Most of us have heard of the dangers of antibiotic-resistant bacteria. But doctors are growing increasingly concerned about a new infectious threat: drug-resistant fungal diseases.
Until now, these superbugs have been mainly confined to hospital patients with weak immune systems. But drug resistance has recently arisen in a common fungal skin infection called ringworm or “jock itch” that can affect anyone.
So far, a few hundred cases of the resistant strain have been reported in the UK, but these are probably not all of them, said Professor Darius Armstrong-James, a fungus expert at Imperial College London.
“That number is continuing to increase exponentially,” he added. “We don’t know how this ends.”
Ringworm was until recently seen as a fairly minor skin infection, passed on by skin contact or sharing clothes or towels. The rash tends to affect sweaty areas like the groin and armpits, hence the term jock itch, but it can appear anywhere.
Despite the name, it is nothing to do with worms: the condition is just a raised red or darker patch caused by the fungus multiplying in the top layer of the skin. Sometimes it can also be caused by the germ that causes athlete’s foot and fungal toenails spreading elsewhere on the body.
While it can be intensely itchy, ringworm is usually easily treated with one of two antifungal creams that can be bought over-the-counter. “It is one of the most straightforward skin conditions to treat. It usually clears within a few weeks,” said Dr Babak Ashrafi, an online doctor for chemist chain Superdrug.
But the resistant strain of fungus, which has been named Trichophyton indotineae, is now impervious to the medicines in the usual creams. Instead, those affected have to take tablets of a drug called itraconazole for two months.
“[The infection is] usually very itchy, painful and quite upsetting, because by the time people get to my clinic, they’ve had it for months and haven’t been able to get rid of it,” said Armstrong-James. “And then we have to work hard to get rid of it.
“We have to give the maximum dose [of itraconazole], which is the dose we usually use for an invasive fungal infection.”
Drug can cause hair loss and liver inflammation
Itraconazole can cause liver inflammation, hair loss and nerve damage, so patients need monitoring through a hospital clinic.
The resistant fungus is thought to have come to the UK from India, where it is common. Indian scientists say it might have arisen there because of widespread use of generic “anti-itch” creams and skin lightening creams. These contain mixtures of steroid drugs – which suppress the immune system and also cause skin to lighten – along with anti-fungal drugs and antibiotics.
Together, these medicines could have encouraged the ordinary strain of ringworm to evolve resistance because the person’s weaker immune response meant the fungus hung around for longer.
The resistant fungus was first discovered in the UK in 2018. By last August there had been 363 cases reported to the UK Health Security Agency, with 310 of those in the previous two years, according to a recent study.
About eight in 10 of those affected were British-Asian. Most patients were in the south of England, especially London. Some were members of the same household or close neighbours, suggesting that is how the infection had spread.
Sexual transmission may also be playing a role, as this form of ringworm seems more likely to affect the groin, buttocks and thighs, said Armstrong-James.
Professor Andrew Borman, of the UK Health Security Agency (UKHSA), added: “Clinicians should suspect this [resistant] fungus in patients with skin infections of the groin, buttocks and thighs, particularly those with travel links to south Asia or when first-line antifungal treatments fail to work.
“People with infections should limit skin-to-skin contact with others until lesions have completely resolved, and wash clothes, towels and bedding at high temperatures and dry them thoroughly before use. And avoid sharing towels to reduce the chances of passing the infection on.”
Borman is acting head of the UKHSA National Mycology Reference Laboratory, and was involved in the recent study.
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