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Special Article

Epidemic of Difficult‑to‑Treat Tinea in India: Current Scenario,

Culprits, and Curbing Strategies
Manjunath M. Shenoy, Jyothi Jayaraman1
Department of Dermatology, Venereology and Leprosy, Yenepoya Medical College, 1Department of Dermatology, Venereology and Leprosy, Father Muller Medical
College, Mangalore, Karnataka, India

Abstract
Dermatophytes cause superficial skin infections of skin, nail, and hair known as dermatophytosis. It is commonly called as “ring worm” infection. There
has been an emergence of an epidemic of recurrent and chronic dermatophytosis in India. Several reasons have been implicated that are related to the
agent, host, and the treatment. Topical steroid misuse has been considered as an important contributor that has led to the persistence and atypicality of
the infection. This article emphasizes on the salient features of the current dermatophyte epidemic to sensitize all physicians who treat the infections.

Keywords: Chronic dermatophytosis, recurrent dermatophytosis, tinea, topical steroid misuse

Introduction humidity, demographic factors of patient, occupation, genetic

Dermatophytes are fungi that metabolize keratin to produce
superficial skin infections of skin, nail, and hair known as
dermatophytosis. It is commonly called as “ring worm” infection
due to the round, itchy, and inflammatory patches seen in the
common form of the disease. The lesions may sometimes
become widespread and may have a significant impact on social,
psychological, and occupational health compromising the quality
of life.[1] It is a contagious disease that spreads by direct or indirect
contact. Until a few years ago, it had been a disease treated with
ease using antifungal agents. In the recent past, there has been a
failure of treatment with conventional therapy and emergence of
an epidemic of recurrent and chronic dermatophytosis in India.[2,3]
Dermatologists across the country are sensitized to this aspect,
but the disease is not managed by dermatologists alone. Many
patients are first reported to the family practitioners, physicians, and
pediatricians. This article hence intended to bring awareness among
all our colleagues. In India, practitioners of alternate medicine and
unqualified quacks also manage these patients with allopathic
medications who have inadequate knowledge of these drugs. This
has also been a hindrance in tackling epidemics of this magnitude.
Epidemiology
The prevalence of the dermatophytosis depends on the
host and environmental factors such as temperature,
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predisposition, and socioeconomical status.[4] Dermatophytes
evolve along with the change in geography and socioeconomic
conditions. These keratinophilic fungi have the ability to
invade hair, nails, and the skin of the living host.
Conventionally, dermatophytes are classified as asexual or
imperfect (anamorphic) molds belonging to three genera,
namely Trichophyton, Microsporum, and Epidermophyton.
There are about 40 species of dermatophytes under these three
genera.[5] The taxonomy of dermatophytes is an evolving area
and the use of molecular techniques to study the relatedness
of species has led to confusion and conflicts in the literature.
Dermatophytes are found in three different ecological sources,
namely humans, animals, and soil, based on which they
are classified into geophilic, zoophilic, and anthropophilic
species.[6] There is geographic variation in the dominance of
infecting agents. Most of the infections are generally mild and
are treated with common antifungal agents.
The prevalence of superficial mycotic infection worldwide
according to the World Health Organization in 2015 has been
Address for correspondence: Dr. Manjunath M. Shenoy,
Department of Dermatology, Venereology and Leprosy, Yenepoya
Medical College, Deralakatte, Mangalore ‑ 575 018, Karnataka, India.
E‑mail: manjunath576117@yahoo.co.in
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DOI: How to cite this article: Shenoy MM, Jayaraman J. Epidemic of

10.4103/amhs.amhs_72_19 difficult‑to‑treat tinea in India: Current scenario, culprits, and curbing
strategies. Arch Med Health Sci 2019;7:112-7.

112 © 2019 Archives of Medicine and Health Sciences | Published by Wolters Kluwer ‑ Medknow

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Shenoy and Jayaraman: Tinea epidemic in India
found to be 20%–25%.[7] In the past 7–8 years, there has been
an escalation in difficult to treat, recurrent as well as chronic
dermatophytosis in India. In a study conducted in Sikkim,
India, about 60.4% of patients gave a history of recurrent
dermatophytosis.[8] These changes may be contributed to a
complex interplay of host, agent, and environmental factors.
In India, common species noted are Trichophyton rubrum,
followed by Trichophyton mentagrophytes and Microsporum
gypseum. There have been reports of an increase in T.
mentagrophytes as a leading causative agent in many studies
from India.[9‑11] The recent worldwide trends have been
summarized in a review article published by Hayette MP et al.;
it has been briefly depicted in Table 1.[12]
Current Scenario in the World and India
Dermatophytosis was always common but was never considered
as a major public health hazard in India. It rarely causes major
complications. Published literature on dermatophytosis in the
past highlighted the clinical and epidemiological trends but
rarely focused on the chronic and recurrent infections since it
was a rare occurrence. Treatment failure was also uncommon.
The current epidemic of dermatophytosis in India has many
characteristic features due to which it has been among the
common topic of discussion in most conferences. A fresh
literature from India has been emerging focusing the changing
clinic‑epidemiological and therapeutic aspects. Major aspects
have been enlisted here.
1. Overall increased frequency of dermatophyte infection
across the country
2. Increased incidence of recurrent and chronic infections[13]
• Recurrent dermatophytosis is defined as reoccurrence
of the signs and symptoms within few weeks of
apparent cure
• Chronic dermatophytosis refers to the persistence of the
infection despite treatment for over 6 months–1 year.
3. Deviation in the clinical patterns with extensive and
morphologically atypical lesions
4. Increased trends of potent topical steroid misuse to treat
the disease
5. Failure of systemic antifungal agents with lack of adequate
response[14]
Table 1: Epidemiology of dermatophytosis in the world
Dermatophytosis Common dermatophyte
Tinea pedis and onychomycosis T. rubrum
Tinea corporis T. mentagrophyte
T. verrucosum
M. canis
T. rubrum
Tinea capitis T. tonsurans
M. audouinii, T. soudanense, T. tonsurans, T. violaceum Africa (Mali, Nigeria, Senegal, Ethiopia, Botswana)
T. rubrum: Trichophyton rubrum, T. mentagrophyte: Trichophyton mentagrophyte, T. verrucosum: Trichophyton verrucosum, M. canis: Microsporum
canis, M. audouinii: Microsporum audouinii, T. soudanense: Trichophyton soudanense, T. violaceum: Trichophyton violaceum, T. tonsurans: Trichophyton
tonsurans
Archives of Medicine and Health Sciences  ¦  Volume 7  ¦  Issue 1  ¦  January‑June 2019
6. Emergence of T. mentagrophytes as the dominant or
codominant pathogen.
Most infections that are reported at higher frequency primarily
infect the glabrous skin (tinea corporis, cruris, and faciei).
Tinea capitis, onychomycosis, tinea pedis, and tinea manuum
have not been a major part of the current epidemic in India.
Pathogenesis
Infection starts after contact with spores or conidia.
Dermatophytes growing in a vertebrate host normally form
only arthrospores (arthroconidia) or asexual spores that develop
within the hyphae. Invasion of the epidermis by dermatophytes
begins with adherence between arthroconidia and keratinocytes
followed by penetration through and between cells and the
development of a host response. In laboratory culture medium,
they can also produce microconidia, macroconidia, and asexual
spores that develop outside the hyphae.
Growth of dermatophytes is associated with the development of
areas of inflammation. Geophilic and zoophilic dermatophytes
generally produce more inflammatory lesions than
anthropophilic dermatophytes.[15] The amount of inflammation
exhibited by the host is determined by the cell‑mediated
immunity which place a major role in curtailing the infection.
Host factors such as site of infection, barrier function, age,
obesity, immunosuppressive state, use of topical steroids, or
other immunosuppressive medications may affect the spread
of infection and clinical presentation. Anatomical variations
such as the presence of skin folds, sebaceous glands, variable
thickness of the stratum corneum, and presence of vellus hair
follicle involvement may also determine the progress and
persistence of infection.
In the Indian scenario, presence of hot and humid climate,
low socioeconomic status, overcrowding, sharing of infected
clothes and footwear, poor hygiene, and migration of population
may be predisposing recurrence of dermatophytosis.
Diagnostic Challenges
Dermatophytosis is classified according to the site of
involvement. Salient features of the various forms of
Region
Europe, Middle east, North and central America, Asia (Japan)
Middle East
Middle East (Iran)
Europe (Italy)
Asia (India)
Caribbean
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Shenoy and Jayaraman: Tinea epidemic in India

dermatophytosis have been depicted in Table 2. Most nonhairy
infections are characteristically show ring like (annular)
reddish scaly lesions with active, spreading, and inflammatory
borders [Figure 1]. Hairy areas often show more inflammation
often due to the invading fungus which are frequently zoophilic
in origin.[16] Extensive disease, atypical presentations, and
extension of the disease into the scalp and face are common.
The appearance of the lesions at the site of the rings,
drawstrings, wrist bands and body threads worn for cultural and
religious reasons has been seen indicating these articles may
serve as reservoir of the infection [Figure 2]. Most infections
are diagnosed based on the clinical manifestations. Rarely
laboratory diagnosis using mycological examination is carried
out to confirm the diagnosis.
The diagnostic difficulty has been posed in the recent past
with the emergence of atypical dermatophytosis.[17] Majority
of such presentation can be attributable to the usage of
over‑the‑counter steroid containing creams.[18] These creams
can give quick relief in the symptom but eventually leading to
atypical presentation, persistence, and widespread infection.
Rampant use of such creams has immensely contributed to
the current epidemic.
Atypical tinea presents with clinical appearances ranging
from eczematous, psoriasis‑like, pustular lesions,
pseudoimbricata (concentric rings), and rosacea‑like lesions
which are resilient to treatment [Figures 3‑5].[17] Topical
steroid misuse has been the main culprit for the atypical
presentations. Many cases are also associated with cutaneous
adverse effects of steroid abuse such as striae, atrophy of
skin, acneiform eruptions, and rosacea [Figures 6 and 7].[19,20]
Understanding the impact of topical steroids in the current
epidemic is crucial and can be considered as a gap in the
research. Topical steroid abuse shall be considered as one
of the major health tragedies in India. These drugs impede
the cutaneous inflammatory response that the skin mounts
to resist and limit the fungal infection. Concomitantly, there
is local suppression of T‑cell‑mediated immune response to
the dermatophytes. Tinea “incognito” refers to the steroid
modified tinea that has lost the inflammatory signs with
masked margins [Figure 7].

Figure 1: Tinea corporis; annular and polycyclic erythematous scaly

plaques with active borders Figure 2: Tinea corporis occurring at the site of the wrist band

Table 2: Salient features of dermatophytosis

Clinical type Synonym Site of infection Common agents Clinical features of the common variety
Tinea capitis Scalp hair T. violaceum, T. tonsurans, Noninflammatory lesions characterized by
M. canis patches of alopecia with scaling and broken hairs.
Inflammatory lesions show tender boggy swelling
Tinea barbae Barber’s itch Beard and T. violaceum, T. tonsurans, Similar to tinea capitis often with deep folliculitis
moustache hair M. canis
Tinea faciei ‑ Nonhairy skin of T. rubrum, T. mentagrophytes, Erythematous scaly annular plaques
the face E. floccosum
Tinea corporis Ringworm Non‑hairy skin of T. mentagrophytes, T. rubrum, Erythematous scaly annular plaques
the body T. violaceum
Tinea cruris Jock itch, Nonhairy skin of T. mentagrophytes, T. rubrum Erythematous scaly annular plaques
Dhobi itch the groin
Tinea manuum ‑ Palms T. interdigitale, T. rubrum Diffuse scaling of palm
Tinea pedis Athlet’s foot Feet T. interdigitale, T. rubrum Fissuring, scaling or maceration in the interdigital
or subdigital areas
Tinea unguium Onychomycosis Finger and toenails T. interdigitale, T. rubrum Subungual scaling and lifting up of the distal nail
T. rubrum: Trichophyton rubrum, T. mentagrophyte: Trichophyton mentagrophyte, T. verrucosum: Trichophyton verrucosum, M. canis: Microsporum canis,
T. soudanense: Trichophyton soudanense, T. violaceum: Trichophyton violaceum, T. tonsurans: Trichophyton tonsurans, E. floccosum: Epidermophyton
floccosum

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Shenoy and Jayaraman: Tinea epidemic in India
Figure 3: Psoriasis‑like atypical tinea
Figure 5: Tinea pseudo imbricata due to topical steroid misuse
Laboratory diagnosis relies primarily on the conventional
diagnostic techniques, namely direct microscopy and
mycological culture. Currently, there has been a major
shift in the epidemiology with T. mentagrophytes emerging
as the dominant pathogen overtaking the T. rubrum. This
has also been attributed to various host and environmental
factors. T. mentagrophytes has many subspecies, and detection
of it is of great epidemiological importance. Molecular
biological techniques are adapted to detect the fungus to the
subspecies level.[21,22] In India, there are very few centers
offering those services.
Therapeutic Challenges
Antifungal therapy can be administered as topical or oral
formulations. Topical therapy alone can cure localized lesions,
but such an occurrence in the current epidemic is rare. Topical
antifungal therapy is safe for pregnant, lactating women,
infants, and small children.[23] It is important to mention once
again that topical antifungal alone without any antibiotics or
steroids shall be used to manage dermatophytosis,
Systemic antifungals commonly used for the treatment of
dermatophytosis include griseofulvin, terbinafine, itraconazole,
and fluconazole. Textbooks and published literature describes
the conventional doses and duration of therapy which has been
Archives of Medicine and Health Sciences  ¦  Volume 7  ¦  Issue 1  ¦  January‑June 2019
Figure 4: Annular lesion of tinea corporis with pustules
Figure 6: Tinea incognito
summarized with modifications in Table 3. This therapy is
often inadequate in the current scenario, and we require fresh
management guidelines.
If not contraindicated, systemic antifungals have become necessary
in virtually all cases of dermatophytosis. There have been reports
of failure of systemic therapy, especially with terbinafine
indicating there may be a possible antifungal resistance.[24] A
few Indian studies have reported mutation in squalene epoxidase
enzyme leading to drug resistance in terbinafine.[25,26]
Apart from treatment, prevention of recurrences, reinfection
and spread to family members and contacts is important. This
can be made possible by an elaborate counseling of every
patient. Various aspects of counseling have been summarized
in Table 4. Important aspects include hygiene, avoiding
the steroid‑containing creams, and treating all contacts. It
is very common to notice that many family members are
simultaneously affected in the current scenario, which causes
economic burden too.[27]
Conclusion
Superficial mycosis that was amenable to minimal interventions
has grown into a bothersome health problem accountable to
epidemic in India. Atypical presentations, poor therapy
response, chronic disease, and recurrent infections are the
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Shenoy and Jayaraman: Tinea epidemic in India

Table 3: Conventional therapy of dermatophytosis

Type Standard therapy
Tinea corporis, Terbinafine: 250 mg/day for 1 week
cruris, faciei Itraconazole: 200 mg/day for 1 week
Tinea capitis, Griseofulvin: 10 mg/kg/day for 6‑8 weeks
tinea barbae Terbinafine: 62.5 mg (<20 kg), 125 mg (20‑40
kg) or 250 mg (40 kg) daily for 3‑4 weeks
Tinea pedis, Terbinafine: 250 mg/day for 2 weeks
tinea manuum Itraconazole: 200‑400 mg/day for 1 week
Tinea unguium Terbinafine: 250 mg/day for 12 weeks
(toenails) or 6 weeks (fingernails)
Itraconazole: 200 mg bid for 1 week/month for
3 months (toenails) or 2 months (fingernails)
Alternate therapy
Fluconazole: 150‑200 mg/week
for 2‑4 weeks
Itraconazole: 5 mg/kg/day
(maximum 500 mg) × 4‑8 weeks
Fluconazole: 5 mg/kg/week for
4‑6 weeks
Fluconazole: 150‑200 mg/week
for 3‑9 months
Comments on therapy in the current scenario
Terbinafine and itraconazole therapy may require
extension for 3 weeks or more
Griseofulvin is still the gold standard, and the
therapy is generally effective
Not a major part of the current epidemic
Not a major part of the current epidemic and the
recommended therapy is effective

Table 4: Counseling of patients with dermatophytosis

Counseling points
Regular bath (at least once a day) and wiping the body dry
Regular laundering of clothes
Washing and storing clothes and bed linen separately from others
Avoidance of sharing of clothes, towels, and soaps with others
Avoidance of wearing bands, threads, drawstrings, and rings
Losing weight (in obese patients)
Avoid contact with pets
Avoid applying topical corticosteroids containing creams
Complete the course of treatment
Treatment of other infected house members and close contacts
Benefits
May reduce fungal load and colonization
May reduce the recurrence of the disease through infected clothes
Reduces chances of transmission to family members
Reduces transmission to contacts and family members
Avoidance of infected materials to reduce recurrence
Reduces chances of the fungal infection in groin and other intertriginous area
Avoids chances of animal (zoophilic) infections
Reduces recurrence and atypical presentations
Ensures complete cure
Reduces chances of transmission and recurrence

Figure 7: Cutaneous atrophy with striae due to steroid misuse
hallmark of this epidemic. Many factors related to the fungus,
host, environment, and drug are responsible for it, but topical
steroid abuse is a leading cause of it. Apart from a negative
impact on the quality of life, tinea epidemic in India has
caused economic burden to the affected family. Physicians
treating the infections should be aware of all these aspects and
comprehensively treat the infections with pharmacological
therapy and counseling.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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