Recalcitrant Dermatophytosis Research Articles

Dermatophytosis Caused by Trichophyton indotineae (Trichophyton mentagrophytes ITS Genotype VIII) in Sri Lanka.

Over the past few years, a recalcitrant dermatophytosis has been observed on the Indian subcontinent, including Sri Lanka, which has caused a major public health issue in the region. An emerging species, Trichophyton indotineae, first described as Trichophyton mentagrophytes ITS genotype VIII, is thought to be responsible for this fast-spreading, mostly terbinafine-resistant dermatophytosis. Recalcitrant dermatophytosis is a challenge to dermatologists, and knowing the causative species and antifungal sensitivity in the earlier stage of management would be invaluable. We report a case series of patients with dermatophytosis caused by T. indotineae in Sri Lanka. This is the first detection of this highly terbinafine-resistant strain in Sri Lanka, and existence of this species should be taken seriously by dermatologists and healthcare policymakers for better management of tinea infections and antifungal stewardship in the country.

Prevalence of Dermatophytes in Egypt & Mycological assessment before and after Itraconazole therapy in patient with Recalcitrant Dermatophytosis

Prevalence of Dermatophytes in Egypt & Mycological assessment before and after Itraconazole therapy in patient with Recalcitrant Dermatophytosis

Recalcitrant dermatophyte infections: identification and risk factors.

Recalcitrant dermatophytosis is an emerging phenomenon that occurs worldwide, and Trichophyton indotineae is currently the prominent cause. Skin specimens from patients with tinea infection were obtained by scrubbing and then sectioned into three fragments. Two fragments were subjected to direct microscopic examination and culture, while the third portion was utilized in the PCR method. Isolates were morphologically identified as Trichophyton mentagrophytes/interdigitale complex (n = 60 [83.33%]), Microsporum canis (n = 8 [11.11%]), Trichophyton rubrum (n = 3 [4.16%]), and Epidermophyton floccosum (n = 1 [1.38%]). Among 60 T. mentagrophytes complex isolates, 53 (88.33%) were classified as T. indotineae and seven as T. interdigitale genotype II. The disease duration was longer in the T. indotineae group (P = 0.035). Both Gradient PCR and skin-sampling methods yield similar results in terms of positive and negative cases (P = 1.0000). The time patients stopped their medication did not impact the positive case numbers (P = 0.803). Gender had no effects on the frequency (P = 0.699). Familial contamination, dermatologic disorder, and other underlying conditions did not differ in the two group infections (P > 0.05). Steroid usage is strongly associated with the emergence of tinea infection (P < 0.04). The duration of antifungal administration had a substantial effect on the emergence of resistant organisms (P = 0.05). Steroid usage, T. indotineae involvement, and prolonged exposure to antifungals were the solid and influential factors in recalcitrant involvement. Regarding quick and suitable diagnosis and treatment, which is essential in preventing recalcitrant cases, we suggest that direct skin sample PCR can meet the demands.

Clinical Use of Super-Bioavailable Itraconazole for the Management of Dermatophytosis: Consensus Statement by Dermatologists from India via the Modified Delphi Technique

Super-bioavailable itraconazole (SB ITZ) overcomes the limitations of conventional itraconazole (CITZ) such as interindividual variability and reduced bioavailability. It has been approved for systemic mycoses in Australia and Europe as 50 mg and the USA as 65 mg and in India as 50 mg, 65 mg, 100 mg, and 130 mg. However, data on the ideal dose and duration of SB ITZ treatment in managing dermatophytosis are insufficient. This consensus discusses the suitability, dosage, duration of treatment, and relevance of using SB ITZ in managing dermatophytosis in different clinical scenarios. Sixteen dermatologists (>15 years of experience in the field and ≥2 years clinical experience with SB ITZ), formed the expert panel. A modified Delphi technique was employed, and a consensus was reached if the concordance in response was >75%. A total of 26 consensus statements were developed. The preferred dose of SB ITZ is 130 mg once daily and if not tolerated, 65 mg twice daily. The preferred duration for treating naïve dermatophytosis is 4–6 weeks and that for recalcitrant dermatophytosis is 6–8 weeks. Moreover, cure rates for dermatophytosis are a little better with SB ITZ than with CITZ with a similar safety profile as of CITZ. Better patient compliance and efficacy are associated with SB ITZ than with CITZ, even in patients with comorbidities and special needs such as patients with diabetes, extensive lesions, corticosteroid abuse, adolescents, and those on multiple drugs. Expert clinicians reported that the overall clinical experience with SB ITZ was better than that with CITZ.

Hypothalamus-pituitary-adrenal axis (HPA axis) suppression with inappropriate use of steroids in recalcitrant dermatophytosis - A cross-sectional study.

Improper use of over-the-counter (OTC) steroid medication has been linked to recalcitrant dermatophytosis. There is proven evidence of HPA axis suppression by the use of long-term oral steroids. This study aims to determine the prevalence and pattern of inappropriate OTC steroid use and its effects on the hypothalamus-pituitary-adrenal (HPA) axis in adults with recalcitrant dermatophytosis. This cross-sectional study of 2 months was conducted in a hospital setting and included patients of recalcitrant dermatophytosis with a history of OTC steroid use. Clinico-demographic details and basal serum cortisol levels were recorded in all and analyzed. Of a total of 103 patients, 59.22% (n = 61/103) were males, and the mean duration of steroid abuse was 17.78 months. About 48.54% (n = 50/103), 3.88% (n = 4/103), and 47.57% (n = 49/103) patients reported the use of topical steroids, oral steroids, and both oral and topical steroids, respectively. Among all the topical steroid users (n = 99), clobetasol propionate 48.48% (n = 48/99), while among oral steroid users (n = 53), prednisolone 45.28% (n = 24/53) were the most commonly used agents, respectively. The morning serum cortisol levels (8-9 AM) were found to be decreased in 42.7% (n = 44/103), with a mean value of 44.28 ± 17.34 μg/dL. Improper OTC steroid use in recalcitrant dermatophytosis leads to HPA axis suppression. This highlights the need for intervention from apex health officials.

Immunohistochemical analysis of chronic and recurrent dermatophytosis.

Dermatophytosis has assumed epidemic proportions with rising resistance, recalcitrance and recurrence, especially in tropical regions. While various factors contribute to high prevalence worldwide, yet little is known about the interactions between host defence mechanisms and dermatophytes, particularly in chronic and recalcitrant dermatophytosis. We aimed to compare the population of various immune cells in specimens of chronic recurrent dermatophytosis and those with acute superficial dermatophytosis. We investigated the density of various immune cells-Langerhans cells (CD1a+), macrophages (CD68+), dermal dendrocytes (Factor XIIIa+) in the skin of chronic dermatophytosis patients and those with successfully resolved lesions (controls). Langerhans cells were significantly decreased in the epidermis of patients, both in affected and unaffected areas in comparison with controls. In the dermis, however, no differences in the density of immune cells (macrophages and fibroblasts) were observed. The limited sample size and immune cells evaluated could be expanded further in future research. These results indicate that the decreased number of Langerhans cells could be a potential risk factor for the development of chronic and recurrent dermatophytosis.

Difficult to treat superficial fungal infections: Which factors one should consider in clinical practice – An Indian perspective

Dermatophytosis is a superficial fungal infection caused by filamentous fungi- dermatophytes affecting the skin, hair and/or nails. They have also been termed tinea infections. Dermatophytes, the most common contributing agents, are pretending high importance in developing countries like India. Emerging Pathogen Causing Recalcitrant Dermatophytosis like Trichophyton indotineae, which is terbinafine resistant. Development of Anti-fungal resistance due to irrational usage of antifungals, steroid misuse, availability of topical creams with steroid combination on OTC, improper and inadequate treatment, lack of patient counselling and education are the most important factors which made dermatophyte difficult to treat. Proper diagnosis, correct selection of anti-fungal, with adequate duration of therapy, avoidance of steroid, patient education on lifestyle changes will be probable solutions in resolving current challenges.

Rapid emergence of recalcitrant dermatophytosis caused by a cluster of multidrug-resistant Trichophyton indotineae in China.

We describe 14 cases of native refractory dermatophytes caused by Trichophyton indotineae diagnosed at a hospital in China since 2021, primarily diagnosed in the past 1 year and from the same province. Trichophyton indotineae isolates were resistant to multiple antifungals and harboured Phe397Leu or Leu393Ser substitutions in the squalene epoxidase enzyme. Short-term rapid emergence of multidrug-resistant T. indotineae in China poses increasing threats to public safety and warrants continued public health surveillance.

IADVL SIG Recalcitrant Dermatophytosis Position Statement on Super Bioavailable Itraconazole.

Itraconazole (ITZ) has been the mainstay of oral antifungal treatment for the current epidemic of recalcitrant dermatophytosis (RD) in India. Recently, a newer formulation of ITZ, super bioavailable itraconazole (SUBA-ITZ), is made available in the market by many pharmaceutical companies. It is important for dermatologists to understand the pharmacokinetic properties of SUBA-ITZ vis-a-vis conventional pellet formulation to use it effectively and safely. Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) has established a special interest group for recalcitrant dermatophytosis (SIG-RD) to strengthen research, continuing medical education, and industry collaboration on the subject. This position statement on SUBA-ITZ by SIG-RD is an attempt to address current pieces of evidence and the position of this new formulation in the management of RD.

Comparison between the efficacy of terbinafine and itraconazole orally vs. the combination of the two drugs in treating recalcitrant dermatophytosis

Fungal infections are a challenging to treat cutaneous condition. Approximately 20–25% of humans are affected by superficial fungal infections that invade and multiply within keratinized tissues. To compare the efficacy of either terbinafine or itraconazole orally versus the combination of the two drugs in the treatment of recalcitrant dermatophytosis. The current study included 45 patients with recalcitrant dermatophytosis who were distributed into 3 groups (each of 15 patients); Group A received terbinafine 250 mg twice a day for 4 weeks. Group B received itraconazole 200 mg twice a day for 4 weeks. Group C received terbinafine 250 mg once daily and itraconazole 200 mg once daily for 4 weeks. The patients were followed up for 12 weeks after initiation of treatment by clinical and microbiological assessment to determine the cure rate. At the end of twelve weeks, 12 (80%) patients in group A; 13 (86.7%) patients in group B and 15 (100%) patients in group C were completely cured. Despite of cure rates being higher in the combined group C; yet results were not statistically significant (p = 0.207). Clinical cure rates were non significantly higher in itraconazole + terbinafine combined group (p = 0.207). Combination of terbinafine and itraconazole had a higher clinical and mycological cure rate when compared to the use of either drug alone as monotherapy. Further randomized, multicenter, large cohort studies are warranted to validate the use of combination antifungal treatments.

Efficacy of super bioavailable itraconazole in the management of dermatophytosis in India

Itraconazole (ITZ) is a commonly prescribed oral antifungal agent in India and has a low minimum inhibitory concentration when compared to other oral antifungals. However, clinicians have reported inconsistent clinical responses despite its high skin levels, which may be due to variations in pelletization parameters, which affect its bioavailability and serum levels. Conventional ITZ has a maximum bioavailability of 55%; however, this is unpredictable and inconsistent. In contrast, the novel ITZ formulation, super bioavailable ITZ (ITZ-SB), has targeted drug release in the small intestine, resulting in predictable serum levels with minimal interindividual variability. This makes it a potentially useful drug in treating recalcitrant dermatophytosis. This expert opinion highlights the benefits of novel ITZ-SB with the incorporation of SUBA® technology. The SUBA® technology improves the bioavailability of poorly soluble drugs by ‘solid dispersion’ in polymer to increase drug absorbency. This technology also has potential to reduce variability in absorption and adverse effects. Benefits of this technology include more predictable clinical response and lower drug quantities necessary to achieve therapeutic blood levels, making it a promising treatment option for recalcitrant dermatophytosis. Fixtral SB, which uses this technology, is a novel weapon in the arsenal of treatments for superficial mycoses.

Antifungal Resistance, Susceptibility Testing and Treatment of Recalcitrant Dermatophytosis Caused by Trichophyton indotineae: A North American Perspective on Management.

There is an ongoing epidemic of chronic, relapsing dermatophytoses caused by Trichophyton indotineaethat are unresponsive to one or multiple antifungal agents. Although this new species may have originated from the Indian subcontinent, there has been a notable increase of its reporting in other countries. Based on current literature, antifungal susceptibility testing (AFST) showed a large variation of terbinafine minimum inhibitory concentrations (MICs) (0.04 to ≥ 32 µg/ml). Elevated terbinafine MICs can be attributed to mutations in the squalene epoxidase gene (single mutations: Leu393Phe, Leu393Ser, Phe397Leu, and double mutations: Leu393Phe/Ala448Thr, Phe397Leu/Ala448Thr). Itraconazole MICs had a lower range when compared with that of terbinafine (0.008-16 µg/ml, with most MICs falling between 0.008 µg/ml and < 1 µg/ml). The interpretation of AFST results remains challenging due to protocol variations and alack of established breakpoints. Adoption of molecular methods for resistance detection, coupled with AFST, may provide a better evaluation of the in vitro resistance status of T. indotineae. There is limited information on treatment options for patients with confirmed T. indotineae infections by molecular diagnosis; preliminary evidence generated from case reports and case series points to itraconazole as an effective treatment modality, while terbinafine and griseofulvin are generally not effective. For physicians working outside of endemic regions, there is currently an unmet need for standardized clinical trials to establish treatment guidelines; in particular, combination therapy of oral and topical agents (e.g., itraconazole and ciclopirox), as well as with other azoles (i.e., fluconazole, voriconazole, ketoconazole), warrants further investigation as multidrug resistance is a possibility for T. indotineae.

Terbinafine-Resistant Dermatophytes and the Presence of Trichophyton indotineae in North America.

Dermatophytes are common causes of skin, hair, and nail infections in humans. The most common species causing infections in humans are Trichophyton rubrum, Trichophyton mentagrophytes, and Trichophyton interdigitale. Outbreaks of recalcitrant dermatophytosis have been reported in parts of South Asia, including those caused by a hypervirulent and resistant species, Trichophyton indotineae. We evaluated the antifungal susceptibility profiles of dermatophytes received by our laboratory from institutions across North America between 2021 and 2022 and performed species identification for isolates deemed to demonstrate in vitro resistance. Susceptibility testing was performed by CLSI broth microdilution methods, and species identification was performed by DNA sequence analysis. During this 2-year period, 271 dermatophyte isolates were included, the majority of which demonstrated low MIC values for terbinafine (geometric mean [GM] and modal MIC, 0.031 μg/mL and 0.008 μg/mL, respectively) and the azoles itraconazole, posaconazole, and voriconazole (0.035 to 0.049 μg/mL and ≤0.03 μg/mL). However, 18.6% of the isolates tested were resistant to terbinafine (MIC ≥ 0.5 μg/mL), including 21 T. rubrum and 21 T. indotineae isolates. These isolates were received from several different states in the United States and two provinces in Canada. In contrast, resistance to itraconazole was relatively rare. We also searched our laboratory database for earlier isolates that were resistant to terbinafine and identified 3 additional T. indotineae isolates, the earliest of which was from 2017. These results demonstrate that terbinafine resistance in dermatophytes was relatively common over this 2-year period and that T. indotineae is present in multiple areas in North America. Continued surveillance is warranted.

Clinico-Mycological Profile of Recurrent Dermatophytosis with Drug Sensitivity in a Tertiary Care Center in Southern Odisha

Background: Recurrent dermatophytosis is a pressing problem worldwide due to inadequate treatment, drug resistance, and indiscriminate use of topical steroids. This scenario increases the need for the study of risk factors and antifungal susceptibility testing. There is a paucity of information on this subject. Objective: We aimed to find the clinico-mycological pattern of recurrent dermatophytic infections, the factors responsible for recurrence and determine the sensitivity pattern of isolates against four antifungals (fluconazole, itraconazole, terbinafine, and amphotericin B). Materials and Methods: Patients with recurrent dermatophytosis attending the outpatient Department of Our Tertiary Care Institute were enrolled in this study. A detailed history was taken; clinical examination was done; samples were collected for mycological examinations, and in-vitro antifungal sensitivity testing was done by broth microdilution method as per Clinical and Laboratory Standard Institute M38-A guidelines. Results: One hundred and twenty-eight patients were included in the study with a male:female ratio of 1.38:1. The most commonly affected age group was 31–40 years. Tinea corporis with tinea cruris was the most common type of clinical presentation. Potassium hydroxide mount was positive in 53 samples and culture was positive in 59 samples. Trichophyton rubrum was the predominant species isolated, followed by Trichophyton mentagrophytes. On in-vitro antifungal susceptibility testing, itraconazole and amphotericin B had the lowest minimum inhibitory concentrations (MIC), followed by terbinafine. Fluconazole had the highest MIC among the drugs tested. Conclusion: Topical corticosteroid abuse, lack of personal hygiene, and habit of sharing clothes were seen in many patients with recalcitrant dermatophytosis. T. rubrum was the most common isolated species. Antifungal susceptibility testing revealed itraconazole and amphotericin B to have the lowest MIC value and fluconazole to have the highest MIC value.

Comprehensive Taxonomical Analysis of Trichophyton Mentagrophytes/Interdigitale Complex of Human and Animal Origin from India

Taxonomic delineation of etiologic agents responsible for recalcitrant dermatophytosis causing an epidemic in India is still debated. The organism responsible for this epidemic is designated as T. indotineae, a clonal offshoot of T. mentagrophytes. To evaluate the real identity of the agent causing this epidemic, we performed a multigene sequence analysis of Trichophyton species isolated from human and animal origin. We included Trichophyton species isolated from 213 human and six animal hosts. Internal transcribed spacer (ITS) (n = 219), translational elongation factors (TEF 1-α) (n = 40), ß-tubulin (BT) (n = 40), large ribosomal subunit (LSU) (n = 34), calmodulin (CAL) (n = 29), high mobility group (HMG) transcription factor gene (n = 17) and α-box gene (n = 17) were sequenced. Our sequences were compared with Trichophyton mentagrophytes species complex sequences in the NCBI database. Except for one isolate (ITS genotype III) from animal origin, all the tested genes grouped our isolates and belonged to the "Indian ITS genotype", currently labeled as T. indotineae. ITS and TEF 1-α were more congruent compared to other genes. In this study, for the first time, we isolated the T mentagrophytes ITS Type VIII from animal origin, suggesting the role of zoonotic transmission in the ongoing epidemic. Isolation of T. mentagrophytes type III only from animal indicates its niche among animals. Outdated/inaccurate naming for these dermatophytes in the public database has created confusion in using appropriate species designation.

Comparative Efficacy of Super Bioavailable Itraconazole Capsules 50 mg vs 65 mg Twice Daily in the Management of Glabrous Tinea.

Owing to pharmacokinetic challenges of itraconazole, super-bioavailable itraconazole (SB) was developed and recently approved in strengths of 50mg and 65mg. But comparative study was lacking between these two strengths in glabrous tinea (dermatophytosis) management. Hence, this study was planned to compare the efficacy of both these strengths in dermatophytosis. One hundred eligible patients were enrolled in this prospective, randomized, clinical study during May-2022 to September-2022 at tertiary hospital in Ahmedabad in adults. Efficacy and safety assessments were done at week-3 and 6 with follow up at week-10 for relapse. Primary objective was to assess the proportion of patients achieving complete cure at week-6 following treatment in both the groups. Secondary outcomes compared safety, clinical and mycological cure rates. Of the 100 patients enrolled, 98 patients (50 in SB-50mg and 48 in SB-65mg group) included in the final analysis. At week 6, 20 patients (40%) and 30 patients (62.5%) achieved complete cure (p < 0.05) in SB-50mg and SB-65mg groups, respectively. In completely cured patients, relapse was reported in 3 (15%) and 5 (17%) patients of SB-50mg and SB-65mg groups, respectively (p = 1). A significant difference was noted in clearance of symptoms and lesions in SB-65mg group (p < 0.05). Moreover, similar results were also obtained in sub-group analysis of recalcitrant dermatophytosis. Both the treatments were found to be safe and well tolerated with no discontinuation. Study result concluded the superiority of SB-65mg over SB-50mg in terms of cure rate and resolution of symptoms in dermatophytosis management.

“A CROSS-SECTIONAL STUDY OF CLINICO-MYCOLOGICAL PROFILE OF DERMATOPHYTES AND ANTIFUNGAL SUSCEPTIBILITY AMONG PATIENTS ATTENDING DERMATOLOGY OPD AT A TERTIARY CARE HOSPITAL IN TELANGANA”

Background: Dermatophytosis is the most common supercial fungal infection worldwide, caused by dermatophytes that cause infections of the skin, hair, and nails due to their ability to invade keratin. Belong to three closely related genera: Trichophyton, Microsporum, and Epidermophyton. It is common in the tropics &amp; subtropical regions and in areas of high humidity. Recent years have seen an alarming increase in chronic, recurrent, and recalcitrant dermatophytosis in India. Despite the availability of a wide range of antifungals, treatment failure is often observed. This is often attributed to the probable emergence of drug-resistant strains. To identify t Objectives: he dermatophyte species causing Dermatophytosis and to determine antifungal susceptibility patterns to Fluconazole and Griseofulvin by Broth microdilution. A cross-sectional study was conducte Method: d over a period of 18 months duration i.e., from June 2021 to November 2022. Skin scrapings, hair plucking, and nail clippings were collected from 200 clinically diagnosed cases of dermatophytosis who attended the outpatient department of Dermatology (DVL) and samples were processed at the upgraded Department of Microbiology at Osmania General Hospital, Afzalgunj, Hyderabad. A total of 2 Results: 00 clinically diagnosed dermatophytosis patients were included in our study following inclusion and exclusion criteria. Their demographic details and clinical examination of cutaneous lesions were recorded. In our study, most patients affected were males 57% and the most common age group was 21-30 years seen in 25.5% of patients. Tinea corporis (40%) was the most common dermatophyte lesion followed by Tinea cruris (19.5%) seen in our study. KOH positivity was seen in 42% and culture was positive in 69.5% of cases. Dermatophytes isolated are 42% and non-dermatophytes isolated are 27.5% of cases in our study. The most common dermatophyte isolated in culture was Trichophyton rubrum (45%), followed by Trichophyton mentagrophytes 28 (33.3%). Among isolates of dermatophytes, Fluconazole is sensitive to 33.3% of isolates, whereas Griseofulvin is sensitive to 52.3% of isolates. Therapeutic failure is alarmingly common in t Conclusion: he current scenario of dermatophytosis in India. Failure is probably seen with all common isolates, younger patients, high contagious nature. This study will help to standardize care, provide guidance on management, and assist in clinical decision-making for healthcare professionals

Review on host-pathogen interaction in dermatophyte infections.

Dermatophytosis is a common superficial fungal infection of the skin and its appendages caused by dermatophytes. Recent times have witnessed a dynamic evolution of dermatophytes driven by their ecology, reproduction, pathogenicity and host immune response, influenced by population migration and socioeconomic status. Dermatophytes establish infection following successful adherence of arthroconidia to the surface of keratinized tissues. The proteolytic enzymes released during adherence and invasion not only ascertain their survival but also allow the persistence of infection in the host. While the cutaneous immune surveillance mechanism, after antigen exposure and presentation, leads to activation of T lymphocytes and subsequent clonal expansion generating effector T cells that differentially polarize to a predominant Th17 response, the response fails to eliminate the pathogen despite the presence of high levels of IFN-γ. In chronic dermatophytosis, antigens are a constant source of stimulus promoting a dysregulated Th17 response causing inflammation. The host-derived iTreg response fails to counterbalance the inflammation and instead polarizes to Th17 lineage, aggravating the chronicity of the infection. Increasing antifungal resistance and recalcitrant dermatophytosis has impeded the overall clinical remission. Human genetic research has the potential to generate knowledge to explore new therapeutic targets. The review focuses on understanding specific virulence factors involved in pathogenesis and defining the role of dysregulated host immune response against chronic dermatophytic infections for future management strategies.

A Clinical-Mycological Study of Dermatophytosis in Western India with Focus on Antifungal Drug Resistance as a Factor in Recalcitrance.

Dermatophytosis have assumed epidemic proportions in India. Antifungal drug resistance solely cannot explain disease magnitude and changing epidemiology. Aim of this study was to analyse clinical-mycological aspects of dermatophytosis, and estimate contribution of drug resistance in clinical recalcitrance. This single-centre observational, cross-sectional, descriptive study was done in tertiary centre of western India after ethical approval, enrolling dermatophytosis patients of all ages and sex. After history and examination, KOH mount and culture in modified SDA medium was done. Culture positive isolates were subjected to E-strip antifungal susceptibility method to test MIC for Terbinafine, Itraconazole, Fluconazole and Griseofulvin. Total 300 patients were included, with mean age of 33.83±27.5 years and male-to-female ratio of 1.22:1; tinea corporis et cruris being commonest, 39.33% (n=118). Only 11.67% (n=35) were treatment naïve, having classical annular morphology. History of topical steroid abuse was found in 81.67% (n=245), with pseudoimbricate lesions in 70.61% (n=173). 86.67% (n=260) had KOH positivity while 83.33% (n=250) had culture positivity: Trichophyton mentagrophytes 45.6% (n=114), followed by Trichophyton rubrum in 34.4% (n=86). A total of 265 patients fit into definition of recalcitrance, from which 12.45%, i.e., 33 isolates showed in-vitro fluconazole resistance. 14.33% (n=43) cases were chronic, 37% (n=111) persistent, 46% (n=138) recurrent while 17% (n=51) had relapse in their disease course. Steroid abuse was the commonest denominator. Role of antifungal resistance in recalcitrant dermatophytosis remains debatable. Stopping steroid abuse, which is often the commonest culprit, with adherence to standard antifungal therapy remains the paradigm in management.

Multidrug resistant tinea corporis/cruris: Response to voriconazole

The increasing worldwide resistance to terbinafine and older antifungal drugs, coupled with often erratic clinical responses to itraconazole, leaves dermatologists with limited options to deal with dermatophytic infections. Recalcitrant dermatophytoses has however, over past few years, become a significant public health issue, especially in India. In this context, we present a patient who failed four systemic antifungals sequentially and was subsequently cured with a 2 week course of voriconazole, an antifungal not routinely used for dermatophytoses as yet.