Chronic Fungal Infection: Persistent Skin Issues and Treatments

Fungal infection

Hello, doctor.
Around the end of May 2017, I was scratched on the skin above my right ankle by a stray cat from school that had a skin disease.
Since the wound looked shallow and only had broken skin, I just rinsed it with water and applied a topical ointment.
However, a few days later, as the wound was healing, a red rash appeared on it, which was itchy.
It then developed into a patch.
After seeing several doctors who all diagnosed it as eczema, I initially applied various eczema ointments.
I have seen a total of seven doctors, including two from Chang Gung Memorial Hospital and two from National Taiwan University Hospital.
During a biopsy at Chang Gung, they said it was a fungal infection and prescribed antifungal medication.
I must admit that I often did not take the medication on time, so I'm not sure if I completely eradicated the fungus.
The condition continued to worsen, and later the doctor said it had turned into chronic eczema and prescribed more eczema medication.
Despite this, the lesions kept appearing.
I then visited another clinic where they first prescribed eczema ointment and later antifungal medication, which made it worse.
Eventually, I returned to National Taiwan University Hospital, where the doctor scraped the skin to culture it and identified it as a type of spore-forming fungus typically found on animals.
I was prescribed an antifungal medication called "Fuhyou" for eight weeks.
After finishing the treatment, the scraping showed no fungus, but the lesions continued to appear.
The doctor then prescribed steroids.
Recently, due to difficulty in getting an appointment at National Taiwan University, I have continued to use the steroids, but the lesions have spread to areas where they had not appeared before, almost encircling the skin above my ankle.
The doctors have said they have never seen a fungal infection persist for this long, and exposure to sunlight, prolonged walking, or friction from clothing exacerbates the condition.
It has been two and a half years, and I would like to ask the doctor a few questions (the skin in that area has become very thin due to the steroids, and the current symptoms include small red spots that look like they are composed of subcutaneous microvessels, which then protrude and eventually form raised patches that are very itchy).
The appearance has changed significantly over the past two and a half years.

1.
Is it possible that this has developed into a deep fungal infection? The itching is unbearable, and sometimes it seems to improve only to return.
Could this be due to the infection being deep-seated and not fully eradicated?
2.
Is it possible for one area of skin to have both eczema and a fungal infection simultaneously?
3.
Could the prolonged duration of this condition be related to staying up late and using too much steroid cream?
4.
If it truly cannot be resolved, is there a definitive treatment that is guaranteed to work?
5.
Is there a possibility that this skin area has become cancerous, or could it be due to another underlying cancer that is causing it to persist (as I am not in good health and I know some cancers can cause skin issues; I don't want to scare myself, but it has been too long)?
6.
The area of skin underneath (the front of the ankle) has not developed lesions but is itchy.
Do doctors know the possible reasons for this? Additionally, the color has darkened; could this be due to scratching?
7.
Is there a risk of developing a super fungus?
8.
Should I continue using the steroids or stop them for now?
9.
Is it normal for this to last so long (with periods of improvement followed by recurrence)? I would like to share pictures, but I don't know how to do that.
Thank you, doctor, and I apologize for writing so much.
I appreciate your hard work.

Cai Xiaojie, 20~29 year old female. Ask Date: 2019/10/08

Dr. Wu Yuxin reply Dermatology

Do you want to seek medical attention directly? Without actually seeing the lesion, it's impossible to determine the issue; we need to examine it to understand what the problem is and how to address it.

Reply Date: 2019/10/08

More Info

Chronic fungal infections can be particularly challenging to manage, especially when they present with persistent symptoms such as itching, redness, and skin changes. Your situation, which has evolved over several years with multiple diagnoses and treatments, raises several important considerations.

1. Possibility of Deep-Seated Fungal Infection: It is indeed possible for a fungal infection to persist in deeper layers of the skin, especially if the initial treatment was not fully effective. Fungal organisms can sometimes evade treatment, particularly if the medication was not taken consistently or if the strain of fungus is resistant to the prescribed antifungal agents. This could explain the recurring symptoms you are experiencing.

2. Coexistence of Eczema and Fungal Infection: Yes, it is possible for both eczema (or dermatitis) and a fungal infection to coexist in the same area of skin. Eczema can compromise the skin barrier, making it more susceptible to secondary infections, including fungal infections. This dual diagnosis can complicate treatment, as the management strategies for eczema and fungal infections can differ significantly.

3. Impact of Lifestyle Factors: Chronic stress, lack of sleep, and excessive use of topical steroids can all contribute to skin issues. Steroids can thin the skin over time, making it more vulnerable to infections and irritation. Additionally, poor sleep can affect your immune system, potentially allowing fungal infections to persist or recur.

4. Ultimate Treatment Options: If conventional treatments have failed, it may be worth discussing with your dermatologist the possibility of systemic antifungal therapy, which can target deeper infections more effectively. In some cases, a combination of therapies may be necessary. If the condition is particularly stubborn, referral to a specialist in dermatology or infectious diseases may be beneficial.

5. Concern for Skin Cancer: While it is understandable to be concerned about the potential for skin cancer, especially with long-standing skin changes, the likelihood of a fungal infection transforming into cancer is low. However, chronic inflammation and irritation can lead to changes in the skin that warrant monitoring. A biopsy may be necessary if there are significant changes in the appearance of the skin.

6. Itching and Color Changes: The itching and darkening of the skin could be due to a variety of factors, including chronic inflammation, post-inflammatory hyperpigmentation, or even lichenification (thickening of the skin due to chronic scratching). It is essential to avoid scratching, as this can exacerbate the condition.

7. Super Fungal Strains: The concept of "super fungi" typically refers to strains that have developed resistance to standard antifungal treatments. This can occur with overuse or inappropriate use of antifungal medications. Continuous monitoring and appropriate culture tests can help identify any resistant strains.

8. Use of Topical Steroids: The decision to continue or discontinue topical steroids should be made in consultation with your healthcare provider. Long-term use can lead to skin thinning and other side effects, so a careful evaluation of your current skin condition is necessary.

9. Duration of Symptoms: Chronic skin conditions can take a long time to resolve, and it is not uncommon for symptoms to wax and wane. However, if you have been experiencing this for over two years without significant improvement, it is crucial to reassess your treatment plan.

In conclusion, I recommend that you seek a follow-up appointment with a dermatologist who can evaluate your skin condition in person. They may consider performing additional tests, including skin scrapings or cultures, to identify the specific fungal organism involved and tailor your treatment accordingly. It may also be beneficial to explore alternative therapies or a multidisciplinary approach to address both the fungal infection and any underlying skin conditions.

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