Clinicoepidemiological profile of steroid modified dermatophytosis following abuse of irrational combination of topical corticosteroid containing preparations (ICSP)

Background: Topical corticosteroids are the most commonly used drug and mainstay of dermatotherapeutics for many dermatoses. Topical corticosteroids are irrationally combined with other medications and widely available as the over the counter preparations (OTC) and are widely misused for various conditions. Dermatophytosis is a superficial fungal infection which is becoming resistant and difficult to treat because of inappropriate usage of irrational combination of topical corticosteroid containing preparations (ICSP). Aims and Objective: To study the prevalence and factors which promotes the abuse of Irrational combination of topical corticosteroid containing preparations(ICSP) in dermatophyte infection. Materials and Methods: A Prospective observational study conducted at department of Dermatology, Venereology & Leprosy in a tertiary care centre, South India. The sample size of this study is n=55. Results: Out of 55 patients most common age group is 15 -30 years (n=16,29.09%).Females (n=30,54.54%) predominated over males with male:female ratio of 0.83:1.The most common complaint was intractable itching (n=46,83.64%) .The majority of study group had disease duration was 0-1 months (n=27,49.1 %) with mean duration of 4 months. The main source of referral was Over the counter (OTC) (n=32,58.18%). The most common irrational combination was FDC 3 combination(30.9%). Most commonly abused brand was betnovate GM(n=17,30.9%).Most of the patients used Clobetasol propionate 0.05% (n=25,45.5%).Patients were using ICSP mostly for less than 1 month (n=27,49.1%),with intermittent(n=19,34.5%) frequency of application. Most common side effect was tinea incognita (n=33,60%).Potassium hydroxide mount was positive in 25 patients(45.45%).Fungal culture was done in all patients and 12 patients(21.81%) showed growth. The commonest organism isolated among culture positive specimen was Trichophyton rubrum(12.72%). Conclusion: Inappropriate usage of irrational combination of topical corticosteroid containing preparations (ICSP) in dermatophyte infection induces short term clearance whereas the long term side effects results in variable presentation. Awarness of this problem leads to prevention of steroid modified dermatophytosis which is the rising menace. © This is an open access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

ICSP -Irrational combination of topical corticosteroid containing preparations OTCOver the counter preparations FDCFixed dose combination Tinea Incognita

A B S T R A C T
Background: Topical corticosteroids are the most commonly used drug and mainstay of dermatotherapeutics for many dermatoses. Topical corticosteroids are irrationally combined with other medications and widely available as the over the counter preparations (OTC) and are widely misused for various conditions. Dermatophytosis is a superficial fungal infection which is becoming resistant and difficult to treat because of inappropriate usage of irrational combination of topical corticosteroid containing preparations (ICSP). Aims and Objective: To study the prevalence and factors which promotes the abuse of Irrational combination of topical corticosteroid containing preparations(ICSP) in dermatophyte infection. Materials and Methods: A Prospective observational study conducted at department of Dermatology, Venereology & Leprosy in a tertiary care centre, South India. The sample size of this study is n=55. Results: Out of 55 patients most common age group is 15 -30 years (n=16,29.09%).Females (n=30,54.54%) predominated over males with male:female ratio of 0.83:1.The most common complaint was intractable itching (n=46,83.64%) .The majority of study group had disease duration was 0-1 months (n=27,49.1 %) with mean duration of 4 months. The main source of referral was Over the counter (OTC) (n=32,58.18%). The most common irrational combination was FDC 3 combination(30.9%). Most commonly abused brand was betnovate GM(n=17,30.9%).Most of the patients used Clobetasol propionate 0.05% (n=25,45.5%).Patients were using ICSP mostly for less than 1 month (n=27,49.1%),with intermittent(n=19,34.5%) frequency of application. Most common side effect was tinea incognita (n=33,60%).Potassium hydroxide mount was positive in 25 patients(45.45%).Fungal culture was done in all patients and 12 patients(21.81%) showed growth. The commonest organism isolated among culture positive specimen was Trichophyton rubrum(12.72%). Conclusion: Inappropriate usage of irrational combination of topical corticosteroid containing preparations (ICSP) in dermatophyte infection induces short term clearance whereas the long term side effects results in variable presentation. Awarness of this problem leads to prevention of steroid modified dermatophytosis which is the rising menace.

Introduction
Topical corticosteroids were introduced in the year 1952 by Schulzberger and Witten. 1 Since then topical corticosteroids becomes most commonly used drug in dermatology practices. The clinical effects are mediated by steroid containing preparations are known to suppress the immune response against dermatophytes and also have the potential to produce a wide variety of cutaneous adverse effects. 3 In this study we aimed to highlight the adverse effects of topical steroid combination preparations abuse on fungal infection.

Aims and Objectives
To study the prevalence and factors which promotes the abuse of Irrational combination of topical corticosteroid containing preparations(ICSP) in dermatophyte infection.

Materials and Methods
This is a prospective observational study performed on 55 patients conducted at department of Dermatology, Venereology & Leprosy, Rajah Muthiah Medical College and Hospital, Annamalai University for a period of 2 years from Oct 2018-Sep 2020. Ethical clearance was sought from instituitional ethical committee. Patients were included according to the inclusion criteria. Present study aimed to find out the outcome of dermatophytosis following abuse of ICSP. Patients were asked about their personal details such as age, sex, education, occupation, and residence were noted. Patients were asked to bring the used topical preparations or previous prescriptions. Information regarding irrational combination of topical corticosteroid containing preparations such as source of referrals, their combinations type of steroid abused, potency of steroid, duration of therapy, frequency of application, were collected. Detailed history regarding duration of disease, family history as well as any co-morbid conditions were asked. On examination dermatological signs of steroid abuse such as atrophy, striae, telengiectasia and other changes were noted. Photographic documentation of patients was done with their consent participated in the study. Diagnosis was made clinically and confirmed by potassium hydroxide (KOH)mount. Fungal culture was done in all cases

Results
In our study a total of 100 cases were enrolled out of which 45 cases were excluded due to irregular follow up.  Table 1 Shows that, the most common age group in which ICSP abuse were more include 15-30 years in 16 patients (29.09%) followed by 31-50 years in 14 patients (25.45%). Females(54.54%) predominated over males(45.45%) with male: female ratio was 0.83:1.  Table 2 Shows that the most common complaint was Itching in 46 patients (83.64%). The duration of the disease is presented in Table 3. The major disease duration was 3-6 months in 21 patients (38.2%). Table 4 Shows that Tinea corporis was the most common clinical diagnosis seen in 15 patients (27.27%) followed by Tinea cruris in 13 patients (23.63%). Table 5 Shows that the commonest source of referral of ICSP was Over the counter(OTC) in 32 patients (58.18%) Table 6 Shows that most common irrational combination was FDC 3 combination in 17 patients(30.9%) which was used for 0-1 month in 7 patients(25.9%) on an intermittent basis in 7 patients(36.8%) causes most common side effect of Tinea Incognita in 14 patients(25.45%), followed by FDC        Table 7 Shows that most common brand name abused was Betnovate GM in 17 patients (30.9%) which was used for 0-1 month in 7 patients(25.9%) on an intermittent basis in 7 patients(36.8%) causes most common side effect of Tinea Incognita in 14 patients(25.45%), followed by Dermi 5 in 14 patients(25.5%) which was used for 0-1 month in 8 patients(29.6%) on twice daily basis in 5 patients(35.7%) causes most common side effect of Tinea Incognita in 5 patients(15.2%). Table 8 Shows that clobetasol propionate 0.05% was the most commonly abused steroid in 25 patients(45.45%) which was used for 0-1 month in 13 patients(48.1%) on an twice daily basis in 7 patients(63.63%) causes most common side effect of Tinea Incognita in 12 patients(36.36%), followed by Betamethasone valerate 0.1% in 17 patients(30.9%) which was used for 0-1 month in 7 patients(36.8%) on an intermittent basis in 7 patients(36.8%) causes most common side effect of Tinea Incognita in 14 patients(25.45%).  Table 9 Shows that Potassium hydroxide mount was positive in 25 patients (45.45%). Fungal culture was done in all patients and 12 patients (21.81%) showed growth.
Organism isolated is presented in the Table 10. The most common organism isolated was Trichophyton rubrum in 7 patients(12.72%), and Trichophyton mentagrophytes in 3

Discussion
There is a rising epidemic of superficial fungal infections in India. Dermatophyte infection is more common in India due to hot and humid climate, low hygiene, poor access to water, overcrowding, high interpersonal contact. Dermatophyte infection become resistant and difficult to treat because of the rising trend of misuse of potent topical steroids by Houlbar and Male pointed out the grammatical error but has been sadly ignored. 4 Females (54.54%) predominated males in our study .Whereas male predominated female in a study conducted by Lakhani J et al, 3 Thakur R et al, 5 Kothiwala R et al. 6 This discordance in our study is because of inhibition of female to go to hospital particularly in private parts and so they purchased the easily available over the counter preparation and come to the hospital once it become severe. Most common age group was 15-30 years (29.09%).This was in concordance with the study conducted by Thakur R et al, 5 Kothiwala R et al, 6 Most of them resides in rural areas(45.45%). This was in concordance with the study conducted by Lakhani J et al. 3 Most common duration of disease in our study was 3-6 months(38.2%). This was in concordance with the study conducted by Lakhani J et al. 3 Most common source of referral was over the counter (58.18%). This was in concordance with the study conducted by Kothiwala R et al. 6 Most common irrational combination was FDC 3 combinations(30.9%) showing that FDC 3 combination drugs were freely available in market. Paucity of literature regarding the Irrational combination of topical corticosteroid containing preparations. Most common brand name was Betnovate GM(30.9%) in our

Conclusion
Misuse of irrational combination of topical steroid formulations in dermatophyte infections can lead to untowards adverse effects like tinea incognita, atrophy,acneiform eruptions etc as well as chronicity. Thus the irrational FDC (Combination of topical antifungal, antibacterial, steroid) and various others available in the market freely should be banned by Drug Controller General of India(DCGI) and state licensing authorities to curb the epidemic of steroid modified dermatophytosis.

Limitations
This is a hospital based small scale study might not be a true problem in the community. Hence this study could not be generalized to entire population.

Source of Funding
No financial support was received for the work within this manuscript.

Conflict of Interest
The authors declare they have no conflict of interest.