Table 3 Dermatophytosis (Tinea Corporis, Cruris and Pedis) management pearls in Indian settings

Diagnosis

1. Microscopic examination of 10% KOH mount should be the point of care testing for dermatophytosis.

 a) Skin scrapings should be collected from the edge of the lesions.

 b) Transportation should be in dry black strong paper.

2. Sensitivity and specificity of diagnosis depend on

 a) Adequacy of the sample

 b) Appropriateness of the sample collection

 c) Personnel expertise

3. Fungal culture should be reserved in

 a) Recalcitrant and multisite tinea cases.

4. Dermoscopy examination helps to delineate vellus hair involvement

 a) Vellus hair involvement requires systemic therapy.

Management

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.

Management of Trichophyton Rubrum Syndrome

1. Identify predisposing host environmental factors

2. Establish the diagnosis:

 a) Clinically (Involvement of two or more noncontagious sites, hands, feet, nails, absence of deeper lesions)

 b) Investigation: KOH positivity from all sites, culture positive from at least one site

3. Check for factors such as concomitant HIV infection, use of immunosuppressive etc.

Their presence may suggest other diagnosis.

4. 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:

 a. Itraconazole 200 mg/ day, for 4–6 weeks. Therapy may be extended till complete clinical resolution.

 b. Combination of Itraconazole 200 mg/day and Terbinafine 250 mg/day for 4–6 weeks or extended periods.

 c. Itraconazole 200 mg twice a day × 7 days/month, for 3–5 months, depending on the clinical response.

 d. Topical Luliconazole/Sertaconazole once/twice a day, for 6 weeks or Topical Terbinafine/Amorolfine, twice daily, for extended periods.

5. Taking care of fomites/household contacts.

6. Fungal Culture and antifungal susceptibility tests, if facility is available.

7. If nails are involved, onychomycosis should be suspected and treated accordingly.

8. 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.