Study of tinea genitalis in adult female in tertiary care center

INTRODUCTION

Tinea genitalis, also referred to as genital dermatophytosis, is a relatively underreported, rising clinical subtype of superficial dermatophytosis, involving mons pubis, labia majora, labia minora and vulva in females, and penile shaft, glans penis, preputial skin and scrotum in males. It typically presents as a well-demarcated erythematous annular plaque with scaly, centrifugally growing edges with central clearing. However, sometimes due to steroid abuse, it can also present as kerion-like boggy swelling and infiltrative plaques.^[1]

Dermatophytes often do not penetrate the epidermis; they only grow inside keratin layers.^[2] Males (more frequently than females), hot and humid weather, tropical climatic conditions, lack of hygiene, chronic uncontrolled diabetes, and long-term infectious diseases such as human immunodeficiency virus are among the risk factors.^[2]

Autoinoculation, sharing clothing (towels, bed linens, undergarments), sexual transmission (commercial sex workers, homosexuals, married women from their spouses), and other factors (poor personal hygiene, hyperhidrosis, tight-fitting synthetic garments) are all potential ways to acquire tinea genitalis.^[3]

Easy access to the highly potent topical corticosteroid creams, such as clobetasol propionate with a combination of antibacterial and antifungal agents, available as over-the-counter drugs, has resulted in the spread of lesions, atypical appearance, and various other cutaneous side-effects.^[1] Many forms of dermatophytosis can be difficult to distinguish clinically from other skin conditions, as the clinical picture of the disease may overlap. Misdiagnosis can result in untoward consequences, particularly in immune-compromised patients as disease can invade deeper tissues.^[4]

In cases of confusing clinical scenarios, the identification of dermatophytes requires both a light microscopic mycologic examination and fungal culture from skin scrapings.^[5,6]

Fungal cultures are usually coupled with subsequent antifungal drug sensitivity assessments to guide the antifungal therapies.^[4] Moreover, it helps in recognizing the changing trends in the prevalence of dermatophytic species and any rising drug resistance. Early initiation of the correct antifungal therapy is of paramount importance as it has been demonstrated to have a direct impact on the patient’s clinical outcome and quality of life.^[7]

MATERIALS AND METHODS

This was a hospital-based observational study done in 70 female patients, between the ages of 18 and 60 years, having clinical features of tinea genitalis attending Dermatology, Venereology, and Leprology Outpatient Department (OPD) of Muzaffarnagar Medical College and Hospital, who gave written consent, using consecutive sampling of eligible OPD patients. Patients who were on prior topical or systemic antifungal therapy recently (within 7 days) were excluded from the study. The study was done over 12 months, i.e., October 2023-September 2024.

The study procedure included detailed history and clinical examination, followed by taking skin scraping for KOH and fungal culture. The lesion was first cleaned with 70% isopropanol, and then the scrapings were taken with the blunt edge of the scalpel blade from the edge of the lesion and directly collected on the glass slide held against the skin. 10% KOH was added to the slide and visualized under a microscope after 15-20 min.

The specimen was further cultured using the direct plating method by furrowing it into the Sabouraud Dextrose agar medium containing chloramphenicol and cycloheximide with a scalpel. After 4 weeks of isolation, fungal culture growths were seen macroscopically (colony morphology) and microscopically (using lactophenol cotton blue mount).

Antifungal sensitivity testing was done using the Hexahead disk diffusion method by interpretation of average inhibition zone diameter (IZD) as per National Committee for Clinical Laboratory Standards guidelines (M38-A guidelines). Fluconazole, itraconazole, clotrimazole, amphotericin B, nystatin, and ketoconazole were the antifungals available for testing. Salts were bought from Himedia Laboratories Pvt. Ltd [Table 1].^[8]

RESULTS

In the present study, the sociodemographic profile of the participants reveals that the maximum patients were in the age group of 30-40 years, i.e., 28/70 (40%) and residing in rural areas, i.e., 40/70 (57.14%). 30/70 (42.85%) patients had disease for 3-6 months [Table 1].

Primary outcome

The distribution of cases according to the 10% KOH mount indicates that out of a total of 70 cases, 49 cases (70%) tested positive, whereas 21 cases (30%) tested negative, 37 isolates (52.8%) showed growth in culture, 33 isolates (47.2%) showed no growth [Table 2].

Table 2: Socio-demographic profile of study participants with tinea genitalis.

Variables	Number	Percentage
Age group
20-30	22	31.43
30-40	28	40
40-50	14	20
50-60	06	8.57
Residence
Urban	30	42.86
Rural	40	57.14
Duration of disease
0-3 months	22	31.42
3-6 months	30	42.85
6-9 months	10	14.28
9 months-1 year	01	1.42
>1 year	07	10

Predominant isolates were Trichophyton mentagrophyte (23/70; 32.86%), followed by Trichophyton rubrum (9/70; 12.85%), others included Trichophyton tonsurans, Microsporum canis, and Candida [Figure 1].

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Figure 1:

Distribution of patients according to organism isolated.

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The study reveals varying levels of sensitivity and resistance to several antifungal agents. 29/37 (78.4%) isolates was found sensitive to itraconazole, 11/37 (29.7%) isolates to fluconazole and 31/37 (83.8%) isolates to ketoconazole. Varying sensitivity was observed for nystatin, clotrimazole, and amphotericin B across isolates, as seen in Table 3.

Table 3: Distribution of tinea genitalis according to 10% KOH mount and culture.

	KOH positive	KOH negative
Culture positive	30	07
Culture negative	19	14
Total	70	100%

KOH: Potassium hydroxide

Table 4: Distribution of antifungal sensitivity and resistance with different causative organisms on the basis of IZD: (n=70).

Species	Drug	Sensitive (n)	Resistant (n)
Trichophyton mentagrophyte(n=23)	Itraconazole (10 µg)	15	8
	Fluconazole (25 µg)	6	17
	Ketoconazole (10 µg)	23	0
	Nystatin (100 U)	7	16
	Clotrimazole (10 µg)	14	9
	Amphotericin B (100 U)	7	16
Trichophytonrubrum(n=9)	Itraconazole (10 µg)	9	0
	Fluconazole (25 µg)	4	5
	Ketoconazole (10 µg)	3	6
	Nystatin (100 U)	3	6
	Clotrimazole (10 µg)	6	3
	Amphotericin B (100 U)	3	6
Trichophytontonsurans(n=2)	Itraconazole (10 µg)	2	0
	Fluconazole (25 µg)	1	1
	Ketoconazole (10 µg)	2	0
	Nystatin (100 U)	0	2
	Clotrimazole (10 µg)	1	1
	Amphotericin B (100 U)	1	1
Microsporumcanis(n=2)	Itraconazole (10 µg)	0	2
	Fluconazole (25 µg)	0	2
	Ketoconazole (10 µg)	2	0
	Nystatin (100 U)	0	2
	Clotrimazole (10 µg)	1	1
	Amphotericin B (100 U)	1	1
Candida(n=1)	Itraconazole (10 µg)	0	1
	Fluconazole (25 µg)	1	0
	Ketoconazole (10 µg)	0	1
	Nystatin (100 U)	1	0
	Clotrimazole (10 µg)	1	0
	Amphotericin B (100 U)	1	0
Total	Itraconazole	29	9
	Fluconazole	11	25
	Ketoconazole	31	6
	Nystatin	11	26
	Clotrimazole	23	14
	Amphotericin B	13	24

IZD: Inhibition zone diameter

Secondary outcome

The distribution of patients according to various other clinical types associated with tinea genitalis highlighted the prevalence of coexistence of different tinea conditions. Among the cases recorded, tinea corporis was most commonly seen associated with tinea genitalis, affecting 54 patients (77.14%); following closely was tinea cruris, with 40 cases (57.14%). In contrast, tinea unguium was less prevalent, while Tinea pedis and Tinea faciei were even rarer. In addition, there were 2 cases (2.8%) presenting with isolated tinea genitalis [Figure 2].

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Figure 2:

Distribution of patients according to other clinical types seen in association with tinea genitalis.

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Figure 3

(a): Large erythematous plaque on genitalia extending to inner aspect of thighs and buttocks; (b): fungal hyphae seen on 10% potassium hydroxide mount on microscope (10x); (c): powdery white to granular colonies of Trichophyton mentagrophytes seen on sabouraud dextrose agar culture media; (d): multiple grape-like clustered microconidia and cigar-shaped macroconidia were seen on lactophenol cotton blue (LPCB mount) of Trichophyton mentagrophytes; (e): antifungal drug sensitivity of T. mentagrophyte showing sensitivity to ketoconazole, itraconazole, nystatin, and clotrimazole.

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The present study observed that a notable portion of patients, 34 (48.57%), had a history of using topical steroids alone or in combination with other antifungals/antibiotics. It was also observed that out of 70 cases, 30 cases had some systemic illnesses, out of which most common being diabetes mellitus (15 patients).

The chi-square test was used to evaluate the association of antifungal resistance with risk factors (steroid use, diabetes). Association of resistance with steroid use (n = 34) was calculated: χ² = 11.17 (P = 0.0008, i.e., statistically significant). Association of antifungal resistance with diabetes (n = 15) was calculated as: χ² = 9.24 (P = 0.0024, i.e., statistically significant).

DISCUSSION

Our study enrolled 70 females aged between 20 and 60 years. “In the present study, the socio-demographic profile of the participants reveals that the mean age of the patients was 35.57 years, with the least representation in the 50-60 years age group and highest in the 30-40 years age group as shown in Table 1.” The study also indicated a higher proportion of tinea genitalis among rural residents.

Thakur et al. (2018) examined patients with dermatophytic lesions in the genital region and found that the most common age group for males presenting with these lesions was between 15 and 25 years, comprising 55.17% of the male participants. In contrast, the most prevalent age group for females was between 26 and 35 years, accounting for 47.06% of the female participants.^[9] Yin et al. (2017) found a higher prevalence in rural areas (70%) due to a warmer and humid climate, poor hygiene, and limited health access, which is the same as the present study.^[10]

The results of the 10% KOH mount in our study indicated that 49 cases (70%) tested positive for fungal elements, while 21 cases (30%) tested negative. Ramanath et al. (2021) found a KOH positivity rate of 64.54% among 1,520 samples, which closely aligns with our findings, highlighting the importance of standardization in diagnostic practices.^[11]

In our study, 52.8% of cases were culture-positive for fungal species. Surendran et al. (2014) reported a culture positivity rate of 52.1%, which is nearly identical to our results, confirming consistency across different populations and reinforcing the reliability of our findings.^[12]

Our study identified T. mentagrophyte as the most commonly isolated organism, followed by, T. rubrum, T. tonsurans, and M. canis [Table 2]. Ramanath et al. (2021) concluded that T. mentagrophyte was dominant in 21.64% of cases, which supports the findings of our study and indicates that this species is a significant causative organism in certain populations.^[11]

In our study, itraconazole demonstrated overall high sensitivity, particularly against T. rubrum. This suggests that itraconazole is an effective treatment option for infections caused by this species. Conversely, fluconazole and nystatin exhibited high resistance rates, indicating limited efficacy in treating the infections observed in our patient population. In addition, ketoconazole was found to be highly effective against T. mentagrophyte, further supporting its use in specific cases.

Gupta et al. (2023) reported high resistance to Fluconazole (Minimum inhibitory concentration [MIC] of 1-64 µg mL [−1] IZD of 10 mm), which is consistent with our findings and highlights a growing concern regarding the effectiveness of this antifungal agent.^[13] Similarly, Surendran et al. (2014) found itraconazole to be highly effective (MIC 0.015-0.25 µg mL [−1], IZD of 28 mm), aligning with our results and reinforcing its role as a preferred treatment option.^[12] This highlights the importance of tailoring antifungal therapy based on susceptibility profiles to improve treatment success rates.

In the present study, the most common clinical type was tinea corporis associated with tinea genitalis, followed closely by tinea cruris. In addition, there were 2 cases (2.8%) presenting with isolated tinea genitalis. In a study done by Thakur et al. (2018), “102 female patients of tinea genitalis, 99 (97.05%) had concomitant tinea cruris and 12 (11.76%) had concomitant tinea corporis. Only 3 (2.94%) female patients had tinea genitalis, without tinea cruris or dermatophytic infection of any other body site.”^[3]

CONCLUSION

Tinea genitalis is emerging as a significant concern in the clinical spectrum of superficial dermatophytoses, particularly with changing epidemiological trends, widespread misuse of topical steroids, and coexisting systemic conditions like diabetes. This study revealed a distinct profile of tinea genitalis in adult females. Contrary to historical trends favoring T. rubrum, our study found T. mentagrophyte to be predominant. Antifungal sensitivity varied, with ketoconazole and itraconazole showing the best efficacy and highest resistance with ketoconazole. By evaluating the clinical profile, mycological findings, and antifungal sensitivity patterns specific to this condition, the study provides valuable data that can aid dermatologists in making informed treatment decisions and improve patient outcome.