extensive disease) was affected. While trunk was the most common site affected in 29.4% patients, palms and soles were least affected [Table 2].
Table 2: Primary sites involved

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[Table 3] describes distribution of disease in relation to age group. Buttocks are the common site in the infant. While face and neck was the most common site affected in toddler, trunk was most common site affected in older children.
Table 3: Distribution of disease in relation to age group

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Out of 235 patients, 216 had positive family history of tinea infection. A total of 221/235 patients (94%) had applied topical steroid/steroid antifungal combination preparations for atleast 15 days before presentation. Maximum patients (86%) had applied class I topical steroid preparation (clobetasol propionate) followed by Class III (betamethasone valerate) in 8.6% and Class V (fluticasone propionate) topical steroidal preparations in 5.4%. Mean duration of steroids application was 5.16 ± 3.30 weeks with a range of ranging 1–30 weeks.

Patients with extensive disease applied topical steroid for mean duration of 6.25 ± 4.35 weeks while patients with limited disease applied steroid for 4.74 ± 2.68 weeks. Similarly, history of topical steroid application was seen more in patient with extensive disease (96.9%) compared to those having limited disease (93%). In addition, more patients (84.4%) with extensive disease applied clobetasol propionate compared to patients (79.5%) having limited disease. In addition, the fungal culture was positive and yielded growth in 95.3% patients of extensive disease compared to only 81.3% patients having limited dermatophytosis. Further 96.9% of patients with extensive tinea gave positive history of similar disease in family compared to 90% of patients having limited disease.

Only 200/235 (85.1%) KOH positive enrolled patients yielded positive fungal culture. Most common species identified on culture was Trichophyton mentagrophytes, followed by Trichophyton rubrum, and Trichophyton violaceum as shown in [Table 4].
Table 4: Dermatophyte species identified

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Trichophyton mentagrophyte was most common species identified on all the sites except on the scalp where Trichophyton tonsurans was the common species identified.

On comparing the mean duration of disease and mean duration of steroid application between localized and extensive dermatophytosis, duration of steroid application was statistically significantly more in extensive tinea patients (P = 0.001) [Table 5].
Table 5: Comparison between localized versus extensive disease

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We found significant positive correlation of BSA affected with duration of disease and duration of topical steroid application [Table 6].
Table 6: Body surface area correlation with duration of disease and duration of steroid application

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  Discussion Top


Dermatophytes are closely grouped fungi that invade the keratinized tissues and cause a wide spectrum of clinical manifestations.[7] These fungi have worldwide distribution, and at present, there are 40 recognized species in the dermatophyte genera.[8] Of these, about 25 species belonging to the genera Epidermophyton, Microsporum, and Trichophyton are presently known to infect man.[9] The distribution, frequency, and etiological agents of dermatophytoses vary according to the geographic region studied, the climatic variations, the socioeconomic level of the population, the time of study, the presence of domestic animals, and age of the individual.[10] Dermatophytoses are the most common types of cutaneous fungal infections seen in humans in developing countries due to advent of immunosuppressive drugs and diseases.[11] Most of the studies done in this field dealt with adults or with a specific clinical form of dermatophytosis.[12] Only few surveys were performed in children and in those incidence varied from 2.5% to 15.2% depending on the country of the study.[13],[14],[15]

In the few past epidemiological studies done among pediatric population, Tinea capitis was reported as most common superficial fungal infection among the children, especially under 12 years of age.[16],[17],[18]

In the present study, maximum children were in the age group of 3–9 years (54.9%). This is similar to few studies done in the past on tinea capitis [19],[20] and differed from another study where majority (51.51%) of cases were in the age group of 11–15 years.[21]

The male-to-female ratio of 1.8:1 in the present study corresponds to the past study.[21] This may be due to the social stigma attached with a female child and hence parents avoid-seeking treatment for female child. In addition, India has a predominantly patriarchal society.

In the present study, 7% BSA was affected with a range of 1%–25%; this represents a very large average BSA involved. This may be because of long-term use of topical steroid or mixed antifungal preparations by most of the patients in our study (94%) which is easily available in the market in India. As there is no study mentioning BSA in children but in adults BSA is reported.[22]

Majority of the children were aged <=9 years. Most children were of school (31.5%) and preschool (23.4%) age group who may be more exposed to other children and/or family members. These may be an indirect representation of the fact that the treatment pattern is influence by parent's behavior in this age group.

Another peculiar and alarming finding in the present study was 8.9% infants out of total pediatric study population. Large number of infants with a large BSA involvement gives clue to infection getting transmitted from their parents or close relatives. Here, the role of family history is very much important. In our study, family history was positive in 91.95% of children which corresponds to past study (83.84) done by Dash et al.[21] In another past study done on adult patients, positive family history was recorded in only 30.9% of study population.[22] A possible reason for concurrent positive family history may be due to rampant topical steroid used in the family. Topical steroid suppresses local immunity so fungal population increases rapidly and can spread to others in family, in this case the child.

In 73% children, disease was limited to one site while 27% had extensive disease involving more than one site. The past study on dermatophytes reported higher percentage (46.8%) of extensive body involvement among adults.[22]

In our study, the most common site affected was trunk (29.45%) followed by face and neck (24.3%) and scalp was involved least (1.7%). These findings do not corroborate with most of the past studies done in children where scalp was the predominant reported site.[14],[15],[16],[17],[23] However, recent adult studies have reported findings similar to the present study.[22],[24] This highlights the changing clinical pattern of dermatophytic infections among children and its following the pattern of adult dermatophytic infection.

In infants most common site affected was buttock. It may be because of excessive diaper use. In toddlers most common site affected was face and neck which was unusual. The reason may be more handling or inadverdent use of topical steroid application at these sites by infected family members.[25] Another possible cause may be fungal spread due to close/hands contacts from infected adults in these children.

In preschool and school children, the most commonly affected sites were trunk and face and neck. Hygienic factors may play a role here. Survey of bathing practices and frequency of washing clothings may throw some logical explanation over these findings. However, such data were not collected in the present study.

In late adolescent age group, the most common affected site was groin which corresponds to adults as this age group is very close to adults.[25]

Most of the children had applied Class 1 steroid (clobetasol propionate). This may be due to its ability to suppress inflammation quickly which relieves symptoms such as itching immediately. Nowadays, most of over the counter topical drug combinations contain clobetasol propionate in combination with topical antifungals and/or antibacterials. Due to their widespread availability and low-price community misuses, such topical preparations. Hence, new policies should be incorporated, and drug controllers should control the use of clobetasol (Class 1) in OTC preparations.

The possibility of occurrence of extensive disease with multiple site involvement increased; with increasing duration of steroid application, use of higher potency of steroids, duration of disease, positive family history, and more fungal culture positivity rates. Mean duration of steroid application and mean duration of disease were significantly more in patients with extensive disease compared to patients having limited disease. The reason behind this may be application of topical steroids which reduce inflammation and pruritus but ultimately help in proliferation of fungi by modifying their microenvironment and skin immunosuppression.[22]

More number of patients applied topical steroid for a longer period in patients with extensive disease as compared to limited disease so topical steroid may be a main culprit of extensive disease.

In our study, most common species identified on culture was T. mentagrophytes followed by T. rubrum and Tricholosporum violaceum. Recent studies elsewhere have also reported an almost similar pattern; albeit in adults.[22]


  Conclusion Top


The present study provides evidence that dermatophytosis in pediatric patients is following the pattern of adult dermatophytosis clinically and microbiologically now. Logically treatment of dermatophytosis in pediatric patients should also be revised henceforth on the lines of adult infection.

Such a epidemiological change in the type of fungal infection seen in pediatric population is a significant event, and there is a need for more larger multicentric studies on urgent basis to further investigate the cause of findings of the current study. Other studies are required to find out the role of topical steroid in cutaneous superficial fungal infection. We need to further investigate and form a policy regarding topical steroid use/abuse.

The limitations of the study were as follows

  1. A small sample size on which species isolation was done
  2. Single center and hospital-based study
  3. Data regarding personal hygiene and habits was not collected in this study.


What's new in this study?

  1. This study documents the changing clinical and mycological patterns of dermatophytosis in children which is now slowly resembling the adult presentation patterns
  2. The predominant species identified in the pediatric dermatophytosis is T. mentagrophytes.


Acknowledgment

Authors would like to thank the technician for helping prepare the patients for the procedure. We would also like to thank the patients for their cooperation.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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