An unreported epidemic of skin fungal infections is gripping southern Asia.

“Almost every second patient I treat has a case of superficial fungal infection and 80% of those are cases of reinfection or recalcitrant fungus,” says Dr Ruchika Mehndiratta, a dermatologist based in Ghaziabad.

A recent estimate says that nearly one billion people have had skin mycoses, which makes fungal infection only slightly less common on the planet than headaches or dental caries.

However, the last 5-6 years have seen a widespread failure of antifungal medications to treat superficial cutaneous mycosis, especially dermatophytic infections, which have become a daunting nuisance for practitioners across the region.

These are some of the findings of a paper published in the Indian Dermatology Online Journal in 2019. It deals in detail with the causes of the fungal epidemic and possible solutions to it.

Another paper published in 2020 elaborates that “this epidemic parallels the rise of antibiotic resistance; however, the significance of this problem has yet to gain global attention.”

While black fungus has been in the news of late, dermatologists emphasise that the chances of it affecting the majority of people are negligible.

“People with impaired immunity such as with uncontrolled diabetes, covid19, or cancer when given steroids lowers their immunity even more. This causes severe opportunistic fungal infections like mucormycosis which have always been around,” says Dr Mehndiratta.

A contributing factor is the taboo associated with fungal infections of the skin.

“It is a common belief that you get these diseases if you’re unhygienic which is why most of us hesitate to talk freely” says Swati Srivastava, a resident of Allahabad, who had ringworm for more than 3 months.

She tried self-treating the disease as she was ashamed to discuss it with her friends or family. This practice of self-treatment adds to the problem, says Dr Mehndiratta, “Most patients have already treated themselves before they reach me and have usually harboured the infection for months to years.”

Prof Dr M.U Kabir Chowdhury, a dermatologist based in Dhaka agrees that “there is a sense of phobia in discussing fungal skin infections among patients in the same family. These family members come at different times for treatment due to lack of communication among them.”

Meanwhile, dermatologists have also pointed out the gross mistreatment of patients by primary care physicians and chemists in the 2019 paper.

Dr Saurabh Shah, senior consultant dermatologist at the Bhatia Hospital, Mumbai says “the core problem behind misuse of topical corticosteroids and injudicious use of antifungals is the deficient training of primary care physicians.”

He says the need of the hour is to draft guidelines and extend their benefit to healthcare personnel, who treat much larger patient populations than those treated by dermatologists.

Dr Shah also advocated for improving the standards of dermatology training in medical schools at the undergraduate and postgraduate levels.

“Antifungal resistance also has to do with low quality medicines,” says Dr Smriti Shrestha, assistant professor of dermatology at the Kathmandu Medical University. A 2017 WHO report argues that 1 in 10 medical products in developing countries is substandard.

Various research papers have explicitly mentioned the role of oral triazole antifungals, especially itraconazole, in the development of Anti-Fungal Therapeutic Failure (AFTF).

According to Prof Dr Chowdhury, “Voriconazole is being used in Bangladesh in extremely high doses. When patients stop their treatments midway and come back due to reinfection, the fungus becomes resistant to most anti-fungals.”

It then becomes incredibly difficult to treat such cases, he explained.

“Patients with tinea [a fungal infection] visiting a dermatologist are not naive, rather polypharmacy-abused in more than 90% cases, having received multiple antifungals, especially oral itraconazole/ topical azoles,” says Dr Sidharth Sonthalia in a recent paper.

A dermatologist and member of the International Dermoscopy Society, he explained that itraconazole-resistant strains then become resistant to multiple triazoles, and are more virulent.

Quoting statistics from the Indian government’s ministry of agriculture, he said the period from 2012 to 2016 saw an estimated 34.2% increase in the consumption of fungicides.

He blamed the widespread use of these agricultural fungicides as the primary cause of azole resistance.

Beyond the abuse of steroids and fungicides, regional factors are also at play.

“High temperature and humidity in south Asia causes people to sweat. This helps the fungus thrive in moist regions of the body” says Dr Pankaj Tiwary, a dermatologist based in Patna.

He added that wearing tight-fitting clothes like jeans aids fungal growth. A further problem is that instead of drying clothes in sunlight, which can kill fungus, people are using washing machines these days.

“Apart from high treatment cost, defective host states like diabetes mellitus, obesity and iron deficiency anemia are important factors as well,” said Dr Tiwary.

The 2019 paper also suggests that psychological disturbances such as depression or anxiety have also been a neglected factor in patients with complicated fungal infections.

Dermatologists say there is an urgent need for redressal.

Prof Dr Chowdhury advised that health institutions across the region must come forward to address the menace of azole resistance, as even post-covid it is going to be a major problem in all these countries.

“Awareness among the masses and primary care physicians is urgently needed, as even reporting on this issue has been minimal,” he said.

Dr Shrestha advised prolonging the dose and duration of treatment, as she thinks the threat at the moment is recurrence.

“While many conferences and webinars have been held on this topic, the need of the hour is to have multiple studies to determine anti-fungal susceptibility patterns across south Asia,” said Prof Dr Chowdhury.

Antifungal Resistance | Fungal Diseases | CDC