Tinea capitis: focus on African American women

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

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

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

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

Tinea capitis among schoolchildren in Ethiopia: A systematic review and meta analysis

BACKGROUND

Tinea capitis accounts for25 to 30% of all fungal infections, but it is often ignored because it is not life threatening in nature. It is more common among schoolchildren particularly in developing countries. Due to the presence of significant variability among the previous studies, this study was conducted to provide a pooled prevalence and associated factors of tinea capitis in Ethiopian schoolchildren.

METHOD

We conducted a systematic search in five major databases for articles similar to our topic. This review included school-based cross-sectional studies that were reported in English and conducted from 2006 through 2022. The data were extracted using Microsoft Excel and further analysis was done using StataTM Version 17.0 statistical software. Forest plots were used to assess the presence of heterogeneity with 95% confidence intervals. A random effects meta- analysis model was used to pool primary estimates. To declare the presence or absence of association, 95% confidence interval with odds ratio was used.

RESULTS

Fourteen studies with a total of 9465 schoolchildren were included. The pooled prevalence was 29.03% (95%CI: 15.37-42.71). There was observed heterogeneity, which could be explained by publication bias (P = 0.04). Family history of tinea capitis (OR: 9.18, 95%CI: 3.5-24.02), under the age of 10 years (OR: 1.65, 95%CI: 1.17-2.33) were factors increasing the development of tinea capitis among schoolchildren and schoolchildren who had hair wash at least once a week (OR: 0.31, 95%CI: 0.24-0.42) was significantly associated with reduced risk for tinea capitis.

CONCLUSION

One of the most prevalent childhood health condition in Ethiopia is tinea capitis, which affects over one in every four schoolchildren. Schoolchildren who had family history of tinea capitis and under the age of 10 years were the identified risk factors but they had hair wash at least once a week was the protective factor of tinea capitis among schoolchildren. Clinical and public engagement activities are needed to overcome the burden of the disease.

Tinea Capitis Presenting as Diffuse Hair Loss and Significance of Trichoscopy: Four Case Reports

Tinea capitis is a common fungal infection in children but is less frequently encountered in adults. Tinea capitis presenting as diffuse hair loss is a rare presentation. When patient presents with a diffuse hair loss, tinea capitis is not commonly thought of as differential diagnosis. Low clinical suspicion can lead to inappropriate empiric treatments that delay diagnosis. Trichoscopy in tinea capitis obviates the need for lengthy and invasive procedure or even KOH examinations in the absence of a side lab for diagnosing this common scalp disorder and also avoids misdiagnosis. Trichoscopy not only differentiates tinea capitis from female patterned hair loss but also aids in differentiating ectothrix from endothrix. Here, we present case reports of tinea capitis masquerading as female pattern hair loss with trichoscopy aiding in diagnosis of endothrix infection.

Aetiological changes of tinea capitis in the Hubei area in 60 years: Focus on adult tinea capitis

BACKGROUND

Tinea capitis is a common dermatophyte infection of the scalp primarily affecting children, with less frequent, though not rare, observation in adults.

OBJECTIVE

This study aimed to assess changes in the causative agents of adult tinea capitis over a 60-year period in the Hubei area.

METHODS

A retrospective, single-centre study was performed on 164 adults with tinea capitis between 1960 and 2020.

RESULTS

Out of 1113 cases of tinea capitis, 164 patients were adults, representing 14.7% of all patients. Adult tinea capitis was slightly more prevalent in males (91, 55.5%) than in females (73, 44.5%), but gender difference was not statistically significant between adults and children. Adult tinea capitis was most prevalent between the ages of 18 and 29 years, with a mean age of 22 years. Trichophyton schoenleinii was the most common dermatophyte in adult tinea capitis (78, 47.6%), followed by Trichophyton violaceum (58, 35.4%). Most adult tinea capitis cases before the 1980s were caused by T. schoenleinii, but T. violaceum has become the leading pathogen for recent adult tinea capitis cases.

CONCLUSION

Tinea capitis is not a disease exclusive to children. On the contrary, an upward trend of tinea capitis in adults has been observed in recent years. T. violaceum has become the dominant causative agent of adult tinea capitis in the Hubei area, replacing T. schoenleinii. These results provide a better understanding of the treatment and prevention of tinea capitis in adults.

Clinical and epidemiological characteristics of tinea capitis in northern Taiwan during 2014-2019: An unusual bimodal distribution of patients and comparison of paediatric and adult cases

Tinea capitis (TC) mainly occurs in children, and related studies in adults are rare. We aimed to investigate the current epidemiological, clinical and mycological characteristics of TC and to compare adult and paediatric patients in northern Taiwan. We conducted a retrospective study at Chang Gung Memorial Hospital, Linkou Branch, from 2014 to 2019. The dataset included age, sex, records of underlying diseases, animal contact history, frequent hair salon visits, clinical patterns, treatment and outcome via chart or phone call reviews. The average ages of 72 children and 104 adults recruited were 6.0 and 74.0 years, respectively. A female predominance was noted in both groups, and the ratio of females was significantly higher in adults (94.2% vs 59.7%, P < .0001). Microsporum canis (76.4%) and Trichophyton mentagrophytes (11.1%) in children, and M. canis (49.0%) and T. violaceum (31.7%) in adults were the most common pathogens. Adults were more likely to be infected with T. violaceum (OR = 10.14, 95% CI = 2.04-50.26) than children. In contrast, adults were less likely to be infected with M. canis than children (OR = 0.31, 95% CI = 0.11-0.90). Furthermore, adults visited hair salons more, had less animal contact and were more immunosuppressed than children. TC is not unusual in the adult population. Dermatologists are advised to realise risk factors such as immunosuppression and regular hair salon visit in adult TC.

Asian Hair: A Review of Structures, Properties, and Distinctive Disorders

Asian hair is known for its straightness, dark pigmentation, and large diameter. The cuticle layer in Asians is thicker with more compact cuticle cells than that in Caucasians. Asian hair generally exhibits the strongest mechanical properties, and its cross-sectional area is determined greatly by genetic variations, particularly from the ectodysplasin A receptor gene. However, knowledge on Asian hair remains unclear with limited studies. This article aimed to review and summarize the characteristics and properties of Asian hair. It also aimed to discuss hair disorders including linear lupus panniculitis and pseudocyst of the scalp that occur distinctively in Asian populations.

Factors affecting the severity of central centrifugal cicatricial alopecia

BACKGROUND

Central centrifugal cicatricial alopecia (CCCA) is a type of scarring hair loss primarily seen in African-American women. The risk factors that affect the severity of disease remain unclear.

OBJECTIVES

This study was designed to elucidate risk factors that may be associated with severity of CCCA.

METHODS

A cross-sectional survey study was conducted. Women with biopsy-confirmed CCCA responded to a questionnaire and were grouped according to a photographic scale of central scalp alopecia. The severity of disease was considered: grade 1 and 2 disease was interpreted as early-stage CCCA, and grade 3-5 disease was interpreted as advanced-stage CCCA. Data from the questionnaire were compared with levels of severity to determine the strength of associations with severity of disease.

RESULTS

A total of 38 women with biopsy-confirmed CCCA were recruited to participate in this study. Early-stage CCCA was seen in 22 subjects (57.9%), and advanced-stage CCCA was noted in 16 subjects (42.1%). The average duration of hair loss was 5.7 years in early-stage disease and 10.1 years in advanced-stage disease. There was a positive correlation between duration of hair loss and degree of hair loss (Spearman's correlation 0.471, P = 0.003).

CONCLUSIONS

This study reports on data sourced from patients with biopsy-confirmed CCCA and examines the relationships between various factors and severity of CCCA. The findings demonstrate that duration of hair loss is positively associated with severity of disease and that androgen-related conditions are prevalent in those affected with CCCA.

Prevalence of Tinea capitis in school going children from Mathare, informal settlement in Nairobi, Kenya

Background

Tinea capitis is a common infection especially in poor resource settings. This study was aimed at determining the prevalence Tinea capitis in children from selected schools from an urban slum in Nairobi city of Kenya.

Methods

A cross-sectional study was carried out in 150 school going children during the period between May and September 2013. A questionnaire was administered and cultures of scalps, skin scrapping/hair stubs samples were performed and the etiological agents identified and confirmed.

Results

In a total of one hundred and fifty (150) children recruited 89 (59.3%) were males and 61 (40.7%) females aged between 3 and 14 years. The overall prevalence rates in dermatophytes infection was 81.3% (122/150) with etiological agents consisting Trichophyton spp. (61.3%), Microsporum spp. (13.3%) and Epidermophyton spp. (7.3%) infections with infections occurring either singly (56%), duo (38%) or tipple co-infections (6%).

Conclusion

This study demonstrates a high prevalence of Tinea infections with Trichophyton tonsurans as the predominant etiological agent in school going children of the urban slums of Nairobi.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1240-7) contains supplementary material, which is available to authorized users.

Central hair loss in African American women: incidence and potential risk factors

BACKGROUND

Although central scalp hair loss is a common problem in African American women, data on etiology or incidence are limited.

OBJECTIVE

We sought to determine the frequency of various patterns and degree of central scalp hair loss in African American women and to correlate this with information on hair care practices, family history of hair loss, and medical history.

METHODS

Five hundred twenty-nine subjects at six different workshops held at four different sites in the central and/or southeast United States participated in this study. The subjects' patterns and degree of central scalp hair loss were independently assessed by both subject and investigator using a standardized photographic scale. Subjects also completed a detailed questionnaire and had standardized photographs taken. Statistical analysis was performed evaluating answers to the questionnaire relative to pattern of central hair loss.

RESULTS

Extensive central scalp hair loss was seen in 5.6% of subjects. There was no obvious association of extensive hair loss with relaxer or hot comb use, history of seborrheic dermatitis or reaction to a hair care product, bacterial infection, or male pattern hair loss in fathers of subjects; however, there was an association with a history of tinea capitis.

LIMITATIONS

There was no scalp biopsy correlation with clinical pattern of hair loss and further information on specifics of hair care practices is needed.

CONCLUSIONS

This central scalp photographic scale and questionnaire provide a valid template by which to further explore potential etiologic factors and relationships to central scalp hair loss in African American women.

Tinea capitis among children in the Columbus area, Ohio, USA

Tinea capitis is a fungal infection of the hair follicles of the scalp. In the US, the most common organisms have traditionally been Trichophyton tonsurans, and occasionally Microsporum canis. This study was designed to examine patterns of organisms causing tinea capitis and determine factors associated with infection. A retrospective database analysis was conducted to locate records of patients with tinea capitis from May 2001 to May 2006 at Nationwide Children's Hospital in Columbus, OH. Descriptive statistics, frequency analysis, chi-squared test, and Student's t-test were performed to evaluate types of causative organisms and associated patient characteristics. One hundred and eighty-nine charts of patients with a positive scalp culture for tinea capitis were located. Trichophyton tonsurans (88.9%) was the foremost causative agent followed by Trichophyton violaceum (4.2%). Tinea capitis was more prevalent among African Americans and was more common in urban areas (P < 0.05). Children of African descent inhabiting urban settings were most vulnerable to tinea capitis. The most common organism isolated in this retrospective study was T. tonsurans. Trichophyton violaceum and Trichophyton soudanense were also isolated, which are not commonly reported causes of tinea capitis in the US.

Hair breakage in normal and weathered hair: focus on the Black patient

Hair breakage and fragility are a large problem for many patients as well as a treatment challenge to the dermatologist. Understanding the factors that lead to acquired hair shaft fragility and breakage is paramount to recommending appropriate treatment to affected patients. African or Black hair is known to be more affected by breakage with easily observed fragility in vivo. To date there are no known structural or chemical differences in Black hair as compared to Caucasian or Asian hair that explains this observed fragility. This review explores the impact of hair care practices on the development of hair breakage with a focus on patients of color. The examination and recommended ancillary testing for the process are discussed, and advances in the measurement of mechanical fracture of human hair are reviewed.

Dermatologia na pele negra

Este estudo aborda a dermatologia na pele negra. Inicialmente, discute os conceitos de raça e etnia, assim como os critérios de classificação da população brasileira, indicando as regiões em que a população negra se concentra. A seguir, faz breve explanação sobre os sistemas de classificação da cor da pele e descreve particularidades estruturais, biológicas e funcionais da epiderme, derme e anexos cutâneos que diferenciam as peles clara e escura. Posteriormente, mostra algumas alterações fisiológicas comumente observadas na pele, nas unhas e nas mucosas dos indivíduos negros. Aponta, também, alguns padrões de reações e modificações da cor das lesões, decorrentes da hiperpigmentação cutânea, que determinam aspectos inusitados às dermatoses, dificultando seu reconhecimento. Finalmente, destaca algumas doenças em especial, enfatizando particularidades inerentes ao padrão das lesões e à freqüência de algumas dermatoses na pele negra. Nesse contexto, a intenção foi fornecer dados para auxiliar o dermatologista a se familiarizar com as diferentes nuanças que as doenças podem adquirir na pele mais pigmentada.

Pediatric tinea capitis: recognition and management

Tinea capitis (ringworm of the head) is the most common dermatophytosis of childhood with an increasing incidence worldwide. If suspected clinically, further diagnostic procedures, including direct microscopy and culture, should be performed. Other scalp alterations, such as seborrheic dermatitis, atopic eczema, psoriasis, alopecia areata, folliculitis, and pseudopelade, may mimic ringworm of the head and must be identified. A proven fungal infection of scalp skin and hairs warrants immediate initiation of systemic treatment. At present, only oral griseofulvin is approved for therapy of scalp ringworm in children by health authorities. However, the advent of several newer antifungal agents such as itraconazole, fluconazole, and terbinafine has broadened the therapeutic armamentarium in recent years. These agents offer shorter treatment intervals, and their adverse effects and drug interaction profiles appear to be well within acceptable limits. In patients with tinea capitis, systemic therapy at weight-dependent dosages for an appropriate amount of time in conjunction with topical supportive measures will help to prevent disfiguring hair loss, permanent formation of scar tissue, spread of fungal organisms to other cutaneous regions, and infection of other persons.

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.

Tinea capitis: a treatment update

Currently, many experts consider griseofulvin to be the drug of choice for tinea capitis. It is FDA approved for this indication, highly efficacious, and has an excellent long-term safety record. Nonetheless, there is now ample evidence documenting the efficacy and safety of other antifungal agents. Terbinafine, itraconazole, and fluconazole have been used off-label in the United States and United Kingdom for tinea capitis. Several studies have shown that short-term terbinafine, itraconazole, or fluconazole each are comparable in efficacy and safety to griseofulvin. High-dose griseofulvin is still the first-line therapy for tinea capitis in our practice, but a large-scale, multicenter trial of higher dose terbinafine is now ongoing, and positive efficacy and safety results from that study may lead to a change in our standard of care. Terbinafine, itraconazole, or fluconazole currently are used in patients who have either failed griseofulvin or developed adverse reactions to this medication. Families must be informed that these other antifungal agents are not FDA-approved for this indication when they are used. Guidelines for therapy with each of these agents are summarized in Table 5. In addition, the adjuvant use of antifungal shampoos is recommended for all patients in order to decrease the viability of fungal spores present on the hair, as well as for all household contacts to prevent infection or eliminate the carrier state.

Prevalence of skin disorders in school children in Ibadan, Nigeria

Although skin diseases are common in children, there are very few population-based studies in West Africa. Recently, there has been considerable emphasis on hygiene and socio-economic impact on the incidence of allergic disorders in children. We determined the prevalence of skin diseases in a public primary school in Ibadan (southwest Nigeria). A questionnaire for assessing factors associated with the prevalence of diseases was completed, and a complete physical examination was carried out on 1066 students. The study included 529 (49.6%) boys and 537 (50.4%) girls with a mean age of 8.8 +/- 2.5 years. The mean family size of the subjects was 6.7 +/- 2.3 while the mean number of rooms in their homes was 2.6 +/- 1.45. Infectious dermatosis was commonly observed. Of 375 children with a skin lesion, 162 (15.2%) had dermatophytosis, most often tinea capitis, 50 (4.7%) had pityriasis versicolor, and 50 (4.7%) had scabies. Other dermatoses observed included papular urticaria in 35 (3.3%) and angular cheilitis in 27 (2.5%) children. One or more melanocytic nevi were found in 40 (3.8%) children while 138 (12.9%) and 77 (7.25%) had tribal and scarification marks, respectively. Atopic eczema and viral warts were virtually absent. We concluded that fungal infections and scabies were the most common skin diseases in our study population, whereas allergic illnesses were nearly absent.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Medical and surgical therapies for alopecias in black women

Hair loss is a common problem that challenges the patient and clinician with a host of cosmetic, psychological and medical issues. Alopecia occurs in both men and women, and in all racial and ethnic populations, but the etiology varies considerably from group to group. In black women, many forms of alopecia are associated with hair-care practices (e.g., traction alopecia, trichorrhexis nodosa, and central centrifugal cicatricial alopecia). The use of thermal or chemical hair straightening, and hair braiding or weaving are examples of styling techniques that place African American women at high risk for various "traumatic" alopecias. Although the exact cause of these alopecias is unknown, a multifactorial etiology including both genetic and environmental factors is suspected. A careful history and physical examination, together with an acute sensitivity to the patient's perceptions (e.g., self-esteem and social problems), are critical in determining the best therapy course. Therapeutic options for these patients range from alteration of current hair grooming practices or products, to use of specific medical treatments, to hair replacement surgery. Since early intervention is often a key to preventing irreversible alopecia, the purpose of the present article is to educate the dermatologist on all aspects of therapy for hair loss in black women--including not only a discussion of the main medical and surgical therapies but also an overview of ethnic hair cosmetics, specific suggestions for alterations of hair-care practices, and recommendations for patient education and compliance.

Hair and scalp disorders in ethnic populations

Treating scalp and hair disorders is challenging because of the emotional nature of hair loss and because of unknown pathogenesis. Treating African American patients can add an extra layer of complexity to this treatment if the dermatologist is not familiar with hair care practices. Only the dermatologist who strives to understand hair care practices, the common disease entities of the hair and scalp in African Americans, and the disturbance in quality of life from alopecia will effectively approach treatment in these patients.