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Jannatul Sharmin Joarder

 

Jannatul Sharmin Joarder

Dhaka Medical College Hospital, Bangladesh

Abstract Title: Antifungal resistance in dermatophytes: A growing concern

Biography:

Dr. Jannatul Sharmin Joarder is an Assistant Professor in the Department of Dermatology and Venereology at Dhaka Medical College. She completed her MBBS in 2009 followed by a Diploma in Dermatology and later earned a Fellowship in Laser from Italy in 2025, strengthening her expertise in clinical dermatology and advanced aesthetic procedures. Alongside her academic responsibilities, Dr. Joarder is actively involved in patient care through her personal chamber, where she provides comprehensive dermatological and laser based treatments. She has contributed to the medical field through many publications, reflecting her commitment to research, education and the advancement of dermatological practice.

Research Interest:

Background: Dermatophytes commonly known as ringworm or tinea is a wide spread superficial fungal infection affecting the skin, hair and nails. It is caused by a group of keratophilic fungi known as dermatophytes, primarily form thr genera Trichophyton, Microsporum and Epidermophyton. Traditionally, dermatophyte infections are easily managed with topical or systemic antifungal agents, including azoles, allylamines and griseofulvin.

Over recent years, dermatologist and clinicians have reported a significant rise in recalcitrant and chronic dermatophtosis, particularly in parts of South Asia including India and Bangladesh. This shift in clinical response has been attributed largely to the emergence of antifungal resistance, most notably in Trichophyton indotineae .These resistant strains demonstrate reduced susceptibility to terbinafine, the first line systemic therapy for tinea infections.

The increasing misuse and overuse of topical combination creams-often containing potent corticosteroids, antifungals and antibiotics has played acrucial role in driving resistance. Additionally, self medication, lack of treatment adherence and insufficient regulation of over the counter antifungal products have compounded the problem.

This rising trend of resistance has challenged the effictiveness of conventional treatments and prompted concern among dermatologist regarding the future management of dermatophytosis. Accurate diagnosis, resistance detection and proper antifungal stewardship are now essential to combat this escalating theat in dermatological practice.

Methods: A prospective observational study was conducted over a 12 month period in dermatology outpatient departments of teritary care hospital. Patients with clinically suspected dermatophytosis(tinea corporis, tinea cruris, tinea faciei or tinea pedis) were enrolled after obtaining informed consent.

Sample collection and Processing:

  • Skin scapings were collected from the active margins if lesions using sterile scalpel blades>
  • Direct KOH(10-20%) mount was used for initial mivroscopic examination.
  • Samples were cultured on Sabouraud dextrose agar (SDA) with chloramphenicol and cycloheximide.
  • Isolated fungi were identified based on colony morphology and microscopic feature.

Antifungal Susceptibility Testing(AFST):

  • Performed using both microdilution method following CLSI M38-A2 guidelines.
  • Tested antifungals included-Terbinafine, itraconazole, fluconazole, griseofulvin and ketoconazole.
  • Minimum inhibitory concentrations were recorded and interpreted based on available epidemiological cutoff values.

Molecular Identification:

  • A subset of resistant isolates was subjected to PCR amplification and sequencing of the ITS region.
  • Point mutations in the squalene epoxidase gene were analyzed to determine terbinafine resistance mechanisms.

Results: 

  • A total of 250 patients were enrolled; 178(71.2%) were cultar positive for dermatophytes.
  • The most common species identified was Trichophyton indotineae accounting for 62% of isolates.
  • Terbinafine resistance was observed in 39% of isolates with MIC>1ug/ml
  • Resistance to fluconazole was noted in 25%of isolates while itraconazole retained good activity in most cases.
  • Mutation in the SQLE gene particularly Leu39Phe and Phe397Leu were detected in 72% of terbinafine resistance strain.
  • A strong correlation was noted between previous use of topical steroid antifungal combinations and resistant infections. Recurrence rate in resistant cases was significantly higher (p<0.01) compared to susceptible infections. ​​​​​​​

Conclusion: The emergence and rising prevalence of antifungalresistance among dermatophytes, prticularly Trichophyton indotineae, poses a significant threat to effective dermatological care. This resistance has led to increase treatment failures, prolonged disease duration and a higher rate of recurrence.The widespread misuse of topical corticosteroid antifungal combinations, poor treatment adherence and lack of regulatory oversight have contributed to this alarming treand. There is a n urgent need for improved diagnostic capabilities including routineantifungal susceptibility testing and molecular identificationof resistant strains.Clinicians must adopt evidence based treatment protocols, discourage irrational use of topical steroids and educate patients on the importance of completing antifungal therapy. Public health strategies, surveillance system and antifungal stewardship programs are essential to control the spread of resistant dermatophytes strains and preserve the effectiveness of current antifungal agents. Without timely intervention, antifungal resistance will continue to challenge the management of superficial fungal infections and may lead to a future where common skin conditions become increasingly difficult to treat.