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ORIGINAL ARTICLE
Year : 2020  |  Volume : 21  |  Issue : 4  |  Page : 264-269

Clinical pattern of superficial fungal infection and steroid use among pediatric patients: Our experience from a tertiary care hospital in Northern India


1 Department of Dermatology, Base Hospital, New Delhi, India
2 Station Health Organization, Jabalpur Cantonment, Madhya Pradesh, India
3 MLN Medical College, Allahabad, Uttar Pradesh, India
4 AFMC Pune, Pune, Maharashtra, India
5 Base Hospital, Guwahati, Assam, India

Date of Submission29-Dec-2018
Date of Decision18-Oct-2019
Date of Acceptance13-Nov-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Dr. Pooja Shankar
Department of Dermatology, Base Hospital, Delhi Cantt, New Delhi - 110 010
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_159_18

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  Abstract 


Background: Fungal infections are increasingly encountered in the pediatric age group for the past few years. Majority of children at some point in time suffer from one or other clinical form of these infections. Although encountered in healthy patients also, an increase in immunocompromised patients is thought to be the major reason responsible for its increased prevalence world over. Indiscriminate use of irrational over-the-counter steroid combination has increased the menace of dermatophytes in children. Aims: The aim of the study was to describe the common clinical types of superficial fungal infections in children and to assess the use of topical steroid and its source. Materials and Methods: An observational study was done over a 5-month duration, wherein all children in the age group of 3–14 years with superficial fungal infection were examined and the data regarding the use of any topical steroid, and its source was accessed. Results: A total 313 children were included. One hundred twenty-nine (41.2%) children were between the age of 7–10 years, 194 (61.9%) were male, while 119 (38%) were female. Ninety-seven (30.9%) children were in the class 4th–6th. The duration of infection ranged from 30 to 60 days in 86 (27.4%) children. There was no significant association between steroid use and duration of infection as well as steroid use and gender (P value + 0.845 and 0.567, respectively). Conclusion: This study aims to highlight the common clinical type of superficial fungal infection. Type of topical steroid used and its source in these children was inquired.

Keywords: Fungus, tinea capitis, tinea corporis, topical steroids


How to cite this article:
Saraswat N, Chopra A, Shankar P, Kumar S, Neema S, Kamboj P. Clinical pattern of superficial fungal infection and steroid use among pediatric patients: Our experience from a tertiary care hospital in Northern India. Indian J Paediatr Dermatol 2020;21:264-9

How to cite this URL:
Saraswat N, Chopra A, Shankar P, Kumar S, Neema S, Kamboj P. Clinical pattern of superficial fungal infection and steroid use among pediatric patients: Our experience from a tertiary care hospital in Northern India. Indian J Paediatr Dermatol [serial online] 2020 [cited 2020 Oct 25];21:264-9. Available from: https://www.ijpd.in/text.asp?2020/21/4/264/296852




  Introduction Top


Fungal infection of the skin, nails, and hairs is estimated to affect 20%–25% of the world population at present, making it one of the most frequent infections seen in the dermatology outpatient department (OPD).[1] It is a major public health problem in school-going children, mainly in low-to-middle-income nations world over. There has been a rise noticed in these infections in the pediatric age group over the past few decades. From a mundane infection, it is now becoming a pandemic all over the world.[2] Multiple factors are postulated to predispose a patient to fungal infections such as poor hygiene, overcrowding, and factors associated with low socioeconomic factors.[3]

It is more common in the age group of 3–9 years and spreads by direct skin-to-skin contact with an infected patient, by sharing items with the person suffering from it, or touching a surface contaminated with fungus.[4]

Over the period of time, superficial fungal infection has gained notoriety for its difficult management which is attributed to multiple factors such as climate change, Westernization, casual health-seeking attitude of patients, and casual drug control policy in our country.[5] The present study was done to highlight the pattern of these infections in school-going children and the use of topical steroids in them.


  Materials and Methods Top


It was an observational study conducted over a period of 5 months between February 2018 and June 2018 at a tertiary care hospital in Northern India. Approval from the institutional ethics committee was obtained, and children or their parents/guardian were briefed about the nature of the study. Written informed consent was obtained from all the study participants including assent from minors. All consecutive children between the age of 3–14 years attending the dermatology OPD of the hospital who were diagnosed as superficial fungal infections such as tinea corporis, cruris, tinea capitis, unguium, manuum, pedis and tinea versicolor were included. Each child was subjected to skin scraping, hair plucking, or clipping of nail as per the site involved for potassium hydroxide (KOH) mount. Patients in whom KOH mount was negative or consent could not be obtained were excluded from the study. The demographic details including age, gender, class, and history of similar complaints in family members were inquired. All the patients were thoroughly examined to find the clinical pattern and type of fungal infection. Patients/guardians were also asked regarding the use of topical medication done prior to reporting to a dermatology center. Most of the patients could name the topical medication applied and its source. Patients who could not name the medication were told to bring it during the next visit. The data were endorsed and tabulated in proforma and were analyzed at the end of the study period. Statistical analysis was carried out using SPSS version 20.0 (IBM Corp., IBM SPSS Statistics for Windows, Armonk, NY: USA).


  Results Top


Of total 313 patients with superficial fungal infection, 194 (61.9%) were male, while 119 (38%) were female. The male-to-female ratio was 1.63. One hundred twenty-nine (41.2%) of the study participants were in the age group of 7–10 years. The distribution of age is depicted in [Figure 1]. Ninety-seven (30.9%) children were in the 4th–6th standard followed by 72 (23%) in the 1st–3rd standard. [Figure 2] describes the level of schooling of the children participated in the study. The duration of infection varied from 30 to 60 days in 86 (27.4%) children to 7–15 in 43 (13.7%) children. The duration of infection in the rest of the children is shown in [Table 1]. The degree of freedom was 4 indicates that goodness-of-fit test carried out to see any evidence if any of the proportion was different and the significance level was P = 0.007, implying that choices made by the study participants are not all equal likely. Two hundred thirty-four (74.1%) children denied similar complaints in family members, while 79 (25.2%) had a similar complaint in family. Seventy-six (24.2%) gave a history of application of topical steroids, while 237 (75.7%) denied it. The value of P was <0.0001, while degree of freedom was 6. The type of infection is shown in [Figure 3]. [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9] show various clinical presentations seen during the study. Of 76 (24.2%) children who gave a history of application of topical steroids, 25 (32.8%) applied it on the recommendation of friends, 23 (30.2%) by pharmacists, while 11 (14.4%) got it based on the television advertisement. The rest of the details are shown in [Table 2]. [Figure 10] depicts in a child. [Figure 11] gives a detailed account of type of steroids used by these children. There was no significant association between the steroid use and duration of infection as well as between the steroid use and gender (P value + 0.845 and 0.567, respectively). The plus sign is used to indicate positive difference clearly; however, the same is omitted to avoid the repetition [Table 3] and [Table 4].
Figure 1: Distribution of age

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Figure 2: Level of education

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Table 1: Duration of infection

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Figure 3: Clinical type of infection, orange signifies inspected patients and blue signifies not have type of infection

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Figure 4: Tinea cruris et corporis in a 14-year-old male

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Figure 5: Tinea cruris in a 10-year-old boy

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Figure 6: Tinea corporis in 11-year-old male

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Figure 7: Tinea capitis in a 7-year-old boy

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Figure 8: Tinea capitis in a male

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Figure 9: Tinea cruris in a 12-year-old boy

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Table 2: Steroids advised by

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Figure 10: Potent steroid application in tinea corporis

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Figure 11: Type of steroid applied

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Table 3: Steroid use * Duration of infection cross-tabulation

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Table 4: Steroid use and gender

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  Discussion Top


Superficial fungal infection includes infection caused by both dermatophytes and nondermatophytes. Infections caused by dermatophytes are tinea capitis, tinea faciei, tinea corporis, tinea unguium, tinea manuum, and tinea pedis, while nondermatophyte infections include pityriasis versicolor, cutaneous candidiasis, tinea nigra, black piedra, and white piedra.[3] These infections are quite common in the pediatric age group world over. The present study found that most common age affected was between 7 and 10 years which is in alignment with earlier studies where it was seen more commonly in children <12 years of age.[6],[7] Males were more commonly involved than females and a male-to-female ratio was 1.63. This finding is also in coherence with the previous study findings.[8]

Tinea corporis was the most common clinical type of infection seen in the present study. Gandhi et al. also reported tinea corporis as the most common clinical type in school-going children.[9] However, tinea capitis was the most common fungal infection reported in other studies done in school-going children.[1] The reason for this difference in the clinical types of fungal infection in various studies can be explained due to the cultural and climatic variations in different parts of the world. The present study also had children with multiple infections such as combination of pityriasis versicolor and tinea capitis and corporis, which has been reported as seen in earlier studies also. It is proposed to be the result of autoinoculation of dermatophytes from the scalp to other regions of the body.[10]

Tinea capitis was the second common infection in the present study followed by tinea cruris. The clinical type of infection as reported by various authors is varied. Dash et al. found equal prevalence of tinea cruris and corporis. Ogbu et al. notice tinea capitis as the most common type of fungal infection in children. In the present study, tinea capitis was the second most common clinical type seen.[2],[11] Other patterns such as faciei, unguium, manuum, and pedis were also encountered but were relatively less common like other studies.[10]

The source of infection can be one of the family members or peer group in these children, as the transmission is via close skin contact. We had 79 (25.2%) children where one member of the family had similar complaints. Similar history in family members, joint family setup, has already been associated with increased prevalence of superficial fungal infection in these children.[9]

The management of superficial dermatophytes is increasingly becoming a challenge for dermatologists for the past few years with steroid abuse seen very commonly in our country. Lax regulation on drug control and its easy availability are the major reasons for it. Other factors such as type, duration, and dose of antifungal chosen and natural selection of resistant fungal strains add to the growing burden. We noticed that 76 (24.2%) children were already treated with other topical medication on advice of various sources prior to reporting to us. Das et al. reported in his study that the majority of nondermatologists treat their patients with topical steroids before the patient finally comes to a dermatologist. It was alarming to notice that the advice for managing these infections with topical steroids came from friends, relatives, pharmacists, television advertisement, and even teachers. Similar findings were observed in earlier studies.[12],[13]

Betamethasone-based preparation was the most common topical agent used by these children followed by this finding is the same as recorded in the previous studies.[12],[13] An increase in topical steroid use in fungal infections is evident from the fact that the Indian Association of Dermatologists, Venereologists, and Leprologists has started a nationwide campaign against the use of topical steroids.[14]

This study attempts to highlight the frequent clinical pattern of superficial fungal infections in school-going children and the menace of corticosteroid use in them. The limitation of the study is that the socioeconomic profile of the children was not taken into account which has an important role in these infections. This arena may further be explored in future such studies to make it more relevant and meaningful.


  Conclusion Top


The increase in the prevalence of superficial fungal infection in the pediatric age group is a challenge for the present-day dermatologist. This study attempts to find the common clinical pattern of infection, related demography, and factors associated with them. The use of topical steroid in these patients and its source was also assessed which has not been done so far in earlier studies. It is recommended at present an urgent need to form strict guidelines against the easy access and availability of over-the-counter drugs in our country.

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.



 
  References Top

1.
Havlickova B, Czaika VA, Friedrich M. Epidemiological trends in skin mycoses worldwide. Mycoses 2008;51 Suppl 4:2-15.  Back to cited text no. 1
    
2.
Dash M, Panda M, Patro N, Mohapatra M. Sociodemographic profile and pattern of superficial dermatophyte 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.
Verma S, Heffernan M. “Superficial fungal infection“. In: Fitzpatrick's Dermatology in General Medicine. 7th ed. Edition, Vol 2: McGraw Hill Professional; 2008. p. 1807-31.  Back to cited text no. 3
    
4.
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. 4
    
5.
Panda S, Verma S. The menace of dermatophytosis in India: The evidence that we need. Indian J Dermatol Venereol Leprol 2017;83:281-4.  Back to cited text no. 5
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6.
Nweze EI, Okafor JI. Prevalence of dermatophytic fungal infections in children: A recent study in Anambra state, Nigeria. Mycopathologia 2005;160:239-43.  Back to cited text no. 6
    
7.
Omar AA. Ringworm of the scalp in primary-school children in Alexandria: Infection and carriage. East Mediterr Health J 2000;6:961-7.  Back to cited text no. 7
    
8.
Soyinka F. Epidemiologic study of dermatophyte infections in Nigeria (clinical survey and laboratory investigations). Mycopathologia 1978;63:99-103.  Back to cited text no. 8
    
9.
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  Back to cited text no. 9
    
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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 2017;18:191-5.  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.
Dutta B, Rasul ES, Boro B. Clinico-epidemiological study of tinea incognito with microbiological correlation. Indian J Dermatol Venereol Leprol 2017;83:326-31.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
Mahar S, Mahajan K, Agarwal S, Kar HK, Bhattacharya SK. Topical Corticosteroid Misuse: The scenario in patients attending a Tertiary Care Hospital in New Delhi. J Clin Diagn Res 2016;10:FC16-20.  Back to cited text no. 13
    
14.
Kumar S, Goyal A, Gupta YK. Abuse of topical corticosteroids in India: Concerns and the way forward. J Pharmacol Pharmacother 2016;7:1-5.  Back to cited text no. 14
[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]
 
 
    Tables

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



 

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