Highly Contagious, Drug-Resistant Ringworm Reported In U.S. For First Time

There’s a big difference between someone giving you a ring and someone giving you highly contagious, drug-resistant ringworm. While the former may already be quite common in the U.S., the latter had never really been reported in this country. That is until the May 12, 2023, issue of the Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR) reported not just one but two cases of ringworm caused by Trichophyton indotineae, a highly contagious and drug-resistant fungus. Although this not-so-fun fungus has already been causing a yikes epidemic in South Asia, it had never really been officially seen in the U.S. prior to these two cases.

That’s obviously not great news. While you may congratulate someone who gets a ring, the same typically shouldn’t be said to someone who gets ringworm. That’s especially true when the ringworm is drug-resistant, which makes such an infection even harder to treat. And a fungal infection that’s harder to treat is certainly no treat at all.

Public health officials heard of these two cases from a New York City dermatologist on February 28, 2023, which happened to be National Inconvenience Yourself Day. One of the patients, a 28-year-old woman who had no history of recent international travel, had first noticed very itchy rashes on different parts of her body back in the Summer of 2021 and then eventually saw a dermatologist in December 2021. By that time she was in her third trimester of pregnancy and had developed large, round, scaly, very itchy rashes on her neck, abdomen, pubic region, and buttocks. After oral terbinafine treatment didn’t do a whole lot, doctors started her on itraconazole, which eventually helped get rid of her rashes.

The second patient, a 47-year-old woman unrelated to the first patient, had a somewhat similar history. The main difference is that while the first patient hadn’t had any recent international travel, this second patient was in Bangladesh when she first noticed a widespread, itchy rash. Other family members in Bangladesh had suffered from similar rashes as well. This second patient then returned to the U.S. where she made the “rash” decision of going to the emergency department three times during the Autumn 2022. All the treatments that she’d received— including various topical antifungal and steroid creams such as hydrocortisone 2.5% ointment and diphenhydramine, clotrimazole cream, and terbinafine cream—did not relieve her symptoms. Eventually, she saw a dermatologist in December 2022. The dermatologist’s first prescribed treatment, a four-week course of oral terbinafine, didn’t help much. Finally, a four-week course of griseofulvin did lead to approximately 80% improvement in her symptoms. As of the writing of the CDC MMWR, doctors were still considering treatment with itraconazole, given that testing had eventually confirmed T. indotineae as the culprit.

If you haven’t figured it out yet, having ringworm is not fun, assuming that your idea of fun isn’t having red, itchy, ring-shaped rashes on different parts of your body. The “ring” in the “ringworm” name comes from these ring-shape lesions. When ringworm affects parts of your body that have hair, you can suffer hair loss. Such body parts include your scalp and those that rhyme with the words “botch” and “benitals.”

The “worm” in the “ringworm” name doesn’t ting completely true, though. It’s actually different types of fungus that can cause ringworm rather than some kind of worm. There are many other names for ringworm because things that suck tend to have many names. For example, dermatophytosis and tinea are two general names for ringworm. When it affects the main trunk of your body, it can be called tinea corporis. When it affects your scalp, it can be called tinea capitis. When it affects your feet, it can be called athlete’s foot or tinea pedis. When it affects your crotch, it can be called tinea cruris or jock itch or my-crotch-is-really-itchy.

Various types of fungi can cause ringworm, with T. indotineae being one of them. The CDC MMWR called T. indotineae a novel dermatophyte species. In this case, novel means “new” and not a book like 50 Shades of Grey. As mentioned earlier, there’s been an epidemic of T. indotineae. The misuse and overuse of topical antifungal medications and corticosteroids have probably driven the spread of this drug-resistant not-so-fun fungus. While T. indotineae infections had already been reported in Asia, Europe, and Canada, the U.S. hadn’t joined the fun until these two cases. Plus, since the first patient had no history of recent international travel, she may have gotten it from someone else in the U.S., which would mean that T. indotineae has already been spreading in this country.

You can catch ringworm by direct contact with someone with ringworm. So don’t share things like shirts, pants, skirts, sweater vests, hats, underwear, towels, combs, and jock straps with someone who is already infected. In fact, it’s a bad idea to share jockstraps, underwear, or sweater vests whether or not the other person has ringworm. Getting your own jockstraps and underwear is a worthwhile investment, and no one should be wearing sweater vests anymore.

You can also get the infection from other animals that have ringworm. So don’t share shirts, pants, skirts, sweater vests, hats, towels, combs, and jock straps with dogs, cats, cows, goats, pigs, and horses either when they are infected.

A third source of ringworm infections is the environment. You can find such fungi on various surfaces, especially when they are damp. Therefore, don’t walk barefoot or slide crotch-first on the floors of locker rooms or public showers.

The CDC also recommends additional measure to take to prevent ringworm. This includes keeping your skin clean and dry, wearing shoes keep your feet well-ventilated, and keeping your fingernails and toenails short and clean. You should also wear clean clothes. The CDC recommends changing your socks and underwear at least once a day. This can help you prevent fungal infections and get you more dates.

Speaking of dates, if you tend to cover yourself with steroid creams before dates, be careful. Rubbing steroid creams on anything that itches or is red can be very problematic if that itchy, reddish thing happens to be ringworm, regardless of whether it is drug-resistant. Steroid creams can actually make ringworm even worse. That’s because steroid creams can weaken your skin and its defenses, allowing the fungus to spread more widely and deeper in your skin. It can also give ringworm a more unusual appearance, which is less red and less scaly. This co-called tinea incognito appearance can make ringworm harder to diagnose and be mistaken for other conditions such as atopic dermatitis otherwise known as eczema. So avoid the ‘roids when its ringworm.

It is important to ring the alarms about the continued overuse of various steroid and antifungal creams. This includes telling doctors to stop prescribing such creams for anything that happens to be red and itchy. And since many such creams are already widely available over-the-counter, it means warning the public as well. In other words, “it rubs the lotion (or the cream) on its skin” shouldn’t always be the solution when you’ve got some kind of skin issue.