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ORIGINAL ARTICLE
Year : 2019  |  Volume : 20  |  Issue : 1  |  Page : 52-56

Clinicoepidemiological study of dermatophyte infections in pediatric age group at a tertiary hospital in Karnataka


Department of Dermatology, Venereology and Leprosy, Gulbarga Institute of Medical Sciences, Gulbarga, Karnataka, India

Date of Web Publication14-Dec-2018

Correspondence Address:
Dr. Suma Patil
Room 124, Gulbarga Institute of Medical Sciences, Gulbarga, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_35_18

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  Abstract 


Background: The incidence of fungal infections is increasing at an alarming rate, presenting an enormous challenge to healthcare professionals. Apart from the resistance of the causative organisms, there are many modifiable environmental factors contributing to this sudden pandemic. The prevalence of the disease and the associated environmental factors need to be evaluated further. Aims and Objectives: The aim of this study was to ascertain the epidemiological features of dermatophyte infection in children such as its incidence, clinical presentation, knowledge regarding over-the-counter drugs, compliance to therapy, and steroid abuse among others. Subjects and Methods: All children with dermatophytic infections up to the age group of 18 years were studied for the pattern of infection and various environmental associations. Results: The prevalence rate of pediatric dermatophyte infection was found to be 19% and was mostly seen in the age group of 10–14 years, with a male-to-female ratio of 1.27:1. About 72% of patients belonged to a rural background, and 64% were from a low socioeconomic background. Among the environmental factors, 83% of patients reported contact history with an affected family member, 55% reported joint family setup, and 81% of patients were found to maintain poor personal hygiene. Tinea corporis was the most common clinical variant of dermatophyte infection (45%). Nearly 58% of patients had been treated by unqualified personnel before visiting our hospital, and 51% had applied steroids. Out of 17% patients who had been prescribed anti-fungals only 8% received accurate dose and duration related treatment; while none of them completed their prescribed course before visiting our hospital. Conclusions: This study attempts to highlight the clinicoepidemiological features of dermatophytic infections and the various social and environmental factors associated with it.

Keywords: Childhood tinea, pediatric dermatophyte infection, tinea corporis


How to cite this article:
Gandhi S, Patil S, Patil S, Badad A. Clinicoepidemiological study of dermatophyte infections in pediatric age group at a tertiary hospital in Karnataka. Indian J Paediatr Dermatol 2019;20:52-6

How to cite this URL:
Gandhi S, Patil S, Patil S, Badad A. Clinicoepidemiological study of dermatophyte infections in pediatric age group at a tertiary hospital in Karnataka. Indian J Paediatr Dermatol [serial online] 2019 [cited 2019 Jul 22];20:52-6. Available from: http://www.ijpd.in/text.asp?2019/20/1/52/247551




  Introduction Top


Superficial fungal infections of the hair, skin, and nails are a major cause of morbidity in the world. Dermatophytoses are the most common cause of fungal infection in men, although candidiasis and pityriasis versicolor are also examples of major superficial mycoses.[1] In the recent times, dermatophyte infections are emerging as a serious concern for dermatologists. Apart from the etiological factors, several environmental factors are contributing to the current pandemic.[2] This mundane infection is now ushering into an era of resistance which has led to justified concern. There also has been a rise of dermatophyte infection among the pediatric age group.

It is especially common among children aged 3–9 years, particularly among those, who live in crowded conditions in urban areas. Dermatophyte infection spreads by direct skin-to-skin contact with an infected person, by sharing items with an infected person or by touching a contaminated surface (such as floors in shower and locker rooms).[3]

The current scenario calls for further delving into understanding of pathogenesis and epidemiological data of the dermatophyte infection in an attempt to treat the infection effectively. This study aims at determining the epidemiological features of dermatophyte infection in children such as its incidence, clinical presentation, knowledge regarding the over the counter (OTC) drugs, compliance to therapy, and steroid abuse among others.


  Subjects and Methods Top


This study was conducted on 100 pediatric individuals over 3 months from September to November 2017 after obtaining approval from the ethical committee at a tertiary hospital in Karnataka. The aim of this study was to determine the epidemiological features of dermatophyte infection in children such as its incidence, clinical presentation, knowledge regarding environmental factors contributing to dermatophytoses, adequacy of the treatment offered before visiting us and abuse of over the counter (OTC) steroids.

All children visiting the outpatient department between the age groups of 0–18 years, presenting with clinical diagnosis of dermatophyte infection were included in the study. Written informed consent was taken from parents of each patient before enrolling in the study. Each patient was subjected to skin scraping, hair plucking, and nail clipping, according to the site of affection for potassium hydroxide (KOH) mount. The patients unwilling to be a part of the study and with a negative KOH mount were excluded from the study. The patients were studied with regards to their epidemiological profile, duration, site, symptoms, personal hygiene, history of similar complaints in the family members, associated skin or systemic conditions, history of application of native medications, steroids, topical or systemic antifungals, and results were tabulated in a prestructured pro forma.


  Results Top


Of the total 521 children visiting the hospital with skin conditions, 100 were diagnosed with superficial dermatophyte infection giving the prevalence rate of about 19%. Most of these children were in the age group of 10–14 years (56%), and males were slightly more affected in the study group with a male: female ratio of about 1.27:1. Majority of the patients belonged to a rural background (72%) and were from a low socioeconomic background (64%). About 83% of patients reported contact history with an affected family member, of which the most common source was found to be the mother followed by a sibling followed by the father. With regard to housing, a joint family setup (55%) was the most common, and hostel setup (17%) was the least encountered in the present study. Personal hygiene was found to be poor in most of our patients (81%) which included the failure to bathe daily and wear freshly washed clothes, wearing of damp undergarments, and sharing of clothes, towels, and combs among the affected family members [Table 1].
Table 1: Epidemiological data of dermatophyte infection in the study

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With regard to the clinical parameters of the study, tinea corporis [Figure 1] was the most commonly reported, seen in about 45% of patients. This was followed by tinea cruris (28%), tinea capitis (11%) [Figure 2], and tinea faciei (8%) [Figure 3]. Tinea manuum, tinea pedis, and onychomycosis were among the least commonly encountered clinical variants.
Figure 1: Tinea corporis: Fourteen-year-old male child with multiple erythematous patches with raised active margin and central clearance. There was a history of application of over the counter (OTC) with steroid, antifungal and antibacterial cream

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Figure 2: Four-year-old female child with itchy skin lesion of three weeks duration and history of steroid application. Examination revealed solitary well-defined patch with active margin and central clearing

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Figure 3: Five-year-old boy with partially treated lesion of tinea faciei for four months. History of application of OTC steroids followed by noncompliance with antifungal therapy was reported

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On studying the treatment pattern in our patients, we found that only 32% of the patients had visited the hospital without any prior treatment whereas 58% of patients had either visited a local general practitioner (GP), MBBS, nonallopathic practitioner, a medical shop, and other unqualified personnel before visiting a dermatologist. Only about 10% of the patients had been previously treated by a dermatologist before visiting our hospital. Of the 58% of patients with previous treatment by a non-dermatologist, only 7% had received antifungals while the rest had invariably applied double/triple/quadruple combinations containing steroids and antifungals among others. Of the 17% of patients who had not been prescribed steroids, only about 8% had been advised treatment in appropriate dose and duration, and none of these patients had completed the total regimen prescribed by the dermatologist before approaching our hospital.


  Discussion Top


Fungal infections involving the skin can be either superficial or subcutaneous mycosis. Superficial mycoses are among the most frequent forms of human infections, affecting more than 20%–25% of the world's population.[4]

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.[2] 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.[5] Tinea infections classically present as annular plaques or patches with raised erythematous borders often associated with central clearing. The lesions may also be associated with inflammatory papules and pustules.

Dermatophyte infections are common global problems while children are mostly affected because of predisposing factors such as poverty, overcrowding, and lack of guidance. The prevalence of superficial fungal infections in children was found between 11.3% and 40.57% in different studies,[2],[6],[7],[8] indicating a rising trend of superficial fungal infections in children which was similar to our findings (19%).

We found the infection to be more common in the age group of 10–14 years (56%). This was similar to the study done by Oke et al.[7] and Dash et al.,[2] while the other studies have found the infection to be more common in children <10 years.[6],[8]

The age predilection in younger children is believed to result from the biological and behavioral patterns in children which include lack of fungistatic properties of fatty acids of short and medium chains that is found in postpubertal sebum. From a behavioral aspect, the additional reason cited is the poor hygiene common at this age. It is expected that younger the age, poorer will be the hygiene, and hence, more likely it is to contact infectious diseases. As children approach their teenage, they become more concerned with their outlook and are neater. These reasons are also advanced for the observed preponderance among those aged 12 and younger in this study.[9]

Dermatophyte infection was more commonly seen in males than females in our study with a sex ratio of 1.27:1. The outcome on the matter of gender prevalence in dermatophyte infections in various studies has been fragmentary, with some studies claiming that males predominate,[2],[6] while others have found a predominance in female sex[9] though none of the studies have shown a statistical difference. It has been postulated that low prevalence in girls could be associated with the fact that most of the females, especially the older ones, tend to practice better personal and hair hygiene when compared to their male counterparts.[6]

These infections were also commonly found in patients from a rural background (72%) and from a lower socioeconomic status which was similar to the findings of George and Altraide[8] and Dash et al.[2] Few studies have reported on the prevalence of these infections in rural areas such as ours. This finding has been explained due to lack of personal hygiene and also poor healthcare facilities prevalent in these areas.[2]

About 83% of patients reported contact history with an affected family member, of which the most common source was found to be the mother followed by a sibling followed by the father. With regard to housing, a joint family setup (55%) was the most common, and hostel setup (17%) was the least encountered in the present study. Personal hygiene was found to be poor in most of our patients (81%) which included the failure to bathe daily and wear freshly washed clothes, wearing of damp undergarments, and sharing of clothes, towels, and combs between the affected family members. These factors play an important role in causing the spread of infection, leading to its persistence, and its recurrence which are important factors in treatment failure. Educating the parents in detail about the personal hygiene, particularly the need to avoid overcrowding, washing clothes separately with hot water each day, avoiding dampness, and sharing of clothes and other fomites among children is essential for tackling dermatophyte infection.

With regard to the clinical features, we found tinea corporis to be the most common type of dermatophyte infection, which was seen in 45% of patients, while the second most reported infection was tinea cruris in 28% of patients. The clinical patterns of the dermatophyte infection reported by different authors have been varied; with Dash et al.[2] reporting an almost equal prevalence of tinea cruris (50%) and tinea corporis (47.47%) in their study, while Ogbu et al.[6] and George and Altraide[8] found tinea capitis to be the most common pattern in their study. Tinea capitis was the third most common type of infection in our study as well as Dash et al. The difference in the pattern of the clinical distribution in our study and the others is most likely due to the geographical difference in the current study and the previous studies which were done in African countries where the climate conditions, humidity, and hair care practices differ from India.

Dermatophyte infection has been on a steep rise since a few years, and the treatment protocols have been head scratching for the dermatologists on account of the increasing resistance and recurrence. The natural selection of resistant fungi is just a minor part of this problem with the major contributing factors being steroid abuse, less than effective doses, and duration of antifungal treatment. These very aspects were highlighted in our study as well when we found that, out of 100 children in the study, 58 children had been treated either by a local GP, nonallopathic practitioner, a medical shop, and other unqualified personnel before visiting a dermatologist and only about 10 children had been previously treated by a dermatologist before visiting our hospital. Of the total 58 children, who had been primarily treated by a non-dermatologist only 7 ended up with a prescription of anti-fungals. This signifies that 87.94% of the children who did not visit a dermatologist were probably not diagnosed correctly and were definitely not treated appropriately. This number also signifies a major lacuna and an area of emphasis in battling dermatophyte infection. In India, where the onus of health care (especially in rural areas), lies with the non-specialists, it is becoming increasingly transparent that steps need to be taken to educate the public and non specialist practitioners to seek help at the right place at the right time. Further, of the total 17 children who had not been prescribed steroids, only about eight children had been advised treatment in appropriate dose and duration, and none of these patients had completed the total regimen prescribed by the dermatologist before approaching our hospital. Dash et al.[2] have reported that a majority of their participants (61.11%) too were treated by non dermatologists and with steroid creams. Thus these findings underline the realization that education on approach to the management of dermatophyte infection is lacking, especially in the periphery. This further, raises the bar on us dermatologists to take extra steps to communicate, educate and counsel each patient of tinea that crosses our doors about the importance of compliance with therapy as well other environmental measures and to spread the message across in the community as well.


  Conclusions Top


This study marks an increasing trend in dermatophytic infection in the pediatric masses and also highlights the social and environmental factors including overcrowding, lack of personal hygiene and poor education of the dermatophyte infection, and its treatment aspects among the general public. As authors, we suggest that there should be three arms to the management of dermatophyte infection. First being appropriate antifungal therapy, second being education of the patients on matters of hygiene, spread of infection through fomites, importance of compliance to the antifungal regimen prescribed by the dermatologist and regular follow-up, and third, the education of masses and non specialists regarding the menace whose name is tinea infection.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for 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.



 
  References Top

1.
Dias MF, Quaresma-Santos MV, Bernardes-Filho F, Amorim AG, Schechtman RC, Azulay DR. Update on therapy for superficial mycoses: Review article part I. An Bras Dermatol 2013;88:764-74.  Back to cited text no. 1
    
2.
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.  Back to cited text no. 2
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3.
Jain A, Jain S, Rawat S. Emerging fungal infections among children: A review on its clinical manifestations, diagnosis, and prevention. J Pharm Bioallied Sci 2010;2:314-20.  Back to cited text no. 3
    
4.
Havlickova B, Czaika VA, Friedrich M. Epidemiological trends in skin mycoses worldwide. Mycoses 2008;51 Suppl 4:2-15.  Back to cited text no. 4
    
5.
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. 5
    
6.
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. 6
    
7.
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. 7
    
8.
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. 8
    
9.
Adefemi SA, Odeigah LO, Alabi KM. Prevalence of dermatophytosis among primary school children in Oke-oyi community of Kwara state. Niger J Clin Pract 2011;14:23-8.  Back to cited text no. 9
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