Chromoblastomycosis in resource-limited settings: a review

Abstract

Chromoblastomycosis is a chronic skin-related neglected tropical disease caused by melanized (dematiaceous) fungi, predominantly from the Fonsecaea and Cladophialophora species. The disease primarily affects individuals in tropical and subtropical areas, especially those engaged in soil-related occupations. Infection typically ensues following the traumatic introduction of fungal elements into the skin through contaminated plant or soil. This disease exhibits a polymorphic clinical picture. Early manifestations include erythematous patches or small papules, which may gradually develop into nodules, verrucous (warty) plaques, tumorous growths, or scarring lesions. These lesions may be associated with itching, localized pain, and the presence of characteristic black dots on the surface. Without timely intervention, lesions can become disfiguring and complicated by disabling tissue fibrosis, secondary infections, lymphedema, and rarely, malignant transformation (squamous cell carcinoma). The global disease burden observation indicates that the prevalence of chromoblastomycosis varies by region, with certain areas in the world reporting higher rates, particularly Latin America, Africa, and Asian countries. However, the true burden is likely underestimated due to clinical underdiagnoses and a lack of a health surveillance system. Diagnosis relies on a combination of clinical suspicion and identification of muriform cells through direct microscopy, histopathological analysis, and fungal culture. Molecular techniques are increasingly used for precise species identification where it is feasible. Treatment strategies depend on the severity and extent of the disease. Mild cases are managed surgically, and advanced-stage infections usually require prolonged antifungal treatment with itraconazole or terbinafine. These two antifungal agents are commonly used to treat this condition, and some observational studies strongly recommend them as effective first-line therapies against chromoblastomycosis. Additionally, refractory chromoblastomycosis often benefits from combination antifungal therapy and adjunctive treatments. Preventive strategies emphasize the use of protective clothing and the avoidance of skin trauma during outdoor work in the most vulnerable or endemic countries. In resource-limited settings, such as Ethiopia and other parts of the world, prevention faces several challenges, including delayed diagnosis, poor treatment adherence, and lack of community awareness, all of which contribute to chronicity, disability, and poor quality of life. To improve outcomes, it is still critical to strengthen early detection, raise community awareness, and make antifungal therapy more accessible. This review summarizes the epidemiology, pathogenesis, diagnosis, treatment, and prognosis of chromoblastomycosis in resource-limited settings to raise awareness or equip healthcare professionals with the knowledge needed to improve early diagnosis and treatment.