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Tinea capitis: a treatment update.

Currently, many experts consider griseofulvin to be the drug of choice for tinea capitis. It is FDA approved for this indication, highly efficacious, and has an excellent long-term safety record. Nonetheless, there is now ample evidence documenting the efficacy and safety of other antifungal agents. Terbinafine, itraconazole, and fluconazole have been used off-label in the United States and United Kingdom for tinea capitis. Several studies have shown that short-term terbinafine, itraconazole, or fluconazole each are comparable in efficacy and safety to griseofulvin. High-dose griseofulvin is still the first-line therapy for tinea capitis in our practice, but a large-scale, multicenter trial of higher dose terbinafine is now ongoing, and positive efficacy and safety results from that study may lead to a change in our standard of care. Terbinafine, itraconazole, or fluconazole currently are used in patients who have either failed griseofulvin or developed adverse reactions to this medication. Families must be informed that these other antifungal agents are not FDA-approved for this indication when they are used. Guidelines for therapy with each of these agents are summarized in Table 5. In addition, the adjuvant use of antifungal shampoos is recommended for all patients in order to decrease the viability of fungal spores present on the hair, as well as for all household contacts to prevent infection or eliminate the carrier state.

Antifungal Agents↗

Aetiological agents of tinea capitis in Tehran (Iran).

A total of 1568 patients with suspected tinea capitis were examined for causative fungal agents between 1994 and 2001. Laboratory examination confirmed tinea capitis in 209 patients. Males were affected more frequently (67.5%) than females (32.5%) and in both sexes, those who were 3-11 years old, were more infected. Trichophyton violaceum was the most common aetiological agent (37.3%) followed by Trichophyton schoenleinii (21.5%), Microsporum canis (18.6%), Trichophyton verrocosum (14.8%), Trichophyton tonsurans (5.3%), Trichophyton rubrum (1%), Microsporum gypseum (1%) and Trichophyton mentagrophytes (0.5%). A higher incidence of the disease was found to be correlated with larger family and class size. The findings are discussed in relation to different socioeconomic and hygienic backgrounds of the children.

Adolescent↗

Tinea capitis in Germany. A survey in 1998.

Under the assignment of the ECMM (European Confederation of Medical Mycology) a survey regarding frequency, infectious spectrum and therapy of tinea capitis was conducted in Germany in 1998. In this survey 154 dermatology practitioners and 19 hospitals throughout Germany participated. There were 394 conditions reported, 377 with and 17 without identification of the infectious agent. The most frequent infectious agent was M. canis (n = 216; 54.8%) before T. mentagrophytes (n = 58; 14.7%), T. verrucosum (n = 32; 8.1%), T. violaceum (n = 24; 6.1%) and T. tonsurans (n = 15; 3.8%). Zoophilic dermatophytes (n = 306; 81.2%) predominated over anthropophilic species (n = 71; 18.8%) in the ratio of 4:1. Tinea capitis microsporica showed to be a more frequent infectious disease again which due to its high virulence and contagiosity of the infectious agent represents a therapeutical problem. Tinea capitis occurred in an average age of 17.3 years. The preferred therapeutical regimen was a combination of systemic and topical antimycotics in 61.5% (n = 176) of the reported cases (n = 286). A solely topical or systemical monotherapy was reported in 25.2% (n = 72) respectively 13.3% (n = 38) of the patients. In case of systemic antimycotics the most frequent used drugs were griseofulvin (43.0%, n = 101), fluconazole (25.1%, n = 59) or itraconazole (18.7%; n = 44), in topical preparations ciclopiroxolamine dominated (53.3%, n = 121) prior to clotrimazole (13.2%, n = 30) and terbinafine (7.1%, n = 16). Different from the situation in Germany and in Southern Europe some of the western European countries show a tendency of an increase of anthropophilic agents in tinea capitis.

Germany↗

Tinea capitis in south-western Ethiopia: a study of risk factors for infection and carriage.

BACKGROUND: Tinea capitis is a common dermatophyte infection which constitutes an important public health problem among children worldwide. The endemic nature of scalp ringworm in Africa is perpetuated mainly by the lack of knowledge about the prevalence and carrier status, and the absence of control measures. METHODS: Two hundred and nineteen schoolchildren from urban and rural communities of the Illubabor district, south-western Ethiopia, were examined, and scalp samples were taken. Children were classified according to clinical signs and mycologic findings. RESULTS: Physical examination revealed that 29% of the children had clinical lesions compatible with tinea capitis. Dermatophytes were isolated from 33% of the children's scalp samples; of these, 16% had clinical lesions and 17% were identified as carriers. Trichophyton violaceum was responsible for 97% of infections. CONCLUSIONS: Tinea capitis was the second most prevalent cutaneous finding in these children, with a higher prevalence in the urban community; the predictive value of the clinical diagnosis was low and a high proportion of children were identified as carriers in these communities. No relationship between household overcrowding and scalp infection was found.

Adolescent↗

Tinea capitis in Europe: new perspective on an old problem.

A survey of tinea capitis conducted under the auspices of the European Confederation of Medical Mycology showed that laboratories contributing to a voluntary scheme for reporting have recently been seeing a different pattern of scalp ringworm. The survey was conducted among 92 medical mycology laboratories across 19 European countries by postal questionnaire comparing the years 1987 with 1997. The survey shows an overall increase in the numbers of cases caused by anthropophilic infections, which, in 1997, were the dominant causes of scalp infection; the greatest increase was seen in laboratories covering urban populations and in African Caribbean children living in Europe. While the commonest infection remains Microsporum canis, the largest overall increase has been in Trichophyton tonsurans, which in 1997 was the second commonest cause of infection overall and the commonest in urban populations. The pattern of change is not uniform in Europe and while some cities have reported large increases in T. tonsurans others, e.g. in France, have seen more cases of infection due to T. soudanense and M. audouinii. While these figures do not necessarily reflect changes in the underlying prevalence of infection, the trends are important to recognize as the control measures for anthropophilic tinea capitis differ from those used in zoophilic infections. In particular there is a need for an increased level of surveillance and more advice on control given to primary care physicians, dermatologists and school health authorities.

Data Collection↗

Tinea capitis in adults.

Scalp ringworm is unusual after puberty. Etiological, epidemiological and clinical data regarding cases of tinea capitis in the elderly observed over a period of 15 years are discussed and some explanations are given for the conditions which favoured the mycotic infection of the scalp in adults. This study underlines that tinea capitis in the elderly is usually characterized by very variable and often atypical lesions and that female preponderance in adult cases of scalp ringworm is striking and unexplained. Moreover, all the dermatophytes we isolated from scalp lesions in children can cause tinea capitis in adults.

Adolescent↗

Doubled dose of oral terbinafine is required for Microsporum canis tinea capitis.

Fourteen children, ages 1-15 years, with Microsporum canis tinea capitis were given oral terbinafine for 4 weeks at the recommended daily dose according to their weight: 10-20 kg, 62.5 mg; 20-40 kg, 125 mg; > 40 kg, 250 mg. Because none of the patients had clinically responded to treatment by week 4 the dose of terbinafine was doubled (up to 250 mg) for an additional 4-8 weeks in six patients, and continued at the original dose in six patients. Two patients dropped out of the study. On final evaluation, four patients were cured after 8-12 weeks of treatment. All cured patients received the doubled dose of terbinafine, except for one who was on the usual adult dose of 250 mg from the onset. Oral terbinafine was well tolerated by all but one patient, who experienced gastrointestinal disturbance and slightly raised transaminase levels during the first 4 weeks of treatment. Terbinafine side effects were not correlated with dosage or duration of treatment. We conclude that oral terbinafine should be dosed for M. canis tinea capitis at a revised schedule according to body weight: 10-25 kg, 125 mg/day and > 25 kg, 250 mg/day. The appropriate duration of terbinafine treatment remains to be determined.

Administration, Oral↗

Tinea capitis in The Netherlands (Rotterdam area).

This retrospective study reviews the occurrence and treatment of various forms of tinea capitis at the out-patient clinic for Dermatology and Pediatric Dermatology of the University Hospital Sophia/Dijkzigt over the period 1977-1988. Tinea capitis was diagnosed in 64 children. Trichophyton violaceum was the pathogen most frequently isolated, with Microsporum canis ranking second. The potassium hydroxide preparation was positive in 58% of the cases. Four cases showed a positive potassium hydroxide preparation with a negative culture. Immigrant children from Morocco were the largest group (61%). A zoophilic dermatophyte was isolated in 15 cases (27%). A pet animal was the source of infection in 4 cases. The ratio between boys and girls was equal in the patient population studied. In 43% of the children suffering from tinea capitis the clinical features were mild flaking without hair loss (so called seborrheic dermatitis-like infection).

Adolescent↗

Terbinafine: efficacy and tolerability in young children with tinea capitis due to Microsporum canis.

AIMS: We carried out an open, prospective, uncontrolled study to evaluate the efficacy and tolerability of terbinafine in the treatment of young children with tinea capitis due to Microsporum canis. METHODS: A total of 83 healthy, immunocompetent children (age range 2-13 years) were enrolled in eight centres in Estonia, Latvia and Lithuania. Patients received oral terbinafine in dosages based on weight, 62.5 mg for those weighing 10-20 kg, 125 mg for 20-40 kg, plus application of topical 1% terbinafine cream twice daily to affected areas. Treatment lasted for 4 weeks, followed by an 8-week observation (treatment-free) period. All the subjects were assessed for efficacy and tolerability at 12 weeks. RESULTS: Eighty-one subjects were available for assessment at 12 weeks: 32 had completely recovered, with no evidence of relapse during the observation period, and 21 showed mycological cure, but presented residual physical signs of infection. Thus the effective cure rate was 65.4% in an infection known to be more difficult to cure than other causes of tinea capitis. Terbinafine was well tolerated by these children. CONCLUSIONS: This study showed effective cure of two-thirds of 81 cases of tinea capitis caused by M. canis with a 4-week course of treatment. As one-third of the cases did not respond to treatment, we suggest using combined oral and topical treatment with terbinafine in children with tinea capitis caused by M. canis.

Administration, Oral↗

Tinea capitis among rural school children of the district of Magude, in Maputo province, Mozambique.

The study was carried out in two rural primary schools of the District of Magude, the largest district of Maputo Province in 2001. The prevalence of tinea capitis in each school was 11.6% (49/422) and 6.8% (18/263) and affected predominantly male children. The most common dermatophytes isolated from both schools were Microsporum audouinii. However, Trichophyton mentagrophytes was also found to be an important causal agent of tinea capitis in the District of Magude. Although the prevalence of tinea capitis found in our study is relatively high compared to previous cross-sectional studies carried out in Mozambique, it is still closely related to the prevalence rates reported for African countries. Tinea capitis continues to be an important public health issue in Mozambique, particularly in primary school setting.

Adolescent↗

Pathogenesis of hair infection and black dots in tinea capitis caused by Trichophyton violaceum: a histopathological study.

The majority of tinea capitis in southern Taiwan occur in adult women and are caused by Trichophyton violaceum. We report the histopathological findings of a series of 10 cases of tinea capitis caused by T. violaceum, the largest such study to date. Our study provides new information regarding the process of hair infection, mechanism of black dot formation, and chronicity of infection caused by this fungus. The cuticle remains intact. The fungi enter the proximal cortex where the cuticle is immature. They then colonize the proximal keratinized cortex and generate septate hyphae which transform gradually into arthrospores as they are carried upwards by the growing hair. At the infundibular level, the hair cortex is almost completely replaced by spores and swells, impeding further exit of the growing hair and causing the already weakened hair to coil up inside the infundibulum, forming a black dot. In one patient who had infection for more than 20 years, there were changes suggestive of cyclic reinfection of the same follicles which might contribute to the chronicity of the infection.

Adolescent↗

Case Reports. Tinea capitis due to Trichophyton soudanense and Trichophyton schoenleinii.

Four cases of tinea capitis, two due to Trichophyton soudanense in Italian children who had had contact with Africans, and two due to Trichophyton schoenleinii in an African and an Italian child, respectively, are reported. Infections caused by anthropophilic dermatophytes are rare in Italy and are related to immigration. The most frequent agents of tinea capitis in Italy are zoophilic dermatophytes.

Child↗

Tinea capitis in south-east London--a new pattern of infection with public health implications.

Recent observations on tinea capitis cases in London suggest that there has been a change in the pattern of infection with a recent and significant rise in the incidence of infections due to anthropophilic fungi. The purpose of this study was to investigate the prevalence and identity of tinea capitis in schools in south-east London and factors which might affect the spread of infection. This was achieved by carrying out a survey of all children, with parental consent for scalp examination, in 14 nursery, infant or junior schools in Lambeth. In addition, the accuracy of clinical diagnosis was compared with mycological findings. There were 1057 children from 4 to 14 years of age in the study. The infection rate in different schools ranged from 0 to 12% with a mean of 2.5%. A further 4.9% of children were scalp carriers of dermatophytes (range in classes 0-47%). A striking feature was that all infections were caused by anthropophilic fungi, mainly Trichophyton tonsurans or Microsporum rivalieri, and there was a correlation between the presence of two or more carriers within a class and the infection in the other children. There was a poor correlation between ability of trained observers to predict infection on clinical grounds and mycological results. This investigation shows variable but significant levels of scalp ringworm in schools and that the dominant organisms are anthropophilic. It provides support for the observation that there has been a shift in the pattern of tinea capitis in London and, possibly, other U.K. centres, with a trend towards more infections transmissible among children, with T, tonsurans being the commonest organism. The implications for control, which involve screening in schools, where appropriate, and guidance to general practitioners on treatment, are discussed.

Carrier State↗

Tinea capitis in California children: a population-based study of a growing epidemic.

OBJECTIVE: To describe trends in tinea capitis incidence among California children and to determine subpopulations at increased risk. DESIGN: Retrospective population-based study. SETTING: California, 1984 through 1993. POPULATION: Children < 10 years of age enrolled in Medi-Cal. OUTCOME MEASURES: California Medi-Cal provider data for first-time prescriptions of oral griseofulvin suspension were used to estimate annual incidence of tinea capitis and calculate risk ratios. RESULTS: From 1984 through 1993, the incident rate for prescriptions of oral griseofulvin suspension increased by 84.2% for all children, 140.4% for white children, and 209.7% for African-American children. In 1993, incidence rates (per 10,000 enrolled) were 252.1 claimants for African-American children, 23.1 for white, 17.5 for Hispanic, and 14.3 for Asian/Pacific Islander. The highest rate by location was San Francisco County (172.2). In age groups < 5 years and 5 to 9 years, African-American children were 13.1 and 17.6 times more likely to be prescribed griseofulvin than Hispanic children. Since 1987, incidence rates for children 5 to 9 years of age were higher compared with children ages < 5 years. CONCLUSIONS: Tinea capitis is epidemic among California children with higher rates in the northern counties studied. African-American children are the most affected by this epidemic; however, white children have also experienced increased rates.

Administration, Oral↗

Tinea capitis due to Microsporum gypseum in an adult.

A case of tinea capitis due to Microsporum gypseum in an adult is described. An otherwise healthy 69-year-old woman presented two large patches of slightly erythematous scaling alopecia localized on the vertex and on the left parietal region of the scalp. The only subjective sign was itching. A mycological culture was positive for Microsporum gypseum. Tinea capitis is uncommon in adults; furthermore, isolation of Microsporum gypseum from this type of lesion is rare.

Age Factors↗

Trichophyton tonsurans tinea capitis in the San Francisco Bay area: increased infection demonstrated in a 20-year survey of fungal infections from 1974 to 1994.

Tinea capitis caused by Trichophyton tonsurans has been increasing in the United States for the past 25 years. A retrospective study of dermatophyte culture data at the University of California, San Francisco, and a parallel study of patient visits for tinea capitis at an affiliated hospital demonstrates a dramatic rise in Trichophyton tonsurans tinea capitis in the San Francisco Bay area.

Humans↗

Tinea capitis due to Microsporum audouinii in Malta.

We describe a case of tinea capitis in a 4-year-old boy caused by Microsporum audouinii var. langeronii. This is the first recorded case of tinea capitis due to this dermatophyte in the Maltese Islands.

Antifungal Agents↗

Efficacy and tolerability of 8 weeks' treatment with terbinafine in children with tinea capitis caused by Microsporum canis: a comparison of three doses.

BACKGROUND: Tinea capitis caused by Microsporum canis is the most common mycosis of the scalp in preschool and school-aged children in Greece. OBJECTIVE: To compare the efficacy, safety and tolerability of an 8-week course of oral terbinafine at different doses. METHODS: Patients received oral terbinafine at doses ranging from 3.3 to 12.5 mg/kg/day for 8 weeks, as follows: group A, terbinafine 3.3 to </= 6.0 mg/kg/day (40 patients); group B, terbinafine > 6.0 to 7.0 mg/kg/day (23 patients); group C, terbinafine > 7.0 to 12.5 mg/kg/day (37 patients). Fungal microscopy and cultures were performed 4 weeks before the start of the treatment, at the end of the treatment (week 8) and at a follow-up visit at week 16. RESULTS: At week 8 mycological cure was achieved in one patient (2.7%) in group A, in 21 patients (91.3%) in group B and in 34 patients (97.1%) in group C. At week 16 mycological cure was achieved in one patient (2.7%) in group A, in 22 patients (95.7%) in group B and in 35 patients (100%) in group C. There was a statistically significant difference (P < 0.0005) between dose level and efficacy of terbinafine at the end of the treatment period and also at the follow-up visit at week 16. Five patients (three in group A and two in group C) discontinued treatment because of adverse events. CONCLUSIONS: The administration of terbinafine at a dose of either 6-7 or 7-12.5 mg/kg/day for 8 weeks is safe and effective for the treatment in children of tinea capitis caused by M. canis.

Administration, Oral↗