Introduction
Dermatophytic infections are superficial fungal infections caused by Trichophyton, Epidermophyton, and Microsporum species. They have undergone a enormous change in the last decade and has changed from a mundane and innocuous infection to a recalcitrant communicable and widespread illness, affecting all age groups. The classical annular itchy lesions are often replaced by cases mimicking other dermatoses. This phenomenal change has become a matter of great concern for the entire population, often causing error and delay in diagnosis. The paediatric population is seen to visit Paediatricians and General Practitioners more frequently than Dermatologists. It becomes imperative to identify the varying clinical manifestations of the disease in various body sites and treat adequately, thereby protecting them from undergoing undesirable therapeutic trials. We have made an attempt to identify the various clinical manifestations and also the factors governing the clinical patterns. The efficacy of laboratory methods in confirming clinical diagnosis and species identification has also been assessed. Though dermatophyte infections are very much rampant in this hot and humid part of the country, studies on children are very few and far between.
Materials and Methods
A prospective observational cross sectional study was undertaken on all patients up to 15 years of age presenting with a clinical picture characteristic/suggestive of a superficial fungal infection attending the Dermatology outpatient department of a tertiary care centre. Institutional ethical committee clearance and parent’s/guardian’s consent was taken. Samples of skin scrapings and infected hair were collected from the patient and subjected to 10% potassium hydroxide mount at the first visit. All cases which showed fungal elements on direct microscopy were included in the first visit; cases with negative results on mycological examination were included after a positive therapeutic response to topical antifungal medications, assessed at 2 weeks .Fungal culture was done on 100 cases, and growth was identified from studying colony characteristics, pigment production and microscopic examination in lactophenol cotton blue preparation. Special tests such as hair perforation test, urease production and slide culture were performed using standard techniques whenever necessary.
Results
A total number of 270 cases were found to be presenting with dermatophyte infections in our study population over a one year period extending from July 2016 to June 2017. A total number of 611 children presented with dermatological manifestations, of which 270 cases presented with dermatophyte infections accounting for a prevalence of 44.1%.
Age ranged from one month of age to 15 years. The maximum number of cases were in the 11 to 15 years age group comprising of 170(62.9%) cases, followed by the 1 to 5 years age group with 45(16.7%) patients. Twenty one (7.8%) cases were less than I year of age, with the youngest being a month old.
There were 146(54%) males and 124(46%) female cases with a male: female ratio of 1.17:1.
Patients presented as early as 4 days to as late as one year from onset of illness. A large number of 75(27.7%) cases presented within 15 days, 121(44.8%) cases presented by 6 weeks of illness. Twenty nine (10.7%) cases presented to us with a one year history, and mostly belonged to the 11-15 years age group.
Family history was positive in 200(74%) cases. Most of our patients had parents from lower to medium socioeconomic status working as farmers, manual laborers, carpenters and painters. In 240(88.9%), Out of the 270 cases, 210(77.8%) cases had history of applying topical medications. Topical corticosteroids ranging from moderate to high potency accounted for 174(82.85%) of the cases. The remaining 36 cases had used ayurvedic and OTC non steroidal preparations. None of our cases had applied calcineurin inhibitors.
The distribution of lesions varied; male patients showed a predominance of lesions over the extremities (M:F=2:1) while female patients showed maximum lesions over the face (M:F=1:2).
Our cases had three forms of presentation (Table 1). We had 270 cases, of which maximum number of cases were tinea corporis with 156(57.8%) cases, followed by tinea faciei with 84(31.1%) cases, tinea cruris with 22(8.14%) cases, tinea pedis with 5(1.8%) and tinea capitis with 3(1.1%)cases. Out of 270 cases, 122(45.2%) cases presented with classical features (Table 1), 80(29.6%) cases showed some diversion in appearance while 68 (25.1%) cases presented with morphological atypia(tinea incognito).
The first group presented as classical (Figure 1) well marginated annular and arcuate lesions over glabrous skin, alopecia and /or swelling over hairy skin. The presenting site was as tinea corporis in 68, tinea faciei (Figure 2) in 32 cases, tinea cruris in 18 cases, tinea capitis in 3 cases and tinea pedis in a single case. It was an interesting observation that out of the 174 cases, 29 cases retained their classical features even after prolonged steroid use and presented in this cataegory.
The second group presented with some alteration in respect to size, colour, margin, surface and scaling, but retained characteristics of a dermatophyte infection. Morphologically they appeared as, diffuse scaling in 32, large scaly patches (Figure 3) in 13, pseudoimbricata in 8, hyperpigmented scaly patches in 7, hypopigmented scaly patches in 3, scaling over ears in 10, and with associated atrophy in 2, striae/telengiectasia in 4, and hypertrichosis& telengiectasia (Figure 4) in 1 patient. They were all cases with history of topical mid and high potency steroids. According to site of involvement, there were 58 cases of tinea corporis, 16 cases of tinea faciei, 4 cases of tinea cruris and 2 cases of tinea pedis.
The third group comprised of 68 cases of tinea incognito, the majority of 65 cases following potent topical steroid abuse while 3 cases presented with 15 days of onset, and denied history of applying any topical product. As per their distribution, they appeared over sites of tinea corporis in 30 cases, tinea faciei in 36 cases, and tinea pedis in 2 patients, Morphologically, they resembled the following conditions: nummular eczema (Figure 5) in 10, atopic eczema (Fig 6) in 7, seborrhoeic dermatitis in 8, pityriasis alba in 6, contact dermatitis in 8, infectious eczematoid dermatitis in 2, insect hypersensitivity in 2, PLE in 6, malar rash in 4, pityriasis rosea in 4, granuloma annulare (Figure 7) in 2, psoriasis in 2, papulopustular lesions in 2, Borderline tuberculoid Hansen’s in 2, prurigo nodularis in 2 and pyoderma in 1 patient.
Out of the 174 cases who had history of topical steroid application, 29(16.7%) cases did not show any alteration in morphology. Eighty (45.9%) cases showed few alterations in surface, scaling, size, colour and margin. Tinea incognito was the presenting pattern in 65(37.3%) cases.
Direct microscopy was positive in 230(85%) cases. Fungal culture could be done in 100 cases only. The positivity rate was 60%. The culture positivity showed the following pattern; Trichophyton rubrum in 36(60%) cases, Trichophyton mentagrophytes in 19(31.7%) cases, Trichophyton tonsurans in 3(5%) cases, Epidermophyton floccosum in 1(1.6%) case, Microsporum canis in 1(1.6%) cases respectively. (Table 1)
Table 1
Total number of cases for each type of clinical presentation with theirsite of distribution, direct microscopy results and fungal culture positivity
Discussion
Our cases showed a prevalence trend of 44.1%. The prevalence of dermatophyte infections in children have been found to range from 11.3% to 48.5% in various studies. 1, 2, 3, 4
Age ranged from one month of age to 15 years. The maximum number of cases were in the 11 to 15 years age group comprising of 170(62.9%) cases, followed by the 1 to 5 years age group with 45(16.7%) patients. This was similar to studies from Eastern and Southern India who reported 51% and 56% cases in the same age group.2, 5 Twenty one (8%) cases were less than I year of age, with the youngest being a month old.
There were 146(54%) males and 124(46%) female cases with a male female ratio of 1.17:1. Male predominance was also observed in other studies showing a ratio of 1.27:1, 1.13:1 and 1.8:1. 1, 5, 6 Male predominance has been observed by authors outside the country also. 7. Boys are found to be more engaged in outdoor activities both through work and play, causing earlier implantation of spores. Females are often more conscious of their appearances and practice better personal and hair hygiene.
Patients were brought early by their parents/guardians with a majority of 121(44.8%) cases presenting by 6 weeks of illness. A smaller group of 21(10.7%) cases, belonging to the 11-15 years age group, presented late.
Family history was positive in 200(74%) cases. A positive family history and/or close contact was seen in (83.84%) and 83% cases by Dash et al and Gandhi et al, who found the most common source of infection to be the mother.
A large majority of 240(88.9%) patients, had parents from lower to medium socioeconomic status working as farmers, manual labourers, carpenters and painters. Other studies have also reported low socioeconomic status in 64% and rural background in 39.39% (1.5).
We had 270 cases, of which maximum number of cases were tinea corporis with 156(57.8%) cases, tinea faciei with 84(31.1%) cases, tinea cruris with 22(8.14%) cases, tinea pedis with 5(1.8%) and tinea capitis with 3 (1.1%) cases. We did not come across any case with nail involvement. Our study differed slightly in respect to pattern of distribution compared to previous studies on paediatric cases where tinea corporis with 45%, 47.4%, 53.12% was closely followed by cases of tinea cruris with 28% 31.25% to 50% cases. Our study had a similar presentation with a study on paediatric tinea incognito, where 46.3% cases corresponded clinically to tinea corporis and 38.9% cases to tinea faciei.1, 4, 5 We had higher number of cases with tinea faciei compared to other studies. The increasing number of cases on the face is a feature more commonly seen in modified / tinea incognito. A large number of our cases had used topical steroids on the face because misdiagnosis was commonest on the face accounting for 36(52.9%) cases of tinea incognito. It also reflects the importance of having a high index of suspicion in cases of lesions involving face which can very easily masquerade common paediatric dermatoses like atopic eczema, seborrhoeic dermatitis and pityriasis alba.
We had fewer number of cases with tinea cruris as compared to previous studies. This could be because of the tendency of self medication of such sites either due to inhibition or due to the familiarity owing to the very high prevalence. There were 3 cases presenting with Tinea capitis (Kerion 2, black dot 1); all were male patients. In earlier studies, authors have found tinea capitis to be the most common pattern. 2, 8 But the present trend is to follow an adult pattern, with less number of Tinea capitis. 6, 9
Out of 270 cases, 68(25.1%) cases presented with morphological atypia (tinea incognito), 80(29.6%) cases showed some diversion in appearance while 122(45.2%) cases presented with classical features (Table 1). Though the majority of 65 cases, showed morphological atypia following topical steroid abuse, some cases presented as mimickers of other dermatoses from the outset. Though the term tinea incognito was originally described in 1968 by Ive and Marks, for the atypical clinical presentation of dermatophytic infections following use of topical or systemic steroids. Atzori et al opines that clinical atypia may be due to variable dermatophyte invasive capacity, the site of invasion, physiology of the individual, and acquired factors such as excessive washing or sun exposure. 10, 11 Conversely, it was seen that prolonged steroid use did not alter the morphology in 29 out of 174 cases.
Direct microscopy was positive in 230(85%) cases, similar to studies on children which showed a positivity of 91.5% and 93.8% respectively. Fungal culture could be done in 100 cases only. The positivity rate was 60%. The culture positivity showed the following pattern; Trichophyton rubrum in 36(60%) cases, Trichophyton mentagrophytes in 19(31.7%) cases, Trichophyton tonsurans in 3(5%) cases, Epidermophyton floccosum in 1(1.6%) case, Microsporum canis in 1(1.6%) cases respectively.(Table 1)
In an earlier study on dermatophytoses, culture was positive in 85.1%, showing maximum cases of Trichophyton mentagrophytes, followed by Trichophyton rubrum, and Trichophyton violaceum.2, 12 A study on tinea incognito in children also showed a similar pattern showing fungal culture positivity in 85.2% cases] where Trichophyton mentagrophytes was isolated in 44.4% of the cases, Trichophyton rubrum in 13% and Microsporum canis in 7.4% of cases.3 These studies show that the culture positivity and the organisms isolated are almost similar in studies on dermatophytoses as well as in tinea incognito, which has been observed in the older population also.
Conclusion
Dematophytoses have undergone a paradigm shift in children and are increasingly involving sites more commonly seen in adults. The dermatophytoses can present atypically from the outset and also under the influence of immunosuppressive drugs. It becomes imperative to have a very high index of suspicion, specially in sites like face which more commonly present with other paediatric dermatoses. An early diagnosis and treatment will prevent the child from troublesome symptoms, spare them from cosmetic embarrasement and protect them from the harmul side effects of hepatotoxic drugs. The silver lining here is the tendency of parents to seek early consultation for their children. This group of patients should be considered a target population whereby we can not only counsel patients and guardians on the importance of early reporting but show them the therapeutic efficacy of adequate and appropriate treatment. The vicious cycle of steroid abuse and recalcitrant dermatoses, which arises from ignorance and negligence can be broken, ensuring a breakthrough in combating this manmade menace of steroid abuse not only in the paediatric population but across all generations.
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