Ringworm Outbreak of India: The despicable dermatological disease

The commonest fungal infection of skin is known in common language as “ringworm” due to its ring-like appearance. It has become a serious healthcare problem in India in the recent one decade. Many patients and families suffer from the disease, and it causes negative impact on the wellbeing of the patients and family. Patients often resort to taking over-the-counter (OTC) creams from chemists which usually contain illogical combinations of antifungal, corticosteroid and antibacterial. They generally give a temporary relief from symptoms but it recurs with very severe infections.¹ The problem is far greater than what it appears to be. So, let us understand the disease scientifically and learn tips for a better care.

Fungal germs can be found in plants, soil, and even on your skin. Although there are millions of species of fungi, only about 300 of them can actually cause infections in humans. Fungal infection is a contagious disease that spreads by direct or indirect contact with fungi from an infected person or animal, or clothing, towels or other items. ²

Many fungal infections can affect the skin with dermatophytosis (ringworm) caused by fungal agents called dermatophytes being the most common. Dermatophytes are capable of growing by invading the upper layers of the skin, hair and nail for obtaining nutrients.³ This was never considered as a major public health hazard since it responded to standard medical treatments. Recently we have noticed inadequate response to the standard treatments which has forced to resort to an extended duration of treatment. Despite treatment, often patients experience recurrence of the disease.

Dermatophytosis has been named with different clinical terms like tinea corporis, tinea cruris, tinea unguinum etc depending on the body part involved. Common areas affected are the groin, lower part of the trunk, buttocks and underarm, but any part pf the body including face, hands and feet can be affected. Symptoms of fungal infection include itching, burning, scaling, redness and gradual spread to the surrounding and distant part of the body.² Skin lesions are usually ring shaped that expand peripherally, while similar fresh lesions appear and coalesce to form large patches. Amount of itching is variable, but it is usually severe and disturb the sleep and daily activities causing embarrassment.

Apart from dermatophytosis, incidence of various other fungal infections across the world has risen substantially over the past few decades. They are more prevalent in tropical and subtropical countries, where the heat and humidity are high for most part of the year.³ In India, 1-12 cases out of every 1,000 patients are found to be affected with fungal infection. Farmers working in the field may get eye infection when tips of wood or straw enter their eyes and cause fungal infection.⁴ Fungus can invade any organs of the body including the lungs and brain. Dermatophytes, however, do not cause such serious illness but is capable of causing serious impact on wellbeing due to intense itching and discoloration of the skin.

Apart from climate, several other risk factors may contribute to the acquisition or persistence of dermatophytosis
•    Poor personal hygiene, excessive sweating
•    Sharing of dresses, towels and other articles
•    Exposures to contaminated surfaces (Ex. shower facilities, swimming pools, hot tubs/spas)
•    Taking part in activities that involve frequent skin-to-skin contact
•    Wearing tight-fitting innerwear, thongs, jeans, or other pants
•    Obesity, internal diseases, malnutrition in children ⁴
•    Weakened immune system (ex. HIV/AIDS, steroid medications or chemotherapy)
•    Using OTC creams that usually contain corticosteroids as one of the ingredients that suppresses local skin immunity
•    Faulty treatments due to inadequate advices or stopping treatment prematurely when the symptoms improve

Skin fungal infections are a cause of negative impact on social, psychological and occupational health, and can seriously compromise the quality of life. India shares a huge burden of fungal infections which is underreported. We need to have a robust reporting system, and improved facilities for rapid diagnosis and improved treatment strategies.⁵ Dermatologists across India have been warned of  the “epidemic of ringworm infection” that is resistant to even the strongest antifungal treatments. The bigger concern has been the misuse of topical corticosteroid creams, which has turned these infections highly resilient. These creams are fast-selling products, readily available as OTC and harmful.¹

Indian association of dermatologists, venereologists and leprologists (IADVL), the largest representative body of dermatologists has launched initially a task-force and later a special interest group to address this problem of recalcitrant dermatophytosis.⁶  A number of activities to train the healthcare professionals and to educate the public have been carried out to tackle this epidemic. A consensus has also been brought to address the management of current scenario of this fungal infection.⁷ It is important for all the healthcare professionals to be aware of this fungal menace prevailing in India. It is the duty of everyone to manage these infections adequately utilizing the consensus guidelines and counsel the patients to control this epidemic. Patients with ringworm should stick to the advice of the doctors and complete the course of treatment. In case of inadequate response, a dermatologists advice should be taken as soon as possible. It is imperative not to resort to any OTC creams as an alternate to medical advice.

References
1.    CDC. (2020, May 14). Steroid creams can make ringworm worse. Retrieved March 27, 2021, from https://www.cdc.gov/fungal/diseases/ringworm/steroids.html
2.    Seladi-Schulman, J. (2020, January 07). Fungal skin infection: Types, treatment, prevention. Retrieved March 27, 2021, from https://www.healthline.com/health/fungal-skin-infection#most-common-infections
3.    Lakshmanan A, Ganeshkumar P, et al. Epidemiological and clinical pattern of dermatomycoses in rural India. Indian J Med Microbiol 2015;33, Suppl S1:134-6
4.    Singh, J. (2014, January 09). Alarming rise in fungal INFECTION CASES: PGIMER STUDY. Retrieved March 27, 2021, from https://www.downtoearth.org.in/news/alarming-rise-in-fungal-infection-cases-pgimer-study--43222
5.    Emerging fungal infection- A challenge, adapted from https://www.ecronicon.com/eccmc/pdf/ECCMC-02-00066.pdf
6.    Last accessed on 2021 Jul 19]. Available from: https://www.iadvl.org/itart.php
7.    Rengasamy M, Shenoy MM, et al.. Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) Task Force against Recalcitrant Tinea (ITART) Consensus on the Management of Glabrous Tinea (INTACT). Indian Dermatol Online J. 2020;11(4):502-519.

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