Updated: 2/9/2020

Tinea Capitis

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Snapshot
  • Tinea CapitisA 10-year-old previously healthy African-American boy presents to the office with 2 weeks of a pruritic scalp. His mother reports that he has had patchy hair loss, and his two younger brothers have had mild scalp itchiness. She cuts all of their hair with the same hair trimmer. On exam, he has three scaly and circular patches about 3 cm in diameter, as well as alopecia and black dots in the areas of hair loss. He also has diffuse and shotty cervical lymphadenopathy.
Introduction
  • Clinical definition
    • superficial fungal skin infection of the scalp
  • Epidemiology
    • incidence
      • common
    • demographics
      • most common in pre-pubertal boys
      • more common in African-Americans
    • location
      • on the scalp ("capitis" = "head")
  • Etiology
    • infectious agents are fungi called dermatophytes, including
      • Trichophyton
      • Microsporum
    • acquired through direct contact with the fungus
      • e.g., shared combs and hats
      • athletes with head-to-head contact (wrestling)
  • Prognosis
    • excellent since most cases resolve with treatment
Presentation
  • Symptoms
    • pruritic scalp with patchy hair loss
  • Physical exam
    • single or multiple scaly patches on the scalp
    • alopecia with small black dots from broken-off hairs
    • cervical lymphadenopathy
    • less common
      • kerion
        • inflammatory plaque with drainage and crusting
      • favus
        • perifollicular erythema progresses to yellow cupping
Studies
  • Labs
    • potassium hydroxide (KOH) prep
      • will show fungal elemants inside or surrounding hair
    • Wood lamp with ultraviolet light
      • if hair fluoresces
        • Microsporum spp. is the cause   
      • if hair does not fluoresce 
        • probable cause is Trichophyton spp.
  • Culture
    • can be done for definitive diagnosis
  • Diagnostic criteria
    • most commonly diagnosed based on physical findings
Differential
  • Alopecia areata
    • autoimmune form of hair loss
    • presents with patchy alopecia with black dots without scaling
  • Seborrheic dermatitis
    • presents with diffuse scaling on the scalp with erythema and pruritis
  • Psoriasis
    • presents with scaly, erythematous plaques that are well-demarcated
Treatment
  • Conservative
    • management of close contacts
      • indication
        • when multiple children are in the home
      • treatments
        • use of antifungal shampoo by all house members
        • avoid sharing and clean hair clippers, combs, and hats
  • Medical
    • oral antifungals
      • indication
        • when diagnosis is made by physical exam before culture results are available
        • must be given for tinea capitis or kerions as topical therapy alone is insufficient
      • medications 
        • griseofulvin 
        • terbinafine
        • less common
          • azoles (fluconazole and itraconazole)
Complications
  • May progress to kerion or favus
 

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Questions (6)
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(M2.DM.17.4732) A mother arrives to your clinic with her 5-year-old son afraid that he caught lice from a recent preschool outbreak. She reports that for the past week the son has had, “white flakes,” in his hair despite daily baths. The patient denies pain, but reports that his scalp is itchy at night. The patient has also developed a small area of hair loss which the mother feels is related to the patient scratching. The patient has no significant past medical history, but did have "cradle cap" when he was an infant. Family medical history is significant for eczema and asthma in the mother. Upon further questioning, the mother reports that the family got a new cat two months ago and that her other daughter has also been experiencing similar symptoms. On examination, the patient's scalp has a 1 cm scaly patch, with evidence of excoriation and an overlying yellow crust. There is a central area of alopecia. A skin scraping is performed. The results are shown in Figure A. Which of the following is the appropriate course of treatment? Tested Concept

QID: 108613
FIGURES:
1

Oral itraconazole

32%

(19/59)

2

Selenium sulfide 2.5% shampoo

25%

(15/59)

3

Topical corticosteroids

2%

(1/59)

4

Topical terbinafine

31%

(18/59)

5

Pyrethrin 5% shampoo

10%

(6/59)

M 7 D

Select Answer to see Preferred Response

(M2.DM.17.4732) A 21-year-old female is being evaluated for worsening "flaky scalp." She does not remember exactly when it started, but reports it has been at least a couple months. Her symptoms then developed into a scaling patch at the top of her head. She has begun ritualistically and repetitively combing her to the left 3 times every time she feels any "flakes." The patient reports that in the past she chemically treated her hair, but stopped when she noticed the scalp scaling had developed into an area of balding. She admits to feeling tired lately and gained 5 lbs in the last 2 months, but admits she has been staying up late to study for exams. The patient's past medical history is significant for bipolar I disorder, for which she takes lithium, and acne, for which she uses topical salicylic acid. The patient reports fatigue, but denies headache, shortness of breath, chest pain, polyuria, hematuria, or other rashes. Vital signs include a temperature of 99°F (37°C), blood pressure of 122/76 mmHg, a pulse of 88/min, and an oxygen saturation of 99% on room air. Physical exam is negative except for scalp findings shown in Figure A. Routine lab values are drawn, including:

Leukocyte count: 9,500/mm^3
Platelet count: 200,000/mm^3
Hemoglobin: 14.5 g/dL

Serum:
Na+: 144 mEq/L
K+: 4.3 mEq/L
Cl-: 85 mEq/L
HCO3-: 22 mEq/L
BUN: 11 mg/dL
Creatinine: 1.2 mg/dL
Serum osmolality: 295 mOsmol/kg H2O
Urine osmolality: 320 mOsmol/kg H2O

Which of the following is the best initial diagnostic test?
Tested Concept

QID: 108616
FIGURES:
1

Skin biopsy

0%

(0/22)

2

Psychiatric assessment for obsessions and compulsions

36%

(8/22)

3

KOH preparation of scale scraping

55%

(12/22)

4

Wood's lamp

9%

(2/22)

5

Skin patch test

0%

(0/22)

M 6 D

Select Answer to see Preferred Response

(M2.DM.17.4733) A 28-year-old homeless male with a past medical history significant for asthma comes to your clinic complaining of a chronic rash on his scalp and feet. He describes the rash as “dry and flaky,” and reports it has been present for at least a year. He was using a new dandruff shampoo he got over the counter, with little improvement. The patient reports it is extremely itchy at night, to the point that he can't sleep. On exam, you note a scaly patch of alopecia, enlarged lymph glands along the posterior aspect of his neck, and fine scaling in between his toes and on the heel and sides of his foot. His temperature is 99°F (37°C), blood pressure is 118/78 mmHg, and pulse is 81/min. Which of the following is the most accurate test for the suspected diagnosis? Tested Concept

QID: 108615
1

Wood's lamp

10%

(4/40)

2

Culture in Sabouraud liquid medium

15%

(6/40)

3

KOH preparation of scalp scraping

55%

(22/40)

4

CBC and total serum IgE

2%

(1/40)

5

Microscopic visualization of skin scraping

15%

(6/40)

M 6 D

Select Answer to see Preferred Response

(M3.DM.16.15) A 4-year-old girl is brought to the pediatrician by her mother because she is concerned that her child is balding. The mother states that she has been scratching at her head and that her daughter complains that it is itchy. An image of the child's scalp is shown in Figure A. Wood's UV lamp examination causes the hair to fluoresce bright green. What is the most likely organism responsible for the patient's condition? Tested Concept

QID: 102956
FIGURES:
1

Malassezia furfur

0%

(0/10)

2

Trichophyton tonsurans

80%

(8/10)

3

Trypanosoma cruzi

0%

(0/10)

4

Toxocara canis

0%

(0/10)

5

Microsporum canis

20%

(2/10)

M 10 E

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