JournalofSymptomsandSigns

2014;Volume3,Number5

Expert Opinion

Tinea capitis in adults

Laura Atzori, Nicola Aste, Monica Pau
Dermatology Clinic, Department of Medical Science M.Aresu, University of Cagliari, Italy.

Abstract
Background Tinea capitis is a rare infections occurring in adults, as after puberty the fungistatic sebum activity and the thicker hair caliber protect
from scalp dermatophytes colonization. Several predisposing factors have been suggested, mainly hormonal variations in menopausal women and
immunosuppression, especially HIV related. Besides, a recent alarming increase has been reported in young immunocompetent adult, due to more
resistant dermatophytes strains, able to survive and parasites the post-pubertal scalp, such as Trycophyton tonsurans. Changes in epidemiology due
to globalization and migration fluxes favor the diffusion of African and Caribbean species in the Western countries.
Methods Critical revision on current knowledge and published literature.
Results Clinical presentation is usually atypical in adults tinea capitis, mimicking any scalp dermatitis, from mild to severe inflammatory conditions,
with ill-defined hairloss patches, normal appearing hairs mixed with black dots or irregularly broken hairs, variable scaling and pustules. More severe
cases have scarring and atrophic evolution, simulating decalvans folliculitis, dissecting cellulitis. Responsible dermatophytes are the same of childrens
tinea capitis. Contagion from asymptomatic dermatophyte carriers or tinea capitis affected children in the household should be considered. Agropastoral environment and close contact with domestic animals might be relevant in some patients.
Conclusions Medical awareness of this rare entity is mandatory to avoid diagnostic delay, unnecessary investigations and possible inappropriate
treatment. Mycological samples should be sent to reference laboratory whenever a patchy hair loss occurs in adults, especially when previous treatment for common dermatitis have been disappointing.
Keywords: adults tinea capitis; scalp ringworm; dermatophyte infections; tinea capitis in adults; scalp infections.
Received: March 21, 2014; Accepted: May 29, 2014; Published: December 16, 2014
Corresponding Author: Laura Atzori, Clinica Dermatologica, Via Ospedale 54, 09124, Cagliari, Italy.
E-mail: [email protected].

Introduction
Tinea capitis (TC) or scalp ringworm of the AngloSaxon literature is a common and worldwide distributed dermatophyte infection, which is mostly age related,
being characteristic of pre-pubertal children and extremely rare in adults [115]. The reported frequency of

tinea capitis in immunocompetent adults range from < 1%

to up 5% [1015]. Disease duration at time of diagnosis
varies from 1 week to 5 years [613], and the delay
increases in older patients and very severe cases [5, 6].
Women are preferentially affected in all case series
(from 66% to 94%), and post-menopausal condition is

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common, but age varies greatly (from 17 to 76 yearold), with not conclusive average esteem [6, 7, 13]. The
TC epidemiological profile differs from country to
country, and among different geographical areas in the
same country, being conditioned from climate and natural dermatophytes selection along centuries [15, 16].
Adults tinea capitis was mainly reported in Italy,
France, Tunisia, Greece, China and Taiwan [37, 11
15]. Besides, last few decades migration fluxes, especially from Africa to Western countries, have diffused
worldwide very resistant strains, able to survive on the
adult scalp. Especially Tricophyton tonsurans has been
increasingly reported in the United Kingdom, United
States, Brazil [710, 16]. Alerting physician and performing more mycological examinations should avoid
under-estimation of the disease, especially in those patients with long-standing mild scaling dermatitis of the
scalp, not responding to current medications. Misdiagnosis and inappropriate treatment prolong illness and
might induce more inflammatory patterns, with pustules and erosive features, eventually causing scarring
alopecia.

Ethiology and Transmission

The epidemiology of adults TC reflects childrens disease, with isolates over the years variations due to increased sanitation, and personal hygiene, but also environmental changes, especially after antifungals introduction. M.audouini and T.schoenleinii infections have
disappeared worldwide after the advent of griseofulvin.
Actually, the majority of adults TC series report prevalence of Tricophyton (T) species, followed by Microsporum canis [1, 715]. Our personal experience support a major role of M.canis [6], but the datum simply
reflects the predominance (82%) of this dermatophyte
as cause of tinea capitis in Sardinian children [18], a
major island of the Mediterranean Basin. Isolation,
warm climate and an ancient agro-pastoral tradition
might be responsible of such peculiar epidemiology,
which is also consistent with the frequent isolation of
other zoophile strains on our adults, T.mentagrophytes
and T.verrucosum [6]. Close contacts with domestic
animals, especially kittens, but also dog, rabbit, cows
have been documented in our cases. T.violaceum has
become exceptional in Sardinia, while it remains
among the most frequent isolates in Tunisia, Taiwan,
China, South Africa, Eastern Europe [2, 1215, 17].

Tricophyton tonsurans, which has strong phenotype

and genotype similarity to T. violaceum [19], has been
responsible of a dramatic TC increase in UK and USA
[7-10, 17], affecting primarily children and then young
African and Caribbean adults. The control of this peculiar strain contagion is difficult, as fomites resists on
various material surfaces for extensive periods of time
[10]. Contact with shed hairs, brushes, personal items,
dolls, but also class-room surfaces and rent car have
been implicating in the soaring American incidence.
Despite that, inter-human transmission remains the
principle source of infection in adults, taking cares of
affected children or living in shelter with children [10].
A familial history of TC is reported in 10% of Tunisian
cases [15]. Contagion from affected children is also
relevant in Microsporum canis infection, because contacts with pets is less frequent in adults, while the nursing and child assistant role is common, especially for
grandparents. Asymptomatic carriers have been reported among adults taking cares of tinea capitis affected
children [2023], and the condition is probably more
diffused than expected. Concomitant tinea corporis [6]
and/or autoinoculation from pre-existing onychomycosis have been reported [19].
Dermatophytes are direct human pathogen, having
adapted to subside on keratin degradation, but to parasites the adults scalp there must be some predisposing
conditions, usually being the host defenses very effective.

Protective Factors
The pubertal increase in sebum secretion, rich of fungistatic saturated fatty acids is a main factor protecting
the scalp from dermatophytes parasitism [24]. Some
Trycophyton species might be less sensitive, being able
to perforate the hair external sheet (endothrix parasitism), and safely shelter from sebum cap. Malassezia
spp competitive colonization of the scalp might interfere with dermatophytes growth, while another natural
barrier to fungal invasion is the increased caliber and
thickness of adults hairs [12].

Favoring Factors
The majority of adults affected with tinea capitis are
postmenopausal women, ranging from 20% to 7590%
of the reported cases [315]. Sebaceous glands involu-

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tion parallel the decreased estrogen levels, and various

degree alterations of hormonal patterns were documented in a previous experience of our Institute [6].
Other factors influencing transmission in adults are
overcrowding, low socioeconomic status, and underlying conditions such as anemia, and diabetes [15]. Another major risk factor is immune suppression, which
may be due to HIV infection [19, 25, 26], but also secondary to drug administration, as in renal transplant
recipients [27], and in advanced breast cancer under
trastuzumab treatment [28]. Systemic administration of
corticosteroids for autoimmune diseases has been reported [15].
Hair care practices might favor dermatophytes infection: less shampooing, typical of dry hairs in menopausal woman and any age African Americans [10], might
reduce removal of spores, while styling (dyeing, perm,
traction) might impair hair shaft integrity [29].

herent scaling on a more erythematous base might simulate psoriasis, chronic lupus erythematosus, and lichen
planus, especially when minimal atrophic and scarring
changes appears. Pustular infections require differentiation from bacterial folliculitis, decalvans folliculitis,
and dissecting cellulitis [34].

Diagnosis
Examination of the hair and skin scraping after 1020%
potassium hydroxide (KOH) clarification is the simplest and rapid diagnostic tool, showing hyaline fungal
hyphae and arthrospores on hair root and scales. The
type of hair shaft invasion under the microscope (Figure 4) is suggestive of the causative dermatophytes
specie:

Clinical Manifestations
Adults might present with sharply circumscribed patchy
tinea capitis (Figure 1), but more often the features are
atypical (tinea atypica), simulating more common affections [30]. Pruritus and hairloss are the main patients
complaints, leading to several visits and sometimes
inconclusive treatment, before the infection is sought.
Clinical examination often reveals ill-defined hair loss
areas, with mixed truncated and normal appearing hairs
(Figure 1), variable seborrhea and scaling (Figure 2)
and isolate inflammatory lesions, from pustules to nodules. Black-dots features are frequently reported in
T.Tonsurans infection, but lacking in other cases.
Franck kerion celsi is extremely rare in adult [3133],
but severe, with very painful pustules and nodules
(Figure 3), tending to patches coalescence, discharging
pus mixed with hairs follicle debris, and a risk of scarring alopecia.
Very inflammatory infections might depends on the
type of dermatophytes, being zoophile species more
aggressive, but evolution from a misdiagnosed tinea
capitis treated with incongruous topical medication is
another possibility.
Polymorphic presentation leads to diagnostic delay,
mimicking more common scalp pathologies. Minimal
to mild inflammatory infections are confused with seborrheic dermatitis, alopecia areata, trichotillomania,
psoriasis, secondary syphilis. Diffuse or stratified ad-

A- Ectothrix infection: hyphae and arthroconidia

cover the outside of the hair shaft, with cuticle destruction, but remaining confined to the hair surface. This kind of parasitism is characteristic of
Microsporum Canis, but also T.verrucosum might
be involved.
B- Endothrix parasitism: the hairs shaft is filled
with hyphae ans arthroconida, like a walnuts bag.
The main responsible fungi are T.violaceum and
T.tonsurans, which are able to internalize into the
hair cell.

Samples culture on Sabouraud media is necessary to

further identify the isolates by colonies and conidia
morphology, but require expertise and shipment to reference laboratory is advisable. The use of colorimetric
media (Dermatophyte Test Medium; DTM) might be
easy to read in a general office, and have the advantage
of room temperature storage, but it is quite expensive.
Woods lamp examination might be useful in M.canis
infections (characteristic green fluorescence). False
negative results in T.tonsurans infection have been postulated to cause a certain diagnostic delay and have
favored the recent epidemics in American children and
young women [10].
Very unusual and severe cases might require a scalp
biopsy and histological examination to exclude major
diseases or super-infections [34]. It is important to advise the pathologist of the clinical suspect, to perform
periodic acid-Schiff (PAS) or other additional stains.

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pitis

Figgure 1. Examples of typical annular pseudo-alopecic patchess of tinea capitiss in adults

Several examples of adults tinea capitis with iill-defined hair loss areas, mixeed truncated annd normal appeaaring hairs, variaFigure 2. S
ble scalingg and seborrhoeeic crusting.

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pitis

Figure 3. Examples
E
of moore extensive innvolvement, mim
micking female androgenetic alopecia
a
and/or psoriasis and eeventual evolution
to very inflaammatory infecctions, from locaalized kerion to generalized eroosive and pustular dermatitis.

Dermatophyte tyypes of hair parrasitism under tthe microscope:: native hair preeparations after 20% KOH clarification (MagniffiFigure 4. D
cation: uppper 10 and boottom 40 )

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Tinea capitis

Therapy and Evolution

A recent meta-analysis comparing tinea capitis golden
standard griseofulvin with terbinafine has confirmed
species-specific differences in treatment efficacy [35],
with griseofulvin superiority in Microsporum spp. infections, and terbinafine advantage for Trichophyton
spp. infection. Giseofulvin suggested dosage in adults
tinea capitis is 2025 mg/kg/d for 68 weeks [6, 15].
Considering that the majority of adults TC are caused
by Trichophyton strains, terbinafine 250 mg/d is a good
option, showing a good sebum and hairs penetration,
and higher compliance towards griseofulvin in adults
[35]. Besides, HIV patients might not respond or develop adverse reactions to both griseofulvin and terbinafine [19, 36]. Itraconazole 400 mg/d prolonged treatment (16 months) was effective in 2 very problematic
HIV patients [19].
Topical treatment with one of the many different
antifungal (imidazole, allylamine, ciclopirox olamine)
is also very important, because patches are less defined
in respect to children, and real extension of the infection is difficult to be evaluated. Relapses are more frequent than in children, especially in HIV patients [19].
Bacterial super-infection and scary alopecia are main
possible complications.

Conclusion
Dermathophytes have survived along millennia for their
ability to many different conditions adaptation, from
soil dependency to animals and finally humans. Natural
selection actually favours species able to hide itself,
simulating more common dermatologic conditions, thus
maintaining illness along times. Adults tinea capitis is
a rare condition, but a rising incidence has been reported worldwide and it is likely to further escalate, considering the migration fluxes of globalization, and diffusion of very resistant strains, such as T. Tonsurans.
Asymptomatic carriers are probably more frequent than
believed, and might sustain environmental diffusion.
Physicians should be regularly trained to recognised
minimal signs and suspect dermatophytes scalp infections, especially when dealing with erythematous scaling dermatitis, and irregular patches hairloss, present
for long periods of time and when previous therapies
have proved to be ineffective. Misdiagnosis and incongruous therapy further prolong illness, favour progres-

sion to severe inflammatory pustular and erosive forms,

with the risk of scary alopecia, which might be overcome through a higher use of mycological tests.

Disclosure
There are no conflicts of interest.

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