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Background: Dermatophytosis is a common, superficial fungal infection of the skin. Recently, there has been tremendous increase in the incidence of dermatophytosis attributed mainly to misuse of steroids in the management of fungal infection. Methods: A cross sectional study of 6 months duration was done in patients with dermatophytic fungal infections, diagnosed clinically, with history or findings of some form of steroid use. Both quantitative and qualitative data were collected regarding steroid formulations about type, duration of use, route of administration and their availability by prescription or “over the counter”. Various cutaneous and systemic adverse effects of steroids were also observed. Results: Out of the total 200 patients of dermatophytosis, 120 patients (60%) had used steroid formulations either topical(80%), oral(12.5%), intralesional or injectable(7.5%).The mean duration of illness in patients who had used steroids was 24 ± 3 weeks. Multiple site infection of dermatophytosis was present in 65% with steroid misuse and in 40.8% with nonsteroid use patient group. Cutaneous adverse effects were common in patients with steroid misuse, as suggested by relatives, friends, chemist, general practitioners or due to self-medication. Conclusions: Misuse of steroid formulations in dermatophytic infections may result in various cutaneous and systemic side effects. Strict drug control policies and awareness of adverse effects of steroid abuse are truly the need of the hour to control this menace.
Dermatophytes are fungi that metabolize keratin to produce superficial infections of the skin, nails, and hair, known as dermatophytosis. Conventionally, dermatophytes are classified as asexual or imperfect (anamorphic) molds belonging to three genera: Trichophyton, Microsporum, and Epidermophyton. Dermatophytic infections have shown a rising trend across India. ¹ Once considered an easily curable infection, treatment has now become increasingly challenging. Patients often present with extensive, recurrent, and recalcitrant disease, frequently exhibiting atypical lesion morphology of superficial dermatophytosis.
The widespread availability of over-the-counter potent and super-potent topical steroids—used alone or in combination with antifungals and antibiotics—and the common practice of self-medication have contributed to the evolution of these atypical presentations. Topical and systemic steroids are known to suppress the immune response against dermatophytes and have the potential to cause a wide range of cutaneous adverse effects. ²
In this study, we aim to highlight the various adverse effects of steroids and evaluate their impact on the progression and management of fungal infections.
This was a cross-sectional study conducted over a period of six months in the Dermatology Outpatient Department (OPD) of Rama Medical College, Hospital & Research Centre, Hapur. The diagnosis was made clinically. The aim of the study was to observe various adverse effects of topical and/or systemic steroids in patients with dermatophytic infections.
Patients were asked to bring any previously used medications or topical preparations, along with their containers and old prescriptions. Information regarding steroid formulations—such as type, route of administration, duration of use, and whether the drugs were obtained over the counter or via prescription—was collected.
Various cutaneous side effects of steroid use, including skin atrophy, striae, telangiectasia, and others, were assessed in all patients. A detailed history was taken, including duration of disease, family history, and the presence of co-morbid conditions. Specific attention was paid to the history of diabetes, hypothyroidism, and other endocrine disorders.
Additionally, history of systemic steroid use for autoimmune, hematological, or respiratory diseases was also inquired. All patients diagnosed with dermatophytic infection were initially selected, from which those with a history or clinical findings of steroid use—whether topical, oral, intralesional, or injectable—were analyzed separately.
A total of 200 patients with dermatophytosis were enrolled in our study. The mean age of the patients was 25.5 years (range: 5–55 years). There were 135 males and 65 females (M: F = 2:1).
Of the 200 patients, 120 (60%) had used steroid formulations in some form—topical, oral, intralesional, or injectable. Among these 120 patients:
The majority of these patients, 74 (61.66%), had practiced self-medication based on suggestions from family or friends. Steroid-containing combination creams were prescribed by chemists in 28 (23.33%) cases and by unqualified registered medical practitioners in 18 (15%) cases. None of these patients had ever consulted a dermatologist for their condition.
A family history of dermatophytosis was present in 44 patients (36.66%). Many of these individuals reported sharing clothes and towels, suggesting possible fomite transmission.
Patients who used steroids in any form experienced a longer duration of illness. In this group, the mean duration of illness at the time of presentation was 24 ± 3 weeks. This extended duration may be due to topical steroids masking the immune response against the fungus, thereby allowing the infection to persist or worsen. ³
Multiple site involvement was observed in 78 out of 120 (65%) steroid-using patients. In contrast, among the 80 patients who did not use steroids, only 51 (40.8%) had fungal infections affecting multiple sites.
The most common clinical presentation was Tinea corporis (83.33%), followed by Tinea cruris (41.67%), and Tinea faciei (8.3%).
Various cutaneous side effects were noted in patients with steroid misuse:
All patients who received intralesional steroids developed both striae and acneiform eruptions. Overall, 108 out of 120 patients (90%) who had used steroids developed some form of cutaneous adverse effect. Figure 1, 2, and 3 illustrate these findings.
In our study, none of the patients developed any systemic side effects.
Dermatophytosis is a widely prevalent superficial mycosis in India with a recent upsurge in its incidence and a myriad of atypical presentations due to a complex interplay of agent factors (true resistance, parasitism of vellus hair), host factors (changing clothing habits, ping pong effect within the family, untreated sanctuary sites, casual health-seeking attitude, lack of adherence to standard therapy) and social factors (hesitation to seek medical advice due to involvement of groins, gluteal region, or the inframammary regions).4,5
In India, several combination creams are easily available over the counter and are cheaper too. They give quick symptomatic relief to the patients due to the anti-inflammatory properties of steroids. These medicines are widely recommended by general practitioners, quacks, paramedics, pharmacists, friends, and family without adequate knowledge about the diagnosis and management of dermatophytosis. Steroids in any form, be it topical, oral, injectable or intralesional tend to cause a prompt symptomatic relief and thus the patients have a false security of efficacy of medication and they tend to continue it or even reuse it on recurrence of the infection.
Absence of awareness and casual health-seeking attitude of Indian patients is reflected in our study where only one-third (32%) of the patients visit the Dermatologist on developing any skin rash. The data are comparable to the previous studies wherein dermatologists were approached by 14%–40% of patients.6,7 The major source of advice for the use of combination creams medicines were pharmacists(30.8%) and friends/relatives(29.4%). Pharmacists have been a major source of prescription (20%–78%) in the earlier studies also.7,8 Hence, spreading awareness among public and educating pharmacists and general practitioners about the adverse effects of irrational use of steroid containing combination creams and medications is crucial.8
Patients with use of steroid in any form present with prolonged mean duration of the disease.9Also, the patients, in whom steroid abuse was noted, had dermatophytosis at multiple sites implying that use of steroids can change the presentation and worsen the disease course. Diagnosis of fungal infections is often confusing and even delayed in such patients due to the atypical morphology of the lesions resulting from application of topical steroids.10 Steroid modified tinea is less scaly, lacks raised margins, maybe more extensive and may be associated with pustules.11
Various adverse effects of steroids may include atrophy, striae, rosacea, perioral dermatitis, acneiform eruptions, purpura, pigmentalteration, perioral dermatitis, hypertrichosis, delayed wound healing, and exacerbation of skin infections, some of which were present in our patients. In our study, various cutaneous adverse effects were noted with most severe side effectscaused byuse of intralesional steroids. Systemic adverse effects were more in patients given injectable steroids. In Literature, various systemic side effects have been mentioned like a trogenic Cushing's syndrome, hyperglycemia, glaucoma, Cataracts, hypothalamic-pituitary-adrenal axis suppression, femoral head avascular necrosis and others due to topical steroids. In a developing country like India, with low literacy rates and lack of awareness, most of the patients (89%) had neither heard of steroids nor were aware of their adverse effects. One of the major effects of steroid misuse may be epidemic spread of superficial fungal infections across the country.
The growing threat of steroid containing combination creams misuse in India is evident from this study. More awareness regarding adverse effects of steroids in fungal infections is needed among doctors, paramedics and the general population at large. The need is also to regulate marketing of irrational topical cocktail formulations containing a combination of steroid and antifungal. Many active steps are being taken by the IADVL (Indian association of Dermatologists, Venereologists and Leprologists) to tackle this issue including creating a new task force named IADVL Task Force Against Steroid Abuse (ITASTA).12However, more such pertinent measures are needed in this direction. There is a need to health educate community and medical professional that topical steroids are also dangerous, have serious side effects and judicious as well as rational use is anticipated to prevent the same.
Misuse of steroid formulations in dermatophytic infections may lead to various cutaneous and systemic adverse effects. In addition, variation in morphology, multiple site infection, prolonged illness, recurrence and delay in diagnosis may result due to steroid misuse. Strict drug control policies, health education and spreading awareness of this problem is needed for prevention of steroid modified dermatophytosis and control this menace.
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