“A clinico epidemiological study of dermatophytosis in a tertiary care center, Ujjain”

Introduction: Dermatophytes are fungi that can cause infections of the skin, hair & nails due to their ability to invade keratin. Dermatophytosis is the most common superficial fungal infection worldwide, more common in tropics and subtropical regions. It may present in epidemic proportions in areas of high humidity. Aims and Objectives: The present study is aimed to determine the distribution and to identify the clinical types of dermatophytosis that are prevalent in Malwa region. Materials and Methods: A total of 298 samples were collected from infected skin, hair and nails for a period of 1 year.Samples were collected under aseptic condition by skin scrapping, nails and hairs clipping by using scalpel or forceps and were then subjected to direct microscopy by potassium hydroxide (KOH) mount. Results: Dermatophytosis manifested more in the age group of 21-30 years, with male predominance. Among various clinical types, tinea cruris was the commonest type. Direct microscopy on KOH mount revealed the presence of dermatophytic fungi in 71.8% of the samples. Conclusions: Dermatophytosis is the commonest disease presenting in dermatology clinics and are responsible for myriad of clinical manifestations in human. Empirical use of steroid/mixed preprations, poor patient compliance due to high cost and changing dress sense are some important contributing factors for the real upsurge in incidence and prevalence of dermatophytosis in the last few years.


Introduction
Dermatophytes are a group of closely related filamentous fungi that can cause infections of the skin, hairs & nails due to their ability to utilize keratin. 1 They are classified into three genera: Microsporum, Trichophyton, and Epidermophyton. Trichophyton rubrum has been the most common isolates. These superficial cutaneous mycoses affect 20% to 25% of the world's population. 2 In the present scenario of India, dermatophytoses (Ring worm infections) constitute the most common skin condition in dermatology clinics.Clinically, dermatophytoses can be classified on the basis of site involved.
The hot and humid climate in tropical and subtropical countries like India makes dermatophytoses a very common fungal skin infection. Obesity, poor hygiene, overcrowding, immunodeficient conditions are some other risk factors. Chronic steroid abuse has now become the leading cause of chronic and recalcitrant dermatophytoses now a days. Many significant changes in the classical features have been noted in the present epidemic.

Materials and Methods
The present study was conducted in the department of Dermatology at R.D.G.M.C Ujjain (Malwa region of Madhya Pradesh) for a time period of one year from Jan2017 to Jan 2018.The study group comprised of 298 clinically suspected cases of dermatophytoses. A detailed clinical history including age, sex, duration, occupation and the clinical presentation were noted. On the basis of anatomical site of involvement they were grouped into various clinical types. Samples were collected under aseptic condition by skin scraping, nails and hair clipping by using scalpel or forceps in sterile petri dishes. Direct microscopy was done by using 10% potassium hydroxide (KOH) for skin scraping and 20% KOH for epilated hair & nail clipping specimens.

Results
Peak incidence of dermatophytoses was seen in the third decade of life. Majority (32.2%) of the patients belonged to the age group of 21-30 years, followed by 31-40 years 22.8% and least from the age group 61-70 years 4.6%, pediatric cases comprised of 7.3% [ Table 1]. There was male predominance (76%) in the study patients and the overall male to female ratio was 2.92:1 [ Table 2]. Majority (57.7%) patients were from rural areas [ Table 3]. The highest number (20.1%) of the patients were agriculture farmer/ labor and the proportion of housewives were 16.1%, students 14.7%, laborers 6% formed the bulk of patients [ Table 4]. The maximum percentage (40.2%) of patients were from lower middle class. The proportion of 28% were in upper lower class, 16.1% in upper middle class, 11%were in lower class and 5.3% were in upper class (Table 5). Family history was found positive in (41.6%)[ Table 6].The proportion of patients who gave history of steroid abuse was (34.9%) [ Table 7]. History of recurrence was found in (37.5%) [ Table 8]. History of recurrence was present in (37.5%) [ Table 8]. Tinea cruris was the most common clinical presentation (23.4%) followed by tinea corporis14%.However the percentage of tinea faciei, tinea pedis, tinea unguium, tinea manuum and tinea capitis were 5.3%, 4.7%, 3.3%, 2.6%, 2% respectively [ Table  9].Combination pattern was present in (44%), where association of tinea cruris with tinea corporis was maximum in (39.3%) followed by tinea cruris et tinea corporis et tinea faciei [

Discussion
In the present study, maximum number of patients belonged to the age group of 21-30 years (32.2%) followed by 31-40 years 22.8% similar inference has been drawn by other workers. [3][4][5] Males (76%) were more commonly affected than females (24%) and male to female ratio was 2.92:1 which has also been observed in other studies. [6][7][8][9][10] Male predominance could be due to more outdoor physical activities and tight fitting clothing, which could have lead to pronounced sweating and an increased opportunity for infections. Males visit hospital frequently than females who might not be very open for hospital visits for dermatological infections.
The study of occupational profile of the patients showed that agriculture farmer/labor constituted the majority of patients.Housewives are also at high risk due tolong hour of immersion of hands and feet in water,increasing the risk of tinea manuum, tinea pedis, tinea unguium, Even the students have a significant proportion, probably attributable to changing fashion trends, skin fit denim jeans which are increasingly preferred by youngsters and their non-suitability to our hot and humid environment. Association of occupation and dermatophytoses was also observed by many workers in the past, showing negative impact on the quality of life and productivity which was concordance to previous studies.High incidence of dermatophytosis infection in farmers and forestry workers was also reported by Sahin et al. 11 In the present study most of the patients belong to lower middle class (40.2%) and upper lower class 28%,which could be attributed to poor hygienic practices poverty, lack of self care, ignorance and social belief of seeking nonmedical advice and remedies.Family history of superficial dermatophytoses was present in 41.6%, just like that of scabies, there by showing familial tendency.Probably due to direct physical contact &fomites like sharing of beds,linens and clothing is common among family members. [12][13][14] The history of steroid/FDC cream usewas found in (34.9%) patients & the proportion of (37.5 %) had history of recurrence, as irrational FDC creams (containing potent topical steroid, antifungal, antibacterial) are freely available over the counter, which are cheaper than standard topical antifungal creams. These are used by patients on their own will for weeks,months and sometimes even for years, whenever patient has symptoms of itching and inflammation leading to a chronic and recurrent course. 12,13 We also observed an increased number of atypical presentation of tinea infection [ Fig. 2 & Fig. 3].
Inthe present study tinea cruris was most common variety which was accordance with studies by other workers. 15,16 Tight ill fitting dressing, complex anatomical structures and over humidification could be the reason behind it. Among mixed clinical types tinea cruris et tinea corporis was the highest (39.3%) similar findings have been reported in other studies. 17 KOH wet mount direct microscopy examination showed (71.8%) samples were positive in our study, while positive rates ranging from 23.8% to 91.2% have been reported by various workers. [18][19][20][21] Selection criteria of cases and the skill involved in sampling technique might be responsible for the difference.

Conclusion
Dermatophytosis (superficial fungal infection) is the commonest disease presenting in dermatology O.P.D.
A real upsurge in the incidence and prevalence of dermatophytosis has been noted for last few years. Empirical use of steroid / FDC preparations, poor patient compliance due to high cost of treatment and changing dress sense not suitable to our enviroment are the chief reasons.
Atypical clinical presentations, multiple site involvement, familial clustering and recurrence of cases have been noted in our study.