Tinea Capitis 1363

TABLE 1  Clinical Manifestations of Tinea Capitis in Children

BASIC INFORMATION
Clinical Feature Comment
T
DEFINITION
Scalp
Tinea capitis is a dermatophyte infection of hair
shaft and follicles of the scalp, eyebrows, and Alopecia One or multiple patches; may simulate alopecia areata
eyelashes. It is a form of superficial mycosis. Scaling May be minimally inflammatory; may mimic seborrheic dermatitis
Etiologic agents are fungal species of the gen- Erythema Localized or widespread
era Microsporum and Trichophyton. Pustules Differential diagnosis includes sterile folliculitis or bacterial folliculitis
“Black dots” Alopecia with hair shafts broken off at surface of skin; may simulate trichotillomania
SYNONYMS Kerion Boggy, tender plaque with pustules and purulent discharge; represents a vigorous host
Ringworm of the scalp immune response

Ringworm of the head
Gray patch tinea capitis
Black dot tinea capitis
Tinea tonsurans
Herpes tonsurans
Kerion
Favus
ICD-10CM CODE
B35.0  Tinea barbae and tinea capitis
EPIDEMIOLOGY &
DEMOGRAPHICS
Tinea capitis primarily affects prepubertal chil-
dren with peak age between 3 and 7 yr old.
Adult cases are rare, possibly because of the
fungistatic effect of the sebum found in older
persons. Urban living, large family size, low
socioeconomic status, and crowded living con-
ditions may contribute to an increased inci-
dence of tinea capitis. The elderly and immu-
nocompromised individuals have an increased
risk of infection. The incidence of the disease
varies worldwide; however, it is relatively low
in the U.S. It is reportedly widespread in parts
of Central and South America, India, and Africa.
In the U.S., peak incidence occurs in school-
aged children of low socioeconomic status, with
African American male children accounting for
the greatest proportion of cases. About 3% to 8%
of American children are affected, and 34% of
household contacts are asymptomatic carriers.
PHYSICAL FINDINGS & CLINICAL
PRESENTATION
• Classic triad of scalp scaling, alopecia, and
cervical adenopathy. Table 1 summarizes clini-
cal manifestations of tinea capitis in children.
• Most forms of tinea capitis begin with one
or few round patches of scale (Fig. E1) or
alopecia (Fig. E2).
• Primary lesions include plaques, papules,
pustules, or nodules on the scalp (usually
occipital region).
• Secondary lesions include scales, alopecia (usu-
ally reversible), erythema, exudates, and edema.
• Scalp pruritus may be present.
• Fever, pain, and lymphadenopathy (common-
ly postcervical) may occur with inflammatory
lesions.
• Different clinical patterns of tinea capitis
have been described:
1.  Gray patch: Lesions are scaly and well
demarcated. The hairs within the patch break
off a few millimeters above the scalp. One or
several lesions may be present; sometimes
the lesions join to form larger ones.
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Scarring Rarely seen when untreated; usually follows kerion
Favus Yellow, cup-shaped crusts around the hair
Other
Lymphadenopathy Common; cervical or occipital
Id reaction Widespread, papular or papulovesicular eruption; extremity-predominant; usually seen
after initiation of therapy; must be recognized as distinct from true drug reaction
From Paller AS, Mancini AJ: Hurwitz clinical pediatric dermatology, a textbook of skin disorders of childhood and adolescence, ed 5,
2016, Elsevier.
2. Black dot: Early lesions with erythema
and scaling patch are easily overlooked
until areas of alopecia develop. Hairs
within the patches break at the surface
of the scalp, leaving behind a pattern of
swollen black dots.
3. Kerion (Fig. E3): Inflamed, exudative, pustu-
lar, boggy, tender nodules exhibiting marked
edema, and hair loss seen in severe tinea
capitis. Caused by immune response to the
fungus. May lead to some scarring.
4. Favus: Production of scutula (hair matted
together with dermatophyte hyphae and
keratin debris), characterized by yellow
cup-shaped crusts around hair shafts. A
fetid odor may be present.
ETIOLOGY
Although fungi of the Microsporum or
Trichophyton genera cause most cases of tinea
capitis, causative species vary between geo-
graphical areas and across time. T. tonsurans is
the predominant cause of tinea capitis, present
in more than 90% of cases in North and Central
America. Microsporum canis, M. audouinii, and
Trichophyton mentagrophytes are less common.
The most common causative species for black
dot tinea capitis is T. tonsurans, while gray patch
tinea capitis tends to be caused by M. audouinii
and M. canis. Infection of the hair shaft is pre-
ceded by invasion of the stratum corneum of
the scalp. Transmission of T. tonsurans occurs
from person-to-person via infected persons or
asymptomatic carriers, fallen infected hairs, ani-
mal vectors, and fomites. M. audouinii is com-
monly spread by dogs and cats. Infectious fungal
particles may remain viable for many mo. Even
though the organism remains viable on combs,
hairbrushes, and other fomites for long periods of
time, the role of fomites in spreading the infection
may vary in different geographic areas.
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
Seborrheic dermatitis and psoriasis may be
confused with tinea capitis. Other conditions
and Disorders
Diseases
I
that resemble tinea capitis include alopecia
areata, impetigo, pediculosis, trichotillomania,
traction alopecia, folliculitis, pseudopelade, seb-
orrhea/atopic dermatitis, psoriasis, carbuncles,
pyoderma, lichen ruber planus, and lupus ery-
thematosus; these should also be considered
in the differential. Table 2 highlights distinctive
features of conditions that may be confused for
tinea capitis.
WORKUP
• KOH testing of hair shaft extracted from the
lesion, not the scale, because the T. ton-
surans spores attach to or reside inside hair
shafts and will rarely be found in the scales.
• Wood’s ultraviolet light fluoresces blue-green
on hair shafts for Microsporum infections but
will fail to identify T. tonsurans.
• Fungal culture of hairs and scales on fungal
medium such as Sabouraud agar may be
used to confirm the diagnosis, especially if
uncertain.
• Histology of biopsies with fungal staining in
cases where mycology tests are negative
because of treatment initiation.
TREATMENT
• Griseofulvin is the gold standard FDA-approved
treatment. Published studies show mean
efficacy for griseofulvin treatment of about
68% for Trichophyton species and 88% for
Microsporum. It is less costly than other drug
options and has an excellent long-term safety
profile. Micronized and ultramicronized prepa-
rations are absorbed better, and side effects are
infrequent, especially when administered with
fatty meals. Periodic monitoring of hematologic,
liver, and renal function may be indicated, espe-
cially in prolonged treatment over 8 wk.
1.  Children: Griseofulvin is approved for
children older than 2 yr of age: microsize
griseofulvin 10 to 25 mg/kg PO per day
in one single dose or two divided doses
(maximum, 1 g/day; for tinea capitis,
higher doses [20 to 25 mg/kg/day] have
been recommended) or ultramicrosize
1364 Tinea Capitis
sulfide 2.5% used for 5 min or ketoconazole
TABLE 2  Differential Diagnosis of Tinea Capitis
shampoo used 2 to 3 times/wk can help
Disorder Differentiating Features prevent infection or eradicate asymptomatic
carrier state by inhibiting fungal growth.
Psoriasis Red skin with thick, uniform, silvery scale, sharply demarcated; often psoriasis • Severe inflammatory kerion can be managed
at other body sites also. with additional prednisone 40 mg daily (1 mg/
Dermatitis Main possibility is seborrheic dermatitis: Usually more diffuse and has uniform kg/day in children) and tapering over 2 wk.
fine scaling, rather than localized areas; doesn’t typically cause alopecia • Prompt treatment is indicated, as is examina-
or significant inflammation. May also be present on the face, especially the tion of siblings and other household contacts
nasolabial fold, or as otitis externa. Atopic dermatitis is generally diffuse on
scalp and almost inevitably present at other sites, but may coexist with tinea
for evidence of tinea capitis.
capitis, especially in children. • Recommend follow-up visit every 2 to 4 wk
Pityriasis amiantacea Thick sheets of asbestos-like scale, very adherent, generally a solitary patch.
with Wood’s light, microscopic study, and
This may occur in various dermatoses. fungal culture. A mycologic documented cure
Lichen simplex Usually nape of neck; cobblestoned or lichenified skin thickening, with broken
is the goal of treatment.
hairs that are not coated with scale. • Pets that are infected or asymptomatic carri-
Alopecia areata Usually not inflamed (may be mildly so), not scaly, usually sharply defined.
ers should be treated.
“Exclamation mark” hairs occur but are not coated with fungus; “cadaver- • Children receiving treatment for tinea capitis
ized” hairs especially cause difficulty, as they mimic black dot alopecia. may attend school once they start therapy
Scarring alopecias Examples: Discoid lupus erythematosus, lichen planus of scalp; cause perifol- with griseofulvin or other effective systemic
licular inflammation around intact hairs; usually associated with lesions at agent.
other sites also. Dissecting cellulitis of scalp is also in this differential.
Bacterial infections Impetigo causes crusting but little inflammation, and hairs are intact; carbuncle
is deeper and very tender but may be in the differential of kerion.
PEARLS &
Trichotillomania Broken hairs of unequal length, but hair shafts themselves and the scalp are
CONSIDERATIONS
normal.
• Systemic antifungal therapy is required for
Damage from hairdress- Usually clear from the timescale. tinea capitis because topical antifungal medi-
ing processes
cations are not effective.
Neoplasm May be in the differential of kerion; usually slower-growing and mainly on • Shaving of the head, haircuts, or wearing a
elderly, balding scalp, whereas kerion is in children or young adults with
previously intact hair.
cap or scarf during treatment is unnecessary.
• Sharing of combs, hair ribbons, and hair-
From White GM, Cox NH (eds): Diseases of the skin, a color atlas and text, ed 2, St Louis, 2006, Mosby. brushes should be discouraged.

griseofulvin, 5 to 15 mg/kg PO per day
(maximum, 750 mg/day), in one single
dose or two divided doses. Optimally,
griseofulvin is given after a meal con-
taining fat (e.g., peanut butter or ice
cream). Recommended treatment length
is 6 to 8 wk and should be continued 2
wk beyond clinical resolution (until hair
regrowth occurs). Some children may
require higher doses to achieve clinical
cure.
2.  Adults and elderly persons: Microsize
griseofulvin 500 mg PO per day in one
single dose or divided doses. The other
option is ultramicrosize griseofulvin 375
mg PO per day in one single dose or
divided doses. Recommended treatment
length is 4 to 6 wk.
• Newer alternative treatments: Oral terbin-
afine, itraconazole, or fluconazole are com-
parable in efficacy and safety to griseofulvin,
with possibly shorter treatment and better
COMMENTS
patient compliance. Preferred when resistant
• Confirming the diagnosis of tinea capitis with
or when an allergy to griseofulvin is of con-
a laboratory specimen is important because
cern. Monitoring of CBC, liver function tests,
misdiagnosis will result in delay or improper
and renal function may be indicated.
treatment.
1. Terbinafine—4-wk course of therapy as
• Patients and their families should look for
effective as with griseofulvin. Dosages
sources of infections and disinfect con-
are 67.5 mg/day for patients weighing
taminated objects such as combs, brushes,
<20 kg; 125 mg/day for patients weigh-
towels, and headgear. Avoid sharing personal
ing 20 to 40 kg; and 250 mg for patients
hygiene utensils.
weighing >40 kg
• Culture of hairs and scalp dander facilitates
2. Itraconazole—3.5 mg/kg daily for 4 to 6
carrier identification and prevention.
wk or pulse therapy of 5 mg/kg daily for
1 wk each mo for 2 to 3 mo (not approved
for children) SUGGESTED READING
3.  Fluconazole—the only oral antifungal
Available at ExpertConsult.com
agent approved for children <2 yr, 6 mg/
kg/day for 6 wk in children (3 to 6 wk in
adults) or 8 mg/kg weekly for 8 to 12 wk RELATED CONTENT
(cap at 150 mg weekly for adults) Tinea Capitis (Patient Information)
• The adjuvant use of antifungal shampoos
may be recommended for all patients and AUTHORS: Priya Sarin Gupta, MD, MPH, Nadine
household contacts. Shampoo like selenium Mbuyi, MD, and Alvaro M. Rivera, MD

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Tinea Capitis 1364.e1

SUGGESTED READING
Gupta AK, Drummond-Main C: Meta-analysis of randomized, controlled trials
comparing particular doses of griseofulvin and terbinafine for the treatment of
tinea capitis, Pediatr Dermatol 30(1-6), 2013.

FIG. E1  Tinea capitis. Diffuse scaling with minimal erythema and patchy alopecia. (From Paller AS, Mancini
AJ: Hurwitz clinical pediatric dermatology, a textbook of skin disorders of childhood and adolescence, ed 5,
2016, Elsevier.)

FIG. E2  “Black dot” tinea capitis. This well-demarcated patch of alopecia is composed of numerous
broken-off hair shafts (black dots). (From Paller AS, Mancini AJ: Hurwitz clinical pediatric dermatology, a text-
book of skin disorders of childhood and adolescence, ed 5, 2016, Elsevier.)

FIG. E3  Kerion. This fluctuant, erythematous, boggy, crusted plaque was exquisitely tender to palpation.
Trichophyton tonsurans was isolated in fungal culture. (From Paller AS, Mancini AJ: Hurwitz clinical pediatric
dermatology, a textbook of skin disorders of childhood and adolescence, ed 5, 2016, Elsevier.)
Downloaded for FK UIN Auriquilla (tentirkuliah19@gmail.com) at State Islamic University Syarif Hidayatullah Jakarta from ClinicalKey.com by Elsevier on February 22, 2021.
For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.