“CLINICO STUDY O Disser M.D. (DERMA DEP M THE TAMIL EPIDEMIOLOGICAL, MYCOLO OF CHRONIC DERMATOPHYT rtation submitted in partial fulfilment of t Requirements for the degree of ATOLOGY, VENEREOLOGY & BRANCH XX PARTMENT OF DERMATOLOG MADRAS MEDICAL COLLEGE CHENNAI - 600 003 LNADU DR. M.G.R. MEDICAL UNI CHENNAI MAY - 2019 OGICAL TOSIS” the LEPROSY) GY IVERSITY
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“CLINICO EPIDEMIOLOGICAL, MYCOLOGICAL
STUDY OF CHRONIC DERMATOPHYTOSIS”
Dissertation submitted in partial fulfilment
M.D. (DERMATOLOGY, VENEREOLOGY & LEPROSY)
DEPARTMENT OF DERMATOLOGY
MADRAS MEDICAL COLLEGE
THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY
CLINICO EPIDEMIOLOGICAL, MYCOLOGICAL
STUDY OF CHRONIC DERMATOPHYTOSIS”
Dissertation submitted in partial fulfilment of the
Requirements for the degree of
(DERMATOLOGY, VENEREOLOGY & LEPROSY)
BRANCH XX
DEPARTMENT OF DERMATOLOGY
MADRAS MEDICAL COLLEGE
CHENNAI - 600 003
THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY
CHENNAI
MAY - 2019
CLINICO EPIDEMIOLOGICAL, MYCOLOGICAL
STUDY OF CHRONIC DERMATOPHYTOSIS”
of the
(DERMATOLOGY, VENEREOLOGY & LEPROSY)
DEPARTMENT OF DERMATOLOGY
THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY
CERTIFICATE
This is to certify that the dissertation titled
“CLINICO EPIDEMIOLOGICAL, MYCOLOGICAL STUDY OF
CHRONIC DERMATOPHYTOSIS” is a bonafide work done by
DR.KARUNYA.S, Post graduate student of the Department of
Dermatology, Venereology and Leprosy, Madras Medical College,
Chennai - 3, during the academic year 2016 - 2019. This work has not
previously formed the basis for the award of any degree.
Prof. Dr. A. RAMESH, Prof Dr.U.R. DHANALAKSHMI,
M.D., D.D.,DNB, (DVL) MD.,D.D., DNB Professor,
Professor, Professor and Head, Department of Dermatology, Department of Dermatology, Madras Medical College, Madras Medical College, Chennai- 600 003 Rajiv Gandhi Govt.General Hospital, Chennai- 600 003.
Prof.Dr.R.JAYANTHI, MD., FRCP(Glasg).
Dean, Madras Medical College & Rajiv Gandhi Govt General Hospital,
Chennai - 600 003.
DECLARATION
The dissertation entitled “CLINICO EPIDEMIOLOGICAL,
MYCOLOGICAL STUDY OF CHRONIC DERMATOPHYTOSIS”
is a bonafide work done by Dr. KARUNYA S, Department of Dermatology,
Venereology and Leprosy, Madras Medical College, Chennai - 3,
during the academic year 2016 - 2019 under the guidance of
Prof. DR. A. RAMESH M.D., D.D., DNB (DVL) Professor, Department of
Dermatology, Madras Medical College, Chennai -3.
This dissertation is submitted to The Tamil Nadu Dr. M.G.R. Medical
University, Chennai towards partial fulfillment of the rules and regulations for
the award of M.D Degree in Dermatology, Venereology and Leprosy
(BRANCH – XX)
Prof. Dr. A. RAMESH, M.D.,D.D.,DNB (DVL),
Professor, Department of Dermatology,
Madras Medical College,
Chennai - 600 003.
DECLARATION
I, Dr.KARUNYA. S, solemnly declare that this dissertation titled
“CLINICO EPIDEMIOLOGICAL, MYCOLOGICAL STUDY OF
CHRONIC DERMATOPHYTOSIS” is a bonafide work done by me at
Madras Medical College during 2016 - 2019 under the guidance and
supervision of Prof.U. R.DHANALAKSHMI, M.D., D.D., D.N.B., Professor
and Head of the Department, Department of Dermatology, Madras Medical
College, Chennai-600003.
This dissertation is submitted to The Tamil Nadu Dr. M.G.R. Medical
University, Chennai towards partial fulfillment of the rules and regulations for
the award of M.D Degree in Dermatology, Venereology and Leprosy
(BRANCH – XX).
(DR. KARUNYA S)
PLACE :
DATE :
SPECIAL ACKNOWLEDGEMENT
My sincere thanks to Prof.Dr.R.JAYANTHI MD., FRCP(Glasg)
Dean, Madras Medical College, Chennai-3 for allowing me to do this
dissertation and utilize the Institutional facilities.
ACKNOWLEDGEMENT
I am grateful to Prof. Dr. U.R. DHANALAKSHMI, M.D., D.D.,
D.N.B., Professor and Head of the Department, Department of Dermatology,
Madras Medical College, for her advice, guidance, motivation and
encouragement for my study.
I would like to express my sincere and heartfelt gratitude to
Prof. Dr. S. KALAIVANI, M.D., D.V., Director and Professor, Institute of
Venereology, for her kindness and support throughout the study.
I sincerely thank My Guide Prof. Dr. A. RAMESH, M.D., D.D.,DNB,
Professor, Department of Dermatology, for his valuable support. He has been a
source of constant motivation and encouragement throughout the study. I am
extremely grateful to him for guiding me throughout the study.
I sincerely thank Prof. Dr. S. NIRMALA MD., Professor, Department
of Dermatology for her constant help and support.
I thank Prof. Dr. R. PRIYAVATHANI ANNIE MALATHY, M.D.,
D.D., D.N.B., M.N.A.M.S., Professor, Department of Dermatology for her
advice and encouragement.
I thank Prof. Dr.V.SAMPATH, M.D., Professor Department of
Dermatology for his invaluable guidance, advice and encouragement.
I wish to thank Prof. Dr.S.KUMARAVEL M.D., D.D., and
Prof.Dr.J.MANJULA M.D., DNB., former Associate Professor, Dermatology
for theirs support and motivation
I humbly thank my Co-Guide, Dr.R.MADHU, M.D.,(DERM).,D.C.H.
Assistant professor, Department of Dermatology for her valuable guidance
throughout my work. I would like to express my sincere and heartfelt gratitude
for the time which she devoted for my research project.
I extend my gratitude to DR.V.N.S.AHAMEDSHARIFF, M.D.D.V.L.,
Dermatophytoses of Hair � Tinea capitis � Tinea barbae � Dermatophytic
folliculitis Majocchi’s granuloma
Dermatophytoses of nails (onychomycosis): Onychomycosis is a term used for all fungal infections of the nail and includes those due to dermatophytes as well as nondermatophytes
Tinea corporis is most commonly caused by T. rubrum; however, the
inflammatory type is caused by T. verrucosum, T. mentagrophytes, M. canis,
and M. gypseum. The most common causative agents for Tinea cruris, Tinea
pedis, and Tinea manuum are E. floccosum, T. rubrum, and T.
mentagrophytes.12 The typical incubation period is 1 to 3 weeks.45
TINEA CORPORIS:
Synonyms: Tinea circinata/ Tinea glabrosa / Ringworm of the body.
Tinea corporis is ringworm of glabrous skin. Fungi affects non hairy
skin of body like trunk and limbs excluding scalp, nails, groin, beard, face,
hands and feet. T.rubrum, T.mentagrophytes, M.canis and rarely M.audounii
are the common organisms causing tinea corporis.13 In case of family members
of children with Tinea capitis and wrestlers, T.tonsurans is commonly isolated.
25
T.corporis in wrestlers called as Tinea gladiatorum. They present singly or
multiple erythematous, circinate lesions, in plaques, papules, vesicles or
pustules, with centrifugal growth, in such a way periphery is more active, with
a tendency to central healing.80 When granulomatous infections occur, and
with pustules around the follicles, it is called Majocchi granuloma.
Inflammation is minimal with Tinea corporis when compared to Tinea capitis
or Tinea barbae. Pustules, vesicles or frank bulla are seen in case of
inflammatory lesions.13,80
Variants of Tinea corporis include Tinea profunda, Tinea imbricata,
granuloma). T.profunda is characterized by kerion like lesion with a red boggy
pustular surface.80(table-8)
Table-8: Variants of Tinea Corporis12
Type Organism Clinical feature
Tinea profunda T. verrucosum An intense inflammatory reaction against zoophilic fungi can result in large pustular lesions or a kerion with a red, boggy, pustular surface. The follicular pustules represent the deep invasion of organism into hair follicle
Majocchi’s granuloma (dermatophytic granuloma)
T. rubrum Women with tinea pedis or onychomycosis who shave their legs, get perifollicular papulopustules or granulamatous nodules. This dermatophytic folliculitis is a foreign body granulomatous reaction in the dermisafter response to the fungal elements because of follicular rupture
Tinea imbricate
T. concentricum Plaque with erythematous concentric annular rings
Bullous tinea corporis
T. rubrum Intense inflammatory response causes vesicles at the margins
26
TINEA IMBRICATA:
One type of chronic recurrent dermatophytosis is Tinea imbricata (TI),
caused by anthropophilic dermatophytes T.concentricum which has many local
synonyms such as Kaskado in Papua, Kihis in Central Kalimantan, Chimbere
in Bolivia, and Le pita in Tokelau island. It is endemic in certain parts of the
world, for instance in Polynesia (“Tokelau” ), and in Brazil (Mato grosso and
Cmazônia), where it is called “chimberê”.6 TI is endemic in several remote and
isolated tropical areas in South Pacific, South-East Asia, Central and South
America, and Mexico.1 It is a genetically mediated and race dependent
dermatophytosis. Inherited as autosomal recessive which affects both sexes and
all ages. Infection starts as a scaling ring, centrifugal spread follows, but within
the area of central clearing a second wave of scaling soon arises and it is
repeated further to produce concentric rings. Whole body can be affected and
its natural course is prolonged. Intense puritis leads to lichenification.
Hypopigmentation may also be seen.6
MAJOCCHI’SGRANULOMA:
It is commonly seen in women with Tinea pedis or onychomycosis.
Fungus affects dermal and subcutaneous tissue and it is present in two forms,
namely perifollicular papule or nodule in immunocompetant individuals and
deep nodular plaque or abscess form in immuo-compromised patients
Pathogenesis is due to fungal elements in the dermis after follicular rupture
eliciting a foreign body granulomatous reaction. Hair follicle acts as a
27
reservoirand so lesionsinvolving hair follicles are usually resistant to treatment
It is the dermatophytosis of groin, surrounding pubic area, perineum and
perianal areas. Tinea cruris is common in men who wear tight fitting garments.
It is the second most common dermatophytosis in the World after Tinea pedis.
It is more common in men than women and in the adults more than
children.12T.rubrum, T.mentagrophytes and E.floccosum are the most common
organisms isolated. It is common in hot and humid climate characterized by
itchy, erythematous plaques, with sharp margin extending from groin to thighs.
T.rubrum mostly causes chronic nodular infection and it extends from groin to
buttock, abdomen and lower back. The lesions produced by T.mentagrophytes
are vesicular and inflammatory.13
TINEA FACIEI:
Glabrous facial skin infection of dermatophytes is called Tinea faciei.
T.mentagrophytes, T.rubrum and T.tonsurans are the most common organisms
isolated13. It excludes moustache and beard areas of adult males, clinically
characterized by well circumscribed plaques with elevated margins and central
clearing. Cheek, nose, periorbital area, chin and forehead are the most common
sites involved. Simple papules, flat patches of erythema, few vesicles or
pustules can occur due to steroid application. Due to photosensitivity and
28
frequent absence of scaling it can be confused with discoid lupus
erythematosus or polymorphic light eruption.80 Examination of scalp is
important to rule out glabrous type of Tinea capitis.7
TINEA BARBAE:
Synonym: Ringworm of beard, Barber’s itch.
Trichomycosis affecting the beard areas of face and neck with hair
shaft invasion. T.veruccosum and T.mentagrophytes are the common species
causing Tinea barbae. M.canis, T.violaceum, T.schonleinii, T.rubrum and
T.tonsurans are other species isolated occasionally.13 (table-9)
TABLE-9 : CLINICAL TYPES OF TINEA BARBAE12,80
Clinical types
Organism
Clinical feature
Deep inflammatory Zoophilic organisms like T.mentagrophytes
var.
mentagrophytes
and T.verrucosum
The clinical presentation is severe with intense inflammation and multiple follicular pustules resembling kerion . Hairs are loose or broken, and depilation is easy and painless. Constitutional symptoms such as malaise, fever, and lymphadenopathy may be present; scarring alopecia may develop
Superficial Anthropophilic T. violaceum
Lesions similar to bacterial folliculitis with mild erythema along with perifollicular papules and pustules, leading to exudation and crusting
Circinate T.rubrum Dry scaly erythematous lesions with active border and central clearing resembling tinea corporis. Hairs are usually spared
29
TINEA MANUUM:
Dermatophytosis of palmar aspect of hand is called Tinea manuum.
Infection of dorsal surface of hand is referred as Tinea corporis, T.rubrum,
E.floccosum and T.mentagrophytes and rarely T.violaceum and T.erinacei are
mostly islolated. Most common clinical presentation is diffuse hyperkeratosis
of palm and fingers with characteristic accentuation of flexural creases.13
TINEA CAPITIS:
Synonyms: Ringworm of scalp, Tinea tonsurans, Herpes tosurans.
Dermatophyte infection of scalp hair shaft is Tinea capitis. Children in
the age group between 3 to 14 years of age are most commonly affected. Adult
and adolescents are protected, because of the fungistatic nature of sebum, but it
can occur in any age group. Infection can be ectothrix and endothrix, in which
arthroconidia are seen outside and within the hair shaft respectively. Organisms
causing ectothrix are M.audouinii, M.canis, M.equinum, M.ferrugineum.
Endothrix is caused by T.tonsurans, , T.violaceum, T.yaoundei,T.soundanense,
T.gourvilii.13 E.floccossum and T.concentricum wil not cause scalp hair
infection . Clinical presentation may be inflammatory, non-inflammatory or
mixed type. Kerion, favus, abscess and pustular types are inflammatory types
while grey patch, block dot, sebrorrheic dermatitis like, alopecia areata like and
glabrous type are the non-inflammatory manifestations.80
TINEA UNGIUUM AND ONYCHOMYCOSIS:
Fungal infection of nail is called as onychomycosis. Dermatophytic
infection of nail is called as Tinea unguium. T.rubrum, T.mentagrophytes and
30
E.floccosum are the most common organisms isolated. Onychomycosis
clinically presents as Distal lateral subungual onychomycosis, White
superficial onychomycosis, Proximal subungual onychomycosis, Endonyx and
Total dystrophic onychomycosis.13
Most common clinical presentation is distal lateral subungual
onychomycosis. T.rubrum is the common etiologicalagent isolated. Clinically
presents with subungal hyperkeratosis with discolouration of distal and lateral
aspect of nail. In proximal subungal type of onychomycosis, infection starts at
the cuticle and gradually spreads upto the tip of nail and it is the most common
in patients with AIDS.80T. interdigitale is the most common organism causing
Superficial white onychomycosis and it produces white patches or pits on the
nail surface. Black superficial onychomycosis is caused by melanized non
dermatophytic fungus – Neocytalidium dimidiatum. Endonyx is due to infection
ofT.soudanese and T.violaceum. Crumbling and disappearanceof nail plate
expose hypertrophic nail bed and is seen in total dystrophic
onychomycosis.13,80
TINEA PEDIS:
Dermatophytic infection of soles and interdigital web spaces of the feet
is called tinea pedis. It is more common in adult males wearing shoes due to
occlusion and maceration of the toe clefts. T.rubrum, T.mentagrophytes and
E.floccosum are common organisms isolated in patients with Tinea pedis.13
Various clinicalmorphologies include chronic scaly hyperkeratotic (Moccasin),
ii. T.interdigitale13 Fast growing White powdery surface with creamy center
Tan or reddish brown with pale edge
Spherical microconidia in clusters -macroconidia present
iii.
T.mentagrophytes13
Rapidly growing
Intensely granular surface is fully white or cream centre, edge- thinner, spiky/ stellate
Yellow, tan or red brown
Spherical microconidia in grape like clusters, spiral hyphae and thin walled cylindrical macroconida may be present.
42
iv. T.tonsurans13 Slow growing Velvety/ powdery surface grey, cream yellow in color ,surface circlular or radial folds are present
Chocolate brown/mahogany or yellow.
Variable micro conidiae – balloon shaped /clavate microconidia and stacked matches like macroconidia – large numbers chlamydoconidia seen microconidia are present.
v. T.schonleinii13 Glabrous/velvety heaped and the periphery is folded with fringe of hyphae at the edge of medium
White to cream Pale Dichotomously branching hyphae with flattened tips
vi. T.verrucosum13 Slow growing White or grey waxy - 26 deg c – short hyphae along with terminal chlamydoconidia clavate or elongate microconidia along the sides of hyphae - rat tailed macroconidia
vii. T.violaceum13 Slow growing
Waxy or leathery in texture Deep purple to red in color
- Micro and macro conidia are usually absent. Chlamydoconia and distorted hyphae may be present.
viii.
T.soundanense13
Slow growing Glabrous/leathery/ brittle in texture with characteristic stellate/eye lash fringe around the edge. Color apricot to yellow
- stiff and brush like hyphae, regularly septate with zigzag appearance of arthroconidia
43
Table 12: Genus Microsporum and Epidermophyton:7,13
Agent Colony Surface Reverse Microscopy
M.audouinii Glabrous to velvety like a mouse fur
White to tan colour,silky growth , thicker, downy white surface
Salmon pink to tan colour
Terminal and intercalary chlamydoconidia seen. racquet hyphae present
M.canis Rapid growth Coarse colones. fluffy to wooly / hairy texture. Surface White to pale yellow
Deep yellow to orange
Macroconidia –large spindle shaped, thick walled .it has an asymmetrical knob ,it has up to 16 cells
M.gypseum Rapidly growing
Floccose or powdery growth in texture. Cinnamon colured . Surface buff / fawn
Range from colorless to deep mahogany brown
macroconidia seenas clusters in large numbers. cylindrical to fusiform shaped,echinulations present, thin walled 4 to 6 septa seen- racquet and pectinate hyphae may be present
Epidermophyton
floccosum13 Grows rapidly form velvety or sude like colonies with central or radial folds
Khakhi or olive green
Light to dark brown
Large clavate macroconidia maximum of upto six cells seen, apex rounded. Microconidia – absent Chlamydoconidia – large numbers in older cultures.
DERMATOPHYTE IDENTIFICATION: This is done on the basis of
colony characteristics,physiologic tests and microscopic morphology.
Dermatophytes can be distinguished based on the appearance of macroconidia.
Few physiological tthere to confirm the identification of some species. In
additionto this special amino acid tests and requirements of vitamin can
differentiate trichohyton species from others. The property of the organism to
44
hydrolyse urea is used to differentiate T.mentagrophytes (urease positive) and
T. rubrum (urease negative).94
c. Hair perforation test
The colonies to be tested is inoculated on the sterile hair suspended in
distilled water supplemented along with yeast extract and incubated at 28
degree celsius for 2 weeks. The hair is then examined for wedge shaped
penetrations that are perpendicular to the hair axis.7 The test is positive in case
of T. mentagrophytes and M.canis .Penetrations are not seen with T.rubrum and
M.equinum.94
d. Urease test
The colonies to be tested is inoculcated in to the sterilized urea agar
base and is mixed with sterile molten agar ,then it is incubated at 28 degree
celsius for 7 days. Hydrolysis of urea is observed by T.mentagrophytes and
turns the color from yellow to magenta red, while T.rubrum does not.94
e. Vitamin test
Vitamin test help us to differentiate Trichophyton species based on their
requirement of vitamins for growth . T.tonsurans,T.concentrum and
T.violaceum require thiamine. T.verucosum requires thiamine and inositol,
while nicotinic acid is required for T.equinum, T.meigninii uses histidine.
Agar free inoculum from soa medium is inoculated into Trichophyton agar 1-7
namely Agar – 1: casein based – vitamin free and it is used as control,Agar 2: –
like, striae, depigmentation with scaling etc. Patients with steroid modified
tinea require longer duration of treatment.
In our study, among the scrapings from 100 patients with KOH
positivity subjected to culture in modified SDA, 83% showed isolates positive
for dermatophytes which was higher than 52%, that was observed by Karthika
et al107,41.3% by Prasad et al110,68% by Zachariya et al102,66.6% by Senthamil
86
selvi et al in 199855 and 71% observed by Bindhu et al116 , but was lower than
87.3% reported by Ghosh et al.36
In this study, Trichophyton mentagrophytescomplex was the most
common dermatophyte(63.9%) and Trichophyton rubrum(31.3) being the
second common isolate.this is in contrast to the studies on chronic
dermatophytosis such as Sentamil selvi et al,3 Karthika et al,48 Prasad et al110
and Zachariya et al102 whichis shown in the table-
Table 37 Studies on Chronic Dermatophytosis
Study T.rubrum T.mentagrophytes
Senthamil selvi et al 1998 64.5% 25%
Karthika et al at 2016 46% 34.6%
Prasad et al at 2016 17.3% -
Zachariya et al 41.2% 11.8%
Current literature in India is not available to know the prevalence of
T.mentagrophytes complex among the patients with chronic
dermatophytosis.However this study on chronic dermatophytosis is in con
cordance with the observations of other studies like Kumaran et al17(67.34%
and 22.4%), Jagadesh et al 18(64% and 12%),Noronha et al19(48.3% and
38.3%), Kaur et al25(48.2% and 32%),Kansara et al 23(46.43 % and
24.29%),Kainthola et al24(42.85% and 28.15%) of T.mentagrophytes and
T.rubrum respectively .This reflects the change in the trend of the causative
organism of dermatophytes in India which is considered as one of the most
87
important factorsthat has led to the increased prevalence of chronic and
recurrent dermatophytosis.
In this study inflammatory lesions were seen in 71.7% of the patients
from whom T.mentagrophytes complex was isolated and 15.3% of the
patients with T.rubrum as isolate. It is a known observation that inflammatory
lesions are produced by zoophilic organism but in the current scenario of
increased prevalence of T,mentagrophytes complex ,speciation is very pertinent
to decide on the anthropophilc or zoophilic species of the organism .However
speciation of T.mentagrophytes complex has evolved into a complex issue as
most of the patients with inflammatory lesions do not give history of contact
with animals.T.rubrum has always been known to be the major causative agent
of chronic dermatophytosis charecterised by non inflammatory lesions.
Inflammatory lesions seen due to T.rubrum warrants further studies. It is not
known whether inflammatory lesions in the absence of contact with animals
due to T.mentagrophytes or T.rubrum could be due to the local
immunosuppression produced by the rampant abuse of TSAF combination
creams, virulence of the organism, increased fungal load or theinterplay
between the host immunity and the organism. Noniflammatory lesions were
seen in 86.6% of patients with T.rubrum isolate and 15.3% of patients with
T.mentagrophytes complex isolate. The clinical presentation of lesions
produced by the former is mostly large geographic,diffuse, scaly , lichenified
or hyperpigmented which is similar to the observations by Senthamil selvi et
al3 in 2000 and Karthika et al48.
88
LIMITATION :
Speciation of T.mentagrophytes complex could not be done due to the
non availability of research laboratory facilities
89
CONCLUSION
� Most common age group affected was 21-30 years followed by 31-40 years
� Females were predominantly affected than males
� Proportion of patients belonging to both lower and middle socioeconomic
status was almost equal
� Most of the patients were from urban and semiurban areas
� Housewives were most commonly affected followed by manual labourers
� Most of the patients had infection for more than 6 months to 1 year
� Episodic manifestations are common, with more than 3 episodes being
common than continuous clinical manifestations
� Most of the patients had used over the counter drugs, while almost half of
the patients had used topical steroid anti fungal combination creams
� Diabetes mellitus was the most common association in this study
� Use of topical steroid anti fungal combination creams, poor compliance,
sharing of fomites, wearing leggings/jeans, synthetic dresses and unwashed
dresses kept in wardrobe, spending time more than 2 hours in kitchen
during noon were some of factors that played a role in predisposition to
chronic dermatophytosis
� Infection of multiple family members were noted in most of the patients
� Most of the patient with chronic dermatophytosis had more than 40% BSA
� Occurrence of multiple clinical types in an individual patient was more
common than single type.
90
� Overall, Tinea corporis was the most common clinical presentation
followed by tinea cruris
� Multiple combination of tinea corporis and tinea cruris was the most
common clinical presentation seen among the various combination clinical
types
� In patient who had abused TSAF combination creams, various clinical
presentations observed were erythema, atrophy, ring within ring
appearance(tinea pseudoimbricata), pustules, vesicles and erythrodermic
forms.
� Culture was positive in 83 patients
� Trichophyton mentagrophytes complex was the most common organism
isolated followed by Trichophyton rubrum, Trichophyton tonsurans,
Trichophyton verrucosum and Microsporum gypseum.
� Majority of the patients infected by T.mentagrophytes complex presented
with inflammatory lesions
� Most of the patients from whom T.rubrum was isolated had non
inflammatory lesions
In the past predisposing factor for chronic dermatophytosis considered
were obesity, diabetes mellitus, immunosuppresion, atopy, etc. but in the
current scenario of tinea epidemic, in India rampant abuse of topical steroid
creams, sharing of fomites, wearing synthetic tight clothing and poor
compliance seems to play a major role in predisposition to chronicity of
dermatophytosis.
91
The exact reason for the shift of the organismfrom T.rubrum which has
been the most common organism implicated in chronic dermatophytosis
worldwide to T.mentagrophytes remains an enigma which necessitates further
studies on the environmental factors ,mycological, antifungal susceptibility ,
molecular and genomic aspects of dermatophytosis.
BIBLIOGRAPHY
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48. 48.Karthika Sivaprakasam, Balaji Govindan,A Clinico-Mycological Study of Chronic Dermatophytosis of More Than Years Duration
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ANNEXURES
10.1 ABBREVIATIONS
SDA - Sabouraud Dextrose Agar
KOH - Potassium Hydroxide
GMS - Gomori Methamine Silver
PAS - Periodic Acid Schiff
SES - Socio Economic Status
MIC - Minimum Inhibitory Concentration
OTC - Over The Counter
HIV - Human Immunodeficiency Virus
MALDITOF - Matrix Associated Laser Desorption Ionization Time Of
Fight Mass Spectrometry
TSAF - Topical Steroid Antifungals
TI - Tinea Imbricata
DTM - Dermatophyte Test Medium
PCR - Polymerase Chain Reaction
RFLP - Restriction Fragment Length Polymorphism ,
AFLP - Amplified Fragment Length Polymorphism ,
RAPD - Random Amplified Polymorphic Dna
10.2 PROFOMA
Case No:
Name: Age: Sex: OP No:
Address: Occupation: Phone number:
Rural /urban: Community: Income:
CHIEF COMPLAINTS:
Duration: Total -
Present illness - Frequency:
TREATMENT HISTORY:
Historyof selfmedication/OTC drugs/prescription from doctors
Site of involvement: Tineacorporis/ T.axillaris/ T.cruris/ T.glutealis/
T.faciei/ T.manuum/Glaborous type of T.capitis
Size of lesions:
Number of lesions:
Shape:
Surface:
Periphery of lesions:
Ring within ring appearance:
Erythema:
Pustules:
Pigmentation:
Diffuse scaling:
Vesicular:
Granulomatous/Verrucous
Others:
Palms and soles:
Nails:
Scalp, hair, mucosa:
INVESTIGATIONS
1. Blood haemogram
2. Blood sugar
3. RFT
4. LFT
5. Serum electrolytes
6. Potassium hydroxide mount
7. Culture
TREATMENT GIVEN: topical and Systemic antifungals
10.3 INFORMATION TO PARTICIPANTS
Investigators : Dr.S. Karunya
Dr.A.Ramesh
Dr.R.Madhu
Name of Participant:
Title: CLINICO EPIDEMIOLOGICAL AND MYCOLOGICAL STUDY OF
CHRONIC DERMATOPHYTOSIS
You are invited to take part in this study. The information in this document is meant to help you decide whether or not to take part. Please feel free to ask if you have any queries or concerns
We are conducting a study on“CLINICO EPIDEMIOLOGICAL AND
MYCOLOGICAL STUDY OF CHRONIC DERMATOPHYTOSIS” among patients attending Rajiv Gandhi Government General Hospital, Chennai
• And for that your participation may be valuable to us.
• The purpose of this study is to determine the epidemiology, clinical profile, associated co morbid condition and various predisposing conditions of chronic dermatophytosis.
• In this study history of patient will be taken, examination will be done and clinical photographs will be taken without disclosing the identity of patients, sample from patient(scales)will be subjected to KOH mount and examined under light microscope for fungal hyphal elements, if found positive fungal culture will be done. Routine blood test will be taken and specific treatment will be given based on diagnosis.
• The privacy of the patients in the research will be maintained throughout the study. In the event of any publication or presentation resulting from the research, no personally identifiable information will be shared.
• Taking part in this study is voluntary. You are free to decide whether to participate in this study or to withdraw at any time; your decision will not result in any loss of benefits to which you are otherwise entitled.
• The results of the special study may be intimated to you at the end of the study period or during the study if anything is found abnormal which may aid in the management or treatment.
Signature of Investigator Signature of the Participant
10.4 PATIENT CONSENT FORM
Title of the study:
CLINICO EPIDEMIOLOGICAL AND MYCOLOGICAL STUDY OF
CHRONIC DERMATOPHYTOSIS
Name of the Participant:
Name of the Principal investigator : Dr.S. Karunya.
Name of the Institution : Rajiv Gandhi Government General
Hospital, Chennai
Documentation of the informed consent
1. I ___________________________ have read the information in this form (or it has been read for me). I was free to ask any questions and they have been answered. I am over 18 years of age and exercising my free power of choice, hereby give my consent to be included as a participant in the study.
2. I have read and understood this consent form and the information provided to me.
3. I have had the consent document explained to me.
4. I have been explained about the nature of the study.
5. I have been explained about my rights and responsibilities by the Investigator.
6. I am aware of the fact that I can opt out of the study at any time without having to give any reason and this will not affect my future treatment in this hospital
7. I hereby give permission to the investigators to release the information obtained from me as result of participation in this study to the sponsors, regulatory authorities, govt. agencies and IEC.I understand that they are publicly published
8. I have understood that my identity will be kept confidential if my data are publicly presented.
9. I have had my questions answered to my satisfaction.
10. I have decided to be in the research study
11. I am aware that if I have any question during this study, I should contact at one of the addresses listed above. By signing this consent form I attest that the information given in this document has been clearly explained to me and apparently understood by me. I will be given a copy of this consent document.
Name and signature/thumb impression of the participant (or legal representative if participant incompetent)