Superficial fungal infections (SFIs) are the most common communicable skin diseases of human beings across the globe. They are caused by many fungi that infect a wide range of keratinized tissues, including the skin, hair, and nails. World epidemiological surveys have all concluded that SFIs infect approximately 20–25% of the world's population at any given time, and are therefore amongst the most prevalent infectious diseases of humans.¹ While generally non-fatal, SFIs have high morbidity, chronicity, recurrence, and economic cost, each to patients' quality of life and to the strain on healthcare systems individually, particularly in low- and middle-income countries (LMICs), where treatment is not readily accessible.^2,3

Patients frequently suffer pain, pruritus, and cosmetic deformity, all of which lead to stigma and decreased social confidence, particularly in low-resource settings with poor treatment facilities. Taken in a broader context, SFIs occupy valuable outpatient dermatologic resources, highlighting their importance as a chronic public health concern.¹

The key causative agents of SFIs are representatives of three genera: dermatophytes, Candida spp., and Malassezia spp. The aforementioned dermatophytes like Trichophyton rubrum, Trichophyton mentagrophytes, Microsporum canis, and Epidermophyton floccosum are recognized globally as major pathogens.³ On the other hand, Candida albicans and other yeasts typically cause candidiasis of intertriginous areas, mucosal oral, and nails and Malassezia furfur in pityriasis versicolor causation, a chronic superficial yeast disease.^2,4 Consequently, SFIs are most prevalent in the tropical and subtropical regions, wherein socioeconomic and environmental factors combine to raise the risk of transmission.¹

Certain risk factors for SFIs have been described in international as well as regional literature. Demographic factors, such as younger age and gender that is male, have been associated with increased prevalence, primarily in communal or occupational environments where face-to-face contact and sharing of clothing or facilities are facilitated and allow easy spread.⁵ These medical risk factors include diabetes mellitus, HIV/AIDS, and other immunosuppressive conditions, as well as the use of corticosteroids and prolonged antibiotic treatment, all of which weaken host defense mechanisms and subject patients to risk of infection.⁶

South Asia, consisting of India, Bangladesh, Nepal, Pakistan, and Sri Lanka, is an area of special interest due to its high population density, humidity, and mostly resource-limited healthcare systems. In India, for instance, the dermatophytoses are one of the most common dermatoses encountered in dermatology clinics, and their prevalence estimates have ranged from 20–25% of outpatients with dermatology.⁷ Bangladesh is in the heart of South Asia and experiences a hot, humid, monsoon-influenced climate, extremely favorable for fungal growth. Small case series and anecdotal evidence indicate that SFIs are a leading cause of skin morbidity in the country but that few well-strong, hospital-based prevalence studies exist. Unlike India and Nepal, where several documented epidemiological surveys exist, Bangladesh lacks extensive studies to estimate the burden of SFIs and study their associated risk factors in the tertiary care units. This absence of evidence is worrying, considering that SFIs have been well documented to be associated with modifiable risk factors such as overcrowding, poor personal hygiene, low socio-economic status, diabetes mellitus, immunosuppression, fomite sharing, and occupational exposure.³ The relative importance of these determinants has not been researched adequately in Bangladesh.

Given the recognized international burden, the extreme prevalence in neighboring countries, and the favorable climatic and socioeconomic context of Bangladesh, there is a clear and urgent necessity for structured epidemiological research in this regard. This study thus tries to bridge the gap by systematically assessing the determinants and prevalence of SFIs among patients reporting to the dermatology department of a Bangladeshi tertiary-level hospital.

Objectives

To assess the prevalence and risk factors associated with superficial fungal skin infections.

This hospital-based cross-sectional study was conducted in the Department of Dermatology and Venereology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh, from March 2007 to February 2008. Total 200 patients presenting with clinically suspected superficial fungal infections were enrolled in this study. Both male and female patients of all age groups were included, provided they gave informed consent to participate. Patients who had received systemic or topical antifungal treatment within the previous two weeks or those with severe systemic illnesses that could interfere with diagnosis were excluded to avoid confounding. Each participant underwent a detailed history-taking and clinical examination, with special attention to socio-demographic characteristics (age, sex, residence, occupation, socioeconomic status), hygiene practices, and relevant medical history such as diabetes mellitus, immunosuppressive conditions, and prior recurrence of similar lesions. Additional information on potential risk factors, including overcrowded living conditions, occupational exposure, sharing of clothing or fomites, and personal hygiene habits, was systematically documented using a structured questionnaire. Clinical diagnosis of superficial fungal infections was made by dermatologists based on lesion morphology and distribution. To confirm the diagnosis, samples such as skin scrapings, hair, or nail clippings were collected under aseptic precautions. These were subjected to direct microscopic examination using potassium hydroxide (KOH) wet mount preparation for detection of fungal hyphae, and when necessary, samples were inoculated onto Sabouraud’s dextrose agar for culture to identify specific fungal species. All data were compiled and analyzed using appropriate statistical methods. Descriptive statistics were applied to calculate prevalence rates and to summarize the distribution of superficial fungal infections according to age, sex, and other socio-demographic variables. Associations between potential risk factors and superficial fungal infections were assessed using chi-square tests, while logistic regression analysis was applied to determine independent predictors of infection. Data were processed and analyzed using the computer software Excel and SPSS 16 (Statistical Package for Social Sciences). A p-value of less than 0.05 was considered statistically significant. Ethical approval for the study was obtained from the institutional review board of BSMMU, and informed written consent was taken from all participants prior to inclusion.

Table I presents the demographic characteristics of the study population. Among the 200 patients included in the study, the majority belonged to the 21–30 years age group (30.0%), followed by those aged 31–40 years (25.0%). Patients aged less than 20 years accounted for 15.0%, while 17.5% were between 41–50 years, and 12.5% were above 50 years of age. With respect to gender distribution, males were slightly more represented (55.0%) compared to females (45.0%). Regarding occupation, students constituted the largest subgroup (25.0%), followed by service holders (20.0%), housewives (17.5%), farmers (15.0%), day laborers (12.5%), and players (10.0%). In terms of socio-economic background, half of the study population (50.0%) were from low-income families, while 37.5% were from middle-income groups and only 12.5% belonged to the high-income category.

Table II summarizes the risk factors associated with superficial fungal infections. Overcrowding was the most frequently reported factor, affecting 42.5% of patients, followed by poor personal hygiene (35.0%) and low socioeconomic status (30.0%). Diabetes mellitus was identified in 15.0% of cases, while immunosuppression was present in 7.5%. Behavioral and environmental exposures also contributed, with sharing of fomites reported in 20.0% and occupational exposure in 10.0% of patients.

The types of infections observed in this study is also shown in Figure 1. The most common type of superficial fungal infection was tinea corporis, which affected 25.0% of patients, followed by tinea cruris (20.0%) and tinea pedis (15.0%). Onychomycosis and candidiasis were diagnosed in 12.5% and 10.0% of patients, respectively, while pityriasis versicolor accounted for 7.5%. Tinea capitis was present in 10.0% of cases.

Table III illustrates the distribution of different clinical types of superficial fungal infections among age groups. A significant association was observed between age and clinical pattern of infection (p < 0.001). Tinea corporis was more frequent among patients aged 21–30 years (30.0%) and 31–40 years (24.0%). Tinea cruris was also predominantly seen among individuals aged 21–40 years, whereas tinea pedis was most common in the 31–40 years group (33.3%). Tinea capitis was strongly concentrated among children and adolescents below 20 years (75.0%). In contrast, onychomycosis occurred more often in older adults, with the highest prevalence among patients aged 41–50 years (32.0%) and above 50 years (24.0%). Candidiasis and pityriasis versicolor were more evenly distributed across age groups, though they appeared more common in young adults (21–30 years).

Finally, the gender distribution of superficial fungal infections is presented in Table IV. Tinea corporis was observed slightly more among males (56.0%) compared to females (44.0%), whereas tinea cruris and tinea pedis were predominantly male infections, affecting 75.0% and 66.7% of males, respectively. Tinea capitis and onychomycosis also showed a male predominance (60.0% each). In contrast, candidiasis was more common among females (60.0%), and pityriasis versicolor demonstrated an almost equal distribution between both sexes. Although these differences were evident in pattern, only tinea corporis demonstrated statistical testing, which showed no significant gender association (p = 0.169).

Table-I: Demographic characteristics of the study patients (N=200)

Table-II: Risk factors of superficial fungal infections among study patients (N=200)

Figure 1: Types of superficial fungal infections among study patients (N=200)

Table-III: Distribution of different types of superficial fungal infections among age groups (N=200)

Table-IV: Distribution of different types of superficial fungal infections among age groups (N=200)

The present study provides a comprehensive assessment of the prevalence and risk factors of superficial fungal infections (SFIs) among patients attending a tertiary care hospital in Bangladesh. The findings reveal important demographic, clinical, and epidemiological patterns that correspond with, and in some cases diverge from, previous research conducted in South Asia and globally.

The demographic analysis of our study population demonstrated that young adults were the most affected, particularly those aged 21–30 years (30.0%) and 31–40 years (25.0%). This finding is in close agreement with earlier studies, which consistently highlight that dermatophytoses and other superficial fungal infections are particularly common in young and middle-aged adults, largely due to higher levels of outdoor activity, occupational exposures, and perspiration.^1,7 This age-related predilection has been consistently reported in global studies.^1,8 Similarly, a Saudi Arabian study demonstrated high prevalence of onychomycosis in adults (40.3%) and tinea capitis in children (21.9%), further reinforcing the age-related distribution patterns observed in our study.⁹ With respect to gender distribution, males (55.0%) were slightly more affected than females (45.0%). This male predominance aligns with existing studies. In the study of Tan et al.¹⁰, where 72.3% of patients (n=9335) were males. Interestingly, Abanmi et al.⁹ also reported a female predominance in their Saudi cohort, underscoring possible regional and cultural influences on gender distribution.

In our study, tinea cruris and tinea pedis were predominantly male infections, affecting 75.0% and 66.7% of males, respectively, findings that correspond closely with the study of Tan et al.¹⁰, where the most common infection was tinea pedis (27.3%), followed by pityriasis versicolor (25.2%) and tinea cruris (13.5%). Candidal infections were also common (n=1430), the majority of which were cases of candidal intertrigo. Conversely, candidiasis was more common among females (60.0%), consistent with the established association between candidal infections and female hormonal, anatomical, and hygiene-related factors.³ Pityriasis versicolor demonstrated no significant gender bias in our cohort, a pattern also documented in earlier studies.¹ Importantly, although tinea corporis was more common among males, this difference did not reach statistical significance, which may suggest that while gender differences exist, they are not uniformly consistent across all clinical types.

The risk factor profile of our patients further reinforces the role of socioeconomic and environmental determinants in shaping the epidemiology of SFIs. Overcrowding (42.5%) and poor personal hygiene (35.0%) emerged as the most common contributors, followed by low socioeconomic status (30.0%). These findings parallel those of Ingordo et al.⁵, who reported high prevalence of tinea pedis, cruris, and onychomycosis among Italian navy cadets, strongly linked to communal living, footwear, and occupational settings. Diabetes mellitus was identified in 15.0% of cases, and immunosuppression in 7.5%, corroborating earlier observations that host-related factors substantially increase susceptibility to recurrent and chronic fungal infections.³ Additionally, the contributions of fomite sharing (20.0%) and occupational exposure (10.0%) observed in this study highlight behavioral and environmental routes of transmission that have also been well documented in prior epidemiological work.¹ Many risk factors for contracting tinea pedis have been suggested, including a close community living, occlusive shoes, a hot and humid climate, sports practice as a profession.^11-14 In terms of clinical distribution, tinea corporis (25.0%), tinea cruris (20.0%), and tinea pedis (15.0%) were the most common infections in our cohort, echoing trends documented worldwide.^1,15 Onychomycosis (12.5%) was also common, especially in older adults, in agreement with global data suggesting a rising burden of nail infections in aging populations.⁸ Tinea capitis (10.0%) was concentrated in children, while candidiasis (10.0%) and pityriasis versicolor (7.5%) were more evenly distributed across age groups, with a slight concentration in young adults, consistent with earlier epidemiological findings.³

Taken together, the findings of this study demonstrate that the epidemiology of superficial fungal infections in Bangladesh is broadly consistent with patterns observed in other tropical, resource-limited settings. The predominance of young adults, the significant contribution of overcrowding and low socioeconomic conditions, the gender-linked differences in clinical patterns, and the age-specific distribution of entities such as tinea capitis and onychomycosis are all well supported by prior literature. However, the relative scarcity of hospital-based epidemiological studies from Bangladesh underscores the importance of this work in providing local evidence.

In our study, there was small sample size and absence of control for comparison. Study population was selected from one center in Dhaka city, so may not represent wider population. The study was conducted at a short period of time.

This current study highlights that superficial fungal infections are highly prevalent in Bangladesh, with young adults and males being most commonly affected. Overcrowding, poor hygiene, and low socioeconomic status emerged as major risk factors, while diabetes and immunosuppression contributed to increased susceptibility. Tinea corporis, tinea cruris, and tinea pedis were the most frequent clinical types, with age- and gender-specific patterns noted. These findings emphasize the need for targeted preventive strategies, patient education, and improved infection control measures.

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