Superficial Dermatomycosis in Primary Care in the Ecuadorian Andean Region: Clinical Presentation and Therapeutic Approaches

Dermatomycosis, encompassing fungal infections of the scalp, skin, and nails, manifests as diverse conditions including tinea capitis, corporis, pedis, and ungueal. Diagnosis typically involves microscopic examination of affected areas, supported by techniques like Potassium Hydroxide (KOH) preparation and lactophenol blue staining. Treatment strategies vary based on infection depth and severity, ranging from topical antifungals for superficial lesions to systemic therapy. Terbinafine emerges as the preferred systemic agent for conditions such as tinea pedis and ungueal infections. This article explores clinical cases highlighting the varied presentations of dermatomycosis and corresponding therapeutic interventions [1]. Dermatomycosis, commonly referred to as fungal skin infections, poses a substantial burden on healthcare systems worldwide due to its high prevalence and diverse clinical manifestations. These infections, predominantly caused by dermatophytes, encompass a wide spectrum of conditions affecting different anatomical sites, including the scalp, skin, and nails. Clinical presentations of dermatomycosis can range from mild, superficial lesions to more severe and chronic infections, underscoring the importance of timely diagnosis and tailored treatment strategies [1]. 

Clinical Presentation 

Dermatomycosis presents with diverse clinical manifestations depending on the anatomical site involved. Superficial infections, such as tinea corporis and pedis, typically manifest as erythematous lesions with central clearing and peripheral scaling. In the case of tinea capitis, characterized by hair loss and scaling, clinical examination may reveal alopecic patches with surrounding erythema. Deep infections, on the other hand, may result in nail plate invasion and destruction, leading to deformity and discoloration [2-5]. 

Diagnostic Approach 

Diagnosis of dermatomycosis relies on clinical evaluation coupled with laboratory tests. Microscopic examination of skin scrapings or nail clippings treated with KOH solution facilitates the detection of fungal elements such as hyphae and yeast forms. Additionally, special stains like lactophenol blue enhance the visualization of fungal structures. Culture techniques, utilizing Sabouraud agar media, further aid in identifying the causative organism and determining its antifungal susceptibility profile [6]. 

Therapeutic Strategies 

Treatment of dermatomycosis varies depending on the extent and severity of the infection. Superficial lesions, such as tinea corporis and pedis, are typically managed with topical antifungals, whereas deeper infections may necessitate systemic therapy. Terbinafine, a fungicidal allylamine, stands as the first-line agent for systemic treatment, exhibiting high efficacy against dermatophytes. However, clinicians must exercise caution due to potential adverse effects, including hepatotoxicity [7]. Adjunctive measures such as hygiene education and footwear modification play a crucial role in preventing recurrence and spread of infection [8].

This review article does not involve experimental studies; hence, there are no specific materials and methods to be described, but a series of representative clinical cases presented as follows. 

Clinical Cases 

Tinea Capitis: A seven-year-old male patient presents with localized alopecia, pruritus, and desquamation, suggestive of tinea capitis. Upon physical examination, a circular lesion of approximately 3cm in diameter is noted on the right parietal region, exhibiting characteristic scaliness. Treatment with topical antifungal agents results in a gradual amelioration of symptoms (Figures 1 & 2).

 Figure 1: Patient presents with localized alopecia, pruritus, and desquamation, suggestive of tinea capitis.

 Figure 2: A circular lesion of approximately 3cm in diameter is noted on the right parietal region, exhibiting characteristic scaliness.

Tinea Capitis: An eight-year-old male patient demonstrates a circular area of alopecia accompanied by prominent scaling, consistent with tinea capitis. Physical examination reveals a 5cm scaly lesion with a silver hue located on the temporal-occipital region. Initiation of terbinafine therapy leads to observable improvement in clinical manifestations (Figure 3)

 Figure 3: Physical examination reveals a 5cm scaly lesion with a silver hue located on the temporal-occipital region.

Tinea Corporis: A twelve-year-old indigenous female patient presents with pruritic, scaly lesions affecting the cheeks and chin, indicative of tinea corporis. On physical examination, superficial scaly lesions measuring 2 cm in diameter are identified on the lower chin, along with a similar lesion of 2cm on the anterior neck. Treatment involving both topical and oral antifungal agents yields rapid resolution of symptoms (Figures 4 & 5).

 Figure 4: Patient presents with pruritic, scaly lesions affecting the cheeks and chin, indicative of tinea corporis.

Figure 5: Physical examination, superficial scaly lesions measuring 2 cm in diameter are identified on the lower chin, along with a similar lesion of 2cm on the anterior neck.

Tinea Corporis: A sixty-five-year-old woman presents with localized pruritus and scaling of the skin, suggestive of tinea corporis. Physical examination reveals a 4cm rounded lesion with uniform scaling and a silver background. Topical therapy with clotrimazole results in resolution of symptoms within a week (Figure 6)

 Figure 6: Physical examination reveals a 4cm rounded lesion with uniform scaling and a silver background.

Tinea Unguium: An eighty-two-year-old woman patient presents with thickened, yellow nails and structural deformities consistent with tinea unguium. Physical examination demonstrates nail thickening and yellowing with alterations in color pattern. Initiation of terbinafine therapy follows hepatic evaluation; however, subsequent follow-up is lost (Figure 7).

 Figure 7: Patient presents with thickened, yellow nails and structural deformities consistent with tinea unguium.

Dermatomycosis manifests across various anatomical sites, ranging from superficial to profound infections. Accurate diagnosis relies on meticulous microscopic examination and specialized staining techniques to identify fungal elements. Tailored treatment approaches are essential, contingent upon infection severity, with terbinafine emerging as a preferred systemic therapeutic option. However, the emergence of therapy-resistant strains presents formidable obstacles to effective management. 

Additionally, the lack of control in antifungal sales worldwide facilitates resistance, leading to more severe systemic infections [9]. Terbinafine resistance has become a global concern, primarily due to point mutations in the SE gene, resulting in amino acid alterations [10]. In 2019, Singh et al. [11], identified a unique multidrug-resistant Trichophyton population responsible for a substantial dermatophytosis outbreak. A 2020 study by Ebert et al. [12], involving 402 patients across eight locations in India, found that seventy-one percent of isolates exhibited terbinafine resistance.  

Dermatophytosis, a prevalent dermatological affliction, demands comprehensive consideration due to diverse clinical presentations and potential complications. Despite the seemingly straightforward diagnosis and treatment, healthcare providers must remain vigilant for potential challenges. Complications such as Kerion celsi further complicate management [13]. 

From the cases presented, children and the elderly were most affected. Although most cases resolved successfully without complications, one patient with onychomycosis persisted for three months before improvement. Studies in Ecuador reveal a heterogeneous distribution of dermatophytosis across age groups, with cases observed from infancy to geriatric age [14]. Age serves as a predisposing factor for fungal infections, varying by geographic area, mycosis type, and causative agent [15]. 

Ecuador's ecological diversity, with tropical and chilly zones due to its elevated Andean terrain, fosters favorable conditions for fungal proliferation. Agricultural activities and prolonged fluctuations in temperature and humidity contribute to superficial mycoses cases, particularly in tropical regions. Such scenarios are commonly encountered in northern Ecuador, notably in Andean provinces like Imbabura, where individuals inhabit shelters alongside animals [16]. 

Moreover, the rise of therapy-resistant strains among dermatophytes poses significant challenges, especially in recurrent or chronic infections. Timely diagnosis and appropriate treatment are crucial to alleviate symptoms, mitigate complications, and curb transmission. Further research into novel antifungal agents and treatment modalities is essential to address evolving dermatomycosis challenges.

The authors acknowledge the contributions of healthcare providers involved in the clinical cases discussed in this article. No specific funding or conflicts of interest are declared.

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