Inflammatory Tinea capitis
study included all patients with clinical presentation of
and 38 female patients (31.4%) with a sex ratio (M ⁄ F)
inflammatory TC (suppurative and painful plaque asso-
ciated with purulent drainage), which confirmed by the
Our patients come from a rural region in 60 cases
mycological examination (direct examination and ⁄ or
(49. 59%), Tunis City in 42 cases (34.71%), and an
culture positive). Mycological investigation, including a
urban area surrounding Tunis city in 19 cases (15.7%).
direct microscopic mount and fungal culture, was
Patients were 8.09 ± 3.99 years middle-aged (med-
performed for every patient. Clinical materials (scales,
ian = 6 years), [range: 18 months to 63 years]. Four
hair) were examined microscopically (30% KOH solu-
cases (3.3%; three girls, one boy) were diagnosed in
tion). In many cases with a positive direct examination,
infants less than 2 years old (ranges: 1–2 years). We
the type of parasitation of the hair was also recorded.
identified six cases (4.6%) of TC in adults (more than
Culture is currently required to identify the precise
18 years) among a total of 42 cases of adult TC
organism. Microbiological cultures were incubated at
(14.28%), concerning five men (83.33%) and one
25 C in Sabouraud 2% glucose chloramphenicol agar
woman (16.67%) with an average age of 31 years
and Sabouraud 2% glucose cycloheximide–chloramphe-
(from 20 to 63 years). The distribution of patients
nicol agar. The specimens were examined twice weekly.
according to age and sex was represented in Fig. 2. We
The identification of dermatophytes was based on
note that 71.9% of cases (87 cases) occurred in children
the macroscopic and microscopic characteristics of the
younger than 10 years of age. The mean duration
fungi. For each patient, we recorded the age, the gender,
of the disease prior to diagnosis was about 1.76 ±
the geographical origin, duration of the disease before
1.25 months (range: 10 days to 3 years; median =
consultation, the clinical presentation, the contact with
other family members or with animals, the responsible
Other family members were infected with tinea in
dermatophyte and the evolution under treatment and
seven cases and contact with animals was reported in
complications. The patients were re-evaluated periodi-
35 cases (cats: 17 cases, dogs: 13 cases, rabbits: five
cally for at least 6 weeks.
cases). Contributing factors were represented in threecases (2.47%): local application of corticosteroids (twocases) and gastric tumour (woman: 63 years old) in one
case. None of the patients had positive HIV serology.
In clinical examination, all patients presented with
Epidemiological, clinical features
follicular pustular elements on squamous erythematous
During the analysed period of 12 years, a total of 121
alopecic patches, realising a kerion (Fig. 3). Cervical
cases (10.08 cases ⁄ year) were diagnosed with inflam-
(auricular and posterior occipital) lymph nodes and
matory TC among a total number of 881 cases of TC
fever were found in 15 patients. Inflammatory TC was
(13.73%). The year-flow for total TC was represented
associated with erythema nodosum in a 5-year-old boy
in Fig. 1. The incidence of TC from 1999 was
(published case). Physical examination showed Tinea
gradually increasing and reaching to its peak in
corporis in eight cases (6.61%) (face: four cases, hand:
2006 and 2009. These are 83 male patients (68.6%)
two cases, neck: one case, trunk: one case) and
Figure 1 The year-flow for total inflammatory Tinea capitis and thedermatophytes isolated from the patients.
Figure 2 Distribution of patients according to age and gender.
2012 Blackwell Verlag GmbHMycoses, 2013, 56, 110–116
I. Zaraa et al.
and rats. The annual distribution of the different speciesis presented in Fig. 1; we note a clear predominance ofT.violaceum and M. canis.
For mycological examination of inflammatory TC in
adults, three cases are due to T. interdigitale complex, onecase to T. violaceum, one case to M. canis and one case wasnegative. According to our data, negative culture repre-sent 11.57% of all cultures (14 cases) and contaminatedsamples were noted in 1.65% of cases (two cases). Thesenegative cultures had a positive direct examination (10ectothrix, 4 endothrix). The relationship between directexamantion and culture is represented in Table 1. These
Figure 3 Kerion of the scalp (suppurative plaque of the scalp).
results may be related to an antifungal treatmentinitiated before sampling (9.91% of our patients), because
onychomycosis in five cases (4.13%). Twelve patients
many antifungal drugs are retained within stratum
(9.91%) were treated with an antifungal treatment
corneum of epidermis for a long time and may inhibit
(with too short followed schedule) before consultation.
the growth of dermatophytes on SaboraudÕs dextrose
Three patients presented with a history of hospitalisa-
agar or the type of dermatophyte is difficult to cultivate.
tion in surgical department with the diagnosis of
The distribution of aetiological agents by gender was
Staphylococcal abscess and treated by intravenous
summarised in Table 2. We note a higher prevalence of
antibiotics and surgical excision.
M. canis and T. interdigitale complex in male patients.
Mycological features
Treatment and follow-up
Direct examination was positive in 110 cases (90.9%).
Treatment regimen consisted of griseofulvin at the dose
Fifty-nine patients (53.63%) were ectothrix and 51
of 20–25 mg kg)1 per day and 1 g per day in adult TC
patients (46.37%) were endothrix. In the 11 cases when
for 6–8 weeks for all patients except for one child
direct examination was negative, the culture was
(5 years old) with inflammatory TC due to M. canis,
positive (Microsporum canis (four cases), Trichophyton
which did not respond to systemic griseofulvin at 20 mg
violaceum (three cases), Trichophyton mentagrophytes [T.
day for 4 months, was treated with oral terbinafine.
mentagrophytes is an older taxonomic name for derma-
During the whole treatment period and follow-up, the
tophytes belonging to the ÔTrichophyton interdigitale
tolerance was excellent and no side effects or abnormal
complexÕ] (three cases), Trichophyton verrucosum (one
results in the blood chemistry tests were observed.
case). Positive cultures of dermatophytes were obtained
A systemic antibiotic and prednisone (0.5 mg kg)1 per
in 105 patients (86.77%): T violaceum (49 cases:
daily) were associated with 15 cases. Antifungal topics
46.66%) was predominant, among them 13 cases of T
were applied once or twice a day in all patients. The
violaceum glabrum, followed by M canis (31 cases:
follow-up in 116 patients (95.8%) noted a complete
29.52%), interdigitale complex (13 cases: 12.38%) and
regression in 88 cases, whereas 28 showed a persistent
T verrucosum (12 cases: 11.44%). Thirteen patients,
alopecia. A relapse was occurred in one woman who
from whom T. interdigitale complex was obtained, had a
had gastric tumour. She was treated with griseofulvin
history of animal contact, including rabbits, dogs, cats
more than 3 months with a relapse.
Table 1 Correlation between direct examination and culture.
Mycological features
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Inflammatory Tinea capitis
Table 2 Aetiology agents of inflammatory TC according to gender.
hygiene, crowded living conditions and low socioeco-nomic status) were associated with this increased
frequency.8,11,12,17 The majority of our patients come
from a rural region (60 cases: 49. 59%).
Trichophyton violaceum
As was found in our study, it appears most often in
Microsporum canis
children between 5 and 10 years of age (Fig. 2).23–25
Our results were similar to those in other Tunisian
Trichophyton verrucosum
studies, noting that living conditions, large family size
and close contact with other infected children at school,physical contact with animals and playing outside may
facilitate fungal transmission.8,11,12,26
TC, Tinea capitis.
Inflammatory TC is secondary to a vigorous host
immune response and its occurrence in neonates andin infants in their first year of life is extremely
infrequent and only a few cases occurring at this age
We report one of the largest case series of inflammatory
have been reported in the literature.27–29 The rare
TC in the literature. The major findings in our study
presentation of inflammatory TC at this age is probably
were the increase over recent years, in the number of
explained by the immaturity of their immunological
cases of inflammatory TC (121cases: 13.73%), compar-
system.29 In our series, we found four cases (3.3%;
atively to our first study in 1998 (22 cases: 1.8%), the
three girls, one boy) of inflammatory TC in infants less
high incidence among boys below the age of 10 years,
than 2 years old and two family members were
and the rarity in adults, in which the male gender is
infected with TC. The most reported factors predispos-
preferred. T. violaceum was the most common pathogen
ing infants to TC are humid environment, broad-
in all cases and T. interdigitale complex was predomi-
spectrum antibiotic use, epidermal immaturity and
nantly in adult.8
impairment of health (anaemia, immunodepression).30
TC is a dermatophytosis of the scalp and hair that it
We do not found predisposing factors in our infants
has been a major public health problem in Tunisia for
such as immunodepression or impairment of heath,
decades.9 The clinical presentation is a great mimicker
but they come from a rural region where hygiene and
and can present itself in various ways, ranging from
socioeconomic conditions are unfavourable. It has also
asymptomatic carriers, scaling lesions and ⁄ or alopecia
been proposed that asymptomatic carriers (mothers),
to cervical lymphadenopathy and large painful inflam-
without clinical signs or symptoms of TC, but with
matory masses. This acute painful inflammatory boggy
positive scalp cultures, could be an important source
mass with alopecia on the scalp, often with crusting and
of disease transmission or a reservoir of dermato-
purulent discharge, is called kerion celsi and it is the
result of an intense hypersensitivity reaction from a
In our study, the proportion of inflammatory adult TC
dermatophytic infection.10 This condition is rare, with
(14.28%) is approximately in accordance with the
only few articles in the literature and most of them are
previous Tunisian studies (15% and 18%).14,15 The
case reports.7,10–12 In our study, 121 cases of inflam-
adultÕs hair seems to be relatively resistant to TC, which
matory TC were reviewed between a total 881 TC
may be due to protection from fungistatic free fatty acids
(13.73%) and a total 96251 consultants (0.125%)
in the sebum and colonisation by Pityrosporum orbicu-
collected through 12 years. The prevalence data we
lare.31–33 Although the rareness of inflammatory adult
obtained from our study were different with results as
TC could be explained by some cases of Inflammatory
reported from many other regions of the world. In
TC can take form of other forms of TC and treated
Tunisia, the incidence of inflammatory TC is varied from
precociously with favourable evolution. The most
2.3% to 13%.1,11–16 This value was lower than that
reported factors for predisposing adults to TC are contact
observed in Spain (18.2%) and Saudi Arabia (19.8%).17
with infected children, animals or objects, impairment of
On the other hand, this rate was higher than that in
health (diabetes mellitus, anaemia, immunodepression)
Nepal (1.5%), Morocco (2.5%), Gabon (4%), Libya
and use of topical or systemic corticosteroids.34–36 In
(8.2%), China (10.3%), rural Kenya (10.1%), the United
our study, one adult had used corticosteroid lotions and
Kingdom and the United States.18–22
one woman had gastric tumour.
Inflammatory TC occurs predominantly in rural or
The incidence of TC may also vary by gender,
suburban areas and some factors (poor personal
depending on the causative organism.19 This study
2012 Blackwell Verlag GmbHMycoses, 2013, 56, 110–116
I. Zaraa et al.
demonstrated that dermatophytes are more frequent in
study, the direct examination was positive in 90.9% of
male genders than female genders. The reason for this is
the cases, while the culture in 86.7%.
not fully understood, but it indicates that gender may
TC is a classic example of the changing geographical
influence susceptibility to particular forms of these
patterns of dermatophytosis that explain the polymor-
infections. Some authors suggest that TC produced by
phisms of clinical and mycological profile of TC.41,42 The
M. canis are more usual in male genders, whereas there
prevalence of different types of dermatophytes varies
is no predominant gender for TC caused by T. violaceum,
between continents and from one country to another,
or that these latter may even be more common in
and it is often difficult to know the precise distribution of
women.17,23 However, these differences in gender have
a particular dermatophyte. Some of the data from
not always been noted.37 In our study, we found a
Europe showed that M. canis and T. violaceum were the
predominance of cases in male genders for inflamma-
predominant dermatophyte in central and southern
tory TC produced by both M. canis (74.1%) and by
Europe.43–46 In the United States, T. tonsurans has
T. violaceum (59.1%; Table 2). A possible explanation for
supplanted M. audouinii and M. canis as the primary
this apparent predominance in boys may be that male
dermatophyte of TC.47–49 In south and central Asia,
children help out on farms and have more contact with
T. violaceum is the most common causative agent of TC,
animals.3,23 TC can be transmitted from animals to
whereas M. canis is predominated in western Asia.50,51
humans or among humans.3,20,38 In our study, only
In east Asia (China), the most common species causing
28.9% patients have contacted with pets like dogs or
TC was T. violaceum followed by T. verrucosum.52 The
cats definitely. This lower percentage is likely due to the
various organisms causing TC may present with differ-
absence of systematic research of the notion of contact
ent clinical patterns, which depend on the type of hair
with animals in our medical records.
invasion and the degree of inflammatory host response.2
Inflammatory TC initiates as a dry tinea with scaling
Inflammatory TC is most often caused by zoophilic
and short hairs. Then, there is erythema and inflam-
dermatophytes (M. canis, T. verrucosum and T. interdig-
mation, which generating a painful lesion with clear
itale complex), but also by anthropophilic (T. rubrum)
borders that is covered with numerous pustules pro-
and rarely by geophilic (M. gypseum) species.11,12
ducing abundant pus and may be associated with
In Tunisia, a north African country, incidence and
marked cervical lymphadenopathy and fever.2 All our
pathogens of inflammatory TC were changed through
patients presented herein had unique lesions with the
years. In a study undertaken in our department
typical clinical aspect of kerion and presence of lymph-
between 1985 and 1998, of 22 cases of inflammatory
adenopathies and fever in 15 cases. After that, the short
TC, the predominant causative agents were T. interdig-
hairs are gradually expelled or remain below the
itale complex (40%) and M. canis (26.6%).8 During the
inflammation. Finally, within around 8 weeks, cell-
period of our study, M. canis was present in 29.52% of
mediated immunity leads to complete elimination of the
parasite. Usually, a definitive alopecia with fibrosis due
On the other hand, our data showed that the
to the sustained attack on the hair follicle was
incidence of T. violaceum (46.6%) exceeded M. canis
(29.52%). As shown in Fig. 1, the incidence of
Confirmation of inflammatory TC diagnosis and
T. violaceum increased gradually from 1999, peaked in
appropriate treatment are therefore of particular impor-
2006, and then dropped quickly in the next 4 years. In
tance in this variety. The gold standard diagnostic
general, anthropophilic species tend to induce less
method is fungal culture.39 This was performed in all
inflammatory lesions than geophilic and zoophilic
our patients. As reported in our study, some cases of
ones.18 Clinic manifestation is often not very evocative;
boggy kerions leading to unnecessary hospitalisations,
they are not always diagnosed, allowing their release.
investigations (scanner), surgical interventions and
This may be explained by the increased number of
delays in diagnosis.40 The short duration of oral
patients treated incorrectly before consultation. Another
antifungal use may imply that patients diagnosed with
explication, it is also possible that adults carry anthro-
TC are still being undertreated or comply poorly with
the therapy because of the inconvenient dosage and
throughout life and develop inflammatory TC only if
duration. If direct examination and culture are negative,
immunodeficiencies or disruption of the scalp protective
a biopsy should be performed and divided to perform
mechanisms occurs.16 As rabbits have become domestic
cultures in specific media for fungi.2 Careful examina-
pets, the frequency of T. interdigitale complex has
tion of people in close contact with family members as
increased with higher presentation of inflammatory
well as pets may help in the clinical suspicion. In our
2012 Blackwell Verlag GmbH
Mycoses, 2013, 56, 110–116
Inflammatory Tinea capitis
Accordingly, 13 of our inflammatory TC were
produced by T. interdigitale complex and rabbits were
observed in both patientsÕ environment. In the othernorth African studies (Morocco), T. mentagropytes wasthe major agent of inflammatory TC (75%).18 Inflam-
matory TC is frequently caused by T. verrucosum. Cattle
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are the main source of T. verrucosum infections. It was
dans la re´gion de Sfax (Tunisie). J Mycol Med 2008; 18: 162–
isolated in 12 cases (11.44%) in our series. Our results
are different to other study in central Tunisia and
2 Rebollo N, Lo´pez-Barcenas AP, Arenas R. Tinea capitis. Actas
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Annex № 1 to the Order № February 15- "Rules of Carriage of Passengers, Baggage and Cargo" "Azerbaijan Airlines" Closed Joint Stock Company Table of contents 1. General provisions Terms, Definitions and abbreviations Compliance with laws and requirements of state authorities Electronic Ticket
Diagnosis,Therapy and Prophylaxis of Fungal Diseases Inflammatory Tinea capitis: a 12-year study and a review of theliterature Ine s Zaraa,1,2 Abdelmohti Hawilo,1 Amina Aounallah,1 Sondes Trojjet,1 Dalenda El Euch,1Mourad Mokni1,2 and Amel Ben Osman1,21Department of Dermatology, La Rabta Hospital Tunis, Tunisia and 2University of Medicine, El Manar Faculty Tunis, Tunis, Tunisia
