Fungal Skin Diseases and Related Factors in Outpatients of Three Tertiary Care Hospitals of Dhaka, an Urban City of Bangladesh: Cross-Sectional Study

Cross-Sectional The main objective was to determine the prevalence of the fungal skin diseases and explore the related factors including demographical, personal hygiene aspect and socio-economic status of the patients, the study was performed at the Dermatology Departments of three tertiary care hospitals. Collection of skin samples and personal interviews of patients were followed by laboratory confirmation of the diseases and their pathogens were completed by direct microscopy and culture. Among 800 patients, 310 patients had fungal infection with highest prevalence [38.75%] where ringworm [81.61%] and Oral candidiasis [2.9%] were highest and lowest. Onchomycosis [27.41%] had highest prevalence among ringworm patients. In case of factors, summer season [59.68%], married [71.93%], secondary education [36.45%], 12000-20000tk monthly [38.06%] and upper-middle class status [38.06%], Muslims [86.13%], businessmen [39.73%], urban areas [69.35%], tap water [69.35%], recurrent infections [62.9%] and overcrowding of family [66.13%] had higher prevalence of fungal infections of skin. This research would add to the scientific literature and health policies as unlike other studies it has specifically evaluated the prevalence of fungal skin diseases of an urban city with associated factors in Bangladesh.


Introduction
Globally, fungal skin diseases are very common in human. As a densely populated developing country and having poor hygiene, sanitation practice, Bangladesh is no different to fungal skin infections. The skin protects us from microbes and the elements of skin help in regulating body temperature and permit the sensations of touch, heat, and cold. As it interfaces with the environment, skin plays an important immunity role in protecting the body against pathogens. It is subject to a wide range of medical conditions and infections ranging from simple manifestations to complicated ones like skin cancer. Symptoms and severity of skin disorders vary greatly. They can be temporary or permanent and may be painless or painful. Some have situational causes, while others may be genetic. Skin and venereal diseases are one of the major public health problems in developing countries. Though it occurs in all class of society but people living in insanitary and poor housings conditions suffer more from the disease, poverty-stricken people with poor hygienic habits and unclean clothing are the usual victims of these diseases. Symptoms of infection depends on the type of organisms that has caused the infection and both symptom and appearance also depend on the part of the body infected. In many studies it has been shown that 30-40% of our population is suffering from skin diseases. Of which about 80% are scabies and pyogenic infections.
Children are the worst sufferers from these diseases (Khanum and Alam 2010). The relation between the skin and venereal diseases of the diabetic patients of different age group and sociodemographic characteristics is very complicated. The sociodemographic aspects are very important to know because in different societies and social groups explain the causes of illness, the type of treatment they believe and to whom they turn if they go get ill (Khanum et al. 2007).
In human anatomy, the largest outer organ, covering throughout the whole body is skin. Skin performs a very significant role in immunization by defending against outer microbes and pathogens.
Moreover, the elements of skin help the body to regulate the temperature throughout the body and create the feelings of heat, cold and touch. However, this important organ of the body has been exposed to a variety of infections and medical sufferings varying from simple acne to very intricating skin cancer types. Worldwide, among human diseases, the most common is skin disease. It can affect individuals anytime during their lifetime [1], can strike at any age, can spread over all societies and cultures. In time skin disease can lead to systematic disorders. Its damaging effects lead to physical disability even death [2].
In 2010, the global burden of disease [GBD] published that skin diseases ranked fourth as the prominent reason for non-fatal disease burden affecting both high-and low-income countries [3].

Tinea corporis [Ringworm of the body] is a fungal infection
that affects the skin of body.

Tinea cruris [Jock itch] is a fungal infection that affects the
warm and moist area such as buttocks, groin, inner thighs etc.

Tinea pedis [Athlete's foot] is a fungal infection that affects
the skin of feet.  According to the 2010 GBD, fungal skin infections were among the top 10 most dominant diseases globally [3]. According to the 2013 GBD, 0.15% of DALYs of the global burden of skin diseases are contributed by fungal skin diseases [4]. In rural areas of Bangladesh fungal skin infections are very common [15]. A study on the common skin diseases revealed that out of 440 patients 13% had fungal infections [11]. Other studies of Bangladesh showed prevalence ranging from 15.5%-26.7% [12][13][14]. India, neighboring country to Bangladesh also reported that Fungal diseases were the highest group of all skin diseases with 18.74% prevalence [16] and second highest with 17.19% prevalence [17]. In Pakistan, a study conducted in 2017 showed 34.80% prevalence of fungal skin infections out of 95983 patients in a tertiary care hospital of Karachi [18]. A community-based survey studying the skin diseases of South Asian Americans found that fungal had 11% prevalence after Acne and Eczema [19].

Numerous factors can influence the prevalence of skin
infections mentioning geographical and cultural factors [20][21], educational status, nutritional status, socio-economic status, as well as seasons, overcrowding, unhygienic habits, and environments are significant factors of defining the distribution of skin diseases in developing countries [1,[22][23][24]. The socio-demographic aspects are very significant to know because in different societies and social clusters rationalize the reasons of illness, what types of treatments and whom they believe in case of their treatments [5].

Ethical Approval
We informed each and every patient about our study aims, methods as well as we assured them about their privacy and confidentiality at any stage of the study [at the time of data, sample collection and laboratory diagnosis] before including them into our study. We also made it flexible to the patients to enter the study and also to withdraw their consent.

Results
In the present observation cross-sectional study has been outlined to determine the prevalence of the fungal skin diseases of tertiary care hospitals in an urban city. The present study also provides a descriptive profile of factors related to the fungal skin diseases including demographical, personal hygiene aspect and socio-economic status of the outpatients attending the Dermatology  (Figure 1).

Figure 1:
Prevalence of ringworm causing agents among the patients.  (Table  3).     In 1993, a study performed by Hossain [25] found that fungal infection [20.19%], and seborrhoeic dermatitis [8.80%] were most common among the skin diseases [25]. In 1995, Bahmadan et al. [22]  There are several studies conducted in Bangladesh had found different results than ours. According to them, the prevalence was higher is rural areas [15], among students [10], patients from low socio-economic status [9], among illiterate patients [9,10], in rainy season [8]. According to Khanum et al. 52.16% of the patients with low socio-economic status showed a high reoccurrence of skin disease which contradicts our study result [8]. From these observations it can be said that skin infections in patients is very frequent in urban regions even if the urban cities of the country have improved standard of living, hygiene and sanitation, better quality healthcare facilities, education, and nutritious food to lessen the fungal skin diseases rather than the rural part of country. So, the present study has tried to give an approximate fungal skin disease prevalence scenario with related factors of the whole country.

Conclusion
Present cross-sectional study has provided some unique results and findings which would add to the scientific literature and health policies as it is first of its kind. No other research work has evaluated the prevalence of fungal skin diseases of an urban city with associated factors in Bangladesh. Moreover, this work can also be scaled up to other pathogens of skin diseases. However, there is no vaccine against skin diseases it is very difficult to control its transmission so to control this disease is to improve socioeconomic condition, change the personal hygiene behaviour and taking appropriate preventive measures.