Health-Seeking Behavior and Antifungal Use among Patients with Dermatophytosis in Bangladesh: A Cross-Sectional Study

Skin fungus is a common nuisance for people across South Asia, causing itchy, red patches that can spread across the body and affect entire families. For decades, doctors treated these infections with straightforward medicines, usually creams or pills that cleared the problem quickly. However, in recent years, this simple approach has begun to fail. The fungi are changing, becoming harder to kill, and the standard medicines are no longer working as well as they used to. This shift has created a difficult situation for patients who suffer from recurring rashes and for the doctors trying to help them. The problem is made worse by how people in the region often seek medical care. Instead of visiting a trained specialist, many turn to local pharmacies or untrained sellers to buy medicine without a prescription. This freedom to choose any drug leads to a chaotic mix of treatments, where the wrong medicines are used for the wrong reasons, potentially making the infections stronger and more resistant to cure.

Researchers in Bangladesh set out to understand exactly how this breakdown is happening. They conducted a study involving 340 patients who came to a university hospital in Dhaka with suspected skin fungus infections. The team interviewed these patients to trace their journey: where they went for advice, who told them what medicine to take, and what they actually used. The goal was to map out the habits of people seeking help for these stubborn infections and to see if the medicines they were taking were sensible or dangerous. The study focused on the period between June 2024 and May 2025, capturing a snapshot of current practices in a country where access to formal healthcare can be limited for many.

The results revealed a troubling pattern of self-medication and confusion. More than half of the patients, about 53 percent, had obtained their treatment from pharmacy salesmen or bought it directly off the shelf without a valid prescription from a doctor. Nearly half of the patients also reported that a family member had been sick with the same infection in the year before, suggesting the disease spreads easily within households. When the researchers looked at the specific medicines people were taking, they found a wide variety of systemic drugs—pills that work from the inside out. The most common pill was terbinafine, taken by about 37 percent of patients, followed by fluconazole, voriconazole, and itraconazole. What stood out was that many patients were taking multiple antifungal pills at the same time, a practice often recommended not by doctors, but by the people selling the medicine in shops.

The use of a specific drug called voriconazole raised particular concern. This medicine is a powerful, expensive reserve drug usually saved for severe, life-threatening fungal infections that invade the blood or lungs. It is not recommended by health authorities anywhere in the world for simple skin infections. Yet, the study found that voriconazole was being prescribed for skin fungus by doctors, general practitioners, and even pharmacy salesmen. In fact, pharmacy salesmen were the second most common source of this drug, after dermatologists. About 10 percent of patients had bought voriconazole over the counter without a prescription. The researchers noted that using such a potent drug for a minor skin condition, especially without strict medical supervision, risks wasting a critical resource that might be needed later for serious illnesses.

The situation was even more complicated with creams and ointments. While doctors often prescribe specific antifungal creams, the study showed that nearly half of the patients were using creams that contained a mix of an antifungal and a strong steroid. Steroids are powerful anti-inflammatory drugs that reduce redness and itching, but they do not kill fungus. In fact, when used on a fungal infection, they can hide the symptoms and allow the fungus to grow unchecked, a condition known as tinea incognito. The most common steroid found in these mixtures was clobetasol propionate. These combination creams were used for an average of 7.2 weeks, but some patients had been using them for as long as 52 weeks. The study found that these steroid-containing creams were most often recommended by pharmacy salesmen rather than doctors, and they were frequently sold without a prescription.

The researchers concluded that the current way people in Bangladesh are treating skin fungus is deeply flawed. The unrestricted sale of antifungal pills and steroid creams by untrained sellers is driving a cycle of ineffective treatment. Patients are taking the wrong drugs, using them for too long, or combining them in ways that do not work. This behavior is not just failing to cure the current infection; it is likely contributing to the rise of drug-resistant fungi that are harder to treat in the future. The study highlights an urgent need for regulators and policymakers to step in. Without changes to how these medicines are sold and prescribed, the problem of stubborn, recurring skin infections will likely continue to grow, leaving patients in distress and doctors with fewer effective tools to help them.