European Journal of Cardiovascular Medicine

Dermatophytosis is a superficial fungal infection of keratinized tissues caused by dermatophytes belonging primarily to the genera Trichophyton, Microsporum and Epidermophyton. Although tinea infections have long been common in tropical countries, the clinical landscape in India has changed substantially, with dermatologists increasingly encountering extensive, chronic, recurrent and treatment-refractory disease. This shift has transformed a traditionally uncomplicated superficial infection into a condition associated with prolonged symptoms, repeated treatment, financial burden and impaired quality of life. Dogra and Uprety highlighted the emerging problem of chronic and recurrent dermatophytosis in India, while subsequent Indian studies documented high recurrence rates and changing clinico-epidemiological patterns.1,2

Several interacting factors contribute to persistence and relapse. Warm and humid climatic conditions, occlusive clothing, excessive sweating, close household contact, sharing of towels or clothing, diabetes mellitus and obesity can facilitate transmission or prolong infection. In a prospective study from a tertiary centre, Pathania et al. described recurrent disease as a clinically important problem with multiple host, environmental and treatment-related determinants.3 Similarly, tertiary-care data from Kerala showed frequent tinea corporis and cruris, household exposure and substantial previous use of topical steroid-antifungal combinations among patients with chronic disease.4 A case-control study also identified diabetes and family history as important risk factors for chronic or chronic-relapsing tinea.5

Treatment practices have become a central concern. Over-the-counter availability of fixed-dose creams containing potent corticosteroids with antifungal and antibacterial agents can suppress inflammation and pruritus without eradicating the dermatophyte, producing atypical morphology, extension of lesions and delayed recognition. Indian expert recommendations have emphasized avoidance of irrational corticosteroid combinations and adequate duration of antifungal therapy.6 Observational evidence from South Asia further demonstrates frequent self-medication and unsupervised topical steroid use in patients with tinea.7 The IADVL Task Force has therefore stressed treatment adherence, patient counselling, hygiene and management of affected household contacts as essential components of care.8

The therapeutic problem is compounded by emerging antifungal resistance. Clinical-mycological studies have linked elevated terbinafine minimum inhibitory concentrations and squalene epoxidase mutations with reduced therapeutic response.9,10 Molecular studies also documented the widespread emergence of the Trichophyton mentagrophytes genotype later recognized within the T. indotineae complex, alongside steroid misuse and recalcitrant clinical disease.11 More recent Indian reports have reinforced the importance of multiple-site involvement, steroid-modified tinea and recurrent patterns.12–14

The present study was undertaken to characterize recurrent and chronic dermatophytosis among patients attending a tertiary-care dermatology service in coastal Andhra Pradesh. The objectives were to describe demographic and clinical patterns, document previous treatment practices, determine the distribution of clinical severity, and assess whether self-medication, incomplete antifungal therapy and topical corticosteroid-containing combination use were associated with chronicity and greater disease severity.

Study design and setting: This prospective observational study was conducted in the Department of Dermatology, Venereology and Leprosy (DVL), KIMS & RF, Amalapuram, Andhra Pradesh, India, from May 2020 to April 2021. The department provides outpatient and inpatient dermatology services to patients from Amalapuram and surrounding areas of the Konaseema region. Consecutive eligible patients presenting with recurrent or chronic dermatophytosis during the study period were considered for enrolment.

Study population and eligibility: Patients of either sex aged 18 years or older with clinically diagnosed dermatophytosis of glabrous skin were screened. Chronic dermatophytosis was operationally defined as persistent disease for at least six months despite previous treatment or repeated temporary improvement, while recurrent dermatophytosis referred to reappearance of clinically compatible lesions after documented or reported clearance following treatment, consistent with terminology used in Indian literature and consensus recommendations.1,3,8 Patients with isolated onychomycosis or tinea capitis, primary immunodeficiency, major systemic immunosuppression, or insufficient treatment history were excluded. Written informed consent was obtained before enrolment.

Sample size and sampling: Assuming a conservative anticipated proportion of 50% for inappropriate previous treatment practices, a 95% confidence level and 10% absolute precision, the minimum sample size calculated using n=Z²p(1-p)/d² was 96. The target was rounded to 100. Consecutive sampling was used until the required sample was achieved.

Clinical assessment and variables: A structured case-record form captured age, sex, duration of illness, previous episodes, diabetes, overweight/obesity, excessive sweating, family or household history, anatomical sites, pruritus, erythema, scaling, excoriations and post-inflammatory hyperpigmentation. The predominant clinical pattern was classified as tinea corporis, tinea cruris, combined tinea corporis and cruris, tinea faciei, tinea pedis, or mixed/multiple-site disease. Skin scrapings from the active margin were examined with potassium hydroxide microscopy when confirmation was required. Previous treatment exposure included topical and systemic antifungals, self-medication, over-the-counter procurement, pharmacist-directed therapy, topical corticosteroid-containing combinations, premature discontinuation after symptomatic relief, medication sharing and household-contact treatment. These treatment-related variables were selected because inappropriate corticosteroid use and inadequate duration are repeatedly emphasized in Indian management guidance.6,8

Severity assessment: Clinical severity was graded using a standardized composite assessment incorporating body-surface-area involvement, number of anatomical sites and intensity of pruritus/inflammatory signs. Each domain was scored from 0 to 2; total scores of 0-2, 3-4 and 5-6 were categorized as mild, moderate and severe disease, respectively. The same clinical team applied the predefined criteria to reduce observer variation.

Statistical analysis and ethics: Continuous variables were summarized as mean ± standard deviation or median with interquartile range; categorical variables were expressed as frequency and percentage. Associations between treatment practices, disease pattern and severity were tested using Pearson's chi-square test, with Fisher's exact test reserved for sparse cells. Variables with clinical relevance or p<0.10 in bivariate analysis were considered for multivariable logistic regression, with severe dermatophytosis as the dependent outcome. Adjusted odds ratios with 95% confidence intervals were reported, and p<0.05 was considered significant. Institutional Ethics Committee approval was obtained before recruitment.

A total of 108 patients with suspected recurrent or chronic dermatophytosis were assessed for eligibility. Eight were excluded: four did not satisfy the predefined eligibility criteria, two had insufficient treatment histories and two declined participation. The remaining 100 patients were enrolled and included in the final analysis. The mean age was 34.8 ± 11.6 years, with the largest proportions in the 21-30-year and 31-40-year groups. Males constituted 62.0% of the cohort. The median disease duration was 7 months (IQR 4-12); 61 patients had chronic dermatophytosis and 39 had recurrent disease. Household history of dermatophytosis was reported by 42.0% (Table 1).

Table 1. Demographic and baseline characteristics of the study participants

Tinea corporis with tinea cruris was the commonest clinical pattern, affecting 37 patients, followed by isolated tinea corporis in 26 and isolated tinea cruris in 14. Multiple anatomical sites were involved in 58.0% of patients. Pruritus was nearly universal (94.0%), and scaling and erythema were observed in 84.0% and 79.0%, respectively. Based on the composite clinical score, 24.0% had mild, 48.0% moderate and 28.0% severe disease (Table 2).

Table 2. Clinical pattern and severity of dermatophytosis

Previous treatment practices showed substantial unsupervised or incomplete therapy. Self-medication was reported by 68.0%, and 55.0% had obtained over-the-counter topical preparations. Fifty-seven patients had used topical corticosteroid-containing combination creams. Incomplete treatment was reported by 63.0%, including 41.0% who stopped therapy after symptomatic improvement. Only 26.0% reported simultaneous treatment of affected household contacts, while regular washing or ironing of clothes and towels was reported by 37.0% (Table 3).

Table 3. Previous treatment practices among study participants

Chronic dermatophytosis was more frequent among patients who had used topical corticosteroid-containing combinations than among non-users (73.7% vs 44.2%; χ²=8.965, p=0.003). Chronic disease was also more frequent in patients with incomplete treatment (71.4% vs 43.2%; χ²=7.784, p=0.005). Self-medication showed a smaller but statistically significant association with chronic disease (67.6% vs 46.9%; χ²=3.947, p=0.047) (Table 4).

4. Association of selected treatment practices with chronic dermatophytosis

Clinical severity also differed according to treatment exposure. Among steroid-combination users, 40.4% had severe disease compared with 11.6% of non-users (χ²=12.864, p=0.002). Severe disease occurred in 36.5% of patients with incomplete treatment compared with 13.5% of those who completed therapy (χ²=7.573, p=0.023). The severity distribution among self-medicating patients did not reach conventional statistical significance (χ²=5.189, p=0.075) (Table 5).

Table 5. Relationship between treatment practices and clinical severity

In the multivariable model, topical corticosteroid-containing combination use, incomplete antifungal treatment and multiple-site involvement remained independently associated with severe dermatophytosis. Steroid-combination exposure was associated with approximately 3.4-fold higher adjusted odds of severe disease, while multiple-site involvement was associated with approximately 3.2-fold higher odds. Disease duration of at least six months and household history did not retain statistical significance after adjustment (Table 6).

Table 6. Multivariable logistic regression for factors associated with severe dermatophytosis

OR: odds ratio; CI: confidence interval.

The present study demonstrates a substantial burden of persistent dermatophytosis in a tertiary-care population, with chronic disease accounting for 61% and recurrent disease for 39% of the 100 included patients. The mean age was 34.8 years, and nearly two-thirds were male. This age distribution is consistent with Indian reports showing that dermatophytosis disproportionately affects young and middle-aged adults who experience greater occupational exposure, sweating and close-contact transmission.2,3 The predominance of combined tinea corporis and cruris and the 58% frequency of multiple-site involvement also resemble contemporary descriptions of extensive glabrous tinea rather than the more localized patterns historically encountered.12,14

Treatment behaviour emerged as a prominent feature. More than two-thirds of participants reported self-medication, 63% had not completed a prescribed antifungal course and 57% had used a topical corticosteroid-containing combination. Similar patterns have been documented in Indian tertiary-care studies and expert reviews, where potent steroid-containing fixed-dose combinations, easy over-the-counter access and symptom-driven discontinuation have been implicated in steroid-modified and recalcitrant tinea.4,6–8 Corticosteroids rapidly reduce erythema and pruritus, which can create a false impression of cure while local immune suppression permits continued fungal proliferation. The subsequent atypical morphology, wider lesion spread and repeated cycles of treatment complicate both diagnosis and management.

The associations observed in this study reinforce that concern. Chronic disease occurred in 73.7% of steroid-combination users compared with 44.2% of non-users, while severe disease was observed in 40.4% and 11.6%, respectively. Incomplete treatment was likewise associated with chronicity and a shift toward greater clinical severity. These findings are broadly concordant with the multicentric Indian study by Shenoy et al., which identified topical corticosteroid misuse, sharing of fomites and multiple-site involvement as frequent features of chronic and recurrent dermatophytosis.14 Saha et al. also reported substantial steroid exposure among chronic and recurrent cases and emphasized the contribution of both host and treatment-related factors.13 The case-control observations of Singh et al. further support the importance of family history and metabolic comorbidity in persistent disease.5

Antifungal resistance provides an additional biological explanation for treatment failure, although resistance testing was outside the scope of the present study. Indian laboratory investigations have demonstrated elevated terbinafine minimum inhibitory concentrations, squalene epoxidase mutations and reduced clinical response in selected isolates.9,10 Molecular epidemiological work has further shown widespread circulation of the T. mentagrophytes/T. indotineae lineage associated with difficult-to-treat dermatophytosis.11 Therefore, persistent infection should not automatically be attributed to drug resistance; adherence, prior corticosteroid exposure, reinfection from untreated contacts and inappropriate duration must also be examined.

The findings support a practical management approach centred on accurate diagnosis, complete antifungal courses, avoidance of steroid-containing combinations, counselling against self-medication, treatment of symptomatic household contacts and reduction of shared fomites. These measures are consistent with Indian consensus guidance and address several modifiable factors identified in the present cohort.6,8

LIMITATIONS

This study was conducted at a single tertiary-care centre with a modest sample size, limiting generalizability to community populations and other geographic regions. Treatment history depended partly on patient recall, creating potential recall and classification bias. Fungal culture, species-level molecular identification and antifungal susceptibility testing were not performed systematically. The observational design identifies associations but cannot establish a causal relationship between treatment practices and disease severity

Recurrent and chronic dermatophytosis in this cohort was characterized by frequent multi-site involvement and substantial exposure to inappropriate treatment practices. Topical corticosteroid-containing combination creams, incomplete antifungal therapy and self-medication were common, while steroid-combination use and incomplete treatment showed clear associations with chronic disease and greater clinical severity. Multiple-site involvement also independently accompanied severe disease. These findings emphasize the need for early dermatological assessment, rational antifungal prescribing, strict avoidance of irrational steroid combinations, completion of adequate treatment courses and counselling on clothing, hygiene and household transmission. Strengthening patient education and restricting unsupervised access to corticosteroid-antifungal combinations can reduce repeated treatment cycles and the overall clinical burden of persistent dermatophytosis in practice.

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2. Sharma R, Adhikari L, Sharma RL. Recurrent dermatophytosis: a rising problem in Sikkim, a Himalayan state of India. Indian J Pathol Microbiol. 2017;60(4):541-545.
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13. Saha I, Podder I, Chowdhury SN, Bhattacharya S. Clinico-mycological profile of treatment-naïve, chronic, recurrent and steroid-modified dermatophytosis at a tertiary care centre in Eastern India: an institution-based cross-sectional study. Indian Dermatol Online J. 2021;12(5):714-721. doi:10.4103/idoj.IDOJ_909_20.
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