Key-words:
Dermatophytic - infection - mycosis - skin
Introduction
Skin fungal infections are fungal diseases that involve the skin, nails, hair, and
mucous membrane.[[1]] Fungal dermatosis are caused by a heterogeneous group of fungi that have the ability
to attack the superficial layers of the skin involve stratum corneum, the outermost
layer of the skin, and the high keratin-concentration containing appendages, the hair,
and nails of the living host.[[2]] Superficial fungal infection can be categorized as dermatophytic and non-dermatophytic
fungal infection. Dermatophytic infections, also known as tinea, affect keratinized
tissues. Meanwhile, non-dermatophytic fungal contagions involve tinea versicolor,
tinea nigra, piedra, and candidiasis.[[3]] Dermatophytosis and other superficial and cutaneous fungal infections are still
globally regarded as a major health concern.[[4]],[[5]]
Fungal skin infection is becoming common in tropical countries such as Libya due to
environmental factors such as heat and humidity but often preventable which necessitates
early diagnosis, quick treatment to avert complications, and hospitalizations. Notwithstanding
their common incidence, they are often not perceived to be a substantial health alarm.[[6]]
According to the World Health Organization, the global incidence of superficial fungal
infection has been reported to be 20%–25%.[[7]] Studies from different parts of Africa suggest a prevalence of superficial skin
fungal infections between 20% and 90%.[[8]] In Libya, previous studies have documented rates of skin fungal infections ranging
from 4.9% to 52.2%.[[7]],[[9]] The variance in occurrence was significantly attributed to differences in climatic
and other geographical conditions in the studied areas.[[9]]
Skin fungal diseases are rarely lethal, but they pose vast economic and psychological
problems for patients. They have a major influence on the quality of life, particularly
when they result in disability, deformity, and symptoms such as pain, itchiness, and
stinging.[[10]],[[11]],[[12]]
Yet, there are very limited data published on the frequency of the skin disease, particularly
Tripoli the capital city of Libya. This study was, therefore, designed to determine
the prevalence of superficial skin fungal infections among patients attending Berustta-Milad
Hospital in Tajoura district, Tripoli, Libya, during 2007–2015.
Methods
This was a clinic-based descriptive cross-sectional retrospective study conducted
during 2007–2015 at the outpatient department of Berustta-Milad Hospital (the largest
skin hospital), Tripoli, Libya.
The review of data archives over the past 8 years (January 2007–December 2015), available
at the Mycology Laboratory of Berustta-Milad Hospital, provided the demographic characteristics
of patients assumed to have skin fungal infections. The specimens were attained from
clinically atypical skin lesions, hair or nail samples of infected patients through
scraping.
Fresh smears were prepared by with 10% potassium hydroxide and were observed directly
under a light microscope as described previously.[[13]] The retrieved data involved sex, age, place of residence (i.e., urban and rural
areas) type of infection, and lesion site. The epidemiological statistics were recorded
in laboratory checklists.
The collected information was evaluated and analyzed, using SPSS version 22 (IBM Corp.
Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY, USA). Chi-square
test was used to compare the collected data. P <0.05 was considered statistically
significant.
Results
Of 253 superficial and cutaneous fungal infections in the suspected patients, referred
to the Mycology Laboratory of Berustta-Milad Hospital, 179 (70.8%) patients were found
to have superficial and cutaneous fungal infections. In a total of 179 patients, 97
(54.2%) were male and 82 (45.8%) were female (P< 0.001) [[Table 1]].
Table 1: Distribution of fungal infections according to gender in patients referred to the
mycology laboratory of Berustta-Milad Hospital, Tripoli, over 8 years (2007-2015)
The majority of infected patients were within the age range of 17–28 years (55.3%),
and the lowest occurrence of skin infections was reported in the age range of 3–8
years (6.1%). Overall, 142 (79.3%) of the patients exist in urban areas. The most
commonly affected area in Trichophyton dermatophytic lesions was the scalp (32.7%),
while the least affected site was the back region (1.8%). Among Candida infections,
the most frequently affected region was the nail (63.3%), while the least commonly
affected region was the scalp (3.0%). Furthermore, in Aspergillus lesions, the most
commonly affected regions were the nails (68.6%), whereas the least commonly affected
site was the back region (2.8%), as shown in [[Table 2]].
Table 2: Distribution of fungal infections according to the localization of the affected lesion
Discussion
This clinic-based retrospective cross-sectional study reported the frequency of skin
fungal lesions among patients who attended the outpatient department of a skin hospital
in Tripoli, Libya. Superficial and cutaneous fungal contagions are among the most
extensive groups of mycoses. The occurrence of superficial mycotic infections has
expanded over the past few decades.[[5]]
Dermatophytic infections are more widespread in the developing and undeveloped countries,
and the infection is cumulative in these areas of the world.[[6]],[[14]] Despite this fact, studies on dermatophyte infections in Libya are insufficient,
and therefore, our aim was to determine the disease pattern and the prevalence of
dermatophyte infections in patients attending a tertiary care hospital in Tripoli.
Of all the collected clinical samples from patients with cases of suspected dermatophytosis
during the study period, dermatophytes were detected in almost three quarters of the
samples. The current incidence rate of culture-confirmed dermatophytic infection was
relatively high, compared to previous local studies (Libya) among clinical samples
with rates between 52.2% and 4.9%.[[5]],[[15]] Nevertheless, a prevalence rate of culture-proven dermatophytic infections of 83.7%
has been reported by another local study.[[9]] The differences between the two reports rates of dermatophytosis in different studies
could result from variances in the lifestyle, socioeconomic situations, risk factors
linked with study subjects, and environmental influences of the study area.[[16]]
The current study exhibited a high rates of cutaneous and superficial fungal infections
in males than females (54.2%, 45.8%, respectively). These findings were similar to
those reported by the earlier studies in Zliten, another city in the west of Libya
which also revealed a higher prevalence of dermatophytes in males in comparison with
females.[[15]] In addition, Naseri et al. reported a higher prevalence of dermatophytosis in males
in comparison with females.[[17]] On the other hands, some other studies recorded a higher prevalence of dermatophytes
in females than males.[[18]],[[19]],[[20]]
The major clinical manifestations of dermatophytosis differ significantly in different
studies described in literature. In a study conducted in Tripoli city of Libya, tinea
versicolor, Candida albicans, and Trichophyton violaceum were the major etiological
agents isolated.[[6]] A similar study conducted in Sabha, Libya, in 2012 by Altayyar[[9]] revealed that Aspergillus spp. (52.47%), Penicillium spp. (22.27%), and Candida
spp. (16.3%) were the most common clinical manifestation. Another survey of dermatophytosis
in Tripoli conducted by Al-Dwibe et al.[[21]] revealed that Tinea spp. and Candida spp. were the predominant clinical manifestations.
Others surveys conducted outside Libya revealed similar findings. A study conducted
in Egypt and Ethiopia depicted that Tinea spp. and Candida spp. were the most frequent
clinical manifestations. In our study, Aspergillus spp. and Trichophyton spp. were
the main clinical manifestations involving 39.1% and 30.7% of the total cases of dermatophytosis,
respectively, followed by candida spp. (18.4%). Our finding in this regard was compatible
with the results of others.[[6]],[[9]],[[21]]
Two classes of dermatophyte, Trichophyton rubrum and Trichophyton interdigitale, are
the most common causes of most onychomycosis. Nevertheless, the infectious agents
are not only dermatophytes but also yeasts and molds of the genus Candida.[[22]] Phudang et al.[[23]] performed a recent epidemiological survey in 2019 of superficial fungal diseases
in India showed that Trichophyton and Candida were the frequency of superficial. Our
results showed that Trichophyton dermatophytes were responsible for 30.7% of all superficial
fungal diseases, while molds of the genus Candida were in 18.4% of the cases.
Globally, the incidence of superficial and cutaneous fungal infections has recently
upraised, making these fungal infections the most frequently encountered infections.
In overall, the etiological agents and main infection sites differ depending on the
environmental factors and geographical area.[[24]]
Conclusion
This study has reported the prevalence of culture-confirmed dermatophytic skin infections,
which was considerably high. The current study has also showed that Aspergillus spp.
were the dominant clinical manifestation involving 39.1% of the entire cases of dermatophytosis.
Of the whole number of 179 dermatophyte isolates, 30.7% was accounted for by Trichophyton
spp. followed by the mold of Candida spp. by 18.4%. More focus should be given to
enhancing hygiene status and living environments to diminish the risk of skin infection.
Therefore, it seems essential to emphasis on the prevention and control of such infections.
Despite experiments on infected skin is demanding, new knowledge of onychomycosis
would be beneficial in improving diagnosis and ideal therapeutic prescription. Heath
education programs are essential for averting and controlling the diseases, with the
aim to decline long-term morbidity and the socioeconomic impact.
Authors' contribution
Concept and design data collection and/or processing: Abdulsalam Ashour; analysis
and/or interpretation: Najla Elyounsi; writing and critical reviews: Ahmed Attia.
Compliance with ethical principles
This study was approved by the ethical committee of University of Tripoli, Tripoli,
Libya.
