Tinea capitis in infants less than 1 year of age

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.

5-aminolevulinic acid-photodynamic therapy is a potential approach for kerion

Kerion is an inflammatory variant of tinea capitis that is caused by ringworm fungi (zoophilic dermatophytes). It often affects prepubertal children. Classical antifungals are primarily used as therapeutic agents to treat kerion. However, many patients do not respond well to these agents and severe hepatotoxic side reactions may occur with the long-term use of such drugs. New therapeutic approaches are urgently needed. Here, we report a juvenile case of kerion successfully treated by ALA-PDT (5-aminolevulinic acid-photodynamic therapy) after the failure of a 4-week course of itraconazole and terbinafine. We find three published cases of kerion in the literature, all of which were successfully cured by application of ALA-PDT, highlighting a potentially superior therapeutic choice for kerion treatment.

Host-driven subspeciation in the hedgehog fungus, Trichophyton erinacei, an emerging cause of human dermatophytosis

Trichophyton erinacei is a main cause of dermatophytosis in hedgehogs and is increasingly reported from human infections worldwide. This pathogen was originally described in the European hedgehog (Erinaceus europaeus) but is also frequently found in the African four-toed hedgehog (Atelerix albiventris), a popular pet animal worldwide. Little is known about the taxonomy and population genetics of this pathogen despite its increasing importance in clinical practice. Notably, whether there are different populations or even cryptic species associated with different hosts or geographic regions is not known. To answer these questions, we collected 161 isolates, performed phylogenetic and population-genetic analyses, determined mating-type, and characterised morphology and physiology. Multigene phylogeny and microsatellite analysis supported T. erinacei as a monophyletic species, in contrast to highly incongruent single-gene phylogenies. Two main subpopulations, one specific mainly to Atelerix and second to Erinaceus hosts, were identified inside T. erinacei, and slight differences in the size of microconidia and antifungal susceptibilities were observed among them. Although the process of speciation into two lineages is ongoing in T. erinacei, there is still gene flow between these populations. Thus, we present T. erinacei as a single species, with notable intraspecies variability in genotype and phenotype. The data from wild hedgehogs indicated that sexual reproduction in T. erinacei and de novo infection of hedgehogs from soil are probably rare events and that clonal horizontal spread strongly dominates. The molecular typing approach used in this study represents a suitable tool for further epidemiological surveillance of this emerging pathogen in both animals and humans. The results of this study also highlighted the need to use a multigene phylogeny ideally in combination with other independent molecular markers to understand the species boundaries of dermatophytes.

Role of trichoscopy in the management of tinea capitis in two infants: A case report

As tinea capitis rarely affects infants, early trichoscopic diagnosis facilitates timely institution of appropriate therapy. We report a 10-month-old female presenting with mixed pattern tinea capitis and coexisting tinea faciei wherein trichoscopy showed perifollicular scaling, comma hair, corkscrew hair, and horse-shoe hair. Case 2 was a 3-month-old female with gray patch tinea capitis, corroborated by the presence of perifollicular scaling, comma hair, corkscrew hair, and prominent telangiectasia on trichoscopy. Both cases were successfully treated with tablet fluconazole (5 mg/kg) for 6–8 weeks.

Tinea manuum due to Trichophyton erinacei from Tunisia

Trichophyton erinacei is a zoonotic fungus affecting hedgehogs. Although several human infections with this organism have been documented in the literature, it has rarely been isolated as a human pathogen. This paper reports on an erythematous lesion spotted on the hand of a 10-year-old girl. Based on the culture of the patient's skin scrapings, the pathogen was mycologically identified as T. erinacei, which was further confirmed by sequencing the internal transcribed spacers of the fungal nuclear ribosomal DNA using universal primer ITS1-ITS4. This is the first case of T. erinacei in a Tunisian patient. A survey was carried out on the environment of our patient, and the results revealed the presence of hedgehogs with suspect scaly lesions. The same fungus was isolated from the hair and scales of the hedgehog, which was confirmed by PCR sequencing. The frequency of T. erinacei has often been underestimated, which is attributed not only to the gaps of knowledge still existing in the current understanding of the dermatophyte but also to differential diagnosis problems. Molecular study offers a simple and rapid tool to identify the source of infection and, hence, avoid the risk of recurrence.

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.

The first case of tinea faciei caused by Trichophyton mentagrophytes var. erinacei isolated in Chile

BACKGROUND

Trichophyton mentagrophytes var. erinacei is a zoophilic dermatophyte transmitted by hedgehogs which human infections manifest as highly inflammatory and pruritic eruptions.

METHODS

We report a 21-year-old woman who presented with a two-week history of a pruritic scaly erythematous plaque on the nose. The patient had kept hedgehogs as pets, and one had bitten her on the tip of the nose two months prior to the appearance of the nasal lesion.

RESULTS

Fungal culture from the scales on the tip of the patient's nose was compatible with T. mentagrophytes var. erinacei. The strains isolated from cultures made from samples taken from the noses and ears of the pet hedgehogs were morphologically similar to the strain isolated from the patient. Morphological identification was confirmed by sequencing the internal transcribed spacer. The lesion was diagnosed as tinea faciei, and therapy was initiated with topical and systemic terbinafine 250mg/day for eight weeks, which resulted in complete improvement.

CONCLUSIONS

Trichophyton mentagrophytes var. erinacei is the most common dermatophyte isolated in hedgehogs. Usually T. mentagrophytes var. erinacei infection manifests as an extremely inflammatory and pruritic eruption that is confined to the site of contact with the hedgehog. Although the identification of T. mentagrophytes by traditional methods is possible, identification by ITS region analysis is a fast, simple, and increasingly available method. The increasing frequency of the practice of keeping exotic animals as pets has resulted in the emergence of several zoonotic diseases that can potentially be transmitted to humans.

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.

Neonatal kerion Celsi: report of three cases

Tinea capitis is a fungal infection caused by dermatophytes, frequent in children but uncommon in the neonatal period. Kerion Celsi is the inflammatory manifestation of tinea capitis secondary to host immunologic responses and its occurrence in newborns is extremely infrequent. We describe three neonates with the diagnosis of kerion Celsi. The isolated dermatophytes were Trichophyton mentagrophytes var. mentagrophytes in two patients and Trichophyton rubrum in the third. Both patients with T. mentagrophytes referred an indirect contact with rabbits and were successfully treated with systemic antifungal (griseofulvin and fluconazole). The patient with T. rubrum had a father with a tinea manuum and both received just topical antimycotic treatment.

Tinea capitis in early infancy treated with itraconazole: a pilot study

BACKGROUND

Tinea capitis is the most common fungal infection of the scalp in childhood, but a very rare disorder in the first year of life.

OBJECTIVE

To evaluate the efficacy, tolerability and safety of itraconazole in 7 children aged between 3 and 46 weeks (median: 36 weeks) suffering from tinea capitis caused by Microsporum canis.

METHODS

Prospective case note study. In all patients KOH testing and fungal cultivation on Sabouraud dextrose agar were performed.

RESULTS

7 patients (5 girls and 2 boys) were included in the period between 2001 and 2008. The causative etiologic agent was Microsporum canis in all children. The patients received itraconazole 5mg/kg bodyweight daily for 3 to 6 weeks with no clinically side effects being noted. In all patients clinical and mycological cure could be achieved.

CONCLUSION

Itraconazole proved to be a safe and effective treatment option for Microsporum canis induced tinea capitis in children in their first year of life.

Trichophyton mentagrophytes of rabbit origin causing family incidence of kerion: an environmental study

Our laboratory was contacted by a family living directly above a rabbit farm. Both their children had developed a kerion, in consequence of a misdiagnosed superficial mycosis. This study was designed to demonstrate a link between the two kerion cases and the environmental contamination. The degree of contamination was estimated and factors favourising the spread of infection were determined. Dermatophytes were isolated from various environmental sites using Rodac plates. For direct sampling of scalp and fur the brushing technique was used. The farm and home environment initially showed a severe contamination by Trichophyton mentagrophytes. At the farm, cages and surfaces covered with rabbit hair were strongly contaminated. As for the home environment, the dog's basket and clothes from the mother carried a large number of spores. Trichophyton mentagrophytes was identified as responsible agent for the children's kerions and the lesions of the rabbits. Mother, eldest child and dog seemed to be excellent carriers. Cleaning and disinfection measures resulted in a reduction of the overall contamination. The home environment was no longer a source of contamination. Nevertheless, on the farm a fair number of dermatophytes could still be isolated from the wire meshes and roof beams covered with fluff.

Tinea capitis in infants in their first year of life

BACKGROUND

Tinea capitis is the most common type of dermatophytosis in children, but is uncommon in the first year of life.

OBJECTIVES

To review clinical, mycological and epidemiological data in a series of 10 infants aged under 1 year diagnosed as having tinea capitis in three Spanish hospitals between 1998 and 2002.

METHODS

A retrospective case note study.

RESULTS

There were six boys and four girls with a mean of age 7 months (range 1.5-12). All the children were born in Spain, but in five cases the parents were immigrants from Africa. In these cases the isolated dermatophytes were two Trichophyton tonsurans, one T. verrucosum and two Microsporum audouinii. Four autochthonous cases were caused by M. canis and one by M. audouinii (but this one was in contact with African immigrants). In two of the five cases produced by anthropophilic dermatophytes other family members were infected by the same fungus. Most cases were treated successfully with griseofulvin.

CONCLUSIONS

Although tinea capitis is rare in infants in their first year of life, the condition should be investigated if scaling and/or alopecia are present. A thorough epidemiological study of other family members is mandatory.

First report of Arthroderma benhamiae in Switzerland

BACKGROUND

Dermatophytes are usually identified on the basis of macroscopic characteristics and microscopic examination of the cultures. Identification of dermatophytes often remains difficult or uncertain because there are variations from one isolate to another and overlapping characteristics between species.

OBJECTIVE

To identify dermatophyte species producing numerous microconidia and resembling Trichophyton mentagrophytes by DNA sequence analysis.

METHODS

The complete ITS1 + 5.6s + ITS2 rDNA region of various dermatophytes isolated in culture was amplified by PCR and sequenced.

RESULTS

Nine isolates of a fast-growing dermatophyte species were identified as Arthroderma benhamiae by DNA sequencing. Retrospective investigations revealed that the isolates were from 8 children and 1 adult suffering from inflammatory dermatophytosis. Eight of the 9 patients had had previous contact with rodents, mostly guinea pigs.

CONCLUSION

It is the first time that A. benhamiae is reported in Switzerland. In cases of dermatophytosis attributed to A. benhamiae, a rodent is the most likely cause of infection.

Tinea capitis in a dermatology center in the city of Fortaleza, Brazil: the role of Trichophyton tonsurans

BACKGROUND

Over a 3-year period (March 1999 to March 2002), 944 patients with scalp lesions attended a dermatology reference center in the city of Fortaleza, Ceará, Brazil. Clinical specimens were examined at the Specialized Medical Mycology Center, Federal University of Ceará, Fortaleza-CE, Brazil, to detect patients with tinea capitis.

METHODS

Specimens were obtained from pus, scales, and hairs from suspected lesions of tinea capitis. Mycologic analyses were conducted by direct microscopy and by fungal culture on Sabouraud dextrose agar, with or without chloramphenicol and Mycosel agar. The culture tubes were incubated at 28 degrees C and examined daily for 1 month.

RESULTS

Fungi were seen in 438 (46.4%) of the 944 clinical specimens. The percentage of positive direct microscopic examinations of the clinical specimens was 83.7%. Of those patients with tinea capitis, 157 (35.8%) were males and 281 (64.2%; P < 0.001) were females. The distribution of dermatophyte species in males, from 136 positive cultures, was Trichophyton tonsurans (54.41%), Microsporum canis (38.97%), T. rubrum (4.41%), T. mentagrophytes var. mentagrophytes (1.47%), and M. gypseum (0.74%). On the other hand, only three species, from 251 positive cultures, were present in females: T. tonsurans (80.08%), M. canis (17.53%), and T. rubrum (2.39%). There was a high proportion of positive results in children under 10 years of age (n = 309). No significant difference was detected in the seasonal distribution of tinea capitis.

CONCLUSIONS

Our data show that T. tonsurans is the main etiologic agent of tinea capitis, and is more likely to be found in females and in the prepubertal population.