The rise of drug-resistant fungal infections, notably Trichophyton indotineae, is emerging as a significant health concern in India. This resilient dermatophyte, linked to the misuse of topical steroids, poses challenges for both patients and healthcare providers. 

Imagine battling a skin infection that refuses to heal despite multiple treatments. This is the reality for many who face infections caused by Trichophyton indotineae, commonly known as ringworm or jock itch. First identified in India, this fungus has now spread to several countries worldwide. The inappropriate use of steroid creams has exacerbated the problem, making this strain particularly hard to treat. 

Shyam Verma, one of the world’s leading experts in dermatophytosis and based at Nirvan Skin Clinic, Vadodara, Gujarat, emphasises the need for careful classification: “It’s premature to label it Trichophyton indotineae based on a few cases. This dermatophyte, found in various regions including Australia and Oman, belongs to genotype VIII within the T. mentagrophytes/T. interdigitale species complex,” he says. 

Clinical Challenges and Symptoms 

Patients often present with persistent, treatment-resistant rashes that can easily be mistaken for eczema or other skin conditions, delaying effective treatment. These rashes can be red, scaly, and itchy, making them similar to more common dermatological issues. The misdiagnosis of these infections often leads to the use of ineffective treatments, which not only prolongs patient suffering but also allows the infection to worsen. 

The diagnostic process involves not just clinical examination but also laboratory tests, such as fungal cultures and molecular diagnostics, to confirm the presence of resistant fungal strains. Educating patients about the importance of following through with recommended tests and treatments is vital. Misdiagnosis and delayed treatment can lead to the spread of the infection, not only worsening the individual’s condition but also increasing the risk of transmission within the community. 

Ravi (name changed), a patient managing Trichophyton indotineae, shares, “I experienced persistent rashes for months, and was misdiagnosed initially as eczema. Once correctly identified, the appropriate treatment made a significant difference. However, the infection spread among my family members, and the relentless itching was unbearable.” His experience underscores the importance of accurate diagnosis and specialised care in managing these infections effectively. By improving diagnostic accuracy and educating both healthcare providers and patients, we can better manage and treat these challenging infections, ultimately reducing their impact on public health. 

Treatment options 

Trichophyton indotineae is a newly-identified dermatophyte species that has been found in  near-epidemic form on the Indian subcontinent. This fungus, identical to genotype VIII within the T. mentagrophytes/T. interdigitale species complex, was described in 2019 by sequencing the Internal Transcribed Spacer (ITS) region of ribosomal DNA. More than 10 ITS genotypes of T. interdigitale and T. mentagrophytes can now be identified. T. indotineae causes inflammatory and itchy, often widespread dermatophytosis affecting the groins, gluteal region, trunk, and face, affecting patients of all ages and genders. 

Resistance to terbinafine due to genetic mutations in the squalene epoxidase gene is a significant concern. Additionally, growing resistance to another major antifungal, itraconazole, is also an area of concern. For infections resistant to standard antifungal medications, alternative treatments such as itraconazole may be necessary. However, these alternatives often come with significant side effects, including gastrointestinal issues, liver toxicity, and interactions with other medications, and will require close monitoring by healthcare providers. 

Dr. Verma explains, “One of the major reasons this is happening is not only because of the topical steroid combinations being used, but also because the itraconazole drug formulations available are not of good quality. This results in suboptimal dosing, even if patients take it as prescribed. Unregulated sales of steroid-containing combination creams that may temporarily reduce the itch but contribute to resistance further complicate treatment efforts.” 

In addition to antifungal medications, integrating comprehensive skin care regimens can enhance treatment efficacy. This includes maintaining skin hydration, using barrier creams to protect affected areas, and avoiding irritants that can exacerbate the condition. Proper skin care supports the healing process and reduces the likelihood of recurrent infections. 

Regular follow-ups with healthcare providers are essential to ensure effective management. Monitoring the patient’s response to treatment allows for timely adjustments to the treatment plan. This might include altering dosages, switching medications, or incorporating additional therapies to address side effects or emerging symptoms. 

Dr. Verma emphasises the complexity of treating this infection: “We don’t even know whether only steroid use is the reason for its resistance or if it inherently does not respond to itraconazole. Practical challenges include identifying the infection through routine tests and the necessity of genomic sequencing, which is only available in academic settings.” 

Patients are also encouraged to adhere strictly to the prescribed treatment regimen, even if symptoms improve before the medication course is completed. This adherence is crucial in preventing the recurrence of the infection and reducing the risk of developing further resistance.

Prevention strategies 

Healthcare professionals strongly advise against the unsupervised use of combination creams containing steroids and antifungals, as these can contribute to drug resistance and worsen infections. Public awareness campaigns are crucial to inform the public about the risks of self-medication and the importance of consulting healthcare professionals for skin conditions. 

Of course, the bottom line is that maintaining good hygiene practices is key to preventing the spread of these infections. Keeping the skin dry and clean is essential since moisture creates an ideal environment for fungal growth. Regularly washing and drying areas prone to sweating, such as the feet, groin, and armpits, can help reduce this risk. Avoiding sharing of personal items like towels, clothing, and grooming tools is another important preventive measure. These items can carry fungal spores and spread the infection. Wearing breathable clothing, particularly loose-fitting fabrics like cotton, helps keep the skin dry and reduces sweating.

In communal environments such as locker rooms and showers, it’s important to wear sandals to prevent picking up fungi from the floor. Proper footwear, along with regular cleaning of bed linens, towels, and clothing in hot water, can kill fungal spores and reduce the risk of infection. 

Jyothi Jayaraman, a senior member of the special interest group IADVL Dermatophytosis, and Assistant Professor in the Department of Dermatology, Father Muller Medical College, Mangalore, advises: “Simple measures such as regular washing of personal items and maintaining personal hygiene can greatly reduce the spread of these infections. Educating the public about these practices is essential.” 

Educating oneself about the signs and symptoms of fungal infections can also help in seeking early treatment. Maintaining a healthy lifestyle by boosting the immune system through a balanced diet, regular exercise, and adequate sleep is also beneficial. By incorporating these practical tips into daily routines, we can significantly reduce the incidence and spread of drug-resistant fungal infections. 

Continuous research is essential to understand the genetic basis of resistance in Trichophyton indotineae and to develop new treatment strategies. Collaborative efforts between dermatologists, researchers, and public health officials are necessary to tackle this growing threat.

Public health concerns in India 

Indians, living in a land that has a tropical climate and high population density, are particularly vulnerable to fungal infections. The prevalence of Trichophyton indotineae is a growing public health concern, especially in rural areas where access to healthcare is limited. Public health initiatives must focus on improving diagnostic facilities and ensuring the availability of effective treatments. 

Dr. Verma adds, “Dermatophytosis has been a rising challenge in India, only now gaining the spotlight, which is regrettable. More studies need to be done, and we need to call it based on the species it represents and not assign it to a particular country.” 

Through prudent medication use, public education, good hygiene practices, and ongoing research, we can combat these infections and improve patient outcomes. Healthcare providers and the public must remain vigilant and proactive in addressing this emerging threat. 

(Dr Monisha Madhumita is a consultant dermatologist at Saveetha Medical College, Chennai and member of the International Alliance for Global Health Dermatology, London, UK. mail.monisha.m@gmail.com )