Tinea capitis: no incision nor excision

Successful treatment of fungal ball-associated tinea capitis in a healthy infant: An unusual presentation

Key Clinical Message

Presentation of tinea capitis with fungal mass in an infant is extremely rare. Tinea capitis with and without abscess formation is prone to be misdiagnosed in infants and should be considered as a differential diagnosis of inflammatory hair loss in infants and toddlers as well as school-aged children.

Abstract

Tinea capitis is the scalp fungal infection that most often affects early school children. It rarely affects neonates and adults. The presentation of fungal ball in the setting of tinea capitis is extremely rare. Herein, we describe a 7-month-old girl with a fungal ball associated with tinea capitis with a scalp mass adjacent to the scalp dermatophytosis. To our knowledge, this is the first case of fungal ball in a healthy infant with tinea capitis.

A Rare Case of Cutaneous Trichophyton verrucosum of the Forearm in a 51-Year-Old Cattle Farmer

Trichophyton verrucosum is a pathogen causing superficial mycoses in cattle worldwide and is one of the few zoophilic dermatophytes. Farmers and veterinarians are at a higher risk for infection owing to frequent direct animal contact. An increase in cases among humans has been observed in the past few years. We report a rare case of T verrucosum of the forearm in a 51-year-old cattle farmer, who after initial treatment with antibiotics and surgery, and in whom diagnosis was delayed, was finally successfully treated with terbinafine and itraconazole.

Kerion Celsi in a Nepalese Boy: An Underdiagnosed Cause of Scalp Swelling

Tinea capitis (TC) is an infection of the scalp and hair caused by a dermatophyte fungus. Typically caused by the zoophilic and geophilic species of Microsporum and Trichophyton, it remains the commonest cutaneous fungal infection in children. A 9-year-old Nepalese boy was evaluated in outpatients for multiple boggy scalp lesions for two months. Suspecting a bacterial etiology, the lesions were excised and sent for cultures. While bacterial cultures failed to grow, endothrix spores were readily detected in potassium hydroxide preparation and histopathology. Trichophyton tonsurans was identified by the phenotype method and later confirmed by matrix-assisted laser desorption ionization-time of flight (MALDI-TOF). Systemic antifungal therapy for 6 weeks along with local wound dressings resulted in complete recovery. At 2-year follow-up, focal alopecia was seen; however, no recurrence was noted.

S1 guidelines: Tinea capitis

Tinea capitis describes a dermatophyte infection of scalp and hair that predominately occurs in children. The diagnostic workup includes microscopic examination, culture and/or molecular tests. Treatment is guided by the specific organism involved and should consist of systemic agents as well as adjuvant topical treatment. The aim of the present update of the interdisciplinary German S1 guidelines is to provide dermatologists, pediatricians and general practitioners with a decision tool for selecting and implementing appropriate diagnostic and therapeutic measures in patients with tinea capitis. The guidelines were developed based on current international guidelines, in particular the 2010 European Society for Pediatric Dermatology guidelines and the 2014 British Association of Dermatologists guidelines, as well as on a review of the literature conducted by the guideline committee. This multidisciplinary committee consists of representatives from the German Society of Dermatology (DDG), the German-Speaking Mycological Society (DMykG), the German Society for Hygiene and Microbiology (DGHM), the German Society of Pediatric and Adolescent Medicine (DGKJ) and the German Society for Pediatric Infectious Diseases (DGPI). The Division of Evidence-based Medicine (dEBM) provided methodological assistance. The guidelines were approved by the participating medical societies following a comprehensive internal and external review.

Surgery of Kerion, a Nightmare for Nondermatologists

Kerion is an inflammatory type of tinea capitis characterized by swelling and alopecia of the scalp, which could be mistaken as bacterial infection. It occurs most frequently in children. We report a 10-year-old child whose kerion was misdiagnosed as bacterial abscess and unnecessarily incised. Later, her condition was rediagnosed as kerion based on clinical appearance and potassium hydroxide wet mount. The lesions resolved completely with systemic antifungal treatment, griseofulvin, leaving residual scarring alopecia. The delay in the proper diagnosis and inappropriate treatment of this patient resulted in permanent scarring alopecia. Thus, clinicians must have a high index of suspicion for tinea capitis when dealing with inflammatory scalp lesions.

First report of kerion (tinea capitis) caused by combined Trichophyton mentagrophytes and Microsporum canis

A 5-year-old boy was presented with large ulcer accompanied by surrounding follicular pustules on the left parietal scalp. Dermoscopy showed "comma" and dystrophic broken hairs. Fungal culture showed mixed growth of two types of colonies. Trichophyton mentagrophytes and Microsporum canis were identified by using mycological examinations. To our knowledge, this is the first case of kerion caused by the combined Trichophyton mentagrophytes and Microsporum canis. Treatment with oral terbinafine for 2 months was effective.

Extensive tinea capitis and corporis in a child caused by Trichophyton verrucosum

A 3-year-old boy presented with multiple lesions of tinea corporis with dermatophytids, and subsequent inflammatory lesions with alopecia on the scalp. At the beginning, topical clobetasone butyrate was prescribed. The infection was diagnosed as dermatophytosis on the basis of positive direct microscopy and fungal culture. The etiological agent was isolated from all sampled sites and identified as Trichophyton verrucosum. Clonal nature of the infection was confirmed by random amplified polymorphic DNA (RAPD) analysis. The child lived in close vicinity of cattle. He was successfully treated with itraconazole.

Spectrum and burden of dermatophytes in children

Tinea capitis is the most important superficial fungal condition in children. It is often unrecognised but the presence of alopecia, scale and lymphadenopathy, especially in inner-city children should prompt investigation. An understanding of changing epidemiology and prevalence of causative organisms is important in deciding appropriate therapy. The use of diagnostic aids including dermoscopy is increasing and is reported to be helpful in identifying subtle signs. Trichophyton tonsurans accounts for the majority of cases in the UK and terbinafine is increasingly advocated as a safe and effective therapy. Exclusion from school is unnecessary provided the child is receiving appropriate systemic and topical therapy, but family members should be screened and carriers should receive treatment. Steroids and surgical treatments should be avoided. Treatment failure is common and may be multifactorial. Mycological cure after completing treatment should be sought and therefore follow up is necessary for Tinea capitis cases. Development of molecular diagnostic methods may improve our ability to diagnose Tinea capitis accurately and quickly in the future. Emerging new dermatophytoses affecting other anatomical sites are discussed which, although not common in the UK, may be seen due to increasing travel worldwide.

Successful treatment of severe kerion Celsi in an immunocompromised girl with evacuation of pus, terbinafine and short course glucocorticosteroids

A 6-year-old girl with a 2-year history of idiopathic thrombocytopenic purpura complained of a 4-week history of scalp desquamation together with small pustules. During the recent 10 days, she complained of high fever with multiple abscesses formation with no response to intravenous antibiotics. She received varied doses of oral prednisone therapy for 2 years. Microscopy showed endothrix infection. We prescribed terbinafine 125 mg/d and prednisone 10 mg/d. After 1 week, she returned to our office with severe ache and persistent high fever. She refused any topical drugs because of pain. Manual pressure to remove pus from sinuses and infected scale under general anesthesia was done and about 100 ml pus was discharged from kerion lesions. Prednisone (1 mg/kg/d) was started and fever disappeared on the same day. Prednisone was tapered to withdraw in 10 days. A total of a 3-month course of oral terbinafine (125 mg/d) resulted in mycological clearance. Hair regrowth was satisfactory 8 months later.

Barriers to Treatment of Tinea Capitis in Children Living in the Jane Finch Community of Toronto

Background:

Tinea capitis is a common fungal infection of the scalp. If left untreated, tinea capitis infection can cause severe inflammatory reactions and the development of kerion. Tinea capitis is effectively treated with oral antifungals, but at present these are not covered under government assistance programs.

Objective:

To assess the potential impact of a limited use code for antifungal therapy in the treatment of childhood tinea capitis.

Method:

Fourteen family physicians practicing in the Jane Finch area were surveyed on their experience treating tinea capitis in this community.

Results:

Seventy-one percent of surveyed family physicians felt that cost impedes the treatment of tinea capitis in their practice, and 100% felt that a limited use code would have a positive impact on their patients.

Conclusion:

A limited use code for oral antifungal treatments of tinea capitis may provide a simple, cost-effective solution to a major problem impacting children in the Jane Finch area.

Inflammatory Tinea capitis: a 12-year study and a review of the literature

Inflammatory Tinea capitis (TC) is a rare form of TC. The aim of this study was to review epidemiological, clinical and mycological profile of inflammatory TC. We present a retrospective study (1999-2010), enrolled all the cases of inflammatory TC observed at a referral hospital in the northern Tunisia. One hundred and twenty-one patients with inflammatory TC, 83 male patients (68.6%) and 38 female patients (31.4%) were enrolled. The mean age was about 8 years. A majority of TC (71.9%) were in patients lesser than 10 years of age. Positive family history and contact with animals were noted in seven and 35 cases respectively. Direct examination was positive in 110 cases (59 ectothrix, 51 endothrix) and positive cultures were obtained in 105 patients (49 Trichophyton violaceum, 31 Microsporum canis, 13 Trichophyton interdigitale complex, 12 Trichophyton verrucosum). Systemic treatment was carried out in 115 patients with griseofulvin, in one with terbinafine. A complete recovery was noted in 88 cases; and persistent alopecia in 28 cases. The inflammatory TC is rare, but more common in rural families. The disease mostly affected male genders (68.6%) and T. violaceum remains the common pathogen of inflammatory TC in northern Tunisia.

Severe kerion celsi due to Trichophyton mentagrophytes: a case report

We report on a 5-year-old girl with a severe kerion celsi, caused by Trichophyton mentagrophytes, probably acquired from a pet guinea pig. The lesions had started as small irritating squamous lesions that had been accurately diagnosed as skin infection, but had only been treated with local antifungal agents. The lesions progressed and developed into a kerion celsi that had to be treated with long-term systemic griseofulvin. Nevertheless, reinfection occurred and treatment had to be restarted. The girl is left with areas of alopecia, as a result of which she is required to wear a wig.

CONCLUSION

Tinea capitis is a common skin infection that should be considered in any type of scalp lesion. It requires systemic treatment, and inappropriate and delayed treatment can result in the development of kerion celsi, with sometimes devastating consequences.

Management of tinea capitis in childhood

Tinea capitis (TC) is a common dermatophyte infection affecting primarily prepubertal children. The causative pathogens belong to only two genera: Trichophyton and Microsporum. Although there is a great local variation in the epidemiology of TC worldwide, T. tonsurans is currently the most common cause of TC with M. canis second. Even though there is an emerging number of anthropophilic scalp infections, M. canis remains the predominant causative organism in many countries of the Mediterranean basin, the most important dermatophyte carriers being stray cats and dogs as well as pet puppies, kittens and rabbits. TC always requires systemic treatment because topical antifungal agents do not penetrate down to the deepest part of the hair follicle. Since the late 1950s, griseofulvin has been the gold standard for systemic therapy of TC. It is active against dermatophytes and has a long-term safety profile. The main disadvantage of griseofulvin is the long duration of treatment required which may lead to reduced compliance. The newer oral antifungal agents including terbinafine, itraconazole, ketokonazole, and fluconazole appear to have efficacy rates and potential adverse effects similar to those of griseofulvin in children with TC caused by Trichophyton species, while requiring a much shorter duration of treatment. They may, however, be more expensive.

[Treatment of 2 cases of kerions with griseofulvin and oral steroids]

We report on 2 cases of kerions in children: one of them was located on the pubis, an exceptional location; the second one was located on the scalp and presented like multiple abscess of the scalp, for which surgical drainage was performed. In both cases, Trichophyton mentagrophytes was involved. This dermatophyte is zoophilic, contrary to the dermatophytes usually involved in tinea capitis, which could explain the poor adaptation of the dermatophyte to the human host, who would therefore react by generating a severe inflammatory reaction. Antifungal drugs are recommended for the treatment of kerions, especially griseofuline for 6 to 8 weeks. The value of oral steroids and surgery continues to be debated.