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ORIGINAL ARTICLE
Year : 2021  |  Volume : 22  |  Issue : 3  |  Page : 236-240

A cross sectional observational study of pediatric dermatophytosis: Changing clinico mycological patterns in Western India


Department of Dermatology and Venereology, K. J. Somaiya Medical College and Research Centre, Mumbai, Maharashtra, India

Date of Submission17-Apr-2020
Date of Decision26-Apr-2020
Date of Acceptance30-Mar-2021
Date of Web Publication30-Jun-2021

Correspondence Address:
Saurabh Jaiswal
C403, Samruddhi Sankul Society, Mhada Colony, Civil Lines, Nagpur - 440 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_63_20

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  Abstract 


Introduction: The last few years have seen a significant rise in the incidence of dermatophytosis across India. Vulnerability of children to this disease is more than adults due to multiple factors. However, limited data are available regarding clinical and mycological variants of dermatophytosis in children. Materials and Methods: A cross-sectional observational study was designed at the dermatology outpatient department in Mumbai. The aim of the study was to assess the clinical profile and identify the causative fungal species in pediatric dermatophytosis. Sixty-seven children below 14 years of age with a clinical diagnosis of dermatophytosis were included by the simple random sampling method. A detailed history (duration of lesions, topical creams used, similar lesions in contacts, contact with pets, and other comorbidities/comedications) was taken and clinical examination (sites of involvement, number of lesions, associated erythema/scaling, morphology, and extent of lesions) was done followed by fungal mount preparation (potassium hydroxide (KOH) and KOH with Chicago Sky Blue stain) and culture of the scrapings on Sabouraud's agar medium containing chloramphenicol and cycloheximide. Microsoft Excel and SPSS-20 software were used to analyze the data. Results: A total of 42 male and 25 female children (mean age – 6.2 years) were included in the study. Prior topical applications of steroids±antifungal combinations were used in 57 cases (85%) before presenting to the dermatologist. About 76.12% (n = 51) of cases had positive family/contact history. Thirty-five children (52.2 %) had extensive disease. Multiple atypical clinical patterns were observed: tinea incognito, irregular geographic plaque, tinea recidivans, tinea pseudo-imbricata, penile tinea, and annular plaques on scalp. Trichophyton mentagrophytes complex was the most common isolate from cultures grown from scrapings, in 14/19 cases (73.7%). Conclusion: This clinico-mycological study highlights the changing clinical patterns (including Tinea pseudoimbricata, geographically patterned plaques) and shift in the etiological agent in childhood dermatophytosis. The study brings into focus the increasing proportion of T. mentagrophytes, high percentages of topical steroid abuse by parents in children, and positive family/close-contact history in children.

Keywords: Child; Trichophyton Rubrum; Trichophyton Mentagrophytes; Tinea; Steroids; Tinea incognita


How to cite this article:
Poojary S, Jaiswal S, Bhalala KB, Bagadia J, Shah KS, Arora S, Patel YR, Gupta P, Khot KS, Rai A, Dhayal M. A cross sectional observational study of pediatric dermatophytosis: Changing clinico mycological patterns in Western India. Indian J Paediatr Dermatol 2021;22:236-40

How to cite this URL:
Poojary S, Jaiswal S, Bhalala KB, Bagadia J, Shah KS, Arora S, Patel YR, Gupta P, Khot KS, Rai A, Dhayal M. A cross sectional observational study of pediatric dermatophytosis: Changing clinico mycological patterns in Western India. Indian J Paediatr Dermatol [serial online] 2021 [cited 2021 Aug 5];22:236-40. Available from: https://www.ijpd.in/text.asp?2021/22/3/236/319949




  Introduction Top


Dermatophytes (Trichophyton, Microsporum, and Epidermophyton) are a group of filamentous fungi which lead to infections of the skin, hair, and nails by obtaining nutrients from keratinized material.[1],[2] Tropical countries in the Indian subcontinent have seen a significant rise in the incidence of dermatophytic infections including recalcitrant dermatophytosis over the last few years. Changing clinical patterns, an epidemiological shift towards Trichophyton mentagrophytes from T. rubrum and a background of topical steroid abuse have characterized this raging epidemic in India.[3] This has also reflected in the pediatric population although there is a relative lack of published evidence.[4] High incidence of superficial dermatophytoses in adult contacts, easy transmission through contacts/pets, sharing of clothes/toys, outdoor play, comparatively lower immunity in children, humid conditions of intertriginous/napkin areas, and malnutrition make children more vulnerable to this disease.[5] Untreated family members are an important source of infection in children, especially in overcrowded conditions. The presence of infection in multiple family members in the present scenario also increases the chances of transmission. Epidemiological and mycological picture of dermatophytosis in pediatric population needs more data from different geographical locations due to the lack of recent and multicentric studies.[4] This study was therefore conducted at a tertiary care center in western India to understand the clinical profile and mycological identification in pediatric dermatophytosis in India.


  Materials and Methods Top


The main objective of the study was to assess the clinical profile of dermatophytic infections in children and to identify the causative fungal species.

Was carried out in the department of dermatology and venereology at K. J. Somaiya Medical College and Research Centre, Mumbai, from March from March 2017 to December 2018 after approval of the institutional ethics committee (Ethics committee ECR/138/Inst/MH/2013, approval dated March 14, 2017, It was first copy of protocol which was accepted by ethics committee. So, it was Protocol no. 1). The sample size was derived with the help of OpenEpi software (OpenEpi, Atlanta, USA) after taking reference frequency value from another study.[6]

Inclusion criteria

All patients below the age of 14 years with clinically diagnosed dermatophytoses were included in the study.

Exclusion criteria

Inability to obtain consent from parents/guardians was the sole exclusion criterion. Informed consent was taken from parents or guardians of all the included cases. Detailed medical history was taken and the following details were recorded: duration of lesions, history of application of topical antifungals/topical antifungal-steroid combinations, present/past history of fungal infection in family members/contacts, history of contact with pets/stray animals, and history suggestive of any immune-compromised state. A complete physical examination of the skin and appendages, including nails and hair, was performed on all children. They were examined for the site of involvement, number of lesions, associated erythema/scaling, shape, morphology, and extent of lesions.

Scrapings were taken from the lesions and mounted with a 10 % potassium hydroxide (KOH) ± 1% Chicago Sky Blue (CSB) stain. Scrapings were sent for culture for identification of species. The culture was done using Sabouraud's agar medium containing chloramphenicol and cycloheximide (incubated at 30°C).

All the medical and mycological observations were recorded in a detailed study pro forma by dermatologists. Proportions, percentages, mean, and standard deviations were used to describe the data. Microsoft Excel and SPSS-20 software (IBM SPSS 20.0 USA) were used to analyze the data.


  Results Top


A total of 67 children (age range - one month to 14 years) were included by simple random sampling method. Forty-two children were male and 25 were female (male-to-female ratio, 1.68:1). The mean age was 6.2 ± 4.3 years (range: 1 month to 14 years). The symptoms were present for a duration ranging from two days to one year. History of superficial dermatophytosis in a family member / close contact was present in 76.12% of children (n = 51). History of application of topical steroid creams with or without antifungal agents was present in 85% of cases (n = 57). Six children had taken oral antifungals, while eight children had not taken any treatment. Only one case had a close contact with a pet (dog).

Clinical variants of tinea (according to the site of involvement)

Tinea corporis was the most common clinical type (n = 49, 73.1%) and the most commonly observed overlap was tinea corporis associated with tinea cruris (n = 24, 35.8%). Thirty-seven children (55.2%) had tinea cruris (including cases of overlap), 12 children had tinea faciei (17.9%, including overlap), and two cases had tinea capitis (3%) with one case each of kerion and black dot type. Nail involvement was absent in all children. Extensive disease (>10% body surface area or involvement of two distant sites of the body) was present in 35 children (52.2%) [Figure 1]. Penile involvement was observed in four cases of tinea cruris [Table 1].
Table 1: Clinical variants of pediatric dermatophytosis (according to the site of involvement)

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Figure 1: (a-d) Extensive dermatophytosis in a 9-year-old boy with involvement of the entire face, upper and lower extremities, abdomen, groin, penis, and thighs and large irregular geographic plaques

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Morphological variants of tinea

Annular plaques (n = 58, 86.6%), tinea incognita (n = 10, 14.9%), and irregular geographical plaques (n = 10, 14.9%) were the most common morphological variants. Overlaps of different patterns in the same patient have been commonly observed in our study [Table 2]. The morphological and atypical variants are depicted in [Figure 2], [Figure 3], [Figure 4].
Table 2: Morphological variants of pediatric dermatophytosis

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Figure 2: Morphological variants of dermatophytosis. (a) Annular plaque of T. faciei (two year-old boy). (b) Tinea incognito: one year-old boy with erythematous papules, scaly ill-defined plaques, and surrounding hypopigmentation on pubic area, genitals, and groins. History of topical steroid application was present in the patient and mother affected with tinea. (c) Large geographic annular plaques with central clearing involving groins, thighs, scrotum, penis, and lower abdomen in a 10-year-old boy. (d) Multiple grouped scaly and excoriated papules on the right buttock, thigh, and groin in a five year-old boy

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Figure 3: Morphological variants of dermatophytosis. (a) Large polycyclic plaques with central clearing, trailing scale within the border on the right groin and thigh in a 2-year-old girl. History of application of topical potent steroid and antifungal combinations was present in both patient and affected mother. (b) Ill-defined plaques with barely perceptible scaling on the right leg of 3-year-old boy with a positive family history

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Figure 4: Atypical variants of tinea. (a) Annular scaly plaques resembling glabrous tinea on the scalp in 1-month female child without follicle involvement. Both mother and father of the child had active lesions of tinea. (b) Tinea pseudo-imbricata with multiple concentric rings of scaling, in a 3-year-old boy. (c) Multiple nonconcentric annular plaques within a single large plaque involving the entire back, with a history of steroid application, (d) Tinea Recidivans: Multiple new annular scaly plaques along the edge of and within the earlier healed plaque

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Microscopy and culture

Microscopy of fungal scrapings was done in all the cases with 10% KOH. CSB 1% as a contrast stain was added to KOH in KOH-negative cases to improve the sensitivity. Abundant hyphae were observed in most of the mounts (n = 62, 92.5%). KOH mount/CSB stain did not show any fungal hyphae in five cases. Culture was done only in 27 cases (due to patients' cost constraints); growth was observed in 19 samples (culture positivity rate: 70.3%) [Figure 5]. T. mentagrophytes complex was the most common isolate from cultures grown from scrapings i.e., in 14/19 cases (73.7%). Trichophyton rubrum was present in 4/19 cases (21.1%). Trichophyton violaceum was isolated from a single case of Kerion [Table 3].
Table 3: Dermatophyte species isolated from culture-positive cases

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Figure 5: (a) Trichophyton mentagrophytes: White powdery colonies at 30°C at 1 week. (b) Trichophyton mentagrophytes in lactophenol cotton blue mount: Septate, cylindrical macroconidia. (c) Trichophyton rubrum: Convoluted white powdery colonies with diffusion of wine red pigment. (d) Trichophyton rubrum in lactophenol cotton blue mount: groups of pear-shaped microconidia arranged in en grappe and en thyrse distribution with thin, long, cylindrical macroconidia

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  Discussion Top


Our study focuses on the current trend of pediatric dermatophytosis in India. The Indian subcontinent has witnessed an alarming rise in incidence of atypical clinical presentations in dermatology clinics recently. With a growing concern, dermatophytosis has also been included in the list of great imitators in dermatology.[7] Varying morphologies and atypical patterns were observed in the pediatric age group, in our study. A higher proportion of tinea corporis, tinea cruris, and tinea faciei was observed, while only two cases of tinea capitis were present. Tinea capitis was the most common type of pediatric dermatophytosis reported in the years prior to the present dermatophyte epidemic (pre-2014).[8],[9] There is however an increasing trend towards tinea corporis, tinea cruris, and tinea faciei, with a decreased share of tinea capitis the overall incidence in recent years.[10],[11] None of the children in our study had tinea unguium (n = 0).

Atypical patterns such as annular plaque over the scalp, penile involvement, pseudo-imbricate pattern, multiple non-concentric annular plaques within a single annular plaque, and tinea recidivans constituted a large proportion of cases in our study. [Figure 4]a, [Figure 4]b, [Figure 4]c, [Figure 4]d. Pseudo-imbricate patterns and tinea recidivans are usually rare, but with growing topical steroid abuse, such lesions are more commonly seen.[7],[12] Penile involvement, annular plaques on the scalp, and multiple non-concentric plaques within a single annular plaque have not been described in children before but were seen on the backdrop of steroid abuse in our study.

Inappropriate use of topical corticosteroids is a major issue in India.[13] Growing misuse of topical corticosteroids containing fixed drug combinations at an early age adds to the burden on dermatophytoses in children. Topical steroid abuse is responsible for the significant shift in clinical and mycological patterns of dermatophytosis in the Indian subcontinent.[14],[15] In our study, topical steroid ± antifungals cream abuse was noted in 85% of children. This tendency of steroid misuse was higher in our western Indian setup than in southern India where Gandhi et al. have observed misuse of steroid preparations in 51% of patients.[16]

History of dermatophytosis in family members or close contacts was present in 76.12% of children which is in concordance with observations of Gandhi et al. (83%).[16] Thus, it is imperative to ensure adequate treatment of all affected family members to prevent recurrences and chronicity of infection.

Upsurge in the proportion of T. mentagrophytes in the pediatric population in comparison to T. rubrum is more significant as compared to adults where incidence is almost equal as per recent literature.[17],[18],[19] The overall prevalence of T. mentagrophytes in western India is 47.2% in contrast to the prevalence of 73.7% in children in this study.[3] A recent molecular study by Nenoff et al. however has demonstrated T. mentagrophytes ITS type VIII to be a predominant species with a proportion as high as 93.2%.[20]

A rising proportion of T. mentagrophytes, especially in children, is alarming as it projects the high virulence, easy penetrance, and growth characteristics of the organism and portends the present epidemic nature of dermatophytosis in India. This changing clinic-mycological pattern of pediatric dermatophytosis can be attributed to (i) rampant steroid abuse altering the local immunological milieu, (ii) increased proportion of T. mentagrophytes, and (iii) adult family members with persistent/recurrent dermatophytosis in the transmission to the vulnerable pediatric population.

Limitation of the study

All patients did not undergo culture due to cost limitation. The small sample size was also a limitation of the study. Molecular study was also not possible due to resource limitations. Our study was done in the western part of the Indian subcontinent, in the city of Mumbai, and it may not reflect the complete picture of mycological shift in other parts of the country. A similar multicentric study on a larger scale can overcome these limitations. Despite the limitations, the study represents a changing clinical scenario of pediatric dermatophytoses in western India. Tinea capitis is now reduced to a small proportion of pediatric dermatophytosis, with T. mentagrophytes being the more dominant species, as against T. rubrum in previous studies.


  Conclusion Top


This study thus highlights the changing clinico-mycological patterns of dermatophytoses in children under the impact of topical steroid abuse.

Acknowledgment

We acknowledge Dr Avani Shah, MD, Clinical Microbiologist at Dr Miskeen's Central Clinical Microbiology Laboratory for processing and reporting of culture samples.

Declaration of consent

The authors certify that they have obtained all appropriate consent forms, duly signed by the parent(s) of the patient. In the form the parent(s) has/have given his/her/their consent for the images and other clinical information of their child to be reported in the journal. The parents understand that the names and initials of their child 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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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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