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Expert Consensus on The Management of Dermatophytosis in India (ECTODERM India)

July 2018 · BMC Dermatology 18(1)

DOI: 10.1186/s12895-018-0073-1
Authors:

Murlidhar Rajagopalan Arun Inamadar Asit Mittal

Autar K. Miskeen
Apollo Hospitals BLDE University Rajasthan University of Health Sciences

Show all 11 authors

Why you
and in th

Citations (52) References (64) Figures (2)

Abstract and Figures

Background: Dermatophytosis management has become an important public health issue, Discover the world's research
with a large void in research in the area of disease pathophysiology and management. 19+ million members
Current treatment recommendations appear to lose their relevance in the current clinical
scenario. The objective of the current consensus was to provide an experience-driven 135+ million publications
approach regarding the diagnosis and management of tinea corporis, cruris and pedis. 700k+ research projects
Methods: Eleven experts in the Yeld of clinical dermatology and mycology participated in
the modiYed Delphi process consisting of two workshops and Yve rounds of
questionnaires, elaborating deYnitions, diagnosis and management. Panel members were Join for free
asked to mark "agree" or "disagree" beside each statement, and provide comments. More
than 75% of concordance in response was set to reach the consensus. Result: KOH mount
microscopy was recommended as a point of care testing. Fungal culture was
recommended in chronic, recurrent, relapse, recalcitrant and multisite tinea cases. Topical
monotherapy was recommended for naïve tinea cruris and corporis (localised) cases, while
a combination of systemic and topical antifungals was recommended for naïve and
recalcitrant tinea pedis, extensive lesions of corporis and recalcitrant cases of cruris and
corporis. Because of the anti-in`ammatory, antibacterial and broad spectrum activity,
topical azoles should be preferred. TerbinaYne and itraconazole should be the preferred
systemic drugs. Minimum duration of treatment should be 2-4 weeks in naïve cases and >
4 weeks in recalcitrant cases. Topical corticosteroid use in the clinical practice of tinea
management was strongly discouraged. Conclusion: This consensus guideline will help to
standardise care, provide guidance on the management, and assist in clinical decision-
making for healthcare professionals.

Consensus Epidemiology of
Work`ow dermatophytosi…

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(PDF) Expert Consensus on The Management of Dermatophytosis in India (ECTODERM India) 26/02/21 04.45

Rajagopalan et al. BMC Dermatology (2018) 18:6

https://doi.org/10.1186/s12895-018-0073-1

RESEARCH ARTICLE Open Access

Expert Consensus on The Management of

Rajagopalan et al. BMC Dermatology

Dermatophytosis in India (ECTODERM India)

https://doi.org/10.1186/s12895-018-0073-1
(2018) 18:6
1,12*
Murlidhar Rajagopalan , Arun Inamadar2, Asit Mittal3, Autar K. Miskeen4, C. R. Srinivas5, Kabir Sardana6,
Kiran Godse , Krina Patel , Madhu Rengasamy9, Shivaprakash Rudramurthy10 and Sunil Dogra11
7 8

Why you c
Abstract
Background: Dermatophytosis management has become an important public health issue, with a large void in
Rresearch
E S E AinRthe
C Harea
ARof Tdisease
I C L Epathophysiology and management. Current treatment recommendations
Openappear
Access
to
lose their relevance in the current clinical 2scenario. The
1,12* 3 objective of the 4current consensus
5 was to provide
6 an
experience-driven
7 approach
8 regarding the diagnosis
9 and management of tinea
10 corporis, cruris and
11 pedis.

Methods: Eleven experts in the field of clinical dermatology and mycology participated in the modified Delphi
process consisting of two workshops and five rounds of questionnaires, elaborating definitions,
definitio ns, diagnosis and
management. Panel
Murlidhar Rajagopalan members
, Arun Inamadar , Asit Mittal , Autar K. Miskeen , C. R. Srinivas statement,
were asked to mark “ agree”
agree ” or “ disagree”
disagree ” beside each and provide
, Kabir Sardana ,
comments. More than 75% of concordance in response was set to reach the consensus.
Kiran Godse , Krina Patel , Madhu Rengasamy , Shivaprakash Rudramurthy and Sunil Dogra
Result: KOH mount microscopy was recommended as a point of care testing. Fungal culture was recommended in
Abstractrecurrent, relapse, recalcitrant and multisite tinea cases. Topical monotherapy was recommended for naïve
chronic,
tinea cruris and corporis (localised) cases, while a combination of systemic and topical antifungals was
Background:
recommendedDermatophytosis management
for naïve and recalcitrant haspedis,
tinea become an important
extensive lesions public healthand
of corporis issue, with a large
recalcitrant voidofincruris
cases
research in the area of disease pathophysiology and management. Current treatment recommendations appear to
and corporis. Because of the anti-inflammatory, antibacterial and broad spectrum activity, topical azoles should be
lose their Terbinafine
preferred. relevance inandtheitraconazole
current clinical scenario.
should be theThe objective
preferred of thedrugs.
systemic currentMinimum
consensus was toofprovide
duration treatment an
experience-driven
should be 2– approach regarding the diagnosis and“ management
” “ of tinea
” corporis, cruris and pedis.
2–4 weeks in naïve cases and > 4 weeks in recalcitrant cases. Topical corticosteroid use in the clinical
Methods: Eleven experts in the field of clinical dermatology and mycology participated in the modified Delphi
practice of tinea management was strongly discouraged.
Expert Consensus on The Management of
process consisting of two workshops and five rounds of questionnaires, elaborating definitio ns, diagnosis and
Conclusion: This consensus guideline will help to standardise care, provide guidance on the management, and
management. Panel members were asked to mark agree or disagree beside each statement, and provide
assist in clinical decision-making for healthcare professionals.
Dermatophytosis in India (ECTODERM India)
comments. More than 75% of concordance in response was set to reach the consensus.
Keywords:
Result: KOHDermatophytosis,
mount microscopy Consensus, Tinea, Delphi,
was recommended as anaïve,
pointRecalcitrant, Combination
of care testing. therapy
Fungal culture was recommended in
chronic, recurrent, relapse, recalcitrant and multisite tinea cases. Topical monotherapy was recommended for naïve
tinea cruris and corporis (localised) cases, while a combination
Background [3]. The lesions of systemic
may become and widespread
topical antifungals and may was have
recommended
Superficial – forinfections
fungal naïve and are recalcitrant
caused tinea pedis, extensive
by dermato- lesionsnegative
significant of corporis and psychological,
social, recalcitrant cases andofoccupa-
cruris
and corporis.
phytes, Because of themoulds
non-dermatophytic anti-inflammatory,
and commensal
comme antibacterial
nsal and broad
tional health spectrum
effects, and activity, topical azolestheshould
can compromise qualitybeof
preferred.
yeasts Terbinafine and the
[1]. Dermatophytes,
[1 itraconazole
most common shouldcausative
be the preferred systemic drugs.
life significantly [4]. Minimum duration of treatment
should are
agents, be 2assuming
4 weeks highin naïve cases andin> 4developing
significance weeks in recalcitrant Currently, cases.dermatologists
Topical corticosteroid across India use inaretheinundated
clinical
practice oflike
countries tineaIndia
management
[1].Thesewas
[1 strongly discouraged.
organisms metabolise with cases of dermatophytosis presenting with unusual
Conclusion:
keratin and cause Thisaconsensus
range of pathologic
guideline will clinical
helppresenta-
presenta -
to standardise largecare,lesions,
providering withinon
guidance ringthelesions,
lesions
management,, multiple andsite le-
tions,
assistincluding
in clinical tinea pedis, tineafor
decision-making corporis,
healthcare tinea cruris,
professionals. sions (tinea cruris et corporis), and corticosteroid modi-
etc. [2] Although usually painless and superficial, these
[2
Keywords: fied lesions, making diagnosis a difficult bet [5 [5]. This
Dermatophytosis, Consensus, Tinea, Delphi, naïve, Recalcitrant, Combination therapy
fungi can behave in an invasive manner, causing deeper changed face of dermatophytosis has created a real panic
and disseminated infection and should not be neglected negle cted among dermatologists. In addition, chronicity of the dis-
Background [3]. The
ease lesions may
has plagued become unlike
the patients widespread any other and may have
dermato-
*Superficial
Correspondence: fungal infections are caused by dermato-
docmurli@gmail.com significant
logical negative insocial,
condition the psychological,
country [
[55 ]. and
The occupa-
recent
1
Departmentnon-dermatophytic
phytes, of Dermatology, Apollo Hospital,
moulds Chennai,andIndia comme nsal tional healthofeffects, and can compromise
12
Department of Dermatology, Apollo Hospital, Greams Road No: 21, Greams
prevalence dermatophytosis in India the quality
ranges fromof
yeasts
Lane, Off [Greams
1]. Dermatophytes,
Road, Chennai, Indiathe most common causative life significantly
36.6–
36.6 –78.4% [6 [4able
[6] (Table
(T ]. 1).
agents,
Full are information
list of author assumingis available
high significance
at the end of thein developing
article Currently, dermatologists across India are inundated
countries like India [1].These organisms metabolise with cases of dermatophytosis presenting with unusual
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
keratin and cause a range of pathologic clinical
International License presenta - large lesions,), which
(http://creativecommons.org/licenses/by/4.0/
(http://creativecommons.org/licenses/by/4.0/
http://creativecommons.org/licenses/by/4.0/), ringpermits
within ring use,
unrestricted lesions , multiple
distribution, and site le-
tions, including tinea pedis, tinea reproduction in any medium,
corporis, tinea provided
cruris,you givesions
appropriate creditcruris
(tinea to the original author(s) andand
et corporis), the source, provide a link to modi-
corticosteroid
1
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
etc. [2] Although usually painless
12 and superficial, these fied) applies
(http://creativecommons.org/publicdomain/zero/1.0/
http://creativecommons.org/publicdomain/zero/1.0/) lesions,
to themaking diagnosis
data made available a difficult
in this article, bet stated.
unless otherwise [5]. This
*fungi can behave
Correspondence: in an invasive manner, causing deeper
docmurli@gmail.com changed face of dermatophytosis has created a real panic
and disseminated
Department infection
of Dermatology, Apollo and should
Hospital, Chennai,notIndiabe negle cted among dermatologists. In addition, chronicity of the dis-
Content
Department of Dermatology, courtesy
Apollo of Springer
Hospital, Greams Nature, terms
Road No: 21, Greams
ease–has ofplagued
use apply. Rightsunlike
the patients reserved. any other dermato-
Lane, Off Greams Road, Chennai, India
Full list of author information is available at the end of the article logical condition in the country [5]. The recent
© The Author(s). 2018 Open Access This articleprevalence ofthedermatophytosis
is distributed under in India
terms of the Creative Commons Attributionranges
4.0 from
36.6 78.4% [),6which
International License (http://creativecommons.org/licenses/by/4.0/ ] (Table
permits1unrestricted
). use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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Rajagopalan et al. BMC Dermatology (2018) 18:6 Page 2 of 11

Table 1 Epidemiology of dermatophytosis in India

Author (Year) Area Sample size Clinical subtype Predominant dermatophyte isolate M:F Common age group affected
Bhatia et al (2014) [55
[55
55]] North India 202 Tinea corporis T.mentagyrophyte (63.5%) 5.7:1 21–
21–50 years
(39.1%) T. rubrum (31%)
Kucheria et alet(2015)
Rajagopalan [56
[56
56]]Dermatology
al. BMC North India 100 Tinea corporis T. rubrum (46.4%) 1.3:1 21–
21–30 years Page 2 of 11
(31%) T. mentagyrophyte (30.35%)
Naglot et al (2015) [6
[6 ] North-east India
(2018)632
18:6 Tinea corporis T. rubrum (50.15%) 4.4:1 21–
21–40 years
(34.82%) T. mentagyrophyte (30.35%)
Putta et al (2016) [57
[57
57]] West India 80 Tinea corporis T.mentagyrophyte (37.74%) 1.5:1 21
21––40 years
(41.25%) T. tonsurans (28.3%) –
Table
Ramaraj1etEpidemiology
al (2016) [58
Author (Year) [58
58]] of
South India 210in India
dermatophytosis
Area Sample Tinea corporis
size Clinical subtype T. rubrum (48.95%)
Predominant dermatophyte isolate 4:3
M:F 21–
21–40 yearsage group affected
Common
(63.27%) T.mentagyrophyte (44.75%) –
Bhatia et al (2014) [55] North India 202 Tinea corporis T.mentagyrophyte (63.5%) 5.7:1 21 50 years
Gupta et al (2014) [1
[1 ] Central India 100 Tinea unguium
(39.1%) T. rubrum (41%)
(31%) 3.7:1 > 60 years
(52.0%) –
Kucheria et al (2015) [56] North India 100 Tinea corporis T. rubrum (46.4%) 1.3:1 21 30 years
(31%) T. mentagyrophyte (30.35%)
–
The etisolation
Naglot al (2015) [6] of the dermatophyte
North-east India 632 species Tineashows assumption,
corporis T. rubrum (50.15%)which is why creating 4.4:1 21 a40consensus
years is diffi-
minor geographic variations, as a s evident in studies (34.82%)con- T. mentagyrophyte
cult. (30.35%) aspects of pharmacokinetics need
The theoretical –
Putta
ducted et alin(2016) [57] parts
different WestofIndia
India (Table 80 1). Tinea corporis T.mentagyrophyte
not match the(37.74%) clinical response 1.5:1 to21the 40 years
drug in different
(41.25%) T. tonsurans (28.3%)
Despite the increasing prevalence of cutaneous derm- individuals. This factor can be decided only with a good
Ramaraj et al (2016)
atophytosis across[58] theSouth India and especially
world, 210 inTinea
thecorporis
tro- T. rubrum (48.95%)
registry. These alarming aspects 4:3 regarding
21 40 years
regardin g dermatophyt-
(63.27%) T.mentagyrophyte (44.75%)
pics, research in this area has often been neglected; osis and their impact on the quality of life, warrant war rant
Gupta
henceetitalcontinues
(2014) [1] to Central India
be prevalent 100
worldwide, Tinea unguium T.
and poses timely (41%)
rubrumaddress. 3.7:1 > 60 years
(52.0%)
a therapeutic challenge to practitioners [2 [2]. The
American Academy of Dermatology guidelines on the Scope and objectives
management of tinea cruris and corporis were published Dermatophytosis management has become an important
two decades ago, while the recent guidelines by the public health issue with a large void in research in the
The isolation
British Association of ofthe Dermatology
dermatophytefocused speciesonly shows on assumption,
area of disease which is why creatingand
pathophysiology a consensus
management is diffi-
[2].
minor capitis
tinea geographic andvariations, a s evident
onychomycosis [7–in
[7 9].studies
Also, con-the cult. existing
The The theoretical
evidenceaspects of pharmacokinetics
is primarily based on observa-
obser need
va-
ducted in different
treatment parts of India
recommendations (Table
in the 1).
standard textbooks not match
tional cohort thestudies
clinicalrather
responsethantorandomised
the drug incontrolled
different
ofDespite
dermatology the increasing
appear toprevalence
have lost their of cutaneous
relevanc ederm-
relevance in the individuals.
trials (RCT).This factordesigned
Properly can be decided
RCTs will onlybewith a good
required to
atophytosis
current across
clinical
clinical the oworld,
scenari
scenario [10
[10
10]. and especially
]. Thus, in the
the management
manage menttro- of registry. these
address These need alarming
gapsaspects
[10
[10
10,, 11 regardin
11].]. Thereg are dermatophyt-
published
pics, research
dermatophytosis
dermatophyt osisininthis
Indiaareais inhas
needoften
need of anbeen neglected;
evidence-bas
evidence-based, ed, osis and their
guidelines on tineaimpact
capitisonand theunguium
quality of [8, life,
[8 war rant
9]. However,
hence
experienceit continues
experience-driven, to be
-driven, practical
prac prevalent
tical approach worldwide,
from the and
from expertsposesin timely
these areaddress.
not applicable for the treatment of other derm-
a therapeutic
the field [10[10
10,, 11 ].challenge
11]. to practitioners
It was therefore decided to set
decided [2]. upThean atophytosis, like tinea corporis,
corporis , cruris and pedis, in the
Scope and objectives
American
Indian Expert Academy of Dermatology
Forum Consensus
Forum Groupguidelines
Group on the
with the objective current scenario in India.
management
of laying down of tinea
recomm cruris
recommendations and corporis
endations for the –were published
diagnosis
diagnosis and Dermatophytosis
The scope of this management
consensus has is tobecome
bridge an thisimportant
gap and
two decades ofago,
management derm while
dermatophytos the isrecent
atophytosis
atophytos in India. guidelines by the public health
provide issue with a largeapproach
an experience-driven void in research
regarding in the
the
British Association of Dermatology focused only on area of disease
diagnosis pathophysiology
and treatment and management
for dermatophytosis,
dermatophytosis [2].
, including
tinea
Issues capitis and onychomycosis [7 9]. Also, the The
tinea existing
corporis, evidence
tinea cruris is and
primarily based on obser va-
tinea pedis.
treatment
The current recommendations
face of dermatophytosis in the standardin India textbooks
has pos-
pos - tional
The cohort
consensus studies
was rather
planned than randomised
around controlled
three clinical do-
of dermatology
sibly been an outcome appear to of have lost their
a complex andrelevanc
intrigued e in the
inter- trials (RCT).
mains: Properly
definitions, designed diagnosis
laboratory RCTs willand be required
treatment. to
current
play between clinical host,
scenarifungus,
o [10]. Thus,drug the andmanage ment nt,
environme
environment, of address these need this
To our knowledge, gapsis [the
10, first
11]. expert
There consensus
are published de-
dermatophytosis
contributed in India factors,
by multiple is in need of an evidence-bas
including more humid ed, guidelinesbyonthe
veloped tinea capitismethod
Delphi and unguiumfor the[8diagnosis
, 9]. However,and
experience
and warmer -driven, practicalthe
climate, approach
absurdfrouse m theofexperts topicalin these are not of
management applicable for the treatment
dermatophytosis in India. of other derm-
the field [10, 11]. It combinations,
corticosteroid-based was therefore decide d to sed
the increased
increa set use
up an of atophytosis,
This consensuslike tinea corporis ,was
statement cruris and pedis,using
developed in thea
Indian Expert
broad spectrum Forum Consensus
antibiotics, theGro up with
increa
increasingsingthe objective
burden of current scenario
modified Delphi in India. - a rigorous process that mini-
method
of laying down recommpopulation,
immune-compromised endations for thethe diagnosis and
widespread use The bias
mises scope andoffacilitates
this consensus is to bridge
a consensual position this[13
gap
]. and
management
of antifungalsofinderm the atophytos
agricultural is inindustry,
India. and the ques- provide an experience-driven approach regarding the
tionable diagnosis and treatment for dermatophytosis , including
Methods
Issues role of antifungal drug resistance [10–12].
It is important to recognise that, in India, India , registries of tineainvitation
An corporis, to tinea cruris andintinea
participate the pedis.
survey was sent by
The current face
all diseases, of dermatophytosis
including fungal diseases
disea ses in are
Indianot hasmain-
pos - Theinconsensus
mail April 2017, wasto planned
14 experts around
working threein clinical
the fielddo-of
sibly been
tained. It isandifficult
outcome to of a complex
predict and intrigued
the climatic, geographi inter-
geographical cal mains: definitions,
clinical dermatologylaboratory
and mycology, diagnosis
selectedand by treatment.
lead ex-
playtherapeutic
or between changes host, fungus, drug andand
in the incidence environme
prevalence nt, To our
pert Dr.knowledge,
Murlidhar this is the first
Rajagopalan, expert consensus
according de-
to their clin-
contributed
of the fungalbyinfection.multiple factors,
Much ofincludingwhat is more discussedhumid is veloped by the their
ical experience, Delphi method
interest in the for field
the asdiagnosis
reflectedand by
and warmer climate, the absurd use of topical management of dermatophytosis in India.
corticosteroid-based combinations, the increa sed use of This consensus statement was developed using a
broad spectrum antibiotics, the increa sing –burden of modified Delphi method - a rigorous process that mini-
immune-compromised Contentpopulation,
courtesy the widespread
of Springer use terms
Nature, mises bias
of useand apply.
facilitates a consensual
Rights reserved. position [13].
of antifungals in the agricultural industry, and the ques-
tionable role of antifungal drug resistance [10 12]. Methods
It is important to recognise that, in India , registries of An invitation to participate in the survey was sent by
all diseases, including fungal disea ses are not main- mail in April 2017, to 14 experts working in the field of
tained. It is difficult to predict the climatic, geographi cal clinical dermatology and mycology, selected by lead ex-
https://www.researchgate.net/publication/326582078_Expert_Conse…s_on_The_Management_of_Dermatophytosis_in_India_ECTODERM_India
or therapeutic changes in the incidence and prevalence pert Dr. Murlidhar Rajagopalan, according to their clin- Page 4 of 13
of the fungal infection. Much of what is discussed is ical experience, their interest in the field as reflected by
(PDF) Expert Consensus on The Management of Dermatophytosis in India (ECTODERM India) 26/02/21 04.45

Rajagopalan et al. BMC Dermatology (2018) 18:6 Page 3 of 11

their international publications, and further, on their ex- including dermatophytosis, chronic dermatophytosis,
perience in generating guidelines. recurrent dermatophytosis,
dermatophytosis, relapse, trichophytonru-
Eleven experts
experts (listed in the appendix)
appendix) including
including eight
eight brum syndrome, recalcitrant, and body surface area
dermatologists,
dermatol ogists, and three
three mycologists
mycologists finally participa
participa
rticipatedted (BSA). The next two sets of questionnaires were based
in five roun
roundsds of a web-bas
web-based
Rajagopalan et al. BMC Dermatology ed modifi
modifieded Delphi Met
Method hod on a laboratory
laborat ory diagnosis
diagn osis exploring
explo ring the potential
po tential
Page ro3leofof11
role
from April to September
September 2017, to develop develop both a consen- KOH mo mount, fu fungal cuculture, de dermoscopy an and momolecular
sual statement
statement on the management
managem(2018)ent of18:6
dermatophytos
dermatophytos
ophytosis is in techniques to know their implication in the disease
the current alarming
alarming situation
situation of increased
increased incidence,
incidence, as management. The fourth and fifth set of questionnaires
well as the prevalence of dermatophy
dermatophy
rmatophytosis
tosis in India (Fig.
(Fig. 1). were based on understanding the current practice in
The literature on dermatophytosis was first reviewed the management of varied tinea presentations. The par-
using key-words like “tinea infection”infection”, “superficial fungal ticipants were also asked to justify their choices.
their international
infections”
infections ” etc. to publications,
retrieve relevant and articles
further, on
on epidemi-
their ex-
epidem i- including
More than dermatophytosis,
75% of concordance chronic dermatophytosis,
in response was ne-
perience
ology, in generating guidelines.
pathophysiology, and management for exploration recurrent
cessary dermatophytosis
to reach consensus. ,Expertsrelapse, trichophytonru-
arrived at this rela-
inEleven expertsDelphi.
the modified (listed All
in the appendix)
experts answeredincluding eight
each round brum low
tively syndrome,
figure for recalcitrant,
consensusand body
based on surface area
Delphi after
dermatol ogists,
(five rounds, 10 and three mycologi
questions each) by sts finally
e-mail. participated
Questions for (BSA).
testing The next two
the initial sets ofires
questionna
questionnaires questionnaires
with very high were based
variabil-
in five
the rounwere
rounds ds offirst
a web-bas
tested ed for modifi ed Delphi
feasibility Method
and clarity by on in
ity a laborat ory This
response. diagnrequired
osis explorestructuring
ring the po tential
of theroques-
le of
from non-participants,
four April to Septemberprior 2017,totodiffusion
develop both
to thea consen-
expert KOH m
tions ountredefinin
and re, fdefinin
ungal cgultwhat
defining ure, deisrmconcordance
oscoordance
conc py and mofor lecuthe
f or lar
sual
panelstatem
(EP).ent
Eachon Delphi
the managem
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interest. The expert panel first achieved consensus on the defini-
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consensus on the definitions for the terminologies the first Delphi round.

Fig. 1 Consensus Workflow

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Fig. 1 Consensus Workflow

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Citations (52) References (64)

... 5 However, it is necessary to consider the patient's need, site and extent of involvement, the presence of
comorbidities, the involvement of underlying vascular impairment, and the possibility of drug interactions before starting
the treatment in elderly patients. 1, 5 Thus, individualized treatment is generally advocated for the elderly. 5,13 A range
of clinical factors such as physiological changes, comorbidities, polypharmacy, limitations in personal care, and type
and extent of infection should be considered before deciding appropriate treatment for dermatophytosis in older people
( Figure 1). 2 In elderly patients, topical therapy is preferred for the treatment of dermatophytosis. ...
... Systemic therapy is indicated only in case of failure of topical therapy, extensive lesions and recalcitrant cases. 1 In
addition, shorter treatment duration and fewer daily applications seem ideal in elderly patients. 2,13 Among oral drugs,
terbinaYne is preferred over azole antifungal agents due to its low propensity for drug-drug interactions, thus making it
suitable treatment agent in elderly patients with comorbid medical conditions and on polytherapy. ...
... 2,13 Among oral drugs, terbinaYne is preferred over azole antifungal agents due to its low propensity for drug-drug
interactions, thus making it suitable treatment agent in elderly patients with comorbid medical conditions and on
polytherapy. 1, 2 Evidence suggest low potential use of griseofulvin in the elderly patient due to its low cure rates and
high relapse rates. 2 It is also associated with prolonged duration of treatment, especially in onychomycosis, since it
persists for only a short duration (~2 weeks) after the treatment is discontinued. 14 Furthermore, the treatment of
onychomycosis in a diabetic elderly patient should be targeted at preventing bacterial infections and associated
complications. ...

Expert consensus on management of dermatophytosis in elderly patients, patients with comorbidities, and
immunocompromised status: an Indian perspective
Article Full-text available
Dec 2020
Jayakar Thomas · Anchala Parthasaradhi · A. K. Bajaj · Bikash Kar

View Show abstract

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(PDF) Expert Consensus on The Management of Dermatophytosis in India (ECTODERM India) 26/02/21 04.45

... 14,15 This could be due to growing urbanization, overpopulation, poverty, nonadherence to standard care, and other
factors related to host immunosuppression like diabetes, HIV/AIDS, and immunosuppressive medications. 16
Currently, limited data is available on effectiveness of different topical antifungal agents due to lack of evidence-based
studies. 17 Eberconazole, a topical broad-spectrum imidazole derivative is widely used for the treatment of Tinea
corporis and cruris. ...
... They also favored use of combination therapy or systemic antifungal therapy in patients with recalcitrant infections.
16 For extensive infections, topical antifungal agents may also be used as an adjunct to oral antifungal therapy. 14,32
Per the Cochrane review on topical antifungal treatment, systemic therapy is preferred in chronic and recalcitrant
infections. ...
... 36 Experts have also advised continuing topical antifungal agents or systemic antifungal therapy for two weeks post
clinical cure. 16 There were a few limitations to this study. Due to the observational, real-world design, the response
rates and compliance to all scheduled follow-up visits were lesser than those observed in interventional clinical trials
with set duration of treatment. ...

Effectiveness and safety of eberconazole 1% cream in Indian patients with Tinea corporis and Tinea cruris: a
prospective real-world study
Article Full-text available
Dec 2020
Jayakar Thomas · Siddhartha Das · Sunil Ghate · Ravindra Kale

View Show abstract

... This changed face of dermatophytosis has resulted in prolonged duration of antifungal therapy, partial treatment
response, and many times, treatment failure. [1] [2][3] Despite the availability of multiple antifungal agents, the
management of dermatophytosis is still challenging. 4 Currently in India, topical imidazole's and allylamines are the
most commonly used antifungal drugs for the management of dermatophytosis. ...
... Dermatophytic infections are one of the commonest skin infections in India, with an increase in the incidence of
diqcult-to-treat cases. [1] [2][3] Despite the availability of multiple antifungal agents, increasing MIC values to
commonly used antifungal agents, and the misuse of topical steroids has led to distressing relapses in patients in
recent times. 4 With a lack of recent studies on the eqcacy of antifungals in the current scenario, dermatologists are
using hit-and-trial methods, since the results of studies of antifungal effectiveness conducted many years ago cannot
be extrapolated to the current scenario. ...
... 4 With a lack of recent studies on the eqcacy of antifungals in the current scenario, dermatologists are using hit-and-
trial methods, since the results of studies of antifungal effectiveness conducted many years ago cannot be extrapolated
to the current scenario. [1] [2][3][4] We evaluated the eqcacy and safety of the recently launched novel antifungal
Ciclopirox Olamine 1% in management of patients with localized tinea infection in real world setting in India. The results
of our study also justify that the effectiveness of ciclopirox in patients who have not responded to other antifungal
drugs. ...

Effectiveness and safety of ciclopirox olamine in patients with dermatophytosis: a retrospective cohort
analysis
Article Full-text available
Dec 2020
Vinay Saraf · Satyaprakash Mahajan · Gaurav Deshmukh · Hanmant Barkate

View Show abstract

... This changed face of dermatophytosis has resulted in prolonged duration of antifungal therapy, partial treatment
response, and many times, treatment failure. [1] [2][3] Despite the availability of multiple antifungal agents, the
management of dermatophytosis is still challenging. 4 Currently in India, topical imidazoles and allylamines are the
most commonly used antifungal drugs for the https://doi.org/10.18231/j.ijced.2020.070 ...
... Dermatophytic infections are one of the commonest skin infections in India, with an increase in the incidence of
diqcult-to-treat cases. [1] [2][3] Despite the availability of multiple antifungal agents, increasing MIC values to
commonly used antifungal agents, and the misuse of topical steroids has led to distressing relapses in patients in
recent times. 4 With a lack of recent studies on the eqcacy of antifungals in the current scenario, dermatologists are
using hit-and-trial methods, since the results of studies of antifungal effectiveness conducted many years ago cannot
be extrapolated to the current scenario. ...
... 4 With a lack of recent studies on the eqcacy of antifungals in the current scenario, dermatologists are using hit-and-
trial methods, since the results of studies of antifungal effectiveness conducted many years ago cannot be extrapolated
to the current scenario. [1] [2][3][4] We evaluated the eqcacy and safety of the recently launched novel antifungal
Ciclopirox Olamine 1% and the most commonly used topical antifungal Luliconazole 1% with background systemic
antifungal therapy in the management of dermatophytosis. ...

Effectiveness and safety of Ciclopirox Olamine compared to that of Luliconazole in management of patients
with multi-site dermatophytosis on background itraconazole therapy
Article Full-text available
Dec 2020
Gaurav Deshmukh · Bela Shah · Deepti Ghia · Neha Jangid

View

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(PDF) Expert Consensus on The Management of Dermatophytosis in India (ECTODERM India) 26/02/21 04.45

... 13 Keratolytic reduces hyperkeratinization and scales by increasing desquamation process thus helps in reducing
fungal load by increasing the shedding of stratum corneum where dermatophytes resides. 1, 7 Keratolytics can also be
helpful in increasing the penetration of antifungal agent by removal of scales and superYcial part of stratum corneum
thus improving the antifungal activity. 14,15 Various clinical trials have shown the better eqcacy with combination of
antifungal agent plus keratolytic in tinea infections. ...
... ECTODERM India guidelines also recommend the combination of topical antifungal with 3 -6% salicylic acid. 1
Goldstein AO et in their review recommend the use of 3% salicylic acid in management of tinea infections. 23 Saoji et al
in their study concluded that "Salicylic acid peel is a cheap and useful option in the treatment of dermatophytic
infection". ...

The menace of hyperkeratotic tinea infection: A new therapeutic combination on horizon

Article Full-text available
Feb 2021
Mukesh Girdhar · Shrichand G Parasramani · Amarkant Jha · Gaurav Deshmukh

View

... Dermatophytosis usually deface patients carrying the infection, though its treatment have been successful with oral
or topical antifungal agent such as terbinaYne, griseofulvin, `uconazole, itraconazole, and other oral azole antimycotics
[4,[10][11][12]. The current expert consensus on the management of dermatophytosis in India suggests the use of
topical azoles, and systemic use of TerbinaYne and itraconazole for the treatment of dermatophytosis, with a minimum
treatment duration of 2 -4 weeks in new cases and >4 weeks in recurrent cases [13] . Problem of recurrence of infection,
which is typical in dermatophytic infection, occur which results in long-term use of antifungal agents as seen in the
consensus report in India [13]. ...
... The current expert consensus on the management of dermatophytosis in India suggests the use of topical azoles,
and systemic use of TerbinaYne and itraconazole for the treatment of dermatophytosis, with a minimum treatment
duration of 2 -4 weeks in new cases and >4 weeks in recurrent cases [13]. Problem of recurrence of infection, which is
typical in dermatophytic infection, occur which results in long-term use of antifungal agents as seen in the consensus
report in India [13] . Notwithstanding, there are increasing reports of resistance to common antifungal drugs used for
the treatment of dermatophytic infections [14][15][16][17]. ...

In Vitro Susceptibility of Dermatophytes to Anti-Fungal Drugs and Aqueous Acacia nilotica Leaf Extract in
Lagos, Nigeria
Article Full-text available
Jan 2021 · JBISE
Muinah Fowora · Faustina U. Onyeaghasiri · Abdul Lateef O. Olanlege · Olumide O. Adebesin

View

... The mechanisms involved in generating immunologic reactions in the skin are complex, with epidermal Langerhans
cells, other dendritic cells, lymphocytes, microvascular endothelial cells, and the keratinocytes themselves all
participating in one way or another. 11 Dermatophytes usually invade the outer layers of skin (i.e., remaining restricted
to the stratum corneum) and do not invade living tissue. Homologous autoimplantation leads to the immune system
being exposed to dermatophyte strains, allowing it to mount a delayed type of hypersensitivity response to
dermatophyte antigens with the production of Th1 cytokines (e.g., inteleukin-2, -4, -5, and -8; interferon-γ; and tumor
necrosis factor α) and causing activation of natural killer and cytotoxic cells. ...

Autoimplantation Therapy in Extensive and Recalcitrant Dermatophytosis: A Case Series

Article
Jan 2021
Sumir Kumar · Amandeep Kaur · Sukhmani Kaur

View Show abstract

... Through this keratolytic mechanism, topical SA may work synergistically with and increase the eqcacy of topical
antifungals in the treatment of hyperkeratotic Tinea Pedis. Several reports have shown the usefulness of SA in the
management of hyperkeratotic Tinea Pedis [6] [7][8]. ...

Usefulness of Luliconazole 1% and Salicylic Acid 3% as FDC Cream in the Treatment of Hyperkeratotic Tinea
Pedis
Article
Jan 2020
Dhiraj S. Dhoot

View

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(PDF) Expert Consensus on The Management of Dermatophytosis in India (ECTODERM India) 26/02/21 04.45

... Itraconazole is also a preferred treatment for tinea incognito and administered at a dose of 200-400 mg daily, for a
minimum duration of 4-6 weeks or more. 2 Amongst the variety of azoles, itraconazole has a distinct in vitro activity
against dermatophytes. It is characterized by good oral absorption, and accumulates in the tissue due to its highly
lipophilic nature. ...

Management of dermatophytosis with a novel itraconazole formulation: a research survey

Article Full-text available
Dec 2020
Susmit Haldar

View Show abstract

... Authors commented that while using combination therapy drugs from two different class should be used for wider
coverage, synergistic or additive action and to reduce the chance of resistance. 6, 14 In our study 90.0% (n = 60)
patients were previously treated with combination of oral and topical azole. ...

Effectiveness and safety of combination of Itraconazole and AmorolYne in management of patients with
recalcitrant multi-site dermatophytosis who failed previous combination antifungal therapy
Article Full-text available
Dec 2020
Gaurav Deshmukh · Vishalakshi Vishwanath · Pradnya Londhe · Dhiraj Dhoot

View

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