488 JO U RN AL of CHINESE CLINICAL MEDICINE VOLUME 21 NUMBER 91 Septem ber 2007

ARTICLES

Tinea pedis am ong diabetics in Basrah: prevalence and predictors

A bbas Ali M a n s o u r , K halil I H am di*

[ Abstract ] Objective Tinea pedis is a chronic fungal infection of the feet ,very often observed in patients who
are imm uno-suppressed or have type 2 diabetes m ellitus( D M ). The aims of the present study are to determ ine the
prevalence of type 2 DM in the adult population with tinea pedis as well as the presence of tinea pedis, for detecting
new of type 2 DM. Methods A cross sectional study of patients attending the diabetes center in A l-Faiha Hospital
in Basrah. Any patients found to have tinea pedis, during the period from January 2004 to end of D ecem ber 2 0 0 6 ,
were enrolled in this study. Diagnosis of tinea pedis is based on history and clinical appearance of the feet in ad d i­
tion to direct microscopy of a potassium hydroxide( K O H ) preparation for fungal hyphae. Results The total num ber
of patients with tinea pedis in this study was 629. The prevalence rate of diabetes among the patients with tinea p e -
dis was 2 4 .8 % . 5 8 ( 9 . 2% ) patients with tinea pedis were discovered to have new diabetes for the first time after
screening. Variables found in patients with tinea pedis, associated with diabetes was o n ly , age > 5 0 ( 0 R , 0 . 4 ; 95%
CI ,0 .2 to 0. 6 ; P = 0 .0 0 0 1 ) and rural residency ( 0 R , 1 . 6 ; 9 5 % CI ,1 .1 to 2 . 4 ; P = 0 . 0 1 ) . Conclusion Tinea
pedis is not uncommon among d iabetics, and any new patients with tinea pedis seen should be investigated for d ia-
betes.

[ Key words ] diabetes mellitus ; fungal infection ; tinea pedis; Iraq

INTRODUCTION lobullous type[5]. Interdigital tinea pedis is the most

Superficial mycoses are considered to affect more fre­
quently patients with type 2 diabetes mellitus ( DM ) ,
especially onychomycosis and tinea pedis.
Tinea pedis is a chronic fungal infection of the
feet ,very often observed in patients who are imm uno-
suppressed or have diabetes mellitus. Three main gene­
ra of fungi may cause tinea pedis : Trichophyton ,Epider-
m ophyton , and M icrosporum. O ther, nondermatophtye ,
fungi such as M alassezia furfur ,corynebacterium m inuti-
ssim u m , and Candida species may also cause tinea pe -
d is[1] .
Tinea pedis is estimated to be the second most
common skin disease in the United States, behind ac-
n e [2,3]. Across Europe and East Asia prevalence rates
reach 2 0 % [ ] . Three variants of tinea pedis have been
described : interdigital type, moccasin type, and vesicu-
common form and usually manifests in the interspace of
the fourth and fifth digits and may spread to the u n d er­
side of the toes[ . Other interdigital inflammatory con -
ditions need to be included in the differential diagnosis
and include erythrasm a, impetigo, pitted keratolysis,
C andida intertrigo, and Pseudom onus aeruginosa inter­
digital infection[ ] .
Paradoxically tinea pedis was associated with a
lower risk of foot ulcer, because tinea pedis needs an
intact autonomic nervous system to causes sweating
a n d , w arm th, which are the predisposing factors [7]
The aims of the present study were to determine
the prevalence of type 2 DM in the adult population
with tinea pedis as well as the presence of tinea p e d is ,
for detecting new of type 2 DM.

D epartm ent of M e d ic in e , * Section of Dermatology , Basrah College of M ed icin e, Basrah 420 0 2 , Iraq
Correspondence to A bb as Ali M ansour, MD , D epartment of M e d ic in e , Basrah College of M ed icin e, H attin , P. 0 Box : 1 4 2 , Basrah 420 0 2 ,Iraq
E -m a il : aambaam@ yahoo, com
JOURNAL of CHINESE CLINICAL MEDICINE VOLUME 21 NUMBER 91 Septem ber 2007 489

MATERIAL AND METHODS was 629. Men constituted 43. 7% and women 56. 2%
A cross sectional study of patients attending the d iabe- ( Table 1) with m ean age of 50. 3 ± 1 3 . 9 years. The
tes center in Al-Faiha Hospital in B asrah. This center disease was bilateral in 54. 3% ; the 4 th web space a -
receives patients with established diabetes and those lone affected in 7 1 .2 % , and both 4 th and 3 rd webs in
want to be screened for it. Any patients found to have 2 1 . 4 % . Only 20 patients ( 3 . 1 % ) were aware of the
tinea p ed is,d u rin g the period from January 2004 to end tinea pedis and the others thought that these white mac -
of Decem ber 2 0 0 6 , were enrolled in this study. Type 2 erate web lesions were benign and used herbal rem e-
DM was diagnosed according to the American Diabetes dies to treat them . Of those who were diabetics none
Association’s ( ADA) of fasting plasm a glucose value ^ thought that it was related to diabetes.
126 m g /d l( 7 . 0 m m o l/L ) on two occasion or symptoms Table 1 Characteristics of 629 Patients with Tinae Pedis
of diabetes and a casual plasm a glucose ^ 2 0 0 m g /d l
(1 1 . 1 m m o l/L ) or established disease on therapy[8]. Item No. ( % )
Only interdigital tinea pedis was considered be -
Sex
cause it is the most common form and has less differen-
tial diagnosis than other types[ ] . Diagnosis of tinea p e- Male 2 7 5 (4 3 .7 )
dis is based on history and clinical appearance of the
feet in addition to direct microscopy of a potassium hy- Females 354 (5 6 .2 )
droxide( KOH ) preparation for fungal hyphae. Fungal
Known case of diabetes 156(24. 8)
culture and Wood’s lamp were not done.
Patients who were widow, separated, single, or d i­ New diabetes 58(9.2% )
vorced were considered as unmarried. According to the
qualifications ( years of school ac h ie v e m e n t), patients Unilateral 2 8 7 (4 5 .6 )
were divided into two groups (6 years of school achieve -
ment and less and those ab o v e). Standing height and Bilateral 342(54. 3)
weight measurements were completed with subjects
* 4 th web 4 4 8 (7 1 .2 )
wearing light-weight clothing and no shoes. Height was
measured to the nearest cm and weight was measured to 4 th and 3rd webs 135(2 1.4 )
the nearest half kilogram ( k g ) . BMI was calculated as
body weight in kilograms divided by the squared value 3 rd web 30(4.7 )
of body height in meters ( k g 7m2 ). Subjects reporting
Second web 2(0.3)
smoking at least one cigarette per day during the year
before the examination were classified as smokers. First web 1(0.1)

STATISTICAL ANALYSIS Total 629(100)

The prevalence of tinea pedis was calculated by divid­
ing the num ber of subjects with the disorder by the total
num ber of subjects. Continuous variables were analyzed
using unpaired t-tests. The relevance of potential risk
factors was analyzed by univariate ( Chi-square ) and
multivariate logistic regression analyses. A P value less
than 0. 05 was considered statistically significant.
RESULTS
Total num ber of patients with tinea pedis in this study
some have more than one sit
The prevalence rate of diabetes among patients
with tinea pedis was 24. 8% . 58 ( 9 . 2% ) of patients
with tinea pedis, were discovered to have new diabetes
after screening.
Variables found in patients with tinea p e d is ,a s s o ­
ciated with diabetes were only, age > 5 0 ( O R , 0. 4 ;
9 5 % C I ,0 . 2 to 0. 6 ; P = 0 .0 00 1 ) and rural residency
( OR , 1 . 6 ; 9 5 % C I,1 . 1 to 2. 4 ; P = 0. 0 1 ) in the
 490 JO U RN AL of CHINESE CLINICAL MEDICINE VOLUME 21 NUMBER 91 Septem ber 2007

univariate analysis( Table 2 ) . In the multivariate analy - was found between genders , marital status, occupation ,
sis( Table 3 ) , both remained an independent risk factor qualification levels, BMI, or smoking state and diabe -
for diabetes in patients with tinea pedis. No association tes.

Table 2 Univariate Association of Demographic Data of Patients with Tinea Pedis Presenting to the Diabetic Clinic
Total No. Diabetic No. Non-diabetic No.
Variable Odd ratio 95% CI P
(% ) (% ) (% )

Age ( years) ( Mean ± SD) 50.3 ± 1 3 . 9 54.8 ± 12.1 48. 8 ± 14.2 0.0001

Age ( years) ^ 50 288(45. 7 ) 48(16. 6) 240(83. 3) 0.4 0.2-0.6 0.0001

>50 341(54. 2 ) 108 (3 1.6 ) 2 3 3 ( 6 8 .3 )

Sex Men 2 7 5 (4 3 .7 ) 69(25. 0) 2 0 6 ( 7 4 .9 ) 1.0 0. 7 ~ 1.4 0.9

Women 354 (5 6 .2 ) 87 ( 2 4 . 5 ) 2 7 5 ( 7 5 .4 )

Marital Married 5 1 1 (8 1 .2 ) 121 (2 3.6 ) 3 9 0 ( 7 6 .3 ) 0. 0.4-1.1 0. 1

status
Unmarried 118 (1 8.7 ) 35(29. 6) 8 3 ( 7 0 .3 )

Occupation Employed 1 1 1 (1 7 .6 ) 24( 21 .6 ) 87 (78.3 ) 0.8 0.4-1.3 0.4

Unemployed 518(82. 3) 132( 25 .4 ) 3 8 6 ( 7 4 .5 )

Qualification ( Mean ± SD) 5.0 ±5.7 4.6 ± 5.7 5. 1 ± 5.7 0.2

Qualification
^6 2 2 5 (3 5 .7 ) 108(2 6.7 ) 29 6 (7 3 .2 ) 1.3 0. 9 ~ 1.9 0. 1
( years)

>6 4 0 4 (6 4 .2 ) 48( 2 1 . 3 ) 177(7 8.6 )

BMI ( Mean ± SD) 29.8 ± 5 . 8 30. 3 ± 5 . 4 2 9 .6 ± 6.0 0. .

BMI ( <30) 332 (5 2 .7 ) 78 ( 2 3 .4 9 ) 254(7 6.5 ) 0.8 0.6-1.2 0.45

( W30) 2 9 7 (4 7 .2 ) 7 8 ( 2 6 .2 ) 219 (7 3 .7 )

Residency Urban 3 9 5 (6 2 .7 ) 111(28. 1 ) 284 (71. 8) 1.6 1 . 1 - 2.4 0.01

Rural 2 3 4 (3 7 .2 ) 45 (19. 2 ) 1 8 9 (8 0 .7 )

Smoker yes 11 8 (1 8 .7 ) 27(22. 8) 91(77.1) 0.8 0 . 5 — .4 0.6

No 5 1 1 (8 1 .2 ) 129 (2 5.2 ) 382(7 4.7 )

JOURNAL of CHINESE CLINICAL MEDICINE VOLUME 21 NUMBER 91 Septem ber 2007
Table 3 Multivariate Association of Demographic Data of Patients with Tinea Pedis Presenting to the Diabetic Clinic
Variable Diabetic No. ( % ) Non diabetic No. ( % )
Age s= 50 48(16.6) 240(83. 3)
>50 108 (3 1.6 ) 233(68. 3)
Residency Urban 11(28. 1) 284 ( 7 1 . 8 )
Rural 45 ( 1 9 . 2 ) 189(80. 7)
DISCUSSION
More women had tinea pedis in this study (5 6 . 2% ver­
sus 4 3 . 7 % ) with m ean age of 50. 3 ± 1 3 .9 years. This
seems different from other stu d ies, where men between
20 and 40 years of age are most frequently affect-
ed, [ 4 , 9 , 10] .
The prevalence rate of tinea pedis among our p a­
tients with diabetes was 24. 8% . A similar prevalence
is seen in Croatia [ 1 1 ] , while Gil Yosipovitch , et al. re-
ported 32% tinea pedis among diabetics [ 1 2]
The problem of our study sample was the unaware -
ness of our people about web lesions. Only 2 0 % had
noticed abnormalities in the web spaces. Even those
who noticed theses chan g es,th ey could not link them to
diabetes. The prevalence of occult tinea pedis in Japan
is 2 5 % [ 4 ] .
Of those found to have tinea pedis in this stu d y ,
9 . 2 % turned out to have diabetes, once they were
screened for diabetes. The message from this, is that
tinea pedis, may be a m arker for diabetes, and any pa -
tients discovered to have tinea p e d is , should be
screened for diabetes.
Variables found in patients with tinea p e d is ,a s s o ­
ciated with diabetes was only, age > 50 and rural resi­
dency in this study. Only gender was predictive for the
occurrence of tinea pedis in one study on the general
population in Spain [ ] , while in other study only type 2
DM versus type 1 was more associated with tinea pedis
but no association was found with gender, age ,or dura -
tion of diabetes [ ] .
The prevalence rate of tinea pedis among patients
with type 2 diabetes was 24. 8% . That has tinea pedis,
9 % turn to have new diabetes. The awareness of our
491
Odd ratio 95% CI P
- 0 . 14 0.29 ~ 0.64 0. 0000
0.06 1. 07 ~ 2. 37 0. 0000
patients regarding web lesions was poor. Variable found
in patients with tinea p e d is , associated with d ia b e te s ,
was only age > 50 and rural residency. Tinea pedis is
not uncommon among d iabetics, and any new patients
with tinea pedis seen should be investigated for d iabe-
tes.
No culture was done , so we could not know the
type of fungi and cases associated with mixed infection
with bacteria also were missed. W ood’s lamp was not
d o n e ,so we may missed some infection with M alassezia
fu rfu r and Corynebacterium M inutissim um 1 ’ ] .
ACKNOWLEDGEMENT
The authors wish to thank Lesley Pocock Publisher and
M anaging Director m edi + WORLD International World
C M E , fo r reviewing o f the m anuscript.
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