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Tinea capitis is unusual in postpubertal individuals and is frequently misdiagnosed. In cases of inflammatory disease, prompt initiation of therapy is essential to prevent scarring and permanent hair loss. Two examples are presented to illustrate principles of evaluation and treatment.
Tinea capitis is rare in the elderly. We report cases of two elderly women who presented to our dermatology clinic within 8 weeks of each other, with scalp scaling and alopecia. In both cases, Microsporum canis grew on fungal culture of their hair, and required prolonged treatment with terbinafine. Neither of them gave a history of contact with young children or any animals. Both were fairly fit and not systemically immunocompromised. However, both had been regularly visiting the same hairdresser, during the presumed period of infectivity, making this the most likely source of infection.
BACKGROUND: Tinea capitis, a fungal infection of the scalp, is of increasing public health importance, and Trichophyton tonsurans has become the primary causative agent in North America. OBJECTIVES: To determine the prevalence of dermatophyte-positive scalp cultures among elementary schoolchildren in Cleveland, Ohio, describe predisposing factors, and measure the antifungal susceptibility of isolates collected. OBSERVATIONS: A total of 937 children from 8 Cleveland elementary schools were cultured for the presence of dermatophytes; 122 children (13%), all of whom were African American, had dermatophyte-positive cultures of the scalp. Sixty percent of cases were asymptomatic, indicating a carrier state. Race, scaling, and the use of anti-dandruff shampoo were associated with increased likelihood of infection. T tonsurans was the only organism isolated (except 1 Microsporum canis isolate). All isolates were susceptible to fluconazole, griseofulvin, itraconazole, and terbinafine. CONCLUSIONS: T tonsurans was the predominant dermatophyte isolated. Further multicenter studies are needed to confirm the predominance of dermatophyte-positive scalp cultures among African American children and to determine modifiable and preventable risk factors.
OBJECTIVE: To evaluate the accuracy of the cotton swab technique for identifying fungal infections of the scalp. The purpose of the study was: 1) to compare the cotton swab technique with the toothbrush method, a popular and reliable means for obtaining specimens; and 2) to ascertain if transport of a specimen, entailing variable transport duration and conditions, impairs the sensitivity and specificity of the technique. MATERIALS AND METHODS: Part 1 consisted of a prospective, investigator-blinded comparison analysis. Fifty children with scalp findings suspicious for tinea capitis were cultured using both techniques: the toothbrush and cotton swab. Ninety-six culture results were obtained for analysis. The second part of the study consisted of a prospective comparison analysis of cotton swab culture results obtained from samples plated immediately after collection in the physician's office as compared with samples transported to outside laboratories for processing. Thirty-one children with presumed tinea capitis were cultured twice with the cotton swab technique; one sample was immediately plated onto fungal medium and the other sent to an outside lab, the selection of which was dictated by the patient's insurance plan. A total of 62 samples were obtained; 58 sample results were used for analysis. RESULTS: In part 1 of the study, 60% of the 48 children analyzed had positive fungal cultures. Eighty percent of these were Trichophyton species. There was 100% agreement in the results obtained; all patients with positive results using the toothbrush method were also positive when the cotton swab method was used. Similarly, there was complete concordance in laboratory results from the second part of the study. Fifty percent of the 28 children analyzed had positive cultures; 86% grew Trichophyton species. All patients who had positive cultures from those samples plated in-office also had positive results from the outside laboratory samples. CONCLUSIONS: The cotton swab technique is an easy, atraumatic, inexpensive, and reliable means to evaluate patients with suspected tinea capitis. The method remains sensitive and specific even when transport of these specimens is required and processing is thus delayed. This painless technique requires little technical expertise and can be rapidly performed with a standard cotton tip applicator. It should prove an invaluable aid to practitioners in evaluating patients with possible fungal infections of the scalp.
A school survey of 4461 primary-school children was carried out in which 204 cases of tinea capitis were clinically diagnosed. All cases were cultured and examined microscopically in order to compare the validity of the two methods. Microscopy detected 92 positive cases (45.1%), whereas culture detected 105 cases (51.4%). We also isolated and identified the species causing tinea capitis in our sample. These included Trichophyton verrucosum (38 cases), T. rubrum (22 cases), T. mentagrophytes var. mentagrophytes (12 cases) and T. tonsurans (11 cases). Our results are compared with other studies.
We undertook a randomized double-blind comparison of griseofulvin and ketoconazole for the treatment of tinea capitis. The outcome was based on fungal culture results and changes in clinical signs and symptoms determined by an assessment system that yielded a severity score. Patients were evaluated at 4-week intervals for 12 weeks. Seventy-nine patients were enrolled; 46 received griseofulvin, and 33 received ketoconazole. Forty-eight patients (26 griseofulvin, 22 ketoconazole) were considered evaluable. Pathogenic fungi were isolated from 78% of the enrolled and 87% of the evaluable patients. Trichophyton tonsurans was the predominant dermatophyte isolated. Potassium hydroxide preparation correlated poorly with culture results (sensitivity 59%). Of 22 evaluable ketoconazole patients, 16 (73%) were considered to have been treated successfully; 25 of 26 (96%) patients who received griseofulvin were successfully treated (chi-square = 3.54, p less than 0.10). The proportion of culture-positive patients at each follow-up visit appeared somewhat greater for the ketoconazole-treated group than for the griseofulvin-treated group, but the differences were not statistically significant. Analysis of severity scores revealed no significant differences between the groups (t test and Mann-Whitney U test). No significant hepatotoxicity or other adverse reactions were observed. We conclude that griseofulvin should remain the drug of choice for treating tinea capitis.
BACKGROUND: Subsequent to detection of several cases of anthropophilic tinea capitis, we wanted to know whether the legal decree requiring eviction from school and an epidemiology survey in the children community or the family is implemented properly. METHODS: Two sample surveys were carried out among 50 school doctors from the Hauts-de-Seine department and 110 dermatologists working the Paris suburbs. RESULTS: Eviction from school was rare and not based on the type of dermatophytes (anthropophilic or zoophilic agent). Likewise, epidemiology survey was neglected, often being solely clinical for other family members. Systematic sampling in the children community or in the family was very exceptional. DISCUSSION: Despite the rise in the number of cases of anthropophilic tinea capitis in Paris suburbs, the decree is not often implemented. Dermatologists would appear to be responsible for this situation, especially in case of M. langeronii, which is very contagious in nursery school.
From among 428 Nepalese schoolchildren hair samples of 102 children with clinical features of tinea capitis, obtained by the sterile hairbrush method, were examined by mycological techniques. Age varied between 4-16 years. Itching was experienced by 96.1% sample subjects and hair loss by 32.4%. Of the 102, 11 (10.8%) were positive for Trichophyton violaceum (TV), 6 being from urban areas, the rest from rural areas. Amongst the 11 patients, 7 (63.6%) were girls and rest boys. Statistical associations were observed between the place of haircut and isolation of the organism (chi2 = 15.2, p <0.01). Statistical association was also present between frequency of bathing and isolation of organism. Sharing of combs was associated with the culture-positive subjects. The prevalence of tinea capitis in the urban and rural children was 2.3% and 3.0%, respectively. The only isolated organism was TV. An association of the isolation of TV was found with risk factors such as family members, sharing of combs, frequency of bathing with the organism. Hair loss was more common in the urban children. Discouragement of sharing combs, increased frequency of hair washing, and use of uncontaminated hair cutting instruments are recommended.
The authors report the results of a study carried out on tinea capitis, in the Department of Dermatology and Venerology at the University Hospital of Donka in Conakry, during one year In this department, the tinea capitis represents 3.2% of the consultations and remains the second mycosis. Out of 414 consulted children, a male predominance of 75% was noted especially regarding the Trichophytic tinea. School children aged of 6-14 years old are the most affected by the disease. The trichophytic tinea is widely spread with 65.5% more than the microsporic 17% and inflammatory tinea 16.5%. The mixed tinea is exceptional and no case of favus has been found. The Trichophyton violaceum is the most dermatophyte to be found 56.70% whereas a survey carried out in 1959 showed the predominance of T. soudanense and M. audouini. The Microsporum canis and an association of M. canis and T. violaceum are also to be found.
A school survey of 4461 primary-school children was carried out. The epidemiological, clinical and mycological features of tinea capitis were recorded. Of 204 clinically diagnosed cases, mycological examination of hair and scalp scrapings gave positive results in 120, a prevalence of 2.7%. Of these 120, 56 were from urban schools and 64 from rural schools. The male to female ratio was 2:1. The prevalence of tinea capitis was higher in children with a low socioeconomic profile, i.e. low standard of living, poor hygiene, low level of parental education and overcrowded living conditions. Intrafamilial infection was found in 27.5% of cases and new settlers to the area accounted for 23.3% of total cases.
We report a randomized, double-blind study, comparing the relative efficacy and tolerability of oral terbinafine, given for 1, 2 or 4 weeks, in tinea capitis. Of 161 evaluable patients, 53 were treated with terbinafine for 1 week, 51 for 2 weeks and 57 for 4 weeks. Isolated pathogens included Trichophyton violaceum (71.5%), T. tonsurans (14.9%), T. verrucosum (4.3%), Microsporum audouinii (4.3%), M. canis (2.5%), T. schoenleinii (1.9%) and T. mentagrophytes (0.6%). The final evaluation, at 12 weeks, showed cure rates of 73.6, 80.4 and 85.9%, in the respective groups. The adverse effects noted, were not drug related. In our opinion, terbinafine given for 1, 2 or 4 weeks, is equally effective for most cases of tinea capitis.
A study of 50 patients with tinea capitis revealed that it affects school children of low socioeconomic status. Clinical diagnosis of grey patch, black dot, seborrheic, kerion, and pustular inflammatory varieties was made. In all, 37 cultures were positive for dermatophytes, wherein most were Trichophyton violaceum. Some grew T. rubrum, T. mentagropytes, and T. verrucosum. A correlation between the clinical variants and fungi was also attempted.
Between 1973 and 1994, 17 cases of tinea capitis in adults were observed in the Dermatology Clinic of the University of Cagliari (Italy). The patients were all women (age range 17-76 years) and came from the district of Cagliari. At the time of referral, they presented with a disease duration varying from 8 to 10 months. The main clinical feature was scalp lesions, but in two cases mycotic lesions on the face were also present. The following dermatophytes were isolated: Microsporum canis (eight cases), Trichophyton violaceum (four cases), Trichophyton mentagrophytes (four cases) and Trichophyton verrucosum (one case). Systemic treatment with griseofulvin or terbinafine led to complete recovery in 40-50 days. In discussing the pathogenesis and transmission mode of the disease, the authors hypothesize that endocrine disorders influencing the secretion and composition of sebum may facilitate dermatophyte invasion of the scalp in the adults.
Forty patients with an average age of 6.5 +/- 3.2 years (28 male 12 female) who applied to the YYU Medical Faculty Dermatology Department outpatient clinic were investigated. Tinea capitis profunda was determined as the most frequent clinical type. The isolated dermatophytic flora of the patients consisted of Trichophyton verrucosum (43%), T. violaceum (30%), T. rubrum (23%) and T. mentagrophytes (3%). The patients with tinea capitis profunda were mostly from rural areas.
Itraconazole 5 mg/kg/day given as pulse therapy, each of 1 week duration, for 1 to 3 pulses appears to be an effective and safe method of treating tinea capitis. The number of pulses of therapy may depend upon several factors, including the severity of disease and area of involvement. Controlled studies are needed to determine the number of pulses of itraconazole required to treat tinea capitis.
A prospective, non-randomized, open clinical trial was conducted to determine the efficacy of itraconazole for treatment of Microsporum ferrugineum tinea capitis. Itraconazole capsules were given every day in continuous group and every day for 1 week on and 3-week off in pulse therapy group. Concomitant topical therapy with 2% ketoconazole shampoo was used daily. Clinical evaluation consisted of assessing the degree of hair loss, scaling, erythema, pustule, and crust. In both groups, the treatment was stopped when the clinical signs of inflammation had resolved and the mycological examination had become negative or at week 12. There were 81 patients consisted of 49 boys and 32 girls enrolled and average dose of itraconazole was 4.5 mg/kg/day. During the 16-week study period (with 4-week follow-up visit) the overall clinical severity score decreased every visit (p < 0.001). The improvement of the scores showed no statistical difference between both groups. The cumulative cure rate using combined clinical and mycological cure at week 16 in patients treated with continuous and pulse regimen was 54.3% (19/35) and 37.0% (17/46), respectively. The cumulative percentage of all cure rates including clinical cure, mycological cure and combined clinical and mycological cure of the continuous group was significantly higher than in the pulse therapy group (p < 0.001). The superior efficacy of the continuous therapy group was observed after week 8. The cumulative cure rate increased with the longer treatment duration but decreased with the larger infected area involvement (p = 0.001). All patients who were not cured showed improvement. There was no significant adverse effect. The higher dosage or the longer treatment duration of itraconazole may be required for treatment of tinea capitis from M. ferrugineum to achieve more cure rate.
This study was conducted on the primary school students in Ceyhan district of Adana, Turkey between May and June 2002 to determine the clinical form, causative agents and prevalence of tinea capitis. A total of 9576 students, with a male-to-female ratio of 50.6-49.4% were screened in 24 primary schools. Tinea capitis superficialis was diagnosed in seven cases, and kerion Celsi in one. Among eight cases, there were seven boys and one girl. Trichophyton violaceum was the most frequent causative agent, followed by T. tonsurans, T. mentagrophytes, Microsporum canis and M. gypseum.
BACKGROUND: Dermatophytes are the most common cause of human fungal infections. Response rates to existing therapy are lower than optimal, but newer agents like terbinafine hold promise for improved management of such infections. This investigation was designed to evaluate the single dose and steady state pharmacokinetics of terbinafine in young children with tinea capitis. METHODS: Twenty-two otherwise healthy children (4-8 years) with tinea capitis were eligible for enrollment. Children were treated with terbinafine once daily according to body weight (<25 kg, 125 mg; 25-35 kg, 187.5 mg), and pharmacokinetic sampling was conducted after the first dose, at the midpoint of treatment and at steady state. Plasma terbinafine concentrations were quantitated, and the pharmacokinetic indices compared with adult data. RESULTS: Absolute estimates of Cmax and area under the concentration curve (AUC)0-24 were comparable between children and adults for the administered dose; however, children demonstrated significantly lower estimates of exposure when dose was corrected for weight (Cmax SS 200 +/- 104 versus 454 +/- 185 ng/mL per mg/kg dose, P < 0.01; AUCSS: 1110 +/- 640 versus 2756 +/- 1775 ng*h/mL per mg/kg dose, P < 0.01). When examined along a continuum, age accounted for approximately 50% of the variability observed in dose-normalized Cmax and AUC (P < 0.01). A slight but significant reduction in apparent oral clearance was observed with increasing age (0.02 L/h/kg per yr) that likely accounts for the lesser degree of accumulation observed in children at steady state (accumulation ratio, 1.5 +/- 0.8 versus 2.3 +/- 0.6, P < 0.01). Adverse events consisted principally of headache (n = 3) and gastrointestinal complaints (altered eating habits n = 3, loss of appetite n = 3, stomachache n = 4, diarrhea n = 2). A reduction in neutrophil count was observed in 5 children and thought to be related to study drug in 2. CONCLUSIONS: Children require significantly larger weight-normalized doses to approximate the exposure estimates observed in adults. The dosing scheme used in this investigation results in absolute exposure estimates at steady state and a safety profile that are not appreciably different from adults.