Tinea capitis: epidemiology, diagnosis, treatment, and control

Tinea capitis et barbae caused by Trichophyton tonsurans: A retrospective cohort study of an infection chain after shavings in barber shops

BACKGROUND

Tinea capitis is a highly contagious infectious disease caused by dermatophytes. In Central Europe, it is mainly caused by zoophilic dermatophytes, as, for example Microsporum (M) canis or Trichophyton (T) mentagrophytes and increasingly by anthropophilic fungi. T tonsurans was commonly related to the Tinea gladiatorum, where transmission occurred between infected persons or via contaminated floors.

OBJECTIVE

Reporting the transmission of this highly contagious dermatophyte for the first time via beard shaving and hairdressing in barber shops in Germany.

PATIENTS AND METHODS

18 young male patients developed tinea capitis and/or barbae shortly after shavings of the beard and/or hair in a barber shop. Native, cultural and molecular diagnostics as well as tissue biopsies and resistance tests were performed of skin and hair samples.

RESULTS

In all samples, T tonsurans could be identified. The medical history and the clinical picture suggest a transmission through contaminated hairdressing tools. The patients were treated with terbinafine or itraconazole in combination with or exclusively with topical antimycotics.

CONCLUSION

The transmission and a resulting increase in the incidence of infections with T tonsurans may be due to shavings with direct skin contact of insufficiently disinfected hairdressing tools. This path of infection has already been observed in Africa and is now being described for the first time in Germany. Knowledge of the pathogen and its transmission ways are essential to interrupt the chain of infection.

Tinea capitis mimicking dissecting cellulitis in three children

Tinea capitis mimicking dissecting cellulitis is a rare presentation, and there is a paucity of information regarding this presentation in the literature. Three children 10-14 years of age who presented with an unusual clinical manifestation of tinea capitis that clinically resembled dissecting cellulitis are reported. The patients were treated with systemic antifungals for 3-4 months. Treatment success was measured according to repeat fungal cultures and clinical assessment of hair regrowth at follow-up visits. All three patients had resolution of infection, with negative repeat fungal cultures and complete hair regrowth without scarring. These cases highlight a rare inflammatory subtype of tinea capitis that can be easily misdiagnosed and therefore improperly treated, prolonging the duration of infection.

Prevalence of Tinea Capitis among School Children in Nok Community of Kaduna State, Nigeria

In recent years, the prevalence of tinea capitis, an infection of the scalp by dermatophytes, has increased in children worldwide. This cross-sectional study was carried out to determine the prevalence and risk factor of tinea capitis among school children in Nok community of Kaduna State, Nigeria. A total of 100 children were screened and 45% were diagnosed to have tinea capitis after fungal culture and microscopy. The prevalence of tinea capitis among girls was higher (51.4%) than that among boys (41.5%) but not significantly different (p = 0.402). The prevalence with respect to age was lower for the age group 5-10 years (42.6%) than that of 11-15 years (50%) but was not significantly different (p = 0.524). Trichophyton rubrum (28.8%) and Microsporum canis (22.7%) were the most prevalent dermatophytes isolated and the least were Trichophyton verrucosum (4.5%) and Trichophyton tonsurans (4.5%). There were 73.3% single infection while 26.7% had 2-4 dermatophytes of the genera Microsporum and Trichophyton. The predisposing factors with statistically significant association with tinea capitis were number of children in the family (p = 0.02) and sharing of the same bed (p = 0.002). This indicates the high tendencies of spread of tinea capitis through human-to-human mode of transmission and possible animal contact. Community health education on the cause, mode of transmission, prevention, and prompt treatment of tinea capitis is recommended.

Skin diseases among internally displaced Tawerghans living in camps in Benghazi, Libya

BACKGROUND

Benghazi has received many internally displaced persons (IDPs) from other Libyan cities as a result of the armed conflict in Libya. These groups have significant health problems associated with their displacement, including skin diseases.

OBJECTIVES

This study aimed to determine the spectrum and frequency of skin diseases among people living in IDP camps in Benghazi.

METHODS

A total of 480 IDP camp residents with complaints of skin diseases were studied over a period of 6 months.

RESULTS

All subjects were ethnic Tawerghans; about three-quarters were female and half were adults. The disease types found to occur at the highest frequencies were skin infections (40.0%), followed by xerosis (31.3%), eczema (18.3%), acne (17.0%), hair-related diseases (6.7%), and psychosomatic diseases (3.0%).

CONCLUSIONS

People who are resident in IDP camps have skin problems similar to those of other populations in similar circumstances. They have increased vulnerability to infections, environment-associated disorders such as xerosis cutis and eczema, and diseases of psychosomatic origin.

Management of a Trichophyton tonsurans outbreak in a day-care center

Trichophyton tonsurans is the leading cause of tinea capitis in the United Kingdom (UK) as well as causing tinea corporis. This organism has been linked to several outbreaks in the UK and abroad, and such outbreaks may be prolonged since T. tonsurans can be difficult to control. There remains an incomplete consensus in the literature on the optimal management of such outbreaks of this infection. Following notification that a child with T. tonsurans was identified at a day-care center in the UK, initial investigations identified nine cases of fungal infection involving children and staff over the previous 7 months. We report on the management of an outbreak of T. tonsurans tinea capitis and tinea corporis among children and staff in a day-care center. An outbreak control team with representatives from dermatology, microbiology, day-care center management, and the Health Protection Agency initiated case ascertainment by scalp inspection and brushing of all children and staff at the nursery. Two complete rounds of screening were required before the outbreak was declared over. Infection control measures included antifungal shampoo use, exclusion of identified cases for a short period, removal of shared items from the center, and enhanced decontamination of fomites. The outbreak, which lasted longer than 12 months, involved 12 children and 7 staff members. Of these, 12 cases were confirmed by positive fungal culture. T. tonsurans is difficult to manage, especially in childcare settings, but case ascertainment, appropriate treatment with oral agents, and sustained infection control measures can be effective in controlling such outbreaks.

Associated disorders of Chiari Type I malformations: a review

A single pathophysiological mechanism of Chiari Type I malformations (CM-I) has been a topic of debate. To help better understand CM-I, the authors review disorders known to be associated with CM-I. The primary methodology found among most of them is deformation of the posterior cranial fossa, usually with subsequent decrease in volume. Other mechanisms exist as well, which can be categorized as either congenital or acquired. In understanding the relationship of such disorders with CM-I, we may gain further insight into the process by which cerebellar tonsillar herniation occurs. Some of these pathologies appear to be true associations, but many appear to be spurious.

National athletic trainers' association position statement: skin diseases

OBJECTIVE

To present recommendations for the prevention, education, and management of skin infections in athletes.

BACKGROUND

Trauma, environmental factors, and infectious agents act together to continually attack the integrity of the skin. Close quarters combined with general poor hygiene practices make athletes particularly vulnerable to contracting skin diseases. An understanding of basic prophylactic measures, clinical features, and swift management of common skin diseases is essential for certified athletic trainers to aid in preventing the spread of infectious agents.

RECOMMENDATIONS

These guidelines are intended to provide relevant information on skin infections and to give specific recommendations for certified athletic trainers and others participating in athletic health care.

Chronically recurrent and disseminated tinea faciei/corporis--autoinoculation from asymptomatic tinea capitis carriage

We report clinical findings in a 12-year-old girl with long-term recurrent and disseminated multiple eruptions of tinea faciei and tinea corporis, which persisted for 10 years. Mycological examination revealed the dermatophyte Trichophyton tonsurans in both scale samples from the body lesions and in brushing samples from her asymptomatic scalp, suggesting that she was an asymptomatic dermatophyte carrier on the scalp, and autoinoculation of the dermatophyte was responsible for the recurrent and disseminated tinea faciei/corporis.

Hair care practices and their association with scalp and hair disorders in African American girls

BACKGROUND

Few studies have extensively examined the prevalence of hair care practices and their association with scalp and hair conditions in African American girls.

OBJECTIVES

We sought to determine the prevalence of hair care practices and their association with traction alopecia, seborrheic dermatitis (SD), and tinea capitis (TC).

METHODS

A questionnaire was administered to caregivers of African American girls aged 1 to 15 years. Multivariate analyses were performed to determine the association of hair care practices with reported disorders.

RESULTS

A total of 201 surveys were completed from dermatology (n = 98) and nondermatology (n = 103) clinics. Mean patient age was 9.8 ± 4.4 years. Essentially all respondents reported use of hair oils/grease (99%). Ponytails, braids, and cornrows were worn by 81%, 67%, and 49% of girls, respectively, within the past 12 months. In all, 61% reported hair washing every 2 weeks; 80% used hot combs; and 42% used chemical relaxers. Cornrows were significantly related to traction alopecia among respondents from nondermatology clinics only: adjusted odds ratio = 5.79 (95% CI 1.35-24.8, P = .018). Hair extensions and infrequent hair oil use were significantly related to SD: adjusted odds ratio = 2.37 (95% CI 1.03-5.47, P = .04) and 3.69 (95% CI 1.07-12.7, P = .039), respectively. No significant associations were observed for TC.

LIMITATIONS

Small sample size and disorders reported by caregivers were limitations.

CONCLUSIONS

Certain hair care practices were strongly associated with development of traction alopecia and SD. No association was found between hair washing frequency and SD or TC, or between hair grease use and TC. These results can be used to inform practitioners, advise parents, and adapt treatment regimens to accommodate cultural preferences.

Griseofulvin and its uses

Griseofulvin has been used in the treatment of dermatophyte infections for the past 30 years. The use of the drug in treating other medical conditions is reviewed.

Safety and efficacy of terbinafine in a pediatric Iranian cohort of patients with Tinea capitis

BACKGROUND AND OBJECTIVES

Tinea capitis is a common infection of the scalp and hair shaft caused by dermatophyte fungi that mainly affects prepubescent children. Systemic therapy is required for treatment and to prevent spread. The aim of present study was to assess the effect of terbinafine for Tinea capitis treatment in children.

METHODS

Thirty Iranian pediatric patients with a clinical diagnosis of Tinea capitis were enrolled in the study. The Study was conducted in a general and referral teaching hospital (Imam Medical Centre - Tehran, Iran) from 2006 to 2007. Eligible patients with less than 20 kg of body weight were given 62.5 mg terbinafine, and for patients between 20 and 40 kg the dose was 125 mg, on the first visit. All patients had the second clinical visit and second samples for microscopic study were taken. For each patient, direct mycology test (KOH test) and mycological culture were carried out before the study was started and after second, fourth, fifth, sixth and eighth weeks. Probable drug's adverse effects were also recorded.

RESULTS

Based on the results of mycological culture of patients' lesions, Microsporum canis and Trichophyton sheonlini were considered as major causes of Tinea capitis in these children. Out of 30 study patients, KOH test of 93% in the 5th week and 100% in the 6th week was negative. All patients healed completely from signs of infection, after six weeks. Also, no severe side effects were seen in any patients.

CONCLUSION

According to the results of this study, the use of terbinafine is an effective therapy in Iranian cases of Tinea capitis in children without severe side effects.

Tinea capitis among children in the Columbus area, Ohio, USA

Tinea capitis is a fungal infection of the hair follicles of the scalp. In the US, the most common organisms have traditionally been Trichophyton tonsurans, and occasionally Microsporum canis. This study was designed to examine patterns of organisms causing tinea capitis and determine factors associated with infection. A retrospective database analysis was conducted to locate records of patients with tinea capitis from May 2001 to May 2006 at Nationwide Children's Hospital in Columbus, OH. Descriptive statistics, frequency analysis, chi-squared test, and Student's t-test were performed to evaluate types of causative organisms and associated patient characteristics. One hundred and eighty-nine charts of patients with a positive scalp culture for tinea capitis were located. Trichophyton tonsurans (88.9%) was the foremost causative agent followed by Trichophyton violaceum (4.2%). Tinea capitis was more prevalent among African Americans and was more common in urban areas (P < 0.05). Children of African descent inhabiting urban settings were most vulnerable to tinea capitis. The most common organism isolated in this retrospective study was T. tonsurans. Trichophyton violaceum and Trichophyton soudanense were also isolated, which are not commonly reported causes of tinea capitis in the US.

Multilocus genotyping identifies infections by multiple strains of Trichophyton tonsurans

Acquisition of multiple genetic strains of a single dermatophyte species should not be unexpected in areas of high endemicity, and yet multistrain infections are infrequently reported. This communication details mixed Trichophyton tonsurans infections and highlights the need to confirm the presence of multiple strains in a clinical single isolate by use of a multilocus approach.

A twenty-year survey of dermatophytoses in Braga, Portugal

BACKGROUND

Modifications in social habits together with the increase of emigration have contributed not only to increased dermatophytoses but also to an altered etiology. During the last few years, Braga has suffered a radical change from a rural to a cosmopolitan life-style.

METHODS

A statistical study of dermatophytoses and the etiology of their causative agents was performed by a retrospective survey carried out among patients of Hospital de São Marcos, Braga, Portugal, from 1983-2002. In this study, a total of 10,003 patients were analyzed.

RESULTS

Over this period the frequency of dermatophytoses, as defined by the recovery of a dermatophyte in culture, was found to be 23.6%, whereas nondermatophytic infections accounted for 7.0%. Analysis of the clinical forms and the isolated fungi supports that the dermatophyte species have a predilection for certain body areas (P <or= 0.01). Age is a very important factor regarding the occurrence of dermatophytoses (P <or= 0.0001), with a correlation between increasing age and infection, positive for Trichophyton rubrum and negative for Microsporum canis. Overall the gender of the patients is not an association factor for the development of dermatophytoses; however, significant differences were detected in the distribution of some etiologic agents (P <or= 0.05).

CONCLUSIONS

The results showed the main etiologic agent of dermatophytoses to be Trichophyton rubrum (37.4%). Moreover, dermatophytoses are both decreasing and showing a new profile in Braga, and a pronounced decrease of Trichophyton megninii was observed throughout the study.

Training Room Management of Medical Conditions: Sports Dermatology

Athletes' skin is subject to a distinct array of physical and environmental stressors. Trauma, the elements, and pathogenic organisms constantly challenge the skin's integrity. This article intends to arm the clinician with a fundamental knowledge of infections, mechanical injuries, and environmental insults common to the skin of athletes. Photographs corresponding to the described entities are included as figures. Because rapid return to play is the ultimate goal after injury or illness, there is a section dedicated to play restrictions as set forth by the National Collegiate Athletic Association. Although the evaluation and management of cutaneous disease is a challenging endeavor, a consistent and systematic approach to this most accessible organ can result in early diagnosis, appropriate treatment, and ultimate performance.

Tinea capitis caused by Microsporum canis treated with terbinafine

Tinea capitis is a disease found throughout the world. It frequently affects children and only rarely adults, usually post-menopausal women. Numerous dermatophytes of the genus Microsporum and Tricophyton can cause tinea capitis and griseofulvin is still today the treatment of choice. To study the effectiveness and tolerability of terbinafine treatment in tinea capitis caused by Microsporum canis we treated 26 patients - 22 children and four women - for a period of 12 weeks. Dosage adopted was 62.5 mg day(-1) in patients weighing less than 20 kg, 125 mg day(-1) in those weighing between 20 and 40 kg, and 250 mg day(-1) in patients weighing more than 40 kg. Clinical and mycological healing was achieved in 22 patients (84.6%), tolerability was excellent and in no cases were side effects or abnormal results in blood chemistry tests observed.

Prevalence of scalp scaling in prepubertal children

OBJECTIVE

To determine the prevalence and most common etiologies of scalp scaling in infants and prepubertal children and the specificity of head and neck lymphadenopathy for the diagnosis of tinea capitis associated with scalp scaling.

DESIGN/METHODS

A cross-sectional study of 300 children, 200 from an urban general pediatric practice and 100 from 2 urban pediatric dermatology practices, was conducted. Half of the subjects were <2 years old, and half were 2 to 10 years old. Demographic data, medical history, and clinical data noting the presence of scalp scaling and other scalp signs and symptoms, as well as adenopathy of the head and neck, were collected.

RESULTS

Scalp scaling was seen in 66 (22%) children. There was an insignificantly higher prevalence of scalp scaling in those <2 years old compared with the 2- to 10-year-old group. In those <2 years old with scalp scaling, the most common diagnoses were seborrheic dermatitis (thick, adherent, greasy scale predominantly in the frontal and/or vertex areas of the scalp) and atopic dermatitis/eczema. Among those 2 to 10 years old with scalp scaling, the most common diagnoses were nonspecific (fine, white) scaling, seborrheic dermatitis, and atopic dermatitis/eczema. Nine (3%) patients were culture-positive for a dermatophyte, all of whom were black, and grew Trichophyton tonsurans. More than half (52.7%) of all patients had head and neck adenopathy. The presence of posterior nodes was significantly associated with atopic dermatitis/eczema and marginally associated with a positive dermatophyte culture. The presence of scalp scaling plus posterior adenopathy was significantly associated with seborrheic dermatitis and a positive dermatophyte culture in the entire study population and with atopic dermatitis in the pediatric dermatology clinics.

CONCLUSIONS

Scalp scaling was common in children 0 to 10 years old. Infantile-type seborrheic dermatitis was noted in both age groups: it was 3 times as likely in children <2 years old (18%) than in those 2 to 10 years old (6%). Contrary to traditional teaching, seborrheic dermatitis can be found in preadolescent children. Atopic dermatitis/eczema was associated with scalp scaling in both age groups. Head and neck adenopathy was very common and nonspecific for any 1 diagnosis. Posterior adenopathy with concurrent scalp scaling was significantly associated with seborrheic dermatitis, a positive dermatophyte culture, and atopic dermatitis. In this nonselected pediatric population, scalp scaling with adenopathy was not associated exclusively with tinea capitis.

Tinea capitis favosa in Poland. Fallberichte. Tinea capitis favosa in Polen

Tinea capitis favosa is uncommon in Europe. We describe two patients who had local alopecia caused by Trichophyton schoenleinii. In the first case, we observed good clinical response after griseofulvin treatment and in the second case after topical application of ciclopirox cream.

Trichophyton rubrum tinea capitis in a young child

While the primary etiologic agent of tinea capitis in the United States has varied over the past century, the last several decades have been marked by a predominance of infection with Trichophyton tonsurans. Related anthropophilic organisms commonly isolated in other dermatophytoses are infrequently observed in tinea capitis. We report the unusual occurrence of tinea capitis in a young boy infected with Trichophyton rubrum.

Prevalence of tinea capitis in primary schools in Turkey

The aim of our study was to determine the prevalence of tinea capitis in Middle Anatolia. Between February 2000 and April 2000, a school survey of 4760 primary school children was carried out and 34 cases of tinea capitis were clinically diagnosed. Sixteen (0.3%) of them were diagnosed both clinically and using culture. Eighteen cases (52.9%) were diagnosed microscopically whereas the remaining 16 cases (47.0%) had a clinical diagnose. We also isolated and identified the following species of fungi causing the infection: Trichophyton verrucosum (five cases), T. rubrum (three), T. mentagrophytes var. mentagrophytes (three), Microsporum canis (three) and T. tonsurans (two). We detected a higher rate of infection than that of the country's average.

Characteristics of superficial mycoses in Malta

BACKGROUND

A study was conducted to determine the chief agents of superficial mycoses in Malta. Data were collected over a 5-year period from mycologic investigations carried out on all dermatologic specimens sent to the Mycology Laboratory at St. Luke's Hospital in Malta.

METHODS

In the period between January 1995 and December 1999, a total of 1271 specimens from skin, nails, or hair were collected from 1200 clinically suspected cases of dermatomycoses.

RESULTS

The fungi cultivated included dermatophytes (n = 371), yeasts (n = 33), and nondermatophyte filamentous fungi (n = 12). Trichophyton rubrum (n = 121) was the most prevalent, followed by Microsporum canis (n = 109), T. mentagrophytes (n = 80), M. gypseum (n = 27), Epidermophyton floccosum (n = 17), T. soudanense (n = 10), T. tonsurans (n = 2), T. verrucosum (n = 2), M. persicolor (n = 1), and T. violaceum (n = 1). Candida species were also cultivated, with C. parapsilosis (n = 14) being the most common, followed by C. albicans (n = 12) and C. tropicalis (n = 6). Nondermatophyte filamentous fungi were isolated from nail specimens only.

CONCLUSIONS

In this study, superficial fungal infections were reported more commonly in female (n = 207) than in male (n = 182) patients. M. canis was the chief agent of tinea capitis and tinea corporis, whilst T. rubrum was the main causative agent of tinea pedis, tinea manuum, and tinea unguium. Onychomycosis due to Candida species was more common in female than in male patients.

Tinea capitis due to Trichophyton rubrum in a neonate

Tinea capitis is a common infection of school-aged children, but there have been only a few reports of tinea capitis in newborns. Furthermore, Trichophyton rubrum as a causative organism of tinea capitis is documented very rarely. We report herein a neonate in whom T. rubrum was the causative agent. This boy was successfully treated with three pulses of oral itraconazole solution.

Epidemiology of dermatophytoses in children living in northeast France: a 5-year study

Dermatologic fungal infections are thought to occur less frequently in children than in adults. This study, performed over a 5-year period, emphasizes the interregional variability of dermatophytes that cause skin and cutaneous apprendageal diseases in children. In northeast France, two-thirds of dermatophytoses are due to zoophilic fungi, while they are most commonly caused by anthropophilic agents in the Paris region and in other countries. The clinical features of pediatric dermatophytoses vary with the age of the child: tinea capitis and tinea corporis are far more frequent before the age of 12 years. After the age of 12, even if these are still quite frequent, tinea pedis and onychomycosis become more common.

Tinea due to Trichophyton violaceum and Trichophyton soudanense in Hamilton, New Zealand

Between 1994 and 2000, 63 isolates of Trichophyton violaceum and five isolates of Trichophyton soudanense were recorded in both private and public laboratories in Hamilton, New Zealand. A retrospective analysis of medical records of these patients was performed. From these 68 isolates, 58 were recovered from scalp specimens and 10 were recovered from other body sites. There were 51 patients with tinea capitis and nine patients in the tinea corporis group. Six patients had more than one isolate reported at different laboratories. As expected, the vast majority of scalp infections (46/51 patients) were children, with an overall median age of 6 years (range 8 months to 66 years). All patients in the tinea capitis group, except one, were refugee immigrants from East Africa. Of nine patients in the tinea corporis group, six were refugees from the same area. For tinea capitis, 31 patients received systemic antifungal therapy for at least 4 weeks, with either terbinafine (21 patients), griseofulvin (four patients) or itraconazole (six patients). Five patients received topical antifungal creams or shampoo as monotherapy only. The remainder (15 patients) received either no therapy or no record was available. The emergence of these two pathogens as causes of tinea capitis in Hamilton closely correlates with the increasing number of refugees from endemic areas. There is a high rate of person-to-person transmission with these anthropophilic organisms in children as well as adults in the family. Transmission of infection to the local population has been observed, but there is no evidence to date to suggest that these organisms have become endemic in the local population.

Systemic antifungal agents

Anti-fungal agents are classified under two major headings, systematic and topical agents. Only systematic anti-fungal agents will be discussed in this chapter. Since the discovery in 1955, amphotericin B has been the cornerstone of anti-fungal treatment. It is active against most species of fungi. However, Candida lusitaniae, Pseudallescheria boydii, and fusarium spp have primary resistance to amphotericin B. Recently, new liposomal preparations of amphotericin B have been developed. They are less nephrotoxic. The azole family of anti-fungal includes two broad classes: the imidazoles (clotrimazote, ketoconazote, miconazole) and the triazoles (flucouazole and itracouazole). Imidazoles are still widely used for the treatment of superficial mycoses and vaginal candidiasis. The systematic triazoles are more slowly metabolized and have less effect on human synthesis than imidazoles, hence they are preferred for systemic therapy. Flucytosine is a fluorinated pyrimidine. Clinically, the principal use of flucytosine is as adjunctive therapy with amphotericin B in the treatment of candidial or cryptococcal diseases, Griseofuluin is derived from penicillium. It is fungistatic in vitro for species of dermatophytes. It is useful for the treatment of tinea capitis and tinea unginum.

[Epidemiology and ecology of dermatophytoses in the City of Fortaleza: Trichophyton tonsurans as important emerging pathogen of Tinea capitis]

Dermatophytosis is the most common skin infectious disturbance in the world. In this research 2,297 patients were evaluated with suspected clinical lesions of dermatophytosis. It was observed that, 534 (23.2%) patients tested positive for dermatophytes. T. rubrum was the most prevalent specie (49.6%; p < or = 0.05), followed by T. tonsurans (34.4%), M. canis (7%) and T. mentagrophytes (6.2%). When the species isolated was correlated with the respective anatomical localization, it was observed that T. tonsurans was the most frequent isolated in scalp lesions (73.9%; p < or = 0.01). On the other hand, T. rubrum was the main specie involved in body lesions (72.8%; p < or = 0.05). Therefore, in scalp infections it was observed that, there was an absolute prevalence of T. tonsurans. This evidence is different from the statistical data collected in the southeast and south of Brazil, as well as from other areas of the world, which still show M. canis as the most frequent microorganism isolated in Tinea capitis.

Trichophyton tonsurans tinea capitis and tinea corporis: treatment and follow-up of four affected family members

We report a Caucasian family of two veterinary practitioners and their two children, ages 2 years and 6 months, simultaneously infected with the dermatophyte Trichophyton tonsurans, causing tinea capitis and tinea corporis in the children and tinea corporis in the parents. The parents and older child were successfully treated with oral terbinafine. The infant clinically responded to treatment with topical terbinafine and ketoconazole shampoo but presented with recurrent tinea capitis 12 months later, from which T. tonsurans was cultured. At this time, scalpbrush samples from the other family members failed to culture any fungi, and neither were fungi isolated from the family hairbrushes. The infant then received oral terbinafine, resulting in clinical and mycologic cure. After a further 12 months follow-up, there has been no mycologic evidence of recurrence in any family member.

Tinea capitis

Tinea capitis is a common dermatophyte infection of the scalp in children. Dermatophytes are classified into three genera; tinea capitis is caused predominantly by Trichophyton or Microsporum species. On the basis of host preference and natural habitat, dermatophytes are also classified as anthropophilic, geophilic and zoophilic. The etiological agents of tinea capitis usually fall in the first and last categories. In North America, tinea capitis is now predominantly due to Trichophyton tonsurans. During the past 100 years the most common North American organism for tinea capitis was initially Microsporum canis followed later by M. audouinii. In other parts of the world the epidemiology varies. Tinea capitis is generally observed in children over the age of 6 years and before puberty, with African Americans being the most affected group. Clinical presentations are seborrheic-like scale, 'black dot' pattern, inflammatory tinea capitis with kerion and tiny pustules in the scalp. The clinical diagnosis should be confirmed by mycological examination. Wood's light examination was of value in diagnosing tinea capitis due to M. canis and M. audouinii; however, it is not helpful in T. tonsurans tinea capitis. Asymptomatic carriers may be a significant reservoir of infection and spread of spores may also involve inanimate objects. Carriers may benefit from shampooing their hair. Treatment of tinea capitis requires an oral antifungal agent. The data from the use of terbinafine, itraconazole and fluconazole are promising and suggest that these agents have an efficacy similar to griseofulvin while shortening the duration of therapy. Both griseofulvin and the newer antimycotics have a favorable adverse-effect profile and are associated with high compliance.

Oral griseofulvin remains the treatment of choice for tinea capitis in children

Tinea capitis is one of the most common infections of children. The standard treatment is griseofulvin. Itraconazole and terbinafine have in large part replaced griseofulvin in the treatment of onychomycosis and, in addition to fluconazole and ketoconazole, are evolving treatments for tinea capitis. The purpose of this review is to compare the efficacy, safety, and cost of oral antifungal agents for tinea capitis. Small, open-label studies of itraconazole, terbinafine, and fluconazole have reported encouraging results, suggesting that these drugs may be effective alternatives to griseofulvin; however, in large controlled studies griseofulvin continues to exhibit greater or equal efficacy. Ketoconazole appears to be the least efficacious. All five drugs appear relatively safe, however, only griseofulvin has a long track record of safety, is Food and Drug Administration (FDA) approved for the treatment of tinea capitis in children, and has the least known drug interactions. Fluconazole is FDA approved for use in children more than 6 months of age, yet not for the treatment of tinea capitis. Oral griseofulvin and terbinafine tablets are the least expensive of the antifungal agents; griseofulvin suspension is, however, more expensive than fluconazole suspension. For the combined reasons of efficacy, safety, and cost, and a long track record of use, we feel oral griseofulvin is still the present treatment of choice for tinea capitis. Newer antifungals are currently under investigation, and their role in treating tinea capitis in children is still being defined.

Successful treatment of tinea capitis with 2% ketoconazole shampoo

BACKGROUND

Oral antifungal drugs are required for effective treatment of tinea capitis. Topical antifungal shampoo's, namely ketoconazole 2% shampoo or products with selenium sulfide or salicylic acid are recommended as adjunctive therapy. Topical antifungal monotherapy has not been successful in the treated of tinea capitis. The purpose of this open study was to evaluate ketoconazole 2% shampoo as a monotherapy for the treatment of tinea capitis.

METHOD

A total of 16 black children, aged 3-6, all with proven tinea capitis caused by Trichophyton tonsurans, were treated daily for 8 weeks with 2% ketoconazole shampoo for a total of 56 treatments. Clinical and mycologic examinations were performed every 2 weeks and again at 4 weeks following treatment. The number of colonies were counted on each plate after each visit. Patients with positive cultures after 8 weeks were placed on oral griseofulvin; those with negative cultures were followed monthly by culture for an additional 12 months.

RESULTS

Marked clinical improvement occurred in all patients within 2 weeks and absence of pruritus was noted by the patients as early as 2-6 days. After 8 weeks of shampoo, 14 of the 15 (93%) children were clinically healed. Mycologically, the cultures dropped from a confluent growth of T. tonsurans to less than 100 colonies within 2 weeks; fewer than 50 at week 4 and 20 colonies or fewer after week 6. At 8 weeks of treatment the number of colonies remained at 20 or fewer. Six of the 15 children (40%) had negative cultures after 2, 4, and 6 weeks. One child relapsed at the first 4-week follow-up visit. Five of 15 (33%) of the children remained culturally negative for 12 months post-treatment.

CONCLUSIONS

Ketoconazole 2% shampoo alone reduces the number of viable arthroconidia in children with tinea capitis thus reducing the transmissibility and contagious nature of the disease. Unexpectedly, complete cure was obtained in 5/15 (33%) of the children. The children remained clinically and mycologically clear as long as one year after treatment.

Comparison of terbinafine and griseofulvin in the treatment of tinea capitis

BACKGROUND

Griseofulvin has been used for many years in the treatment of tinea capitis. Increase in resistance to this medication has led to a search for new therapeutic alternatives.

OBJECTIVE

Our purpose was to evaluate the therapeutic efficacy of terbinafine in comparison with griseofulvin in the treatment of tinea capitis.

METHODS

We performed a double-blind, randomized, prospective evaluation of 50 patients with a clinical and mycologic diagnosis of tinea capitis. One group received 4 weeks of terbinafine followed by 4 weeks of placebo. The other group received 8 weeks of griseofulvin. We evaluated 5 clinical parameters. Mycologic examinations were performed at baseline and at the end of weeks 8 and 12.

RESULTS

Patients' ages ranged from 1 to 14 years. Fifty-four percent were girls and 46% were boys. Mycologic examinations disclosed Trichophyton tonsurans in 74% of patients and Microsporum canis in 26%. At week 8, the griseofulvin-treated group showed a cure rate of 76%, and the terbinafine-treated group 72%. At week 12, the efficacy of griseofulvin decreased to 44%, whereas the efficacy of terbinafine was 76%.

CONCLUSION

Terbinafine constitutes an alternative for the treatment of tinea capitis. Recurrences were less frequent. No significant side effects were reported.

A risk-benefit assessment of the newer oral antifungal agents used to treat onychomycosis

The newer antifungal agents itraconazole, terbinafine and fluconazole have become available to treat onychomycosis over the last 10 years. During this time period these agents have superseded griseofulvin as the agent of choice for onychomycosis. Unlike griseofulvin, the new agents have a broad spectrum of action that includes dermatophytes, Candida species and nondermatophyte moulds. Each of the 3 oral antifungal agents, terbinafine, itraconazole and fluconazole, is effective against dermatophytes with relatively fewer data being available for the treatment of Candida species and nondermatophyte moulds. Itraconazole is effective against Candida onychomycosis. Terbinafine may be more effective against C. parapsilosis compared with C. albicans; furthermore with Candida species a higher dose of terbinafine or a longer duration of therapy may be required compared with the regimen for dermatophytes. The least amount of experience in treating onychomycosis is with fluconazole. Griseofulvin is not effective against Candida species or the nondermatophyte moulds. The main use of griseo-fulvin currently is to treat tinea capitis. Ketoconazole may be used by some to treat tinea versicolor with the dosage regimens being short and requiring the use of only a few doses. The preferred regimens for the 3 oral antimycotic agents are as follows: itraconazole - pulse therapy with the drug being administered for 1 week with 3 weeks off treatment between successive pulses; terbinafine - continuous once daily therapy; and fluconazole - once weekly treatment. The regimen for the treatment of dermatophyte onychomycosis is: itraconazole - 200mg twice daily for I week per month x 3 pulses; terbinafine - 250 mg/day for 12 weeks; or, fluconazole - 150 mg/wk until the abnormal-appearing nail plate has grown out, typically over a period of 9 to 18 months. For the 3 oral antifungal agents the more common adverse reactions pertain to the following systems, gastrointestinal (for example, nausea, gastrointestinal distress, diarrhoea, abdominal pain), cutaneous eruption, and CNS (for example, headache and malaise). Each of the new antifungal agents is more cost-effective than griseofulvin for the treatment of onychomycosis and is associated with high compliance, in part because of the shorter duration of therapy. The newer antifungal agents are generally well tolerated with drug interactions that are usually predictable.

Identification and genetic homogeneity of Trichophyton tonsurans isolated from several regions by random amplified polymorphic DNA

Trichophyton tonsurans is an anthropophilic dermatophyte mostly causing tinea capitis and tinea corporis. This study was carried out to identify T. tonsurans and to clarify whether it has any genetic differences depending on the phenotype or region of isolation by random amplified polymorphic DNA (RAPD) analysis with three random primers. The assay was performed in 11 Korean, 2 Japanese, 2 Taiwanese, 5 Brazilian and 1 American isolates of T. tonsurans together with the other 10 anamorphic species of dermatophytes and 3 Arthroderma spp. All tested species of dermatophytes showed distinct bands and T. tonsurans was differentiated from other dermatophytes. It was most clearly differentiated from T. mentagrophytes by using primer 5'-GAAGGCTCCC-3' (OPAO-15). No difference was found in RAPD band patterns in all strains of T. tonsurans with these random primers. It was considered that T. tonsurans is a genetically homogeneous species regardless of its isolation regions, morphologic or physiologic characteristics.

Use of the cotton swab method in diagnosing Tinea capitis

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.

Short duration treatment with terbinafine for tinea capitis caused by Trichophyton or Microsporum species. The Study Group

Thirty-five patients with mycologically proven scalp infections were enrolled in a randomized, double-blind clinical trial with oral terbinafine (dose adjusted according to patient weight) for either 1 or 2 weeks. Patients were observed for 12 weeks; after 4 weeks, non-responders were offered an additional 4 weeks of treatment followed by a second observation period. The causative organisms were Microsporum canis (n = 12), Trichophyton tonsurans (n = 12) and other Trichophyton spp. (n = 11). The Trichophyton infections were treated effectively in five of nine (56%) patients treated for 1 week and 12 of 14 (86%) patients treated for 2 weeks. Three of the non-responders were treated for an additional 4 weeks, and one responded. In the Microsporum group only one of seven patients treated for 1 week and none of five treated for 2 weeks responded. However, treatment was effective in four of six (66%) patients treated for an additional 4 weeks. Mild to moderate adverse events believed to be drug related occurred in four patients in each of the two groups. Terbinafine is well tolerated, and requires 2 weeks of treatment in most patients with Trichophyton scalp infections and 4 weeks or more in Microsporum scalp infections, to achieve a successful clinical and mycological response.

Current and emerging azole antifungal agents

Major developments in research into the azole class of antifungal agents during the 1990s have provided expanded options for the treatment of many opportunistic and endemic fungal infections. Fluconazole and itraconazole have proved to be safer than both amphotericin B and ketoconazole. Despite these advances, serious fungal infections remain difficult to treat, and resistance to the available drugs is emerging. This review describes present and future uses of the currently available azole antifungal agents in the treatment of systemic and superficial fungal infections and provides a brief overview of the current status of in vitro susceptibility testing and the growing problem of clinical resistance to the azoles. Use of the currently available azoles in combination with other antifungal agents with different mechanisms of action is likely to provide enhanced efficacy. Detailed information on some of the second-generation triazoles being developed to provide extended coverage of opportunistic, endemic, and emerging fungal pathogens, as well as those in which resistance to older agents is becoming problematic, is provided.

Trichophyton antigens associated with IgE antibodies and delayed type hypersensitivity. Sequence homology to two families of serine proteinases

The dermatophyte fungus Trichophyton exhibits unique immunologic properties by its ability to cause both immediate and delayed type hypersensitivity. An 83-kDa Trichophyton tonsurans allergen (Tri t 4) was previously shown to elicit distinct T lymphocyte cytokine profiles in vitro. The homologous protein, Tri r 4, was cloned from a Trichophyton rubrum cDNA library, and the recombinant protein was expressed in Pichia pastoris. This 726-amino acid protein contained an arrangement of catalytic triad residues characteristic of the prolyl oligopeptidase family of serine proteinases (Ser-Asp-His). In addition, a novel Trichophyton allergen, encoding 412 amino acids, was identified by its human IgE antibody-binding activity. Sequence similarity searches showed that this allergen, designated Tri r 2, contained all of the conserved residues characteristic of the class D subtilase subfamily (41-58% overall sequence identity). Forty-two percent of subjects with immediate hypersensitivity skin test reactions to a Trichophyton extract exhibited IgE antibody binding to a recombinant glutathione S-transferase fusion protein containing the carboxyl-terminal 289 amino acids of Tri r 2. Furthermore, this antigen was capable of inducing delayed type hypersensitivity skin test reactions. Our results define two distinct antigens derived from the dermatophyte Trichophyton that serve as targets for diverse immune responses in humans.