Dermatophytosis refers to superficial fungal infection of keratinised tissue caused by keratinophilic dermatophytes.  They have the affinity to keratin rich tissues and produce dermal inflammatory response, intense itching, and cosmetically poor appearance [1]

Superficial fungal infections are the most common fungal infections. According to observations worldwide, dermatophytosis are the most common of the superficial fungal infections, the expected lifetime risk of getting a dermatophyte infection is between 10 and 20% [2]

It is common in tropical countries like india and may reach epidemic proportions in areas with high rate of humidity, overcrowding, in people living in poor hygienic conditions under low socioeconomic strata.

Identification of dermatophytes at species level in clinical diagnosis is important not only for epidemiological study but also for antifungal treatment [3]

Emmons (1934) classified dermatophytes into three anamorphic (asexual or imperfect) genera, namely, microsporum, trichophyton and epidermophyton of the class hyphomycetes of the deuteromycota (fungi imperfecti). The classification of dermatophytes is based on the formation of conidia and their morphology and is updated with the discovery of 8 new species (ajello, 1977, matsumoto and ajello, 1987). [4]

Clinically, tinea can be classified depending on the anatomical site of involvement including tinea capitis, tinea corporis, tinea cruris, tinea pedis, and tinea barbae [5].

There is local invasion of the fungi and maximum inflammation at the advancing margins leaving a clear central area. The manifestation is the combined result of keratin destruction and inflammatory response generated in the host.

The increase in the prevalence of dermatophytosis can be attributed to a number of factors like age, sex, geographic location and habits, temperature microenvironment, the patient's immune status and associated illnesses but the most common factor predisposing to fungal infection still remains poor personal hygiene.

The two most important methods used to diagnose dermatophytosis are direct microscopy and isolation of the specific species through culture.

The commonly encountered dermatophyte infections are treated both by topical and systemic antifungal therapy.

Our study was permitted and approved by ethics Committee of M. R. Medical College, Kalaburagi. Our study is prospective observational study conducted at mr medical college and basaveshwara teaching and general hospital, kalaburagi during a period of Oct 2017 to April 2019.

Our study comprised of 100 clinically diagnosed cases of dermatophytosis all ages and either sex who gave informed consent for the study were included while patients already on treatment for dermatophytic infection and immunocompromised patients were excluded from the study.

Before study each patient was informed about the aim and objective of the study and written informed consent was taken for each patient.

Brief history of patients including age, sex, occupation, onset and duration of lesions and clinical examination findings were noted. Thorough cutaneous examination was conducted including that of hair and nails. The site of lesion from a clinically diagnosed case was cleaned thoroughly with 70% alcohol and allowed to dry. The edges of the lesion were selected for scraping, as the edge is the active part of the lesion. Scrapings were taken with the help of a scalpel blade with the blunt edge facing the lesion. The scrapings were collected onto a sterile piece of paper, folded appropriately for transport. While taking nail clippings, the nails were cleaned with 70% alcohol and allowed to dry. The deepest part of the nail is clipped with a nail clipper and the debris along the nail plate is also collected onto a sterile paper. In cases of scalp lesions, the hair stubs are epilated with the help of a forceps onto a sterile piece of paper.

Laboratory Investigations

Material collected was subjected to direct microscopic examination using 10% koh and culture on sabourauds dextrose agar with antibiotic & cycloheximide and final identification of the species by lactophenol cotton blue mount was done.

Statistical analysis

Data was analysed using ibm spss 20.0 version software. For qualitative data analysis chi square analysis was applied for significance, for quantitative data analysis t test and anova test was applied for significance. P value <0.05 was considered as significant.

100 patients clinically diagnosed cases of dermatophytosis attended opd of dermatology, basaveshwara teaching and general hospital, attached to mahadevappa rampure medical college, kalaburagi from october 2017 to April 2019 were studied.

Among the 100 patients studied, 60 % were male while 40 % were females. The mean age of males was 28.71 ± 13.45 and females mean age was 32.02 ± 11.82 with no statistical significant difference of age among males and females (p>0.05). By occupation 38 % were laborers, 20 % patients were housewives, 17 % of cases were agriculturists and 15 % of patients were students while 10 % were pursuing other occupation.

The most common complaint was itching with discoloration which was present in 93 % patients, followed by scaling at the affected area in 92 %. 12 % patients complained of discharge from the lesion and 8 % complained of hair loss. History of similar complaints in the past was seen among 35 % of patients while the rest were new clinically diagnosed cases. Family history of similar complains was present in 30 % of our patients

Only 46 % of patients had bath and changed their garments on a daily basis. 31 % of patients groomed themselves once in two days, whereas the rest of the 23 % patients were maintained very poor personal hygiene by having bath and changing clothes once or twice in a week.

76 % of patients shared contaminated towels, combs, clothes, footwear and beddings from other members in the residence and at work. Presence of annular plaque with papule was the most common skin lesion seen being present in 74 % of patients. In this study tinea corporis was the most common clinical diagnosis 55 % (Fig. 2b), 10 % of the cases were tinea cruris (Fig. 2f) and tenia unguium (Fig. 2a) each, 3 % of the cases were tinea capitis(Fig. 2d), tenia faciei (Fig. 2e) and tenia manuum (Fig. 2a) each, 5 % of the patients presented with tinea pedis(Fig. 2c). A combination of tinea corporis and tinea cruris was commonly seen in 5.0% of the total cases.  On direct microscopy dermatophyte hyphae were found in 73 % patients as a highly refractile, branched septate threads and ectothrix or endothrix invasion of infected hairs.

On culture microbiological confirmation of the infection could be obtained only in 38 % patients. Of the 38 patients 23 patients grew trichophyton mentagrophytes(Fig. 1g and Fig. 1h) making it the most common isolate (60.5%). This was followed by trichophyton rubrum (Fig. 1e and Fig. 1f) in 11 patients (28.9 %). Epidermophyton floccosum (Fig. 1a & Fig. 1b) isolated from 1 patient (2.6%) and trichophyton tonsurans (Fig. 1c & Fig. 1d) isolated from 3 patients (7.9%).

Dermatophytosis are believed to affect 20% to 25% of the worlds population 6. Among the 100 patients diagnosed with dermatophytosis, our study demonstrated a male preponderance accounting for 60% of the patients. Showing a male to female ratio of 1.5:1. Verenkar et al, 7 in their study on dermatophytosis reported male preponderance with male to female ratio of 2:1. In our study the age of the patients ranged from 4 years to 76 years with majority belong to 21 to 30 years age group accounting for 33% of the patients. Similar pattern of predominence of patients in second to third decade had been observed by atit shah et al8 and ramaraj v et al9 in their studies with 40% and 49% of patients. In the study maximum number of patients were labourers (38%), house wives 20% and agriculturists (17%).  Similar findings were reported by singla b et al10 and kamothi et al11. In our study 35% of our patients had a positive past history which explains their exposure to contaminants previously and their lack of knowledge to take treatment, 76% of the patients shared contaminated towels, coombs, clothes, footwear and beddings from other members in the residence and at work. Similar findings were seen in a study performed by c.grove et al12 where 62% of the patients gave history of sharing of combs and hair accessories among each other, this confirms that dermatophyte infections are transmitted from person to person by sharing common household clothes and fomites. In the present study, tinea corporis was the most common clinical diagnosis (55%).this was found by itself and also in combination with other lesions including tinea cruris, tinea mannum or tinea pedis. This was followed by tinea cruris (10%) and tinea unguium(10%). Tinea capitis was found in 3% of the patient population. Study conducted by surendran et al13, showed similar results wherein t.corporis constituted 44.3%. In our study t.capitis was the predominant type in children. These findings are in agreement with other workers like yadav et al14. Children have immature immune system and till puberty they lack the effective fungistatic activity of sebum. In the present study t.pedis accounted to 5% each of the total patients. Transmission of tinea pedis often involves the use of communal baths, showers or other acquatic facilities and the infection is promoted by prolonged wearing of covered shoes and contact with water/moisture as is common in our environment where high levels of rainfall occur. In the study conducted by singh et al 15 the predominance of tinea pedis in western countries could be because of regular use of shoes and socks, predisposing to perspiration and maceration.

Culture is the gold standard method for diagnosis. In the present study 38% of cases of dermatophytosis were culture positive. Our study was similar to studies done by dimple et al 16, singla b et al 17 where the culture positivity was observed to be 44% and 49%. The sensitivity culture isolation depends on the types of culture media, sample quality and the expertise in fungal culture techniques. The low rate of culture positivity could be due to inadequate samples or prior treatment. In the present study 73% of the total patients examined were positive by koh mount microscopy. Similar findings were observed in study done by richa sharma et al19 showing a koh positivity of 72.5% in the present study trichophyton mentagrophytes was the most commonest species identified on culture being positive in 60.5% of the total isolates followed by t.rubrum accounting for 28.9%.  The present study finding correlates well with the study conducted by pavani et al study20 where, the predominant isolate was t. Mentagrophytes 69.5%. The second most common isolate in our study was t. Rubrum accounting to 28.9% of total isolates, is similar to the study done by farheen ansari et al21, where the isolation rate of trichophyton rubrum was 27%. Total % of positivity of culture in tinea corporis was 41.8% out of which t. Mentagrophytes was isolated in 21.8%. 12.7% grew t. Rubrum and 1.8% e. Floccosum. Among the patients who were clinically diagnosed with tinea cruris, culture positivity was 30 % positivity. 20% of the culture positivity was t. Mentagrophytes, 10% was t. Rubrum. Four out of ten patients were culture positive in tinea unguium patients of which 30% isolateswas t. Mentagrophytes, 10% was t. Rubrum. In patients having tinea corporis, cruris, pedis and manuum, t. Mentagrophytes was the species predominantly present. Similar findings have been seen in studies done by sundaram et al22 where t.metagrophytes was the predominate isolate from most of the clinical types of tinea.

In this present study, majority of the patients were males (60%) and females comprised the rest of the patients. Majority of patients diagnosed were in third decade of life (33%) followed by the fourth decade (30%). Most of the patients were labourers (38%), housewives (20%) and agriculturists (17%) who presented with the complains of ring lesions with itching and discoloration. The most common complaint was itching with discoloration (93%), followed by scaling. 35 % of the patients had past history of dermatophytosis. Family history was positive in 30% of the patients. Majority of patients (76%) had a history of sharing fomites including towels footwear and bedding. Very poor personal hygiene was a factor in 23% of the patients. 13% of patients infected with tinea were diabetics or immunosuppression. On examination annular plaques with papules was the most common presentation (74%). Tinea corporis was the most common clinical diagnosis (55%) followed by tinea cruris (10%) and tinea unguium (10%). 73% of patients showed elongated branched hyphae on direct microscopic examination after treating with koh. Microbiological cultures were positive in only 38% of the patients and all these patients showed positivity by direct microscopy. T. Mentagrophyte (60.5%) was the most common species isolated followed by trichophyton rubrum (28.9%) followed by epidcrmophyton floccosum (2.6%) and trichophyton tonsurans (7.9%) in patients diagnosed with tinea corporis, tinea cruris, tinea pedis and tinea  manuum,  t. Mentagrophyte was the most predominant species isolated.

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