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E-IJD® - CASE REPORT |
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| Year : 2022 | Volume
: 67
| Issue : 1 | Page : 93 |
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| Chronic eczema developing over skin treated for dermatophytosis in atopic patients -Importance of treating gently and intelligently |
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Shyam Verma1, Ramkumar Ramamoorthy2, J Vasani Resham3
1 Department of Dermatology, Nirvan Skin Clinic, Makarpura Road, Vadodara, Gujarat, India
2 Department of Pediatric Dermatology, Kanchi Kamakoti CHILDS Trust Hospital, Nageswara Road, Nungambakkam, Chennai, Tamil Nadu, India
3 Department of Dermatology, Bhojani Clinic, Babasaheb Ambedkar Road, Matunga, Mumbai, Maharashtra, India
| Date of Web Publication | 19-Apr-2022 |
Correspondence Address:
Shyam Verma
Nirvana Skin Clinic, Makarpura Road, Vadodara - 390 009, Gujarat
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijd.ijd_251_21
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 Abstract | | |
A novel observation of chronic eczema developing over the skin of adequately treated lesions of tinea cruris/tinea corporis in six atopic individuals is being shared. We propose that the skin of atopic individuals affected by dermatophytosis be observed for secondary changes even after the complete resolution of the lesions. The use of bland emollients with topical antifungal agents should be encouraged in atopic patients. The extent and duration of the compromised epidermal barrier function of the skin of atopic individuals with dermatophytosis need to be studied further.
Keywords: Atopy, emollients, lichenified eczema, tinea corporis, tinea cruris
How to cite this article:
Verma S, Ramamoorthy R, Resham J V. Chronic eczema developing over skin treated for dermatophytosis in atopic patients -Importance of treating gently and intelligently. Indian J Dermatol 2022;67:93 |
How to cite this URL:
Verma S, Ramamoorthy R, Resham J V. Chronic eczema developing over skin treated for dermatophytosis in atopic patients -Importance of treating gently and intelligently. Indian J Dermatol [serial online] 2022 [cited 2023 Jun 4];67:93. Available from: https://www.e-ijd.org/text.asp?2022/67/1/93/343293 |
| Introduction | |  |
Dermatophytosis is a major concern in the current epidemic-like situation in India. In addition to the myriad intriguing observations recorded regarding the clinical features of this condition, we report a novel phenomenon of eczematous lesions appearing over adequately treated tinea corporis and cruris in a minority of atopic patients. Further, an attempt has been made to provide explanations for this hitherto undescribed phenomenon.
| Case Report | | |
We would like to share some observations made during the treatment of dermatophytosis (tinea corporis et cruris referred to as 'tinea') in six patients that we treated during the COVID-19 pandemic. All these patients were applying fixed-dose combination creams containing clobetasol propionate, miconazole, and neomycin erratically for a period ranging from 2 weeks to 3 months before seeing us. They were all treated with itraconazole 200 mg daily for 4–6 weeks with 1% luliconazole cream to be applied twice daily for 6–8 weeks resulting in complete clinical resolution of the lesions. These patients returned after 2–6 weeks after completion of both oral and topical treatments with complaints of persistent itching and appearance of minimally scaly hyperpigmented plaques at the sites previously affected by tinea. A few of these patients opted for teleconsultation and those who reported to the clinic could not be examined closely due to the social distancing norms during the pandemic. Assuming a relapse of the infection, they were told to continue the prescribed topical antifungal, as it was considered the safest under the given circumstances and were followed up in 2 weeks. The symptoms persisted at the follow-up visit and a close examination conducted with due precautions revealed hyperpigmented variably lichenified skin over the resolved lesions of tinea [Figure 1]a and [Figure 1]b and [Figure 2], and [Figure 3]. A detailed history revealed a history of atopy in self or close relatives in all the patients. Dermoscopy showed the accentuation of the skin markings over a background of hyperpigmentation [Figure 4]. The skin biopsy in two patients showed features of chronic eczematous dermatitis [Figure 5]a and [Figure 5]b. Periodic Acid Schiff and Gomori's Methenamine Silver stains [Figure 5]c were negative for fungus. A diagnosis of chronic eczematous dermatitis with varying degrees of lichenification appearing over the resolved tinea in patients with atopic diathesis was made. Antifungal creams were withdrawn, and frequent use of emollients with levocetirizine 5 mg at night resulted in a significant reduction of itching in 4–6 weeks. Two patients were additionally given sample tubes of 1% hydrocortisone cream to be applied sparingly once or twice a day only for a maximum period of 2 weeks, due to the concern of self-application in the future. All the patients reported significant relief in itching upon application of regular emollients for 1–3 months. A longer follow-up is required to assess the extent of the change in lichenification and hyperpigmentation though both seemed less in the last follow-up. | Figure 1: (a) Bilateral well-defined hyperpigmented lichenified plaques with a tinge on erythema at the edges in the groin. (b) Close-up of the lichenified plaque showing induration and accentuation of the skin markings
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 | Figure 2: Bilateral ill-defined hyperpigmented lichenified plaques over both inner thighs with similar milder changes over the labia majora
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 | Figure 3: Ill-defined hyperpigmented plaques on the inner thighs with accentuation of skin markings
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 | Figure 4: Dermoscopy, polarized-DL3N (10X)—accentuation of the crisscross markings over a background of pigmentation
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 | Figure 5: (a) H and E, 10X—psoriasiform hyperplasia, spongiosis, superficial and deep perivascular, and interstitial infiltrate suggestive of chronic spongiotic dermatitis. (b) H and E, 40X—focal parakeratosis, spongiosis, exocytosis of lymphocytes, with perivascular infiltrate in the superficial dermis. (c) Giemsa stain, 40X—no fungal elements seen in the stratum corneum
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| Discussion | | |
We hereby attempt to explain this phenomenon which to the best of our knowledge is not described to date. It is an established fact that the skin affected by dermatophytosis displays significant barrier dysfunction.[1] The invasion of the stratum corneum by dermatophytes results in their penetration and proliferation leading to the expression of proliferation-associated cytokeratins. Filaggrin and involucrin also get downregulated leading to an increased transepidermal water loss.[1],[2],[3],[4],[5] Although in these cases, it was not possible to retrospectively look for the causative organism, Trichophyton mentagrophytes type VIII is the predominant dermatophyte responsible for the pan Indian epidemic of dermatophytosis.[6] It has a propensity to often cause primarily inflammatory lesions which may be responsible for the pronounced barrier disruption of the skin in atopic individuals.
Clobetasol, containing combination creams that all these patients had applied for varying periods, would be expected to further vitiate the situation by the molecule's ability to delay barrier recovery by inhibiting the induction of lipid synthesis, compromising permeability barrier homeostasis and stratum corneum integrity as early as 3 days after its use.[7]
All these patients had applied luliconazole 1% cream for at least 6 weeks. One cannot negate the possibility of irritant or allergic potential of the cream base or of the preservative content, contributing to the eczematous process. The inherently lowered threshold of itch in these patients[8] may induce the 'itch-scratch-itch' cycle that ultimately causes lichenification of the tinea-affected area as has been seen in our cases.
Tinea cruris, tinea corporis, and both occurring together comprise the majority of cases seen in the approximately 6-year-old epidemic-like situation in India. While diagnosing tinea and prescribing drugs for it is easy and done quickly, clinical examination and continuation of drugs on follow-up visits are often done cursorily in many overburdened departments and large practices. This practice has become even more common during the COVID pandemic wherein maintaining adequate physical distance and spending the shortest possible time during consultations are recommended. Adequate history taking and close examination enabled us to elicit a history of atopy and appreciate varying degrees of eczematization and lichenification that had earlier been treated mechanically with luliconazole cream as persistent tinea. This case series underscores the importance of eliciting the history of atopy in patients of tinea. Such cases after careful examination should be treated with regular and frequent use of bland emollient creams concomitantly with the antifungal treatment and thereafter. We would recommend the use of mild topical steroids under supervision for the shortest possible time for symptom relief in cases of lichenified eczema—only in severely symptomatic patients after ensuring the complete resolution of the fungal infection. This is bearing in mind that their potential for misuse in this country where all steroid creams are available over-the-counter despite a statutory warning.[9] It may be a worthwhile exercise to study the association of inflammatory tinea cruris and tinea corporis on the skin of atopic individuals during and even after a complete resolution of the infection.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Lee WJ, Kim JY, Song CH, Jung HD, Lee SH, Lee SJ, et al. Disruption of barrier function in dermatophytosis and pityriasis versicolor. J Dermatol 2011;38:1049-53.  |
| 2. | Bhargava P, Nijhawan S, Singdia H, Mehta T. Skin barrier function defect-A marker of recalcitrant tinea infections. Indian Dermatol Online J 2020;11:566-9. [Full text] |
| 3. | Petrucelli MF, Peronni K, Sanches PR, Komoto TT, Matsuda JB, Silva Junior WAD, et al. Dual RNA-Seq analysis of trichophyton rubrum and HaCat keratinocyte co-culture highlights important genes for fungal-host interaction. Genes 2018;9:362. |
| 4. | Elias PM, Hatano Y, Williams ML. Basis for the barrier abnormality in atopic dermatitis: Outside-inside-outside pathogenic mechanisms. J Allergy Clin Immunol 2008;121:1337-43. |
| 5. | Jensen JM, Pfeiffer S, Akaki T, Schröder JM, Kleine M, Neumann C, et al. Barrier function, epidermal differentiation, and human beta-defensin 2 expression in tinea corporis. J Invest Dermatol 2007;127:1720-7. |
| 6. | Verma SB, Panda S, Nenoff P, Singal A, Rudramuruthy SM, Uhrlass S, et al. The unprecedented epidemic-like scenario of dermatophytosis in India: I. Epidemiology, risk factors and clinical features. Indian J Dermatol Venereol Leprol 2021;87:1-23. |
| 7. | Kao JS, Fluhr JW, Man MQ, Fowler AJ, Hachem JP, Crumrine D, et al. Short-term glucocorticoid treatment compromises both permeability barrier homeostasis and stratum corneum integrity: Inhibition of epidermal lipid synthesis accounts for functional abnormalities. J Invest Dermatol 2003;120:456-64. |
| 8. | Koblenzer CS. Itching and the atopic skin. J Allergy Clin Immunol 1999;104:S109-13. |
| 9. | Verma S, Madhu R. The great Indian epidemic of superficial dermatophytosis: An appraisal. Indian J Dermatol 2017;62:227-36. [Full text] |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5] |
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