Dermatophytosis, a scourge in tropical countries and a pandemic in its own right, is common among children and teenagers given their proclivity for outdoor physical activity and lack of excessive concern on personal hygiene among fun and games. In addition, the presence of infected adults who are caretakers places a constant risk for children. Certain biological factors also increase the predisposition of children to dermatophytosis. These include a lack of fungistatic properties of fatty acids of short and medium chains commonly found in postpubertal sebum. It has a long-standing and refractory course that deleteriously affects the quality of life in view of social stigma and upsetting day-to-day activities. This is especially pertinent among children. The widespread antifungal resistance of dermatophyte species fueled by topical steroid abuse and noncompliance has not only led to a huge disease burden among children but also provoked a shift in the causative species. Trichophyton mentagrophytes have been found to be the most common isolate in recent times replacing Trichophyton rubrum.
The aim of this study was to assess the clinical patterns and mycological isolates from the lesions of dermatophytosis in the pediatric age group. We also sought to evaluate the association of fixed-dose combinations containing steroids and antifungals with the clinical and mycological patterns of cutaneous dermatophytosis in the pediatric age group.
Materials and Methods
Following institutional ethical clearance and Clinical Trials Registry of India (CTRI) registration (CTRI/2020/029992), we included 45 pediatric patients (ages 1–14 years) clinically diagnosed with cutaneous dermatophytosis, attending the outpatient department of Dermatology at Father Muller Medical College Hospital, Mangalore. The data were collected from January 2020 to April 2020. Parents and guardians of the children gave both oral and written informed consent/assent as applicable. Patients treated with over-the-counter drugs, including antifungals or topical corticosteroid combination drugs, were included in the study.
At the time of enrollment, a detailed predesigned pro forma was filled with clear clinical history, including age, sex, socioeconomic status, duration of the disease, history of recurrence and type of lesion, similar complaints in the family, and contacts with animals or soil were elicited and recorded in all cases. In addition, details such as overcrowding, hygienic measures, seasonal variation, and details of previous treatment (allopathic and traditional medicines).
KOH mount was done to identify fungal hyphae under low power magnification (×100) [Figure 1]. Skin scales were then collected in a sterile plastic container. The specimen was inoculated into a test tube with Sabouraud’s dextrose agar and incubated for 4 weeks. Fungal isolates were then identified based on the morphology of the colony, growth rate, microscopy, and pigmentation with lactophenol cotton blue mount.
Statistical analysis was done using the frequency and Chi-square test using SPSS IBM; version 25.0, Chicago, Illinois, USA.
A total of 45 patients were enrolled in the study, comprising 29 males (64.4%) and 16 (35.6%) females. The maximum number of cases was in the age groups of 5–10 years and the mean age was 6.42 years, the eldest being 11 years and the youngest being 2 years. The majority of the participants resided in poor hygienic conditions in urban areas (53.3%) and some participants were from rural areas (46.7%). Overcrowding was observed in 60% of cases. Once a day bathing was noted in 48.9%, twice daily bathing in 48.9%, and bathing more than twice was noted in 2.2% of the participants. Most participants (48.9%) reported washing their clothes at least once a week and 22.2% of the participants used to wash the clothes every day. Sharing of towels was observed in 28.9% and clothing was shared by 24.4% of the participants. Seasonal variation was noted in 86.7% of the participants, with an increase in incidence during summer and monsoon. In 84.4% of the cases, there was a positive contact history with the infected person.
Most of the patients reported that the current presentation was a recurrent one (35/45, 77.78%). The average reported duration of symptoms was 28 ± 8 days (mean ± standard deviation [SD]). Similarly, most study participants (80%) were on treatment with either oral or topical medications as reported by parents. Of these, corticosteroid-containing creams were prescribed for 21 of the study participants (57.5%) and two study participants (6.45%) were prescribed topical antifungals. Two study participants (4.6%) were prescribed traditional medications. Topical medication of 11 participants was unknown. Clobetasol propionate was prescribed for 21 (58.3%) of the study participants; betamethasone dipropionate was prescribed for 8 (22.2%) of the study participants. Five of the study participants (11.1%) had been prescribed betamethasone valerate and two participants (4.4%) were prescribed mometasone furoate. The steroid applications were in combination with antibiotics such as neomycin and antifungals such as clotrimazole. The average duration of use of over-the-counter medications (steroid creams/alternative medicines) without dermatologist consultation was 13.6 ± 4 days (mean ± SD).
The most common clinical features observed were itching at the lesion sites in 93% and hyperpigmentation. The color of the lesion was hyperpigmented in 44.4% of cases and erythematous in 44.4% of cases, only 11% had hypopigmented and depigmented lesions (those with a history of steroid use) [Figure 2]. In some patients, eczematization was noted [Figure 3]. Groin and buttocks were the most common sites of the lesion (89.65% and 45.4%, respectively). A wide variety of types of dermatophytoses were observed [Graph 1]. Tinea corporis et cruris was the most common clinical pattern observed (55.6%), followed by tinea cruris and tinea corporis each (15.6%), tinea faciei et corporis et cruris (11.1%) [Figure 4], tinea axillaris (2.2%). Atypical lesions such as the loss of annularity (64.4%) and pseudoimbricata (4.4%) [Figure 5] were present. Scaling was noted in 33.33% of patients and striae [Figure 6] in 2.22% of the participants [Graph 2].
Of the 45 study participants, KOH mount was positive in 39 (86.7%) and negative in 6 (13.3%). Fungal culture revealed T. mentagrophytes (55.6%) as the most common species isolated, followed by T. rubrum (15.6%) and Trichophyton tonsurans (6.7%). No growth was observed in 22.2% of cases [Table 1].
In the present scenario, dermatophytosis has become a menace due to various freely available multicombination drugs with steroids, making it a chronic and recalcitrant disease in tropical nations. The unique features and specific challenges of dermatophytosis in the pediatric age group are explored in this study.
Most patients were of the age group 5–10 years, a finding concordant with other studies. A preponderance of males (64.4%) was noted in our study compared to that of females (35.6%), resonating with other studies. The higher incidence in males could be reflective of the social stigma that may render parents reluctant to seek care for their girl children.
In our study, compared to the study done by Paloni et al., the topical medication most used is clobetasol propionate (50%). Steroid application on tinea results in atypical forms of tinea, such as loss of annularity and striae.
Recent studies in India have witnessed a major epidemiological shift from T. rubrum to T. mentagrophytes, which have been changing worldwide since World War II. T. mentagrophytes (55.6%) was the predominant organism, followed by T. rubrum (15.6%), similar to other studies where the prevalence ranged from 40% to 79% in T. mentagrophytes and 6.6%–13.5% in T. rubrum. Furthermore, it is noteworthy that the most severe inflammatory infection caused by T. mentagrophytes belongs to the T. mentagrophytes-interdigitale complex. A study done at our institute comprising 200 cases showed T. mentagrophytes (59.4%) to be predominantly followed by T. rubrum (55.2%) and T. tonsurans (33.3%). Thus, we can witness both a shift in the morphological patterns of clinical presentation of tinea among pediatric patients and a shift in the subspecies causing dermatophytosis in the group.
Echoing the transition in dermatophytosis in adults, there is a major epidemiological shift of dermatophytosis causing species from T. rubrum to T. mentagrophytes observed in our study among pediatric patients. More children may present with atypical signs such as the loss of the classic annularity and the presence of striae often causing a diagnostic dilemma when history is not forthcoming. This calls for a high degree of suspicion of atypical manifestations by pediatricians and dermatologists alike. This is particularly pertinent as children are more susceptible to the adverse effects of steroids as compared to adults. Topical steroids, even though included as a schedule H drug recently, it has been used widely among the population through unauthorized dispensing by pharmacists and self-medication, even though, recently it is included as a schedule H drug, and awareness regarding the side effects of these medications should be imparted to the public. Children must be taught easy and effective ways of practicing good hygiene to prevent communicable diseases and the overall betterment of their health and well-being. The importance cannot be overemphasized as small efforts in this direction will reap large benefits in the long battle against dermatophytosis, as today’s children become the adults of tomorrow.
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
Conflicts of interest
There are no conflicts of interest.
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