DR7.2 | Superficial Fungal Infection Management — Summary & Reflection

KEY TAKEAWAYS

Superficial fungal infections in India are dominated by dermatophytosis (tinea) — named by site as corporis, cruris, pedis, capitis, and unguium (onychomycosis) — alongside candidiasis (satellite pustules; pseudohyphae + budding yeast on KOH) and pityriasis versicolor (Malassezia). Dermatophytes invade keratin via keratinases; the modern Indian epidemic of chronic, recurrent disease is driven by climate, household spread, topical steroid misuse (tinea incognito), and terbinafine resistance from squalene epoxidase (SQLE) mutations. Confirm with a KOH mount (long branching septate hyphae) before systemic therapy; culture is for recalcitrant cases; the Wood's lamp fluoresces green with Microsporum but NOT Trichophyton (the predominant Indian cause of tinea capitis). Management is by site and extent: topical antifungals for localised disease; systemic terbinafine for extensive tinea; griseofulvin/terbinafine (systemic mandatory) for tinea capitis; terbinafine or itraconazole (long durations) for onychomycosis; fluconazole for candidiasis; topical/short-oral azole for pityriasis versicolor. When KOH-confirmed tinea fails terbinafine, switch to itraconazole for resistant disease, stop steroid creams, and treat contacts. Durations should be confirmed against current IADVL guidance.

REFLECT

Think about the farmer in the opening scenario, or a similar patient you have encountered with chronic, spreading, steroid-modified tinea that had failed previous treatment. How would a systematic approach — confirming the diagnosis on KOH, recognising the role of the steroid combination cream, treating the household, and switching from terbinafine to itraconazole for resistant disease — have changed the outcome compared with another empirical cream? Consider what you will say to a patient who insists on the combination cream that gives quick relief, and how you will explain that the very drug easing their itch is spreading their infection. Grounding your antifungal prescribing in confirmation, resistance awareness, and contact management is what separates a clinician who controls this epidemic from one who unwittingly fuels it.