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

Tinea capitis caused by Microsporum canis: A case study of three family members in India, a non-endemic region

INTRODUCTION

Tinea capitis, a common scalp infection primarily affecting children, is caused by keratinophilic dermatophytic fungi, notably Microsporum and Trichophyton species. Microsporum canis, primarily transmitted from cats and dogs to humans, is rarely reported in non-endemic regions like India. We report a cases involving three family members from Delhi, India, diagnosed with tinea capitis caused by Microsporum canis. The index case, a five-year-old boy, contracted the infection through contact with a cat, while his younger brother and sister acquired it through human-to-human transmission within the family.

METHODS

Clinical examination, microscopic analysis, and molecular identification techniques confirmed the diagnosis. Antifungal susceptibility testing revealed sensitivity to itraconazole and terbinafine but resistance to griseofulvin.

RESULTS

Treatment with oral terbinafine and topical ketoconazole cream led to successful outcomes for all three patients. Molecular typing confirmed clonality of the isolates, indicating human-to-human transmission.

CONCLUSION

This case study underscores the significance of considering atypical sources of infection and human-to-human transmission in the diagnosis and management of tinea capitis caused by Microsporum canis in non-endemic regions. It emphasizes the necessity of thorough contact history assessment and appropriate antifungal therapy for effective control of the infection.

Tinea Capitis in Children Younger than Two Years Old: A Retrospective Study and Treatment Recommendations

BACKGROUND

Tinea capitis (TC) is a dermatophytosis of the scalp and hair, which occurs less common in children younger than two years of age, and the data of TC in this age group are still unknown.

OBJECTIVES

We aimed to reveal the epidemiological, clinical and mycological characteristics of TC in children under two years old.

METHODS

We retrospectively analyzed all reported cases of TC in children in their first two years of life from 1991 to 2022, by searching PubMed, Embase, Web of Science, CNKI, Wanfang and Weipu databases.

RESULTS

A total of 47 articles involving 126 cases of pediatric TC were enrolled in this study. The sex ratio (M/F) was 1.28:1. The age of the children ranged from ten days old to two years old with a median age of three months. The main clinical manifestations were alopecic patches (40 cases, 31.7%) and scaling (39 cases, 31.0%) on the scalp, and 29 infants (23.0%) appeared kerion. The most common sources of contagion were animals (35 cases, 27.78%) and humans (31 cases, 24.60%). The leading pathogens were Microsporidium canis (64 cases, 50.79%), followed by Trichophyton violaceum (13 cases, 10.32%), T. mentagrophytes complex (12 cases, 9.52%) and T. tonsurans (10 cases, 7.94%). Ninety-five children (75.40%) were treated with systemic antifungal drugs and 22 patients (17.46%) were only treated with topical therapy. Except for 10 patients with unknown final prognosis, all the other cases were cured after treatment. There was one child (0.79%) relapsed after treatment with griseofulvin and one case (0.79%) presented with gastrointestinal symptoms from griseofulvin.

CONCLUSION

The principal clinical symptoms of TC in children less than two years old were alopecic patches and scaling. The top four pathogens were M. canis, T. violaceum, T. mentagrophytes complex and T. tonsurans. Oral treatment for pediatric TC had achieved good therapeutic effects, and topical therapy can be an alternative choice.

Small-molecule inhibitors of ferrochelatase are antiangiogenic agents

Activity of the heme synthesis enzyme ferrochelatase (FECH) is implicated in multiple diseases. In particular, it is a mediator of neovascularization in the eye and thus an appealing therapeutic target for preventing blindness. However, no drug-like direct FECH inhibitors are known. Here, we set out to identify small-molecule inhibitors of FECH as potential therapeutic leads using a high-throughput screening approach to identify potent inhibitors of FECH activity. A structure-activity relationship study of a class of triazolopyrimidinone hits yielded drug-like FECH inhibitors. These compounds inhibit FECH in cells, bind the active site in cocrystal structures, and are antiangiogenic in multiple in vitro assays. One of these promising compounds was antiangiogenic in vivo in a mouse model of choroidal neovascularization. This foundational work may be the basis for new therapeutic agents to combat not only ocular neovascularization but also other diseases characterized by FECH activity.

Presumptive Zoonotic Kerion by Nannizzia gypsea: Case Report

Nannizzia gypsea (formerly Microsporum gypseum) belongs to geophilic dermatophytes, fungi involved in keratin degradation in the soil; however, they are also found in dogs and cats. Transmission to humans can occur directly by contact with soil, but indirect transmission via domestic animals is reported too. The exact source of the infection is usually difficult to assess and in most cases only hypothesised and rarely investigated. This case report describes a kerion caused by N. gypsea in a 2-year-old boy, where the contagion was probably secondary to domestic healthy carrier dogs. A “One-Health” approach involving human dermatologists and veterinarians, combined with the use of conventional and molecular-based techniques, allowed tracing of the epidemiological chain and managing of not only the treatment but also the prevention of a recurrence. The child's lesion began to regress after about 8 weeks of treatment with both systemic and topical therapy, while the dogs were given chlorhexidine and miconazole baths. No recurrences nor new infections occurred, demonstrating the effectiveness of the strategies used.

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.

Formulation and evaluation of cyclodextrin-based nanosponges of griseofulvin as pediatric oral liquid dosage form for enhancing bioavailability and masking bitter taste

The aim of this study was the development of griseofulvin (GRI) loaded β-cyclodextrin (β–CD) based nanosponges for bitter taste masking, improving dissolution rate and oral bioavailability. Plain NS (NS1 NS2 and NS3) were fabricated by reacting β-CD with the cross-linker diphenyl carbonate at different molar ratios (1:2, 1:4 and 1:6, respectively) using ultrasonication method. The NS2 provided both highest %yield and GRI solubilization enhancement. Thus, the drug was loaded in NS2 at different NS2: drug weight ratios in presence or absence of 0.25%w/w polyvinylpyrolidone (PVP k30). The GRI loaded NS (F1) that provided highest drug loading capacity and entrapment efficiency (47.20 ± 0.38%, 84.91 ± 0.30%, respectively) was morphologically examined using scanning electron microscopy (SEM). Also, Particle size, zeta potential, differential scanning calorimetry (DSC), Fourier transform infra-red (FT-IR), nuclear magnetic resonance (NMR) spectroscopy, in-vitro release, taste masking potential were evaluated. Moreover, in-vivo Pharmacokinetic studies were performed on rats. The F1 showed particle size 665.9 ± 13.8 nm and zeta potential −21.5 ± 0.7 mV. The DSC and FT-IR analysis confirmed the complexation of GRI with NS2. Nanosponges (F1) provided 3.19, folds increase in dissolution efficiency %, 2.13 and 3.78 folds increase in C_max and AUC_0-48 compared to plain GRI. Taste masking evaluation confirmed the potential of GRI nanosponges (F1) in masking the bitter taste of GRI completely. The study confirmed that complexation of GRI with NS would be a viable approach for masking the bitter taste of GRI and improving oral bioavailability, that Cmax, Tmax and AUC 0–48 were significantly higher for the developed formulation (F1).

Treatment of Tinea Capitis

Tinea capitis is a common fungal infection of the hair of the scalp affecting predominately prepubertal children. In the US, griseofulvin has been considered a first-line therapy agent for tinea capitis since the 1960s. However, it has been falling out of favor due to significant treatment failure, high cost, and long duration of treatment. Other antifungal agents have been researched as an alternative to griseofulvin. This paper will review the relevant pharmacologic properties, dosing, cost, efficacy, and adverse events profile for griseofulvin, terbinafine, itraconazole, fluconazole, and some adjuvant therapy options such as selenium sulfide shampoos and topical ketoconazole.

Effect of spray-drying temperature on the formation of flower-like lactose for griseofulvin loading

The effect of spray-drying temperature has been studied for the first time on the formation of flower-like lactose for drug loading in this work. The synthesis of the flower-like lactose involves two steps, namely spray drying and ethanol washing. Four inlet temperatures (140°C, 150°C, 160°C and 200°C) have been used in the spray-drying step. The effect of the spray-drying temperature was significant on the formation of flower-like lactose, in terms of crystallinity, porosity and drug loading capacity. Higher inlet temperatures are more likely to produce lactose in the β form. The engineered flower-like lactose is highly porous, with pores of 1.4, 3.4 and 29.3nm (diameter). Compared with other inlet temperatures, the flower-like lactose dried at 150°C has the lowest degree of crystallinity, the largest pore surface area (38±4m²/g) and pore volume (0.65±0.09cm³/g), and the highest griseofulvin loading capacity (16.2±0.3%, w/w). A griseofulvin dissolution test has suggested that the flower-like lactose can be used as a drug carrier to enhance drug solubility.

Tinea Capitis in Children and Trichoscopic Criteria

Tinea capitis is the most common pediatric superficial dermatophyte infection. The causative species vary, as for instance, Microsporum canis predominates in Europe, while Trichophyton tonsurans predominates in North America. Tinea capitis does not respond well to topical therapy alone, thus oral therapy is requisite. The drug of choice is griseofulvin; however in some countries, it is no longer available. Fungal culture should be requested in the persistent, scalp lesion and trichoscopy can put forward a speedy diagnosis by its characteristic findings. Scalp dermoscopy or “trichoscopy” represents a valuable, noninvasive technique for the evaluation of patients with hair loss due to tenia capitis. It is simple, quick, and easy to perform.

Systemic antifungal therapy for tinea capitis in children

BACKGROUND

Tinea capitis is a common contagious fungal infection of the scalp in children. Systemic therapy is required for treatment and to prevent spread. This is an update of the original Cochrane review.

OBJECTIVES

To assess the effects of systemic antifungal drugs for tinea capitis in children.

SEARCH METHODS

We updated our searches of the following databases to November 2015: the Cochrane Skin Group Specialised Register, CENTRAL (2015, Issue 10), MEDLINE (from 1946), EMBASE (from 1974), LILACS (from 1982), and CINAHL (from 1981). We searched five trial registers and checked the reference lists of studies for references to relevant randomised controlled trials (RCTs). We obtained unpublished, ongoing trials and grey literature via correspondence with experts in the field and from pharmaceutical companies.

SELECTION CRITERIA

RCTs of systemic antifungal therapy in children with normal immunity under the age of 18 with tinea capitis confirmed by microscopy, growth of fungi (dermatophytes) in culture or both.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 25 studies (N = 4449); 4 studies (N = 2637) were new to this update.Terbinafine for four weeks and griseofulvin for eight weeks showed similar efficacy for the primary outcome of complete (i.e. clinical and mycological) cure in three studies involving 328 participants with Trichophyton species infections (84.2% versus 79.0%; risk ratio (RR) 1.06, 95% confidence interval (CI) 0.98 to 1.15; low quality evidence).Complete cure with itraconazole (two to six weeks) and griseofulvin (six weeks) was similar in two studies (83.6% versus 91.0%; RR 0.92, 95% CI 0.81 to 1.05; N = 134; very low quality evidence). In two studies, there was no difference between itraconazole and terbinafine for two to three weeks treatment (73.8% versus 78.8%; RR 0.93, 95% CI 0.72 to 1.19; N = 160; low quality evidence). In three studies, there was a similar proportion achieving complete cured with two to four weeks of fluconazole or six weeks of griseofulvin (41.4% versus 52.7%; RR 0.92, 95% CI 0.81 to 1.05; N = 615; moderate quality evidence). Current evidence for ketoconazole versus griseofulvin was limited. One study favoured griseofulvin (12 weeks) because ketoconazole (12 weeks) appeared less effective for complete cure (RR 0.76, 95% CI 0.62 to 0.94; low quality evidence). However, their effects appeared to be similar when the treatment lasted 26 weeks (RR 0.95, 95% CI 0.83 to 1.07; low quality evidence). Another study indicated that complete cure was similar for ketoconazole (12 weeks) and griseofulvin (12 weeks) (RR 0.89, 95% CI 0.57 to 1.39; low quality evidence). For one trial, there was no significant difference for complete cure between fluconazole (for two to three weeks) and terbinafine (for two to three weeks) (82.0% versus 94.0%; RR 0.87, 95% CI 0.75 to 1.01; N = 100; low quality evidence). For complete cure, we did not find a significant difference between fluconazole (for two to three weeks) and itraconazole (for two to three weeks) (82.0% versus 82.0%; RR 1.00, 95% CI 0.83 to 1.20; low quality evidence).This update provides new data: in children with Microsporum infections, a meta-analysis of two studies found that the complete cure was lower for terbinafine (6 weeks) than for griseofulvin (6-12 weeks) (34.7% versus 50.9%; RR 0.68, 95% CI 0.53 to 0.86; N = 334; moderate quality evidence). In the original review, there was no significant difference in complete cure between terbinafine (four weeks) and griseofulvin (eight weeks) in children with Microsporum infections in one small study (27.2% versus 60.0%; RR 0.45, 95% CI 0.15 to 1.35; N = 21; low quality evidence).One study provides new evidence that terbinafine and griseofulvin for six weeks show similar efficacy (49.5% versus 37.8%; RR 1.18, 95% CI 0.74 to 1.88; N = 1006; low quality evidence). However, in children infected with T. tonsurans, terbinafine was better than griseofulvin (52.1% versus 35.4%; RR 1.47, 95% CI 1.22 to 1.77; moderate quality evidence). For children infected with T. violaceum, these two regimens have similar effects (41.3% versus 45.1%; RR 0.91, 95% CI 0.68 to 1.24; low quality evidence). Additionally, three weeks of fluconazole was similar to six weeks of fluconazole in one study in 491 participants infected with T. tonsurans and M. canis (30.2% versus 34.1%; RR 0.88, 95% CI 0.68 to 1.14; low quality evidence).The frequency of adverse events attributed to the study drugs was similar for terbinafine and griseofulvin (9.2% versus 8.3%; RR 1.11, 95% CI 0.79 to 1.57; moderate quality evidence), and severe adverse events were rare (0.6% versus 0.6%; RR 0.97, 95% CI 0.24 to 3.88; moderate quality evidence). Adverse events for terbinafine, griseofulvin, itraconazole, ketoconazole, and fluconazole were all mild and reversible.All of the included studies were at either high or unclear risk of bias in at least one domain. Using GRADE to rate the overall quality of the evidence, lower quality evidence resulted in lower confidence in the estimate of effect.

AUTHORS' CONCLUSIONS

Newer treatments including terbinafine, itraconazole and fluconazole are at least similar to griseofulvin in children with tinea capitis caused by Trichophyton species. Limited evidence suggests that terbinafine, itraconazole and fluconazole have similar effects, whereas ketoconazole may be less effective than griseofulvin in children infected with Trichophyton. With some interventions the proportion achieving complete clinical cure was in excess of 90% (e.g. one study of terbinafine or griseofulvin for Trichophyton infections), but in many of the comparisons tested, the proportion cured was much lower.New evidence from this update suggests that terbinafine is more effective than griseofulvin in children with T. tonsurans infection.However, in children with Microsporum infections, new evidence suggests that the effect of griseofulvin is better than terbinafine. We did not find any evidence to support a difference in terms of adherence between four weeks of terbinafine versus eight weeks of griseofulvin. Not all treatments for tinea capitis are available in paediatric formulations but all have reasonable safety profiles.

Neonatal dermatophytosis: report of a case and review of the literature

Tinea capitis is a common fungal infection in children but rare among neonates. We present a case of a 3-week-old infant with multiple scalp lesions for 1 week. A diagnosis of tinea capitis due to Microsporum canis was made based on clinical morphology, Wood's lamp, and biopsy with a positive PAS stain. She was effectively treated with oral griseofulvin and ketoconazole shampoo.

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.

Tinea Capitis in Belgrade 1998-2002 / Tinea Capitis u Beogradu 1998-2002. Godine

Tinea capitis (TC) is a worldwide health problem and a specific therapeutic challenge. The objective of this study was to establish the causative agents and clinical types and to present management options for TC. From 1993 to 2002, we treated 354 children (61% were boys) with TC. The data for the period 1998-2002, were analyzed in detail. After clinical and Wood's light examination, specimens were directly microscopically analyzed and cultivated. Superficial TC was diagnozed in 230 (65%), and kerion in 124 patients (35%), respectively. Of 51 kerion patients, 3 children (6%) had erythema nodosum. Griseofulvin was given at a dose of 15 to 25 mg/kg (average: 18 mg/kg). A 100% cure rate was achieved. In the period 1998-2002, M. audouinii was predominantly found in superficial TC. Oral griseofulvin therapy should be accompanied by shaving the hair from the scalp and topical imidazole creams, which provides 100% cure rate of superficial TC (in 6.5 weeks) and of kerion (in 5.4 weeks).

In vitro antifungal activity of extracts and neolignans from Piper regnellii against dermatophytes

The present study was designated to evaluate the in vitro antidermatophyte activity of extracts from leaves of Piper regnellii as well as of the bioactivity-directed isolation of neolignans. The antifungal assay was performed by microdilution techniques. The hydroalcoholic extract of Piper regnellii leaves presented a strong activity against the dermatophyte fungi Trichophyton mentagrophytes, Trichophyton rubrum, Microsporum canis and Microsporum gypseum with MICs of 15.62, 15.62, 15.62 and 62.5 microg/ml, respectively. On light microscopy and scanning electron microscopy of nail fragments not exposed to hydroalcoholic extract of Piper regnelli leaves, well-formed and extensive mycelial growth was seen. On nail fragments exposed to hydroalcoholic extract at concentrations more than 1.2mg/ml and then inoculated with spore suspension, growth was not seen. The hydroalcoholic extract was fractionated on silica gel in to nine fractions. The active chloroform fraction was lyophilized and chromatographed by column chromatography on silica gel. Structures were established by comparison with literature data and identified as eupomatenoid-3 and eupomatenoid-5. The pure compounds showed strong activity on Trichophyton rubrum with MIC of 50 and 6.2 microg/ml, respectively. Comparing the activity of the active chloroform fraction obtained from hydroalcoholic crude extract with that of isolated compound eupomatenoid-5, it is clear that this showed the same results against Trichophyton rubrum. The results showed that the plant could be explored for possible antifungal agents and provides preliminary scientific validation for the traditional medicinal use of this plant.

Systemic antifungal therapy for tinea capitis in children

BACKGROUND

Tinea capitis is a common contagious fungal infection of the scalp in children. Systemic therapy is required for treatment and to prevent spread.

OBJECTIVES

To assess the effects of systemic anti-fungal drugs for tinea capitis in children.

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (June 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2005), MEDLINE (2003 to June 2005), EMBASE ( 2003 to June 2005), LILACS (1982 to July 2005), CINAHL (1982 to July 2005), the ACP journal club (1991 to July 2005) and Healthstar (1975 to July 2005).

SELECTION CRITERIA

Randomised controlled trials (RCTs) that evaluated systemic antifungal therapy in people with normal immunity under the age of 18 who had tinea capitis confirmed by microscopy or growth of dermatophytes in culture or both.

DATA COLLECTION AND ANALYSIS

At least two authors independently examined each retrieved trial for eligibility and quality.

MAIN RESULTS

We included 21 studies (1812 participants). Infections involving Trichophyton species: Terbinafine for four weeks and griseofulvin for eight weeks showed similar efficacy in 3 studies involving 382 participants (RR 1.09; 95% CI 0.95 to 1.26). Cure rates following treatment with itraconazole and griseofulvin for 6 weeks were similar in 1 study of 35 children (RR 1.06; 95% CI 0.81 to 1.39). Another study of 100 children did not show any significant difference in cure between itraconazole for 2 weeks compared with griseofulvin for 6 weeks (RR 0.89; 95% CI 0.76 to 1.04). There was no difference between itraconazole and terbinafine for treatment periods lasting 2 to 3 weeks in 2 studies involving 160 children (RR 0.93; 95% CI 0.72 to 1.19). Two studies that included 140 children found similar cure rates between 2 to 4 weeks of fluconazole with 6 weeks of griseofulvin (RR 0.92; 95% CI 0.80 to 1.05). Microsporum infections: There was no significant difference in cure between terbinafine and griseofulvin in children with Microsporum infections in 1 small study of 29 children (RR 0.64; 95% CI 0.19 to 2.20).

AUTHORS' CONCLUSIONS

The best evidence suggests that newer treatments including terbinafine, itraconazole and fluconazole may be similar to griseofulvin in children with tinea capitis caused by Trichophyton species. Newer treatments may be preferred because shorter treatment durations may improve treatment adherence, although they may be more expensive. There is not enough evidence on the use of systemic treatments in children with Microsporum infections. Not all treatments for tinea capitis are available in paediatric formulations but all have reasonable safety profiles.

Advances in topical and systemic antifungals

Topical antifungal agents are generally used for the treatment of superficial fungal infections unless the infection is widespread, involves an extensive area, or is resistant to initial therapy. Systemic antifungals are often reserved for the treatment of onychomycosis, tinea capitis, superficial and systemic candidiasis, and prophylaxis and treatment of invasive fungal infections. With the development of resistant fungi strains and the increased incidence of life-threatening invasive fungal infections in immunocompromised patients, some previously effective traditional antifungal agents are subject to limitations including multidrug interactions, severe adverse effects, and their fungistatic mechanism of actions. Several new antifungal agents have demonstrated significant therapeutic benefits and have broadened clinicians' choices in the treatment of superficial and systemic invasive fungal infections.

A randomized controlled trial assessing the efficacy of fluconazole in the treatment of pediatric tinea capitis

BACKGROUND

Griseofulvin is considered first-line therapy for tinea capitis, and the Physician's Desk Reference currently recommends 11 mg/kg per day microsize formulation for use in children. Diverse selective pressures have resulted in waning clinical efficacy of griseofulvin, such that higher doses and longer courses of treatment are required. These events have prompted the search for therapeutic alternatives. Fluconazole is one such treatment option, and a variety of studies using this drug have shown promise in the treatment of pediatric tinea capitis.

OBJECTIVE

We sought to assess the efficacy, safety, and optimal dose and duration of fluconazole therapy compared with standard-dose griseofulvin (11 mg/kg per day microsize formulation) in the treatment of pediatric tinea capitis.

METHODS

This randomized, multicenter, third-party-blind, 3-arm trial was designed as a superiority study to identify a therapeutically superior agent/regimen from the 3 treatment arms: (1) fluconazole 6 mg/kg per day for 3 weeks followed by 3 weeks of placebo, (2) fluconazole 6 mg/kg per day for 6 weeks, and (3) griseofulvin 11 mg/kg per day for 6 weeks. Efficacy variables included mycological, clinical, and combined outcomes. The primary efficacy variable was the combined outcome of the modified intent-to-treat population at week 6. Patient safety was assessed throughout the study. Statistical analysis of the efficacy variables was conducted by means of the Cochran-Mantel-Haenszel test.

RESULTS

At the end of treatment, mycological cures were present in 44.5%, 49.6%, and 52.2% of the fluconazole 3-week, fluconazole 6-week, and griseofulvin groups, respectively. Analysis of the primary efficacy variable failed to identify any superior agent, and differences between the combined outcomes of the fluconazole 6-week and griseofulvin groups at week 6 were not significant (P = .32). Regarding mycological, clinical, and combined outcomes, no significant differences between the fluconazole 6-week and griseofulvin groups were detected at any time point in the study. No new safety concerns were raised by this trial, and the incidence of treatment-related adverse events noted in this study is concordant with previous reports. Patients in the fluconazole arms of the study fared similarly. At the end of the trial, the difference in mycological cures between the fluconazole arms was only 7.5%, and increases in the incidence of certain treatment-related adverse events were observed in the fluconazole 6-week group.

LIMITATIONS

Adjunctive topical therapies and the impact of infected contacts were not assessed in this trial.

CONCLUSION

Systemic therapy with fluconazole 6 mg/kg per day and standard-dose griseofulvin produces comparable but low mycological and clinical cure rates. The limited efficacy of standard-dose griseofulvin and the lack of consensus regarding dose and duration of griseofulvin therapy in tinea capitis emphasize the need for controlled trials to identify optimal treatment parameters. Although the efficacy of fluconazole is no better than that of standard-dose griseofulvin, it may still be useful in select patients with a contraindication or intolerance to high-dose griseofulvin. The outcomes observed in this trial highlight the need to more clearly define the relative importance of adjunctive topical therapies and the evaluation and treatment of infected contacts as factors affecting cure rates.

Poly(lactide)-poly(ethylene glycol) micelles as a carrier for griseofulvin

In this work, the feasibility to develop micelle carriers of griseofulvin based on PLA-PEG copolymers was investigated. With the use of the dialysis method of micelle formation, the micellization behavior of a range of PLA(X)-PEG(5) copolymers was investigated. At copolymer concentrations in the organic solvent 10-20 mg/mL, stable micelles with 100% yield could only be prepared from PLA(X)-PEG(5) copolymers with molar composition in the range 50-70% PEG. The copolymers exhibited sufficiently low CMC to provide stable micelles in vivo. The loading capacity of PLA(4)-PEG(5) micelles with griseofulvin was 6.5 mg of drug/1 g of copolymer. The release of griseofulvin from the PLA-PEG micelles in vitro in phosphate-buffered saline (PBS) was sustained over 30 days. No burst effect was observed. Analysis of the release kinetics suggested that the release was erosion-controlled. The release profile was biphasic. Micelle degradation data in PBS indicated that the second phase of release was induced by copolymer degradation. The PLA-PEG micelles of griseofulvin were stable in simulated gastric and intestinal fluids for a long-enough time for oral application. Overall, the PLA-PEG micelles have suitable properties to be considered as potential oral or topical formulations of griseofulvin, provided that the drug-loading capacity of the micelles is sufficiently improved.

Tinea capitis: epidemiologia e ecologia dos casos observados entre 1983 e 2003 na Faculdade de Medicina de Botucatu, Estado de São Paulo, Brasil

FUNDAMENTOS: Tinea capitis é importante infecção fúngica de interesse dermatológico e pediátrico. No Brasil sua prevalência é desconhecida, e os agentes causais principais são o Trichophyton tonsurans nas regiões Norte-Nordeste e o Microsporum canis no Sul-Sudeste do país. Conhecimento sobre gênero e espécies mais prevalentes tem importância sanitária e terapêutica. OBJETIVOS: Identificar espécies de dermatófitos, causa de Tinea capitis, em serviço universitário que atende clientela do Sistema Único de Saúde, de procedência urbana e rural, no interior do Estado de São Paulo. MÉTODOS: Amostras de casos clínicos suspeitos de Tinea capitis, procedentes da área de abrangência da Faculdade de Medicina de Botucatu-Unesp, foram investigadas por exame direto e cultivo visando ao diagnóstico e isolamento do agente causal. RESULTADOS: De 1.055 suspeitas, 594 foram confirmadas por exame direto, em 364 (61,1%) isolou-se o agente: M. canis em 88,2%, seguindo-se T. tonsurans (4,7%), T. rubrum (3,3%), M. gypseum (1,9%), T. mentagrophytes (1,6%). O sexo masculino correspondeu a 55,7% dos casos, e a faixa etária entre 0-5 anos predominou com 62,6% (p < 0,05). CONCLUSÕES: A prevalência detectada do M. canis superou o esperado para a Região Sudeste do Brasil. A freqüência de 88,2% pode estar influenciada por pacientes procedentes da zona rural. Esse dado deve ser considerado quando de decisão terapêutica.

Antidermatophyte activity of ether extract of Nigella sativa and its active principle, thymoquinone

The antifungal activity of ether extract of Nigella sativa seed and its active principle thymoquinone was tested against eight species of dermatophytes: four species of Trichophyton rubrum and one each of Trichophyton interdigitale, Trichophyton mentagrophytes, Epidermophyton floccosum and Microsporum canis. Agar diffusion method with serial dilutions of ether extract of Nigella sativa, thymoquinone and griseofulvin was employed. The incubation was carried out at 30 degrees C for 14 days. The diameter of fungal colonies and the percentage inhibition of the fungal growth at each dilution were determined, taking those of the controls as 100%. The minimum inhibitory concentration (MIC) was considered as the minimum concentration of the drug, which inhibited 80-100% of the fungal growth. The MICs of the ether extract of Nigella sativa and thymoquinone were between 10 and 40 and 0.125 and 0.25 mg/ml, respectively, while those of griseofulvin ranged from 0.00095 to 0.0155 mg/ml. These results denote the potentiality of Nigella sativa as a source for antidermatophyte drugs and support its use in folk medicine for the treatment of fungal skin infections.

Griseofulvin versus terbinafine in the treatment of tinea capitis: a meta-analysis of randomized, clinical trials

OBJECTIVE

Tinea capitis, a common pediatric infection in the United States, is caused mainly by Trichophyton species and affects many urban children. Although the current treatment of choice is oral griseofulvin, terbinafine has been shown to be variably effective in several comparative, randomized trials. The purpose of this study was to perform a meta-analysis of randomized, clinical trials comparing the efficacies of oral terbinafine and oral griseofulvin for the treatment of childhood tinea capitis.

METHODS

The Medline database was searched for randomized, clinical studies comparing griseofulvin and terbinafine for the treatment of tinea capitis. Acceptance criteria included oral administration of griseofulvin for at least 6 weeks and the identification of a pathogenic dermatophyte from the scalp at the time of enrollment in the study. Scalp culture status at least 8 weeks after enrollment was used as the outcome. The common odds ratio (OR) with 95% confidence intervals (CIs), the Cochran-Mantel-Haenszel test for significance, and the Breslow-Day test for homogeneity were calculated.

RESULTS

Six articles that satisfied all inclusion criteria were identified. These studies were combined by using outcomes at 12 to 16 weeks after enrollment. The common OR was 0.86 (95% CI: 0.57-1.27). When the 5 studies that identified Trichophyton species as the predominant pathogen were combined, using outcomes 12 weeks after enrollment, the results nearly favored terbinafine (OR: 0.65 [95% CI: 0.42-1.01]). For outcomes at 8 weeks after enrollment, no difference was found between the agents (OR: 0.84 [95% CI: 0.54-1.32]). Consclusions.A 2- to 4-week course of terbinafine is at least as effective as a 6- to 8-week course of griseofulvin for the treatment of Trichophyton infections of the scalp. Griseofulvin is likely to be superior to terbinafine for the rare cases caused by Microsporum species.

Increasing tinea capitis prevalence in Stockholm reflects immigration

The aim was to describe the mycological and clinical data in children diagnosed with tinea capitis in a hospital setting in Stockholm. Information concerning demography, symptoms, mycology and treatment were obtained, retrospectively, from medical records of all children up to 15 years of age diagnosed with tinea capitis during two 3-year periods, 1989--1991 and 1999--2001, at the Pediatric Dermatology Unit of the Karolinska Hospital in Stockholm. Between 1989 and 1991, five children were diagnosed with tinea capitis. Between 1999 and 2001, there were 92 children, the vast majority (86%) being of foreign extraction, mostly African (83%). Trichophyton violaceum was the most prevalent pathogen, affecting 68% of the children. Of the anthropophilic infections, 62% were linked to relatives. In 71% of all positive cultures, microscopy was positive. The most common clinical findings were scaling of the scalp (80%), itching (54%) and patches of alopecia (52%). The treatment consisted of the oral antimycotics terbinafine (n = 48) or griseofulvin (n = 49). During the last decade there has been an increase in tinea capitis in Stockholm, most commonly caused by Trichophyton violaceum, corresponding with the increased immigration from Africa. Spread within the family seems to be of importance, and family members are preferably screened in an effort to prevent continued transmission. It is important to bear the diagnosis of tinea capitis in mind, especially as, untreated, some cases can develop permanent alopecia and may also cause further spreading of this infection.

Onychomycosis in children: a brief overview with treatment strategies

Onychomycosis in children is uncommon. In those children that are affected, a family history of onychomycosis is not uncommon, giving importance to the examination of the entire family for fungal nail infections. In the United States, the newer oral antifungal agents itraconazole, fluconazole, and terbinafine, and the topical nail lacquers ciclopirox and amorolfine are not approved for this indication. More data are needed on the use of these antifungal agents for the treatment of onychomycosis in children.

Cutaneous infections dermatophytosis, onychomycosis, and tinea versicolor

Cutaneous fungal infections cause significant morbidity for healthy and ill patients. The incidence of some dermatomycoses is increasing, despite availability of newer and better topical and systemic treatments. Fungal remnants last months to years under the ideal conditions, allowing continued spread of infection. Mycoses treated in one area may recur because of organism travel from concomitant areas of infection. Failure of patients and physicians to recognize a fungal etiology early may lead to more extensive, severe, or difficult-to-treat infections. Finally, a patient's concurrent illnesses may play a part in susceptibility and ability to manage fungal infections. For these reasons, scientists have studied and developed newer antifungal agents with better efficacy and greater convenience in dosing. These drugs, however, still have side effects and medication interactions that may limit their use in some patients. Better efforts to educate patients and physicians alike may aid in faster recognition and treatment of dermatophytoses. More research is needed to continue to develop drugs suitable for use in a broader range of patients and diagnostic tests that may be quicker or more specific than conventional ones.

Tinea capitis in infants less than 1 year of age

Tinea capitis is the most frequent manifestation of dermatophyte infection in children, but because it is rare in the first months of life it is often misdiagnosed. Here we report 15 cases of tinea capitis observed in Italy in infants less than 1 year of age. There were 10 boys and 5 girls (mean age 6 months). Diagnosis was confirmed by mycologic examination. Microsporum canis was isolated in nine cases and Trichophyton mentagrophytes in three. These 12 infants were Italian and animals were the source of infection. Trichophyton erinacei was isolated in one Italian infant, and the source was soil. In the other two cases, Trichophyton tonsurans and Trichophyton violaceum were isolated; these infants were from Central America and India, respectively, and had contracted the infection from humans. All achieved clinical and mycologic recovery after systemic and topical antimycotic therapy.

New developments in chemotherapy for non-invasive fungal infections

Dermatomycosis and subcutaneous mycosis comprise the non-invasive fungal infections commonly encountered in clinical practice around the world. The limited activity of early topical antifungal agents prompted the development of more effective systemic agents. While griseofulvin has been used for more than four decades, the use of early azoles, such as ketoconazole have resulted in better patient compliance and thus greater success. However, poor response and recurrence in dermatomycosis, as well as toxicity associated with ketoconazole therapy, has led to the search for newer antifungal agents and more effective treatment strategies. Terbinafine, itraconazole and fluconazole have the advantage of non-toxicity and a broad spectrum of activity. An overview of non-invasive fungal infections, antifungal agents in clinical use and recent developments in antifungal therapy is reviewed in this article.

Tinea capitis update: a continuing conflict with an old adversary

Infection with tinea capitis in childhood is a common, age-old problem that continues to plague patients and their families. As is true for most infectious diseases, the epidemiology of tinea capitis is in a constant state of flux and varies considerably with respect to geography and specific patient populations. Trichophyton tonsurans is now the most common cause of tinea capitis in the United States. A recent epidemiologic observation is a striking increase in the incidence of tinea capitis, particularly among African-Americans. Clinical studies over the past decade that have investigated the response of tinea capitis to griseofulvin, the mainstay treatment for this condition, suggest a decrease in sensitivity to this pharmacologic agent, in association with this new epidemiology. Important advances in the diagnosis and treatment of tinea capitis include a renewed interest in the use of the cotton swab method of diagnosing fungal cultures in children, and the ongoing investigation of promising new medications for the treatment of tinea capitis, including terbinafine, itraconazole, and fluconazole in this era of resistant organisms.