Consensus recommendations for Trichophyton indotineae : A modified Delphi study

BACKGROUND: Trichophyton indotineae (T. mentagrophytes genotype VIII) is spreading globally and is often terbinafine resistant. Guidance for diagnosis and treatment remains inconsistent. METHODS: We performed a four-round modified Delphi study. A steering group developed a literature-informed, 42-item questionnaire on diagnosis and management. Consensus was predefined as ≥70% agreement. RESULTS: Thirty-four experts were invited; 20 completed rounds 1 and 2 and 19 completed rounds 3 and 4. Consensus was achieved for 34/42 items (80.95%). The panel advised suspecting T. indotineae infection in patients with extensive or terbinafine-recalcitrant dermatophytosis, particularly those with a history of travel to or residence in endemic regions. For diagnosis, the panel recommended KOH direct microscopy and fungal culture for suspected dermatophyte infection, and PCR (polymerase chain reaction) with species-level discrimination or ITS sequencing for confirmation of T. indotineae. For resistance assessment, SQLE sequencing and antifungal susceptibility testing were preferred where available, particularly after treatment failure. For treating superficial fungal infections caused by T. indotineae, experts recommended oral itraconazole therapy (100-200 mg/day for 6-8 weeks, or longer as clinically indicated), with luliconazole 1% cream as the preferred adjunctive topical option. Oral posaconazole (300 mg/day for 4-12 weeks) can be considered as the salvage therapy following itraconazole failure, keeping in mind antifungal stewardship. CONCLUSIONS: These consensus statements provide practical interim recommendations. Randomized controlled trials are needed to validate outcomes and optimize regimens.

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Journal
Journal of the European Academy of Dermatology and Venereology
Published
2026-09-25
DOI
https://doi.org/10.1111/jdv.70731
Primary Topic
Nail Diseases and Treatments
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article
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article

Consensus recommendations for Trichophyton indotineae : A modified Delphi study

Ananta Khurana, Olav Sundnes, Brian W. Morrison, Riad Joekel Kassem et al.
Journal of the European Academy of Dermatology and Venereology
Nail Diseases and Treatments
article

Consensus recommendations for Trichophyton indotineae : A modified Delphi study

Ananta Khurana, Olav Sundnes, Brian W. Morrison, Riad Joekel Kassem, Michael Arabatzis, Eckart Haneke, Carmen Rodríguez‐Cerdeira, Matilde Iorizzo, Avner Shemer, Shari R. Lipner, Avrom S. Caplan, Mesbah Talukder, Ditte Marie Lindhardt Saunte, Anna Lyakhovitsky, Eran Galili, Michela Valeria Rita Starace, Roderick James Hay, Vincent Piguet, Antonella Tosti, Aditya K. Gupta, Bianca Maria Piraccini
article en

Abstract

BACKGROUND: Trichophyton indotineae (T. mentagrophytes genotype VIII) is spreading globally and is often terbinafine resistant. Guidance for diagnosis and treatment remains inconsistent. METHODS: We performed a four-round modified Delphi study. A steering group developed a literature-informed, 42-item questionnaire on diagnosis and management. Consensus was predefined as ≥70% agreement. RESULTS: Thirty-four experts were invited; 20 completed rounds 1 and 2 and 19 completed rounds 3 and 4. Consensus was achieved for 34/42 items (80.95%). The panel advised suspecting T. indotineae infection in patients with extensive or terbinafine-recalcitrant dermatophytosis, particularly those with a history of travel to or residence in endemic regions. For diagnosis, the panel recommended KOH direct microscopy and fungal culture for suspected dermatophyte infection, and PCR (polymerase chain reaction) with species-level discrimination or ITS sequencing for confirmation of T. indotineae. For resistance assessment, SQLE sequencing and antifungal susceptibility testing were preferred where available, particularly after treatment failure. For treating superficial fungal infections caused by T. indotineae, experts recommended oral itraconazole therapy (100-200 mg/day for 6-8 weeks, or longer as clinically indicated), with luliconazole 1% cream as the preferred adjunctive topical option. Oral posaconazole (300 mg/day for 4-12 weeks) can be considered as the salvage therapy following itraconazole failure, keeping in mind antifungal stewardship. CONCLUSIONS: These consensus statements provide practical interim recommendations. Randomized controlled trials are needed to validate outcomes and optimize regimens.

Journal of the European Academy of Dermatology and Venereology
Statens Serum Institut (DK), University of Copenhagen (DK), Oslo University Hospital (NO), University of Miami (US), Tel Aviv University (IL), King's College - North Carolina (US), University of Oslo (NO), University of Toronto (CA), Cornell University (US), Aristotle University of Thessaloniki (GR), Sheba Medical Center (IL), Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital (IN), University Hospital of Bern (CH), Women's College Hospital (CA), University Hospital Complex Of Vigo (ES), Gentofte Hospital (DK), Azienda USL di Bologna (IT), Mediprobe Research (Canada) (CA), BRAC University (BD), New York University (US), Universidade de Vigo (ES), University of Bologna (IT)
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