International Journal of Community Medicine and Public Health

Bashir S et al. Int J Community Med Public Health. 2020 May;7(5):1711-1716

http://www.ijcmph.com pISSN 2394-6032 | eISSN 2394-6040

DOI: http://dx.doi.org/10.18203/2394-6040.ijcmph20201570
Original Research Article

Influence of dermatophytosis on quality of life: a cross sectional study

from Kashmir Valley in North India
Shahnawaz Bashir1, Iffat Hassan1*, Rabbanie T. Wani2

1
Department of Dermatology, Venereology and Leprosy, 2Department of Community Medicine, Government Medical
College, Srinagar, J and K, India

Received: 01 April 2020

Revised: 13 April 2020
Accepted: 14 April 2020

*Correspondence:
Dr. Iffat H. Shah,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Over the past few years, dermatophytosis tends to be prolonged and persistent which negatively affects
quality of life and relationship of patients with other people. There is limited literature available on the impact of
dermatophytosis on the quality of life (QoL). The aim of the study is to investigate the influence of dermatophytosis
on QoL in affected patients and identifying the risk factors associated therein.
Methods: This was a cross-sectional study (descriptive study) in which 425 patients aged ≥18 years with
dermatophytosis were included and evaluated for impact on QoL using dermatology life quality index (DLQI)
questionnaire. Modified Kuppuswamy scale was also used for assessing the socioeconomic status of the study
subjects. Independent t-test and ANOVA were used to find statistical associations between mean DLQI scores and
various variables, wherever applicable.
Results: The mean DLQI score in our study was 13.93±6.26. Dermatophytosis was found to have a very large effect
on the QoL in majority (55.5%) of our subjects followed by moderate effect in 29.5% cases. Mean DLQI was higher
in patients with longer duration of disease, involvement of unexposed sites (groins, gluteal region, axillae), greater
number of sites involved, more body surface area involved, pruritus, redness and burning sensation (p<0.05).
Regarding socio-demographic related variables, Mean DLQI score was higher in females, rural people, in (20-39)
years age group, and in patients belonging to upper middle class (p<0.05).
Conclusions: This study revealed significant impairment of QoL patients with dermatophytosis.

Keywords: Dermatophytosis, Dermatology life quality index, Tinea, Pruritus, Kuppuswamy scale

INTRODUCTION country during different time frames have revealed an

increasing trend of dermatophytosis.2-4
Dermatophytosis, commonly referred as ‘ringworm,’ is
superficial infection of keratinized tissues caused by India, being a tropical country, has a climate that is
organisms belonging to three genera of closely related conducive for superficial fungal infections. The reported
fungi known as dermatophytes.1 It is an indisputable fact prevalence of dermatophytosis in India ranges from 36.6
that an increase in the prevalence of dermatophytosis has to 78.4%.5,6 Overcrowding, areas with high humidity,
been witnessed over the past 4-5 years not only in India poor hygienic conditions are the main factors which
but also globally. Comparison of studies done on predispose to dermatophytosis. The severity of infection
superficial fungal infections in different cities of the varies from mild to moderate according to host immunity,
virulence of the infecting species, site of infection and
environmental factors.7

International Journal of Community Medicine and Public Health | May 2020 | Vol 7 | Issue 5 Page 1711
Bashir S et al. Int J Community Med Public Health. 2020 May;7(5):1711-1716

It has been observed that over the past few years, The severity of pruritus was graded on a scale 0-3; with
dermatophytosis tends to be prolonged and persistent evaluation being as 0- None, 1- mild pruritus, 2- moderate
which can be attributed to widespread use of topical pruritus, 3- severe pruritus.
steroid creams, erratic use of antifungal agents, changes
in the dressing pattern of the host (tight-fitting clothes Assessment of quality of life was done using the
like figure hugging denims, leggings etc.), change in the dermatology life quality index (DLQI) which is a
etiological agent (increased prevalence of trichophyton questionnaire-based survey method to assess, with high
mentagrophytes) and emergence of resistance.8 degree of reliability, the impact and severity of many
dermatology specific diseases and infections.11,12
Although dermatophytosis is not life-threatening and
doesn’t lead to functional impairment, it negatively The DLQI questionnaire consists of 10 leading questions
affects quality of life and relationship of patients with and each question has answers of 4 options expressed as a
other people by leading to shaming, low self-esteem, loss scoring pattern from 0-3. The total score for these 10
of self-confidence and social timidity. Itching is one of questions gives the DLQI score which ranges from 0-30.
the most intensely perceived symptoms and it is As the score increases, quality of life reduces (Table 1).
considered as one the main factors affecting quality of
life. The increased resistance to antifungals resulting in Statistical analysis
recalcitrant cases further adds to the burden of morbidity.
The multiple aspects of the dermatophytosis are now Data was entered in Microsoft excel and analysed using
being studied and discussed on all national and state-level SPSS version 25.0. Independent t-test and one-way
dermatological forums.9 The aim of this study was to ANOVA were used for finding out statistical association.
investigate the influence of dermatophytosis on quality of Quantitative variables were summarized by mean±SD.
life (QoL) in affected patients and identifying the risk
factors associated therein. RESULTS

Few studies have been carried out in different parts of the A total of 425 patients were included in the study out of
country on the impact on quality of life in which 25 filled the responses to the DLQI questionnaire
dermatophytosis, however, there is no study till date either irrelevantly or incompletely and therefore were
which has discussed this aspect in Kashmir valley which excluded. Out of the remaining 400 patients, 273
experiences a huge climatic variation when compared to (68.25%) were males and 127 (31.75%) were females;
rest of the country. The long winter months and less mean age was 34.39±13.10. The largest number of
humid summers may have a bearing on fungal recurrence patients were in the age group of 20-39 years comprising
and subsequently on quality of life. Hence, this study 55.5% followed by 40-59 years (25.5%), <20 years
aimed to fill these lacunae so that better understanding (13.0%) and ≥60 years (6.0%).
could be obtained regarding the impact on QoL in
dermatophytosis among patients residing in cold and hilly The overall mean DLQI score in the present study was
regions of the country. 13.93±6.26. As depicted in (Table 1), 55.5% patients had
a ‘very large’ effect on their quality of life due to
METHODS dermatophytosis while 2.5% patients experienced ‘no
effect’. Also, the people aged between 20 and 39 years
This was a cross-sectional study conducted over a period had a higher mean DLQI than other age groups and the
of one year (September 2018 to 2019) in Department of difference being statistically significant (Table 2).
Dermatology, Venereology and Leprosy, Government
Medical College, SMHS Hospital, Srinagar, India. A total Table 1: Patient distribution as per scoring of DLQI.
of 425 patients aged ≥18 years with clinically diagnosed
dermatophytosis, confirmed by positive potassium DLQI
hydroxide (KOH) microscopy were included in the study. Inference N (%)
score
Exclusion criteria included pregnancy, mental illness, 0-1 No effect on quality of life 10 (2.5)
liver disease, renal disease and other co-existing 2-5 Small effect 20 (5.0)
dermatological diseases.
6-10 Moderate effect 118 (29.5)
A detailed history including age, sex, socio-economic 11-20 Very large effect 222 (55.5)
status, site of onset, symptoms (pruritus, redness, 21-30 Extremely large effect 30 (7.5)
burning) and duration of the disease was taken from every
patient. The socio-economic status of the study subjects Regarding socio-demographic related variables, mean
was assessed using modified Kuppuswamy scale - 2019 DLQI score was higher in females than males; and among
which is based on consumer price index (CPI) issued by rural people than urban people and the difference between
department of labour bureau, government of India.10 them was statistically significant (p<0.05) (Table 3).

International Journal of Community Medicine and Public Health | May 2020 | Vol 7 | Issue 5 Page 1712
Bashir S et al. Int J Community Med Public Health. 2020 May;7(5):1711-1716

Table 2: Association of age distribution with DLQI.

Age group (years) N (%) DLQI 95% CI P value

<20 52 (13.0) 8.62±1.34 16.09-21.49
20-39 222 (55.5) 13.3±2.66 16.41-16.98 P<0.001#
40-59 102 (25.5) 11.26±2.34 7.90-8.45 F=207.4
≥60 24 (6.0) 13.6±3.54 1.64-2.86
#One-way ANOVA test, CI=confidence interval.

Table 3: Association of socio-demographic related variables with DLQI.

Socio-demographic variable N (%) DLQI 95% CI P value

Gender
Male 273 (68.25) 7.06±2.72 9.33-10.80$ P<0.001*
Female 127 (31.75) 17.12±4.67 T=27.0
Residence
Urban 150 (37.5) 9.64±2.13 5.34-7.55$ P<0.001*
Rural 250 (62.5) 13.24±3.21 T=14.83
Socio-economic class (*)
Upper middle 114 (28.5) 20.29±4.24 19.50-21.08
P<0.001#
Lower middle 280 (70.0) 11.46±5.04 10.87-12.06
F=141.6
Upper lower 6 (1.5) 8.0±0.01 7.98-8.01
*Independent t-test, #One-way ANOVA test, CI=confidence interval, $CI values are for t-statistic.

Table 4: Association of disease related variables with DLQI.

Clinical characteristic N (%) DLQI (mean±SD) 95% CI Statistical test results

Disease duration
≤1 month 20 (5.0) 1.70±0.80 1.32-2.08
2-6 months 82 (20.5) 7.43±1.07 7.19-7.66 P<0.001#
7-12 months 96 (24.0) 13.90±4.44 13.00-14.80 F=201.91
≥13 months 202 (50.5) 17.7±4.50 17.16-18.43
No of sites affected
1 100 (25.0) 6.24±2.5 5.74-6.74 P<0.001#
2 110 (27.5) 11.75±2.80 11.22-12.28 F=603.80
>2 190 (47.5) 19.24±3.55 18.73-19.75
Site involved
Exposed sites (face, feet, hands) 110 (27.5) 6.40±2.45 -11.09
Unexposed sites P<0.001*
290 (72.5) 16.78±4.71 9.67$ T= -28.67
(gluteal region, groins, axillae)
BSA involved
<10% 102 (25.5) 6.27±2.50 5.78-6.77
P<0.001#
10-20 % 112 (28.0) 11.96±2.84 11.43-12.50
F=603.38
>20% 186 (46.5) 19.31±3.56 18.79-19.82
Pruritus
Yes 338 (84.5) 15.48±5.42 9.06-10.92$ P<0.001*
No 62 (15.5) 5.48±2.87 T=21.28
Burning sensation
Yes 270 (67.5) 17.36±4.35 9.88-11.23$ P<0.001*
No 130 (32.5) 6.80±2.47 T=30.85
Redness
Yes 310 (77.5) 16.22±5.04 9.39-10.94$ P<0.001*
No 90 (22.5) 6.04±2.57 T=25.76
*Independent t-test, #One-way ANOVA test, CI=confidence interval, $CI values are for t-statistic, BSA=body surface area.

International Journal of Community Medicine and Public Health | May 2020 | Vol 7 | Issue 5 Page 1713
Bashir S et al. Int J Community Med Public Health. 2020 May;7(5):1711-1716

Table 5: Association of severity of pruritus with DLQI.

Severity of pruritus N (%) DLQI (mean±SD) 95% CI Statistical test results

No pruritus 62 (15.5) 5.87±3.44 4.98-6.76
Mild pruritus 160 (40.0) 10.90±3.30 10.38-11.42
P<0.001#
Moderate pruritus 100 (25.0) 18.00±0.01 17.99-18.01
F=354.2
Severe pruritus 78 (19.5) 21.32±4.80 20.24-22.40
#One-way ANOVA test, CI confidence interval.

Participants belonging to upper middle class 114 (28.5%) The overall mean DLQI score in the present study was
had a poor mean DLQI score (20.85) followed by lower 13.93±6.26 which is higher than reported in scabies
middle class 280 (70.0%) with a mean DLQI score of (mean, 10.1±5.9) and in psoriasis (13.0±6.9).15,16 In our
11.46. study DLQI questionnaire, high mean scores were
observed for question 1 (symptoms) followed by question
Considering clinical characteristics of the disease, mean 2 (embarrassment) and question 4 (clothing pattern), with
DLQI was higher in patients with longer duration of low mean scores for question 6 (sports) and question
disease, involvement of unexposed sites (groins, gluteal 8(problems from friends) in the DLQI questionnaire. In a
region, axillae), greater number of sites involved, more study by Narang et al, the mean total DLQI score was
BSA involved, pruritus, redness and burning sensation 13.41±7.56 and the main items in the questionnaire
and the difference between them was statistically influenced by the disease were ‘symptoms and feelings,’
significant (p<0.05) (Table 4). Also, as severity of followed by ‘daily activities,’ ‘leisure’ and personal
pruritus increased, mean score of DLQI also increased relationships.17
and the association was statistically significant (Table 5).
A good proportion of patients (55.5%) had a ‘very large
DISCUSSION effect’ on their QoL. This was because most of these
patients had ≥2 sites involved and had disease duration >1
In recent years, QoL has increasingly been regarded as an year besides taking irregular treatment because of
important component of disease burden and as a relevant financial constraints.
aspect of a comprehensive clinical assessment. World
Health Organization (WHO) defines quality of life as Females had a higher mean DLQI score than males in our
‘individuals’ perception of their position in life in the study; possibly due to greater cosmetic concern among
context of the culture and value systems in which they females. Also, it has been reported that pruritus, in
live and in relation to their goals, expectations, standards general, affects QoL in females more than males because
and concerns’.13 Owing to the fact that skin diseases are of increased frequency of anxiety and stress levels among
known to have strong impact on self-consciousness, women which adversely affects their psychological well-
feelings of unattractiveness, social withdrawal and being.18
emotional stress, QoL indicators have found a special
status in modern health care provision in dermatology. In our study, disease duration emerges as an important
Considering the morbidity and discomfort associated with factor affecting DLQI. Longer the mean duration of the
recurrent and persistent dermatophytosis, this study disease, higher is the mean DLQI score. It was also
provides an insight in understanding the socio- observed that mean DLQI score was higher in patients
demographic parameters and disease related variables that with involvement of unexposed sites (groins, gluteal
have a bearing on quality of life in affected patients. region) which is in contrast to diseases like acne and
psoriasis where higher DLQI is found when exposed sites
In our study the male: female ratio was 2.15:1. This male (face, hands, feet, scalp) are involved.19-20This is because
preponderance may be to increased outdoor exposure and the patient usually finds it embarrassing to itch/scratch
more physical work which results in more sweating.14 the gluteal area and the groins, especially in public
Less cosmetic consciousness in males may also be a domain, which adversely affects his/her day-to-day
contributing factor responsible for delay in seeking activities.
treatment till the condition worsens.
Rural patients had a higher mean DLQI score than urban
In this study majority of the patients were aged between one possibly because of financial constraints, inadequate
20-39 years. This age specific higher prevalence can be access to medicines and inadvertent use of topical
explained by the fact that patients in this age group form steroids prescribed by local quacks in rural areas.
the productive chunk of the population and are usually
exposed to increased physical activity leading to Participants belonging to upper middle class had a poor
excessive sweating which favours fungal growth. DLQI score, the plausible explanation being that people
belonging to this socioeconomic class had more
subjective feeling of embarrassment and uneasiness
following dermatophytosis.

International Journal of Community Medicine and Public Health | May 2020 | Vol 7 | Issue 5 Page 1714
Bashir S et al. Int J Community Med Public Health. 2020 May;7(5):1711-1716

When compared to asymptomatic patients, it was found 4. Narasimhalu CR, Kalyani M, Somendar S. A cross-
that mean DLQI score was higher in symptomatic sectional, clinico-mycological research study of
patients with pruritus, burning, redness, greater number of prevalence, aetiology, speciation and sensitivity of
sites affected and more BSA involved; and the difference superficial fungal infection in Indian patients. J Clin
between them was statistically significant (p<0.05). This Exp Dermatol Res. 2016;7:324.
was in concordance to the findings of Patro et al, who 5. Naglot A, Shrimali DD, Nath BK, Gogoi HK, Veer
found statistically significant association with body V, Chander J, et al. Recent trends of
surface area involvement, demographic variables like dermatophytosis in northeast India (Assam) and
gender, level of education and socio-economic status.21 interpretation with published studies. Int J Curr
Also, it was observed that more severe pruritus had Microbiol App Sci. 2015;4:111-20.
significantly higher mean score of DLQI and therefore 6. Rajagopalan M, Inamadar A, Mittal A, Miskeen
pruritus can be considered as an important parameter AK, Srinivas CR, Sardana K, et al. Expert
having an adverse impact on quality of life in patients Consensus on The Management of Dermatophytosis
with dermatophytosis. in India (ECTODERM India). BMC Dermatol.
2018;18:6.
Limitations 7. Brigida S, Muthiah N. Pediatric Sedation:
Prevalence of Tinea Corporis and Tinea Cruris in
This study excluded the patients suffering from co- Outpatient Department of Dermatology Unit of a
morbid conditions which was done to restrict their impact Tertiary Care Hospital. J Pharmacol Clin Res.
on QoL. Another limitation was that the sample size was 2017;3:555602.
taken from a single tertiary care hospital and thus, cannot 8. Verma S, Madhu R. The great Indian epidemic of
be generalised. Hence, we recommend that more studies superficial dermatophytosis: An appraisal. Indian J
with larger sample size from multiple health care Dermatol. 2017;62:227-36.
centres/hospitals be carried out to further establish the 9. Narang T, Mahajan R, Dogra S. Dermatophytosis:
utility and feasibility of DLQI score-based assessment of Fighting the challenge: Conference proceedings and
QoL in patients with dermatophytosis. learning points. September 2-3, 2017, PGIMER,
Chandigarh, India. Indian Dermatol Online J.
CONCLUSION 2017;8:527-33.
10. Wani RT. Socioeconomic status scales-modified
Dermatophytosis was found to have a significant impact Kuppuswamy and Udai Pareekh's scale updated for
not only on the physiological aspect of patients but also 2019. J Family Med Prim Care. 2019;8:1846-9.
on their emotional and social well-being. The quality of 11. Finlay AY, Khan G. Dermatology Life Quality
life in dermatophytosis is affected by female gender, rural Index (DLQI): a simple practical measure for
residence, involvement of unexposed sites, duration of the routine clinical use. Clin Exp Dermatol.
disease, and socioeconomic status of the patient. This 1994;19:210-6.
study highlights the utility and feasibility of DLQI score 12. Abedini R, Hallaji Z, Lajevardi V, Nasimi M,
based QoL in assessing the perception of patients about Khaledi MK, Tohidinik HR. Quality of life in mild
their health, thus giving a more comprehensive account of and severe alopecia areata patients. Int J Womens
the overall impact of the disease. Dermatol. 2018;4:91-4.
13. The WHO. World Health Organization Quality of
Funding: No funding sources Life (WHOQOL). Geneva: WHO; 2012.
Conflict of interest: None declared 14. Sumathi S, Mariraj J, Shafiyabi S, Ramesh R,
Ethical approval: The study was approved by the Krishna S. Clinico mycological study of
Institutional Ethics Committee dermatophytoses at Vijayanagar Instititute of
Medical Sciences (VIMS), Bellary. Int J Pharm
REFERENCES Biomed Res. 2013;41:32-4.
15. Gang JA, Sheng XX, Sheng BX, Min JW, Mei SG,
1. Klaus W, Lowell GA, Stephen KI, Gilchrest B, Ying YD, et al. Quality of life of patients with
Paller AS, Leffell D. Superficial fungal infection: scabies. J Eur Acad Dermatol Venereol.
Dermatophytosis in: Shannon V, Heffernan Michael 2010;24:1187-91.
P, editors. Fitzpatrick’s Dermatology in General 16. Nayak PB, Girisha BS, Noronha TM. Correlation
Medicine. 7th ed. USA: McGraw Hill Companies; between disease severity, family income, and quality
2008: 1807. of life in psoriasis: A study from South India. Indian
2. Nawal P, Patel S, Patel M, Soni S, Khandelwal N. A Dermatol Online J. 2018;9:165-9.
study of Superficial Mycoses in Tertiary care 17. Narang T, Bhattacharjee R, Singh S, Jha K, Kavita,
Hospital. Nat J Integ Res Med. 2012;3:95-9. Mahajan R, et al. Quality of life and psychological
3. Chudasama V, Solanki H, Vadasmiya M, Javadekar morbidity in patients with superficial cutaneous
T. A study of superficial mycosis in tertiary care dermatophytosis. Mycoses. 2019;62:680-5.
hospital. Int J Sci Res. 2014;3:222-4. 18. Stander S, Stumpf A, Osada N, Wilp S,
Chatzigeorgakidis E, Pfleiderer B. Gender

International Journal of Community Medicine and Public Health | May 2020 | Vol 7 | Issue 5 Page 1715
Bashir S et al. Int J Community Med Public Health. 2020 May;7(5):1711-1716

differences in chronic pruritus: women present 21. Patro N, Panda M, Jena AK. The menace of
different morbidity, more scratch lesions and higher superficial dermatophytosis on the quality of life of
burden. Br J Dermatol. 2013;168:1273-80. patients attending referral hospital in eastern India: a
19. Hazarika N, Rajaprabha RK. Assessment of life cross-sectional observational study. Indian Dermatol
quality index among patients with acne vulgaris in a Online J. 2019;10:262-6.
suburban population. Indian J Dermatol.
2016;61:163‑8. Cite this article as: Bashir S, Hassan I, Wani RT.
20. Raddadi AA, Jfri A, Samarghandi S, Matury N, Influence of dermatophytosis on quality of life: a
Habibullah T, Alfarshoti M, et al. Psoriasis: cross sectional study from Kashmir Valley in North
correlation between severity index (PASI) quality of India. Int J Community Med Public Health
life index (DLQI) based on type of treatment. J 2020;7:1711-6.
Dermatol Surg. 2016;20:15-8.

International Journal of Community Medicine and Public Health | May 2020 | Vol 7 | Issue 5 Page 1716