Updating the epidemiology of dermatophyte infections in Palestine with special reference to concomitant dermatophytosis

Tinea pedis: an updated review

Background

Tinea pedis is one of the most common superficial fungal infections of the skin, with various clinical manifestations. This review aims to familiarize physicians with the clinical features, diagnosis and management of tinea pedis.

Methods

A search was conducted in April 2023 in PubMed Clinical Queries using the key terms 'tinea pedis' OR 'athlete's foot'. The search strategy included all clinical trials, observational studies and reviews published in English within the past 10 years.

Results

Tinea pedis is most often caused by Trichophyton rubrum and Trichophyton interdigitale. It is estimated that approximately 3% of the world population have tinea pedis. The prevalence is higher in adolescents and adults than in children. The peak age incidence is between 16 and 45 years of age. Tinea pedis is more common amongst males than females. Transmission amongst family members is the most common route, and transmission can also occur through indirect contact with contaminated belongings of the affected patient. Three main clinical forms of tinea pedis are recognized: interdigital, hyperkeratotic (moccasin-type) and vesiculobullous (inflammatory). The accuracy of clinical diagnosis of tinea pedis is low. A KOH wet-mount examination of skin scrapings of the active border of the lesion is recommended as a point-of-care testing. The diagnosis can be confirmed, if necessary, by fungal culture or culture-independent molecular tools of skin scrapings. Superficial or localized tinea pedis usually responds to topical antifungal therapy. Oral antifungal therapy should be reserved for severe disease, failed topical antifungal therapy, concomitant presence of onychomycosis or in immunocompromised patients.

Conclusion

Topical antifungal therapy (once to twice daily for 1-6 weeks) is the mainstay of treatment for superficial or localized tinea pedis. Examples of topical antifungal agents include allylamines (e.g. terbinafine), azoles (e.g. ketoconazole), benzylamine, ciclopirox, tolnaftate and amorolfine. Oral antifungal agents used for the treatment of tinea pedis include terbinafine, itraconazole and fluconazole. Combined therapy with topical and oral antifungals may increase the cure rate. The prognosis is good with appropriate antifungal treatment. Untreated, the lesions may persist and progress.

Spatio-temporal six-year retrospective study on dermatophytosis in Rio de Janeiro, Southeast Brazil: A tropical tourist locality tale

Trichophyton, Microsporum, Nannizzia and Epidermophyton genera cause dermatophytosis, the most common and highly contagious infectious skin disease. Rio de Janeiro is one of the most visited cities in the Southern Hemisphere, located in the most visited state of Brazil. This retrospective study investigated epidemiological and laboratorial aspects of dermatophytosis in Rio de Janeiro state, Brazil, by using spatiotemporal analysis. More than half of all individuals were infected by one or more dermatophytes. A variation between 18 and 106 years-old of the studied population was verified, and women more frequently affected. Patients were more frequently infected by Trichophyton spp., most of them T. rubrum, followed by T. mentagrophytes. M. canis and N. gypsea were more frequently isolated in the age group between 40 and 60 years old, while T. rubrum predominates among younger patients. All species presented homogeneous distribution while T. tonsurans appears to be restricted to the Rio de Janeiro capital while E. floccosum to the municipality of Macaé (190 Km apart from RJ). Rio de Janeiro state presented spatial clusters of dermatophytosis with high density in Guanabara Bay (E. floccosum, M. canis, N. gypsea, T. tonsurans) and Niterói (T. rubrum, T. mentagrophytes) but low density in Macaé (E. floccosum). Significant spatiotemporal clusters on dermatophytosis cases were detected in distinct municipalities (p-value ≤ 0.05). The Vulnerability Index (r = 0.293) and Demographic Density (r = 0.652) distributed according to neighborhoods in Niterói were direct related with dermatophytosis cases whereas Income (r = -0.306) was inversely correlated (p-value ≤ 0.05). The dermatophytosis spatiotemporal distinct distribution after two major international events in Rio de Janeiro, Brazil, highlight the pressing need for specific measures of its prevention and controlling. This is particularly relevant in touristic tropical localities which must consider both socio-economical and traveler's medicine variables.

Trends in the epidemiology of dermatophytosis in the Middle East and North Africa region

Dermatophytosis corresponds to a broad series of infections, mostly superficial, caused by a group of keratinophilic and keratinolytic filamentous fungi called dermatophytes. These mycoses are currently considered to be a major public health concern worldwide, particularly in developing countries such as those in the Middle East and North Africa (MENA) region. Here we compiled and discussed existing epidemiologic data on these infections in the MENA region. Most of the available studies were based on conventional diagnostic strategies and were published before the last taxonomic revision of dermatophytes. This has led to misidentifications, which might have resulted in the underestimation of the real burden of these infections in the MENA countries. Our analysis of the available literature highlights an urgent need for further studies based on reliable diagnostic tools and standard susceptibility testing methods for dermatophytosis, which represents a major challenge for these countries. This is crucial for guiding appropriate interventions and activating antifungal stewardship programs in the future.

Tinea pedis-An embarrassing problem for health and beauty-A narrative review

Fungal infections present with a broad spectrum of diseases in humans (from relatively mild superficial infections of the skin and mucous membranes to the invasive or chronic infections of internal organs, which have a high mortality rate). Globally, up to 1.6 million people die each year as a result of various types of mycoses. Currently, many scientific studies focus on the best possible understanding of the aspects of the epidemiology and pathogenesis of invasive mycoses and effective methods to combat them. However, mycoses of the skin and its appendages remain a relatively less explored area. In some communities, superficial mycoses are a frequent problem as they affect nearly 70% of the population, an example of which is the athlete's foot. It involves the nails (onychomycosis) and skin (tinea pedis). It is mainly caused by keratin-decomposing dermatophyte fungi. Less often, infections are caused by non-dermatophyte moulds (Fusarium, Aspergillus, Scopulariopsis) or yeasts. Several factors have been listed as having substantial influence on the development of dermatophytosis, including those related to climate, season, geographical region, as well as to demography, socioeconomic and cultural customs, professions or contact with animals. In this review, we summarise the current knowledge about aetiology, epidemiology, diagnostics and therapy of tinea pedis with a special focus to the role of podologic management in spreading, prevention and therapy of mycoses. The article presents up-to-date knowledge on the management of the patient from the diagnosis, treatment and skincare, to counselling on how to prevent fungal skin infections in the long term.

Comparison of in vitro antifungal activity of novel triazoles with available antifungal agents against dermatophyte species caused tinea pedis

OBJECTIVE

Dermatophytes are a group of keratinophilic fungi that invade and infect the keratinized tissues and cause dermatophytosis. We investigated effectiveness of novel triazole (luliconazole and lanaconazole) in comparison with available antifungal agents against dermatophyte species isolated from patients with tinea pedis.

MATERIAL AND METHODS

A total of 60 dermatophytes species were isolated from the patients with tinea pedis. Identification of species was done by DNA sequencing of the ITS1-5.8S rDNA-ITS2 rDNA region. In vitro antifungal susceptibility testing with luliconazole and lanaconazole and available antifungal agent was done in accordance with the Clinical and Laboratory Standards Institute, M38-A2 document.

RESULTS

In all investigated isolates, luliconazole had the lowest minimum inhibitory concentration (MIC) (MIC range=0.0005-0.004μg/mL), while fluconazole (MIC range=0.4-64μg/mL) had the highest MICs. Geometric mean MIC was the lowest for luliconazole (0.0008μg/mL), followed by lanoconazole (0.003μg/mL), terbinafine (0.019μg/mL), itraconazole (0.085 μg/mL), ketoconazole (0.089μg/mL), econazole (0.097μg/mL), griseofulvin (0.351 μg/mL), voriconazole (0.583μg/mL) and fluconazole (11.58μg/mL).

CONCLUSION

The novel triazoles showed potent activity against dermatophytes and promising candidates for the treatment of tinea pedis caused by Trichophyton and Epidermophyton species. However, further studies are warranted to determine the clinical implications of these investigations.

Biological Properties and Bioactive Components of Mentha spicata L. Essential Oil: Focus on Potential Benefits in the Treatment of Obesity, Alzheimer's Disease, Dermatophytosis, and Drug-Resistant Infections

In the present study, the medicinal aromatic plant Mentha spicata has been investigated as a source of essential oil (EO) and pharmaceuticals. The quantity and composition of EO from M. spicata cultivated in Palestine were analyzed seasonally over a three-year period. A significantly higher EO content was produced in summer and fall months (2.54–2.79%). Chemical analysis of EO revealed 31 compounds with oxygenated monoterpenes (90%) as the most abundant components followed by sesquiterpene and monoterpene hydrocarbons (6 and 3%, respectively). M spicata can be characterized as a carvone chemotype (65%). EO and carvone have shown strong inhibitory activities against the principal enzymes associated with Alzheimer's disease (AD) and overweight diseases (cholinesterase and porcine pancreatic lipase) and also shown strong antidermatophytic activity against Microsporum canis, Trichophyton rubrum, T. mentagrophytes, and Epidermophyton floccosum. The pancreatic lipase inhibition and the synergism showed the potential activity of M. spicata EO and carvone and that their combinations with standard drugs can be useful for the treatment of obesity and overweight. The results also demonstrated that, in addition to their significant inhibitory activity against biofilm formation of methicillin-resistant Staphylococcus aureus (MRSA), M. spicata EO and carvone had a strong inhibitory effect on metabolic activity and biomass of the preformed biofilm. The current study supports the utilization of M. spicata EO as a traditional medicine and opens perceptions to find more potent substances in the EO for the management of obesity, AD, and dermatophytosis and for combating drug-resistant bacterial infections.

The presence of dermatophytes in infected pets and their household environment

ABSTRACT The aim of this study was to diagnose dermatophytosis in pets and investigate the presence of dermatophytes in their home environment. Samples from hair coat were collected from 70 pets: 47 dogs, 19 cats, three guinea pigs and one rabbit. After mycological culture, 188 samples were collected from the household environments in 26 homes: 78 from places were of predominantly used by the tutors, 66 from places used by the animals, 44 from flooring, and 24 samples from contactees. Samples were seeded on Mycosel agar, incubated at 25°C, and the colonies were identified by their macro-and-microscopic characteristics. Dermatophytes were found in 37.1% of the samples originating from the sick animals. Microsporum canis was the most prevalent species, isolated in 12 dogs and eight cats; Trichophyton quinckeanum in three guinea pigs, Microsporum gypseum in two dogs and Trichophyton mentagrophytes in one cat. Dermatophytes were found in 69.2% of the surveyed homes; 29.5% of the places/objects predominantly used by the tutors, 42.4% mainly used by the animals, 31.8% from floors, and 50% from contactees. The meeting of dermatophytes in animals and in the household environment confirms the possibility of transmission by direct or indirect contact and their importance in public health.

Selection and validation of reference genes for qRT-PCR analysis of gene expression in Microsporum canis growing under different adhesion-inducing conditions

Dermatophytes are the group of filamentous fungi infecting keratinized structures such as skin, hair, and nails. Knowledge about genes and molecular mechanisms responsible for pathogenicity, as well as other biological properties of Microsporum canis is still relatively poor. The qRT-PCR is a reliable technique for quantifying gene expression across various biological processes, and choosing a set of suitable reference genes to normalize the expression data is a crucial step of this technique. We investigated the suitability of nine candidate reference genes: β-act, β-tub, adp-rf, ef1-α, sdha, rpl2, mbp1, psm1, and rGTPa for gene expression analysis in the dermatophyte M. canis in response to different carbon sources, phosphate levels, and pH shifts - factors that are extremely important and necessary for growth of dermatophyte in the host tissue. The transcription stability of these genes was evaluated using NormFinder, geNorm, BestKeeper, and RefFinder software. Regarding expression stability, mbp1, β-act, and sdha were the most stable housekeeping genes which we recommend for future qRT-PCR studies on M. canis strains. To the best of our knowledge this is the first study on selection and validation of reference genes for qRT-PCR data normalization in M. canis growth in culture media which promote adhesion-inducing conditions.

Changing in the Epidemiology of Tinea Capitis among School Children in Egypt

Background

Tinea capitis remains a prevalent health problem among school-aged children.

Objective

To estimate the prevalence of tinea capitis among primary school students, in Fayoum, Egypt with identification of etiological agents in both public and private primary schools.

Methods

A cross-sectional study was conducted in twelve primary schools. The students were selected from different grades with a total number of 12,128 students. Hair and scalp were clinically examined for any lesions that may suspect tinea capitis and mycological samples were collected for direct microscopy and culture.

Results

The prevalence of tinea capitis in the study group was 0.4% and higher in public than private schools (73.5% versus 26.5% respectively). Boys were more affected than girls with boy to girls' ratio 5:1. Intrafamily history of infection was present in 40.8% of tested group while 51% showed low social standard profile. Mycological culture revealed that Microsporum canis was the predominant isolated organism followed by M. audouinii (52% and 36% respectively).

Conclusion

M. canis is replacing Trichophyton violaceum as an etiology for tinea capitis in Egypt with lower prevalence rate than reported previously.

Epidemiological survey of dermatophytosis in Damascus, Syria, from 2008 to 2016

Background and Purpose:

It is important to follow annually the probable changes in distribution pattern of dermatophytosis and its etiological agents in different communities. In this study, we determined the prevalence of dermatophytosis and its causative agents in Damascus, Syria, between 2008 and 2016.

Materials and Methods:

A total of 4080 outpatients who visited the dermatological clinics in Damascus, were evaluated. The specimens were collected from clinically suspected tinea. The patients were referred to our laboratory for direct examination by 30 %KOH. Some of the specimens were cultured on Sabouraud Dextrose Agar for fungal identification.

Results:

Out of the 4080 cases, 1138 cases were positive in direct examination(%27.89) , including Tinea pedis (%46.98), followed by tinea capitis(%39.79) , tinea corporis (%25.38), toenail onychomycosi (%20.33), tinea manuum (%16.06), and fingernail onychomycosis .(%15.22) Tinea pedis and toenail onychomycosis were more common in summer %41.19) and %25.78 respectively .(Trichophytic rubrum was the most prevalent fungal pathogen, especially in toenail onychomycosis.

Conclusion:

Dermatophytosis is highly prevalent in Syria. This study provides valuable data for differential diagnosis of dermatophytosis.

Epidemiological trends of dermatophytosis in Tehran, Iran: A five-year retrospective study

OBJECTIVE

Dermatophytosis is the most frequent fungal infection all over the world and its frequency is constantly increasing. The aim of this study was to evaluate clinical features and epidemiological trends of dermatophytosis over the years 2010 to 2014 in Tehran, Iran.

PATIENTS AND METHODS

A total of 13,312 patients clinically suspected of cutaneous fungal infections were examined. Skin scales, plucked hairs, nail clippings and sub-ungual debris were examined by direct microscopy and culture. Dermatophyte species were identified at the species level by a combination of morphological and physiological criteria.

RESULTS

Direct microscopy confirmed a contamination rate of 19.7% (2622/13,312 cases) of which 1535 cases (58.5%) were culture positive distributed in male (1022 cases) and female (513 cases). The most commonly infected age group was the 30-39 years old. Tinea pedis (30.4%) was the most prevalent type of dermatophytosis followed by tinea cruris (29.8%) and tinea corporis (15.8%). Epidermophyton floccosum (31%) was the most prevalent causative agent, followed by Trichophyton rubrum (26.2%) and Trichophyton mentagrophytes (20.3%).

CONCLUSION

Our results showed considerable distribution of dermatophytosis from zoophilic, anthropophilic and geophilic species among population with diverse age groups. Although anthropophilic fungi such as T. mentagrophytes, E. floccosum, and T. rubrum were the main etiologic agents of dermatophytosis, the prevalence of T. verrucosum showed a meaningful increase over the years, which highlights the importance of rural dermatophytosis mainly transmitted from large animals. This noticeable information improves our current knowledge about dermatophytosis and assists to establish effective prevention and therapeutic strategies to overcome the disease.

Environmental and Genetic Factors on the Development of Onychomycosis

Since the early 20th century, onychomycosis originated with the onset of war, the use of occlusive footwear, and the mass migration of people by transportation in the United States. Even though onychomycosis has a high prevalence in the US, other parts of the world including Canada, West Africa, Southeast Asia, Northern Australia, and Europe have been well documented with cases of fungal toenail infection in their environments. Trichophyton rubrum (T. rubrum) is the major dermatophyte responsible for toenail fungal infection and is typically diagnosed in conjunction with tinea pedis, especially in individuals older than 60 years. Gender roles, age, cultural habits, shoe gear, sports activities, and genetic predisposition all contribute to the different presentation of onychomycosis in these areas where organisms like dermatophytes, candida, and molds were isolated in a variety of cases. Despite the differences in isolated pathogens, treatment outcomes remained consistent. This literature review discusses the influence of tinea pedis, genetics, shoe gear, sports, and age on the development of onychomycosis.