1. Introduction

Skin infections are common diseases in developing countries, of which dermatophytosis are of particular concern in the tropics. A fungal skin infection is usually the result of the presence of some types of foreign fungi on the skin. These fungi grow best on those areas of the skin that are warm, dark and moist. Dermatophytes are parasitic fungi that infect the skin and cause infections of the skin, hair and nails because of their ability to obtain nutrients from keratinized material. These organisms colonize the keratin tissues and in response to their metabolic byproducts the host experiences inflammatory reactions. They are usually restricted to the nonliving cornified layer of the epidermis because of their inability to penetrate viable tissue of an immunocompetent host. Acid proteinases, elastase, keratinases and other proteinases reportedly act as virulence factors ^[4]. Dermatophytes cause fungal infections of keratinised tissues, e.g. skin, hair and nails. The organisms belong to three genera, Trichophyton, Epidermophyton and Microsporum. Dermatophytes may be grouped into three categories based on host preference and natural habitat. Anthropophilic species predominantly infect humans, geophilic species are soil based and may infect both humans and animals, and zoophilic species generally infect non-human mammals ^[6]. Diagnosis of these mycoses is made from mycological studies, direct examination, stains, isolation and identification of the fungi. Treatment includes systemic antifungal, tropical antifungal and keratolytics ^[3]. Superficial mycoses are fungal infections limited to the stratum corneum and its adnexal structures. Diagnosis of these mycoses is made from mycological studies, direct examination, stains, and isolation, and identification of the fungi ^[3]. Tinea infections are among the most common dermatologic conditions throughout the world. To avoid a misdiagnosis, identification of dermatophyte infections requires both a fungal culture on Sabouraud's agar media and a light microscopic mycological examination from skin scrapings. Preventative measures of Tinea infections include practicing good personal hygiene, keeping the skin dry and cool at all times and avoiding sharing towels, clothing, or hair accessories with infected individuals ^[6]. Trichophyton rubrum was the most prevalent fungal pathogen isolated from all cases of superficial fungal infections of the skin, except for Tinea pedis, where Trichophyton interdigitale was the most frequently isolated organism. Dermatophytes remain the most commonly isolated fungal pathogens isolated in toenail onychomycosis, whilst Candida species accounted for the majority of isolates in fingernail onychomycosis ^[16]. Though the climatic conditions are not favorable for the fungal growth during most of the time of the year in Rajasthan India, but due to some injuries and inappropriate approach for the treatment of trauma situations in rural population the incidences of dermatophytic infections are increasing.

Therefore, in the present study we aim to evaluate the rate of incidences of dermatophytic infection, to find its etiological agents and the associated symptoms in the study area. Simultaneously the sensitivity of KOH test and culture test for the screening of the infection was also determined.

2. Materials and Methods

Sample collection: A detailed record of patients susceptible for dermatophytic infection visiting Dr. Mohammed Clinical Laboratory, Iraq, Baghdad for clinical diagnosis was maintained. Patient Perform was filled during the collection of sample to obtain information on duration of the lesion, clinical picture, prior therapy as well as demographic data such as age, sex and duration of illness, among others. The final selected cases for this study were 150 cases consisted of 72% (108) males and 28 % (42) females.

Sample collection: Two sample collection methods were used in this study: In one method, samples consisting of epidermal scales and infected hairs were scraped from the scalp/rim of lesions using a sterile scalpel blade following cleaning of the affected sites with 70v/v isopropyl alcohol. The scrapings were collected on a piece of sterile brown paper. In the other method, moist cotton swabs were used to collect pus from inflammatory lesions. The samples were divided into two portions: one for microscopic examination and one for culture. The collected samples were transported to the laboratory within 2 hours for microscopic and cultural analysis ^[5].

Direct microscopic examination: Direct microscopic examination of the scrapping was placed on a microscope slide with one or two drops of 20% potassium hydroxide (KOH) and a cover slip was placed.The sample was warmed for 5 minutes over a flame ^[8]. Each treated slide was then carefully examined under low (X10) and high (X40) power objective for the presence of hyphae and/or arthroconidia.

Fungal culture: Each scraping was cultured into Sabouraud dextrose chloramphenicol actidione agar ^[1]. A duplicate inoculation of the specimen was also cultured on sabouraud's dextrose cycloheximide agar. The plates were incubated at 28°C for up to 4 weeks and examined at 2 to 3 day intervals for fungal growth. Fungal isolates were subcultured onto plates of Sabouraud's agar. The isolates were examined visually and microscopically for morphology of fungi using lacto phenol cotton blue by slide culture technique. The dermatophytes species were identified by gross and microscopic morphology and by in-vitro tests ^[1]. Evaluation of the relative percent occurrence (RPO) of the fungi and sensitivity of KOH test (results of KOH test corresponds to culture test indicated the sensitivity of the KOH test) was done. The clinical isolates were further maintained in agar slants.

3. Results and Discussion

The fungal infections are termed as “Tinea”. Dermatophytic fungal infections caused are due to infestation of fungi in the skin, nails and hairs. These infections are generally predominant in areas having moist and warm climate which help in sustained growth of these organisms.

During the study for dermatophytic infection 150 patient samples susceptible for the infections were collected from Dr. Mohammed Clinical Laboratory, Iraq, Baghdad. Among 150 samples collected and analyzed, it was found that 72% (108 out of 150) patients were males while the remaining 28% (42 out of 150) were females. Among the patient data collected, 69.44% (75 out of 108) males and 78.57% (33 out of 42) females were found to be KOH positive (Figure 1). Similar observations were recorded at the National Skin Centre, a tertiary referral centre for dermatological diseases in Singapore with more than 2,500 cases of superficial fungal infections annually. The majority of patients (n=9335) (72.3%) were males. Similar observations were recorded in anthropophilic species, the main cause of dermatophytosis in adults and are isolated more often in males than in females ^[15]. The patient data was categorized on the basis of age groups of 0-15 years to 60 years and above in groups of 15 years gap and it was found that the maximum incidence (48%) was observed in the age group of 16 to 30 years (Figure 5). The prevalence of Tinea pedis in 15-year-old school children and 20-year-old males was found to be 4% and 6%, respectively ^[15].

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Figure 1. Sex wise incidences in total of 150 patients under study

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Figure 2. Percent incidences of fungal infections at various sites in body of 150 patients under study

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Figure 3. Histogram showing sensitivity of KOH test verses culture test of 150 case study

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Figure 4. Relative percent occurrence (RPO) of different fungi from 118 patients under study showing positive test results

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Figure 5. Age wise percentage incidence in 150 patients under study

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Figure 6. Incidence of fungal dermatophytic infection under case study

Among all the cases showing infection at various sites in the body including scalp, groin, thighs, face, hands, nails, full body, hips, neck and others, the maximum infection 30% was recovered from groin followed by 18% from hands/legs and 14% from thighs (Figure 2). These fungi are the causative agents of various types of dermotophytosis that attack various parts of the body and tend to the following conditions: Tinea capitis, Tinea cruris, Tinea corporis and Tinea pedis ^[14]. A total of two hundred and fifty samples were obtained from infected skin, hair and nails of individuals within Sokoto metropolis ^[13]. But feet are the site of infection in about 50% of the cases, toenails, glabrous skin and inguinal folds equally often in 42%, palms in 6% and the scalp in 2% ^[15]. The most common infection was Tinea pedis (n=3516) (27.3%), followed by pityriasis versicolor (n=3249) (25.2%) and Tinea cruris (n=1745) (13.5%) ^[16]. Similar results were detected in a study conducted in which out of the 60 cases, 13% cases were healthy and 87% cases were found infected with one or more fungi. In 95% of cases, the fungal species recovered were from the infected symptomatic area like inflammatory lesions redness, dry patches itching, flaky rings, and 6.7% of cases from pain. The pattern of distribution of site of infection was recorded maximum at internal parts (54%) followed by hand (15%), neck (12%) and leg (6%) ^[7]. During the infection maximum cases were found to show symptoms such as redness, itching and dry patches while the duration of infection was variable ranging from a few days up to many years while some also complained about the infection to be seasonal and only confined to summers. To test and confirm the presence of fungal infection KOH result and culture findings were considered, which revealed that KOH test is 72% sensitive (out of 150 cases, 108 were both KOH test and culture test positive). The data revealed that the KOH test was false positive (KOH positive and culture negative) in 12 cases and false negative (KOH negative and culture positive) in 108 cases studied but 12 cases were negative from both the test results, and were considered free from fungal infection (Figure 3). On the basis of KOH and culture test results 75 males (out of 108) and 33 (out of 42) females were found to be infected with fungal dermatophytic infection (Figure 6). In a previous study, out of 155 patients clinically suspected with dermatophytosis, 105 specimens were skin scrapings and 50 were hair. Results of KOH microscopy and fungal culture were compared showing that KOH microscopy was positive in 70% cases while fungal culture showed positive results in 25.8% cases ^[4]. Diagnosis usually can be made with a focused history, physical examination and potassium hydroxide microscopy. Occasionally, Wood's lamp examination, fungal culture or histological tissue examination is required ^[2]. Whereas a study conducted indicate conducted that dermatophytosis is the most common skin disease in the rural population and around Sitapura and Sanganer area, Jaipur. Among the 200 suspected patients with clinical symptoms of dermatophytosis, 170 samples (85%) were found to be positive by KOH examination and 120 (60%) confirmed in culture. Tinea corporis (infection of the glabrous skin) was the most common dermatophytosis reported followed Tinea cruris, Tinea capitis, Tinea pedis and Tinea manuum. Tinea barbae and Tinea faciei reported the least among all the cases of dermatophytosis ^[7].

The incidences of infection were caused by various fungi such as Microsporum, Trichophyton, Aspergilllus, Fusarium, Cladosporum, Alternaria, Curvularia and Penicillium. Among these, the maximum incidence was shown by Microsporum sp. (36.6%) followed by Trichophyton sp. (32.5%), Aspergilllus sp. (11.5%), Fusarium sp. (6.5%) and Cladosporium sp. (4.4%) (Figure 4). In the test conducted on dermatophytes, that included clinical dermatophytes of the genera Trichophyton, Microsporum and Epidemophyton ^{[2, 12]}, four dermatophytes were identified to species level and one to genus level; they included Trichophyton rubrum, Trichophyton mentagrophyte, Microsporum audouinii, Microsporum gypseum and Microsporum sp. ^[13]. Two pathogenic dermatophytes Trichophyton rubrum and Microsporum gypseum were collected from dermatophytosis patients ^[10]. In Denmark, zoophilic species like Microsporum canis (from cats), Trichophyton verrucosum (from cattle) and T. mentagrophytes granulare (from rodents) are the common causes of dermatophytosis and are seen in approximately 15% of all cases, also T. rubrum (48%), T. mentagrophytes interdigitale (14%) and Epidermophyton floccosum (10%) are the species usually involved in infection ^[15]. Trichophyton rubrum was the most prevalent fungal pathogen isolated from all cases of superficial fungal infections of the skin ^[16]. Three hundred and thirty six (11.98%) of these children were positive for the dermatophytic infection. Infection was mainly due to Microsporum audoinii, Chrysosporium keratinophilum and Trichophyton mentagrophytes. Infected domestic animals constituted the apparent source of infection for most pupils. Playgrounds of children and animal fields were also source of infection for children and animals ^[9]. The incidence of Aspergillus niger (19%), Cladosporium sp. (14%), Aspergillus flavus (13%), Trichophyton sp. (13%) and Microsporum sp. (5%) was high and Fusarium sp., Curvularia sp., Penicillium sp., Trichothecium roseum, Epidermetaphyton sp., Drechslera sp. and Alternaria sp. was low ^[13].

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