Tinea capitis: epidemiology, diagnosis, treatment, and control

Kerion Celsi: a clinical epidemiological study

We present a case record of patients with kerion Celsi observed in the Clinic of Dermatology, University of Cagliari (Italy) from 1981 to 1995. Altogether, 31 children (18 male and 13 female) with an age range of 40 days to 12 years were studied. In all cases the lesions were confined to the scalp. In 10 cases the disease developed as such, while in 21 patients it represented the inflammatory evolution of tinea capitis secondary to incongruous topical treatment. Microsporum canis was isolated in 22 cases and Trichophyton mentagrophytes in nine cases. Systemic treatment was carried out in 20 patients with griseofulvin, in six with ketoconazole and in five with terbinafine. Complete recovery was obtained in 25-30 days. No cases of relapse were observed. The authors stress the importance of an early diagnosis followed by timely and effective treatment to prevent scarring and permanent hair loss.

Diagnostic dilemmas in pediatric/adolescent dermatology: scaly scalp

Scaly scalp is a common problem in the pediatric and adolescent population. The possible causes range from the commonly seen tinea capitis and seborrheic dermatitis to rare systemic diseases such as dermatomyositis and Letterer-Siwe disease. In all cases a thorough history and physical examination are important first steps to successful diagnosis and treatment.

Accumulation of fluconazole in scalp hair

The accumulation in scalp hair of the antimycotic triazole, fluconazole, was studied during and after administration. Fluconazole 50 mg was administered to 12 healthy subjects as a single capsule each day for 28 days. The concentration of fluconazole 5 hours after administration was measured in different 1-cm sections of scalp hair at intervals during treatment and for 6 months after the end of treatment. In each section of scalp hair the concentration of fluconazole increased during treatment and was consistently higher than values found in plasma. For example, the mean concentration in the first hair section on day 28, 19.8 micrograms/g, corresponded to a mean penetration ratio relative to plasma of 9.42. During administration, the maximal concentration of fluconazole was found in the first hair section. After cessation of administration, the measured concentrations of fluconazole decreased and greater concentrations were found in the distal hair sections, presumably as a result of hair growth. Fluconazole was detectable, however, in the hair of 9 of the 12 subjects even 6 months after treatment. The mean concentration of fluconazole in hair bulbs on day 28 was 12.1 micrograms/g (n = 6), corresponding to a mean penetration ratio of 5.99. In a second study, fluconazole was administered as a single oral 150-mg capsule per week for 4 weeks to a group of 8 healthy subjects. The mean fluconazole concentration in whole scalp hair 5 hours after the last dose was 3.2 micrograms/g.

Tinea capitis in children in the district of Cagliari, Italy

Between 1986 and 1995, 4104 children were observed in the Clinic of Dermatology in Cagliari, Italy. Three hundred and thirty-six children (8.2%), 188 boys and 148 girls, aged 1 month to 13 years, were affected by tinea capitis. Microsporum canis was detected in 278 cases (82.7%) and Trichophyton mentagrophytes in 58 cases (17.3%). Systemic treatment with 20-25 mg kg-1 day-1 griseofulvin led to complete recovery in 30-40 days. None of the patients relapsed. The epidemiology of the infection was analysed according to age, sex and seasonal progression. Microsporum canis was the preponderant aetiological agent of tinea capitis in children in the district of Cagliari, Italy.

Response to initial griseofulvin therapy in pediatric patients with tinea capitis

OBJECTIVE

To estimate the response rate to initial griseofulvin therapy in pediatric patients with tinea capitis and to determine whether clinical or epidemiologic variables differed between patients responding positively and negatively to therapy.

METHODS

A review of patients' medical records with a confirmed diagnosis of tinea capitis was performed retrospectively over a 2-year period. Patients were included only if a positive dermatophyte culture was obtained and the initial prescription for griseofulvin was filled at our pharmacy. Responders were children not returning to the clinic or returning without signs or symptoms of infection. Nonresponders were those returning within 8 months with signs and symptoms of disease, requiring additional therapy.

RESULTS

During July 1993-June 1995, 479 positive fungal cultures were confirmed in 474 patients, and 857 prescriptions for griseofulvin were filled for 765 patients at our institution. Of 122 evaluable patients meeting both criteria, 60.7% were classified as responders to initial prescribed therapy. The remaining 39.3% returned to the clinic within 8 months of initial therapy, requiring additional treatment. An additional 10.7% had a recurrence at a later date. There was no correlation between clinical response and dosage, age, race, or gender, although there was a trend toward longer treatment duration among responders.

CONCLUSIONS

It is evident that tinea capitis persists in the urban pediatric population. Our data suggest that griseofulvin, the current drug of choice, may be ineffective in at least one-third of pediatric patients with tinea capitis.

Treatment of tinea capitis

OBJECTIVE

To review the epidemiology, pathogenesis, mycology, clinical presentation, and pharmacotherapy of tinea capitis, and describe the role of newer antimycotic agents.

DATA SOURCES

A MEDLINE search restricted to English-language articles published from 1966 through 1996 and journal references were used in preparing this review.

DATA EXTRACTION

The data on mycology, pharmacokinetics, adverse effects, and drug interactions were obtained from controlled studies and case reports appearing in the literature. Both open-label and comparative studies were evaluated to assess the efficacy of antimycotics in the treatment of this infection.

DATA SYNTHESIS

Griseofulvin is the drug of choice in the treatment of tinea capitis. Newer agents with greater efficacy or shorter treatment durations continue to be explored. Ketoconazole, the first azole studied for efficacy in tinea capitis, has not demonstrated any clinical advantage over griseofulvin in several controlled clinical trials. Itraconazole is effective, but the available data are limited to case reports and a single uncontrolled study. Terbinafine similarly has shown promise in the treatment of tinea capitis, but the oral formulation was only recently approved in the US. Existing studies reflect the results in infection with pathogens not seen in the US. Both itraconazole and terbinafine achieve high concentrations in the hair and stratum corneum that persist for several weeks following drug administration. This may enable shorter courses of therapy; however, comparative studies need to be conducted in the US.

CONCLUSIONS

Tinea capitis remains the most common dermatophyte infection in young urban children. Oral antifungal therapy is required for effective treatment, often for several months. The combination of griseofulvin with a selenium sulfide shampoo continues to be the mainstay of therapy until more experience is gained with the newer antimycotics.

Tinea capitis in adults

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.

Oral terbinafine in tinea capitis in children

Tinea capitis is a disease that frequently affects children. In most cases systemic antimycotic treatment is necessary Griseofulvin is still the drug of choice, but requires prolonged periods of treatment (several months). To estimate the efficiency and tolerability of terbinafine for treatment of tinea capitis in children, four patients (aged 3-9 years) with tinea capitis proven by culture were treated with terbinafine at a dose of 125 mg a day for different periods (4-10 weeks). Isolates were subjected to minimal inhibitory concentration testing against terbinafine and griseofulvin. In all four cases terbinafine treatment resulted in complete remission. The clinical response was accompanied by negative culture results on follow-up. Terbinafine was well tolerated in each case. Determination of the minimal inhibitory concentration confirmed the excellent in vitro activity of terbinafine against dermatophytes. Controlled studies involving a larger number of children are necessary to answer questions concerning dose and duration of terbinafine treatment as well as the frequency and severity of drug-related side-effects.

Tinea capitis

Tinea capitis is dermatophytosis of the scalp hair follicles, generally producing inflammatory or noninflammatory alopecia. Infection occurs predominantly in prepubertal children older than 6 months, although infection can occur in all age groups. Tinea capitis is one of the most common infectious conditions in children, and it occurs worldwide.

Recent developments in antifungal therapy

There have been many advances during the past few years relating to the treatment of superficial fungal infections. This article focuses on recent developments, particularly in oral therapy, but in topical therapy as well. First, the newer agents (especially fluconazole, itraconazole, and terbinafine) are reviewed, and then the use of these agents in many disorders is discussed, with emphasis on tinea corporis or cruris, tinea pedis, tinea capitis, and onychomycosis.