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

Epidemiologic features and therapeutic strategies of kerion: A nationwide multicentre study

BACKGROUND

Kerion is a severe type of tinea capitis that is difficult to treat and remains a public health problem.

OBJECTIVES

To evaluate the epidemiologic features and efficacy of different treatment schemes from real-world experience.

METHODS

From 2019 to 2021, 316 patients diagnosed with kerion at 32 tertiary Chinese hospitals were enrolled. We analysed the data of each patient, including clinical characteristics, causative pathogens, treatments and outcomes.

RESULTS

Preschool children were predominantly affected and were more likely to have zoophilic infection. The most common pathogen in China was Microsporum canis. Atopic dermatitis (AD), animal contact, endothrix infection and geophilic pathogens were linked with kerion occurrence. In terms of treatment, itraconazole was the most applied antifungal agent and reduced the time to mycological cure. A total of 22.5% of patients received systemic glucocorticoids simultaneously, which reduced the time to complete symptom relief. Furthermore, glucocorticoids combined with itraconazole had better treatment efficacy, with a higher rate and shorter time to achieving mycological cure.

CONCLUSIONS

Kerion often affects preschoolers and leads to serious sequelae, with AD, animal contact, and endothrix infection as potential risk factors. Glucocorticoids, especially those combined with itraconazole, had better treatment efficacy.

Comprehensive Review of Tinea Capitis in Adults: Epidemiology, Risk Factors, Clinical Presentations, and Management

Tinea capitis is a fungal infection of the scalp and hair caused by dermatophyte molds, that most often affects children and may also affect adults. Previous estimates suggest that between 3% and 11% of all tinea capitis cases worldwide occur in adults, although updated epidemiological studies are needed to reassess the prevalence of tinea capitis in adult populations specifically. Postmenopausal adult women are most often affected by tinea capitis, with African American or Black women particularly at risk. Adults who experience crowded living conditions, who live in close proximity to animals, who are immunosuppressed, and/or who live in households with affected children are at greatest risk of infection. Tinea capitis can be non-inflammatory or inflammatory in nature, and the subtype affects the extent and severity of clinical symptoms. Fungal culture and potassium hydroxide preparations are the most commonly used diagnostic tools. Trichoscopy, defined as dermoscopic imaging of the scalp and hair, is a useful adjunct to the physical examination. The mainstay of therapy is oral antifungal therapy, and topical therapy alone is not recommended. Since tinea capitis infection is uncommon in adults, there are no widely accepted treatment guidelines. Rather, the same medications used for tinea capitis infection among children are recommended for adults at varying doses, including griseofulvin, and terbinafine, and, less commonly, itraconazole and fluconazole. The prognosis for tinea capitis in adults is typically excellent when prompt and adequate treatment is administered; however, delayed diagnosis or inadequate treatment can result in scarring alopecia. Over the past decade, dermatophyte infections resistant to treatment with topical and oral antifungal agents have emerged. While tinea capitis infections resistant to antifungal therapy have been rarely reported to date, antifungal resistance is rising among superficial fungal infections in general, and antifungal stewardship is necessary to ensure that resistance to treatment does not develop among dermatophytes that cause tinea capitis.

Expert Panel Review of Skin and Hair Dermatophytoses in an Era of Antifungal Resistance

Dermatophytoses are fungal infections of the skin, hair, and nails that affect approximately 25% of the global population. Occlusive clothing, living in a hot humid environment, poor hygiene, proximity to animals, and crowded living conditions are important risk factors. Dermatophyte infections are named for the anatomic area they infect, and include tinea corporis, cruris, capitis, barbae, faciei, pedis, and manuum. Tinea incognito describes steroid-modified tinea. In some patients, especially those who are immunosuppressed or who have a history of corticosteroid use, dermatophyte infections may spread to involve extensive skin areas, and, in rare cases, may extend to the dermis and hair follicle. Over the past decade, dermatophytoses cases not responding to standard of care therapy have been increasingly reported. These cases are especially prevalent in the Indian subcontinent, and Trichophyton indotineae has been identified as the causative species, generating concern regarding resistance to available antifungal therapies. Antifungal-resistant dermatophyte infections have been recently recognized in the United States. Antifungal resistance is now a global health concern. When feasible, mycological confirmation before starting treatment is considered best practice. To curb antifungal-resistant infections, it is necessary for physicians to maintain a high index of suspicion for resistant dermatophyte infections coupled with antifungal stewardship efforts. Furthermore, by forging partnerships with federal agencies, state and local public health agencies, professional societies, and academic institutions, dermatologists can lead efforts to prevent the spread of antifungal-resistant dermatophytes.

Tinea Capitis at Ibn Sina Hospital in Rabat, Morocco: Epidemiological and Etiological Study Over 25 Years (From 1997 to 2021)

Introduction/Objective In Morocco, tinea capitis is a common reason for consultation, especially in children. Our study aimed to determine the epidemiology of tinea capitis in the Central Laboratory of Parasitology and Mycology at the Ibn Sina University Hospital Center (UHC) in Rabat. Materials and methods This is a retrospective study conducted over 25 years (from 1997 to 2021). It included 247 patients with lesions suggestive of tinea capitis, who underwent a mycological examination. Results Among 594 requests for the diagnosis of tinea capitis, 247 cases were positive. A clear predominance of children (86.23%; n=213) as compared to adults (13.77%; n=34) was observed. The sex ratio (M/F) was 1.77. Hair parasitism was mainly dominated by the pure endothrix type 54.47% (n=122). The two most frequently isolated species were Trichophyton violaceum (51.24%; n=125) and Microsporum canis (36.06%; n=88). In children, these two species represented 47.42% (n=101) and 41.31% (n=88), respectively. In adults, Trichophyton violaceum was the predominant species, accounting for 77.42% (n=24); in females, it was 76.41% (n=68); and Microsporum canis was predominant in males (50.32%; n=78). Conclusion The epidemiology of this condition is in a constant state of flux, influenced by various lifestyle factors. Our research unveiled a notable upward trend in zoophilic species over the 25-year study period, while conversely, anthropophilic species demonstrated a discernible decline.

Expression Profiles of Protease in Onychomycosis-Related Pathogenic Trichophyton rubrum and Tinea Capitis-Related Pathogenic Trichophyton violaceum

The two fungal species Trichophyton rubrum and Trichophyton violaceum are common pathogens on human, infecting keratinized tissue of the outer body parts. Both species are belonging to the "Trichophyton rubrum complex" and share very high similarity in the genome. Secreted proteinases, key factors for keratin degradation, are nearly identical. Contrary, the ecological niches are differing. Trichophyton rubrum preferably infects skin and nails, whereas T. violaceum preferably infects the scalp. We postulate, that differences in the protease expression contribute to differences in ecological preferences. We analyzed the expression profiles of all 22 endoprotease genes, 12 subtilisins (S8A), 5 deuterolysins (M35) and 5 fungalysins (M36), for both species. To compare the influence of the keratin source, we designed experiments with human nail keratin, sheep wool keratin and keratin free cultivation media. Samples were taken at 12 h, 24 h, 48 h and 96 h post incubation in keratin medium. The expression of the proteases is higher in wool-keratin medium compared to human nail medium, with the exception of MEP4 and SUB6. Expression in the keratin-free medium is lowest. The expression profiles of the two species are remarkable different. The expression of MEP1, MEP3, SUB5, SUB11 and SUB12 are higher in T. rubrum compared to T. violaceum. MEP2, NpIIc, NpIIe, SUB1, SUB3, SUB4, SUB7 and SUB8 are higher expressed in T. violaceum compared to T. rubrum. The differences of the protease expression in the two species may expalin the differences in the ecological niches. Further analysis are necessary to verify the hypothesis.Please check and conform the edit made in title.Here I thinke the species of strains shouldnt be capital， and the right expression should be,  "Expression Profiles of Protease in Onychomycosis-Related Pathogenic Trichophyton rubrum and Tinea Capitis-Related Pathogenic Trichophyton violaceum"Author names: Please confirm if the author names are presented accurately and in the correct se-quence (given name, middle name/initial, family name). Author 1 Given name: [Jingjing] Last name [Chen], Author 2 Given name: [Yangmin] Last name [Gao], Author 3 Given name: [Shuzhen] Last name [Xiong], Author 4 Given name: [Ping] Last name [Zhan]. Also, kindly confirm the details in the metadata are correct.YesPlease check and confirm the inserted city and country are correctly identified for affiliation 3.Please change the affiliations, Affiliation 2: ²Jiangxi Provincial Clinical Research Center for Skin Diseases, Dermatology Hospital of Jiangxi Province,The Affiliated Dermatology Hospital of Nanchang University, Nanchang, 330200, Jiangxi; Affiliation 3: 3Institute of Clinical Medicine, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College,Nanchang 330001, Jiangxi. Thanks a lot!

The Epidemiology of Tinea Capitis in Guangxi Province, China

The aim of this study was to analyze the epidemiological characteristics and pathogen spectrum of tinea capitis in Guangxi, southern China. A multicenter prospective descriptive study was conducted in 8 hospitals across Guangxi. From January 2019 to July 2022, one hundred seventy-one (171) patients diagnosed with tinea capitis were included. Demographic data, risk factors, and fungal data were collected. If necessary, species were further identified by morphological or molecular sequencing in the central laboratory. Of the 171 cases of tinea capitis, 74.3% occurred in patients aged 2-8 years. Children with tinea capitis were mainly boys (59.6%) and were more likely than adults to have a history of animal contact (44.2% vs. 33.3%) and zoophilic dermatophyte infection (76.9% vs. 46.7%, P = 0.008). The adults were mainly female (53%) and were more likely than children to have a history of infection with anthropophilic organisms (53.3% vs. 18.9%). The causative agents of tinea capitis in Guangxi were diverse, and the most common pathogen was Microsporum canis (M. cani, n = 98, 62%), followed by Trichophyton mentagrophytes (T. mentagrophytes n = 18, 11.4%) and Trichophyton tonsurans (T. tonsurans n = 12, 7.6%). In addition, tinea capitis caused by Nannizzia incurvata (N. incurvata) and Trichophyton verrucosum (T. verrucosum) was detected in the study. Notably, the proportion of patients with kerion in the study was 41.5% (n = 71), and most of those patients were children (n = 68), especially neglected children living in the rural mountainous areas of Guangxi, where they were unable to receive timely diagnosis and appropriate treatment. In conclusion, the causative agents of tinea capitis in Guangxi, South China, are diverse, and the incidence of kerion is high, indicating that diagnosis and treatment modalities in the region remain grossly inadequate. Clinicians and policy-makers should collaborate to adopt public health strategies to control the disease.

Inflammatory Tinea Capitis Mimicking Dissecting Cellulitis in a Healthy Woman

Introduction

Inflammatory tinea capitis (TC) is uncommon in adults.

Case Presentation

A 29-year-old healthy woman presented with a 2-year history of scalp alopecia with purulent discharge. Clinical, trichoscopic, and histological features and the negativity of a first fungal sampling were consistent with the diagnosis of dissecting cellulitis of the scalp. A second mycological examination guided by trichoscopy was carried out, showing tinea endothrix. Fungal culture isolated trichophyton violaceum. The patient was treated with terbinafine with complete healing.

Conclusion

The diagnosis of adult TC is challenging, mainly the inflammatory form. An exhaustive trichoscopic examination of all alopecic plaques may help make a rapid diagnosis and provide a guide to the mycological examination.

Pediatric Tinea Capitis: A Retrospective Cohort Study from 2010 to 2021

Pediatric tinea capitis displays a wide range of prevalence, with significant variability among populations. We retrospectively extracted the medical records of 456 pediatric patients diagnosed with tinea capitis during the years 2010–2021, from the dermatology outpatient clinics in two tertiary medical centers. Three species were isolated in 90% of patients: T. tonsurans, M. canis, and T. violaceum. While T. tonsurans presented a six-fold increase in incidence during the years 2019–2021, M. canis maintained stable incidence rates. Furthermore, terbinafine was the most efficient antifungal agent against T. tonsurans, achieving complete clinical clearance in 95% of patients, as compared to fluconazole (68%) and griseofulvin (38%) (p < 0.001). The mycological cure was recorded in 61/90 (68%) of patients with available data, at an average of 10 weeks. For patients with M. canis, griseofulvin and fluconazole were equally efficient (73% and 66%, respectively) (p = 0.44). Kerion was described in 36% and 14% of patients with T. tonsurans and M. canis, respectively, (p < 0.001). In conclusion, since 2019, there has been a significant increase in the prevalence of T. tonsurans, establishing this pathogen as the most common cause for tinea capitis in our population. Our data suggest that terbinafine is effective and presents high cure rates for tinea capitis in the pediatric population.

High Trichophyton violaceum-Induced Tinea Capitis with Isolation of Many Non-Dermatophyte Molds in Scalp Scrapings in Patients Referred to a Dermatology Clinic in Addis Ababa, Ethiopia

Objective

This work aimed to determine the magnitude of tinea capitis, the diversity and species composition of fungi, and the predominant dermatophytes implicated in causing tinea capitis.

Methods

A prospective, cross-sectional study was conducted at a dermatology clinic. Scalp scrapings were collected and cultured, and dermatophyte and non-dermatophyte molds were identified.

Results

Of 364 scalp scrapings, fungi were recovered from 301 (82.7%) clinical samples. About 60.7% of the samples were collected from women, while 39.3% were collected from male study subjects. The association between the magnitude of scalp ringworm and gender was not statistically significant (P = 0.105). Two hundred eighty study subjects were less than 15 years of age, of which 254 were culture positive. The association of tinea capitis and the age of patients was statistically significant (P = 0). Three hundred forty-nine fungal isolates were isolated, of which 54.2% were dermatophytes, while 45.8% were non-dermatophyte molds. The occurrence of dermatophytes in their decreasing order was T. violaceum (138; 73%), Trichophyton mentagrophytes (18; 9.5%), Trichophyton tonsurans (16; 8.5%), Trichophyton verrucosum (8; 4.5%), Microsporum audouinii (7; 3.7%), Trichophyton schoenleinii (1; 0.5%), and Trichophyton soudanense (1; 0.5%).

Conclusion

A high prevalence rate of T. violaceum-induced tinea capitis was reported. The magnitude of scalp ringworm in adults was remarkably high. Therefore, conducting a nationwide epidemiological survey on tinea capitis regardless of age is suggested. The isolation of many non-dermatophyte molds in the current study may shade questions about the perception that tinea capitis is caused by dermatophytes only. Therefore, studies on their potential pathogenic role on skin and skin-related (nail and the scalp) infections appear to be an active field of research.

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.

Determining the burden of fungal infections in Zimbabwe

Zimbabwe currently faces several healthcare challenges, most notably HIV and associated infections including tuberculosis (TB), malaria and recently outbreaks of cholera, typhoid fever and COVID-19. Fungal infections, which are also a major public health threat, receive considerably less attention. Consequently, there is dearth of data regarding the burden of fungal diseases in the country. We estimated the burden of fungal diseases in Zimbabwe based on published literature and 'at-risk' populations (HIV/AIDS patients, survivors of pulmonary TB, cancer, chronic obstructive pulmonary disease, asthma and patients receiving critical care) using previously described methods. Where there was no data for Zimbabwe, regional, or international data was used. Our study revealed that approximately 14.9% of Zimbabweans suffer from fungal infections annually, with 80% having tinea capitis. The annual incidence of cryptococcal meningitis and Pneumocystis jirovecii pneumonia in HIV/AIDS were estimated at 41/100,000 and 63/100,000, respectively. The estimated prevalence of recurrent vulvovaginal candidiasis (RVVC) was 2,739/100,000. The estimated burden of fungal diseases in Zimbabwe is high in comparison to other African countries, highlighting the urgent need for increased awareness and surveillance to improve diagnosis and management.

Exploring the human hair follicle microbiome

Human hair follicles (HFs) carry complex microbial communities that differ from the skin surface microbiota. This likely reflects that the HF epithelium differs from the epidermal barrier in that it provides a moist, less acidic, and relatively ultraviolet light-protected environment, part of which is immune-privileged, thus facilitating microbial survival. Here we review the current understanding of the human HF microbiome and its potential physiological and pathological functions, including in folliculitis, acne vulgaris, hidradenitis suppurativa, alopecia areata and cicatricial alopecias. While reviewing the main human HF bacteria (such as Propionibacteria, Corynebacteria, Staphylococci and Streptococci), viruses, fungi and parasites as human HF microbiome constituents, we advocate a broad view of the HF as an integral part of the human holobiont. Specifically, we explore how the human HF may manage its microbiome via the regulated production of antimicrobial peptides (such as cathelicidin, psoriasin, RNAse7 and dermcidin) by HF keratinocytes, how the microbiome may impact on cytokine and chemokine release from the HF, and examine hair growth-modulatory effects of antibiotics, and ask whether the microbiome affects hair growth in turn. We highlight major open questions and potential novel approaches to the management of hair diseases by targeting the HF microbiome.

Tinea capitis in children: A single-institution retrospective review from 2011 to 2019

Tinea capitis remains a common public health problem worldwide, especially in developing countries.

OBJECTIVES

To investigate the changes of the predominant dermatophytes of tinea capitis in children in Hangzhou in recent 9 years.

METHODS

The age, gender and pathogen spectrum of 650 children with tinea capitis at the Department of Dermatology, Affiliated Third People's Hospital of Hangzhou, Anhui Medical University from 2011 to 2019 were analysed, and the distribution of pathogens from 1998 to 2000 was compared.

RESULTS

Among the 650 cases, 340 cases (48.2%) were males and 310 cases (51.8%) were females. The main population infected with tinea capitis was children aged 0-10 years (620 cases, 95.4%). From 2011 to 2019, the predominant dermatophyte was changed from Trichophyton violaceum (2011) to Trichophyton mentagrophytes complex (2012-2015) and later to Microsporum canis (2016-2019). In the past 9 years, M. canis (250 cases, 38.5%) was the most common dermatophyte and followed by T mentagrophytes complex (209 cases, 32.2%). The dermatophyte spectrum was statistically different between the years 2011 and 2019 (Chi square: χ²  = 69.75, P < .05), and the differences in anthropophilic and zoophilic pathogens between 1989-2000 and 2011-2019 were statistically significant (χ²  = 24.4, P < .05).

CONCLUSIONS

Research showed that children diagnosed with tinea capitis were mainly 0-10 years old. With age, the percentage of anthropophilic dermatophytes gradually increased, while the percentage of zoophilic dermatophytes decreased. M. canis was the predominant dermatophyte of tinea capitis in children, followed by T. mentagrophytes complex. The dermatophytes have shifted from anthropophilic to zoophilic dermatophytes in the past two decades.

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

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

Tinea capitis: A single-institution retrospective review from 2010 to 2015

BACKGROUND/OBJECTIVE

Tinea capitis is a common infection of scalp hair in children. The prevalent etiologic organism has changed significantly over time, which may reflect the complex interaction of environmental factors, genetic predisposition, and movement of populations. We evaluate the prevalence of different infectious organisms causing tinea capitis and describe the clinical characteristics.

METHODS

A retrospective chart review of patients diagnosed with tinea capitis with tissue culture confirmation, who were seen in pediatric dermatology at a tertiary care center from 2010 to 2015. Patient demographics, culture data, and clinical characteristics were evaluated. Inflammatory pattern, characterized by presence of pustules, bogginess, or lymphadenopathy, was noted.

RESULTS

Forty-six patients with culture-positive tinea capitis were identified. In the 18 (42.9%) patients who were infected with either Trichophyton violaceum or Trichophyton soudanenese, all were of African ethnicity. In contrast, Trichophyton tonsurans was identified in a minority of African patients (3.8%), revealing a statistically significant difference between ethnicity and infective species (P-value < 0.001). T tonsurans was significantly more likely than T violaceum to exhibit an inflammatory pattern (68% vs 22%, P value < 0.027).

CONCLUSIONS

While T tonsurans remained the most common cause of tinea capitis, T violaceum and T soudanense have increased in prevalence. As these latter agents are less inflammatory, clinical diagnosis may be delayed. Studying changes in the infectious cause of tinea capitis can help us create a snapshot to better understand the evolution of our population make-up, allowing us to provide crucial quality health care to all.

The first case report of kerion-type scalp mycosis caused by Aspergillus protuberus

Background

Scalp mycosis is often caused by dermatophytes and was so called tinea capitis. There is no published report caused by Aspergillus protuberus. We report a rare case of kerion-type scalp mycosis caused by A. protuberus.

Case presentation

A 5-year-old girl developed pyogenic mass with pain for 8 days and got a fever for 2 days prior to admission. Surgical incision and drainage of the mass, intravenous cefuroxime and metronidazole in the local hospital aggravated the skin lesions. Species identification was performed by observation of morphologic and biochemical characteristicsand sequencing of the internal transcribed spacer (ITS) and β-tubulin (BT2). Treatment with oral and topical antifungal agents was effective with no relapse during the six months of clinical follow-up.

Conclusions

Aspergillusis a opportunistic pathogenic fungus and its infection occurs mostly in patients with underlying conditions and immunocompromised statuses. So far no report of kerion-type scalp infection has been reported. The first case of kerion-type scalp mycosis caused by A. protuberus was described to highlight the importance of mycological examination that helps to recognize rare pathogenic fungi. Any boggy lesion with hair loss over the scalp and non-responsive to antibiotics should be suspected as resulting from fungal infection, and mycological examination should be performed, especially in children.

Clinico-mycological profile of tinea capitis and its comparative response to griseofulvin versus terbinafine

Background and Purpose:

Tinea capitis is the most common superficial mycosis in children. This disease is a contagious infection with worldwide distribution and is occasionally associated with permanent alopecia. The treatment of this infection usually requires the administration of appropriate oral antifungal agents. The current study was conducted to evaluate the clinico-mycological profile of tinea capitis and compare the efficiency of oral griseofulvin and terbinafine in the treatment of this disease.

Materials and Methods:

This study was conducted on 69 patients, including 23 females (33.3%) and 46 males (66.7%), clinically suspected of tinea capitis. After the confirmation of tinea capitis diagnosis through direct examination, the subjects were randomly assigned into two groups of griseofulvin and terbinafine. Demographic data, clinical and mycological characteristics, and therapeutic outcome were recorded for both groups.

Results:

According to the results, tinea capitis was more common in children younger than 15 years (73.9%), athletes (37.7%), and males (66.7%), and those with frontal involvement (34.8%), non-inflammatory type (68.1%), endothrix (69.6%), and Trichophyton tonsurans species (41.7%). The griseofulvin and terbinafine groups had the treatment success rates of 90.9% and 80.6%, respectively (P=0.311). The griseofulvin group had a shorter therapeutic course than the terbinafine group (P=0.129).

Conclusion:

Although our findings demonstrated that both griseofulvin and terbinafine were effective in the treatment of tinea capitis, griseofulvin showed a little higher efficacy in this regard. Consideration of some variables, such as age, associated risk factors, clinical type, hair involvement pattern, and dominant pathogenic species, is important in the determination of the drugs.

Trichophyton as a Rare Cause of Postoperative Wound Infection Resistant to Standard Empiric Antimicrobial Therapy

Fungal infections are rare causes of acute surgical wound infections, but Candida is not an infrequent etiology in chronic wound infections. Trichophyton species is a common cause of tinea capitis but has not been reported as a cause of neurosurgical wound infection. We report a case of Trichophyton tonsurans causing a nonhealing surgical wound infection in a 14-year-old male after hemicraniectomy. His wound infection was notable for production of purulent exudate from the wound and lack of clinical improvement despite empiric treatment with multiple broad-spectrum antibiotics targeting typical bacterial causes of wound infection. Multiple wound cultures consistently grew Trichophyton fungus, and his wound infection clinically improved rapidly after starting terbinafine and discontinuing antibiotics.

A Practical Approach to the Diagnosis and Management of Hair Loss in Children and Adolescents

Hair loss or alopecia is a common and distressing clinical complaint in the primary care setting and can arise from heterogeneous etiologies. In the pediatric population, hair loss often presents with patterns that are different from that of their adult counterparts. Given the psychosocial complications that may arise from pediatric alopecia, prompt diagnosis and management is particularly important. Common causes of alopecia in children and adolescents include alopecia areata, tinea capitis, androgenetic alopecia, traction alopecia, trichotillomania, hair cycle disturbances, and congenital alopecia conditions. Diagnostic tools for hair loss in children include a detailed history, physical examination with a focused evaluation of the child’s hair and scalp, fungal screens, hair pull and tug test, and if possible, light microscopy and/or trichoscopy. Management of alopecia requires a holistic approach including psychosocial support because treatments are only available for some hair loss conditions, and even the available treatments are not always effective. This review outlines the clinical presentations, presents a diagnostic algorithm, and discusses management of these various hair loss disorders.

The kerion: an angry tinea capitis

Tinea capitis has a high incidence with a global changing pathogen distribution, making this condition a public health concern around the world. As the infection is initially asymptomatic, it is easily spread. Moreover, it is present in many fomites, including hairbrushes, pillows, and bedding. Prompt recognition and treatment is necessary for kerion, an inflammatory subtype characterized by tender boggy plaques with purulent drainage. Kerion is usually associated with infection by zoophilic dermatophytes, although other sources have been described. Treatment for this severe form of dermatophytic infection can be challenging. In addition to the use of topical treatments, oral administration of griseofulvin, terbinafine, itraconazole, or fluconazole is often required. Griseofulvin, the first-line treatment, may not completely eradicate pathogen colonization of the host and may contribute to reinfection and prevalence of infective but asymptomatic carriers. This review highlights new agents that are being evaluated for the treatment of kerion and typical tinea capitis, enhanced diagnostic criteria, and a grading system for kerion evaluation.

Tinea capitis: a retrospective epidemiological comparative study

BACKGROUND

Currently, a wide spectrum of retrospective studies regarding the incidence of TC among children and adults are available in the world literature, but none of them are comparative, aiming to distinguish etiological diversity depending on the different geographic areas.

OBJECTIVE

This study aimed to investigate the epidemiology of TC in Plovdiv, Bulgaria and Thessaloniki, and Greece, and to compare the results and predominant etiological agents using retrospective comparative analysis for an 11-year time period.

MATERIALS AND METHODS

The subjects included were selected from archives of the Mycological Laboratory of the University Dermatologic Clinic, University Hospital "St. George" Plovdiv, Bulgaria, and the Mycological Laboratory of the First Dermatology Department of Aristotle University Thessaloniki, Greece, by retrospective analysis of data from an 11-year time period (2004-2014). A total count of 374 children aged 0-18, with confirmed diagnosis of TC via direct mycological examination and culture were included (128 children from Plovdiv, Bulgaria, and 246 children from Thessaloniki, Greece). Samples were plated on Sabouraud agar, followed by species identification of the isolated colonies.

RESULTS

Our results demonstrate that the incidence of TC in the region of Bulgaria and Thessaloniki for the investigated period was lower than for the previously reported period. In Plovdiv, Bulgaria, it was 1.20 ± 0.09 % (n = 172 from a total count of 14,278 cases of mycoses), as the disease accounts for 23.10 ± 1.79 % of all mycological infections among the pediatric population and 0.36 ± 0.05 % (n = 49 from a total count of 13,724) among the adults patients in Plovdiv, Bulgaria. The incidence of the disease during the period 2004-2014 in Thessaloniki was 2.49 ± 0.15 % (n = 253 cases of TC from a total count of 10,168 mycoses), as it accounts for approximately 27.06 ± 1.47 % of mycological infections among the pediatric population in Thessaloniki, Greece, and 0.08 ± 0.03 % (n = 7 from a total count of 9259) of the population of adult patients with mycoses. Our study confirmed the presumption that M. canis is the leader among the causative agents in TC in children in both of the included countries, but its presence in the etiology of disease in adult patients was very low and nonsignificant. We categorically identified dominance of the female gender among the children with TC in Plovdiv, Bulgaria; while in Thessaloniki, Greece, the gender distribution had an almost equal ratio of males to females.

CONCLUSION

Our results suggest that the gender predisposition depends also on the investigated geographic region and the time of the study, rather than only on the causative pathogen and age.

Aspergillus niger – a possible new etiopathogenic agent in Tinea capitis? Presentation of two cases

Tinea capitis is generally considered as the most frequent fungal infection in childhood, as it accounts for approximately 92% of all mycosis in children. The epidemiology of this disease varies widely ranging from antropophillic, zoophilic, and geophillic dermatophytes, as the main causative agent in different geographic areas, depending on several additional factors. Nowadays, the etiology is considered to vary with age, as well with gender, and general health condition. The former reported extraordinary Tinea capitis case reports have been replaced by original articles and researches dealing with progressively changing patterns in etiology and clinical manifestation of the disease. This fact is indicative that under the umbrella of the well-known disease there are facts still hidden for future revelations. Herein, we present two rare cases of Tinea capitis in children, which totally differ from the recently established pattern, in their clinical presentation, as well as in the etiological aspect, as we discuss this potential new etiological pattern of the disease, focusing on our retrospective and clinical observation. Collected data suggest that pathogenic molds should be considered as a potential source of infection in some geographic regions, which require total rationalization of the former therapeutic conception, regarding the molds’ higher antimitotic resistance compared to dermatophytes. Molds-induced Tinea capitis should be also considered in clinically resistant and atypical cases, with further investigations of the antifungal susceptibility of the newest pathogens in the frame of the old disease. Further investigations are still needed to confirm or reject this proposal.

Kerion and Tinea Corporis Caused by Rabbit-Derived Trichophyton interdigitale in Three Siblings and One Consulting Doctor Using β-Tubulin Gene to Identify the Pathogen

Trichophyton interdigitale is generally deemed as an anamorph of Arthroderma vanbreuseghemii based on internal transcribed spacer (ITS) sequencing, but recently their anamorph/teleomorph connection should be cautioned based on β-tubulin phylogeny. We report three siblings and one consulting doctor who developed kerion and tinea corporis after contact with domestic rabbits. Seven same strains were isolated from four patients and three regions of a sick rabbit. The ITS and D1/D2 sequences of our isolate were 99 % homologous to A. Vanbreuseghemii, while β-tubulin sequence was 100 % identical to T. interdigitale. Our isolate was identified as T. interdigitale based on maximum likelihood analysis of β-tubulin. Random amplified polymorphic DNA revealed that the band patterns of five isolated strains and another rabbit-derived strain WCH023 were identical for OPF-03 and OPF-12. Skin lesions of all patients resolved completely for 2- to 6-week therapy of oral terbinafine and topical 1 % bifonazole or 1 % terbinafine cream. This study demonstrates that T. interdigitale of rabbit origin can cause various types of human dermatophytosis by mild scratch. Terbinafine may be the first choice for dermatophytosis caused by T. interdigitale.

Griseofulvin and Fluconazole Reduce Transmission of Tinea Capitis in Schoolchildren

OBJECTIVE

We evaluated the efficacy of griseofulvin and fluconazole in reducing the potential for person-to-person transmission of tinea capitis (TC) in children.

METHODS

Children with TC with positive fungal cultures were treated with griseofulvin 25 mg/kg/day (group A) or fluconazole 6 mg/kg/day (group B) for at least 21 days and up to 12 weeks until cure was achieved. Clinical and mycologic examinations occurred before treatment and on days 3, 7, 10, 14, and 21 of treatment. During each visit, mycologic examination was performed from scalp lesions of children and fingertips of medical staff and parents after a brief touch of the patient's scalp lesions.

RESULTS

Ninety patients were enrolled: 48 treated with griseofulvin and 42 with fluconazole. The predominant species were Trichophyton violaceum (n = 44) and Microsporum canis (n = 41), followed by Trichophyton mentagrophytes (n = 3) and Trichophyton rubrum (n = 2). Ten days after treatment more than 75% of patients from both treatment groups were noncontagious. At day 21, all patients from group A were noncontagious and two (7%) with positive culture of M. canis from group B were still contagious.

CONCLUSIONS

No statistically significant differences were found between treatment groups. Griseofulvin and fluconazole reduced the potential for disease transmission in children with TC, with griseofulvin being more effective for M. canis infections, although children with TC may be potentially contagious even after up to 3 weeks of treatment. These data should be considered regarding school attendance of children with TC.

Epidemiological changes in tinea capitis over the sixty years of economic growth in China

BACKGROUND

Tinea capitis is a fungal infection of the scalp occurring commonly in children. Historical data indicate that clinical manifestations and the spectrum of etiologic agents vary greatly with geography, as well as socioeconomic affected populations.

OBJECTIVE

To study the possible connection between socioeconomic status, the disease patterns and the variability of etiological agents.

METHODS

We reviewed tinea capitis in China through literature since 1956. The disease pattern was correlated with economic and public health management protocols. Historical data on fungal identification were mostly obtained by morphology. The accuracy of these historical results was further confirmed by use of both morphological and ITS identification on a control set of 90 isolates collected recently from local hospital.

RESULTS

Full agreement of the two identification methods implies that data from the literature were sufficiently reliable to allow comparison across reported cases. In sum, 88 papers involving 25 administrative provinces and municipalities with 38,962 clinical strains met the inclusion criteria of this review. Zoophilic species Microsporum canis is the most prevalent agent within large, modernized cities in China today accounting for over 80% of infections. In contrast, anthropophilic dermatophytes, particularly Trichophyton violaceum, are geographically endemic only in some southeastern and northwestern regions.

CONCLUSION

Economic development and urbanization of cities favor a shift of etiological agents from anthroponoses to zoonoses in contemporary China. Pets are becoming the most likely sources of infection in modern lifestyles, replacing the earlier human-to-human transmission mode. However, the latter transmission mode is still prevalent in less developed areas lacking adequate social and public health facilities.

Mycology - an update part 2: dermatomycoses: clinical picture and diagnostics

Most fungal infections of the skin are caused by dermatophytes, both in Germany and globally. Tinea pedis is the most frequent fungal infection in Western industrial countries. Tinea pedis frequently leads to tinea unguium, while in the elderly, both may then spread causing tinea corporis. A variety of body sites may be affected, including tinea glutealis, tinea faciei and tinea capitis. The latter rarely occurs in adults, but is the most frequent fungal infection in childhood. Following antifungal treatment of tinea unguium and also tinea capitis a dermatophytid or hyperergic reaction to dermatophyte antigens may occur. Yeast infections affect the mucous membranes both of the gastro-intestinal system and the genital tract as candidiasis mostly due to Candida albicans. Cutaneous candidiasis affects predominantely the intertriginous regions such as groins and the inframammary area, but also the intertriginous space of fingers and toes. In contrast, pityriasis versicolor is a superficial epidermal fungal infection primarily on the the trunk. Mold infections are rare in dermatology; they play a role nearly exclusively in nondermatophyte-mold (NDM) onychomycosis. The diagnosis of dermatomycoses comprises the microscopic detection of fungi using the potassium hydroxide preparation or alternatively the fluorescence optical Blankophor preparation together with culture. The histological fungal detection with PAS staining possesses a high sensitivity, and it should play a more important role in particular for diagnosis of onychomycosis. Molecular biological methods, based on the amplification of fungal DNA with use of specific primers for the distinct causative agents are on the rise. With PCR, such as dermatophyte-PCR-ELISA, fungi can be detected directly in clinical material in a highly specific and sensitive manner without prior culture. Today, molecular methods, such as Matrix Assisted Laser Desorption/Ionization Time-Of-Flight Mass Spectrometry (MALDI TOF MS) as culture confirmation assay, complete the conventional mycological diagnostics.

In vitro antifungal susceptibility of Trichophyton violaceum isolated from tinea capitis patients

OBJECTIVES

Trichophyton violaceum is an anthropophilic dermatophyte that is endemic to parts of Africa and Asia and is sporadic in Europe. T. violaceum mainly causes tinea capitis in both children and adolescents. Although the infections caused by T. violaceum are of considerable medical importance, its antifungal susceptibility profile remains poorly examined.

METHODS

In this study, we tested the in vitro antifungal susceptibility of a set of clinical T. violaceum isolates obtained from tinea capitis patients, using the CLSI broth microdilution method. We tested eight antifungals and used isolates collected from Western China (21), Eastern China (12), the Middle East (1), Europe (20), South Africa (7) and Canada (1).

RESULTS

The geometric means of the MICs of the antifungals for all isolates were as follows (in increasing order): posaconazole, 0.021 mg/L; terbinafine, 0.023 mg/L; voriconazole, 0.062 mg/L; amphotericin B, 0.20 mg/L; itraconazole, 0.34 mg/L; caspofungin, 0.56 mg/L; fluconazole, 4.23 mg/L; and flucytosine, 8.46 mg/L. No statistically significant differences in the susceptibility profiles of T. violaceum were detected within the geographical regions tested.

CONCLUSIONS

Posaconazole, terbinafine and voriconazole were shown to be the most potent antifungal agents against T. violaceum isolates obtained from tinea capitis patients worldwide. These results might help clinicians in developing appropriate therapies that have a high probability of successfully treating tinea capitis due to T. violaceum.

Pharmacological Management of Pediatric Kerion Celsi

We report a case of severe tinea capitis, treated successfully with griseofulvin. In our opinion, the treatment of this severe dermatophytosis with griseofulvin is safe and effective. Other treatments, such as itraconazole pulsed therapy, failed, despite an initial improvement, leading to an aggressive recurrence of the lesion. We chose griseofulvin for its well-known large spectrum activity, also against uncommon species, like Microsporum Gypseum, which are responsible for the most severe cases.

Tinea capitis favosa misdiagnosed as tinea amiantacea

INTRODUCTION

Favus of the scalp or tinea capitis favosa is a chronic dermatophyte infection of the scalp. In almost cases, favus is caused by Trichophyton schoenleinii, anthropophilic dermatophyte. It is characterized by the presence of scutula and severe alopecia. Besides the classic clinical type of tinea capitis favosa, there are many variant of clinical form which may persist undiagnosed for many years. In this work, we report an atypical form of favus to Trichophyton schoenleinii which was misdiagnosed as tinea amiantacea.

CASE-REPORT

An 11-year old girl came to the outpatient department of dermatology (day 0) with history of tinea amiantacea treated unsuccessfully with keratolytic shampoo (day - 730). She presented a diffuse scaling of the scalp with thick scaly patches and without scutula or alopecia. A diagnosis of tinea favosa by T. schoenleinii was made by mycological examination. She was treated with griseofulvin and ketoconazole in the form of foaming gel for twelve weeks. Despite treatment, clinical evolution was marked by appearance of permanent alopecia patches. The follow-up mycological examination was negative.

CONCLUSION

Because of ultimate evolution of favus into alopecia, we emphasize the importance of mycological examination in case of diffuse scaling.