European Journal of Molecular & Clinical Medicine (EJMCM)

ISSN: 2515-8260 Volume 07, Issue 11, 2020

Original research article

A study of the incidence of dermatophyte infections at MGM
Hospital KMC Warangal
Dr. Kakumanu Pradeep Kumar1, Dr. Lakshmi Jyothi2
1Assistant Professor, Department of Microbiology, Surabhi Institute of Medical
Sciences, Siddipet, Telangana, India.
2Additional Professor, Department of Microbiology, AIIMS Bibinagar, Bibinagar,

Yadadri-Bhuvanagiri, Telangana, India

Corresponding Author: Dr. Kakumanu Pradeep Kumar

Abstract
Introduction: In countries like India with tropical hot and humid climates the incidence of
dermatophyte infections is very common. However, the clinical presentations are varied
which may lead to the application of broad-spectrum steroids and other self-medications. We
in this study tried to evaluate the incidence of superficial fungal skin infection confirmed with
laboratory diagnosis and their management.
Methods: The patients were taken from those visiting the Department of Dermatology,
KMC, Warangal. All the suspected cases with dermatophyte infections were included.
Samples were collected from skin, nails, and hairs. The specimens were processed in the
Department of Microbiology with potassium hydroxide (KOH) mount for direct microscopy
and culture. Identification of the organism was based on the colony characteristics,
pigmentation, rate of growth, tease mount using lactophenol cotton Blue preparation, and
slide cultures.
Results: n=150 cases were studied who showed signs and symptoms of superficial
dermatophyte infections. In the current study the category of sample collected for laboratory
diagnosis was n=91 (60.67%) were skin scrapings. N=31 (20.67%) were nail clippings and
n=28 were hair stubs. The fungal isolated obtained shows T. rubrum in 30.8% of cases T.
mentagrophytes in 29.3% cases, T. verrucosum in 26.2% cases, T. violaceum in 9.2% cases,
T. tonsurans in 3% cases, and N. gypsium in 1.5% cases.
Conclusion: This study concludes that the commonest prevalence of dermatophytosis is in
males. The third decade is the most affected age group. T. corporis is a common clinical
manifestation. Trichophyton rubrum was the commonest species of dermatophyte isolated by
culture.
Keywords: Dermatophytosis, Tinea corporis, Tinea unguium, Trichophyton rubrum.

Introduction
Superficial mycoses affect millions of people across the world and the estimated
lifetime risk is about 10 – 20%. Approximately 20 – 25% of the world's population is affected
by this disease. [1] Dermatophytes are the most frequently encountered causative agent of
superficial fungal infections they are caused by a group of closely related keratinophilic fungi
in the Trichophyton, Microsporum, and Epidermophyton. Infection is generally cutaneous;
fungi invade the stratum corneum and are restricted to the nonliving cornified layers because
in immunocompetent hosts the fungi cannot penetrate the deeper tissues or organs. Reactions
to a dermatophyte infection may range from mild to severe because of the host’s response to
the metabolic products of fungus, the causative strain, species, and its virulence, and the local
environmental factors. [2, 3] Dermatophytes are assuming greater clinical significance
developed as well as developing nations due to the common use of immunosuppressive drugs

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and diseases. [4] The hot and humid climate in tropical and subtropical countries like India is
one of the reasons which make dermatophytosis or ringworm a common superficial fungal
skin infection. Species distribution and prevalence vary with the geographical area and during
the time and are governed by environmental conditions, personal hygiene, and individual
susceptibility. [2, 5] The epidemiology of several clinically important dermatophytosis has
changed in recent times. [2, 6] Therefore, a study of dermatophytosis in a population is
important as it may reflect the climatic condition, customs, hygienic and socio-economic
status of the people. [7-9] The clinical presentation is very often confused with other skin
disorders particularly due to rampant application of broad-spectrum steroids and self-
medications, making laboratory diagnosis and confirmation necessary and although it
responds to conventional antifungals, dermatophytosis tends to recur at the same or different
sites. Hence, a correct diagnosis is important to initiate appropriate treatment and essential for
epidemiological purposes. [11-14] Warangal District lies in the Northern part of Telangana and
it is a predominantly tropical climatic area. Although, superficial mycoses are commonly
prevalent in this region a systematic study and analysis have not been made so far. With this
background, we in the present study will be undertaken to isolate and identify the various
etiological agents of dermatophytosis.

Material and Methods

This cross-sectional study was conducted in the Department of Microbiology and
dermatology, MGM Hospital, KMC Warangal. Institutional Ethical committee permission
was obtained for the study. Written permission was obtained from all the participants of the
study. Samples were collected from clinically suspected randomly selected cases of skin, nail,
and hair fungal infections of patients attending the Dermatology OPD. The Collected samples
will be processed in the Department of Microbiology for identification.

Inclusion Criteria
1. All skin, hair, and nail samples of all age groups from clinically suspected cases of
2. dermatophytosis.
3. No history of topical or systemic antifungal therapy for the past two weeks.

Exclusion Criteria
1. Cases of dermatophytosis with secondary bacterial infection, on antifungal treatment
2. and patients on follow-up.

Specimen collection
Skin: Lesions with defined borders were disinfected with 70% alcohol. Small scales scraped
off from the margin by blunt scalpel blade or glass slide. Collected on the sterilized paper
envelope. Hair: Infected scalp hairs were collected over a sterile paper envelope by using
epilation forceps by plucking along with the base of the hair shaft. Nail: Nail cleaned with
70% alcohol. Nail clippings were collected. In superficial white onychomycosis scrapping
from white spots discarding the uppermost layer were collected in sterile black paper.
Samples were processed immediately in the laboratory. Direct microscopic examination by
Potassium hydroxide (KOH) mount was done by using 10% KOH solution for skin scrapings,
infected hairs, and 20%-40% KOH for nail clippings. After keratolysis, the KOH smear
samples were observed under high power objective for the presence of filamentous, septate,
branched hyphae with or without anthrospores. The samples were cultured irrespective of
demonstration of fungal elements by direct microscopy and were inoculated on two tubes of
SDA (Sabouraud Dextrose Agar) with antibiotics (Gentamycin/ Chloramphenicol): one with
actidione and one without actidione, with minor adjustment of pH to 5.4. Inoculation of tubes

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was done at 25°C-30°C for 3-4 weeks and observed weekly for fungal growth. If no growth
was found after four weeks, it was taken as negative for the growth of fungi. Identification
was done based on colony characteristics, pigment production, rate of growth, tease mount
using Lactophenol Cotton Blue preparation and slide culture techniques and urease test and
hair perforation test. Cultures were examined microscopically by removing a portion of aerial
mycelium with a spud and placed on a glass slide into a drop of lactophenol cotton blue and
matted mycelial mass was gently teased with a pair of teasing needles and the cover-slip was
placed on it. Urease test: Christensen’s urease medium was inoculated at 25°C-30°C with the
test fungus for 7-8 days to distinguish between T. mentagrophytes and T. rubrum. All the
available data were analyzed by SPSS version 19 on windows format for descriptive
statistics.

Results
Based on the inclusion and exclusion criteria during the study, a total of n=150 cases
were studied who showed signs and symptoms of superficial dermatophyte infections.
Results obtained through age-wise and sex-wise analysis of the cases are presented in table 1.
Critical analysis of table 1 revealed the commonly affected males (80%) and females (20%)
the male to female ratio was 4: 1 probably to the effect of hormones in males. The
distribution of cases was from 3 years to 70 years common age group involved in the lesions
was between the second and third decade of life. The highest incidence was seen between 21
– 30 years. The mean age of males in the study was 29.5 ± 5.5 years. The mean age of
females in the study was 24.0 ± 6.0 years.

Table 1: Distribution of cases age-wise and sex-wise in the study

Age Group (yrs) Male Female Total Percentage
0 – 10 2 6 8 5.5
11 – 20 21 14 35 23.3
21 – 30 47 3 50 33.3
31 – 40 28 3 31 20.6
41 – 50 8 1 9 6.1
51 – 60 11 2 13 8.6
61 – 70 3 1 4 2.8
Total 120 30 150 100

Among the n=150 cases included in the study n=95 cases were from the lower socio-
economic background. N=45 were from the middle-income group and n=10 were from
higher-income groups. The higher incidence of infections in the lower socioeconomic group
reveals that there may be an issue of hygiene. In lower socioeconomic groups there is a
practice of sharing clothes and bathing towels which may lead to cross infections. Also, the
availability of nutritious food is lesser in lower socioeconomic groups. Based on the locations
in our study we found n=80 cases from rural areas, n=40 from the semi-urban area, and n=30
from urban areas. The occupational status of the cases involved was studied because it could
be a major factor that predisposes people to certain diseases. An analysis revealed that the
incidence was n=35 cases students, n=30 laborer, n=15 office workers, n=10 farmers, n=20
housewives, n=18 petty shop keepers, n=5 drivers, n=17 others. The lesion wise distribution
is depicted in (table 2). T. cruris was the commonest lesion with 29.5% cases out of which
24.6% were positive for culture. T. corporis was the next predominant lesion with 24% cases
out of which 36.9% were positive for culture. Mixed infections of more than one type were
found in 6.6% of cases with clinical lesions being present in different parts of the body.

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Table 2: Relative incidence of different clinical types of dermatophytosis in the study.

Male Female Total Percentage
T. corporis 32 4 36 24
T. cruris 43 1 44 29.5
T. capitis 8 24 32 21.5
T. pedis 4 0 4 2.6
T. manuum 1 0 1 0.6
T. facei 1 0 1 0.6
T. unguium 17 1 18 12
T. barbe 1 0 1 0.6
T. incognatio 3 0 3 2
Mixed infections 10 0 10 6.6
Total 120 30 150 100
In the current study the category of sample collected for laboratory diagnosis was n=91
(60.67%) were skin scrapings. N=31 (20.67%) were nail clippings and n=28 were hair stubs.
The fungal isolated obtained shows T. rubrum in 30.8% of cases T. mentagrophytes in 29.3%
cases, T. verrucosum in 26.2% cases, T. violaceum in 9.2% cases, T. tonsurans in 3% cases,
and N. gypsium in 1.5% cases given in graph 1.

Fungal isolates obtained

N. gypsium
T. tonsurans
T. violaceum
T. verrucosum
T. mentagrophytes
T. rubrum

0 5 10 15 20 25 30 35

Graph 1: Depicting the percentage of Fungal isolates obtained in the cases of study

A: T. mentagrophytes in 10x magnification; B: T. tonsurans 10x magnification

Figure 2: Potassium hydroxide (KOH) mount microscopy

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Discussion
In the current study, we found the occurrence of dermatophytosis was more common
in males with a male to female ratio of 4:1. Venkat et al., [15] in their study on
dermatophytosis reported a male to female ratio of 2.07:1. The male predominance of
dermatophytosis was due to increased outdoor physical activities and increased opportunity
for exposure to infection than females. In this study highest number of cases were found
between the 21 – 30 years age group. Kamothi et al., [16] and Sahai S et al., [9] also found the
common age group affected was 21 – 30 years. Veer P et al., [17] of Aurangabad found the
common age affected was 31 – 40 years. Most of the studies showing a higher incidence of
dermatophytosis in this group of patients because of higher physical activity in this age
group, higher incidence of trauma, and increased sweating in tropical climatic conditions.
The occurrence of disease by occupation revealed the incidence was highest in students
23.33%. It appears that students usually wear synthetic thigh undergarments in which sweat
does get absorbed and they are engaged in a lot of physical activity such as playing sports etc.
long-standing moisture predisposes for fungal infections. The next commonly affected are
laborers which are engaged in heavy physical works and are exposed to unhygienic
conditions. T. cruris was the commonest lesion with 29.5% cases T. corporis was the next
predominant lesion with 24% cases. The results of this study correspond with studies of
Kanwar AJ et al., [18] Prasad PVS et al., [19] Suman et al., [21] have also found that Tinea
corporis was found in > 50% of cases and Tinea cruris in > 15% of cases. In this study, Tinea
capitis cases were in 8% cases most of them were below 10 years of age group. This is
consistent with the reports that tinea capitis is commonly found in children. A culture positive
rate of 24.6% was observed in this study for Tinea corporis and 36.9% Tinea cruris. An over
isolation rate of 30% has been reported by several studies in this field. [20-22] The difference
between the KOH positive rates and culture rates may be due to discrepancy in detecting
fungal hyphae in direct microscopy and culture and he due to various contributory factors
which include collection, inoculation, culture conditions, stage of lesions use of steroids, etc.
There are chances that some scanty fungal elements might be missed during direct
microscopy. Therefore, KOH preparation and culture have their role and importance in the
diagnosis of lesions. Common fungal isolates obtained in this study were the fungal isolated
obtained shows T. rubrum in 30.8% of cases T. mentagrophytes in 29.3% cases, T.
verrucosum in 26.2% cases. Our findings are comparable to the findings of Sumana MN et
al., [5] in their study found 52.7% isolated were Trichophyton rubrum 30.55% were
Trichophyton mentagrophytes and 11.1% were Trichophyton violaceum. Bindu V et al., [23]
showed T rubrum was the predominant species isolated (66.2%) in all clinical types followed
by T. mentagrophytes (25%), T tonsurans (5.9%), and E. floccosum (2.9%). Lavanya V et al.,
[22]
reported T. rubrum (51.35%) was predominant followed by T. mentagrophytes (43.24%)
and E. floccosum (5.4%). The T. rubrum was also the commonest in the studies done by Sen
SS et al., [25] (68.63%), and Mishra M et al., [24] 76%. Various studies done in India have
shown T. rubrum as the commonest isolate. [8, 12, 19]

Conclusion
This study concludes that the commonest prevalence of dermatophytosis is in males.
The third decade is the most affected age group. T. corporis is a common clinical
manifestation. Trichophyton rubrum was the commonest species of dermatophyte isolated by
culture. There is a greater incidence of dermatophyte infections in India due to the
widespread use of corticosteroids and antibacterial agents. Increased use of synthetic clothing
and exposure to hot and humid environments is increasing the burden of the disease,
especially in the younger population.

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