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CONFERENCE PROCEEDINGS
Year : 2017  |  Volume : 8  |  Issue : 6  |  Page : 527-533  

Dermatophytosis: Fighting the challenge: Conference proceedings and learning points. September 2-3, 2017, PGIMER, Chandigarh, India


Department of Dermatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication14-Nov-2017

Correspondence Address:
Sunil Dogra
Department of Dermatology, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/idoj.IDOJ_283_17

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How to cite this article:
Narang T, Mahajan R, Dogra S. Dermatophytosis: Fighting the challenge: Conference proceedings and learning points. September 2-3, 2017, PGIMER, Chandigarh, India. Indian Dermatol Online J 2017;8:527-33

How to cite this URL:
Narang T, Mahajan R, Dogra S. Dermatophytosis: Fighting the challenge: Conference proceedings and learning points. September 2-3, 2017, PGIMER, Chandigarh, India. Indian Dermatol Online J [serial online] 2017 [cited 2019 Jun 26];8:527-33. Available from: http://www.idoj.in/text.asp?2017/8/6/527/218326

The department of Dermatology, Venereology and Leprology and Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India (pgimer.edu.in) organized the conference “Dermatophytosis: Fighting the Challenge” on 2nd and 3rd September 2017. ([Figure 1]a,[Figure 1]b,[Figure 1]c) - The conference was attended by about 250 delegates from all over India. It was the first conference of its kind that was dedicated to dermatophytosis, and eminent speakers from all over India deliberated on various issues and problems which are currently being faced by clinicians in the management of dermatophytosis (tinea). The conference started with a workshop on conventional and current techniques in the diagnosis of dermatophytosis/ superficial fungal infections and antifungal drug susceptibility (AFS) testing in tinea. The highlights and salient points of different lectures and presentations are presented in this paper.
Figure 1: (a-c) Glimpses of the conference

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Session I: Fungal pathogens, immunopathogenesis, and drug susceptibility

Dr. Shivaprakash MR started the first session with his talk on “Advances in laboratory diagnosis of dermatophytosis and PGI experience of antifungal drug susceptibility patterns in recalcitrant dermatophytosis.” Following topics were covered during his talk:

  • Advanced diagnostic techniques such as polymerase chain reaction (PCR) and its different variations and gene sequencing for the diagnosis of dermatophytosis.
  • Stressed about the need for standardization of AFS testing for dermatophytosis on a global scale.
  • PGI experience of AFS patterns in recalcitrant dermatophytosis showed griseofulvin was the most inactive drug (in vitro) with modal MIC of 32 mg/L; resistance to terbinafine (L393F and F397L) and fluconazole was seen in a significant number of cases.


Dr Jagdish Chander shared his experiences about antifungal susceptibility for dermatophytosis in his lecture “Defining Antifungal Drug Resistance in Dermatophytes: High Time we Standardize it Microbiologically.” He discussed about:

  • The current problem of lack of consistent correlation between in-vitro AFS data and clinical outcome and lack of MIC breakpoints to categorize the isolate as susceptible, intermediate, or resistant to a particular antifungal agent
  • He stressed about the need to standardize AFS testing for dermatophytosis on a global scale in view of worrying emergence of drug-resistant dermatophytosis (especially to terbinafine and even itraconazole)
  • MIC and clinical breakpoints: A clinical breakpoint is defined as the MIC at which a strain behaves as a resistant strain. The clinical breakpoint must be set for every drug and fungal species. MICs are numbers determined in vitro, and clinical significance can be determined only by using clinical breakpoints to correctly interpret numerical results
  • He also conveyed that PharmakoKinetic and PharmacoDynamic aspects of antifungals should be taken into account when dealing with clinical resistance
  • There is a need to establish baseline data concerning antifungal agents, which will allow trend observation
  • Surveillance studies to determine the true frequency of antifungal resistance should be implemented
  • Studies to establish in vitro–in vivo correlation should be undertaken in animal models
  • Data should be collected on both clinical and MIC from patients treated with various agents to establish breakpoints for different antifungal agents
  • MIC data, using the developed method, should be collected as part of the drug approval process.


Dr. Biman Saikia elaborated on “Immunology of Dermatophytosis”

  • Elucidated the various innate and cellular defence mechanisms for dermatophytosis
  • New development – stressed on the important role of Th17-producing cells in the defence against dermatophytosis
  • Group 3 innate lymphoid cells (ILC3s) express the retinoic acid receptor (RAR) related orphan receptor RORγt and the signature cytokines IL-22 and IL-17, playing a central role in the defense against dermatophytes
  • IL17-A and IL-22 synergistically exert their function on epithelial cells by inducing the production of chemokines (CXCL8, CXCL1, CXCL2, and CXCL5) and antimicrobial peptides (HBD-2, LL-37, S100A7, S100A8, S100A9, β-defensins, and histatins): direct anti-fungal effects.


Session II: Plenary session: Recurrent/recalcitrant dermatophytosis

Dr. Archana Singal deliberated on the topic “Recurrent Tinea: Myth or reality”

  • She elucidated the various reasons for the scourge of recalcitrant dermatophytosis in India; important ones being:


    • Changing fashion sense in population, e.g., wearing occlusive clothing
    • Treatment with steroids and other over-the-counter medications
    • Inadequate treatment duration for antifungals
    • Using irrational combination agents in treatment
    • Drug resistance


  • Sensitized regarding the various atypical presentations being encountered in the population.
  • Ping-pong effect – spread of dermatophytosis within family members
  • Stressed on the important role of griseofulvin in treating dermatophytosis.


Dr. Roderick J Hay, Special Adviser, The International Foundation for Dermatology, UK delivered key note lecture.

  • Explained the various reasons for treatment failure in dermatophytosis using the fungus, host, and treatment model [Figure 2]
  • Figure 2: The host, fungus and treatment related factors in treatment outcome of dermatophytosis

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    • Host factors: immunity, polypharmacy, comorbid conditions, low immunity (STAT1, CARD9 mutations, SLE, AD, icthyosis, etc.)
    • The various mechanisms of immune modulation by dermatophytes that may cause chronic infection or poor response to treatment are:


      • Antigen interference – glycopeptide
      • IgE, association with atopy, reduced γIFN, and enhanced IL4 – TH1-2 shift
      • Keratinocyte production of Il-8 reduced in anthropophilic dermatophytes – species effect
      • IL17 production reduced – low human beta defensins (HBD)
      • Fungal cell wall melanin – superoxide radical
      • Fungal cell wall mannans can induce TLR-2 mediated IL-10 release – Toll-like receptors


    • Treatment factors: noncompliance, penetration of topical treatments at the site of infection, bioavailability and previous use of inadequate treatments, and steroid combinations.


The controversies and management dilemmas in cases of chronic and recurrent dermatophytosis were discussed in two debate sessions. Topics for “Short Debates” were carefully selected and eminent speakers and moderators participated in these brainstorming sessions and shared their experiences. A brief summary of presentations and expert comments of the first debate session moderated by Dr Abir Saraswat which discussed the epidemiology and clinical features of recalcitrant/resistant dermatophytosis are given below:

What do you label this emerging scenario of tinea in India – Recalcitrant or Resistant dermatophytosis?

Dr. Kabir Sardana (for recalcitrant tinea) and Dr Mukesh Girdhar (for resistant tinea)



Consensus: both resistance and recalcitrance may be contributing to the current scenario.

Is fungal culture and antifungal drug susceptibility test indicated in all cases of recalcitrant tinea?

Dr. Shukla Das (for fungal culture and AFS studies in all recalcitrant tinea) and Dr. Davinder Parsad (against).



Consensus – Fungal culture and AFS testing is not required in all cases, but can be done in cases which do not respond to therapy or take an unusually long time to resolve.

Do you think that topical corticosteroid abuse is the major reason for the current scenario of recalcitrant dermatophytosis?

Dr. Rajeev Sharma (steroid abuse is major reason for recalcitrant tinea) and Dr Vikram Mahajan (against).



Consensus – steroids are not the only reason for the current situation and there are multifactorial reasons for recalcitrant tinea.

Treatment failure – an indicator of evolving resistance?

Dr. Manjunath Shenoy (treatment failure because of resistance) and Dr. Madhu Rengarajan (against).



Consensus: multifactorial causation is present but the resistance in fungal species is present and is a major threat.

Should we give blanket treatment to all family members/contacts in cases of recurrent/chronic tinea?

Dr. P Narsimha Rao (blanket treatment in all recalcitrant tinea) and Dr. Sandipan Dhar (against).



Consensus: blanket treatment not required, treat all symptomatic cases.

Session III: Plenary session: Chronic dermatophyte infections

Dr. Ruth Ashbey, Visiting Lecturer, School of Molecular and Cellular Biology, University of Leeds, UK presented second keynote lecture of conference. “Antifungal aspects of dermatophytosis - the same old, same mould.” The highlights of her talk were.



Other factors to be considered:

Dermatophytes respond to their environment and can upregulate or downregulate various genes depending on the stimulus.

She also reiterated that we should define the clinical breakpoints of antifungal resistance in addition to the mycological breakpoints, which need further refinement.

The fungal forms isolated from the skin are arthrospores which are inherently less susceptible to the antifungals and this form is not tested in the mycological AST.

Dr. DM Thapa, deliberated on various types of onychomycosis, reasons for treatment failure in dermatophytosis, and the various treatment options in onychomycosis.

  • Nail clipping with PAS staining (biopsy) is the most sensitive test, with an overall sensitivity of 84% and specificity of 89%
  • Direct microscopy had a sensitivity of 61% and specificity of 95%
  • Fungal culture had a sensitivity of 56% and specificity of 99%; the only test that can detect the etiological agent
  • He discussed the topical agents used in the management of onychomycosis, including tavabarole and efinaconazole
  • Sometimes physical and chemical modalities such as nail abrasion, lasers, urea have to be combined with topical/systemic treatments for managing difficult cases.
  • Pediatric onychomycosis, although rare, are increasing in prevalence, and mycological tests should be done to confirm or refute the diagnosis; however, due to their thinner, fast-growing nails, children more likely to respond to topical monotherapy than adults and systemic agents such as terbinafine, itraconazole, and fluconazole demonstrated good efficacy and a low rate of side effects in children
  • Prevention of recurrences is also equally important: health education, proper treatment of tinea pedis, good hygiene (e.g., keeping feet clean and dry with short nails), discarding old footwear, avoidance of walking barefoot in damp places, wearing clean socks of absorbent material, and appropriate screening and effective treatment of any household contacts with tinea pedis and onychomycosis are helpful in this.


Dr. Ramesh Bhat spoke about the atypical and unusual emerging clinical presentations of dermatophytosis

  • Sensitized regarding the various atypical presentations of dermatophytic infections such as erythrodermic, psoriasiform, pseudocircinate, involvement of penis in tinea cruris, eczematous, follicular, pustular, annular pustules, multiple grouped lesions, concentric, irritant modified, etc., with wonderful clinical photographs.


Session IV: Therapeutics 1

Dr. Deepika Pandhi in her talk “Is there any clinical relevance of lab diagnosis and antifungal drug susceptibility tests in dermatophytosis?”

Stressed regarding the need for lab investigations in dermatophytic infections and the need to investigate all the cases in view of:

  • Dermatophytic infections becoming more difficult to treat.
  • More number of cases of dermatophytic infections than was present about 2–3 decades back


  • Highlighted the need for standardization of AFS in dermatopytosis for various drugs with interpretive breakpoints
  • Future treatment options:


    • Multidrug therapy
    • Using novel preparations of topical agents such as film-forming solutions and transferosome containing the molecules.


Dr. Madhu Rengarajan discussed the important issue of “repositioning conventional sytemic antifungals in evolving scenario.” She pointed out that that <5% of the patients with dermatophytosis seen these days are treatment naïve, and the rest of the patients have taken some treatment such as steroids (approximately 70%), irrational over-the-counter (OTC) medications, inadequate dose, and duration of oral antifungals in the remaining cases.

  • No new systemic antifungal agents (AFA) in the vicinity – existing AFAs to be used in appropriate dose and duration
  • Counselling prior to the initiation of systemic therapy
  • Suboptimal dose and duration result in clinical failure
  • Immediate necessity for guidelines – the Indian scenario
  • OTC/steroid antifungal combination
  • Systemic antifungals cannot be repositioned as 1,2,3, and treatment should be individualized based on clinical features and past treatments
  • The treatment should be continued for a minimum of 2–4 weeks after clinical remission
  • Itraconazole is the only affordable treatment option for deep and subcutaneous mycoses, and hence, should be used judiciously
  • Combination therapy with two systemic agents should be reserved for chronic/recalcitrant dermatophytosis.


Dr. Shital Poojary Deliberated on nonpharmacologic intervention in the treatment and prevention of recalcitrant dermatophytoses

  • She discussed on the modification of host factors such as weight reduction, hygiene, wearing loose cotton clothes, washing clothes with hot water, proper drying and ironing of clothes, avoidance of sharing items/clothes/towels/footwear to prevent transmission of infection.
  • She also stressed on the role of counselling the patient regarding all these measures and medications (proper dose, duration, importance of adherence) as it remains the cornerstone of management of any disease.


Session V: Therapeutics 2

Dr. Sandipan Dhar delivered a lecture on the management of dermatophytosis in patients with concomitant systemic diseases and dermatoses

  • Special challenges in the management of dermatophytosis are dermatoses predisposing to recurrent infections, systemic illness that may cause immunosuppression, topical and systemic drugs that may depress CMI locally or systemically, associated hepatic and renal dysfunction may affect choice and dose of drugs and possibility of drug interaction due to continuing concurrent medications
  • Barrier impairment essential for the establishment and perpetuation of infection, Dermatoses with barrier defect such as atopic dermatitis (AD) or psoriasis predispose to recalcitrant and rapidly spreading infections and the success of treatment outcome will depend on barrier repair and control of pruritus besides adequate antifungal treatment
  • Talked about the need for modified treatment protocols (higher dose and longer duration) in patients with comorbid conditions (such as lymphomas, diabetes, vitiligo, psoriasis, or AD patients on immunosuppression and those on polypharmacy)
  • He stressed that the treatment of dermatophytosis in these conditions should be at the discretion of the treating dermatologist taking into consideration the adverse effects of the various drugs as well as the laboratory investigations of the patients being treated, and we should aim for both mycological and clinical cure.


Dr. Arun Inamadar deliberated on the important and tricky issue of managing dermatophytosis in pregnancy and children. Antifungal prescription remains a challenge in pregnant women because of uncertainties regarding fetal toxicity and altered maternal pharmacokinetic parameters which may affect efficacy or increase maternal and fetal toxicity.

  • Better to treat all cases of dermatophytosis in pregnant women with topical antifungals (terbinafine and azoles), if possible, as they are safe in all stages of pregnancy
  • Animal and human data provide evidence that azoles could be teratogenic and oral terbinafine is pregnancy category B and can be used safely after 1st trimester in extensive cases taking into account other comorbidities and potential drug interactions
  • Fluconazole >300 mg is pregnancy category C and should not be given
  • Fluconazole ≤300 mg is category B and can be tried after 1st trimester
  • Need to have effective contraception for 2 months after taking oral itraconazole before the female can plan pregnancy
  • Topical antifungals are the first choice when we have to treat children with dermatophytosis, however, most topical azoles are fungistatic and probably require intact local immunity for the eradication of dermatophytes
  • Among the systemic antifungals terbinafine and itraconazole are the preferred agents at doses of 5 mg/kg/day
  • Treatment duration varies with indication, with most studies using 2–4 weeks of therapy in children with tinea capitis or tinea corporis and 6–12 weeks of therapy in children with onychomycosis
  • Oral terbinafine is associated with rare but serious adverse effects (e.g., blood dyscrasias, liver failure), hence if >6 weeks of terbinafine tablets are required, monitor blood count and liver enzymes.
  • The US FDA found that skin reactions were the most often reported post-marketing adverse event for terbinafine for children.


Dr. Sumanas Bunyaratavej (Division of Dermatological Mycology, Department of Dermatology, Faculty of Medicine Siriraj Hospital Mahidol University, Bangkok Thailand delivered a lecture on “Coming of Age in Dermatophytosis: Thailand Experience and Strategic Management.”

Elucidated the different age groups in which different tinea syndromes are seen:

  • Infants – rare
  • Children – tinea capitis
  • Adults onwards – tinea corporis and cruris are most common
  • >40 years of age – tinea faciei
  • >60 years – tinea pedis and tinea unguium.


  • Special mention about screening pets for dermatophytosis using wood's lamp as its obscured in them and leads to recurrences in humans
  • Tinea of vellus hair does not respond well to topical agents and should be treated with systemic agents. Zoophilic organisms have predilection to involve the vellus hair more commonly
  • The British Association of Dermatologists 2014 guidelines for the management of tinea capitis recommends selection of oral antifungal agents according to causative dermatophyte such as terbinafine should be preferred if the causative fungus is Trichophyton tonsurans, T. violaeum, or T. soudanense and griseofulvin or itraconazole for Microsporum canis or M. audouinni
  • Another aspect is treatment of carriers in tinea capitis and asymptomatic carrier close contacts with high spore load should be treated with oral therapy to prevent recurrences
  • Tinea capitis should also be suspected in adults with concomitant tinea of other sites such as corporis/cruris or facei.


Session VI: Advances in Medical Mycology

Dr. Siddhartha Sonthalia enlightened about a relatively new and emerging diagnostic modality in the diagnosis of dermatophytosis – Entodermoscopy

  • Demonstrated the use of dermoscopy in tinea capitis and p. versicolor entodermoscopy
  • Features of tinea capitis:


    • Comma-shaped hair, pigtail hair, corkscrew hair, black dot, and broken dystrophic hair
    • Morse code hairs
    • Translucent hair (if involving vellus hair).


  • Features of P. versicolor


    • Net-like distribution
    • Fine whitish scales
    • Fine array of telangiectasias
    • Hypo and hyperpigmentation.


  • Usefulness:


    • In demonstrating the findings to patient to show the progression or improvement
    • Helpful in counselling patients and ensures compliance better if photographic evidence is shown to them.


Dr. Nidhi Singla elucidated on role of biofilms in persistence of dermatophytosis in patients

  • Biofilms mainly occur in abiotic environment in dermatophytes and serve as a reservoir of infection
  • It mostly occurs in onychomycosis as dermatophytomas
  • T. rubrum >T. mentagrophytes in forming biofilms
  • Advantages of biofilms to dermatophytes:


    • Too big to be phagocytosed and eliminated
    • 1% of all constituents of biofilms are made of persistors
    • 10 to 1000-fold increased MIC
    • Mechanism to acquire resistance.


The second debate on day 2 was the most awaited session as it discussed the dilemma that all dermatologists face everyday while managing dermatophytosis in their routine practice. The session was moderated by Dr. Binod Khaitan.

Is there any relevance of pk/pd studies in management of recalcitrant tinea?

Dr. Kabir Sardana (pk/pd studies are relevant in recalcitrant tinea) and Dr. Nusrat Shafique (against).



Consensus – It is a good start but a long way to go till these studies achieve relevance in dermatophytosis.

Role of updosing antifungal treatment beyond standard recommendation?

Dr. Anil Ganjoo (for updosing beyond standard recommendations) and Dr. Shital Poojary (against)



Consensus – Terbinafine can be updosed till 250 mg BD and itraconazole till 100 mg BD; no role in updosing any further in tinea until there is concrete evidence of justifying higher/double dosage of antifungals as all these systemic agents are associated with serious adverse effects also.

Role of longer duration of antifungal treatment beyond standard recommendation?

Dr. Lalit Gupta (for longer duration to treat dermatophytosis) and Dr. Rashmi Sarkar (against).



Consensus – Treatment duration of 1–2 weeks is grossly inadequate in the Indian setup and new guidelines have be to made to extend the duration based on physician experiences in India.

Role of combination of systemic antifungals in recalcitrant tinea cases?

Dr. Akanksha (for role of combination antifungals in recalcitrant tinea) and Dr. Rajiv Sharma (against)



Consensus – Sequential therapy can be tried in cases of difficult to treat tinea, however, parallel therapy will definitely increase the adverse effects, and hence, should not be tried.

Role of retinoids in the management of chronic/recurrent dermatophytosis?

Dr. Rahul Mahajan (for use of retinoids in chronic dermatophytosis) and Dr. Garima (against)



Consensus – Not recommended as of now; more studies are needed.

The sessions were helpful in answering some queries related to the diagnosis and management of dermatophytosis and generated new ideas for future research as well. It was a good forum where different experts from specialities such as dermatology, microbiology, pathology, and pharmacology came together and presented their views and opinions in tackling the problem of recalcitrant or recurrent dermatophytosis. The current scenario calls for a multispeciality approach in tackling the menace of dermatophyte infections of skin.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.




    Figures

  [Figure 1], [Figure 2]


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