Abstract

This case study relates a six-month-old-infant with severe dermatophytosis of the back, buttocks, chest and groins. Mycological examination revealed a zoophilic dermatophyte infection – Trichophyton mentagrophytes. 

The genotype was of chronic recalcitrant dermatophytosis in India, a significant percentage of which is resistant to terbinafine, and may be partially resistant against itraconazole and voriconazole. 

The baby showed resistance to systemic antifungal agents. She was successfully treated by topical ciclopiroxolamine. Two weeks of this therapy attenuated her symptoms and prolonged usage prevented recurrent lesions.

Introduction 

Ciclopiroxolamine a topical preparation with a unique mechanism of action compared to the commonly used allylamines and azoles. Ciclopiroxolamine – a hydroxypyridone derivative, differs in structure and mechanism of action from the other known antifungal agents. This topical antifungal agent was approved by the US-FDA in the year 2004. The drug is available as a topical cream topical; its nail lacquer formulation is also used in for treating onychomycosis, tinea pedis, tinea corporis/cruris, pityriasis versicolor, seborrheic dermatitis, as well as vuvovaginal candidiasis (VVC).

This drug expresses one of the broadest spectra of antimycotic activity and inhibits nearly all clinically relevant dermatophytes, yeasts and moulds, including certain frequently azole-resistant Candida species, such as Candida glabrata and Candida krusei. Its combined antifungal and antibacterial activity are of particular advantage in the treatment of macerated tinea pedis and “dermatophytosis complex,” – symptomatic intertriginous fungal affections secondarily infected by bacteria.^1-4

Case report

A six-month-old-female infant was diagnoses with severe dermatophytosis of the back, buttocks, chest and groins. Mycological examination performed in Germany revealed the detection of zoophilic dermatophyte Trichophyton mentagrophytes. 

The newly Described genotype VIII within the species T. mentagrophytes was identified by sequencing of the “internal transcribed spacer” (ITS) region of the fungal rDNA. This genotype of T. mentagrophytes is the main causative agent of the current epidemic of chronic recalcitrant dermatophytosis in India. Transmission of this Indian genotype to other countries has resulted due to globalization. 

However, a significant percentage of Indian T. mentagrophytes are resistant to terbinafine. While some are also found to be partially resistant against itraconazole and voriconazole. 

The baby was successfully treated by topical ciclopiroxolamine. Two weeks of this therapy attenuated her symptoms and prolonged usage prevented recurrent lesions.

Discussion

Ciclopirox has a unique mechanism of action; its advantages are in vitro and in vivo efficacy, broad-spectrum antimycotic coverage, additional anti- bacterial and anti-inflammatory activity, well-established safety and excellent tolerance, lack of drug resistance, as well as an extremely low likelihood of the development of resistance in future and easy affordability. Therefore, this agent is considered an ideal topical antifungal for superficial cutaneous mycoses. Additionally, owing to its robust anti-inflammatory effect ciclopirox harbors great potential to be used as a single-agent nonsteroidal preparation even for inflamed tinea.

Moreover, this drug can help in in reducing the menace of steroid-abuse and management of treatment-refractory dermatophytic infections, tinea incognito, mixed infections and recurrent VVC. Clinical trials have demonstrated that patients with tinea corporis/cruris exhibit better mycological and overall response rates with ciclopirox compared placebo and similar response rates as clotrimazole. In other instances, ciclopirox has demonstrated superior results to clotrimazole—for example, in tinea pedis. Researchers have also found that ciclopirox gel applied once or twice daily significantly reduced the signs and symptoms—with much higher rates of mycologic cure, complete cure and bacterial count reduction, than placebo. ^1-4

Conclusion

This article reports a case pf severe dermatophytosis of the back, buttocks, chest and groins in a six-month-old-female infant. Mycological examination revealed a zoophilic dermatophyte infection – Trichophyton mentagrophytes. The genotype was identified as that of a chronic recalcitrant dermatophytosis in India, a significant percentage of which is resistant to terbinafine, and has shown partial resistance against itraconazole and voriconazole. 

The baby was resistant to systemic antifungal agents. She was successfully treated by topical ciclopiroxolamine. Two weeks of this therapy attenuated her symptoms and prolonged usage prevented recurrent lesions.

Dermatophytes exhibit extremely low potential for developing resistance to ciclopirox, both by biochemical or molecular means. Furthermore, this drug is safe for use and inexpensive; these attributed make this drug a potentially ideal antifungal agent for use in recalcitrant tinea infections.

References

1. Pippin MM, Madden ML. Tinea Cruris. [Updated 2020 May 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554602/
2. Noble SL, Forbes RC, Stamm PL. Diagnosis and management of common tinea infections. American Family Physician. 1998;58(1):163.
3. Sonthalia S, Agrawal M, Sehgal V. Topical ciclopiroxolamine 1%: Revisiting a unique antifungal. Indian Dermatol Online J. 2019;10(4):481. doi:10.4103/idoj.idoj_29_19
4. Gupta A, Stec N, Summerbell R et al. Onychomycosis: a review. Journal of the European Academy of Dermatology and Venereology. 2020. doi:10.1111/jdv.16394