A Study of In vitro Antifungal Susceptibility Patterns of Dermatophytic Fungi at a Tertiary Care Center in Western India.

BACKGROUND: Recent years have seen an alarming rise in the prevalence of recalcitrant and relapsing dermatophyte infections in India associated with lack of clinical response to standard antifungal regimens. AIMS AND OBJECTIVES: A study was undertaken to identify the antifungal susceptibility patterns of dermatophyte species isolated from lesions of dermatophytoses in patients examined at our center. MATERIALS AND METHODS: A total of 85 patients with clinically diagnosed dermatophytoses were subjected to skin scrapings for potassium hydroxide mount (microscopic examination) and culture using Sabouraud's agar medium containing chloramphenicol and cycloheximide (incubated at 30°C). Antifungal susceptibilities [minimum inhibitory concentration-90 (MIC-90)] of the identified dermatophytes were tested for seven systemic and topical antifungal agents (terbinafine, griseofulvin, itraconazole, fluconazole, sertaconazole, ketoconazole, and clotrimazole) using Clinical and Laboratory Standards Institute broth microdilution method (M38-A). RESULTS: Trichophyton rubrum (50%) and Trichophyton mentagrophytes complex (47.2%) were the two major species isolated. Isolates of both showed downy and granular forms (61.11%, 38.89% and 32.35%, 67.65%, respectively). The overall in-vitro susceptibility profiles (MIC-90 ranges in µg/mL) of the seven drugs for T. rubrum and T. mentagrophytes complex respectively were as follows: terbinafine (0.008-0256, 0.016-0.256), griseofulvin (0.03-1, 0.06-1), itraconazole (0.125-2, 0.25-2), fluconazole (0.125-1, 0.25-32), sertaconazole (0.03-1, 0.03-1), ketoconazole (0.06-1, 0.125-1), and clotrimazole (0.03-2, 0.06-1). CONCLUSIONS: This study indicates a rising proportion of T. mentagrophytes complex with increased proportion of granular form (T. mentagrophytes var. mentagrophytes). This study represents the current antifungal susceptibility profile of dermatophytic infections in a tertiary care medical center in western India with rising MICs to terbinafine and itraconazole.

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

BACKGROUND: Dermatophytosis management has become an important public health issue, with a large void in research in the area of disease pathophysiology and management. 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 approach regarding the diagnosis and management of tinea corporis, cruris and 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, diagnosis and management. Panel members were 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-inflammatory, antibacterial and broad spectrum activity, topical azoles should be preferred. Terbinafine 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.

White piedra of scalp hair by Trichosporon inkin.

White piedra is a rare fungal infection of hair and is reported to be all the more rare on scalp. Trichosporon inkin is usually associated with white piedra of pubic hair. We report a case of white piedra of scalp hair caused by T. inkin. This is the first case reported from India and the fifth case reported worldwide. A 50-year-old Muslim female presented with white knots over scalp hair. Diagnosis of Trichosporon was made by examining KOH mounts of epilated hair and Lactophenol Cotton Blue preparations of the growth in culture. Automated mini-API test (for biochemical profiles) and Electronmicroscopy studies (for cell wall structures) helped in identification of the species. Mini-API test was also positive for Cryptococcus curvatus which could be due to similarity in biochemical and physiological properties of the two species. Absence of C. curvatus on culture further supports this view. Topical antifungal therapy resulted in clinical clearance within 2 months. Higher incidence of scalp white piedra is observed in Muslim females; contributing factor being the custom of using a veil, leading to higher humidity and limited sunlight exposure.

Extensive neonatal dermatophytoses.

We report a 25-day-old boy who was referred to our dermatology unit for evaluation of extensive annular erythematous lesions on his body. We initially considered the differential diagnoses of candidiasis and neonatal lupus erythematosus but investigations revealed the case as tinea corporis due to a relatively uncommon causative agent, Microsporum gypseum. To the best of our knowledge it is the first case of extensive neonatal dermatophytoses caused by this organism. The possible causes and the role of steroids in producing the clinical picture in our patient are discussed.

Penicillium marneffei infection: an AIDS-defining illness.

A 29-year-old HIV seropositive male patient from Manipur presented with fever, cough, weight loss and asymptomatic papules and nodules all over the body. Differential diagnoses of secondary syphilis, histoplasmosis, cryptococcosis and penicilliosis were considered. Histopathological and mycological study of the skin biopsy tissue, and blood culture confirmed the diagnosis of penicilliosis. Although penicilliosis, an AIDS-defining illness, is restricted to Southeast Asia, more and more cases are being recognized in non-endemic countries.