Abstract
Abstract
Objectives
The aim of this study was to determine the prevalence of groin rash among Thai military personnel and to identify associated risk factors, clinical features and patient perceptions. We also evaluated care-seeking behaviour and treatment practices.
Design
Cross-sectional, questionnaire-based study.
Setting
Conducted among Thai military personnel in a tropical environment.
Participants
A total of 500 male military personnel were recruited between August 2022 and September 2023. Of these, 475 participants were included in the analysis, while 25 were excluded due to non-participation in field training. Eligibility was restricted to those actively engaged in field exercises at the time of study.
Interventions
Not applicable.
Primary and secondary outcome measures
Primary outcome was the prevalence of groin rash, defined by self-report aided by standardised clinical images. Secondary outcomes included risk factors, rash morphology, symptom severity, treatment practices and healthcare-seeking behaviour. Associations were analysed using multivariable logistic regression adjusted for age, body mass index (BMI) and other covariates.
Results
Lifetime prevalence of groin rash was 22.3% (106/475), and the point prevalence was 3.8% (18/475). Among those with rash, 39.6% were classified as probable fungal infections. Independent risk factors included reusing underwear (aOR 2.25; 95% CI 1.27 to 3.99; p=0.005) restricted bathing time (aOR 1.73; 95% CI 1.06 to 2.83; p=0.030) and higher BMI (aOR 1.10; 95% CI 1.02 to 1.42; p=0.030). Most affected participants (54.7%) reported minimal impact on daily life, and only 18.9% sought professional care. Self-medication was common, with 50% using topical over-the-counter antifungals alone, while 16% used a combination of oral and topical drugs. Relapse occurred in 36.1% of cases.
Conclusions
Groin rash is relatively common among young Thai military personnel and is associated with modifiable hygiene-related factors. Only a small proportion of affected individuals appear to present for medical evaluation. Educational interventions emphasising regular laundering and adequate bathing during training may assist in reducing its prevalence.
Keywords: Dermatology, Adult dermatology, Infectious diseases & infestations
STRENGTHS AND LIMITATIONS OF THIS STUDY.
The study used a validated, structured questionnaire that covered a wide range of variables including demographic data, medical history and detailed rash characteristics.
The aim of this study was to focus on a specific high-risk group in a tropical environment—Thai military personnel involved in field training exercises—providing relevant insights into this unique population.
The study’s cross-sectional nature limited the ability to establish causal relationships between identified risk factors and groin rash development.
Introduction
Fungal infections of the skin are frequently encountered, with a prevalence ranging from 20% to 25%, particularly in hot and humid tropical regions where conditions favour fungal growth.1
Certain population groups, such as military personnel, are at an elevated risk of developing fungal skin infections due to their living and working conditions.2,4 This increased risk is attributed to the potential transmission of fungal pathogens through contact with contaminated soil, animals or the proximity of infected individuals. Consequently, factors such as military training and residing in densely populated settings, including shared facilities such as communal bathrooms, can increase the susceptibility to contracting fungal infections. Furthermore, wearing tight-fitting uniforms and limited opportunities to maintain personal hygiene can further exacerbate the risk of fungal infections within the military.3
A previous study conducted in the military environment has revealed that more than 60% of people experience at least one form of skin infection, with fungal infections of the feet being the most prevalent, affecting 15.2% of people. Tinea cruris was less common, with a prevalence rate of 2.7%, but was associated with overall quality of life among military personnel.5
The fungal pathogens responsible for infections in the military closely resemble those found in the general population, primarily belonging to the Trichophyton group. Trichophyton rubrum is the pathogen most frequently encountered, followed by T. tonsurans, T. verrucosum, T. interdigitale, T. mentagrophytes and Microsporum canis. In cases of tinea cruris, Epidermophyton floccosum46,9 has been reported more frequently and, in certain studies, was the sole pathogen identified in this region.7 10
Previous studies have reported on the prevalence and risk factors associated with fungal infections, particularly tinea pedis, among Thai military and police personnel. These risk factors include male sex, inadequate personal hygiene, training conditions and infrequent sock changes.3 11 12 Tinea cruris is a common cause of rashes in the groin area, primarily due to moisture and humidity. However, research on the prevalence and risk factors for tinea cruris among military personnel remains relatively limited.
This study aims to assess the prevalence and risk factors associated with groin rash among military personnel, along with awareness of disease management, which is crucial to assess and manage this problem effectively. Possessing accurate knowledge and a clear understanding of treatment options and preventive measures can greatly contribute to reducing the risk of future groin rashes and fungal infections.
Materials and methods
During the period from August 2022 to September 2023, a cross-sectional study involved Thai military personnel who were actively participating in field training exercises. This study received approval from the Siriraj Institutional Review Board of Siriraj Hospital, Mahidol University, located in Bangkok, Thailand (EC COA no. Si 222/2022). Prior to their participation, all individuals were fully informed about the purpose and procedures of the study and were asked to provide their consent. Military personnel who did not participate or were currently engaged in ongoing field training exercises were not included in the study.
Each participant was required to complete a structured questionnaire (online supplemental figure 1) that covered various aspects, including personal information, underlying medical conditions, medical history, characteristics, symptoms and itch intensity, which was assessed through a visual analogue scale to assess the impact of these symptoms on their quality of life. Additionally, the questionnaire included images depicting various types of rashes, including but not limited to tinea cruris, to ensure comprehensive coverage of potential skin conditions. These images were carefully selected to represent typical visual representations, allowing participants to recognise and differentiate various dermatological conditions such as candidiasis and psoriasis. Images presenting scaly, annular rashes in the questionnaire were classified as ‘probable fungal infection’, whereas images lacking these characteristic features were classified as ‘not likely fungal infection’. Participants were also asked about their previous treatments for rashes in the groin and adjacent areas. The structured questionnaire underwent a thorough development and validation process by a panel of experts and was pre-tested among a group of draftees. It had also been previously used and tested in an earlier study assessing superficial fungal infections among Thai naval cadets, confirming its reliability and applicability in a military population context.10
Statistical methods
Descriptive statistics, encompassing parameters such as mean and frequency, were used to summarise demographic data, predisposing factors and clinical characteristics. Binary logistic regression was applied to estimate the OR of a binary response based on predictor (or independent) variables. A p value of less than 0.05 indicates statistical significance. Additionally, we calculated the OR and a 95% CI for each pertinent variable. Univariable analysis was performed to assess the association between each independent variable and the presence of groin rash, using appropriate statistical tests based on the variable type. Variables with a p value of 0.05 in the univariable analysis were considered statistically significant and subsequently included in the multivariable logistic regression model. The enter method was applied to include all significant variables simultaneously in the multivariable analysis to identify independent predictors of groin rash. Adjusted odds ratios (aORs) with 95% CIs were reported. Statistical significance was defined as a two-tailed p value of <0.05. The primary outcome of interest was the presence of groin rash, assessed through self-report and recorded as a binary variable (yes/no). Independent variables comprised both continuous and binary data. Continuous variables included age, weight, height and body mass index (BMI). Binary variables included sex, the presence of comorbidities and specific risk factors, with the absence of each binary characteristic designated as the reference category in subsequent analyses. All statistical analyses were performed using SPSS for Windows version 18.0 software (SPSS, Inc., Chicago, IL, USA).
Results
The questionnaire was distributed to 531 military personnel. Of these, 500 participants responded, yielding a response rate of 94.1%. The study ultimately included 475 male individuals who were actively participating in field training exercises, while 25 were excluded because they were not engaged in training activities at the time of data collection. Demographic data and risk factors for 475 participants are shown in table 1. The mean age was 22.4±1.3 years, and the mean BMI was 22.7±3.4 kg/m². A notable proportion reported a family history of tinea infection (28.0%), sweaty skin (66.9%) and underwear reuse (25.0%). Contact with soil (76.0%) and animals (68.2%) was also common among participants. The survey revealed various bathing habits, including time limitations (29.7%).
Table 1. Demographic data of the survey participants (n=475).
| Demographic data | N (%) |
|---|---|
| Mean age±SD (year) | 22.4±1.3 |
| BMI±SD (kg/m2) | 22.7±3.4 |
| Comorbidities† | |
| Atopy | 17 (3.6) |
| Autoimmune diseases | 6 (1.3) |
| Diabetes mellitus | 2 (0.4) |
| Hypertension | 1 (0.2) |
| Others* | 3 (0.6) |
| Risk factors | |
| Immunosuppressive drugs or systemic steroids | 17 (3.6) |
| Family history of tinea infection | 20 (4.2) |
| Sharing towel | 133 (28.0) |
| Very frequently | 2 (0.4) |
| Frequently | 5 (1.1) |
| Occasionally | 45 (9.5) |
| Rarely | 81 (17.1) |
| Sweaty skin | 318 (66.9) |
| Very frequently | 82 (17.3) |
| Frequently | 72 (15.2) |
| Occasionally | 113 (23.8) |
| Rarely | 51 (10.7) |
| Underwear reuse | 119 (25.0) |
| Very frequently | 5 (1.1) |
| Frequently | 6 (1.3) |
| Occasionally | 33 (6.9) |
| Rarely | 75 (15.8) |
| Wear tight clothing | 268 (56.4) |
| Very frequently | 12 (2.5) |
| Frequently | 17 (3.6) |
| Occasionally | 104 (21.9) |
| Rarely | 135 (28.4) |
| Contact with soil | 361 (76.0) |
| Very frequently | 106 (22.3) |
| Frequently | 69 (14.5) |
| Occasionally | 121 (25.5) |
| Rarely | 65 (13.7) |
| Contact with an animal | 324 (68.2) |
| Very frequently | 65 (13.7) |
| Frequently | 47 (9.9) |
| Occasionally | 127 (26.7) |
| Rarely | 85 (17.9) |
| Bathing time limitations | 141 (29.7) |
| Very frequently | 4 (0.8) |
| Frequently | 5 (1.1) |
| Occasionally | 45 (9.5) |
| Rarely | 87 (18.3) |
| Presence of rash | |
| Currently present | 18 (3.8) |
| Present in the past but not anymore | 88 (18.5) |
| Never | 369 (77.7) |
| Prevalence of groin rash | |
| Point prevalence of groin rash | 18 (3.8) |
| Lifetime prevalence of groin rash | 106 (22.3) |
| Visit doctor (n=106) | 20 (18.9) |
| Factors for patients not to see a doctor (n=86) | |
| Busy schedules | 29 (33.7) |
| Financial constraints | 12 (14.0) |
| Shame or embarrassment | 11 (12.8) |
| Minimal impact on daily life | 47 (54.7) |
One patient can have more than one comorbidity and reason to not see a doctor.
Other diseases include G6PD deficiency, major depressive disorder and unspecified gastrointestinal disease.
BMI, body mass index.;
Furthermore, the presence of rash was reported, with 3.8% currently experiencing a rash, 18.5% having had a rash in the past and 77.7% never having had a rash. The point prevalence of groin rash was 3.8%, and the lifetime prevalence was 22.3%. Among those with a history of rash, 18.9% sought medical attention, while 54.7% reported minimal impact on daily life as a reason for not seeking medical care.
Table 2 outlines the demographic characteristics and clinical characteristics of the 106 participants with groin rash. The mean age was 22.6±1.3 years, and the mean BMI was 23.4±3.6 kg/m². The majority, comprising 53 participants (50.0%), used topical over-the-counter drugs (OTC) alone, while 17 participants (16.0%) used a combination of topical and oral OTC medications. A small proportion, two individuals (1.9%), reported using oral OTC drugs alone. When evaluating responses to OTC treatment among the 72 participants, various outcomes were observed. 50% of the participants (36 individuals) experienced complete resolution of their condition. A significant proportion, 36.1% (26 participants), reported initial improvement but with subsequent relapse. Furthermore, 8.3% of the participants (six individuals) exhibited partial improvement, while 4.2% (3 participants) reported a stable state with no significant change. A minority, 1.4% (1 participant), indicated a worsening of their condition despite OTC treatment.
Table 2. Demographic data of patients with groin rash (n=106).
| Demographic data | N (%) |
|---|---|
| Mean age±SD (year) | 22.6±1.3 |
| Mean weight±SD (kg) | 69.6±11.6 |
| Mean height±SD (m) | 172.3±5.5 |
| Mean BMI±SD (kg/m2) | 23.4±3.6 |
| Previous history of OTC drugs | |
| No | 34 (32.1) |
| Topical alone | 53 (50.0) |
| Topical and oral | 17 (16.0) |
| Oral alone | 2 (1.9) |
| Response to OTC (n=72) | |
| Complete cure | 36 (50.0) |
| Cure with relapse | 26 (36.1) |
| Partially cured | 6 (8.3) |
| Stable | 3 (4.2) |
| Worsened | 1 (1.4) |
| Morphology | |
| Probable fungal infection | 42 (39.6) |
| Not likely fungal infection | 64 (60.4) |
| Location | |
| Groin and genitalia | 34 (32.1) |
| Genitalia only | 7 (6.6) |
| Spread but in underwear | 50 (47.2) |
| Spread beyond underwear | 15 (14.2) |
| Distribution | |
| Unilateral | 40 (37.7) |
| Bilateral | 62 (58.5) |
| Genitalia only | 4 (3.8) |
| Onset of duration | |
| <2 weeks | 59 (55.7) |
| 2 weeks–2 months | 25 (23.6) |
| 2–6 months | 7 (6.6) |
| 6 months–2 years | 7 (6.6) |
| 2–5 years | 4 (3.8) |
| >5 years | 4 (3.8) |
| Severity of itch | |
| No itch | 17 (16.0) |
| Mild itch | 45 (42.5) |
| Moderate itch | 35 (33.0) |
| Severe itch | 9 (8.5) |
BMI, body mass index; OTC, over-the-counter.
The morphology of the rash varied, with 39.6% identified as probable fungal infection. The rash most affected the groin and genitalia (32.1%) and was present bilaterally (58.5%). Itch severity ranged from no itch (16.0%) to severe itch (8.5%).
In table 3, the continuous variables—namely, age, weight, height and BMI—are presented as means, whereas the categorical variables—namely, the comorbidities and risk factors—are expressed in frequencies and percentages. These categorical variables were coded as binary, with the ‘no’ or ‘absence’ category used as the reference and were also included in the binary logistic regression analysis. In the multivariate analysis adjusted for age, weight, BMI, family history of tinea infection, sharing towels, sweaty skin, reusing underwear, tight clothing and bathing time limitations, a higher BMI emerged as a significant factor (aOR 1.10, 95% CI 1.02 to 1.42, p=0.030). The odds of developing a groin rash among military personnel who reuse underwear are more than double the odds among those who do not reuse underwear (aOR 2.25, 95% CI 1.27 to 3.99, p=0.005). Furthermore, limitations in bathing time exhibited a significant association with groin rash (aOR 1.73, 95% CI 1.06 to 2.83, p=0.030).
Table 3. Risk factor associated with groin rash (n=475).
| Presence of groin rash (%) (n=106) | No groin rash (%) (n=369) |
Univariate analysis | Multivariate analysis | |||
|---|---|---|---|---|---|---|
| Crude OR (95% CI) |
P value | Adjusted OR‡ (95% CI) |
P value | |||
| Mean age±SD (years) | 22.6±1.3 | 22.3±1.3 | 1.19 (1.01 to 1.39) | 0.036* | 1.18 (0.99 to 1.40) | 0.055 |
| Mean weight±SD (kg) | 69.6±11.6 | 66.9±10.9 | 1.02 (1.01 to 1.04) | 0.029* | 1.19 (0.80 to 1.41) | 0.053 |
| Mean height±SD (m) | 172.3±5.5 | 172.5±6.0 | 0.99 (0.96 to 1.03) | 0.692 | – | – |
| Mean BMI±SD (kg/m2) | 23.4±3.6 | 22.4±3.3 | 1.09 (1.02 to 1.16) | 0.009* | 1.10 (1.02 to 1.42) | 0.030* |
| Comorbidities† | 10/106 (9.4) | 21/369 (5.7) | 1.73 (0.78 to 3.79) | 0.174 | – | – |
| Atopy | 5 (4.7) | 12 (3.3) | 1.47 (0.51 to 4.28) | 0.477 | – | – |
| Autoimmune diseases | 2 (1.9) | 4 (1.1) | 1.76 (0.32 to 9.72) | 0.520 | – | – |
| Diabetes mellitus | 0 (0.0) | 2 (0.5) | – | 1.000 | – | – |
| Hypertension | 1 (0.9) | 0 (0.0) | – | 1.000 | – | – |
| Others | 2 (1.9) | 1 (0.3) | 7.08 (0.64 to 78.8) | 0.112 | – | – |
| Risk factors | ||||||
| Immunosuppressive drugs or systemic steroids | 7 (6.6) | 10 (2.7) | 2.54 (0.94 to 6.84) | 0.065 | – | – |
| Family history of tinea infection | 9 (8.5) | 11 (3.0) | 3.02 (1.22 to 7.49) | 0.017* | 1.84 (0.68 to 4.97) | 0.231 |
| Sharing towels | 43 (40.6) | 90 (24.4) | 2.12 (1.34 to 3.33) | 0.001* | 1.24 (0.72 to 2.13) | 0.444 |
| Sweaty skin | 82 (77.4) | 236 (64.0) | 1.95 (1.16 to 3.18) | 0.011* | 1.06 (0.58 to 1.92) | 0.860 |
| Underwear reuse | 44 (41.5) | 75 (20.3) | 2.78 (1.75 to 4.42) | <0.001* | 2.25 (1.27 to 3.99) | 0.005* |
| Wear tight clothing | 71 (67.0) | 197 (53.4) | 1.77 (1.13 to 2.79) | 0.014* | 1.15 (0.67 to 1.96) | 0.606 |
| Contact with soil | 78 (73.6) | 283 (76.7) | 0.85 (0.52 to 1.39) | 0.509 | – | – |
| Contact with an animal | 77 (72.6) | 247 (66.9) | 1.31 (0.81 to 2.12) | 0.267 | – | – |
| Restricted daily bathing time | 47 (44.3) | 94 (25.5) | 2.33 (1.49 to 3.65) | <0.001* | 1.73 (1.06 to 2.83) | 0.030* |
OR was adjusted with age, weight, BMI, family history of tinea infection, shared towel, damp skin, reuse of underwear, tight clothing and bathing infrequently.
Significant difference at the P value <0.05.
One patient can have more than one comorbidity.
Discussion
This study focuses on groin rash, particularly tinea cruris, in a specific population: Thai military personnel, where the prevalence and risk factors for these infections are explored in depth.
This study demonstrated a lifetime prevalence of groin rash affecting 22.3% of individuals at some point in their lives. This finding underscores the persistence and recurrence of groin rash, contributing significantly to the overall health impact on the population. A notable 3.8% of individuals engaged in field training had active groin rashes, indicating an existing burden of this dermatological condition among military men. By comparison, a point-prevalence survey of Korean soldiers found that 60.4% had more than one skin disease, of which 19.4% were fungal infections. The prevalence of tinea pedis, tinea cruris, tinea corporis and onychomycosis in the report was 15.2%, 2.7%, 0.6% and 0.9%, respectively.5 In the Bangladeshi armed forces, dermatophytosis affected 39% of personnel, of which tinea cruris accounted for 19%.13 The findings highlight the importance of addressing groin rash as a prevalent and recurrent problem, necessitating comprehensive interventions for both active cases and individuals with a history of the condition. Targeted strategies, including preventive measures and timely medical interventions, are crucial to mitigate the impact and reduce the prevalence of groin rash in the long term.
This study identified various risk factors associated with groin rash, including a family history of tinea infection, towel sharing, sweaty skin, reuse of underwear, wearing tight clothing and limited bathing time. These factors mirror those reported in studies focusing on fungal infections in military environments globally.3 4 11 12 Male sex, inadequate personal hygiene practices, training conditions and infrequent sock changes are recurring themes, emphasising the need for tailored interventions. In the multivariate analysis adjusted for various factors, BMI emerged as a significant factor associated with groin rash. The practice of reusing underwear was also identified as an important risk factor. Furthermore, limitations in bathing time exhibited a significant association with groin rash, highlighting the role of personal hygiene habits in the prevention of dermatological conditions.
Interestingly, in this study, the prevalence of probable fungal infections was 3.3%, a slightly higher figure compared with a previously published report in South Korea,5 which reported a prevalence of 2.7%. This difference could be attributed to the more humid climate in this study region. A global review of tropical and subtropical regions reported tinea cruris prevalence rates exceeding 20–25% in areas where high heat and humidity prevail,14 suggesting a potential environmental influence on the incidence of these fungal infections.
Examining perceptions and behaviours related to groin rash revealed that among those with a history of rash, only 18.9% sought medical attention. This parallels findings from Korean military units, where merely 22% of soldiers with skin complaints sought dermatologic consultation despite significant impairment in quality of life.5 This low consultation rate may be influenced by multiple factors identified in the study. More than half (54.7%) perceived minimal impact on daily life, suggesting a lack of awareness of the potential complications of untreated fungal infections. Additionally, 33.7% cited busy schedules as a barrier, highlighting the need for healthcare services to accommodate the demanding lifestyles of military personnel. Financial constraints (14.0%) and feelings of shame or embarrassment (12.8%) also contributed to the reluctance to seek medical care. These behavioural findings emphasised the need for targeted educational initiatives to increase awareness of the possible consequences of untreated groin rash and to encourage early medical intervention. Such strategies should encompass educational campaigns, flexible healthcare services and efforts to destigmatise dermatological conditions, with particular attention to the unique challenges faced by military personnel.
Furthermore, this study highlights the widespread use of OTC medications, with the majority opting for topical OTC drugs alone. This finding corresponds with a nationally representative survey of superficial fungal infections in the USA, 55.5% of patients self-medicated with OTC antifungal agents, yet nearly a quarter (24.0%) reported treatment failure, and 28.7% experienced complications such as relapse or local irritation.15 These findings underscore the importance of understanding and addressing the motivations behind OTC drug use in this population. Responses to OTC treatment revealed various outcomes, ranging from complete resolution to relapse or persistent symptoms. This variation in treatment responses highlights the complexity of managing groin rash and suggests potential areas for targeted interventions to improve treatment efficacy.
The cross-sectional design of the study limits the ability to establish causal relationships between identified risk factors and the development of groin rash among military personnel. Longitudinal cohort studies would provide a more robust understanding of the temporal sequence of events. The diagnosis and severity of groin rash were based on self-reported data, and no clinical evaluations were performed. Furthermore, this study did not extensively explore the microbiological characteristics of the fungal pathogens responsible for the groin rash. External factors and potential confounders, such as specific occupational exposures, use of personal protective equipment and geographic variations in fungal prevalence, were not assessed. These factors may contribute to the development of a groin rash and should be considered in future research.
Further research is essential to fully understand the various aspects of groin rash, facilitating the development of effective preventive and therapeutic strategies. It is essential to develop comprehensive strategies to mitigate the impact of groin rash and improve the overall health and well-being of military personnel.
Conclusion
This study not only reveals the prevalence and clinical characteristics of groin rash among Thai military personnel but also provides valuable insights into the perceptions, behavioural patterns and treatment outcomes associated with this dermatological concern. The findings highlight the importance of behavioural factors, particularly the tendency of individuals to avoid seeking medical care and instead rely on OTC treatments. This underscores the need for targeted educational efforts to raise awareness, address misconceptions and encourage timely medical intervention within this population.
Supplementary material
Acknowledgements
The authors express gratitude to Mr. Suttipol Udompunthurak for his invaluable statistical analysis consultation provided for this study and to Prynn Manuskiatti and Apichaya Ketyungyoenwong for their insightful support in revising and improving the clarity of the manuscript.
Footnotes
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Pre-publication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2024-091553).
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Ethics approval: This study involves human participants and was approved by the Siriraj Institutional Review Board of Siriraj Hospital, Mahidol University, located in Bangkok, Thailand (EC COA no. Si 222/2022). Participants gave informed consent to participate in the study before taking part.
Patient and public involvement: Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Data availability statement
Data are available upon reasonable request.
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