February 1997
 --- Tinea faciale, or ringworm of the face, is distinguished by ring-shaped lesions. |
NEW YORK — The incidence of tinea capitis has dramatically increased in the last decade, according to Sheila Fallon-Friedlander, MD, Children's Hospital and Health Center, San Diego. "Tinea capitis is increasing in epidemic proportions. A shifting epidemiology is occurring. The pathogen is changing and an epidemic rise in incidence is occurring, especially among large inner-city populations," she said at the Ninth Annual Infectious Diseases in Children Symposium. This increased incidence is reflected in the increased number of prescriptions for griseofulvin, which is used as first-line therapy of t. capitis, she said. Fallon-Friedlander noted a study that detected the rise in California, where prescription rates between 1984 and 1993 increased 84% for all children, and 209% for black children. |
 --- Lipid-like leukocyte activators attract neutrophils, causing inflammation and redness. |
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Several factors play a role in the increasing incidence of tinea, Fallon-Friedlander said. A high rate of asymptomatic carrier state and more resistant pathogens may each contribute to the increase of cases, as well as increased attendance at day-care centers "where heads are close together," she said. Grooming practices, which are still being studied in the black population, are also a potential factor. Tight braiding, the use of greases and pomades and infrequent shampooing are all believed to increase the risk of tinea infection. In addition, infected fomites can survive for prolonged periods on hats and combs which children will often share in the school or at home. Tinea capitis may present with significant hair loss, inflammation and scaling. However, patients occasionally may have only mild scaling which may be mistaken for dandruff, making the diagnosis more difficult. Short hairs with a black dot appearance may be present, evidence of broken hair which has been invaded by the organism. Kerions or nodular boggy masses can also result from fungal infection of the scalp. The severe inflammation noted in these lesions is thought to be a result of hypersensitivity of the patient rather than an increased fungal burden. Approximately 30% of children with fungal infections will develop an autoeczematization or "id reaction." This diffuse red, papular, itchy eruption may develop immediately after instituting anti-fungal therapy, often leading to the erroneous conclusion that the patient has an allergy to the medication used. |
 --- Symptoms of tinea capitis include dandruff and patchy hair loss with black dots, a sign that the organism has invaded the broken hair shaft. |
 --- A wet cotton swab is very effective method used for culturing t. capitis. |
Patients suspected of having t. capitis should be cultured simply with a wet cotton swab, Fallon-Friedlander said. Swab a large area of the scalp and then rub the swab on either DTM, Mycosel or Sabouraud's medium. Positive results can be read within one to two weeks time.
Diagnosis may also include examining the entire family. If a case persists, the problem may be other family members who need treatment. Studies show that of family members of t. capitis patients, 25% to 48% will have spores or will culture positive, she said.
Griseofulvin is still the primary treatment for t. capitis. Used since 1958, it has a good safety profile, and is relatively inexpensive. Griseofulvin is also easy to use in children because it is best administered with fatty foods like ice cream.
"I call this the gold standard," she said. "There are some theoretical problems with this drug, but in reality they rarely occur."
It is now recommended to begin using at least 15 mg/kg/day of a micro size form of the drug. "Obviously if my patients do not improve within two to four weeks time, I will increase the dose to 20 or 25 mg/kg/day as required. It is thought that a relatively resistant form of tinea now exists but laboratory studies are have yet to clearly confirm this issue," Fallon-Friedlander said.
Other efficacious drugs for t. capitis include fluconazole (Diflucan, Pfizer), itraconazole (Sporanox, Janssen) and terbinafine (Lamisil, Sandoz). Fluconazole is approved by the Food and Drug Administration (FDA) for candidal infections in children older than 6 months, has a good safety profile and is available as a suspension. Itraconazole has broad antifungal activity and will probably be seen more in the future, Fallon-Friedlander predicted, but is currently not FDA approved for treating t. capitis.
Terbinafine is also an antifungal, but is not available as a suspension. It is currently not FDA-indicated for children.
Infections of skin and scalp are common among children. It's estimated that 7% to 15% of pediatric disorders seen in clinics are related to fungal infections, Fallon-Friedlander said.
The two major categories seen most often include yeast infections from Candida common in infants, and dermatophyte infections, usually manifested as t. capitis and common in early childhood. Distinction between the types of categories is important because treatments are often different.
Oral fluconazole can be used for severe mucocutaneous candidiasis if traditional treatment fails. If fluconazole doesn't work, consider another diagnosis, she suggested.
Another new discovery relating to fungal infections is that of "lipid-like leukocyte activators." These serve to attract neutrophils to infected areas, causing significant and sometimes severe inflammation and a beefy redness often seen in candida infections. The erythema can be treated — cautiously — with an anti-inflammatory agent like a topical steroid, for a short time, she said.
Steroid therapy is appropriate with anti-fungal therapy when treating Candida in early stages, but only for a short time. Topical steroids are useful for treating Candida with an underlying condition like seborrheic dermatitis, irritant dermatitis and eczema.
"Often Candida will set up house in skin that's been damaged or traumatized," she said. It is important that the patient first be educated about the use of steroids, she added.
For more information:
- Fallon-Friedlander S. Update on fungal infections in children. Presented at the Ninth Annual Infectious Diseases in Children Symposium. Nov. 24, 1996. New York.
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