Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 82932

AbstractMaterial and MethodsResultsDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"

Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : May | Volume : 17 | Issue : 5 | Page : WC01 - WC05 Full Version

Safety and Efficacy of Oral Itraconazole versus Combination with Oral Isotretinoin in Superficial Dermatophytosis: A Randomised Clinical Trial

Published: May 1, 2023 | DOI:
Divya Priyadarshi, Deepika Agarwal, Ankur Talwar

1. Junior Resident, Department of Dermatology, Venereology, and Leprosy, Hind Institute of Medical Sciences, Safedabad, Barabanki, Uttar Pradesh, India. 2. Assistant Professor, Department of Dermatology, Venereology, and Leprosy, Hind Institute of Medical Sciences, Safedabad, Barabanki, Uttar Pradesh, India. 3. Professor, Department of Dermatology, Venereology, and Leprosy, Hind Institute of Medical Sciences, Safedabad, Barabanki, Uttar Pradesh, India.

Correspondence Address :
Dr. Deepika Agarwal,
202, Scotia Tower 5, Omaxe Heights, Vibhuti Khand, Gomti Nagar, Lucknow-226010, Uttar Pradesh, India.


Introduction: Dermatophytes are the most common skin infections mainly treated with itraconazole. However, the persistent nature of the disease has emerged as the major concern over the last few years. Oral isotretinoin, a keratolytic drug is also used along with itraconazole in the management of dermatophytosis.

Aim: To evaluate safety and efficacy of oral itraconazole versus combination with oral isotretinoin in the treatment and recurrence prevention of superficial dermatophytosis.

Materials and Methods: The randomised clinical trial was conducted in the Dermatology Outpatient Department (OPD) of Hind Institute of Medical Sciences, Barabanki district of Uttar Pradesh over 12 months period. A total of 180 adult patients clinically diagnosed with superficial dermatophytosis were recruited and randomised into group A and B. Patients in group A were treated with oral itraconazole 200 mg daily and patients allotted in group B received oral itraconazole 200 mg plus oral isotretinoin 20 mg daily. Both groups were evaluated after every 15 days for two months and followed-up for next two months to assess relapse rate. Treatment efficacy was assessed by potassium hydroxide (KOH) test done on skin scrapings, erythema score, scaling score and 5D pruritus scale and safety by evaluating for adverse reactions noticed at each sequential visit during study period of two months. The data were analysed by using Chi-square tests and unpaired t-tests and Statistical Package for the Social Sciences (SPSS) software version 26.0. A p-value <0.05 was taken as significant.

Results: Out of 180 patients enrolled, 162 patients (83 in group A and 79 in group B) completed the trial. The patients in group B had early and complete mycological cure, seen in 77/79 (97.5%) patients as compared with 74/83 (89.2%) group A patients (p=0.06) with significantly low recurrence rate (p=0.01). At each follow-up, both groups were assessed on the clinical signs of erythema and scaling rated on 4 points scale (0, 1, 2, 3) and clinical symptom of itching on 5D pruritus scale ranging from 5-25. There was statistically significant difference in the treatment response between studied groups (p<0.05). Hepatic derangements were the most common adverse effects observed in both groups.

Conclusion: Oral isotretinoin can be an effective add on therapy in superficial dermatophytosis management as it induces early remission with significantly less recurrence rate.


Dermatophytes, Potassium hydroxide, 5D Pruritus scale

Dermatophytosis is one of the commonest skin infections with a prevalence rate ranging from 36.6-78.4% (1). The chronic nature of the disease could be due to complex interactions of host, pathogen, environmental, pharmacological and other cofactors (2). Similarly, the world is also experiencing a hike in the magnitude of chronic, recurrent and atypical dermatophytosis, affecting 20-25% world population, caused by keratinophilic filamentous fungi called dermatophytes belonging to 3 genera: Trichophyton, Microsporum and Epidermophyton (3). The mainstay of treatment is the topical and systemic antifungals (1). In today’s scenario, topical antifungals have limited role in adults while systemic antifungals like griseofulvin, fluconazole, ketoconazole and terbinafine are associated with low cure rates, more side-effects, various drug interactions and emergence of antifungal resistance in various parts of the country (4),(5),(6).

On the other hand, newer antifungals like itraconazole although earlier had high cure rates are now no longer providing a satisfactory clinical cure [7,8]. To overcome this, various regimens not proven so far have been tried, like prolonging treatment duration, increasing standard dose of antifungals, combining more than one antifungals and application of penetration enhancers (9),(10),(11). Few studies proposed that isotretinoin being keratolytic, increases exfoliation of epidermis resulting in shedding of the stratum corneum, thereby decreasing burden of fungal colonies and hence can have synergistic action with itraconazole in superficial dermatophytosis (2),(12),(13).

In an attempt to overcome the challenges faced by the dermatologists with antifungals, the study was planned to assess whether addition of oral isotretinoin has an edge over itraconazole monotherapy in treatment and prevention of relapses in superficial dermatophytosis. Itching is an individualised parameter difficult to assess since based on various dimensions and hence, 5D pruritus scale was designed to assess treatment response to an intervention in clinical trials. A 5D pruritus scale is easy to apply, consistent and able to determine changes in itching with time in patients with skin diseases (14). As far as ascertained, no research studies have earlier used 5D pruritus scale as an evaluating parameter to assess clinical response in follow-up visits (14).

Hence, the study was designed to assess safety and efficacy of oral itraconazole versus combination with oral isotretinoin in superficial dermatophytosis. The primary measures were the clinical improvement or resolution of skin lesions assessed by erythema scale, scaling scale and 5D pruritus scale and negative microscopic examination done by KOH test. Secondary measures were examining skin and systemic organs for any adverse effects assessed by laboratory investigations.

Material and Methods

The study was a hospital-based, open-labeled randomised clinical trial conducted on 180 adult participants clinically diagnosed with KOH positive superficial dermatophytosis attending Dermatology OPD of Hind Institute of Medical Sciences, Safedabad, Barabanki district of Uttar Pradesh, India, over 12 months, starting from November 2021 to November 2022 after approval from the Institutional Ethics Committee (IEC Number HIMS/IRB/2021-22/3948).

Inclusion criteria: Superficial dermatophytosis is defined as fungal infection affecting the keratinised layer of epidermis of skin, hairs and nails (1),(3). All skin lesions having itching, erythema, scaling with advancing border was included in the study. Patients aged 18-60 years with tinea corporis and/or tinea cruris and faciei or manuum and pedis with positive KOH test, 20-50% involvement of Body Surface Area (BSA), duration of infection ≥3 months, no prior intake of oral antifungal therapy in last three months and no prior topical antifungal application in last one month were recruited.

Exclusion criteria: Patients with chronic hepatic, renal, cardiac or neurological diseases, patients with dyslipidaemia, immunosuppressed patients, pregnant and breastfeeding women and women aspiring pregnancy during or three months after the study period were excluded from the study.

Sample size calculation: Sample size estimation was based on previous study conducted by Kanishk UK (15);


Zα/2=The critical value of the normal distributions at α level of significance (for confidence level of 95%, α is 0.05 and the critical value is 1.96)
Zβ=The critical value of normal distribution at β (for a power of 80%, β is 0.2 and the critical value is 0.84)
p1 and p2 are the sample proportions of the two groups:
Z1-α/2=1.96 at α=5%=0.05
Z1-β=0.84 at 80% of power:
n=74 in each group
Therefore, 148 total sample size:
Considering 20% dropout of study participants i.e., 29

Sample size was 177~180 (round off). The consort flow chart of study is shown in (Table/Fig 1).

Procedure: After obtaining informed consent from all participants a detailed history was recorded which included age, gender, occupation, duration and distribution of infection, oral antifungal treatment taken previously (like griseofulvin, fluconazole, ketoconazole, terbinafine, itraconazole) and its duration and other co-existing co-morbidities. The BSA involvement was calculated by “Rule of hand” in each patient (16). The worst affected dermatophytic lesion was chosen as target lesion. Skin scrapings from the peripheral margin of target lesion was taken with 10 number scalpel blade and collected on a clean glass slide. One drop of 20% KOH was added and cover slip placed and the specimen was visualised under low power (10×) light microscopy by independent observer to visualise fungal hyphae.

Simple randomisation was done by odd and even number and enrolled patients were assigned to either group A (oral itraconazole 200 mg daily) or group B (combination of oral itraconazole 200 mg plus oral isotretinoin 20 mg daily). No topical antifungal treatment was advised but oral antihistamines (levocetrizine hydrochloride 5mg) was given to control the itching if required. All enrolled patients were investigated for Liver Function Test (LFT), Renal Function Test (RFT), fasting lipid profile, Fasting Blood Sugar (FBS), urine pregnancy test and Complete Blood Count (CBC) at baseline. Photographic documentation by digital camera (Samsung Galaxy Note 10+) was done at baseline and at 2nd month by independent observer.

Severity of infection over target lesion in both groups was assessed by chief investigator on basis of pruritus, erythema and scaling at baseline. Erythema and scaling were rated on 4 points scale ranging from 0-3 where 0-absent, 1-mild, 2-moderate, 3-severe (13). Pruritus was rated on 5D pruritus scale having five domains, namely duration, degree, direction, disability and distribution and ranged from 5 (no pruritus) to 25 (most severe pruritus) (14).

The patients were followed-up every 15 days for next two months with LFT and fasting lipid profile and treatment response was assessed by KOH microscopy, 5D pruritus scale, erythema and scaling score at each sequential visit. Both groups were assessed on clinico-demographic factors which included age, gender, occupation, BSA involvement, duration and distribution of infection. At each follow-up visit, a clinical assessment was made and recorded by chief investigator depending on KOH microscopy, pruritus, erythema and scaling score. A negative KOH microscopy was considered as a mycological cure and absent of erythema, scaling and pruritus score were taken as clinical cure. Both mycological and clinical cure were taken as complete cure (13). The participants of both groups with complete cure were followed-up for another two months to look for relapse. A positive KOH microscopy or reappearance of erythema, scaling or pruritus parameters were taken as relapse of disease (13). Participants’ compliance with treatment was checked by collection of empty drug wrapper and tolerability was assessed by looking for various adverse effects like skin dryness, lip cheilitis, photosensitivity, hepatic or lipid derangements or gastritis at each follow-up visits.

Statistical Anlaysis

Discrete variables were presented as frequency counts and percentages, whereas continuous variables were expressed in mean±Standard Deviation (SD). Unpaired t-test was used to compare continuous variables, whereas Chi-square test was used to compare nominal variables between the two groups. The p-value <0.05 was considered significant. Statistical analysis was done using SPSS software 26 version.


A total of 180 participants were included in the study. Among them, 88 (48.9%) were females and 92 (51.1%) were males. The mean age of study participants was 35.8±11.5 years. Tinea corporis and cruris (24.4%) was present in majority of participants followed by tinea corporis (22.8%) and tinea cruris (21.7%). Both groups were comparable in clinical and demographic characteristics as shown in (Table/Fig 2).

Postintervention KOH microscopic findings between two groups are summarised in (Table/Fig 3). Mycological clearance was achieved in 74/83 (89.2%) patients in group A and 77/79 (97.5%) patients in group B at day 60 with p-value=0.067 signifying that both treatments were statistically comparable in attaining mycological clearance on day 60. Further on, p-value<0.05 on day 30 and day 45 signified that group B participants had attained early mycological cure.

The mean 5D pruritus scale for group A and B was comparable on day 0 of the intervention (p-value=0.17). During follow-up visits, there was gradual reduction in 5D pruritus scale in both groups as shown in (Table/Fig 4). However, there was greater reduction in 5D pruritus scale in group B than group A and the difference was statistically significant on day 30, 45 and 60 of follow-up visits.

Similarly, reduction of erythema and scaling between groups were compared on day 0 to day 60. There was reduction in erythema and scaling scores on both groups, however group B participants showed higher reduction in lesser time interval as shown in (Table/Fig 5),(Table/Fig 6). The p-value<0.05 on day 45 in erythema and scaling score signified that combination of oral itraconazole plus oral isotretinoin gave early resolution of clinical symptoms.

Photographic documentation at baseline and on day 60 is shown in (Table/Fig 7),(Table/Fig 8).

Side-effects were also evaluated and are summarised in (Table/Fig 9). Eighteen (10%) participants discontinued intervention due to gastritis, hepatic and lipid derangements. Six (3.3%) participants had lip cheilitis managed by application of white petroleum jelly over lips 2-3 times daily. Skin dryness was observed in 6 (3.3%) participants and was advised topical coconut oil application at bed time. Six (3.3%) participants complained of photosensitivity and were advised application of physical protection from sunlight and application of topical calamine lotion in morning time 30 minutes prior to sun exposure.

On subsequent follow-up visits for two months, 10/74 (13.5%) and 2/77 (2.6%) in group A and B respectively had relapse (χ2=6.14, p=0.01).


The present study evaluated that combination of oral itraconazole and isotretinoin achieved both mycological and clinical cure faster with less recurrence rate than monotherapy with oral itraconazole in superficial dermatophytosis. Various studies conducted in the recent past and their comparison with the present study is depicted in (Table/Fig 10) (2),(13),(17),(18).

Mycological cure rate in isotretinoin and itraconazole group in present study was 97.5%. This cure rate was much higher on comparison with previous studies reported by many researchers which signifies that oral isotretinoin given at a dose of 20 mg daily for two months have an additional benefit in management of superficial dermatophytic infections (2),(13),(17),(18). Moreover, relapse rate noted in the present study was also much lower in isotretinoin and itraconazole group (2.6%) than observed by various researchers in past thereby emphasising the role of oral isotretinoin in prevention of relapse if given for a longer period of time (2),(13),(17),(18). However, the systemic adverse effects (Gastritis, Hepatic abnormalities, Dyslipidaemia) in both groups was higher in present study (group A-7.7% and group B-12.2%) than previous studies which may be due to higher number of participants enrolled and frequent monitoring of laboratory investigations done (2),(13),(17),(18).

Hence, in the present study addition of oral isotretinoin 20 mg daily for two months induced higher mycological cure with relatively low recurrence rate than previous studies. However, the exact mechanism of action of isotretinoin in superficial dermatophytosis is yet to be explored but previous researches have demonstrated its adjuvant role in dermatophytosis treatment (2),(12),(13). Proposed mechanisms are retinoids being immunomodulator boost immune system by stimulating T and B cells to fight against dermatophytosis (19). Retinoids also modulates epidermal proliferation and differentiation and regulates hyperproliferative epidermis by increasing epidermis cell turnover, this result in clearance and sloughing of growing dermatophytes (20). Moreover, dermatophytes proliferate in acidic pH, retinoids alter skin pH towards alkalinity thereby inhibiting its growth (21). The current study observed that addition of isotretinoin had significantly improved the clearance rate with less recurrence.


The study was limited by short follow-up period and patients and chief investigator were not blinded.


The study concluded that oral isotretinoin can be a good adjuvant with oral itraconazole in achieving faster mycological and clinical cure in superficial dermatophytosis with less relapses. Future studies on the pharmacokinetics of oral isotretinoin in dermatophytic infections are the need of the hour due to the emergence of antifungals resistance.


Rajagopalan M, Inamadar A, Mittal A, Miskeen AK, Srinivas CR, Sardana K, et al. Expert Consensus on The Management of Dermatophytosis in India (ECTODERM India). BMC Dermatol. 2018;18(1):6. [crossref] [PubMed]
Khattab FM, Taha M, Elkholy BM. Recent modality in the treatment of recalcitrant dermatophytosis. Eur J Mol Clin Med. 2021;8(3):3771-77.
Havlickova B, Czaika VA, Friedrich M. Epidemiological trends in skin mycoses worldwide. Mycoses. 2008;51(4):02-15. [crossref] [PubMed]
Salehi Z, Shams-Ghahfarokhi M, Razzaghi-Abyaneh M. Antifungal drug susceptibility profile of clinically important dermatophytes and determination of point mutations in terbinafine-resistant isolates. Eur J Clin Microbiol Infect Dis. 2018;37(10):1841-46. [crossref] [PubMed]
Monod M. Antifungal resistance in dermatophytes: Emerging problem and challenge for the medical community. J Mycol Med. 2019;29(4):283-84. [crossref] [PubMed]
Ebert A, Monod M, Salamin K, Burmester A, Uhrlaß S, Wiegand C, et al. Alarming India-wide phenomenon of antifungal resistance in dermatophytes: A multicentre study. Mycoses. 2020;63(7):717-28. [crossref] [PubMed]
Verma S, Madhu R. The great indian epidemic of superficial dermatophytosis: An appraisal. Indian J Dermatol. 2017;62(3):227-36.
Das S, De A, Saha R, Sharma N, Khemka M, Singh S, et al. The current Indian epidemic of dermatophytosis: A study on causative agents and sensitivity patterns. Indian J Dermatol. 2020;65(2):118-22. [crossref] [PubMed]
Khurana A, Agarwal A, Agrawal D, Panesar S, Ghadlinge M, Sardana K, et al. Effect of different itraconazole dosing regimens on cure rates, treatment duration, safety, and relapse rates in adult patients with tinea corporis/cruris: A randomized clinical trial. JAMA Dermatol. 2022;158(11):1269-78. [crossref] [PubMed]
Singh SK, Subba N, Tilak R. Efficacy of Terbinafine and Itraconazole in different doses and in combination in the treatment of tinea infection: A randomized controlled parallel group open labeled trial with clinico-mycological correlation. Indian J Dermatol. 2020;65(4):284-89. [crossref] [PubMed]
Saoji V, Madke B. Efficacy of salicylic acid peel in dermatophytosis. Indian J Dermatol Venereol Leprol. 2021;87(5):671-75. [crossref] [PubMed]
Ardeshna KP, Rohatgi S, Jerajani HR. Successful treatment of recurrent dermatophytosis with isotretinoin and itraconazole. Indian J Dermatol Venereol Leprol. 2016;82(5):579-82. [crossref] [PubMed]
Arora R, Solanki A. Comparative efficacy of monotherapy of oral itraconazole with oral itraconazole with isotretinoin in chronic and/or resistant superficial dermatophytosis. Indian J Res. 2018;7(6):10-13.
Elman S, Hynan LS, Gabriel V, Mayo MJ. The 5-D itch scale: A new measure of pruritus. Br J Dermatol. 2010;162(3):587-93. [crossref] [PubMed]
Kanishk UK. To compare efficacy of oral isotretinoin and itraconazole combination with salicylic acid 30% chemical peel for Tinea corporis and Tinea cruris. Int J Curr Res. 2019;11(12):8936-39.
Rhodes J, Clay C, Phillips M. The surface area of the hand and the palm for estimating percentage of total body surface area: Results of a meta-analysis. Br J Dermatol. 2013;169(1):76-84. [crossref] [PubMed]
Rahman MH. Role of itraconazole pulse therapy with adjuvant isotretinoin in treating recurrent and recalcitrant dermatophytosis. Gulf J Dermatol Venereol. 2019;26:2.
Alhamdi DK, Alhamdi KI. Efficacy and safety of adding low-dose isotretinoin to itraconazole in the treatment of chronic recurrent dermatophytosis among sample of Iraqi patients: An open-labelled therapeutic clinical comparative study. Indian J Dermatol. 2022;67:624.
Asselineau D, Darmon M. Retinoic acid provokes metaplasia of epithelium formed in vitro by adult human epidermal keratinocytes. Differentiation. 1995;58(4):297-306. [crossref] [PubMed]
Orfanos CE, Zouboulis CC, Almond-Roesler B, Geilen CC. Current use and future potential role of retinoids in dermatology. Drugs. 1997;53(3):358-88. [crossref] [PubMed]
Thune P, Nilsen T, Hanstad IK, Gustavsen T, Lövig Dahl H. The water barrier function of the skin in relation to the water content of stratum corneum, pH and skin lipids. The effect of alkaline soap and syndet on dry skin in elderly, non-atopic patients. Acta Derm Venereol. 1988;68(4):277-83.

DOI and Others

DOI: 10.7860/JCDR/2023/63422.17839

Date of Submission: Feb 11, 2023
Date of Peer Review: Mar 03, 2023
Date of Acceptance: Apr 05, 2023
Date of Publishing: May 01, 2023

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

• Plagiarism X-checker: Feb 13, 2023
• Manual Googling: Feb 22, 2023
• iThenticate Software: Mar 29, 2023 (12%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)