Among all the skin conditions treated at dermatology clinics across India, fungal infections have undergone a troubling transformation in the past decade. What were once straightforward, easily treatable infections have become stubborn, recurring, and in some cases, highly resistant to standard antifungal medications.
The primary driver of this epidemic is not a new pathogen — it is a small, inexpensive tube of cream available at almost every pharmacy in India without a prescription.
The Combination Cream Problem
Across India, combination creams containing a corticosteroid (such as betamethasone or clobetasol), an antifungal (such as clotrimazole), and often an antibiotic are being sold freely and used indiscriminately for any skin condition that presents with redness, itching, or a rash.
These products — often sold under brand names like Candid-B, Clotrimazole+Betamethasone, Lobate-GM, and many others — initially appear to work because the steroid suppresses the visible symptoms (redness, itch) while the antifungal incompletely treats the fungus.
- 1. Steroid suppresses visible symptoms → patient thinks cream is working
- 2. Antifungal may be wrong agent or wrong dose → fungus is not eliminated
- 3. Steroid actually weakens the local immune response → fungus proliferates deeper
- 4. Patient stops cream → symptoms return, often more severely
- 5. Patient applies cream again → cycle repeats for months or years
- 6. Fungus develops resistance to the antifungal → standard treatments no longer work
Why Dermatophyte Resistance Is Now a National Problem
Indian dermatologists have been raising the alarm for several years. Terbinafine-resistant Trichophyton indotineae — a dermatophyte fungus that causes ringworm and other tinea infections — has emerged as a genuinely drug-resistant pathogen, and India appears to be its epicentre globally.
This resistance has developed largely due to prolonged, inappropriate use of antifungals — particularly when combined with steroids. When a fungal infection is incompletely treated (too short a course, wrong agent, or immune suppression by steroids), the surviving fungi develop genetic mutations that allow them to resist subsequent treatment.
The practical consequence: patients are coming in with fungal infections that do not respond to terbinafine (the most common oral antifungal), requiring second-line agents, longer courses, and KOH microscopy plus culture testing to confirm appropriate treatment selection.
How to Recognise a Fungal Infection
Common fungal skin infections and their presentations in Indian patients:
Tinea corporis (ringworm of the body)
Circular or ring-shaped scaly patch with a raised, active border and clearer centre. Can be single or multiple. Most common on the trunk and limbs.
Tinea cruris (jock itch)
Affects the groin and inner thighs. Itchy, red, scaly rash with a sharp border. Very common in India's hot, humid climate. More common in men.
Tinea pedis (athlete's foot)
Scaling, peeling, and itching between the toes and on the soles. Fissuring (cracks) can develop. Often worsens in monsoon season.
Tinea versicolor (pityriasis versicolor)
Caused by Malassezia yeast (different from dermatophytes). Presents as white, pink, or light brown patches, often on the back and chest. Worsens in summer.
Candidal intertrigo
Moist, red, macerated skin in body folds (under breasts, groin, armpits). More common in people who are overweight or have diabetes.
Why Fungal Infections Keep Coming Back
Beyond the steroid cream cycle, recurrence is common for the following reasons:
- • Incomplete treatment courses — stopping antifungal medication as soon as visible clearing occurs, rather than completing the full prescribed course (typically 2–4 weeks for topical, 4–6 weeks for oral)
- • Household transmission not addressed — other household members may be infected or carry the fungus without symptoms; treatment of one person while others remain untreated leads to reinfection
- • Shared towels and clothing — fungal spores survive on fabric and surfaces
- • Uncontrolled diabetes — high blood sugar creates an ideal environment for fungi to proliferate; recurring fungal infections in adults should trigger blood sugar testing
- • India's climate — warm, humid conditions year-round, especially during monsoon season, continuously favour fungal growth
Correct Treatment: What Should Actually Be Done
Effective treatment of fungal infections requires:
- 1. Correct diagnosis first. A KOH (potassium hydroxide) microscopy test confirms the presence of fungal elements and distinguishes dermatophyte tinea from candida from tinea versicolor — each requires a different antifungal agent. Culture testing identifies specific species and — increasingly importantly — resistance patterns.
- 2. Appropriate antifungal selection. For dermatophyte tinea, clotrimazole remains topically effective for mild cases; oral itraconazole is now frequently required for widespread or resistant cases. Terbinafine may still be effective but requires susceptibility testing in resistant-pattern areas.
- 3. Complete the full course. Stopping early when the rash clears is the single biggest driver of recurrence. The fungus may be suppressed but not eliminated.
- 4. No combination steroid creams. The steroid component actively worsens fungal infections by suppressing the immune response that would otherwise help clear the infection.
- 5. Treat household contacts. All symptomatic family members should be treated simultaneously.
- 6. Hygiene measures. Keep skin folds dry, change underwear daily, wear loose cotton clothing, do not share towels or grooming items, and dry thoroughly between toes after bathing.
When to See a Dermatologist
See a dermatologist if:
- • Your fungal infection has been present for more than 4–6 weeks despite treatment
- • It keeps returning within weeks of stopping treatment
- • The rash is widespread, affecting multiple body areas
- • You have diabetes, are immunocompromised, or are on long-term medications
- • You are unsure whether the diagnosis is fungal (tinea, eczema, psoriasis, and skin allergy can look similar)