Dermatology Online Journal
- Author(s): Strober, Bruce E.
- et al.
Department of Dermatology, New York University
Bruce E. Strober,MD,PhD
Dermatology Online Journal 7(1): 12
PATIENT: 59-year-old woman
DURATION: Eight years
Hair loss initially began on the frontal scalp and progressively increased in area over eight years. On the occipital scalp, smaller patches of alopecia developed over the past two to three years. Previously, multiple physicians treated the patient with both topical and intralesional glucocorticoids without improvement. Upon presentation to the Charles C. Harris Skin and Cancer Pavilion, a biopsy was performed, and a skin fungal culture was obtained. The patient was treated with griseofulvin 500 mg daily.
A 10-cm patch of scarring alopecia with an erythematous border was found on the frontal and vertex areas of the scalp. Superimposed were 1-to-2-cm crusted erosions. Smaller, discrete patches of nonscarring alopecia were found on the occipital scalp. There was no lymphadenopathy.
|Figure 1||Figure 2|
A complete blood count with differential analysis, electrolytes, and liver function tests were normal. An antinuclear antibody titer was within normal limits. A fungal culture grew Trichophyton tonsurans.
There were several hair follicles with rounded and box-like arthrospores within the hairshaft. There was a perivascular and perifollicular infiltrate of lymphocytes, plasma cells, eosinophils, and neutrophils.
Tinea capitis, a fungal infection of scalp hair, can be caused by any species of either Trichophyton or Microsporum. However, most cases are due to Trichophyton tonsurans, Trichophyton mentagrophytes, Trichophyton violaceum, and Trichophyton verrucosum. Although primarily affecting children between the ages of three and seven years of age, tinea capitis also occurs in adults and afflicts women more commonly than men. In urban populations, large family size, crowded living conditions, and low socioeconomic status may contribute to an increased incidence of tinea capitis. Transmission occurs via infected persons, shed infected hairs, animal vectors, and fomites. Infectious organisms may remain viable for many months after being shed from their host.
The clinical manifestations of scalp dermatophytosis are diverse. Non-inflammatory lesions often occur as papules with scale around hair shafts, often on the occipital scalp. Inflammatory lesions may involve pustular folliculitis and kerion formation, with associated fever, pain, and lymphadenopathy. Black dot tinea capitis occurs after the breakage of hairs at the scalp. Favus involves the production of scutula, which are hairs matted together with dermatophyte hyphae and keratin debris. Many patients have both inflammatory and non-inflammatory manifestations. Scarring alopecia may result from chronic, inflammatory infections.
Wood's lamp examination may show the fluorescing hair shafts of Microsporum infections but will fail to identify Trichophyton tonsurans.
Griseofulvin remains a mainstay of therapy, used at 20 to 25 mg/kg/day for six to eight weeks. Micronized and ultramicronized preparations exhibit better absorption characteristics, and side effects are infrequent, especially when administered with meals. Reasonable alternatives to griseofulvin include itraconazole (5 mg/kg/day for four to six weeks or in one week treatment intervals for two to three consecutive months), fluconazole (5mg/kg/day for four to six weeks, 6 mg/kg/day for 20 days, or 8 mg/kg once weekly for four to six weeks), and terbinafine (250 mg/day for two to four weeks for adults weighing more than 40 kg).[2,3,4]
References1. Elewski BE. Tinea capitis: a current perspective. J Am Acad Dermatol 2000;42(1 Pt 1):1-20; quiz 21-4. PubMed
2. Gupta AK, Adam P, Soloman R, Aly R. Itraconazole oral solution for the treatment of tinea capitis using the pulse regimen [see comments] Cutis 1999;64(3):192-4. PubMed
3. Gupta AK, Adam P, Hofstader SL, Lynde CW, Taborda P, Taborda V, Morar N, Dlova N, Raboobee N, Konnikov N, Aboobaker J, Summerbell RC. Intermittent short duration therapy with fluconazole is effective for tinea capitis. Br J Dermatol 1999;141(2):304-6. PubMed
4. Caceres-Rios H, Rueda M, Ballona R, Bustamante B. Comparison of terbinafine and griseofulvin in the treatment of tinea capitis. J Am Acad Dermatol 2000;42(1 Pt 1):80-4. PubMed
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