Numerous barriers prevent dermatologists from consistently using fungal diagnostic preparations to diagnose cutaneous fungal infections. In fact, more than one-fifth of dermatologists surveyed said they never or rarely do fungal preparations in practice and more than 43% said that very often the clinical diagnosis is adequate, according to a study published August 2019 in The Journal of Drugs in Dermatology.1
The problem with that is even dermatologists misdiagnose and mismanage fungal infections. Adam Friedman, M.D., the senior author on this paper, realized this when he asked dermatologists at a meeting to look at 13 clinical images and determine whether or not each was a fungal skin infection. The subsequent study, published in the Journal of the American Academy of Dermatology in 2016, found that more than 75% of the dermatologists surveyed accurately identified only four of 13 dermatophytosis cases.2
Performing direct microscopy with potassium hydroxide (KOH) or other stains to confirm a suspected fungal infection should be a central tenant in dermatology, says Dr. Friedman, professor and interim chair of dermatology at the George Washington School of Medicine and Health Sciences.
“There are exceptions to every rule. I’m sure there are times when you can tell from a mile away when you look at a foot that it’s tinea pedis. But very often, cutaneous dermatophyte infections can look like a lot of things. They can look like eczema; they can look like psoriasis. They can look like cutaneous T-cell lymphoma. And because they can be protean in nature, why not do something so simple?” He says. “We have a bedside diagnostic that will help you confirm your clinical suspicion. Everyone should be doing it and everyone should be proficient in it.”
SO WHY NOT?
Dr. Friedman’s latest study on the topic reflects 308 completed survey responses from dermatologists on the Orlando Dermatology and Aesthetic and Clinical Conference email list. Survey questions delved into dermatologists’ perceptions of fungal preparations and Clinical Laboratory Improvement Amendment (CLIA) certification, which is necessary for getting reimbursed for performing the stains. While nearly 21% of respondents said they rarely or never use the prep when they suspect fungal infection, another 19.86% indicated they’ll “sometimes” perform fungal preparations. In addition to believing clinical diagnoses are adequate, dermatologists said they’re also unlikely to do the preps because they take too long.
1. Murphy EC, Friedman AJ. Use of In-Office Preparations by Dermatologists for the Diagnosis of Cutaneous Fungal Infections. J Drugs Dermatol. 2019;18(8):798-802.
2. Yadgar RJ, Bhatia N, Friedman A. Cutaneous fungal infections are commonly misdiagnosed: A survey-based study. J Am Acad Dermatol. 2017;76(3):562-563.