Incidence of steroid modified tinea in tertiary care centre Lucknow

INTRODUCTION

The dermatophytoses are a group of superficial fungal infections of keratinized tissues like the epidermis, hair and nails.¹ Depending on their genera, dermatophytes can be classified into three groups: trichophyton, epidermophyton, and microsporum.² As per World Health Organization (WHO), the prevalence of superficial fungal infection worldwide has been found to be 20-25% and its more prevalent in tropical and subtropical countries like India where the heat and humidity is high throughout the year.³ Recently there is a surge in menace of dermatophytosis because of over the counter sale of topical steroids and self-medication. Steroid modified tinea is the variety of tinea, which occurs after the application of topical steroids. Previously “Tinea incognito” which literally means the variety of tinea which is not recognizable and atypical Tinea were used interchangeably. The term tinea incognito was originally described in 1968 by Ive and Marks, for the atypical clinical presentation of dermatophytic infections caused by prior use of topical or systemic steroids.⁴ In a recently published article, Verma has compared “tinea incognito” and “steroid modified tinea” and concluded that topical steroids do modify the morphology of tinea to varying extent but do not necessarily make the disease difficult to recognize. Therefore, a majority of them are better described as “steroid-modified tinea” rather than “tinea incognito”.⁵ As there is rapid increase in use of topical steroids and over the counter creams, incidence of such cases is increasing day by day. This study aims to find the incidence of SMT, common clinical patterns, causative pathogens and commonly used topical agents by the patients.

METHODS

Prospective cross-sectional study was conducted after ethical clearance, in outpatient department of Dermatology in collaboration with Department of Microbiology, Era’s Lucknow Medical College and Hospital (ELMCH) between March 2018 to May 2018. All patients attending Dermatology OPD of ELMCH during study duration were screened and clinically diagnosed tinea patients were asked about the application of topical steroids. Patients with history of usage of topical steroids were included in the study. Detailed predesigned proforma was filled which included, name, age, family history, type of topical medications applied, prescription details, duration of illness and history of oral medications. KOH smear and culture was done. Patients not willing to participate in the study were excluded from the study.

Specimen collection^6-12

Skin, hair or nail specimens were collected as per standard techniques in the department of Microbiology in Era’s Lucknow Medical College and Hospital, Lucknow. This was performed only after an informed written consent from each patient/guardian and he/she was assured that the information would be kept strictly confidential. The affected part was first cleaned with 70% alcohol (and left to dry) to remove contaminants. As the site of invasion and localization of infection differ in the different types of superficial mycoses the following collection techniques were followed.

Skin scrapings

Scrapings were collected from the border of skin lesions with a sterile scalpel blade. The specimen was collected in a piece of stiff black paper 10 × 10 cm and fastened with a paper clip after folding. Each specimen was labeled with name, age, sex of patient, site of lesion and identification number and was kept at room temperature till further processing.

Hair

Affected site was disinfected with alcohol before collecting specimen. Basal root portion of hair was taken by plucking, scraping scales and excavating hair for direct examination and culture.

Nails

The nails were clipped short with the nail clippers and debris was discarded. Scrapping was collected (a) from nail bed (b) from the underside of nail plate (if nail plate was affected).

Processing of specimens

Skin scraping, hairs stubs and nails were examined by direct microscopy and culture using following techniques:

a) Microscopic examination: Two methods of direct microscopy were used.

• • Potassium hydroxide (10% KOH) preparation.
• • Potassium hydroxide (10%) with dimethyl sulfoxide (40%) (KOH/DMSO) preparation.

b) Culture and isolation of causative fungi: Specimen was cultured for the isolation of dermatophytes, non-dermatophytes as well as Yeast.

• • Sabouraud’s Dextrose Agar (SDA); chloramphenicol (0.05 g/l) was added to the culture media to inhibit bacterial growth.
• • SDA with Chloramphenicol (0.05 g/l) and cycloheximide (0.5 g/l) to inhibit the growth of contaminated fungi.
• • Dermatophyte test medium (DTM) (Hi Media India) with chloramphenicol (0.05 g/l).

Procedure

The specimens were inoculated on the surface of the medium (two sets of tubes containing SDA with chloramphenicol with/without cycloheximide and DTM with sterile forceps or loop (L shape) breaking the surface of medium without becoming completely embedded. The use of cycloheximide free media allows other potentially pathogenic fungi to grow and is usually added to culture media to inhibit bacterial overgrowth.¹³

Identification of fungal isolates

Fungal isolates were identified by procedures detailed in standard mycology textbooks by Rippon and Larone.^8,10,11

A. Identification of moulds:

Colonial morphologic features

• • Colony obverse: Colour (e.g. white, pearl, ivory and black), consistency (e.g. cottony, fluffy, suede like, wiry), and topography (e.g. flat, folded, plicate, rugose) were noted.
• • Colony reverse: Extent and color of pigmentation was noted, colony color and morphology including folds and rugosities on reverse were also noted.

Microscopic morphologic features: Definitive identification was made by micro-slide culture method.

Slide culture technique: It was carried out to observe intact microscopic morphology of the fungus, particularly the position of the macroconidia, micro conidia and chlamydoconidia in relation to each other and the mycelia.

The growth was examined under microscope with high power (40X) magnification for appearance of morphological features.

Statistics

Sample size with basis for exemption for calculation.

Sample size was calculated on the basis of incidence of steroid modified tinea among the OPD patients using the formula

N=Z²_αpq/L²

Where p= 32%, the expected incidence is based on pilot study

q= 100-p

Type 1 error α=5%

Allowable error l=10% of p for detecting results with 90% power of the study.

Data loss = 10%

The sample size of n = 900 was calculated.

Whole of the data was entered in Microsoft Excel Sheets and analysed.

RESULTS

980 patients were clinically diagnosed as cases of tinea. Out of 980 patients, 550(56%) gave history of application of topical steroids. Male preponderance was noted (Table 1). Most common age group involved was 3^rd decade. No age group was spared as 6-month old infant was also brought with usage of topical steroids while the maximum age noted was 78 years (Table 2). Disseminated form of tinea was most common variety followed by tinea corporis, tinea cruris Figure 1a, 1b,1c) tinea capitis and tinea capitis with secondary infection (Figure 2a and b) (Table 3). The morphology of lesions was not typical, mainly seen as tinea pseudoimbricata (Figure 1b and c) that is with multiple rings. Itching was very common symptom. Family history was positive in 289(52.5%) patients out of 550 (Table 4). Duration of treatment varied from few days to 20 months. Most of the patients were using topical steroids for less than 12 months (Table 5). Most commonly used topical steroids were betamethasone, clobetasol, mometasone etc. These were being used by 216 (39.3%) subjects (Table 6). Use of multiple drug combinations was very common which included antifungals, antibacterials and steroid combinations. Very few subjects were using oral medications. 0.4% subjects were on oral fluconazole, 0.4% subjects were on oral itraconazole and 0.2% were on oral terbinafine as shown in (Table 7).

After specimen collection, KOH was done and it was positive (Table 9) in approximately 76% of cases, (Figure 3) showing KOH wet mount-branched network of fungal hyphae under low power 40X.

Fungal culture was done on Sabourauds Dextrose Agar (SDA) (Figure 4 a) showing Sabourauds’s Dextrose Agar uninoculated fungal culture media. Fungal Culture (Table 9) was positive in 396(72%) patients. Culture bottle (Figure 4b) of T. Mentagrophytes colony obverse showing white colony growth was positive in 130 cases that is 29.84%.Culture bottle (Figure 4c) of T. rubrum colony obverse showing white, cottony growth. Colony reverse shows red pigment, this was positive in 79 cases that are 24.60%. T. verrucosum was positive in 23 cases (5.2%) and T. tonsurans in 17 cases (3.8%). Among non-dermatophyte group Candida was the most common causative fungus which contributes 65 cases, culture bottle (Figure 4d) of Candida species colony obverse showing moist pasty cream colored growth and Aspergillus 43 cases, culture bottle (Figure 4e) of Aspergillus species colony obverse showing blackish growth, followed by Acremonium species in 19 and Fusarium in 11 cases.

DISCUSSION

This study analyzed the use of topical steroids in fungal infections. Due to easy availability and ineffective regulations on sale of topical steroids, the incidence of steroid modified Tinea is increasing. Tropical climate in most parts of our country favours fungal infections. Most of the patients prefer self-treatment and present to Dermatologist at late stages. In our study, 56% of subjects were using topical steroids with male preponderance (Table 1). Philpot suggested that males may be more vulnerable to infection due to the higher exposures in the army, school and sporting activities and due to the types of shoes and socks used.¹⁵ Similar observation was made by Kothiwala, Poudyal et al. Dutta et al noted female preponderance in their study.^16-18 All age groups were involved in usage of topical steroids and infants were also not spared while the maximum age noted was 78 years. Most common age group involved was 3^rd decade (Table 2). Similar scenario was mentioned in other studies also. Disseminated form of tinea was most common variety followed by tinea corporis, tinea cruris, tinea faciei, pedis and capitis (Table 4). As this infection is highly communicable, direct transmission explains the conjugal cases, while transmission in family members might be due to fomites or de novo infection.¹⁹ Poor adherence to treatment and wrong treatment also may be a cause for prolonged course of disease. Various types of topical medications were being used by the subjects. Easy availability of topical steroids, dispensing of steroids without prescription and feeling of instant relief on applying topical steroids are the main factors in promoting the use of topical steroids. Use of multiple drug combinations was also common which included antifungal, antibacterial and steroid combinations. Prescription was not a criterion for applying medications. 50.3% of topical steroids users were advised by local medical practitioners/quacks. 30% of the subjects were using topical steroids on advice of chemists while 3.9% were influenced by friends and relatives. Self-treatment group included 9.7% of subjects as shown in (Table 8).

In our study KOH mount was positive in approximately 76% of cases, (Table 9), similar to observation made in other studies.^20-25 Fungal culture (Table 9) was positive in 396 (72%). In other studies, culture positivity varied from 24- 87%.^20,26-29 T. mentagrophytes species was found in 130 (29.84%) cases, which corelates with previous studies.^20,30 Previous studies mention T. Rubrum as the most common species identified.¹⁶ The type of predominant fungal species may vary from region to region. In our study, the second most common isolated species was T. rubrum (24.60% cases) followed by T. verrucosum (5.2% of cases) and T. tonsurans in 17 cases (3.8%). The Trichophyton group was the most frequently isolated genera in almost all studies, except for one, in which Microsporum canis was the most common fungus isolated.³¹

Among non-dermatophyte group (Table 10) Candida was the most common causative fungus which contributed to 65 cases, (culture bottle (Figure 10)) followed by Aspergillus (43 cases). This was followed by Acremonium species in 19 and Fusarium in 11 cases.

CONCLUSION

This was an institution based and time bound study were the drawbacks of this study and the incidence we found may be an iceberg’s phenomenon. As KOH mount and fungal culture is not routinely done at all the centers, the real intensity of this problem still eludes. Most of the patients visiting us were already using some medications. Our study highlights the menace with unsupervised use of topical steroids. This not only prolongs the duration of illness but also makes the disease more resistant to treatment. This study emphasizes the need to spread awareness regarding the drawbacks of self-medication, especially with topical steroids. Doctors, chemists, public and government authorities need to work in conjunction to fight with this menace of unregulated topical steroid usage.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

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