Dermatologists in India have reported that the liberal use of topical steroids has resulted in greater difficulty in treating fungal infections. Many patients would now find their condition resurfaces upon cessation of treatment.

The root cause of this increased resistance is due to the liberal prescription and usage of topical steroid creams, resulting in infections becoming increasingly resilient. Compounding this issue are that these creams are readily available over-the-counter and readily prescribed by hakims (physicians using traditional remedies in India) and doctors, but their effectiveness remains questionable.

Dr. Nina Madnani, a consultant dermatologist at P.D. Hinduja Hospital in Mumbai added that, “this is a fungal epidemic. A fungal infection that was so easy to manage and was 100% curable is now so difficult to treat. At least 50% of these infections are not reacting to treatment. Drugs once effective are no longer so.”

Effects of resistance not replicable in labs


Resistance to topical creams, which is distinct from antibiotic resistance, are not showing up in laboratories.

“Resistance is a microbiological term based on lab data, but these are recalcitrant infections — they are not resistant but are relapsing,” explains Dr. Kabir Sardana, professor of dermatology at the Post Graduate Institute of Medical Education and Research, Ram Manohar Lohia Hospital in New Delhi.

He added that the proliferation of topical steroids usage by people, aided by increased and often arbitrary prescriptions by hakims and quacks, has led to a reduced immune response.

One example is Itraconazole 200 mg and 400 mg, which is not approved by the Drug Controller General of India (DCGI) but approved by the State Food and Drug Administration. Dr. Kabir added that this drug has almost 40 drug interactions but is still widely used.

A survey of 74,589 Asians over a two-year period in Singapore found that the most common skin conditions are atopic dermatitis, acne, and viral infections. There were more cases of urticaria in the Chinese, psoriasis and alopecia (baldness) occurred more often in Indians, and a greater occurrence of post-inflammatory hyperpigmentation (PIH) in Malays and Indians.

Proposed measures to combat overuse


“Irrational combinations — antifungal and antibacterial are being combined with steroids — which are flaring up the problem. Prolonged steroid use is leading to side effects and distorting clinical diagnosis. The solution is regulation of these combinations,” suggested Dr. Shyamanta Barua from the Indian Association of dermatologists, venereologists & leprologists (IADVL) and faculty in the department of dermatology of Assam Medical College in Dibrugarh.

The increased and improper usage of such creams are not the only contributing factor as the increased trend of wearing tight fitting clothing in a hot and humid environment also contributes to increased resistance to treatment regimes, leading to a prolonged infection. MIMS

Sources:
http://www.thehindu.com/opinion/op-ed/an-era-of-untreatable-skin-infections/article9070401.ece
http://www.medscape.com/viewarticle/704995_5
https://www.moh.gov.sg/content/dam/moh_web/Publications/Reports/2014/Singapore Burden of Disease Study 2010 Report_v3.pdf
http://www.ncbi.nlm.nih.gov/pubmed/1428445

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