Original Article Mycological study on incidence of tinea incognito in a tertiary hospital Arun B 1* , Remya V S2, Sheeba P M3, PratyushaKokkayil 4 1Associate Professor, Department of Microbiology, Government Medical College, Palakkad, Kerala, INDIA. 2Sr.Lecturer, Department of Microbiology, Pariyaram Medical College, Kannur, Kerala, INDIA. 3,4 Assistant Professors, Department of Microbiology , Government Medical College, Palakkad, Kerala, INDIA. Email: [email protected] Abstract Objective: The aim of the study was to analyses the clinical and mycological features of tinea incognito cases, distribution of the etiological agents and commonly affected age group and gender also evaluated in this study. Method: Specimens collected were skin scrap ings from clinically diagnosed tinea incognito patient’s attended the dermatology OPD of a tertiary care hospital. Patient’s details were collected using a pretested structured questionnaire. Result: Out of 125 cases 67were males and 58 were female’s patie nts. The predominantly affected age grou p was 30-40 with mean age 32.4. M ost of the tinea incognito cases ware resembled with eczema (45%), followed by seborrheic dermatitis (20%) and atopic dermatitis (15%). tinea incognito lesions are commonly seen in th e skin and groin area. frequently isolated dermatophyte was Trichophyton rubrum [36.2%) followed by Trichophyton mentagrophyte (26%) Conclusion: Differential clinical diagnosis in skin infections is difficult. Treatment without laboratory confirmation of fu nga etiology may increase atypical presentation dermatophytosis. Laboratory confirmation is necessary before starting steroid treatment which will avoid the misuse of drugs and limit the bizarre appearance of skin lesions. Keywords: Dermatophytes, Tinea incognito, Trichophyton.. *Address for Correspondence: Dr. Arun B., Associate Professor, Department of Microbiology, Government Medical College, Palakkad, Kerala, INDIA. Email: [email protected] Received Date: 20/08/2015 Revised Date: 28/09/2015 Accepted Date: 14/10/2015 Access this article online depends on immune response and suppress the immune reaction. The infection, therefore, spreads and acquires a form quite different from classical ringworm. The patient Quick Response Code: Website: is often satisfied initially with the treatment because www.medpulse.in itching becomes controlled and the inflammatory signs settle. When application of the steroid creams are DOI: 15 October stopped, eruptions rel apse with varying rapidity. Further applications bring renewed relief and the cycles are 2015 repeated. Typically the raised margin is diminished, INTRODUCTION scaling is lost and the inflammation is reduced and it is Dermatophytosis is a fungal infection commonly seen in confused with other skin diseases like eczema, psoriasis, candidiasis, impetigo, rosacea, lichinoid dermatitis, atopic humans and animals. It is caused by a group of fungi 2 known as dermatophytes. Tinea incognito is a steroid dermatitis, itertrigo etc. To differentiate tinea incognito from these types of diseases, mycological examinations modified clinical type caused by dermatophytes. In 1968, 3 Ive and Marks used the term ‘tinea incognito’ for cases of like direct microscopy and culture have to be employed. epidermomycosis, erroneously treated with topical An increase in the n umber of cases of tinea incognito has steroids, having clinical manifestations that mimicked been observed in different places, particularly in other skin conditions, such as seborrheic dermatitis, European and Asian countries. Published data on the lichen planus, folliculitis, scleroderma and rosacea; one mycological aspects of tinea incognito in our country is third of cases also had typical ringworm lesions 1. Tinea very less. In this study we investigated the mycological incognito is difficult to diagnose because of the absence aspects of tinea incognito in a tertiary care hospital in of the typical ringworm appearance. The steroid induced North Kerala. infection is frequently because the patient tried topical steroids without consulting a doctor. In fact, corticosteroids decrease resistance to infection, which How to site this article: Arun B, R emya V S, Sheeba P M, PratyushaKokkayil . Mycological study on incidence of tinea incognito in a tertiary hospital. MedPulse – International Medical Journal October 2015; 2(10): 649-651. http://www.medpulse.in (accessed 16 October 2015). MedPulse – International Medical Journal, ISSN: 2348-2516, EISSN: 2348-1897, Volume 2, Issue 10, October 2015 pp 649-651 MATERIALS AND METHODS glabrous regions of the skin predominantly trunk and During the study period of one year, skin scrapings were groin (48%). 34% of lesions were seen in the face. collected from 125 patients clinically diagnosed as Tinea Remaining 28% lesions were seen in different body sites incognito from the skin and venereal disease OPD of a including foot, hand and palms. Out of the 125 skin tertiary care hospital in north Kerala, India. Details of the scrapings, 98(78.4%) specimens were positive by light patients were collected using pre tested structured microscopy using 10% KOH. 69(55.2%) of these were questionnaire. Specimens were examined by 10%KOH also culture positive. There were no KOH negative mount and culture was doneon SDA with cyclohexamide culture positive cases. The commonly identified and chloramphenicol. Cultures were incubated at 25 0C for dermatophytes were Trichophyton rubrum (36.2%), at least 3 weeks. Dermatophytes were identified by followed Trichophyton .mentagrophyte s (26%), theircolony morphology, microscopic appearance, Trichophyton .tonsurans (17.4%), biochemical reactions and nutritional studies. Epidermophytonfloccossum (13%) Microsporumcanis (4.3%) and Microsporumgypseum (2.9%). (Figure-2). RESULT Total of 125 patients were included in the study among 4% 3% T.rubrum which 67 (53.5 %) were males and 58 (46.5%) females T.mentagrophyte (1.15:1). The incidence of tinea incognito was found to be 13% 36% highest in patients between the ages of 30 – 40 years. T.tonsurans Meanage being 32.4years. The rate of infection was 18% E.floccosum found to be lower in the extremes of ages. Age wise 26% M.canis distribution of cases has been depicted in Table -1 and M.gypseum Figure – 1. Table 1: Age wise distribution of Tinea incognito cases Figure 2: Dermatophytes species isolated from tinea incognito Age group No of patients Percentage cases 0-9 2 2 DISCUSSION 10--19 20 16 The term tinea incognito has been used to describe 20-29 30 24 dermatophyte infections modified by corticosteroid 30-39 31 25 treatment. Clinical presentation of tinea may be altered by 40-49 15 12 the use of steroids through the suppression of the fungus- 50-59 12 9 60-69 10 8 induced local immunity. Thus inflammatory effect is >70 5 4 inhibited, erythema and scaling are decreased, but the Total 125 100 growth of the fungus is enhanced, transforming the typical clinical presentation of ringworm and mimicking other skin diseases 4. In recentreports, not only 35 30 31 30 corticosteroids, but also new class topical non-steroidal 25 20 medications including pimecrolimus and tacrolimus have 5,6 20 15 been also reported to induce tinea incognito . 12 15 10 Commonly the lesions mimicother skin disorders like 10 5 atopic dermatitis, seborrheic dermatitis, lichenoid, 5 2 rosacea, psoriasis and eczema, contact dermatitis, and 0 5 other dermatological lesions . In our study male patients 0-9 10--19 20-29 30-39 40-49 50-59 60-69 >70 (53.5%) were found to beinfected morethan female Figure 1: Diagrammatic representation of age wise distribution of (43.5%). The present study also observed that the dermatophytosis commonly affected age group was 30-40 years followed Among the clinically diagnosed tinea incognito cases by 20-30 years. The mean age group was 32.4 years. A included in the study, 45% mimicked eczema, 20% study regarding tinea incognito in Italy7 reportedsimilar seborrheic dermatitis, 15% atopic dermatitis and gender distribution and mean age (42 years). A study by remaining 25% resembled other skin disorders like Kim. J.W et al 8 also reported equal gender distribution psoriasis, contact dermatitis, lichen planus, and vitiligo. with younger mean age (32.6 yr). Results from all these 85% of the patients had previously self-medicated studies suggest that tinea incognito predominantly affects themselves with steroids or were prescribed steroids by patients in the age group 30 to 40 years. Among the 125 quacks. 15% patients were immune compromised with clinically diagnosed cases of Tinea incognito included in different factors. Lesions were commonly seen in the the present study, 45% cases mimicked the clinical MedPulse – International Medical Journal, ISSN: 2348-2516, EISSN: 2348-1897, Volume 2, Issue 10, October 2015 Page 650 Arun B, Remya V S, Sheeba P M, PratyushaKokkayil features of eczema, 20% and 15% cases CONCLUSION resembledseborrheic dermatitis and atopic dermatitis Most of the studies and text books articulate the need for respectively. Several studies have reported that clinical laboratory confirmation of mycological etiology before manifestations of tinea incognita are mostly misdiagnosed starting antifungal treatment. This is so because clinical as eczema and impetigo. Some of them may also diagnosis of fungal infection could many a times be resemble lupus erythematosus, rosacea, plaque type or inaccurate. Misdiagnosis of dermatophytosis results in pustular psoriasis, vasculitis, seborrheic dermatitis, and 7,9,10,11 improper treatment