Widespread dermatophytosis in a healthy adolescent: the first report of multidrug-resistant Trichophyton indotineae infection in the UAE

Abstract

A multidrug-resistant dermatophyte species recently arose in India, first described as terbinafine-resistant Trichophyton interdigitale and soon given a separate name: T. indotineae. Thanks to its treatment recalcitrance, person-to-person spread, and frequent travel, before long it was identified in many countries on all continents. We describe here the case of a boy with widespread, extremely pruritic, inflammatory dermatophytosis affecting his face, neck, trunk, and extremities, unsuccessfully treated for months with oral terbinafine and fluconazole and a range of topical antimycotics. Qualitative polymerase chain reaction of skin scrapings from his lesions identified a T. interdigitale complex fungus, highly probably T. indotineae due to conspecificity and antifungal resistance. Oral itraconazole, administered over 8 weeks, cleared the infection. Because the patient had not traveled outside the United Arab Emirates for months before the infection became obvious, it must have been acquired from a local source.

Trichophyton indotineae, an Emerging Drug-Resistant Dermatophyte: A Review of the Treatment Options

“…In fact, our analysis clearly indicates that a dosage of 100 mg/day, regardless of the therapy duration, was generally insufficient to obtain complete cure, even for prolonged therapies (up to eight weeks) [ 43 , 48 ]. On the other hand, disease resolution was achieved most effectively with itraconazole 200 mg/day, administered for a variable duration ranging from 1 to 12 weeks, as evidenced by 15 reported cases [ 41 , 55 , 57 , 58 , 60 , 65 , 67 , 68 , 69 ].…”

“…Most cases identified outside the Indian subcontinent are related to travel or migration. Cases have been described in China [ 36 , 37 ], Kuwait [ 38 ], Japan [ 39 ], Vietnam [ 40 ], the United Arab Emirates [ 41 ], Turkey [ 42 ], Iran [ 43 ], and Singapore [ 44 ]. In the United States (US), at the beginning of 2023, two cases of tinea unresponsive to oral terbinafine treatment were reported, subsequently identified as being caused by T. indotineae .…”

“…The most effective treatment leading to disease resolution was itraconazole at a dosage of 200 mg/day for a variable duration of 1 to 12 weeks, with 15 described cases [ 41 , 55 , 57 , 58 , 60 , 65 , 67 , 68 , 69 ]. The majority of patients (six cases) were cured with itraconazole 200 mg/day for 2 weeks [ 60 , 67 ].…”

“…In general, itraconazole appeared to be relatively effective, also showing a synergistic effect with topical azoles, particularly clotrimazole cream, ketoconazole 2% cream, luliconazole 1% cream, and bifonazole cream [ 40 , 41 , 65 , 69 ].…”

“…Regarding clotrimazole, Pavlovic et al described a case resolved with the combination of itraconazole 200 mg/day and clotrimazole cream for 8 weeks [ 41 ], while Kong et al successfully combined a twice-daily application of clotrimazole cream with itraconazole 200 mg BID (400 mg/day) for 5 weeks [ 70 ].…”