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Tinea Capitis: Current Concepts in Clinical Practice

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Tinea Capitis: Current Concepts in Clinical Practice CONTINUING MEDICAL EDUCATION Tinea Capitis: Current Concepts in Clinical Practice Matthew J. Trovato, MD; Robert A. Schwartz, MD, MPH; Camila K. Janniger, MD GOAL To understand tinea capitis to better treat patients with the condition OBJECTIVES Upon completion of this activity, dermatologists and general practitioners should be able to: 1. Describe the etiology of tinea capitis. 2. Recognize and diagnose tinea capitis. 3. Effectively treat tinea capitis. CME Test on page 88. This article has been peer reviewed and is accredited by the ACCME to provide continuing approved by Victor B. Hatcher, PhD, Professor of medical education for physicians. Medicine, Albert Einstein College of Medicine. Albert Einstein College of Medicine designates Review date: January 2006. this educational activity for a maximum of 1 This activity has been planned and implemented category 1 credit toward the AMA Physician’s in accordance with the Essential Areas and Policies Recognition Award. Each physician should of the Accreditation Council for Continuing Medical claim only that credit that he/she actually spent Education through the joint sponsorship of Albert in the activity. Einstein College of Medicine and Quadrant This activity has been planned and produced in HealthCom, Inc. Albert Einstein College of Medicine accordance with ACCME Essentials. Drs. Trovato, Schwartz, and Janniger report no conflict of interest. The authors discuss off-label use of fluconazole, itraconazole, ketoconazole, and terbinafine. Dr. Hatcher reports no conflict of interest. Tinea capitis is a common infection, particularly seen in Europe and many other countries, which among young children in urban regions. The emit a green fluorescence. However, T tonsurans, infection often is seen in a form with mild scaling like other fungi, also may less often produce an and little hair loss, a result of the prominence of intense inflammatory reaction, which is sugges- Trichophyton tonsurans (the most frequent cause tive of an acute bacterial infection. of tinea capitis in the United States). T tonsurans Cutis. 2006;77:93-99. does not fluoresce under Wood light, unlike the common tinea capitis–causing fungal organisms inea capitis, or ringworm of the scalp, is most Accepted for publication September 9, 2005. common in preschool and school-age children From Dermatology and Pediatrics, UMDNJ-New Jersey T and often is associated with crowded living Medical School, Newark. Dr. Trovato is a plastic surgery resident, conditions.1-5 In the United States, Trichophyton Dr. Schwartz is Professor and Head of Dermatology, and tonsurans causes most cases of tinea capitis and Dr. Janniger is Clinical Professor and Chief of Pediatric Dermatology. Reprints: Camila K. Janniger, MD, Pediatric Dermatology, at times produces widespread scaling with minimal New Jersey Medical School, 185 S Orange Ave, Newark, NJ hair loss, prompting suspicion of seborrheic derma- 07103-2714 (e-mail: [email protected]). titis. T tonsurans also may induce violent tissue VOLUME 77, FEBRUARY 2006 93 Tinea Capitis reactions, including inflammation and pustulation, species of dermatophyte are capable of producing which is suggestive of an acute bacterial infection.2 tinea capitis, some species have a greater tendency Alternatively, childhood infections with this fungus than others, and a few (namely Epidermophyton may be asymptomatic. A central European study floccosum) are noted for no involvement of the scalp showed a peak incidence of scalp fungal infections hair. When molds other than the 3 dermatophytic in children aged 4 to 6 years.5 Another survey con- fungi described above attack the hair, nails, or skin, ducted in an urban pediatric clinic in the United infection by these nondermatophytic fungi is called States reported an overall incidence of scalp fungal dermatomycosis rather than dermatophytosis. infections of 4%, with the highest incidence, 12.7%, Tinea capitis is characterized by broken hair occurring among black girls.1 This higher incidence and often produces alopecia (Figure). Previously, was thought to be related to the use of occlusive Microsporum audouinii and Microsporum canis were pomades and tight braiding of the girls’ hair. How- the most common causes of tinea capitis in pre- ever, a race-matched case-controlled study showed pubescent children because of the children’s contact that use of oils or grease, hairstyling, frequency of with cats and dogs.17 M audouinii and M canis emit washing, and other hair care practices were not asso- a green fluorescence under a Wood light; however, ciated with the presence of tinea capitis.6 The pres- nonfluorescent T tonsurans has replaced these ence of an adult carrier state in juvenile tinea capitis 2 organisms as the most common cause of tinea warrants a thorough evaluation of the patient’s capitis in North America.8-13 This development immediate and extended families.2 may be due to shifting immigration patterns from Mexico, Central America, and South America.18 In Etiology Africa, Pakistan/India, South America, and eastern Tinea capitis is caused by dermatophytic infections Europe, the most common cause of tinea capitis is that belong to 3 genera of fungi: Trichophyton, Trichophyton violaceum, whereas in western Europe, Microsporum, and Epidermophyton.5-16 Ecologically, it is M canis,5,8 with cats serving as a common vec- these fungi can be classified by host preference as tor.13 Trichophyton soudanense is a significant cause either anthropophilic (humans), geophilic (soil), or of tinea capitis in Africa but is a rare cause else- zoophilic (animals). Clinically, the patterns of infec- where in the world. M audouinii often produces a tion of these fungi are classified by anatomic prefer- noninflammatory infection that is almost asymp- ence, such as tinea capitis (scalp), tinea pedis (foot), tomatic. At the other end of the spectrum, a severe, or tinea corporis (body). These fungi characteristi- inflammatory kerion may be produced that is most cally produce infections with an active circinate often because of either T tonsurans or M canis. margin, hence the term ringworm. Although most Another severe, inflammatory type of tinea capitis, Tinea capitis displaying a patchy alopecia with some evidence of matting, which is suggestive of kerion development. 94 CUTIS® Tinea Capitis called favus, is due to Trichophyton schoenleinii.15 at the site of the broken hairs. The alopecia charac- Granulomatous perifolliculitis also may be seen, teristically is asymptomatic without evidence of scar- usually due to Trichophyton rubrum, manifesting on ring, atrophy, or erythema. T tonsurans often produces shaved legs rather than on the scalp. dry, seborrheic dermatitis–like scaling without When hair is involved, fungal infections are inflammation and with only slight loss of scalp hair.13 divided into 2 types: ectothrix (M audouinii, This virtually asymptomatic infection may persist M canis), whereby spores are present on the hair sur- throughout childhood. However, a more serious face only, and endothrix (T tonsurans, T violaceum, reaction may occur, with the formation of black-dot T soudanense), whereby spores are present within stubs in areas of marked alopecia. Pruritus with the hair follicle; endothrix infection spores also are lichenification and secondary excoriation may occur present on the skin surface, hence the ability to per- in some patients. The pruritus is thought to be psy- form a fungal culture of this infection. Fungi enter chogenic in nature.19 Other patients experience a the proximal cortex where the cuticle is immature; severe inflammatory reaction. the fungi then colonize the proximal keratinized The 2 severe types of tinea capitis are kerion and cortex and generate septate hyphae that become favus. A kerion is a painfully inflamed, crusty, mat- arthrospores and replace the cortex; this may cause ted mass that often is associated with purulent the weakened hair to coil up inside the infundibu- drainage from the sinuses. Regional lymphadenopa- lum and form the black dots of black dot ringworm. thy is characteristic.20,21 Kerions tend to be small T rubrum rarely affects the hair shaft; nevertheless, and solitary, though multiple plaques or one giant when it does, the infection may be both nonfluores- mass involving most of the scalp may be seen. Favus cent ectothrix and endothrix.11,16 produces inflammation and scarring, and is charac- terized by yellow cup-shaped crusts called scutula Historical Considerations that are found around a hair.15 These crusts contain In Rome around 30 AD, an acute inflammatory infectious hyphal masses that coalesce into a yellow scalp condition with purulent drainage was first hyperkeratotic mass. described by Celsus; thus, the kerion is some times referred to as kerion celsi.11,14 During the turn of Laboratory Characteristics the 20th century, tinea capitis was a plague.14 A 10% potassium hydroxide preparation of skin Accordingly, Europeans attempting to immigrate scrapings provides an adequate cytologic specimen to America who had tinea capitis, especially the for examination and diagnosis. Smearing the speci- favus type, were barred at Ellis Island. The history men on a glass slide using a scalpel blade or the of this infection has had a predictable effect on its edge of the slide, and then applying the 10% potas- epidemiology in the United States, which differs sium hydroxide, yields consistent diagnostic from that in Europe. M audouinii was responsible results.22 Results of microscopic examinations for causing most tinea
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