Common causes of paediatric alopecia

BACKGROUND: Hair loss in children aged 12 years and younger is most often due to a benign or self-limiting condition. This article presents a review of the assessment of common causes of paediatric alopecia and outlines the implications for general practice. OBJECTIVE: The objective of this article is to help readers systematically assess a child presenting with alopecia, manage the most common diseases of paediatric alopecia and identify patients requiring referral to a dermatologist. DISCUSSION: The most common causes of paediatric alopecia are largely non-scarring. These include tinea capitis, alopecia areata, trauma due to traction alopecia or trichotillomania, and telogen effluvium. Scarring alopecia can also occur in childhood and requires scalp biopsy and further investigation by a dermatologist. General practitioners should treat clear cases of tinea capitis. Referral to a dermatologist is necessary in cases when the diagnosis is uncertain, treatment is failing or there is evidence of scarring alopecia.

Analysis of trichoscopic signs observed in 24 patients presenting tinea capitis: Hypotheses based on physiopathology and proposed new classification.

INTRODUCTION: Trichoscopy (hair dermoscopy) is a non-invasive and very useful technique for the diagnosis and follow-up of hair and scalp disorders. In tinea capitis, specific aspects of the hair shaft have been described, with the main ones being: comma hair, corkscrew hair, bar code-like hair (BCH) and zigzag hair (ZZH). METHOD: Herein we report on a retrospective study of 24 patients with tinea capitis (TC). All patients underwent trichoscopic examination and mycological culture. RESULTS: Trichoscopy was abnormal in all 24 patients showing hair-shaft abnormalities. We observed three types of images depending on the nature and the mechanism of infection and discuss the different trichoscopic aspects of the hair shaft (comma hair, corkscrew hair, bar code-like hair, zigzag hair, broken hair and black dots) resulting from 3 mechanisms of penetration of the fungus in the hair shaft (endothrix, ectothrix and ectothrix-endothrix). All patients had positive mycological cultures: 15 with trichophytic TC (8 with Trichophyton tonsurans, 5 with T. soudanense and 2 with T. verrucosum) and 9 microsporic TC (7 with Microsporum audouini, and 2 with M. canis). DISCUSSION: We propose for the first time, to our knowledge, a classification of trichoscopic signs of TC. This classification will enable rapid diagnosis and prediction of the nature of the fungus before mycological culture. CONCLUSION: Our study shows the importance of trichoscopy in the diagnosis and monitoring of TC as well as its very good correlation with mycological culture. We propose a new classification of trichoscopic signs dependent on the nature of the mycological agent and the mechanism of infection. Further prospective studies with more patients are needed to confirm this classification.

[Role of cytokine secretion of human keratinocytes in dermatophytosis].

The clinical presentation of dermatophytosis depends on species of the infecting fungus. The infections caused by the anthropophilic species tend to be chronic and intractable, and the resultant inflammation is minimal. On the other hand, the infections caused by the geophilic and zoophilic species tend to be self-healing, and the resultant inflammation is more severe. We investigated the role of cytokine secretion of human keratinocyte during dermatophyte infections: Arthroderma benhamiae, a zoophilic dermatophyte, and Trichophyton tonsurans, an anthropophilic dermatophyte. The results demonstrate that keratinocytes secrete a broad spectrum of cytokines including proinflammatory cytokines, chemokines, and immunomodulatory cytokines in response to A. benhamiae infection, whereas T.tonsurans infection stimulates the production of only a limited number of cytokines. Such differential cytokine secretion of the keratinocytes in response to infection by dermatophyte species may reflect the distinct inflammatory responses in the skin.

Trichophyton tonsurans-Ringworm in an NICU.

Ringworm is very rarely found in the neonate, especially infants who have been confined from birth to an intensive care unit. We report an infection with the dermatophyte Trichophyton tonsurans, the most common cause of tinea capitis in children but not yet described in a premature baby who has never left the nursery. Our case illustrates the need to consider this diagnosis among the causes of dermatitis in the newborn, especially in at-risk populations such as indigenous Australians. Though our infant's presentation was the classic "ring" shape, a literature review revealed varied presentations. In contrast to the usual need for long-term antifungal medication, our case responded rapidly to a topical azole preparation. Although we did not screen visiting family members, screening would have been appropriate, and those found positive might have benefited from at least antifungal shampoo.

Changes in frequency of agents of tinea capitis in school children from Western China suggest slow migration rates in dermatophytes.

Tinea capitis is a common dermatophyte infection of the scalp of children in Western China, with the gray-patch from being the most prevalent. Twenty years ago, the most widespread etiologic agent was reported to be Trichophyton violaceum, which was later succeeded by Microsporum ferrugineum and Trichophyton schoenleinii. In the framework of our recent study, 97 isolates were collected from patients with clinically suspected tinea capitis. Identification was performed by conventional methods and by sequencing the ribosomal DNA internal transcribed spacer region. In the case of T. violaceum an additional microsatellite primer set (T1) was used. Five species (in order of frequency, Trichophyton violaceum, T. schoenleinii, Microsporum ferrugineum, zoophilic strains of Arthroderma vanbreuseghemii, and Trichophyton tonsurans) were identified. Results of molecular and phenotypic ID of the same strains showed good correspondence. Comparison with earlier data showed that dermatophytes species in former rural societies must have migrated extremely slowly. Preponderance of local transmission from domesticated animals was proven by the occurrence of zoophilic strains of Arthroderma vanbreuseghemii. Etiologic agents in the rural communities of Western China tend to be different from those of the other regions in the country, despite modern communication and traffic.

Examining Trichophyton tonsurans genotype and biochemical phenotype as determinants of disease severity in tinea capitis.

Trichophyton tonsurans infections occur in various host populations, on various body sites and with varying degrees of inflammation. This investigation was undertaken to determine whether fungal factors could explain the degree of severity in clinical symptomatology among infected children. Otherwise healthy children (n=54) presenting with tinea capitis were enrolled in this study. A thorough history was performed, the extent and severity of infection graded and a fungal specimen collected from each child. Strain type was determined by genotyping for 11 sequence variations in the rDNA and ALP1 loci. Secreted protease activity was quantitated after 5 days of growth in aqueous medium. Forty participants were evaluable. Infection duration ranged from 1 day to 3 years and clinical severity score (CSS) from 4-19. Seventeen unique fungal genotypes were present. Keratinase, collagenase and elastase activity varied 32.7-fold, 64.9-fold and 303.3-fold, respectively. A significant association was observed between genotype and disease severity with the rDNA sequence variations accounting for over 50% of the variation observed in CSS (r2=0.539; P<0.001). Phylogenetic analyses appear to suggest that the ancestral strain types of T. tonsurans cause more severe disease. These observations are consistent with reports that recently diverge anthropophilies are associated with diminished inflammatory involvement.

Tinea capitis: ringworm of the scalp.

The guideline tinea capitis, as passed by three German medical societies, is presented in the present study.

Tiña inflamatoria de la cabeza / Inflammatory tinea capitis

La tiña de la cabeza es un cuadro infeccioso relativamente frecuente, con manifestaciones clínicas muy variadas, lo que conlleva que, en ocasiones, su diagnóstico se retrase. Presentamos el caso de una niña de 4 años con una tiña inflamatoria, de localización interparietal y de un mes de evolución, que fue diagnosticada y tratada previamente de abscesos múltiples de cuero cabelludo. El diagnóstico de tiña inflamatoria de la cabeza tipo querion de Celso y su confirmación mediante visión directa es fácil. si tenemos en cuenta este cuadro y los antecedentes epidemiológicos (contacto con animales entre otros). Es importante establecer un diagnóstico precoz para iniciar cuanto antes el tratamiento oportuno y así evitar una alopecia cicatricial residual inestética secundaria al proceso inflamatorio

Tinea capitis is a relatively common fungal infection with highly variable clinical manifestations, a circumstance that can delay its diagnosis. We present the case of a 4-year-old girl with an interparietal inflammatory lesion that had developed one month earlier. She had initially been diagnosed with and treated for multiple scalp abscesses. Inflammatory tinea capitis (kerion celsi) is frequently misdiagnosed; nevertheless, its diagnosis on the basis of direct visual inspection is easy when there is a high degree of suspicion and knowledge of the epidemiological background (prior contact with animals, among others). The microscopic examination and culture of samples obtained from the scalp are rapid and simple diagnostic procedures. Early diagnosis and prompt initiation of the proper treatment are essential to prevent scarring alopecia secondary to the inflammatory process

Fluconazole in the treatment of pediatric tinea capitis caused by Microsporum canis.

Fluconazole has been shown to be effective in the treatment of fungal scalp infections in children; however, there is limited experience of its use in Microsporum scalp infections. We studied 11 children with tinea capitis caused by Microsporum canis who received oral fluconazole at a dose of 5-7.5 mg/kg/day for 6 weeks. Mycological cure was observed in two of the 11 patients at week 4 from the start of therapy, in four patients at week 8 and in three patients at week 16. One of the remaining patients had positive mycology at week 8, but was unavailable for further evaluation. Fluconazole was effective in treating pediatric tinea capitis caused by Microsporum canis and was well tolerated. Clinical and mycological response was achieved in some patients weeks after the cessation of the administration of fluconazole.

Variación clínica e epidemiológica de dermatoficias zoófilas / Clinical and epidemiologic variability of zoophytical dermatophytosis

Las dermatoficias son micosis superficiales causadas por agentes geófilos,zoófilos o antropófilos.Las dermatoficias zoófilas representan el 25 por ciento de las tiñas de piel lampiña,mientras que en cuero cabelludo alcanzan el 90 por ciento.El germen aislado con mayor frecuencia es el Microporum canis,transmitido por perros y gatos.Desde la introducción del conejo como mascota doméstica en las ciudades,observamos la aparición de dermatoficias de carácter altamenente inflamatorio,trasmitidas por este animal.Se estudiaron,entre mayo y septiembre de 2000,28 pacientes con dermatoficias,secundarias al contacto directo o indirecto con conejos(25 pacientes pediátricos y 3 adultos)Cinco pacientes presentaron querion de Celso(uno de ellos de 55 días de vida)11 tinea facei y 12,combinaciones de tinea facei,corporis y capitis.Se realizó estudio micológico de todos los pacientes y de cinco conejos convivientes,aislandoses T mentagrophytes var.mentagrophytes.Destacamos la amplia variedad clínica y topográfica y la mayor intensidad inflamatoria de este agente,en relación con las dermatoficias zoófilas por M.canis,usuales hasta el momento

Variación clínica e epidemiológica de dermatoficias zoófilas / Clinical and epidemiologic variability of zoophytical dermatophytosis

Las dermatoficias son micosis superficiales causadas por agentes geófilos,zoófilos o antropófilos.Las dermatoficias zoófilas representan el 25 por ciento de las tiñas de piel lampiña,mientras que en cuero cabelludo alcanzan el 90 por ciento.El germen aislado con mayor frecuencia es el Microporum canis,transmitido por perros y gatos.Desde la introducción del conejo como mascota doméstica en las ciudades,observamos la aparición de dermatoficias de carácter altamenente inflamatorio,trasmitidas por este animal.Se estudiaron,entre mayo y septiembre de 2000,28 pacientes con dermatoficias,secundarias al contacto directo o indirecto con conejos(25 pacientes pediátricos y 3 adultos)Cinco pacientes presentaron querion de Celso(uno de ellos de 55 días de vida)11 tinea facei y 12,combinaciones de tinea facei,corporis y capitis.Se realizó estudio micológico de todos los pacientes y de cinco conejos convivientes,aislandoses T mentagrophytes var.mentagrophytes.Destacamos la amplia variedad clínica y topográfica y la mayor intensidad inflamatoria de este agente,en relación con las dermatoficias zoófilas por M.canis,usuales hasta el momento

Pediatric dermatology: that itchy scaly rash.

Primary care practitioners in the pediatric setting treat children for numerous skin complaints. The most frequently seen dermatologic conditions are those that are persistent and cause children discomfort, such as atopic, contact seborrheic dermatitis and tinea infections. Familiarity with the presentation, pathophysiology, and treatment of these common skin conditions enables the practitioner to successfully manage these rashes.

Relapsing tinea capitis by Microsporum canis in an adult female renal transplant recipient.

Scalp ringworm is very uncommon in adults. The occurrence and the atypical clinical course of this unusual dermatophytosis in a female renal transplant recipient are described. Furthermore, the prevalence and the clinical features of superficial fungal infection in renal transplant recipients are reviewed. As immunosuppression enhances the risk of antifungal therapy failure, more prolonged treatment and careful follow-up are necessary to obtain complete recovery from any dermatophytosis in renal transplant recipients.

Tinea caput medusa: an unusual presentation of Trichophyton mentagrophytes on the scalp.

Tinea capitis has a wide variety of clinical presentations in adolescents and adults. However, the occurrence of fingerlike projections in the scalp has not been previously described. A 14-year-old girl presented with a one-year history of a painful scalp mass. Debridement of this mass revealed slender papillomatous growths resembling those seen in elephantiasis nostras verrucosa. A fungal culture grew Trichophyton mentagrophytes. We describe the first case of this unusual clinical variant of tinea capitis and hypothesize on its pathophysiological basis.

Itraconazole in the treatment of tinea capitis.

Seventy-one patients with tinea capitis were treated with itraconazole (50 or 100 mg once daily) for a median period of six weeks in an open multicenter study. Many of the patients were children. Of those patients treated with itraconazole 100 mg, 93 percent showed a clinical response at the end of treatment. This increased to 94 percent two months later. The mycologic cure rate at the end of treatment was 57 percent. At the final visit this had increased to 89 percent. Patients taking 50 mg itraconazole also responded to treatment, but to a lesser degree: only 67 percent showed a clinical response at the final visit. The corresponding mycologic cure was 60 percent. Only one patient reported a side effect while taking itraconazole (papular eruption) and it is uncertain whether this was related to treatment. It was concluded that both treatment schedules were effective and safe for children with tinea capitis.

Tinea capitis.

Tinea capitis is dermatophytosis of the scalp hair follicles, generally producing inflammatory or noninflammatory alopecia. Infection occurs predominantly in prepubertal children older than 6 months, although infection can occur in all age groups. Tinea capitis is one of the most common infectious conditions in children, and it occurs worldwide.

International summit on cutaneous antifungal therapy, focus on tinea capitis, Boston, Massachusetts, November 11-13, 1994.

This article reports the highlights of presentations made at an international symposium held on November 11-13, 1994, in Boston, Massachusetts, on the subject of cutaneous antifungal therapy. Some of the key points pertaining to the epidemiology, etiology, pathogenesis, presentation, and management of tinea capitis are discussed.