Tinea capitis (overview) B35.0

The term tinea capitis covers infectious fungal diseases of the terminal hair on the head, eyebrows and eyelashes, caused mainly by pathogens of the genera Trichophyton and Microsporum.

• Dermatophytes:
  • frequently Microsporum canis (> 50%)
• rarer
  • Trichophyton tonsurans
  • Trichophyton mentagrophytes (about 15-25%)
  • Trichophyton verrucosum (10-22%)
  • Trichophyton rubrum (about 10-15%)
  • Trichophyton violaceum
  • Trichophyton soudanese
  • Trichophyton schoenleinii
  • M. audouinii
  • Trichophyton (Arthroderma) benhamiae (perfect form of Trichophyton mentagrophytes).

From a clinical point of view, a distinction is made between 2 forms, the development of which depends on the pathogen:

• Superficial or aphlegmatic form (gray-patch tinea); mostly anthropophilic pathogens, see below. Tinea capitis superficialis
  • Moth-eaten tinea capitis
  • "Black-dot" form of tinea capitis. Less inflammatory form, hairs broken off at skin level like stubble (tinea capitis superficialis)
  • Pityriasis -capilliti-like tinea capitis. Prominent diffuse scaling of the scalp without signs of inflammation
  • Pustular tinea capitis with yellowish follicular pustules.
• Deep, phlegmatic (chronic-inflammatory-infiltrative) form, see below. Tinea capitis profunda; see also Kerion Celsi (always zoophilic pathogens);

For historical reasons, in addition to the infection criterion (superficial or deep tinea), tinea capitis is often classified according to:

• microsporia
• and (the special case)
• favus

Almost exclusively in children aged 2-14 years. Tinea capitis is a distinct rarity in adults.

The clinical picture is varied (see classification). Depending on the pathogen and the immune situation of the patient, it ranges from a simple non-inflammatory disease to a seborrheic dermatitis-like disease (often triggered by T. tonsurans). Furthermore, there are gray-scaly alopecic areas or, in the inflammatory forms, granulomatous plaques or nodules, often interspersed with follicular pustules. In tinea capitis, dermatophyte-induced mycides (dermatophytids) can show a wide clinical variance as an expression of a late-type reaction to pathogen antigens. They must be differentiated from UAWs and can basically occur on all parts of the body. Pathogens cannot be detected in the lesions Definition (Mayser P et al. 2020).

Material collection: A prerequisite for valid examination results is optimal material collection. Sterile instruments must be used. Suspicious foci can be demarcated with the Wood lamp.

Then disinfect the suspicious area with 70% alcohol.

In the case of highly inflammatory lesions, marginal hairs can be easily and painlessly epilated. They are well suited for culture. In less inflammatory lesions, scales and hair can be removed from the scalp with the blunt side of a scalpel or a brush (e.g. toothbrush/hairbrush-diagnosis - MacKenzie 1963).

Conventional detection methods: For direct microscopy (native preparation), the material is coated on a microscope slide with 10-20% potassium hydroxide solution (KOH) and kept in a moist chamber for 10-30 minutes. Although the detection of hyphae and spores in the native preparation indicates the fungal infection, it does not provide any reliable information about the type of fungus. The sensitivity of the native preparation is therefore not very high.

The following culture media are suitable for cultivating the fungi from the skin material:

Sabouraud glucose agar with 2 or 4% glucose, Kimmig agar and an agar containing antibiotics or cycloheximide (example: ^Mycosel® agar) to suppress bacterial or mold growth

The culture is stored at room temperature for 3-6 weeks.

Molecular diagnostics: Conventional PCR methods are used with subsequent species identification by sequencing or by using special probes (ELISA formats, micorarray, blot) or real-time PCR. MAL-DI-TOF mass spectrometry is also highly specific. On the one hand, these methods allow the exact differentiation of the pathogen from the primary culture. On the other hand, the pathogens can be identified directly from the clinical material using molecular PCR methods. This means that molecular techniques are significantly faster (24-28 hours compared to 2-6 weeks for cultural methods) and more sensitive than native preparations and culture (Mayser P et al. 2020)

According to the guidelines, the following guidelines apply to pathogen detection:

• Pathogen detection before therapy
• Therapy always systemic+adjuvant topical
• Goal: negative culture
• Zoophilic pathogen: examine pets
• Anthrophilic pathogens: Examine contact persons.

Microscopic examination of epilated hair and dandruff. Anthrophilic pathogens grow mainly endotrichous (penetrating the hair).

The exception is M. audouinii (see microsporia below).

Zoophilic pathogens grow ectotrichously (around the hair - see illustration) with large spore cuffs. This is why zoophilic pathogens are highly contagious.

Cultures must be observed for up to 5 weeks because some pathogens ( T. verrucosum, T. violaceum, T. soudanense) grow very slowly.

S.a. Subforms.

• CDLE
• Impetigo contagiosa
• Folliculitis
• Alopecia areata
• Folliculitis decalvans
• Lichen planus capillitii
• Psoriasis capitis
• Pityriasis simplex capillitii
• Eczema, seborrheic of the scalp
• Pustulosis, sterile eosinophilic
• Alopecia areolaris syphilitica

• Tinea
• tinea capitis profunda
• superficial tinea capitis
• Microsphere
• Favus.

In principle, it is always necessary to treat tinea capitis systemically and locally in combination. The pathogen specification is important as some antimycotics are less sensitive to certain pathogens. In the guideline of the European Society for Pediatric Dermatology, the antimycotics terbinafine, itraconazole and fluconazole (regardless of their approval status) were given recommendation grade A.

• Terbinafine is the drug of choice for Trichophyton species due to its high efficacy and lack of pathogen gaps.
• Itraconazole and griseofulvin are less effective. Both are recommended for Microsporum canis, M. audouinii, M. ferrugineum (for griseofulvin see below)
• Fluconazole is resistant to Trichophyton mentagrophytes var. granulosum and Trichophyton verrucosum.

Adults: Terbinafine, griseofulvin (in Germany for economic reasons off the market/available via an international pharmacy - single import according to §73 AMG)), itraconazole, fluconazole.

Children: Only griseofulvin is approved for systemic therapy, fluconazole for children > 1 year. Itraconazole or terbinafine can only be prescribed as an individualized treatment trial ( off-label use) after the parents have been informed accordingly. Itraconazole should only be prescribed for a maximum of 3 months due to potential toxic effects.

In a randomized comparative study of all commercially available antimycotics, 50 children each with tinea capitis caused by a Trichophyton species were treated as follows: griseofulvin (20mg/kgKG/day for 6 weeks), terbinafine (>40kg bw - 250mg/day, 20-40kg bw - 125mg/day for 2 or 3 weeks), itraconazole (5mg/kgKG/day for 2 or 3 weeks), fluconazole (6mg/kgKG/day for 2 or 3 weeks). The cure rates after 12 weeks were: griseofulvin 92%, terbinafine 94%, itraconazole 82%, fluconazole 82%.

Local treatment with a topical antifungal agent of the fungicidal action type (cicloproxolamine, terbinafine) is recommended. This should be applied to the entire capillitium. Supplementary antimycotic shampoos should be used 2x a week.

In highly inflammatory forms, the use of fixed combinations of glucocorticoids and antifungals is recommended initially (maximum duration 1-2 weeks) (Mayser P 2014). Glucocorticoids lead to rapid decongestion of acute weeping lesions with resolution of pain and itching.

The term "tinea" (Latin for woodworm or moth) is the historically developed term for a dermatophyte infection of the hairy head, which was compared to a "moth-eaten" picture.

Itraconazole has not yet been approved for use in children. However, studies have shown good therapeutic success. In a randomized study with 34 children (< 12 years), tinea capitis was treated with 500 mg griseofulvin and 100 mg itraconazole daily for a total of 6 weeks. Both groups showed an identical treatment success with 88% cure. In addition, no side effects occurred in the group treated with itraconazole.

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