INTRODUCTION

Tenia is the most common transmissible fungal illness [1]. It is caused by dermatophytes, a fungus that enters, multiplies, and harbors keratinized tissues such as the nails, hair, and skin [2]. These organisms are predominantly well adapted to this place because they can use keratin as a source of nutrients; therefore, they differ from most of the other pathogenic fungi in that they are not opportunists [3]. They are filamentous fungi, classified into three genera: Trichophyton, Microsporum, and Epidermophyton [2]. In humans, the most common isolate is Trichophyton rubrum, followed by Trichophyton mentagrophytes [4]. The high incidence of Trichophyton rubrum is in Europe, whereas the incidence of Trichophyton mentagrophytes is higher in Asia [5].

Dermatophytes are divided according to the method of transmission: geophilic, zoophilic, and anthropophilic. Clinically, they are classified as follows: tinea corporis, which refers to infections of the limbs or trunk; tinea cruris, affecting the groin; tinea unguium, involving the nails; tinea pedis, targeting the feet; tinea manuum, affecting the hands; tinea barbae, occurring in the beard area; tinea faciei, involving the face; and tinea capitis, affecting the scalp [6]. Reactions to a dermatophytosis may vary from mild to severe, influenced by the host’s response to the fungus’s metabolic byproducts, the virulence of the infecting strain or species, the anatomical location of the disease, and local environmental conditions [7].

Iraq has been facing a challenging situation of relapsing, extensive, chronic, odd, and recalcitrant superficial fungal skin infections due to type VIII of T. mentagrophytes [7–9]. Recently, there has been a major increase in superficial fungal skin infections, in addition to their unusual clinical features; moreover, the diagnosis relies on clinical, direct microscopic examination and sometimes culture. Clinicians’ concerns about the standard treatment with antifungals have been increasing, especially in areas such as Iraq, where an emergence of terbinafine-resistant superficial mycoses caused by T. mentagrophytes type VIII has been detected [8,9]. The management of superficial dermatophytosis infection has created a real problem in some groups of people, for example, elderly patients, pregnant women, and children [10,11].

This study was designed to describe and update the frequency of the clinical types of tinea infections and their dermatological findings that attended the outpatient dermatological unit.

MATERIALS AND METHODS

A cross-sectional, clinical, descriptive study was conducted for patients with tinea at the Dermatology Outpatient Private (TAK) Clinic, Ramadi, Iraq, for the period of two winter months (November and December 2024). Written informed consent was obtained voluntarily by the patients or their parents to use their information and photos in this study. Individuals of both sexes of any age who were visiting the Dermatology Outpatient Clinic and who presented with annular lesions with an active border and a healing center, in addition to scaly patchy hair loss or distal nail color changes, were appropriate for the research. After uncovering the body of the patient, an examination and clinical diagnosis supported by a dermatologist were completed. A history regarding contact with animals, which may be a major cause of the spread of infection, was recorded. Demographic information was reported, including name, age, sex, marital status, residence, associated symptoms, site of involvement, a family history of the same condition, and a history of relapse or chronic infection. Clinical examinations regarding the clinical type of tinea were done and documented in the questionnaire, including the type of the lesion (macules, papules, nodules, pustules), color of the infected site (erythematous or pigmented), and figure (annular or linear). Cases with atypical clinical presentation, and repetitive negative 10% potassium hydroxide (KOH) direct microscopical examination were omitted.

Statistical analysis was done using Microsoft Excel and IBM Statistical Package for the Social Sciences (SPSS), version 22. The data was expressed using fundamental statistical measures, including the mean, standard deviation, frequency, percentage, and range. The chi-squared examination, two-tailed, was used to evaluate the significance of diverse ratio differences in the qualitative information. The significance of statistics was determined by evaluating whether a p value of ≤ 0.05 would be considered vital.

RESULTS

Over the two months, a total of 102 patients were evaluated and diagnosed with superficial dermatophytosis, with their ages ranging (mean ± SD) from 1 to 80 (28.22 ± 18.79) years, with 55 (54%) females and 47 (46%) males. Around 56 (54.9%) of the cases lived in rural zones and 46 (45%) in urban zones. In-house pets were reported in 43 (42.15%) of the participants. Furthermore, more than half (50.9%) of the patients experienced a relapsing attack of tinea during the last six months. The commonest distinctive clinical features were red macules and papules in 75 (73.52%) and 31 (30.39%) subjects, respectively (Table 1).

Table 1: Demographic features of the patients with tinea (n=102).

Different ages were affected by this type of disease. The spreading of tinea infection was more significant between 1–10 years and 21–30 years of age, where 26 (25.49%) and 21 (20.58%) cases showed different kinds of disease, respectively. There is a negative association between superficial dermatophytosis and the older age group, where there is a solitary enrolment of one (0.98%) individual who was eighty years old (Fig. 1).

Figure 1: Frequency of tinea infections depending on age group.

The clinical terms of superficial dermatophytosis depend on the sites involved by the organism. In this study, it was estimated that 31 (30.4%) participants had a spread of infection for more than one type or site. Of those, one (0.98%) man showed almost all clinical tinea infection at the same time (his nails and hair were not involved). Moreover, all recognized types were elucidated in this research, but uncommonly, the tinea unguium was reported only in one (0.98%) case (Fig. 2). Alternatively, there were highly significant presentations of tinea corporis and tinea cruris in 53 (51.96%) and 40 (39.21%) patients, respectively (Table 2) (Fig. 3).

Figure 2: Frequency of the clinical types of tinea.

Table 2: Relation between age and type of tinea infections.

Figure 3: Different patients presented with tinea infection. (a and b) Tinea involved all over the body. c) Tinea unguium associated with tinea manuum. (d and e) Tinea pedis.

Regarding tinea pedis, it was present in 3 (12%) cases within the age group of 41–50 years, more often than in others, and it was more likely in females. Concerning tinea capitis, it was involved in 13 (76.47%) males, more often than in females (4; 23.52%), and most commonly affected children between 1–10 years old. Tinea corporis was not significantly affecting women (33; 62.26%), more often than men (20; 37.73%), yet was more likely to be seen within the age group of 21–30 years, in 15 (44.11%) participants (Table 3). On the other hand, tinea cruris was detected in 23 (57.5%) males, which was more than in females (17; 42.5%), and significantly stated in 13 (38.23%) cases, within the age group of 21–30 years. Tinea manuum was nearly equally recognized in both sexes (Fig. 4).

Table 3: Relation between sex and type of tinea infections.

Figure 4: Different cases presented with tinea infection. a) Tinea capitis, (b and c) tinea cruris, and (d and e) tinea manuum.

DISCUSSION

This was a clinical descriptive study designed to investigate the frequency and clinical types of tinea infections, principally of the skin, hair, and nails of patients who attended an outpatient dermatological unit. This study provides critical insights into this condition, particularly in the context of the evaluated individuals.

The current work indicated that younger individuals are particularly susceptible to dermatophytosis as well as showed a slight predominance of females over males. This finding aligned with other studies, as in Najaf, where out of 339 dermatophytosis patients, the mean age was 30.54 ± 16.77 [12], but there was a great majority of female participants. Moreover, the same age groups were involved in a report from Saudi Arabia. Suggesting that age-related aspects may play a role in the spreading of fungal infections [13]. Furthermore, in-house pets were reported in 42.15% of the participants. The high frequency of superficial fungal infection may be explained by the fact that it is easily transmitted either through direct or secondary contact. Additionally, other studies considered that animals might have a vital role in human tinea infection [13–15].

Previous research showed that there was a similar infection by tinea to other members of the family, reaching 81.8% of the participants [16–18]. This finding was consistent with the present work, whereas the family history was positive in 66.6% of the cases. This may be clarified by the spread of spores among different family members, especially close-contact people and those with shared clothes and baths.

In this study, it was estimated that 30.4% of the cases had the spread of infection for more than one type or site. Of those, one (0.98%) man showed tinea infection all over the body. The interpretation is the increased severity of the infection, mistreatment, new grave organism, rising humidity that changed the virulence (data collected in winter months), low immunity, and/or poor hygiene practices. Moreover, these could be a cause for one of the prominent findings, which was the high rate of relapsing tinea, in 50.9% of the cases and long-lasting infections in 20.58% over the past six months. Recent studies have proposed the epigenetic theory. There are also multiple dermatophyte infections, thus they suggested that better treatment with more effective antifungal therapy is needed [13,19]. A recent study from Iraq has shown a major outbreak of dermatophyte infection that has unusual clinical pictures and mimics numerous cutaneous diseases [8].

This research showed that more than half of the cases were tinea corporis and tinea cruris, especially in young age groups. The explanation might be due to lifestyle variations such as increased physical activity, sweating, and exposure to infection during daily activities. Also, these sites are considered hidden parts of the body, not exposed to sunlight, considered natural sterilization for the human body. Nowadays, an advanced new therapy regimen is reported for resistant dermatophytosis, especially the commoner variants of tinea corporis and cruris [17].

For instance, tinea capitis was significantly more common in boys (1–10 years old) than in girls. Suggesting the small length of hair, close contact among children, especially in primary school, and lower immune response than an adult person as a major reason for this presentation. This finding is in line with other studies, which described that the majority of patients were younger boys under ten years of age [10,14,20]. Herein, adults were mostly affected by tinea pedis, which may have been linked to their lifestyle, no daily sports, while younger people were less likely to be affected by this type of infection. On the other hand, tinea pedis was more significantly present in 12% of the cases within the age group 41–50 years than in others, and it was more likely in females. This disagrees with previous studies that consider tinea pedis exacerbated in athletic individuals [13,16,21]. Tinea unguium is associated with difficulties in performing hand activities, although it is not a well-demarcated condition. Tinea unguium was uncommon and was reported in one (0.98%) patient. This might be correlated with the difficulty in diagnosis and the poor response to treatment. Previous studies similarly reported minor nail fungal infections [8,22].

The limitations of this study were the short duration and the time of season, where winter months might have interfered with the variation of tinea infection. Also, this study was done in a single medical center, missing the prevalence of the disease in Ramadi City.

CONCLUSION

Tinea capitis affects young boys more significantly than girls. Meanwhile, tinea corporis and cruris are the most common clinical types of superficial fungal infection, with a miserable high tendency to relapse. Nowadays, this is considered an emerging health problem. Further studies need to be done at multiple medical centers in Iraq with the aim of establishing the prevalence and isolating the dermatophyte species.

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