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Tinea capitis (also known as "herpes tonsurans", "ringworm of the hair", "ringworm of the scalp", "scalp ringworm", and "tinea tonsurans") is a cutaneous
fungal A fungus (plural The plural (sometimes abbreviated An abbreviation (from Latin ''brevis'', meaning ''short'') is a shortened form of a word or phrase, by any method. It may consist of a group of letters, or words taken from the full ...

fungal
infection An infection is the invasion of an organism's body tissues by disease-causing agents, their multiplication, and the reaction of host A host is a person responsible for guests at an event or for providing hospitality during it. Host may ...
(
dermatophytosis Dermatophytosis, also known as ringworm, is a mycosis, fungal infection of the skin. Typically it results in a red, itchy, scaly, circular rash. Hair loss may occur in the area affected. Symptoms begin four to fourteen days after exposure. Mu ...

dermatophytosis
) of the
scalp The scalp is the anatomical area bordered by the human face The face is the front of an animal's head that features the eyes Eyes are organs An organ is a group of tissues with similar functions. Plant life and animal life rely on ...
. The disease is primarily caused by
dermatophytes Dermatophytes (from Greek Greek may refer to: Greece Anything of, from, or related to Greece Greece ( el, Ελλάδα, , ), officially the Hellenic Republic, is a country located in Southeast Europe. Its population is approximately 10.7 mi ...
in the genera ''
Trichophyton ''Trichophyton'' is a genus Genus /ˈdʒiː.nəs/ (plural genera /ˈdʒen.ər.ə/) is a taxonomic rank In biological classification In biology, taxonomy () is the scientific study of naming, defining (Circumscription (taxonomy), ci ...
'' and ''
Microsporum ''Microsporum'' is a genus Genus (plural genera) is a taxonomic rank Taxonomy (general) is the practice and science of classification of things or concepts, including the principles that underlie such classification. The term may also refe ...
'' that invade the hair shaft. The clinical presentation is typically single or multiple patches of hair loss, sometimes with a 'black dot' pattern (often with broken-off hairs), that may be accompanied by inflammation, scaling, pustules, and itching. Uncommon in adults, tinea capitis is predominantly seen in pre- children, more often boys than girls. At least eight species of dermatophytes are associated with tinea capitis. Cases of ''Trichophyton'' infection predominate from Central America to the United States and in parts of Western Europe. Infections from ''Microsporum'' species are mainly in South America, Southern and Central Europe, Africa and the Middle East. The disease is infectious and can be transmitted by humans, animals, or objects that harbor the fungus. The fungus can also exist in a carrier state on the scalp, without clinical symptomatology. Treatment of tinea capitis requires an oral antifungal agent;
griseofulvin Griseofulvin is an antifungal medication used to treat a number of types of dermatophytoses (ringworm). This includes fungal infections of the nails and scalp, as well as the skin when antifungal creams have not worked. It is taken by mouth. Co ...

griseofulvin
is the most commonly used drug, but other newer antimycotic drugs, such as
terbinafine Terbinafine, sold under the brand name Lamisil among others, is an antifungal medication used to treat pityriasis versicolor, onychomycosis, fungal nail infections, and ringworm including jock itch and athlete's foot. It is either oral administra ...

terbinafine
,
itraconazole Itraconazole, sometimes abbreviated ITZ, is an antifungal medication An antifungal medication, also known as an antimycotic medication, is a pharmaceutical A medication (also referred to as medicine, pharmaceutical drug, medicinal drug o ...

itraconazole
, and
fluconazole Fluconazole is an antifungal medication An antifungal medication, also known as an antimycotic medication, is a pharmaceutical A medication (also referred to as medicine, pharmaceutical drug, medicinal drug or simply drug) is a drug ...

fluconazole
have started to gain acceptance.


Symptoms

It may appear as thickened, scaly, and sometimes boggy swellings, or as expanding raised red rings (
ringworm Dermatophytosis, also known as ringworm, is a fungal infection Mycosis is an infectious disease An infection is the invasion of an organism's body Tissue (biology), tissues by Pathogen, disease-causing agents, their multiplication, and t ...

ringworm
). Common symptoms are severe
itching ITCH is a HECT domain In molecular biology, the HECT domain is a protein domain A protein domain is a region of the protein's Peptide, polypeptide chain that is self-stabilizing and that folds independently from the rest. Each domain forms a c ...

itching
of the scalp,
dandruff Dandruff is a skin condition that mainly affects the scalp The scalp is the anatomical area bordered by the human at the front, and by the at the sides and back. Structure The scalp is usually described as having five layers, which ...
, and
bald Hair loss, also known as alopecia or baldness, refers to a loss of hair Hair is a protein filament In biology Biology is the natural science that studies life and living organisms, including their anatomy, physical structure, ...

bald
patches where the fungus has rooted itself in the skin. It often presents identically to dandruff or seborrheic dermatitis. The highest incidence in the United States of America is in American boys of school age. There are three type of tinea capitis, microsporosis, trichophytosis, and
favus Favus (Latin for "wikt:favus#Latin, honeycomb") or tinea favosa is the severe form of tinea capitis, a Skin disease, skin infectious disease caused by the dermatophyte fungus ''Trichophyton schoenleinii.'' Typically the species affects the scalp, ...

favus
; these are based on the causative microorganism, and the nature of the symptoms. In ''microsporosis'', the lesion is a small red
papule A papule is a small, well-defined bump in the skin Skin is the layer of usually soft, flexible outer tissue covering the body of a vertebrate animal, with three main functions: protection, regulation, and sensation. Other cuticle, animal cov ...
around a hair shaft that later becomes scaly; eventually the hairs break off 1–3 mm above the scalp. This disease used to be caused primarily by '' Microsporum audouinii'', but in Europe, ''M. canis'' is more frequently the causative fungus. The source of this fungus is typically sick cats and kittens; it may be spread through person to person contact, or by sharing contaminated brushes and combs. In the United States, ''Trichophytosis'' is usually caused by ''
Trichophyton tonsurans ''Trichophyton tonsurans'' is a fungus in the family Arthrodermataceae that causes ringworm infection of the scalp. It was first recognized by David Gruby in 1844. Isolates are characterized as the "–" or negative mating type of the ''Arthroderm ...
'', while ''T. violaceum'' is more common in Eastern Europe, Africa, and India. This fungus causes dry, non-inflammatory patches that tend to be angular in shape. When the hairs break off at the opening of the , black dots remain. ''Favus'' is caused by ''T. schoenleinii'', and is endemic in South Africa and the Middle East. It is characterized by a number of yellowish, circular, cup-shaped crusts ( scutula) grouped in patches like a piece of honeycomb, each about the size of a split pea, with a hair projecting in the center. These increase in size and become crusted over, so that the characteristic lesion can only be seen around the edge of the scab.


Pathophysiology

From the site of inoculation, the fungus grows down into the
stratum corneum The stratum corneum (Latin Latin (, or , ) is a classical language A classical language is a language A language is a structured system of communication Communication (from Latin ''communicare'', meaning "to share" or "to be ...
, where it invades keratin. Dermatophytes are unique in that they produce keratinase, which enables them to use keratin as a nutrient source. Infected hairs become brittle, and after three weeks, the clinical presentation of broken hairs is evident. There are three types of infection: Ectothrix: Characterized by the growth of fungal spores (
arthroconidiaArthroconidia are a type of fungus, fungal spore typically produced by segmentation of pre-existing fungal hyphae. These spores are asexual reproduction, asexual and are generally not as durable and environmentally persistent as, for instance, bac ...
) on the exterior of the hair shaft.  Infected hairs usually fluoresce greenish-yellow under a Wood lamp (blacklight). Associated with ''
Microsporum canis ''Microsporum canis'' is a pathogenic In biology Biology is the natural science that studies life and living organisms, including their anatomy, physical structure, Biochemistry, chemical processes, Molecular biology, molecular interactio ...

Microsporum canis
'', ''
Microsporum gypseum ''Microsporum gypseum'' is a soil-associated dermatophyte Dermatophytes (from Greek '' derma'' "skin" ( GEN ''dermatos'') and ''phyton'' "plant") are a common label for a group of fungus A fungus (plural: fungi or funguses) is any memb ...
'', ''
Trichophyton equinum ''Trichophyton'' is a genus of fungi, which includes the parasitic varieties that cause tinea, including athlete's foot, ringworm, jock itch, and similar infections of the nail, beard, skin and scalp. Trichophyton fungi are Mold (fungus), molds ...
'', and ''
Trichophyton verrucosum ''Trichophyton verrucosum'', commonly known as the cattle ringworm fungus, is a dermatophyte largely responsible for fungal skin disease in cattle, but is also a common cause of ringworm in donkeys, dogs, goat, sheep, and horses. It has a worldw ...
''. Endothrix: Similar to ectothrix, but characterized by arthroconidia restricted to the hair shaft, and restricted to anthropophilic bacteria.  The cuticle of the hair remains intact and clinically this type does not have fluorescence.  Associated with ''
Trichophyton tonsurans ''Trichophyton tonsurans'' is a fungus in the family Arthrodermataceae that causes ringworm infection of the scalp. It was first recognized by David Gruby in 1844. Isolates are characterized as the "–" or negative mating type of the ''Arthroderm ...
'' and '' Trichophyton violaceum'', which are anthropophilic. Favus: Causes crusting on the surface of the skin, combined with hair loss.  Associated with '' Trichophyton schoenleini''.


Diagnosis

Tinea capitis may be difficult to distinguish from other skin diseases that cause scaling, such as
psoriasis Psoriasis is a long-lasting, noncontagious autoimmune disease An autoimmune disease is a condition arising from an abnormal immune response to a functioning body part. There are at least 80 types of autoimmune diseases. Nearly any body part c ...

psoriasis
and
seborrhoeic dermatitis Seborrhoeic dermatitis, sometimes inaccurately referred to as seborrhoea, is a long-term skin disorder. Symptoms include red, scaly, greasy, itchy, and inflamed skin. Areas of the skin rich in sebum, oil-producing glands are often affected includi ...

seborrhoeic dermatitis
; the basis for the diagnosis is positive microscopic examination and microbial culture of epilated hairs.
Wood's lamp A blacklight (or often black light), also referred to as a UV-A light, Wood's lamp, or ultraviolet light, is a lamp that emits long-wave (UV-A Ultraviolet (UV) is a form of electromagnetic radiation In physics Physics (from ...
examination will reveal bright green to yellow-green fluorescence of hairs infected by ''M. canis'', ''M. audouinii'', ''M. rivalieri'', and ''M. ferrugineum'' and a dull green or blue-white color of hairs infected by ''T. schoenleinii''. Individuals with ''M. canis'' infection
trichoscopy Trichoscopy is a method of hair and scalp evaluation and is used for diagnosing hair and scalp diseases. The method is based on dermoscopy. In trichoscopy hair and scalp structures may be visualized at many-fold magnification. Currently magnificat ...
will show characteristic small comma hairs. Histopathology of scalp biopsy shows fungi sparsely distributed in the stratum corneum and hyphae extending down the hair follicle, placed on the surface of the hair shaft. These findings are occasionally associated with inflammatory tissue reaction in the local tissue.


Treatment

The treatment of choice by dermatologists is a safe and inexpensive oral medication,
griseofulvin Griseofulvin is an antifungal medication used to treat a number of types of dermatophytoses (ringworm). This includes fungal infections of the nails and scalp, as well as the skin when antifungal creams have not worked. It is taken by mouth. Co ...

griseofulvin
, a secondary metabolite of the fungus ''Penicillium griseofulvin''. This compound is ''fungistatic'' (inhibiting the growth or reproduction of fungi) and works by affecting the system of fungi, interfering with the
mitotic spindle In cell biology Cell biology (also cellular biology or cytology) is a branch of biology Biology is the natural science that studies life and living organisms, including their anatomy, physical structure, Biochemistry, chemical processes ...
and cytoplasmic
microtubules Microtubules are polymer A polymer (; Greek ''poly- Poly, from the Greek :wikt:πολύς, πολύς meaning "many" or "much", may refer to: Businesses * China Poly Group Corporation, a Chinese business group, and its subsidiaries: ** Po ...

microtubules
. The recommended pediatric dosage is 10 mg/kg/day for 6–8 weeks, although this may be increased to 20 mg/kg/d for those infected by ''T. tonsurans'', or those who fail to respond to the initial 6 weeks of treatment. Unlike other fungal skin infections that may be treated with
topical A topical medication is a medication that is applied to a particular place on or in the body. Most often topical administration means application to body surface area, body surfaces such as the human skin, skin or mucous membranes to treat ail ...
therapies like creams applied directly to the afflicted area, griseofulvin must be taken orally to be effective; this allows the drug to penetrate the hair shaft where the fungus lives. The effective therapy rate of this treatment is generally high, in the range of 88–100%. Other oral antifungal treatments for tinea capitis also frequently reported in the literature include
terbinafine Terbinafine, sold under the brand name Lamisil among others, is an antifungal medication used to treat pityriasis versicolor, onychomycosis, fungal nail infections, and ringworm including jock itch and athlete's foot. It is either oral administra ...

terbinafine
,
itraconazole Itraconazole, sometimes abbreviated ITZ, is an antifungal medication An antifungal medication, also known as an antimycotic medication, is a pharmaceutical A medication (also referred to as medicine, pharmaceutical drug, medicinal drug o ...

itraconazole
, and
fluconazole Fluconazole is an antifungal medication An antifungal medication, also known as an antimycotic medication, is a pharmaceutical A medication (also referred to as medicine, pharmaceutical drug, medicinal drug or simply drug) is a drug ...

fluconazole
; these drugs have the advantage of shorter treatment durations than griseofulvin. A 2016 meta-analysis of randomized controlled trials found that terbinafine, itraconazole and fluconazole were at least equally effective as griseofulvin for children infected with ''Trichophyton'', and terbinafine is more effective than griseofulvin for children with ''T. tonsurans'' infection''.'' However, concerns have been raised about the possibility of rare side effects like
liver toxicity Hepatotoxicity (from ''hepatic toxicity'') implies chemical-driven liver The liver is an organ Organ may refer to: Biology * Organ (anatomy) An organ is a group of Tissue (biology), tissues with similar functions. Plant life and anima ...
or interactions with other drugs; furthermore, the newer drug treatments tend to be more expensive than griseofulvin. On September 28, 2007, the U.S.
Food and Drug Administration The United States The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country Continental United States, primarily located in North America. It consists of 50 U.S. state, st ...
stated that
Lamisil Terbinafine, sold under the brand name Lamisil among others, is an antifungal medication used to treat pityriasis versicolor, onychomycosis, fungal nail infections, and ringworm including jock itch and athlete's foot. It is either oral administrat ...
(Terbinafine hydrochloride, by Novartis AG) is a new therapy, treatment approved for use by children aged 4 years and older. The Antifungal medication, antifungal :wikt:granule, granules can be sprinkled on a child's food to treat the infection. Lamisil carries hepatotoxic risk, and can cause a metallic taste in the mouth.


Epidemiology

Tinea capitis caused by species of ''
Microsporum ''Microsporum'' is a genus Genus (plural genera) is a taxonomic rank Taxonomy (general) is the practice and science of classification of things or concepts, including the principles that underlie such classification. The term may also refe ...
'' and ''
Trichophyton ''Trichophyton'' is a genus Genus /ˈdʒiː.nəs/ (plural genera /ˈdʒen.ər.ə/) is a taxonomic rank In biological classification In biology, taxonomy () is the scientific study of naming, defining (Circumscription (taxonomy), ci ...
'' is a contagious disease that is endemism, endemic in many countries. Affecting primarily pre- children between 6 and 10 years, it is more common in males than females; rarely does the disease persist past age sixteen. Because spread is thought to occur through direct contact with afflicted individuals, large outbreaks have been known to occur in schools and other places where children are in close quarters; however, indirect spread through contamination with infected objects (''fomites'') may also be a factor in the spread of infection. In the US, tinea capitis is thought to occur in 3-8% of the pediatric population; up to one-third of households with contact with an infected person may harbor the disease without showing any symptoms.Richardson, pp. 83–84. The fungal species responsible for causing tinea capitis vary according to the geographical region, and may also change over time. For example, '' Microsporum audouinii'' was the predominant etiological agent in North America and Europe until the 1950s, but now ''
Trichophyton tonsurans ''Trichophyton tonsurans'' is a fungus in the family Arthrodermataceae that causes ringworm infection of the scalp. It was first recognized by David Gruby in 1844. Isolates are characterized as the "–" or negative mating type of the ''Arthroderm ...
'' is more common in the US, and becoming more common in Europe and the United Kingdom. This shift is thought to be due to the widespread use of griseofulvin, which is more effective against ''M. audounii'' than ''T. tonsurans''; also, changes in immigration patterns and increases in international travel have likely spread ''T. tonsurans'' to new areas.Richardson, p. 84. Another fungal species that has increased in prevalence is '' Trichophyton violaceum'', especially in urban populations of the United Kingdom and Europe.


See also

* List of cutaneous conditions * Ringworm affair


Footnotes


References

*


External links

{{DEFAULTSORT:Tinea Capitis Animal fungal diseases Mycosis-related cutaneous conditions Hair diseases Scalp