Itraconazole in the treatment of tinea capitis

Pediatric tinea capitis in Jilin Province: analyzing previous results from a new perspective

OBJECTIVES

To investigate the current etiological, diagnostic, and therapeutic characteristics of tinea capitis in children in Jilin Province.

METHODS

Sixty pediatric patients with tinea capitis were enrolled between August 2020 and December 2021. Data on calcofluor white (CFW) fluorescence microscopy, fungal culture, Wood's lamp examination, dermoscopy, treatment, and follow-up were collected and analyzed.

RESULTS

1. Of all the enrolled patients, 48 had a history of animal contact, mostly with cats and dogs. Fifty-one strains were isolated, of which 46 were Microsporum canis (M. canis). 2. All enrolled patients were examined using fluorescence microscopy, and 59 were positive. Forty-one cases of tinea alba were examined using Wood's lamp, and 38 were positive. Forty-two cases of tinea alba were examined using dermoscopy, and 39 demonstrated specific signs. Effective treatment manifested as a fading bright green fluorescence, decreased mycelial/spore load, reduced specific dermoscopic signs, and hair regrowth. 3. Treatment was terminated in 23 and 37 cases based on mycological and clinical cures, respectively. No recurrence occurred during follow-up.

CONCLUSION

1. M. canis is the predominant pathogen causing tinea capitis in children in Jilin Province. Animal contact is considered the main risk factor. 2. CFW fluorescence microscopy, Wood's lamp, and dermoscopy can be used to diagnose ringworms and follow-up patients. 3. Both mycological and clinical cures can be the endpoint of adequate treatment for tinea capitis.

Therapeutic options in the treatment of tinea capitis

Tinea capitis is primarily a disease of pre-adolescent children. In North America and the UK, Trichophyton tonsurans is responsible for > 90% of cases. Microsporum canis is the predominant pathogen in certain parts of Europe. The standard of care for the treatment of tinea capitis is oral griseofulvin and so far, it remains the only medication approved by the US FDA for this condition. The newer oral antifungal agents, such as terbinafine, itraconazole and fluconazole, appear to be effective, safe and have the advantage of a shorter treatment duration. Although a significant number of clinical trials and reports have documented experience with terbinafine and itraconazole for the treatment of tinea capitis, it should be noted that only a few trials have been conducted utilising fluconazole. Both 2% ketoconazole and 1% selenium sulfide shampoos have been shown to reduce surface colony counts of dermatophytes in infected individuals, and these agents are often recommended for adjuvant therapy. This article reviews data currently available on various therapeutic alternatives for the treatment of tinea capitis and summarises all relevant clinical trials that have thus far investigated the use of these drugs for tinea capitis in the paediatric population.

Clinical use of antimicrobial pharmacodynamic profiles to optimise treatment outcomes in community-acquired bacterial respiratory tract infections: application to telithromycin

Despite the revolutionary introduction of antibiotic therapy in the post-World War II era, primary care physicians continue to struggle with the issue of optimal treatment strategies for bacterial infection and the growing problem of antimicrobial resistance. The aggressive use of potent agents as first-line therapy maximises the potential for successful eradication of bacterial pathogens and slowing of the development of drug-resistant strains. Therapeutic drug monitoring and quantitative assessment of antibacterial potency are not always feasible in daily practice, but the pharmacodynamic profiles of antibacterials - which integrate pharmacokinetic profiles and microbiological properties - can be used to predict clinical success. Telithromycin possesses pharmacodynamic characteristics that make this novel ketolide an optimal choice for the empirical management of community-acquired respiratory tract infections.

Efficacy and safety of itraconazole use in children

Current dosing regimens for itraconazole are effective, safe, and versatile for use in superficial fungal infections in children, particularly tinea capitis. Good efficacy rates have been noted in both Trichophyton and Microsporum tinea capitis infections. Itraconazole has a high affinity for keratin, and accumulates to high levels at the site of superficial fungal infections. A pulse regimen may be chosen over continuous dosing, because the accumulation persists after dosing of itraconazole has been stopped. An oral solution of itraconazole is available, and may be more convenient for children who cannot swallow capsules. The oral solution also produces good rates of efficacy, but may be associated with a somewhat higher potential for gastrointestinal adverse events than the capsules. The range of adverse events noted with itraconazole capsules or oral solution use in children is similar to the range in adults. Events are generally mild and transient. Attention must be taken to note any medications that the child is using, because itraconazole is associated with a range of potential drug interactions. This safety of use, in combination with itraconazole's wide antifungal spectrum and pharmacokinetic properties, which allow for shorter dosing regimens, may make itraconazole a suitable alternative to griseofulvin for pediatric superficial fungal infections.

Itraconazole in the treatment of tinea capitis in children. Case reports with long-term follow-up evaluation. Review of the literature

Although griseofulvin is considered the standard treatment of tinea capitis in children, alternatives are being investigated. Our purpose was to determine the efficacy of itraconazole for kerion and noninflammatory tinea capitis. An open label study was performed on five patients. It was planned to treat them with itraconazole until they were mycologically and clinically cured. A 28-112-day course of 100 mg itraconazole daily, combined with a topical antifungal treatment resulted in clinical and mycological cure in all children. One child stopped taking itraconazole after 28 days, before it was clinically cured, because of nausea. Nevertheless, this child also achieved clinical and mycological cure. No other side-effects were reported. In long-term follow-up evaluation of between 2 and 3.5 years no recurrence or reinfection was observed. There was complete regrowth of hair, even after kerion. These findings and the review of the literature suggest that itraconazole offers an alternative to griseofulvin for the treatment of tinea capitis in children, although it is more expensive and not approved by German state authorities for this indication.

Systemic antifungal therapy

Systemic antifungal therapy for superficial mycoses has advanced greatly since the introduction of griseofulvin in 1958. The discovery of the azole antifungal compounds, ketoconazole, itraconazole, and fluconazole, allowed for a broader spectrum of treatment and a shorter treatment duration. Terbinafine, through a unique mechanism of action, has a fungicidal power not seen previously in the other antifungals. It is important to use our knowledge of the pharmacology in combination with clinical experience and cost of therapy in order to select the proper drug. The search to identify new oral antifungal agents should continue, since none of the five currently used drugs fulfill the criteria of the "ideal" antifungal.

Optimizing the therapeutic approach in tinea capitis of childhood with itraconazole

BACKGROUND

Tinea capitis is the most common dermatophytosis of childhood with increasing incidence. Whereas griseofulvin is considered by many as the mainstay of treatment, newer oral antifungal agents, including fluconazole, itraconazole and terbinafine have demonstrated higher efficacy, resulting in shorter treatment durations.

OBJECTIVES

We aimed to determine the optimum regimen for the treatment of childhood tinea capitis with itraconazole.

METHODS

A mycological culture outcome-dependent combination of a 28-day continuous and facultative additional 14-day courses with itraconazole was used in 42 children (20 girls; 22 boys) aged 12-140 months (mean 66) with tinea capitis due to Microsporum canis (n = 26) and Trichophyton violaceum (n = 16). The drug was given orally according to the patients' body weight (50 mg daily for < 20 kg; 100 mg daily for > or = 20 kg) over 4 weeks. Direct microscopy and fungal culture as a parameter for efficacy were repeated 2 weeks after termination of treatment. Assessment of efficacy was based on the evaluation of results from light microscopy and culture at 8 weeks after initiation of treatment, and in the case of a further positive mycological culture at 14 and 20 weeks, respectively. A positive fungal culture at these times resulted in an additional course for 2 weeks with the initially chosen itraconazole dosage.

RESULTS

In 34 of 42 patients a single 4-week course of itraconazole resulted in a complete mycological cure of lesions as demonstrated by light microscopy and mycological culture. Four of 42 patients had to be treated by a second itraconazole course for 2 weeks, and four children received a third course of itraconazole for 2 weeks until all lesions showed negative direct microscopy and mycological culture. No abnormal haematological or biochemical results occurred. Apart from transient, completely reversible indigestion in two children, no side-effects were observed.

CONCLUSIONS

A culture-based 28-day continuous therapeutic regimen plus facultative cultural outcome-dependent additional 14-day courses of a body weight-adapted dosage of itraconazole in tinea capitis due to M. canis and T. violaceum is discussed; this offers the advantage of an effective therapy with complete negative direct microscopy as well as negative cultural results, within a shorter active treatment period (cf. previous studies with continuous administration of itraconazole).

Tinea capitis

Tinea capitis is a common dermatophyte infection of the scalp in children. Dermatophytes are classified into three genera; tinea capitis is caused predominantly by Trichophyton or Microsporum species. On the basis of host preference and natural habitat, dermatophytes are also classified as anthropophilic, geophilic and zoophilic. The etiological agents of tinea capitis usually fall in the first and last categories. In North America, tinea capitis is now predominantly due to Trichophyton tonsurans. During the past 100 years the most common North American organism for tinea capitis was initially Microsporum canis followed later by M. audouinii. In other parts of the world the epidemiology varies. Tinea capitis is generally observed in children over the age of 6 years and before puberty, with African Americans being the most affected group. Clinical presentations are seborrheic-like scale, 'black dot' pattern, inflammatory tinea capitis with kerion and tiny pustules in the scalp. The clinical diagnosis should be confirmed by mycological examination. Wood's light examination was of value in diagnosing tinea capitis due to M. canis and M. audouinii; however, it is not helpful in T. tonsurans tinea capitis. Asymptomatic carriers may be a significant reservoir of infection and spread of spores may also involve inanimate objects. Carriers may benefit from shampooing their hair. Treatment of tinea capitis requires an oral antifungal agent. The data from the use of terbinafine, itraconazole and fluconazole are promising and suggest that these agents have an efficacy similar to griseofulvin while shortening the duration of therapy. Both griseofulvin and the newer antimycotics have a favorable adverse-effect profile and are associated with high compliance.

Comparison of terbinafine and griseofulvin in the treatment of tinea capitis

BACKGROUND

Griseofulvin has been used for many years in the treatment of tinea capitis. Increase in resistance to this medication has led to a search for new therapeutic alternatives.

OBJECTIVE

Our purpose was to evaluate the therapeutic efficacy of terbinafine in comparison with griseofulvin in the treatment of tinea capitis.

METHODS

We performed a double-blind, randomized, prospective evaluation of 50 patients with a clinical and mycologic diagnosis of tinea capitis. One group received 4 weeks of terbinafine followed by 4 weeks of placebo. The other group received 8 weeks of griseofulvin. We evaluated 5 clinical parameters. Mycologic examinations were performed at baseline and at the end of weeks 8 and 12.

RESULTS

Patients' ages ranged from 1 to 14 years. Fifty-four percent were girls and 46% were boys. Mycologic examinations disclosed Trichophyton tonsurans in 74% of patients and Microsporum canis in 26%. At week 8, the griseofulvin-treated group showed a cure rate of 76%, and the terbinafine-treated group 72%. At week 12, the efficacy of griseofulvin decreased to 44%, whereas the efficacy of terbinafine was 76%.

CONCLUSION

Terbinafine constitutes an alternative for the treatment of tinea capitis. Recurrences were less frequent. No significant side effects were reported.

Itraconazole

Itraconazole is a broad spectrum triazole antifungal agent. It has favourable pharmacodynamic and pharmacokinetic profiles and is available as both oral and i.v. formulations. Over the last two decades, clinical and animal infection studies have demonstrated the efficacy of itraconazole in a wide range of superficial fungal infections including difficult-to-treat dermatophytoses and onychomycoses. Furthermore, shortened treatment regimens have proven to be effective, ranging from 1-day treatment for vaginal candidosis to 1-week pulse therapy per month, for 2-4 months, in onychomycosis and follicular dermatophytosis. Clinical experience with itraconazole in the treatment of deep mycoses is less comprehensive. However, results in systemic candidosis, sporotrichosis, blastomycosis, paracoccidioiodomycosis, certain types of histoplasmosis and aspergillosis are extremely encouraging. Itraconazole is less effective in the treatment of chromomycosis and coccidioidomycosis. Nevertheless, considering the refractory nature of these diseases, itraconazole has proven to be a valuable addition to the antifungal drugs currently available for treatment. Itraconazole has been well-tolerated with doses of up to 400 mg/day being generally free of serious adverse effects. However, a potential for drug interactions exists, mediated through the cytochrome P450 enzyme 3A4 system, which should be considered when itraconazole is used as part of a multi-drug regimen.

Treatment of tinea capitis: beyond griseofulvin

Tinea capitis is a common pediatric scalp infection caused by dermatophytes. Topical therapy alone is ineffective, so oral griseofulvin has traditionally been the standard treatment. The new antimycotic agents itraconazole, terbinafine, and fluconazole represent effective treatment alternatives that have fewer problems with tolerability and adverse effects. More comparative studies are needed to determine the optimal treatment with these agents and adjuvant therapies such as antifungal shampoos, topical antimycotic agents, and corticosteroids.

Tinea capitis: an overview with emphasis on management

Tinea capitis is perhaps the most common mycotic infection in children. In North America the epidemiology of tinea capitis has changed so that Trichophyton tonsurans now predominates over Micro-sporum audouinii. With this transition the utility of the Wood's light for diagnosis has been reduced since T. tonsurans infection is Wood's light negative. Griseofulvin has been the mainstay of therapy for the last 40 years. The newer antifungal agents-itraconazole, terbinafine, and fluconazole-appear to be effective and safe for the treatment of tinea capitis. When tinea capitis is due to T. tonsurans or other endothrix species the following regimens have been used: itraconazole continuous regimen (5 mg/kg/day for 4 weeks), itraconazole pulse regimen with capsules (5 mg/kg/day for 1 week plus 1-3 pulses 3 weeks apart), and itraconazole pulse regimen with oral solution (3 mg/kg/day for 1 week plus 1-3 pulses 3 weeks apart). With terbinafine tablets the continuous regimen (>40 kg body weight, 250 mg/day; 20-40 kg, 125 mg/day; and <20 kg, 125 mg/day) is given for 2 to 4 weeks. Fluconazole tablets or oral suspension (6 mg/kg/day) were administered for 20 days in one trial. Another possibility may be 6 mg/kg/day for 2 weeks and evaluating the scalp 4 weeks later. An extra week of therapy (6 mg/kg/day) can be administered if clinically indicated at that time. A once-weekly regimen may also be effective. When ectothrix organisms (e.g., Microsporum canis) are present, a longer duration of therapy may be required. The data suggest that the newer agents are effective, safe with few adverse effects, and have a high benefit:risk ratio. It remains to be seen to what extent griseofulvin will be superseded for the treatment of tinea capitis. Adjunctive therapies may help decrease the risk of infection to other individuals. Appropriate measures should be taken to reduce the possibility of reinfection.

The evolving role of itraconazole, fluconazole and terbinafine in the treatment of tinea capitis

Tinea capitis has become an increasing public health concern in the last decade. The increased incidence of the disease; its sometimes subtle, nonspecific clinical presentation; and the development of tolerance to griseofulvin therapy have led to the need for alternative safe, efficacious, inexpensive therapies that work rapidly. Itraconazole, fluconazole and terbinafine all possess pharmacologic and pharmacokinetic characteristics that theoretically would make them ideal therapies for tinea capitis. However, few randomized double blind controlled studies using these agents have been published. Thus far none have been conducted in the United States. The best available data support the utility and safety of the new antifungals in the treatment of tinea capitis. However, one must keep in mind that they are not yet approved by the Food and Drug Administration for this indication. Safety and cost considerations favor terbinafine for the treatment of T. tonsurans infections. M. canis infections may respond better to itraconazole, but good controlled studies to confirm this speculation have not been conducted. Short course and pulse dosing are particularly exciting options that may decrease cost and lower the risk of adverse side effects. Further useful information will hopefully come from future randomized double blind studies that will include patients from the United States. Studies using standardized definitions of disease, cure and appropriate follow-up evaluation of clinical and mycologic cure will best identify the optimal therapy for pediatric tinea capitis infections. The new systemic antifungals may provide more therapeutic options for fungal infections of the scalp. Note added in proof A recent trial comparing short course terbinafine and intraconazole therapy demonstrated that 2-week therapy with either drug provided good results and high cure rates (Jahangir M, et al. Br J Dermatol 1998;139:672-4).

Current and emerging azole antifungal agents

Major developments in research into the azole class of antifungal agents during the 1990s have provided expanded options for the treatment of many opportunistic and endemic fungal infections. Fluconazole and itraconazole have proved to be safer than both amphotericin B and ketoconazole. Despite these advances, serious fungal infections remain difficult to treat, and resistance to the available drugs is emerging. This review describes present and future uses of the currently available azole antifungal agents in the treatment of systemic and superficial fungal infections and provides a brief overview of the current status of in vitro susceptibility testing and the growing problem of clinical resistance to the azoles. Use of the currently available azoles in combination with other antifungal agents with different mechanisms of action is likely to provide enhanced efficacy. Detailed information on some of the second-generation triazoles being developed to provide extended coverage of opportunistic, endemic, and emerging fungal pathogens, as well as those in which resistance to older agents is becoming problematic, is provided.

Treatment of tinea capitis with itraconazole capsule pulse therapy

BACKGROUND

The number of newly diagnosed cases of tinea capitis in children appears to be on the rise, particularly in urban centers.

OBJECTIVE

The purpose of this study was to assess the effectiveness, safety, and compliance of itraconazole pulse therapy for tinea capitis.

METHODS

Fifty subjects (48 children [less than 18 years of age] and 2 adults) with tinea capitis were treated with pulse itraconazole in a multicenter evaluation. Each pulse lasted 1 week, with 2 weeks between the first two pulses and 3 weeks between the second and third pulses. The decision to administer a second or third pulse was determined by the response of the subject at the time that the next pulse was due. During the 1-week pulse of active therapy, itraconazole (5 mg/kg/day) was dosed as follows: more than 40 kg, 200 mg per day (two capsules per day); 20 to 40 kg, 100 mg per day (one capsule per day); and 10 to 19 kg, 50 mg per day (one half of a capsule per day). The duration of the study was 12 weeks with mycologic evaluation at this time. Subjects who were classified as treatment failures at 12 weeks after the start of therapy were given the option of receiving an additional 1-week pulse of active therapy, with 3 weeks between successive pulses.

RESULTS

The causative organisms were Trichophyton tonsurans (41 subjects), T violaceum (7), T. soudanense (1), and T rubrum (1). Thirteen subjects were lost to follow-up, with 37 subjects (35 children and 2 adults) available for evaluation 12 weeks after the start of therapy. At this time, cure (clinical and mycologic) was observed in 30 (81%) of 37 subjects. When the tinea capitis was mild, cure was obtained after one pulse in two subjects and after two pulses in five subjects. With tinea capitis of moderate extent, complete cure was obtained after one pulse in one subject, two pulses in eight subjects, and after three pulses in seven subjects. When tinea capitis was severe, two and three pulses produced complete cure in one and six subjects, respectively. Of the seven subjects whose conditions failed to respond (three subjects with moderate disease and four subjects with severe disease), five subjects chose to receive extra itraconazole. Clinical and mycologic cure was observed after four pulses in four subjects and after five pulses in one subject. There were no associated clinical adverse effects with itraconazole therapy.

CONCLUSION

With tinea capitis, itraconazole pulse therapy is effective and safe and is associated with high compliance. The pulse regimen enables the duration of treatment to be individualized, according to the extent of disease and its rate of resolution.

Pediatric antifungal therapy

The most common superficial dermatophyte infections in children involve the scalp, skin, and nails. Griseofulvin has traditionally served as the standard of care for scalp and nail infections, but an increasing proportion of tinea capitis infections are proving refractory or very slowly responsive to treatment. This article will review new antifungal therapies available and their future role in the treatment of pediatric dermatophyte infections. As these new agents are not yet FDA approved for use in the pediatric dermatophyte infections, the practitioner must be aware of possible risks and benefits of such drugs, and counsel families appropriately regarding "off-label" use.

Efficacy of itraconazole in children with Trichophyton tonsurans tinea capitis

BACKGROUND

Tinea capitis is prevalent in children. Although widely used as the drug of choice, the response to griseofulvin may be incomplete and an extended duration of therapy is often required. The response to newer antifungals has not been methodically evaluated in children with Trichophyton tonsurans infection.

OBJECTIVE

Our purpose was to determine the efficacy of itraconazole in children with tinea capitis caused by T. tonsurans.

METHODS

Pediatric patients with culture proven tinea capitis were enrolled from a hospital-based primary care clinic between January and December of 1996. Patients were treated with itraconazole 100 mg/day and a selenium sulfide-containing shampoo for 4 weeks. Children were evaluated mycologically and clinically every 2 weeks for 2 months. Patients were considered successfully treated if they were culture negative and clinically improved at the end of the study period. Children who remained culture positive or who were clinically not improved at 2 months were classified as treatment failures and retreated.

RESULTS

Twenty-five patients completed the study, and 10 (40%) were successfully treated. Fifteen children required re-treatment: 14 remained culture positive at week 8, and one was mycologically negative but clinically worse.

CONCLUSION

Itraconazole at a dose of 100 mg/day for 4 weeks may be effective in less than half of children with T. tonsurans tinea capitis.

Diagnostic dilemmas in pediatric/adolescent dermatology: scaly scalp

Scaly scalp is a common problem in the pediatric and adolescent population. The possible causes range from the commonly seen tinea capitis and seborrheic dermatitis to rare systemic diseases such as dermatomyositis and Letterer-Siwe disease. In all cases a thorough history and physical examination are important first steps to successful diagnosis and treatment.

Tinea capitis in children in the district of Cagliari, Italy

Between 1986 and 1995, 4104 children were observed in the Clinic of Dermatology in Cagliari, Italy. Three hundred and thirty-six children (8.2%), 188 boys and 148 girls, aged 1 month to 13 years, were affected by tinea capitis. Microsporum canis was detected in 278 cases (82.7%) and Trichophyton mentagrophytes in 58 cases (17.3%). Systemic treatment with 20-25 mg kg-1 day-1 griseofulvin led to complete recovery in 30-40 days. None of the patients relapsed. The epidemiology of the infection was analysed according to age, sex and seasonal progression. Microsporum canis was the preponderant aetiological agent of tinea capitis in children in the district of Cagliari, Italy.

Pediatric dermatology: advances in therapy

Several recent therapeutic advances in pediatric dermatology have been made. Of particular importance are new developments in the use of antimicrobials, antivirals, antifungals, retinoids, calcipotriene, and intravenous gamma globulin. We review safety and efficacy data of these drugs in their use in children with cutaneous disease.

Response to initial griseofulvin therapy in pediatric patients with tinea capitis

OBJECTIVE

To estimate the response rate to initial griseofulvin therapy in pediatric patients with tinea capitis and to determine whether clinical or epidemiologic variables differed between patients responding positively and negatively to therapy.

METHODS

A review of patients' medical records with a confirmed diagnosis of tinea capitis was performed retrospectively over a 2-year period. Patients were included only if a positive dermatophyte culture was obtained and the initial prescription for griseofulvin was filled at our pharmacy. Responders were children not returning to the clinic or returning without signs or symptoms of infection. Nonresponders were those returning within 8 months with signs and symptoms of disease, requiring additional therapy.

RESULTS

During July 1993-June 1995, 479 positive fungal cultures were confirmed in 474 patients, and 857 prescriptions for griseofulvin were filled for 765 patients at our institution. Of 122 evaluable patients meeting both criteria, 60.7% were classified as responders to initial prescribed therapy. The remaining 39.3% returned to the clinic within 8 months of initial therapy, requiring additional treatment. An additional 10.7% had a recurrence at a later date. There was no correlation between clinical response and dosage, age, race, or gender, although there was a trend toward longer treatment duration among responders.

CONCLUSIONS

It is evident that tinea capitis persists in the urban pediatric population. Our data suggest that griseofulvin, the current drug of choice, may be ineffective in at least one-third of pediatric patients with tinea capitis.

Treatment of tinea capitis

OBJECTIVE

To review the epidemiology, pathogenesis, mycology, clinical presentation, and pharmacotherapy of tinea capitis, and describe the role of newer antimycotic agents.

DATA SOURCES

A MEDLINE search restricted to English-language articles published from 1966 through 1996 and journal references were used in preparing this review.

DATA EXTRACTION

The data on mycology, pharmacokinetics, adverse effects, and drug interactions were obtained from controlled studies and case reports appearing in the literature. Both open-label and comparative studies were evaluated to assess the efficacy of antimycotics in the treatment of this infection.

DATA SYNTHESIS

Griseofulvin is the drug of choice in the treatment of tinea capitis. Newer agents with greater efficacy or shorter treatment durations continue to be explored. Ketoconazole, the first azole studied for efficacy in tinea capitis, has not demonstrated any clinical advantage over griseofulvin in several controlled clinical trials. Itraconazole is effective, but the available data are limited to case reports and a single uncontrolled study. Terbinafine similarly has shown promise in the treatment of tinea capitis, but the oral formulation was only recently approved in the US. Existing studies reflect the results in infection with pathogens not seen in the US. Both itraconazole and terbinafine achieve high concentrations in the hair and stratum corneum that persist for several weeks following drug administration. This may enable shorter courses of therapy; however, comparative studies need to be conducted in the US.

CONCLUSIONS

Tinea capitis remains the most common dermatophyte infection in young urban children. Oral antifungal therapy is required for effective treatment, often for several months. The combination of griseofulvin with a selenium sulfide shampoo continues to be the mainstay of therapy until more experience is gained with the newer antimycotics.

Unusual Microsporum canis infections in adult HIV patients

Tinea capitis in men, even if infected with HIV, is infrequent. Microsporum species nail infections are extremely rare. In most cases Microsporum canis infection is usually easy to treat with antifungal agents. We describe two HIV-infected men with an unusual M. canis infection. Both patients had tinea capitis, presenting as alopecia in one and scaling of the scalp in the other. One patient also had tinea unguium caused by M. canis. Ketoconazole was ineffective in both patients; terbinafine was tried in one patient without benefit; itraconazole was effective in both, but treatment took many months and only one patient was cured.

Microsporum canis infections in children: results of a new oral antifungal therapy

Clinical and laboratory data from 22 children with tinea corporis and tinea capitis caused by Microsporum canis (10 tinea corporis, 12 tinea capitis), confirmed by microscopic examination and culture and partly pretreated with griseofulvin or terbinafine, are summarized. The children were treated consecutively with itraconazole in our clinic during 1994/95. The age of the children ranged between 4 and 13 years, with girls being affected much more frequently than boys. Oral, individually adapted, high-dose treatment of 5 mg itraconazole per kg body weight proved to be successful. In all 22 children, although pretreatment with griseofulvin or terbinafine was partly unsuccessful, fungal infections could be cured clinically and also were culture negative at control examinations. In 10 children with tinea corporis treatment was performed only for 4-14 (middle 11) days. In the children with tinea capitis itraconazole treatment was continued for 3-11 weeks. Among the six children without pretreatment, itraconazole solution was administered for 4-11 weeks (average 7.5 weeks). Of the patients in whom pretreatment was unsuccessful, four with griseofulvin and two with terbinafine, the duration of the subsequent oral treatment with itraconazole solution was 3-5 weeks (average 3.6 weeks). The drug seemed to be well tolerated-no significant side-effects occurred, with the exception of possible minor gastrointestinal disturbances in two patients. Laboratory values remained within normal limits.

Cutaneous mycoses in children

This article describes common cutaneous mycoses in children: mucocutaneous candidiasis, pityriasis versicolor, tinea corporis, tinea pedis, onychomycosis and tinea capitis. Topical therapy is effective in tinea corporis and pedis, pityriasis versicolor and cutaneous candidiasis. It is ineffective in tinea capitis, in immunocompromised children and onychomycosis. Griseofulvin has been the main treatment until now in children, but it is only fungistatic, may cause interactions and has to be given for long periods. Ketoconazole has not been widely accepted for use in children because of hepatotoxicity and it is not an effective as griseofulvin. There are few data on paediatric use of fluconazole, although it is available in liquid form, has an excellent safety profile and may become important for treating paediatric mycoses. Similarly, there are only limited data on itraconazole in this area, with most experience in tinea capitis. There is only a 100-mg capsule available, which is not easy to administer in paediatric dosages. All azoles have the potential for drug interaction. Most experience in the treatment of children with the allylamine, terbinafine, has been in tinea capitis. A treatment time of 4 weeks with terbinafine and 8 weeks with griseofulvin has produced similar results at 12 weeks. There are also limited data on the use of terbinafine in paediatric onychomycosis. Terbinafine has the best safety profile, least risk of drug interactions and may be the most suitable alternative to griseofulvin in children. The lack of a liquid formulation may preclude its use. Itraconazole and fluconazole are also potential replacement drugs for griseofulvin.

Tinea capitis

Tinea capitis is dermatophytosis of the scalp hair follicles, generally producing inflammatory or noninflammatory alopecia. Infection occurs predominantly in prepubertal children older than 6 months, although infection can occur in all age groups. Tinea capitis is one of the most common infectious conditions in children, and it occurs worldwide.

International summit on cutaneous antifungal therapy, focus on tinea capitis, Boston, Massachusetts, November 11-13, 1994

This article reports the highlights of presentations made at an international symposium held on November 11-13, 1994, in Boston, Massachusetts, on the subject of cutaneous antifungal therapy. Some of the key points pertaining to the epidemiology, etiology, pathogenesis, presentation, and management of tinea capitis are discussed.

Recent developments in antifungal therapy

There have been many advances during the past few years relating to the treatment of superficial fungal infections. This article focuses on recent developments, particularly in oral therapy, but in topical therapy as well. First, the newer agents (especially fluconazole, itraconazole, and terbinafine) are reviewed, and then the use of these agents in many disorders is discussed, with emphasis on tinea corporis or cruris, tinea pedis, tinea capitis, and onychomycosis.

The dermatophytes

The etiologic agents of the dermatophytoses (ringworm) are classified in three anamorphic (asexual or imperfect) genera, Epidermophyton, Microsporum, and Trichophyton. Species capable of reproducing sexually belong in the teleomorphic genus, Arthroderma, of the Ascomycota. On the basis of primary habitat association, they may be grouped as geophilic (soil associated), zoophilic, and anthropophilic. Adaptation to growth on humans by most geophilic species resulted in diminished loss of sporulation, sexuality, and other soil-associated characteristics. The dermatophytes have the ability to invade keratinized tissue (skin, hair, and nails) but are usually restricted to the nonliving cornified layer of the epidermis because of their inability to penetrate viable tissue of an immunocompetent host. However, invasion does elicit a host response ranging from mild to severe. Acid proteinases, elastase, keratinases, and other proteinases reportedly act as virulence factors. The development of cell-mediated immunity correlated with delayed hypersensitivity and an inflammatory response is associated with clinical cure, whereas the lack of or a defective cell-mediated immunity predisposes the host to chronic or recurrent dermatophyte infection. Chronic dermatophytosis is mostly caused by Trichophyton rubrum, and there is some evidence that mannan produced by this fungus suppresses or diminishes the inflammatory response. Since dermatophytes cause a communicable disease, modes of transmission and control are discussed as well as a survey of recent trends in therapy. Collection of specimens, culture media, and tests for identification are also presented. Genetic studies have led to an understanding of incompatibility mechanisms, pleomorphism and variation, resistance to griseofulvin, and virulence. Molecular biology has contributed to our knowledge of the taxonomy and phylogenetic relationships of dermatophytes.

Tinea capitis: new perspectives on an old disease

Tinea capitis caused by Trichophyton tonsurans is a common infection in children, and has become a significant public health problem in the United States. Epidemics of tinea capitis occur both in families and in institutions such as schools and day care centers. Infection is often difficult to eradicate. Fomites and asymptomatic carriers likely contribute to the spread of the disease and to re-infection of treated patients. The morphology of tinea capitis is diverse, from seborrhea-like scaling to tender, inflammed nodules on the scalp. Because a lengthy course of systemic griseofulvin is required to treat this infection, management of tinea capitis can be challenging. As newer antifungal agents are developed, more effective and convenient therapy for tinea capitis may become available.

Trichophyton rubrum as the causative agent of tinea capitis in three children

Tinea capitis, which is caused by Trichophyton rubrum, is only rarely described in medical literature. Incidence of this disease appears to lie well below 1% in Europe. Microsporum canis, Trichophyton mentagrophytes and Trichophyton tonsurans are the predominant causative agents discussed here. In April 1993 T. rubrum was isolated from typical pathological changes to the capillitium area in three children from a Nigerian family, who had been living in Germany for 3 years. All three children revealed multiple, round or irregularly formed, partially infiltrated, partially pustular, hairless areas measuring up to 2 cm in diameter and covered with tightly clinging scales. The children's parents did not suffer from any dermatological complaints. The oldest child had had these pathological changes for about 5 months, the other two for a shorter length of time. Therapy with 10 mg kg(-1) body weight of griseofulvin led to rapid recovery over a period of 4 weeks.

Successful treatment of griseofulvin-resistant tinea capitis in infants

We report on three siblings, children of a farmer, aged 3-8 years, suffering from tinea capitis due to Microsporum canis. Initially, the infection was treated systemically with griseofulvin as well as externally for 5 months without success. Therapy was changed to itraconazole 33 mg per day orally. Laboratory investigations followed every 4-6 weeks. Dependent on the dose per kg body weight the children were cured clinically after 2-5 months and microbiologically after 5-8 months. Thus, itraconazole seems to be superior to conventional treatment with Microsporum canis-induced tinea capitis.

Itraconazole versus griseofulvin in the treatment of tinea capitis: a double-blind randomized study in children

BACKGROUND

Tinea capitis is a fungal infection in which topical therapy is often unsuccessful. Griseofulvin has been considered to be a first-line therapy. Other antifungal agents are the azole derivatives. Among these, itraconazole was compared with griseofulvin in children in a double-blind study.

PATIENTS AND METHODS

Thirty-four children and one adult with clinical signs and symptoms of tinea capitis and with positive culture and microscopy for dermatophytes have been included in a double-blind comparison between itraconazole, 100 mg daily, and ultramicronized griseofulvin, 500 mg daily. Both drugs were given for 6 consecutive weeks. The final evaluation was made 8 weeks after the end of treatment to allow the hairs to regrow. Seventeen itraconazole- and 15 griseofulvin-treated patients received the complete 6-week treatment course. Fifteen of these 17 itraconazole patients and 14 of the 15 griseofulvin patients had infections caused by Microsporum canis. Fifteen of 17 patients were cured by itraconazole (88%) and 15 of 17 patients by griseofulvin (88%). One of the patients who discontinued griseofulvin therapy after 4 weeks was clinically and mycologically cured. Two of the original 17 griseofulvin patients discontinued therapy because of vomiting. None of the itraconazole-treated children experienced side effects.

CONCLUSIONS

Itraconazole is the first azole derivate that matches griseofulvin for the treatment of tinea capitis in children. The drug also appears to be better tolerated than griseofulvin.

Tinea capitis: epidemiology, diagnosis, treatment, and control

Since the 1970s there has been a steady rise in the number of cases of tinea capitis in the United States, most of them caused by Trichophyton tonsurans. Although the infection is seen most frequently in black children, it can occur in white persons and can affect persons of all ages. Control of tinea capitis is difficult for several reasons, including subtle clinical infection, asymptomatic carriage of fungus, fomite spread, and the need for weeks to months of oral medications. Although griseofulvin remains the mainstay of therapy, preliminary studies of itraconazole and terbinafine suggest that these compounds may also be useful in the treatment of tinea capitis. Selenium sulfide shampoo, prednisone, and oral antibiotics are frequently used as adjunctive therapy. The role of fomites in the spread of tinea capitis has yet to be fully understood, as does the best means of decontamination.

Tinea capitis: itraconazole in Trichophyton tonsurans infection

BACKGROUND

Although griseofulvin is considered the standard treatment of tinea capitis, alternatives are being investigated in hopes of identifying more rapid and better cure rates.

OBJECTIVE

Our purpose was to determine the efficacy of itraconazole as therapy for tinea capitis.

METHODS

An open label study was performed on three patients who did not respond to or could not tolerate griseofulvin therapy.

RESULTS

A 30-day course of 100 mg of itraconazole daily resulted in clinical and mycologic cure in all three patients; no side effects were reported.

CONCLUSION

Although these results need to be confirmed by larger, controlled trials, it appears that itraconazole offers a viable alternative to griseofulvin for the treatment of children with tinea capitis.

Antifungal agents: an overview. Part II

The recent introduction of a new generation of antifungal drugs promises to alter significantly therapy for both systemic and superficial mycoses, in particular, onychomycosis. This article presents an in-depth review of the azoles (the triazoles itraconazole and fluconazole), the allylamines (naftifine and terbinafine), and the morpholine derivative amorolfine.