ORIGINAL ARTICLE

Clinico‑Mycological Study of Dermatophytosis among Diabetic and

Non‑Diabetic Patients in a Tertiary Level Hospital: A Comparative Study
Abarna Rajagopal, Rangappa Vinutha, Padubidri Kombettu Ashwini, Veeranna Shastry,
Chitharagi B. Vidyavathi1

Abstract From the Department of

Background: Dermatophytosis is a major public health concern in India, especially in Dermatology, Venereology and
recent years, with an alarmingly rising trend, particularly in relation to recurrent and Leprosy, JSS Medical College
and Hospital, JSS Academy
chronic infection. The number of studies examining the relationship between an individual’s
of Higher Education (Deemed
glycemic status and the development of dermatophytosis, and a comparison of the evolving to be University), Mysuru,
species trend between diabetic and non‑diabetic patients infected with dermatophytes, is Karnataka, 1Department of
limited. Aims and Objectives: To study and compare the clinical and mycological aspects Microbiology, JSS Medical College
of dermatophytosis among diabetic and non‑diabetic patients and to compare the culture and Hospital, JSS Academy of
isolates in both groups. Materials and Methods: The study included 378 patients of Higher Education (Deemed to be
clinically suspected dermatophytosis, divided into two groups of 189 known diabetics and University), Mysuru, Karnataka,
non‑diabetics each. We subsequently analysed and compared the demographics, clinical data, India
potassium hydroxide (KOH) mount, calcofluor white (CW) staining and fungal culture results
of all patients in both groups. Results: Among the 378 patients, diabetic patients had a Address for correspondence:
significantly greater extent of involvement and higher rates of recurrence when compared to Dr. Veeranna Shastry,
non‑diabetics. The overall positivity rate was higher in CW staining (77.8%) as compared to Department of Dermatology,
KOH (57.7%) in both non‑diabetics and diabetics. Trichophyton mentagrophytes was the most Venereology and Leprosy, JSS
common isolate (47.6%) in both diabetic (55.0%) and non‑diabetic (61.4%) patients, followed Medical College and Hospital,
JSS Academy of Higher
by Trichophyton rubrum (31.8% and 29.6%, respectively). The positivity percentages of fungal
Education (Deemed to be
culture, KOH and CW staining increased to 100%, 77.9% and 95.7%, respectively, when scrapings University), Mysuru – 570 004,
were taken from ≥2 sites. Conclusion: The pattern of dermatophytosis is comparatively more Karnataka, India.
chronic and severe in diabetics compared to non‑diabetics. T. mentagrophytes was the most E‑mail: veerannashastry9@gmail.
common culture isolate in both groups. CW staining can potentially be used as the initial com
method of choice for the diagnosis of dermatophytosis as it has significantly outperformed
the conventional KOH mount. Scrapings can regularly be taken from ≥2 sites to avoid false
negative results.

Key Words: Calcofluor white, dermatophytosis, diabetics, fungal culture, KOH

Introduction mellitus. Owing to insufficient or improper usage of

The word ‘dermatophytosis’ (tinea) is used to describe antifungal medications, resistant strains have emerged,
a superficial fungal infection that can affect the making standard treatment less effective.[4] There
nails, hair and skin.[1] Tinea corporis has emerged as are not many studies that look at the link between
a serious public health concern in India, especially a person’s glycemic status and the development of
in recent years, with a disconcertingly rising trend, dermatophytosis or compare the changing species
particularly in the case of recurring and chronic trend between diabetic and non‑diabetic patients
dermatophytosis infection.[2] Reduced cellular immunity who have dermatophytosis. The primary objective of
caused by underlying immunosuppressive disorders, the this study is to fill the above‑mentioned lacunae and
use of immunosuppressive medications and endocrine analyse whether there are any clinical or mycological
abnormalities can all contribute to an unusually
widespread dermatophyte infection.[3] As in the majority This is an open access journal, and articles are distributed under the terms of
of other studies, fungal infections were discovered the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
which allows others to remix, tweak, and build upon the work non‑commercially,
to be widespread among persons with diabetes
as long as appropriate credit is given and the new creations are licensed under
Access this article online the identical terms.
Quick Response Code: For reprints contact: WKHLRPMedknow_reprints@[Link]
Website: [Link]
How to cite this article: Rajagopal A, Vinutha R, Ashwini PK, Shastry V,
Vidyavathi CB. Clinico‑mycological study of dermatophytosis among
diabetic and non‑diabetic patients in a tertiary level hospital: A comparative
DOI: 10.4103/ijd.ijd_1111_23 study. Indian J Dermatol 2024;69:486.
Received: December, 2023. Accepted: May, 2024.
 Rajagopal, et al.: Clinico‑mycological study of dermatophytosis among diabetic and non‑diabetic patients in a tertiary level hospital: A comparative study

differences between diabetics and non‑diabetics with Results

dermatophytosis. Out of 378 patients, most cases were between the ages
of 45 and 60 years (164 cases), with diabetics being
Materials and Methods comparatively older than non‑diabetics, with an overall
This was a cross‑sectional study conducted for 18 months. mean age of 45.67 ± 9.23 years. There was an overall
After obtaining Institutional Ethical Committee approval, male preponderance (203 cases). The male/female ratio
378 patients were recruited by means of purposive was 1.3:1 in diabetics and 1:1 in non‑diabetics. Most
sampling, in accordance with the study’s inclusion and patients had the lesions for 1–6 months (149 cases),
exclusion criteria. followed by 7–12 months (104 cases). There were
In the pilot study based on the prevalence of diabetes slightly greater chronicity and recurrence rates
among 30% of patients with dermatophytosis, with 10% among diabetics (84 cases) when compared to
allowable error and a ⍺ level of 5%, the sample size had non‑diabetics (21 cases). Diabetics had a greater
been calculated to be 189 across each group with a total extent of involvement compared to non‑diabetics, with
of 378 patients, by using the formula, n = Z2PQ/d2, where 85 diabetics having >10% body surface area (BSA)
n is the sample size, Z is the normal standard deviate, involvement, as opposed to 26 non‑diabetics who
set at 1.96 (which corresponds to a 95% confidence had >10% BSA involvement [Table 1]. Overall,
interval), P is the proportion in the target population tinea corporis with cruris (113 cases) was the
estimated to have required characteristics (in this most prevalent clinical presentation, followed by
study, 0.2), Q = 1 − P (in this study, 0.8), d = degree of isolated tinea corporis (70 cases); however, extensive
accuracy desired, set at 0.05. dermatophytosis (56 cases) was more common in
diabetics (38 cases) [Figures 1–3].
Inclusion Criteria:
The overall positivity of KOH, CW and fungal
• All clinically suspected cases of dermatophytosis of culture was seen in 218, 294 and 310 patients,
both genders. respectively [Figures 3–5]. Based on this, fungal culture
• Patients between 18 and 80 years of age group. was taken as the gold standard for statistical analysis.
Exclusion Criteria: The overall positivity was higher in CW staining (294,
77.8%) as compared to KOH (218, 57.7%) in both
• Pregnant and lactating mothers.
non‑diabetics and diabetics [Table 2]. When comparing
• Patients having isolated nail/scalp lesions.
the positive and negative rates of the various diagnostic
• Patients who have taken systemic antifungals in the
modalities for diabetics and non‑diabetics, there was no
past 3 months and topical antifungals in the past
statistically significant difference [Table 2].
4 weeks.
The most common species isolate in our study
After obtaining written informed consent, a detailed
was T. mentagrophytes in both diabetics and
history was taken and an examination was done. The
non‑diabetics (180 cases), followed by Trichophyton
patients were then divided into two groups each of
rubrum (95 cases), Trichophyton tonsurans (23 cases),
189 known diabetics patients with diagnosed diabetes
Trichophyton violaceum (10 cases) and Trichophyton
mellitus who have an HbA1C value of more than or
schoenlenii (2 cases) [Table 3]. Fungal culture was negative
equal to 6.5% and non‑diabetics. We subsequently
in 68 cases. CW staining had a specificity of 97.06%,
analysed and compared the demographics, clinical data,
sensitivity of 94.19%, NPV of 78.57%, PPV of 99.32% and
KOH mount, calcofluor white (CW) staining and fungal
diagnostic accuracy of 94.71%. KOH had a specificity of
culture results of all patients in both groups.
81.25%, sensitivity of 60.99%, NPV of 24.38%, PPV of
Statistical analysis was carried out using SPSS 21.0 95.49% and diagnostic accuracy of 63.69% Table 4. Overall,
software for Windows. For categorical/binary variables, CW significantly outperformed KOH in terms of specificity,
summary statistics were calculated using proportions, sensitivity, NPV, PPV and diagnostic accuracy [Figure 6].
and for continuous variables, mean, median, standard
deviation and interquartile range. The Chi‑square test
Table 1: Demographic details and clinical presentation
and Fisher’s exact test were utilised for comparing two or
Parameters Diabetics Non‑diabetics
more independent proportions. Whenever the expected
Total number of patients 189 189
numbers in >25% cells were >5, the Chi‑square test was
Age group (45–60 yrs) 83 81
used, and whenever it was <5, Fisher’s exact test was
Duration (1–6 months) 77 72
used. The validity of diagnostic tests was measured by
sensitivity, specificity, negative predictive value (NPV), Duration (7–12 months) 57 47
positive predictive value (PPV) and accuracy, all of which Recurrence 84 21
were measured with a 95% confidence interval (CI). >10% BSA involvement 85 26
 Rajagopal, et al.: Clinico‑mycological study of dermatophytosis among diabetic and non‑diabetic patients in a tertiary level hospital: A comparative study

Table 2: Comparison of KOH, CW and culture results among diabetics and non‑diabetics
Investigation Non‑diabetic Diabetic Total
Count (n) Column (n%) Count (n) Column (n%) Count (n) Column (n%)
KOH Positive 107 56.6% 111 58.7% 218 57.7%
Negative 82 43.4% 78 41.3% 160 42.3%
CW Positive 150 79.4% 144 76.2% 294 77.8%
Negative 39 20.6% 45 23.8% 84 22.2%
Culture Positive 158 83.6% 152 80.4% 310 82.0%
Negative 31 16.4% 37 19.6% 68 18.0%

Table 3: Fungal culture isolates among diabetics and non‑diabetics

Fungal culture Known diabetic
No Yes Total
Count (n) Column (n%) Count (n) Column (n%) Count (n) Column (n%)
Negative 31 16.4% 37 19.6% 68 18.0%
T. mentagrophytes 97 51.3% 83 43.9% 180 47.6%
T. rubrum 47 24.9% 48 25.4% 95 25.1%
T. violaceum 6 3.2% 4 2.1% 10 2.6%
T. tonsurans 7 3.7% 16 8.5% 23 6.1%
T. schoenlenii 1 0.5% 1 0.5% 2 0.5%
Total 189 100.0% 189 100.0% 378 100.0%

Table 4: Diagnostic parameters of KOH and CW when

compared to fungal culture
Parameter Calcofluor white (%) KOH (%)
Sensitivity 94.19 60.97
Specificity 97.06 81.25
PPV 99.32 95.45
NPV 78.57 24.38
Diagnostic accuracy 94.71 63.69

The positivity percentages of fungal culture, KOH

and CW staining increased to 100% (140 cases),
77.9% (109 cases) and 95.7% (134 cases), respectively, Figure 1: Various clinical presentation among diabetics and non‑diabetics
when scrapings were taken from ≥2 sites [Table 5].

Discussion without diabetes, and that diabetes is more frequent in

In India, the incidence and prevalence of dermatophytosis middle‑aged adults than in younger people. Similar to
has increased to epidemic proportions recently and the most studies,[5,8,9] a large proportion of patients in our
frequent inappropriate usage of over‑the‑counter (OTC) study presented after 1–3 months of onset of symptoms.
topicals often results in recalcitrant infections and Overall, the chronicity rate was greater among people
atypical presentations.[3] Although dermatophytosis is with diabetes than among those without the disease.
typically a clinical diagnosis, it can sometimes closely
mimic other dermatoses, necessitating the need for In this study, 20.6% of the cases made use of OTC
laboratory workup. Hence, getting a definitive diagnosis combination topicals, with the vast majority acquiring
before starting antifungal therapy is beneficial. In this these medications from neighbourhood pharmacies
study, most cases of dermatophytosis were found in without first consulting a doctor. Vineetha et al.[10] (63%),
people aged 45 to 60, both diabetics and non‑diabetics. Mahajan et al.[11] (70.6%) and Dabas et al.[12] (77.94%)
Contrarily, a few studies observed a frequent peak in reported an increased incidence of usage of combination
the age group of 20–30 years.[5‑7] It is plausible that topicals. Their inexpensive cost, as well as the early
the higher prevalence in this age group is because this alleviation of inflammatory symptoms, encourages
study included an equal number of patients with and patients to use them for extended periods. Irritant
 Rajagopal, et al.: Clinico‑mycological study of dermatophytosis among diabetic and non‑diabetic patients in a tertiary level hospital: A comparative study

Figure 2: Tinea corporis over the abdomen Figure 3: Positive KOH mount showing long filamentous branching septate hyphae

b
Figure 4: Positive fluorescence microscopy using CW stain

indigenous formulations, as well as those containing

coal tar, anthralin and salicylic acid, were used by 4.5% a
of patients in this study at the time of presentation. Figure 5: (a) Trichophyton mentagrophytes colonies on culture. (b) Trichophyton
mentagrophytes on LPCB mount showing spiral hyphae
Dabas et al.[12] observed that just 7.35% of his study
participants were using topical antifungal medications,
while 14.7% were using formulations including coal tar, In a recent survey, 29% of UK microbiology
dithranol, lactic acid, salicylic acid or urea. laboratories reported that fluorescence microscopy
is preferable for the diagnosis of superficial mycoses
The diagnosis of superficial mycoses relies on a as it is easier to perform, faster and safer than
combination of clinical features and mycological conventional microscopy.[17] In our study, fungal
identification of pathogenic fungi in dermatological culture was taken as the gold standard for statistical
specimens. However, conventional techniques like the analysis and the diagnostic parameters of KOH and CW
KOH mount frequently lack sensitivity, and species staining were compared with culture. The sensitivity
identification from cultures may take up to 4 weeks. of the CW stain in the diagnosis of dermatophytosis
Trichophyton mentagrophytes was the most frequently has been reported to be higher than that of KOH
cultured organism in our study, as reported by various mount by other authors like Mourad et al.,[18] Attal
authors.[5,11,13,14] There was no difference in species et al.,[19] Shwetha et al.[20] and Dass et al.[21] Similar
isolate between diabetics and non‑diabetics in our study. to these studies, CW staining had a specificity of
However, T. rubrum was the most common species isolate 97.06% and sensitivity of 94.19%, while KOH mount
in the majority of similar studies conducted before 2011 had a specificity of 81.25% and sensitivity of 60.99%
in India, indicating the recent changing epidemiological when culture was used as the gold standard method
trend [Figure 1].[9,15,16] of diagnosis in our study. Singh et al.,[22] however,
 Rajagopal, et al.: Clinico‑mycological study of dermatophytosis among diabetic and non‑diabetic patients in a tertiary level hospital: A comparative study

Table 5: Analysis of rate of positivity of investigations in relation to taking scrapings from ≥2 sites
Scrapings Fungal culture KOH Calcofluor white
taken from Negative Positive Negative Positive Negative Positive
≥2 sites Count Column Count Column Count Column Count Column Count Column Count Column
(n) (n %) (n) (n %) (n) (n %) (n) (n %) (n) (n %) (n) (n %)
No 68 28.6 170 71.4 129 54.2 109 45.8 78 32.8 160 67.2
Yes 0 0.0 140 100.0 31 22.1 109 77.9 6 4.3 134 95.7

of choice for the diagnosis of dermatophytosis as it has

significantly outperformed the conventional KOH mount
in terms of diagnostic speed, sensitivity and accuracy,
even though its sensitivity and specificity were lesser
when compared with fungal culture.
Recommendations
• Scrapings can regularly be taken from ≥2 sites to
avoid false negative results.
• CW staining can potentially be used as the initial
method of choice for the diagnosis of dermatophytosis
in settings where it is feasible, as it is quicker and has a
greater sensitivity, specificity and diagnostic accuracy.
Figure 6: Comparison of diagnostic parameters of KOH vs CW stain
Declaration of patient consent
reported that KOH had a higher sensitivity (96.96%) The authors certify that they have obtained all
when compared to fungal culture. appropriate patient consent forms. In the form, the
patient(s) has/have given his/her/their consent for
Compared to a positive rate of 71.4%, 45.8% and 67.2%,
his/her/their images and other clinical information
respectively, for fungal culture, KOH and CW staining
to be reported in the journal. The patients understand
when scrapings were taken from <2 sites, the positivity
that their names and initials will not be published and
rate for these tests increased to 100%, 77.9% and 95.7%,
due efforts will be made to conceal their identity, but
respectively, when scrapings were taken from ≥2 sites.
anonymity cannot be guaranteed.
This may aid in avoiding a high rate of false negative
results. In our study, CW staining had an NPV of 78.57%, Key messages
PPV of 99.32% and diagnostic accuracy of 94.71%, while The pattern of dermatophytosis is comparatively
KOH mount had an NPV of 24.38%, PPV of 95.49% and more chronic and severe in diabetics compared to
diagnostic accuracy of 63.69%. Overall, CW significantly non‑diabetics. Scrapings can regularly be taken from ≥ 2
outperformed KOH in terms of sensitivity, specificity, sites to avoid false negative results. Calcofluor white
PPV, NPV and diagnostic accuracy. staining can potentially be used as the initial method of
Limitations choice for the diagnosis of dermatophytosis.
• The overall specificity and sensitivity of the study Financial support and sponsorship
may have been affected by the possibility that KOH Nil.
mount findings might have been misinterpreted as
false negatives due to cognitive bias and interpersonal Conflicts of interest
observer variance. There are no conflicts of interest.
• Owing to purposive sampling, we were unable
to analyse and compare the total prevalence of References
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