In India, it is a common infection that was easily responding to treatment with topical and systemic
antifungals. However, the past few years have seen a tremendous increase in the number of patients
with recalcitrant dermatophytosis (fungal infection) across the country.
There has been apparently more number of new cases as well as frequent recurrences in those earlier
affected. The problem has been worsened and perhaps even been caused by the widespread use of
creams containing a combination of antifungals, super potent corticosteroids and antibiotics, either by
self-medication or due to prescription by misinformed persons.

Site of invasion, physiological variation of host skin barrier, age of patient, obesity,
immunosuppressive state, and acquired conditions such as excessive washing or sun

Anatomical characteristic of affected area which includes the presence of skin folds,
sebaceous glands, variable thickness of the corny layer, and vellus hair follicle involvement
also affects the typical centripetal progression and favors inflammation and crusting.

Ringworm syndromes – Based on site of involvement
• Tinea corporis – body
• Tinea capitis – scalp
• Tinea barbae- beard
• Tinea faciei – face
• Tinea pedis- foot
• Tinea manuum- hand
• Tinea cruris- groin
• Onychomycosis caused by dermatophytes – nails
• Steroid‐related tinea
• Dermatophytide reactions

 Annular erythematous scaly patch or plaque with raised margins
 They tend to be extensive, pruritic, erythematous and pustular, and may mimic other skin
 The central area becomes hypopigmented or brown and less scaly as the active border
progresses outward.
 Tinea incognito is a term used to describe a tinea infection modified by topical steroids. It is
caused by prolonged use of topical steroids, sometimes prescribed as a result of incorrect
 Topical steroids suppress the local immune response and allow the fungus to grow easily. As
a result, the fungal infection may take on the bizarre appearance seen in this patient
 Rings within the ring appearance
  Local side effects include atrophy, striae, folliculitis, perioral dermatitis, and telangiectasis.
The face and intertriginous areas (e.g. axilla, groin, perineum, inframammary area) are
particularly susceptible to these side effects because of increased absorption through a thin
stratum corneum epidermidis in these areas.
 Tinea imbricata (Tokelau), caused by Trichophyton concentricum species, is a geographically
restricted, morphologically unique form of dermatophyte infection, characterized by multiple
concentric rings.


Topical and systemic antifungals
As dermatophytes grow radially, the topical antifungal should be applied inward, from beyond the
margin of the lesion.
The topical antifungals should be applied 2 cm beyond the margin of the lesion for at least 2 weeks
beyond clinical resolution. We call this recommendation of applying topical antifungals 2 cm beyond
the margin, twice a day for 2 weeks beyond clinical resolution “The rule of Two”
Hepatic function to be monitored when patient is on systemic antifungals.
There will be a delay in clinical response seen in patients with steroid modified dermatophytosis, who
will hence require an extended duration of treatment.
There will be a delay in clinical response seen in patients with steroid modified dermatophytosis, who
will hence require an extended duration of treatment.


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