Tinea CapitisContributor Information and DisclosuresAuthorGrace F Kao, MD Clinical Professor of Dermatopathology, Department of Dermatology, University of Maryland School of Medicine and George Washington University Medical School Director, Dermatopathology Section, Department of Pathology and !aboratory Medicine, "eterans #ffairs Maryland $ealthcare System, %altimore, MarylandGrace & 'ao, MD is a member of the follo(ing medical societies) #merican #cademy of Dermatology,#merican Society of Dermatopathology, International Society of DermatopathologyDisclosure) *othing to disclose+%ac,ground-inea capitis is a disease caused by superficialfungalinfection of the s,in of the scalp, eyebro(s, andeyelashes, (ith a propensity for attac,ing hair shafts and follicles .see the image belo(/+ -he disease isconsidered to be a form of superficial mycosis or dermatophytosis+ Several synonyms are used, includingring(ormof thescalpandtineatonsurans+ IntheUnitedStatesandother regionsof the(orld, theincidence of tinea capitis is increasing+Gray0patchring(orm.microsporosis/isanectothri1 infection or prepubertaltinea capitis seen here in an #frican #merican male child+ Gray patch refers to thescaling (ith lac,ofinflammation,asnotedinthispatient+ $airsinthe involvedareasassume acharacteristic dull,grayish, discolored appearance+ Infected hairs are bro,en and shorter+ Papular lesions around hair shafts spread andform typical patches of ring forms, as sho(n+ Culture from the lesional hair gre( Microsporum canis+See 23 4ashes 5ou *eed to 'no() Common Dermatologic Diagnoses, a CriticalImages slidesho(, forhelp identifying and treating various rashes+#lso, see the 23 %ac,0to0School Illnesses 5ou Should 'no( slidesho( to help identify conditions that mayoccur in young patients after they return to the classroom+Dermatophytosisincludes several distinctclinical entities,dependingontheanatomicsiteandetiologicagents involved+ Clinically, the conditions include tinea capitis, tinea favosa .favus resulting from infectionby Trichophyton schoenleinii/, tinea corporis .ring(ormof glabrous s,in/, tinea imbricata .ring(ormresulting from infection by Trichophyton concentricum/, tinea cruris .ring(orm of the groin/, tinea unguiumor onychomycosis .ring(orm of the nail/, tinea pedis .ring(orm of the feet/, tinea barbae .ring(orm of thebeard/, and tinea manuum .ring(orm of the hand/+Clinical presentationof tineacapitisvariesfromascalynoninflameddermatosisresemblingseborrheicdermatitis to an inflammatory disease (ith scaly erythematous lesions and hair loss or alopecia that mayprogress to severely inflamed deep abscesses termed ,erion, (ith the potential for scarring and permanentalopecia+ -he type of disease elicited depends on interaction bet(een the host and the etiologic agents+-he term tinea originally indicated larvae of insects that fed on clothes and boo,s+ Subse6uently, it meantparasitic infestation of the s,in+ %y the mid 27th century, the term (as used to describe diseases of thehairy scalp+ -he term ring(orm referred to s,in diseases that assumed a ring form, including tinea+ -hecausative agents of tinea infections of the beard and scalp (ere described first by 4ema, and Sch8nlein,then by Gruby, during the 29:;s+ #ppro1imately 3; years later, in Sabouraud+?ffective treatment of tinea capitis by griseofulvin became available in the 2=3;s+Pathophysiology-inea capitis is caused by fungiof species of genera Trichophyton andMicrosporum+ -inea capitis is themost common pediatric dermatophyte infection (orld(ide+ -he age predilection is believed to result fromthe presence ofPityrosporum orbiculare .Pityrosporum ovale/, (hich is part of normal flora, and from thefungistatic properties of fatty acids of short and medium chains in postpubertal sebum+Causative agents of tinea capitis include ,eratinophilic fungi termed dermatophytes+ -hese molds usuallyare present in nonliving cornified layers of s,in and its appendages and sometimes are capable of invadingthe outermost layer of s,in, stratum corneum, or other ,eratini@ed s,in appendages derived from epidermis,such as hair and nails+Dermatophytes are among the most common infectious agents of humans, causing a variety of clinicalconditions that arecollectivelytermed dermatophytosis+&rom the site of inoculation,thefungal hyphaegro( centrifugally in the stratum corneum+ -he fungus continues do(n(ard gro(th into the hair, invading,eratin as it is formed+ -he @one of involvement e1tends up(ards at the rate at (hich hair gro(s, and it isvisible above the s,in surface by days 2A02>+ Infected hairs are brittle, and by the third (ee,, bro,en hairsare evident+-hree types of in vivo hair invasion are recogni@ed+ ?ctothri1 invasion is characteri@ed by the development of arthroconidia on the e1terior of the hairshaft+ -he cuticle of the hair is destroyed, and infected hairs usually fluoresce a bright greenish0yello(color under aWoodlampultraviolet light+ Commonagentsinclude Microsporumcanis, Microsporumgypseum, Trichophyton equinum, and Trichophyton verrucosum. ?ndothri1 hair invasion is characteri@ed by the development of arthroconidia (ithin the hair shaftonly+-hecuticleof thehair remainsintact andinfectedhairsdonot fluoresceunder aWoodlampultraviolet light+ #ll endothri10producing agents are anthropophilic .eg, Trichophyton tonsurans,Trichophyton violaceum/+ B2C &avus, usually caused by T schoenleinii, produces favusli,e crusts or scutula and correspondinghair loss+?pidemiologyFrequencyUnited StatesDccurrence of the disease is no longer registered by public health agencies therefore, true incidence isun,no(n+ -he reported pea, incidence occurs in school0aged #frican #merican male children+-ineacapitis is predominantlyadiseaseof preadolescent children+ It accounts for upto=A+3Eofdermatophytoses in children younger than 2; years+ -he disease is rare in adults, although occasionally, itmay be found in elderly patients+ -inea capitis occurrence is (idespread in some urban areas in the UnitedStates+International-inea capitis is (idespread in some urban areas, particularly in children of #fro0Caribbean e1traction, in*orth #merica,Central#merica,and South #merica+Itis common in parts of #fricaandIndia+BA, :, >, 3C InSoutheast #sia, the rate of infection has been reported to have decreased dramatically from 2>E .averageof male and female children/ to 2+AE in the last 3; years because of improved general sanitary conditionsand personal hygiene+ In northern ?urope, the disease is sporadic+In theUnited'ingdomand*orth#merica, Ttonsurans accounts for greater than=;Eof cases ofinfection .B7C In the nonurban communities, sporadic infections ac6uired from puppies and ,ittens are dueto M canis, (hich accounts for less than 2;E of cases in the United 'ingdom+ Dccasional infection fromother animal hosts .eg, T verrucosum from cattle/ occurs in rural areas+Mortality/MorbidityClassification and severity of tinea capitis depend on the site of formation of their arthroconidia+ ?ctothri1 infection is defined as fragmentation of the mycelium into conidia around the hair shaft orFust beneath the cuticle of the hair, (ith destruction of the cuticle+ Inflammatory tinea related to e1posureto a ,itten or puppy usually is a fluorescent smallspore ectothri1+ Some mild ring(orm or prepubertaltinea capitis infections are of the ectothri1 type, also termed the gray0patch type .microsporosis see theimage belo(/+ Some ectothri1 infections involute during the normal course of disease (ithout treatment+Depending on the e1tent of associated inflammation, lesions may heal (ith scarring+Gray0patch ring(orm.microsporosis/ isan ectothri1 infection or prepubertal tinea capitis seen here in an #frican #merican male child+ Gray patch refers to thescaling (ith lac, of inflammation, as noted in this patient+ $airs in the involved areas assume a characteristic dull,grayish, discolored appearance+ Infected hairs are bro,en and shorter+ Papular lesions around hair shafts spread andform typical patches of ring forms, as sho(n+ Culture from the lesional hair gre( Microsporum canis+ ?ndothri1infectionsarenotedin(hicharthrosporesarepresent (ithinthehair shaft inbothanagen and telogen phases, contributing to the chronicity of the infections+ ?ndothri1 infections tend toprogress, become chronic, and may last into adult life+ !esions can be eradicated by systemic antifungaltreatment+ Since the organisms usually remain superficial, little potential for mortality e1ists+ Disseminatedsystemic disease has been reported in patients (ho are severely immunocompromised+Se-he incidence of tinea capitis may vary by se1, depending on the causative fungal organism+Microsporumaudouinii Grelated tinea capitis has been reported to be up to 3 times more common in boys than in girls+#fter puberty, ho(ever, the reverse is true, possibly because of (omen having greater e1posure to infectedchildren and possibly because of hormonal factors+ In infection by M canis, the ratio varies, but the infectionrate usually is higher in boys+ Girls and boys are affected e6ually by Trichophyton infections of the scalp,but in adults, (omen are infected more fre6uently than are men+A!e-inea capitis occurs primarily in children and occasionally in other age groups+ It is seen most commonly inchildren younger than 2; years+ Pea, age range is in patients aged :0H years+$istorySee the list belo() -inea capitis begins as a small erythematous papule around a hair shaft on the scalp, eyebro(s,or eyelashes+ Withinafe(days, theredpapulebecomespalerandscaly,andthehairsappeardiscolored,lusterless, and brittle+ -hey brea, off a fe( millimeters above the scalp s,in surface+ -he lesion spreads, forming numerous papules in a typicalring form+ 4ing0shaped lesions maycoalesce (ith other infected areas+ Pruritus usually is minimal but may be intense at times+ #lopecia is common in infected areas+ Inflammationmaybemildor severe+ Deepboggyredareascharacteri@edbyasevereacuteinflammatory infiltrate (ith pustule formation are termed ,erions or ,erion celsi .see the image belo(/+-ypical lesionsof ,erioncelsi ontheverte1scalpof ayoungChineseboy+ *otenumerousbright yello(purulent areasons,insurface, surroundedbyadFacent edematous,erythematous, alopecic areas+ Culture from the lesion gre( -richophyton mentagrophytes+ Courtesy of S,in Diseasesin Chinese by 5au0Chin !u, MD+ Permission granted by Medicine -oday Publishing Co, -aipei, -ai(an, 2=92+ &avus .also termed tinea favosa/ is a severe form of tinea capitis+o &avus is a chronic infection caused most commonly by T schoenleiniiand, occasionally,by T violaceum or Microsporum gypsum+o Scalplesionsarecharacteri@edbythepresenceof yello(cup0shapedcruststermedscutula, (hich surround the infected hair follicles+o &avus is seen predominantly in #frica, the Mediterranean, and the Middle ?ast and, rarely,in *orth #merica and South #merica, usually in descendants of immigrants from endemic areas+o &avus usually is ac6uired early in life and has a tendency to cluster in families+o In favus, infected hairs appear yello(+Physical# variety of clinical presentations of tinea capitis are recogni@ed as being inflammatory or noninflammatoryand are usually associated (ith patchy alopecia+ Physical e1amination (ith a hand lens or trichoscopy maybe helpful in demonstrating the affected hairs+BHC -he infection may be (idespread, and the clinicalappearances can be subtle, especially in blac, children (ith Trichophyton tonsurans infection, in (hom thefindings may mimic patches of seborrheic dermatitis (ith hair loss+ In urban areas, tinea capitis should beconsideredinthedifferential diagnosisof childrenolderthan:months(ithascalyscalpuntil provennegative by mycological e1amination+ Infection may also be associated (ith painful regionallymphadenopathy, especially in the inflammatory variants+Pertinent physical findings are limited to the s,in of scalp, eyebro(s, and eyelashes+B9C Primary s,in lesions of tinea capitiso !esions begin as red papules (ith progression to grayish ring0formed patches containingperifollicular papules+o Pustules (ith inflamed crusts, e1udate, matted infected hairs, and debris may be seen+o %lac, dot tinea capitis refers to an infection (ith fracture of the hair, leaving the infecteddar, stubs visible in the follicular orifices+o 'erion celsi may progress to a patchy or diffuse distribution and to severe hair loss (ithscarring alopecia .see the image belo(/+Discrete patches of hair loss or alopecia caused by -richophytonviolaceum infection of the verte1 scalp of a young -ai(anese boy+ Courtesy of S,in Diseases in Chinese by 5au0Chin !u, MD+ Permission granted by Medicine -oday Publishing Co, -aipei, -ai(an, 2=92+ Id reaction) Dermatophyte idiosyncratic or id reactions are manifestations of the immune responseto dermatophytosis+o Id reactions occur at a distant site, and the lesions are devoid of organisms+o Id reactions may be triggered by antifungal treatment+o -he most common type of id reaction is an acute vesicular dermatitis of the hands andfeet+ -he grouped vesicles are tense, pruritic, and sometimes painful+ Id reactions are noted in patients(ith inflammatory ring(orm of the feet, primarily resulting from infection by Trichophytonmentagrophytes+ Similar lesions may occur on the trun, in tinea capitis+o "esicular lesions may evolve into a scaly ec@ematoid reaction or a follicularpapulovesicular eruption+o Dther less common types of id reactions include annular erythema and erythemanodosum+ -hese patients have a strong delayed0type hypersensitivity reaction to intradermaltrichophytin+ Distributionof tineacapitis lesions) S,inlesions appear onthescalp(ithe1tensiontotheeyebro(s andIor eyelashes+ 4egional lymph nodes) Cervical lymphadenopathy may develop in patients (ith severeinflammation associated (ith ,erion formation+CausesSee the list belo() Infection of the scalp by dermatophytes usually is the result of person0to0person transmission+ -heorganism remains viable on combs, brushes, couches, and sheets for long periods+ Certain species ofdermatophytes are endemic only in particular parts of the (orld+ Joophilic fungal infections of the scalpare rare+ IntheUnitedStates, Ttonsurans hasreplaced Maudouinii and Mcanis asthemost commoncause of tinea capitis+ T tonsurans also is the most common cause of the disease in Canada, Me1ico,and Central #merica+ $istorically, M audouinii (as the classic causative agent in ?urope and #merica and Mferrugineum (asmost commonin#sia+ Currently, Maudouinii and Mcanis remainprevalent inmostparts of ?urope, although T violaceum also is common in 4omania, Italy, Portugal, Spain, and the formerUSS4, as (ell as in5ugoslavia+ In#frica, Tviolaceum, Tschoenleinii, and Mcanis commonlyareisolated+B=C T violaceum and M canis are prevalent agents in #sia+B2;C T schoenleinii is common in Iran and-ur,ey, (hile M canis is common in Israel+ Epidermophyton floccosum and T concentricum do not invadescalp hair+ Trichophyton rubrum, (hich is the most common dermatophyte isolated (orld(ide, is not acommon cause of tinea capitis+ Dermatophytic fungi causing tinea capitis can be divided into anthropophilic and @oophilicorganisms+ #nthropophilic fungi gro( preferentially on humans, and the most common type forms largeconidia of appro1imately :0> Km in diameter (ithin the hair shaft+ Joophilic fungi are ac6uired throughdirect contact (ith infected animals+ Smaller conidia of appro1imately 20: Km in diameter typically arepresent, e1tending around the e1terior of the hair shaft+ Dermatophytosis customarily is divided into endothri1 .inside the hair shaft/ and ectothri1.e1tending outside the hair shaft/ infection based on the location of proliferation of pathogenic fungi anddestruction of the hair structure+ Commoncausesof endothri1infectioninclude Ttonsurans, characteri@edbychainsof largespores and T schoenleinii, characteri@ed by hyphae (ith air spaces+ Infected hairs brea, off sharply at thefollicularorifice, leavingaconidia0filledstuborblac,dot+ Suppurationand,erionformation.seetheimage belo(/ commonly are associated (ith T tonsurans infection+-ypical lesionsof ,erioncelsi ontheverte1scalpof ayoungChineseboy+ *otenumerousbright yello(purulent areasons,insurface, surroundedbyadFacent edematous,erythematous, alopecic areas+ Culture from the lesion gre( -richophyton mentagrophytes+ Courtesy of S,in Diseasesin Chinese by 5au0Chin !u, MD+ Permission granted by Medicine -oday Publishing Co, -aipei, -ai(an, 2=92+ In ectothri1 infection, fragmentation of the mycelium into spores occurs Fust beneath the cuticle+ Incontrastto endothri1 infection,destruction ofthe cuticle occurs+ -histypeof infectioniscausedby Tverrucosum, T mentagrophytes, and all Microsporum species+Diagnostic Considerations%acterial folliculitisDissecting folliculitis .folliculitis decalvans/#bscess*eoplasiaPyodermaSecondary syphilisSeborrheic dermatitis occurs in older children and, unli,e tinea capitis, does not cause hair loss+ In somecases of tinea capitis, the erythematous scaly lesions closely resemble those seen in seborrheic dermatitisho(ever, in seborrheicdermatitis,hairsarenotbro,en+Seborrheic dermatitisand psoriasismay causeaccumulation of scales in matted masses on the scalp+ Scales are more prominent in psoriasis, and hairsare not bro,en+Impetigo may be difficult to distinguish from inflammatory tinea capitis, although pain is less severe in tineacapitis, and hairs tend to be seated firmly in impetigo+ #lopecia areata also causes circumscribed areas ofhair losssimilar totineacapitis, but alopeciaareatadoesnot causescaling+ !esionsmayhaveanerythematous border in the early stages of the disease, but this reverses to normal color at later stages+-he e1clamation mar, hairs seen in alopecia areata, in (hich bro,en hairs taper from the fractured endto(ard the s,in surface, are pathognomonic+In secondary syphilis, areas of alopecia have a characteristic moth0eaten appearance or resemble alopeciaareata+ Serologic testing for the presence of treponemal antibody .rapid plasma reagin and Treponema 0specific tests, eg, microhemagglutinationG Treponema pallidum test/ and testing by special silverimpregnation histochemical stain .Warthin0Starry stain/ for the demonstration of treponemal organisms aidin the accurate diagnosis of syphilis+-he patient may present (ith a generali@ed eruption of itchy papules, particularly around the outer heli1 oftheear, occurringasareactivephenomenon.anidresponse/+ -hesesymptomsmaystart (iththeintroduction of systemic treatment for tinea capitis thus, they be mista,en for a drug reaction+Differential Diagnoses #lopecia #reata #topic Dermatitis Drug ?ruptions Id 4eaction .#utoec@emati@ation/ Impetigo Pediatric Syphilis Pla6ue Psoriasis Pustular Psoriasis Seborrheic Dermatitis Subacute Cutaneous !upus ?rythematosus .SC!?/ -richotillomania!aboratory StudiesSee the list belo() !aboratory diagnosis of tinea capitis depends on e1amination and culture of s,in rubbings, s,inscrapings, or hair pluc,ings .epilated hair/ from lesions+o %eforespecimencollection, any ointmentorotherlocal applicationspresentshould beremoved (ith alcohol+o Infected hairs appearing as bro,en stubs are best for e1amination+ -hey can be removed(ithforceps(ithout unduetraumaorcollectedbygentlerubbing(ithamoist gau@epad bro,en,infectedhairsadheretothegau@e+ #toothbrushmaybeusedinasimilar fashion+B22C#lternatively,affected areas can be scraped (ith the end of a glass slide or (ith a blunt scalpel to harvest affectedhairs, bro,en0off hair stubs, andscalpscale+ -his is preferabletopluc,ing, (hichmayremoveuninvolved hairs+ Scrapings may be transported in a folded s6uare of paper+ S,in specimens may bescraped directly onto specialblac, cards, (hich ma,e it easier to see ho( much materialhas beencollected and provide ideal conditions for transportation to the laboratory ho(ever, affected hairs areeasier to see on (hite paper than on blac, paper+o Definitivediagnosisdependsonanade6uateamount of clinical material submittedfore1amination by direct microscopy and culture+ -he turn0around time for culture may ta,e several (ee,s+o Selected hair samples are cultured or allo(ed to soften in 2;0A;E potassium hydro1ide.'D$/ beforee1aminationunder themicroscope+ ?1aminationof 'D$preparations.'D$mount/usually determines the proper diagnosis if a tinea infection e1ists+o Conventional sampling of a ,erion can be difficult+ *egative results are not uncommon inthese cases+ -he diagnosis and decision to treat lesions of ,erion may need to be made clinically+ #moistened standard bacteriological s(ab ta,en from the pustular areas and inoculated onto the cultureplate may yield a positive result+B2ACo Microscopic e1amination of the infected hairs may provide immediate confirmation of thediagnosis of ring(orm and establishes (hether the fungus is small0spore or large0spore ectothri1 orendothri1+o Culture provides precise identification of the species for epidemiologic purposes+B2:C Primary isolation is carried out at room temperature, usually on Sabouraud agar containing antibiotics.penicillinIstreptomycinor chloramphenicol/ andcyclohe1imide.#cti0Dione/, (hichis anantifungalagent that suppresses the gro(th of environmental contaminant fungi+ In cases of tender ,erion, theagar plate can be inoculated directly by pressing it gently against the lesion+ Most dermatophytes canbe identified (ithin A (ee,s, although T verrucosumgro(s best at :HLC and may have formed only intosmall andgranular coloniesat thisstage+ Identificationdependsongrosscolonyandmicroscopicmorphology+ Specimens shouldbeinoculatedontoprimaryisolationmedia, suchasSabouraudde1trose, and incubated at A70A9LC for > (ee,s+ -he gro(th of any dermatophyte is significant+o In some cases, other tests involving nutritional re6uirements and hair penetration in vitroare necessary to confirm the identification+ Wood lamp e1amination) In 2=A3, Margarot and Deve@e observed that infected hairs and somefungus culturesfluoresce inultraviolet light+ -heblac,lightcommonlyistermedWoodlamp+!ightisfiltered through a Wood nic,el o1ide glass .barium silicate (ith nic,el o1ide/, (hich allo(s only the longultraviolet rays to pass .pea, at :73 nm/+ Wood lamp e1amination is useful for certain ectothri1 infections.eg, those caused by Mcanis,Maudouinii,Microsporumrivalieri). In cases (ith endothri1 infection,ho(ever, negative Wood lamp e1amination findings are of no practical value for screening or monitoringinfections+o $airsinfectedby Mcanis, Maudouinii, Mrivalieri, and Mferrugineumfluoresceabrightgreen to yello(0green color .see the image belo(/+Woodlampe1aminationof agray0patchareaonthescalp+ InMicrosporum canis infection, scalp hairs emit a diagnostic brilliant green fluorescence+ -richophyton tonsurans doesnot fluoresce (ith Wood lamp+o $airs infected by T schoenleinii may sho( a dull green or blue0(hite color, and hyphaeregress leaving spaces (ithin the hair shaft+o T verrucosum e1hibits a green fluorescence in co( hairs, but infected human hairs do notfluoresce+o -he fluorescent substance appears to be produced by the fungus only in actively gro(inginfected hairs+o Infected hairs remain fluorescent for many years after the arthroconidia have died+o Whenadiagnosisof ring(ormisunderconsideration, thescalpise1aminedunderaWood lamp+ If fluorescent infected hairs are present, hairs are removed for light microscopice1amination and culture+ Infections caused by Microsporum species fluoresce a typical green color+o Unfortunately, most tinea capitis infections in *orth #merica are caused by Ttonsurans and do not demonstrate fluorescence+B2>Co In favus, infected hairs appear yello( .see the image belo(/+Woodlampe1aminationof agray0patchareaonthescalp+ InMicrosporum canis infection, scalp hairs emit a diagnostic brilliant green fluorescence+ -richophyton tonsurans doesnot fluoresce (ith Wood lamp+ Serology is not re6uired for a diagnosis of dermatophytosis+ "ideodermatoscopy)# smallstudyin patients (ithtinea capitisfrom M canisfound thatcommahairs (ereaprominent and distinctive feature onvideodermatoscopycomma hairs (erenotseeninpatients (ith alopecia areata+B23C$istologic &indingsS,in biopsy (ith particular emphasis on e1amination of infected hairs (ith special histochemical stains aidsin the identification of the causative fungus, especially in cases of fungal folliculitis .MaFocchi granuloma/andonychomycosis+ %ulloustineademonstrates subepidermal edema and reticular degenerationoftheepidermis+ -inea corporis demonstrates subacute and chronic dermatitis (ith or (ithout follicularinflammation and destruction+ Suppurative folliculitis may be present+ In the mildest form, hyper,eratosis,para,eratosis, spongiosis, slight vasodilatation, andaperivascular inflammatoryinfiltrateintheupperdermis are present+ &ungal hyphae can be demonstrated using routine hemato1ylin and eosin stain, andidentification can be facilitated by using special stains+ Periodic acid0Schiff stain (ith diastase digestion orcounterstained (ith green dye facilitates identification of fungal elements+ See the image belo(+Photomicrograph depicting an endoectothri1invasionof ahair shaft byMicrosporumaudouinii+ Intrapilaryhyphaeandsporesaroundthehair shaft areseen.hemato1ylin and eosin stain (ith Periodic acid0Schiff counterstain, magnification M A3;/+&ungi are seen sparsely in the stratum corneum .see the first image belo(/+ $yphae e1tend do(n the hairfollicle, gro(ing on the surface of the hair shaft+ $yphae then invade the hair, penetrate the outermost layerof hair .ie, cuticle/, and proliferate do(n(ard in the subcuticular portion of the corte1, gradually penetratingdeep into the hair corte1+ Pronounced inflammatory tissue reaction (ith follicular pustule formationsurrounding hair follicles is seen in patients (ith the clinical form of infection termed ,erion celsi .see thesecond image belo(/+&ungal hyphae and yeast cells of-richophyton rubrum seen on the stratum corneum of tinea capitis+ Periodic acid0Schiff stain, magnification A3;M+Pronounced inflammatory tissue reaction (ith follicular pustuleformationsurroundingahairfollicleseeninapatient (ithclinical formof infection, termed,erioncelsi+ *ofungalhyphaeorspores(ereidentifiedinthelesionineithertissuesectionsorculture+ &luorescein0labeled -richophytonmentagrophytes antiserumcross0reacted (ithantigens of dermatophyteinthe infectedhairs (ithin thepustule.hemato1ylin and eosin stain, magnification M H3/+In endothri1 infection, sphericalGtoGbo10li,e spores are found (ithin the hair shaft+ -his type of infection iscaused by T tonsurans or T violaceum+In ectothri1 infection,organismsform a sheath around thehairshaft+ In contrastto endothri1 infection,destruction of the cuticle by hyphae and spores occursMedical CareChoiceof treatment fortineacapitisisdeterminedbythespeciesof fungusconcerned, thedegreeofinflammation, and in some cases, by the immunologic and nutritional status of the patient+ Systemic administration of griseofulvin provided the first effective oral therapy for tinea capitis+B27, 2HC -opical treatment alone usually is ineffective and is not recommended for the management of tineacapitis+ *e(er antifungal medications, suchasitracona@ole, terbinafine, andflucona@ole, havebeenreported as effective alternative therapeutic agents for tinea capitis+B27, 2HC Df these agents, itracona@ole andterbinafine are used most commonly+ Selenium sulfide shampoo may reduce the ris, of spreading the infection early in the course oftherapy by reducing the number of viable spores that are shed+Medication SummaryGriseofulvin has been the traditionaltreatment of choice in allring(orm infections of the scalp+ # A;;9meta0analysis foundthat griseofulvinremainsaneffectivetherapyfor tineacapitis+B29C Most specialistsrecommend a griseofulvin dosage of A;0A3 mgI,gId for 709 (ee,s+ Griseofulvin accumulates in ,eratin ofthehornylayer, hair, andnails, renderingthemresistant toinvasionbythefungus+ -reatment mustcontinuelongenoughfor infected,eratintobereplacedbyresistant ,eratin, usually>07(ee,s+ Ininflammatorylesions, compresses oftenarere6uiredtoremovepus andinfectedscale+ -herapeuticprogress is monitored by regular clinical e1amination (ith the aid of a Wood lamp for fluorescent speciessuchas Maudouinii and Mcanis+ #dverseeffectsincludenauseaandrashesin9023E+ -hedrugiscontraindicated in pregnancy, and the manufacturers caution against men fathering a child for 7 monthsfollo(ing treatment+B2=CSeveral ne(er antimycotic agents, including itracona@ole, terbinafine, and flucona@ole, have been reportedaseffectiveandsafe+# revie(foundthat theseagentsmaybesimilartogriseofulvinfortreatment inchildren (ith tinea capitis caused by Trichophyton species and have the advantage of shorter treatmentdurations ho(ever, they may be more e1pensive+BA;CGupta et alBA2C reported the follo(ing alternative effective and safe treatment regimens for tinea capitis (ithendothri1 species infection including T tonsurans) itracona@ole continuous regimen .:03 mgI,gId (ith a fullmeal for >07 (,/, itracona@ole pulse regimen (ith capsules .3 mgI,gId for 2 (, times : pulses : (, apart/,and itracona@ole pulse regimen (ith oral solution .: mgI,gId for 2 (, times : pulses, ie, 2 (, per mo/+ -heoral solutioncontainscyclode1trin, (hichmaycausediarrheainchildren+-hepharmaco,ineticsof theli6uid formulation are not (ell established in children+ In some children .(eighing A;0>; ,g/, a single 2;;0mg capsule daily for >07 (ee,s has been used successfully+%ecauseitracona@olehasbeenassociated(ithheart failure, it iscurrentlynot favoredasafirst0linetherapyfor tinea+ #ne1ceptionmaybeserious Mcanisinfections, (hicharerelativelyinsensitivetoterbinafine, or, according to some authors, if griseofulvin is not available+BAAC-erbinafine tablets at doses of :07 mgI,gId for appro1imately A0> (ee,s have been used successfully forTtonsurans infections+BA:, A>C #n international study found that terbinafine has potent activity againstdermatophyte isolates obtained frompatients (ith tinea capitis (orld(ide+BA3C #pediatric study foundterbinafine produced significantly better cure rates than griseofulvin for tinea capitis caused by Ttonsurans but not for disease caused by M canis.BA7C # meta0analysis of H studies concluded that terbinafine(asmoreeffectivefortineacapitisprimarilycausedbyTrichophyton species, (hereasgriseofulvin(asmore effective for tinea capitis primarily caused by Microsporum species+BAHC M canis is relatively resistant toterbinafinebut hasbeentreatedeffectively(ithhigher dosesandlonger coursesof therapy+Generalguidelines for tinea capitis aretreatment for A0> (ee,s, (ith dosage determined by body (eight, as follo(s) 2;0A; ,g 0 7A+3 mgId A;0>; ,g 0 2A3 mgId Greater than >; ,g 0 A3; mgId-erbinafineacts onfungal cell membranesandisfungicidal+ #dverseeffects includegastrointestinaldisturbances and rashes in :03E of cases+BA9C&lucona@ole tablets or oral suspension .:07 mgI,gId/ are administered for 7 (ee,s+ In 2 trial, a dose of 7mgI,gId for A; days (as effective+ #n e1tra (ee, of therapy .7 mgI,gId/ can be administered if clinicallyindicated at that time+In ectothri1 infection .eg, M audouinii, M canis/, a longer duration of therapy may be re6uired+Dral ,etocona@oleisrarelyanacceptablealternativetogriseofulvinbecauseof theris,of hepatoto1iceffect and higher cost+Dral steroids may help reduce the ris, for and e1tent of permanent alopecia in the treatment of ,erion+#void using topical corticosteroids during treatment of dermatophyte infections+#ntifungal agentsClass SummaryMechanismof action may involve an alteration of 4*#and D*#metabolismor an intracellularaccumulation of pero1ide that is to1ic to the fungal cell+"ie( full drug informationGriseofulvin .&ulvicin/ #ntibiotic derivedfroma Penicillium species that is depositedinthe,eratinprecursor cells that arereplacedgraduallybynoninfectedtissue+ #saresult, ne(,eratinbecomeshighlyresistant tofungalinvasions+ #ctive against dermatophytes but not against yeasts or bacteria+ 4esistant strains ofdermatophytes are rare+ In its fine particle form, is absorbed readily from gut, and absorption is enhanced(hen fatty food is ta,en simultaneously+ #ccumulates in ,eratin of the stratum corneum, hair, and nails+$as a long record of safety, but ne(er regimens may prove more cost effective+"ie( full drug informationItracona@ole .Sporano1/ Dne of A tria@ole antimycotic medications (ith potential for treatment of superficial dermatophyte infectionsinpediatricpopulation+ Sinceit ispoorly(ater soluble, shouldbeta,en(ithfattymeal toimproveabsorption+ Most of absorbed itracona@ole is bound to plasma albumin+ %ecause of lipophilic property, it isfound in highest concentrations in fat, omentum, s,in, nails, and vaginal and cervical tissues+#ntimycotically significant concentrations may remain in s,in up to > (, after cessation of medication+$ydro1yitracona@oleis 2 of :;metabolites active pharmacologically+ -erminal eliminationhalf0life ofitracona@ole is A;07; h, (hich indicates that steady0state concentrations are reached only after at least A(, of daily administration+ !arge biliary e1cretion of itracona@ole and its metabolites occurs because oftheir large molecular si@es and high molecular (eights+ -hey are e1creted 73E in feces and :3E in urine+*oindicatione1istsfor dosageadFustment for impairedhepaticandrenal functions+ $assignificantlygreater selectivity for inhibiting fungal en@ymes than does ,etocona@ole+4esults of several clinical trials indicated that itracona@ole is a safe and effective alternative to griseofulvin0failed cases+ Itracona@ole has slightly higher cure rate in children (ith tinea capitis infection caused by Tviolaceum, compared to treatment (ith terbinafine+ -reatment duration is A (,+ In children (ith Ttonsurans infection treated (ith 20: pulses of itracona@ole, a 2;;E cure rate has been reported by Guptaet al in a small series+ -he pulse schedule (as itracona@ole 3 mgI,gId for 2 (,, then A (, (ith no drug,follo(ed by 2 (, (ith medication+ When a third pulse (as re6uired, : (, elapsed bet(een second andthird drug treatments+"ie( full drug information'etocona@ole .*i@oral/ Manysaferalternativesareavailable+ 4arelyusedtotreat tineacapitis+ Isabroad0spectrumsyntheticantifungal compound of the a@ole group+ Whenorally administered, is active against anthropophilicdermatophytes+ Is hydrophilic and high concentrations of the drug develop (ithin s,in, ma,ing it potentiallybeneficial for treating superficial dermatophytosis+ Delivery of this drug to the s,in is accomplished throughnormal blood circulation and s(eat+ Some e1cretion occurs into sebum and epidermal basal layer+ In thepresence of normal gastric acidity, is (ell absorbed, and pea, plasma concentrations are achieved in :0> d+Df the drug, ==E is bound to plasma proteins+?1tensivelymetaboli@edthrougho1idationanddegradationof imida@olering, D0deal,ylation, o1idativedegradation of pipera@ine ring, and aromatic hydro1ylation+ Untransformed ,etocona@ole is the only activeantifungal compound+ *one of the metabolites possesses therapeutic activity+Despite active metabolism, ,etocona@ole is e1creted in bile and eliminated unchanged+ Dosage adFustmentis not re6uired in patients (ith impaired renalfunction in vie( of the rapid metabolism and active biliarye1cretion+"ie( full drug information&lucona@ole .Diflucan/ -ria@ole compoundthat is relatively (ater solubleand(ell absorbeduponingestion+ Pea, plasmaconcentration is achieved (ithin 20A h after oral administration+ Drug is distributed (idely to body tissues,and fluids free (ithout binding to plasma proteins+ Drug has a long half0life of AA0:; h in adults, and steady0state levels are reached (ithin 702; d after initiation of treatment+ Most of the drug is e1creted unchangedin urine (ith little hepatic metabolism+ ?liminated slo(er from s,in than from plasma, (hich contributestherapeutic benefit against superficial dermatophytosis, even after dosage has been discontinued+ DosageadFustment is re6uired for patients (ith renal impairment, since drug is eliminated primarily by the ,idneys+More dosing regimen studies are needed+ #vailable in orange flavor oral suspension as 2;0>; mgIm!+"ie( full drug information-erbinafine .!amisil/ #llylamine (ith antifungal properties+ Well absorbed upon oral administration+ Pea, plasma concentration isreached in appro1imately A h+ Drug has strong plasma protein binding+ $as large lymphatic distribution andis associated (ith chylomicrons+ Preferential upta,e into fat resulted in relatively high concentration in thes,in+ Concentration (ithin the stratum corneum reaches H3 times that of plasma concentration during first A(, of therapy+ #ntifungalactivity remains in the s,in for A mo after plasma concentration has depleted,follo(ingcessationof medication+ &ifteeninactivemetabolitesfollo(ingingestionhavebeenidentified+Metaboli@edthrough N 0demethylationandaromaticringo1idation+ Most metabolitesareeliminatedby,idneys therefore, dosage adFustment is indicated in patients (ith renal or hepatic dysfunction+Comparedto itracona@ole,terbinafine has slightly lo(er cure rate >(,oftreatment (ith terbinafineisreported as effective as 9 (, of griseofulvin therapy+$igh cure rates of fungal infections in children are reported+&urther Dutpatient CareSee the list belo() $ousehold contacts of tinea capitis patients should be screened for clinically silent fungal carriageon the scalp+ BA=C #symptomatic carriers, including adults and siblings in the family of patients (ith tineacapitis and patient careta,ers and playmates, re6uire active treatment, since they may act as a continuingsource of infection+ B:;Co Shampoo and oral antimycotic therapy have been advocated for eradication of the carrierstate+o Studies have sho(n that most children (ho received griseofulvin plus bi(ee,lyshampooing (ith A+3E selenium sulfide (ere negative for fungi on scalp culture after A (ee,s+o Shampoo containing povidone0iodine has been sho(n to be more effective in producingnegative cultures than shampoos containing econa@ole and selenium sulfide and than Nohnson consecutive (ee,s+%othpovidone0iodineandseleniumshampoosre6uirefurtherclinical studyforthecontrol of fungalspore loads in infected children and asymptomatic carriers+ Classrooms (ith young children .ie, ,indergarten through second grade/ must be evaluated fortineacapitisinfection, sincethesechildrenaremost susceptibleandhaveagreater ris,of diseasetransmission+ Playmates in close physical contact (ith patients can spread tinea capitis organisms by sharingtoys or personal obFects including combs and hairbrushes+ -hese individuals need to be evaluated for thepresence of infection+DeterrenceIPrevention#symptomatic carriers should be detected and treated, since they are the continuous source of infection+Siblingsandplaymatesof patientsshouldavoidclosephysical contact andsharingof toysor otherpersonal obFects, such as combs and hairbrushes, since organisms can spread from one person to anotherand infectious agents can be transported to different classrooms (ithin the same or in different schools+Shared facilities and obFects also may promote spread of disease, both (ithin the home and the classroom+Public health measures regarding the source of infection should be a concern for controlling tinea capitis+-he source of some @oophilic species often is difficult to trace+ Dutbrea,s ofM canis can be e1tensive+Patients< cats and dogs must be inspected under a Wood lamp and referred for treatment+ #t times, animalcontrol agenciesarecontactedtoroundupstraydogsandcats+ Tmentagrophytes mayfollo(,no(ncontact (ith rodents, but often, no source can be identified+#s many as 2>E of asymptomatic children have been found to be carriers of causative dermatophyte fortinea capitis in a primary school in Philadelphia+B:2CWithout therapy, >E developed symptoms of infection,39E remained culture positive, and :9E became culture negative (ithin an average A+:0month follo(0upperiod+ComplicationsSee the list belo() -he causative fungal organisms of tinea capitis destroy hair and pilosebaceous structures,resulting in severe hair loss and scarring alopecia+ Since tinea capitis is the most common dermatophyteinfection in the pediatric population in the United States, (ithout accurate diagnosis and proper treatment,the disease is detrimental, both physically and mentally, to children (ho are affected+ 5oung patients (ithitchy scalp and patchy or total hair loss fre6uently are ridiculed, isolated, and bullied by classmates orplaymates+ In some cases, the disease can cause severe emotional impairment in vulnerable childrenand can destabili@e family relationships+PrognosisSee the list belo() Continuous shedding of fungal spores may last several months despite active treatment therefore,,eeping patients (ith tinea capitis out of school is impractical+ -he causes of treatment failure includereinfection, relative insensitivityoftheorganism,suboptimalabsorptionofthemedication,and lac,ofcompliance (ith the long courses of treatment+ T tonsurans andMicrosporum species are typicaloffending agents in persistent positive cases+ If fungi can still be isolated from the lesionals,in at thecompletion of treatment, but clinical signs have improved, the recommendation is to continue the originalregimen for another month+Patient ?ducationSee the list belo() Patient education is paramount in eradicating tinea capitis+ -he current recommendations of theCommittee on Infectious Diseases of the #merican #cademy of Pediatrics state that OChildren receivingtreatment for tineacapitismayattendschool+ $aircuts, shavingof thehead, (earingacapduringtreatment are not necessary+O