Need for modification of guidelines for systemic steroid-modified tinea

Sir,

We read with interest the review article titled ‘The unprecedented epidemic-like scenario of dermatophytosis in India: III. Antifungal resistance and treatment options’ by Verma et al.¹ Indeed, it was badly needed in the current situation.

However, as a postgraduate in a premier institute in North India, we came across a very large number of patients of dermatophytosis per day who had been administered large doses of injectable long-acting steroids, namely dexamethasone, by local practitioners. When they presented, most had suppressed morning cortisol levels (a few had undetectable levels). It would be interesting if the authors had commented on their management, because these patients must be concomitantly started on oral steroids to prevent life-threatening hypoadrenalism. A routine medicine referral is also shunned by most patients due to time and cost constraints, since in most hospitals medicine is usually the busiest department with very long waiting times. None of the standard textbooks or available guidelines discuss treatment options under such circumstances.

A simple regimen of how to wean such patients off steroids and whether they merit a modification (i.e., higher doses, like itraconazole 200 mg twice daily, or, perhaps, longer duration) of systemic antifungals during the period systemic steroids are being gradually tapered off is the need of the hour.

The author’s experience is that such patients respond very unsatisfactorily with very high relapse and recurrence rates with the antifungal agents prescribed in the article. Our experience is that such tinea may behave differently, with a higher incidence of dermatophytic erythroderma, pustular tinea and extensive tinea corporis. Any guideline in this regard will be extremely useful in the current situation.