Expert Consensus on the Management of Dermatophytosis in India
BioMed Central (BMC Dermatol) Journal: ECTODERM
India
Superficial fungal infections are caused by dermatophytes,
non-dermatophytic moulds and commensal yeasts. Dermatophytes, the most common
causative agents, are assuming high significance in developing countries like
India.
Currently, dermatologists across India are inundated with
cases of dermatophytosis presenting with unusual large lesions, ring within
ring lesions, multiple site lesions (tinea cruris et corporis), and
corticosteroid modified lesions, making diagnosis a difficult bet.
Dermatophytosis management has become an important public
health issue. 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.
TAKE HOME MESSAGE:
This consensus guideline will help to standardise care,
provide guidance on the management, and assist in clinical decision-making for
healthcare professionals.
KOH mount microscopy was recommended as a point of care
testing. Fungal culture was recommended in chronic, recurrent, relapse,
recalcitrant and multisite tinea cases.
The majority of the experts recommended the use of topical
therapy in the management of naïve cases of tinea cruris and corporis
(localised lesion) while combination therapy is recommended in recalcitrant
tinea cruris & tinea
pedis. .
Experts recommended
that topical azoles should be the empiric agent of choice in the management of
naïve and recalcitrant cases, while no consensus was formed for systemic
antifungal agent of choice.
In case of systemic antifungal agents, experts preferred
either terbinafine (250 mg once
daily) or itraconazole (100 mg
– 200 mg/day) in naïve cases whereas itraconazole
(200 mg - 400 mg/day) was preferred in recalcitrant cases.
The minimum duration of the treatment should be
2–4 weeks in naïve tinea cruris and more than 4 weeks in recalcitrant
cases.
In case of tinea incognito, where corticosteroids had been
used, experts recommended abrupt stoppage of corticosteroids except in settings
of steroids induced rosacea, where it is withdrawn in few days.
The panel recommended Itraconazole 100 mg–200 mg,
twice daily, for the treatment of tinea incognito. The duration of the therapy
should be 4–6 weeks or more, in tinea incognito.
Experts recommended that the treatment should be continued
for 2 weeks, post clinical cure for topical agents, whereas systemic therapy
should be continued in recalcitrant cases only.
Looking at the current explosion of dermatophytosis in India,
experts unanimously rejected the role of topical corticosteroid in the
management of dermatophytosis.
Doubling of the dose in case of systemic antifungal agents is not required in case of naïve tinea cases, while in the case of recalcitrant tinea infections, doubling the dose is strongly favoured for terbinafine (500 mg/day), while a consensus could not be reached for doubling the dose of itraconazole.
Doctors Liked to Read More
Stress on the importance of regularity of medication and
adherence to the advice of the physician.
Avoid use of tight clothing. Sharing of bed linen, towels and
clothes should be avoided.
Undergarments, socks, and caps should be regularly washed and
dried in the sun and ironed.
Patients should be assessed for associated conditions like
excessive sweating or obesity which may lead to recurrence. Hence in such
patients, frequent change of clothing, use of absorbent powders and deodorants
(decrease perspiration), and weight loss should be encouraged.
In case of tinea pedis, medicated powders can be used
prophylactically. Use of occlusive footwear and use of slippers in public
washrooms should be avoided.
Foul smelling and macerated lesions point towards secondary
bacterial infection, and should be treated appropriately, using either systemic
or topical antibacterial agent.
1. The choice of the antifungal depends
on
a) Pharmacological properties
b) History of prior exposure to antifungals
c) The site and extent of the lesion
d) Skin area involved (dry/sebum rich), and the age of
patient
2. Naive and recalcitrant tinea pedis
cases to be treated empirically with a combination of topical and systemic
antifungals.
3. Naïve tinea cruris and corporis
(localised lesion) cases to be treated empirically with topical antifungals
alone. For extensive lesions and recalcitrant cases, a combination of topical
and systemic antifungals should be used.
4. Topical azoles should be the drug of choice, since they exert
anti-inflammatory, antibacterial and broad spectrum antimycotic activity.
5. Preferred systemic agents for naïve
tinea cases are terbinafine 250 mg daily
or itraconazole 100 mg–200 mg daily, and in recalcitrant cases, itraconazole 200 mg–400 mg daily. A
higher dose of systemic antifungals can be considered in certain cases
including deep inflammatory, multisite lesions, non-responders, T. rubrum
syndrome.
6. The minimum duration of treatment
should be 2–4 weeks in naïve cases and > 4 weeks in recalcitrant cases.
7. Systemic therapy should be considered
in villous hair involvement.
8. Abrupt withdrawal of
corticosteroids should be practised in tinea incognito, with Itraconazole, 200
mg – 400 mg daily, for a minimum duration of 4–6 weeks or more.
9. Topical corticosteroid use in
clinical practice of tinea management is strongly discouraged.
10. Adjuvant therapies like
antihistamines, salicylic acid and moisturisers play important role in the
management.
11. Baseline LFTs and periodic
monitoring to be considered during systemic therapy and the elderly.
12. Empiric therapy of choice in
paediatric age group is topical antifungals alone. Systemic agents like
fluconazole and terbinafine to be reserved for extensive lesions and
recalcitrant cases.
13. In the elderly, and patients with
comorbid conditions, the treatment should be individualised.
14. In pregnancy, topical antifungals
are the agents of choice in any trimester.
A. Antifungals are to be used for a
longer period, and can go up to 3 months. Sometimes They may have to be
combined with other antifungals. Some options are:
1. Itraconazole 200 mg/ day, for 4–6 weeks. Therapy may be
extended till complete clinical resolution.
2. Combination of Itraconazole 200 mg/day and Terbinafine
250 mg/day for 4–6 weeks or extended periods.
3. Itraconazole 200 mg twice a day × 7 days/month, for 3–5
months, depending on the clinical response.
4. Topical Luliconazole/Sertaconazole once/twice a day, for
6 weeks or Topical Terbinafine/Amorolfine, twice daily, for extended periods.
B. Taking care of fomites/household
contacts.
C. Fungal Culture and antifungal
susceptibility tests, if facility is available.
D. If nails are involved,
onychomycosis should be suspected and treated accordingly.
E. Assuring patient compliance for the
need of continuous therapy till complete clearance of infection from all sites,
use of a topical drug in a proper manner and quantity, etc.
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