Fungal infections in Kerala's monsoon
Every monsoon my clinic fills with fungal infections that have been turned into something far harder to treat by a single over-the-counter cream. This is the article I most wish people read before visiting the pharmacy.
Fungi need warmth, moisture and darkness. Kerala's monsoon provides all three for four months a year, which is why tinea infections rise sharply from June onwards. This is not a hygiene failure — it is a climate reality.
The single most important thing in this article
Steroid-containing combination creams make fungal infections far worse
India has a widespread problem with over-the-counter creams that combine a steroid with an antifungal and often an antibiotic. Sold freely, recommended by well-meaning shopkeepers, and used by millions.
Here is what happens. The steroid suppresses inflammation, so the itching and redness improve within two days. It feels like it is working. But the steroid also suppresses local immunity, so the fungus spreads underneath — wider, deeper and with a faint, atypical appearance that is genuinely hard to diagnose. This is called tinea incognito.
The result is an infection that now needs weeks of oral antifungals instead of a few weeks of cream, often with permanent pigmentation and sometimes stretch marks where the steroid thinned the skin. This is, without much competition, the most common avoidable harm I see in my practice.
If a cream has betamethasone, clobetasol, mometasone, or any name ending in "-sone" or "-onide" in it, do not use it on an itchy ring-shaped rash.
Recognising the common types
| Type | Where | Appearance |
|---|---|---|
| Tinea corporis (ringworm) | Trunk, arms, back | Ring with a raised, scaly, active edge and a clearer centre. Itchy. Expands outward. |
| Tinea cruris (jock itch) | Groin, inner thighs | Red-brown patches spreading from the fold outward, intensely itchy |
| Tinea pedis (athlete's foot) | Between toes, soles | Peeling, cracking, white soggy skin between toes, itching, smell |
| Tinea capitis | Scalp, mostly children | Scaly patches with hair breakage or bald areas. Always needs oral treatment. |
| Tinea unguium | Nails | Thick, yellow-white, crumbly nails. Needs months of oral treatment. |
| Pityriasis versicolor | Chest, back, shoulders, neck | Flat pale or light-brown patches, mild fine scale, minimal itch. Very common here. |
| Malassezia folliculitis | Chest, upper back, shoulders | Uniform small itchy bumps. Frequently misdiagnosed and treated as acne for months. |
| Candida intertrigo | Under breasts, groin, armpits, abdominal folds | Moist, red, sore areas with small satellite spots at the edge |
Treating it properly
Topical antifungals
For limited infections: terbinafine, clotrimazole, luliconazole, ketoconazole or miconazole cream. Two points where nearly everyone goes wrong:
- Apply beyond the visible edge — two to three centimetres past the rash, in every direction. The fungus extends further than you can see.
- Continue for two weeks after it looks clear. Stopping when the rash disappears is the main reason infections recur within a month. Total course is usually four weeks or more.
When oral treatment is needed
Oral antifungals — itraconazole, terbinafine, fluconazole, or griseofulvin in children — are required for scalp and nail infections, extensive or widespread disease, infections that failed topical treatment, tinea incognito after steroid misuse, and in immunosuppressed or diabetic patients. These need a prescription because they interact with several common medications and, rarely, affect liver function.
An honest note about a growing problem: terbinafine resistance in Trichophyton is now well documented in India, and treatment courses are longer than they were a decade ago. If your infection has not improved after three to four weeks of correct treatment, that is a reason to return, not to change creams again.
Preventing recurrence — this is where the real gains are
Fungal infections in this climate recur constantly unless the environment changes. These measures matter more than any cream:
- Change out of wet or sweaty clothes immediately. The single most effective step. This includes wet uniforms and gym clothes.
- Dry skin folds thoroughly after bathing — between toes, groin, under breasts, neck creases. Pat, do not rub.
- Loose cotton clothing. Avoid tight synthetic underwear and jeans in monsoon.
- Never share towels, combs, footwear or clothes. Household spread is extremely common — if one person has it and it keeps returning, others may need treating too.
- Wash clothes and towels in hot water and dry them completely. Damp-dried clothes in monsoon reinfect you.
- Antifungal dusting powder in the groin and feet during humid months, as prevention.
- Do not walk barefoot in shared bathrooms; alternate footwear so shoes dry fully.
- Control diabetes. Uncontrolled blood sugar makes recurrence far more likely, and recurrent fungal infection is sometimes how diabetes is first discovered.
A note on "it's just acne on my back"
If you have small, uniform, itchy bumps on your chest and upper back that have not responded to months of acne treatment, especially in humid weather, consider Malassezia folliculitis. It responds to antifungals, not to benzoyl peroxide or antibiotics. This is one of the most common misdiagnoses I correct, and the fix is usually quick once identified.
When to see a doctor rather than self-treat
- The rash involves the scalp, face, or nails
- It is spreading despite two weeks of antifungal cream
- You have already used a steroid or combination cream on it
- It is widespread, or keeps returning after treatment
- You are diabetic, pregnant, or on immunosuppressive medication
- There is pus, severe pain, fever, or spreading redness — possible bacterial infection
- It is a child with a scaly scalp patch and hair loss
A dermatologist can confirm the diagnosis with a simple KOH microscopy test in minutes, which matters because eczema, psoriasis and fungal infection can look similar and their treatments are opposite — steroids help eczema and worsen fungus. Guessing wrong is precisely how mild infections become month-long problems.
Frequently asked questions
The steroid suppresses inflammation, so itching and redness improve within days and it seems to work. But it also suppresses local immunity, letting the fungus spread wider and deeper with an atypical appearance called tinea incognito. What needed a few weeks of cream then needs weeks of oral antifungals, often leaving permanent pigmentation.
Apply two to three centimetres beyond the visible edge and continue for two weeks after the rash has cleared — usually four weeks or more in total. Stopping when it looks clear is the main reason infections come back within a month.
Because the environment favours it: warmth, sweat and damp clothing. Changing out of wet clothes immediately, drying skin folds thoroughly, loose cotton clothing, not sharing towels, and washing clothes in hot water matter more than any cream. Uncontrolled diabetes also drives recurrence.
Yes, and this is commonly missed. Small, uniform, itchy bumps on the chest and upper back that have not responded to acne treatment are often Malassezia folliculitis, which needs antifungals rather than benzoyl peroxide or antibiotics.
Very. It spreads through shared towels, clothes, bedding, combs and footwear, and household transmission is a common reason for repeated reinfection. If it keeps returning, other family members may need checking and treating at the same time.
A simple KOH microscopy test on a skin scraping gives an answer within minutes. This matters because eczema, psoriasis and fungal infections can look alike but their treatments are opposite — steroids help eczema and worsen fungus.
