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Year : 2018  |  Volume : 19  |  Issue : 1  |  Page : 51-56

Tinea capitis in children: A report of four cases trichoscopic with trichoscopic features

Private Practice, Dermatology OPD and Academia, Queensland University, QLD, Australia

Date of Web Publication28-Dec-2017

Correspondence Address:
Dr. Ebtisam Elghblawi
St James Hospitals Group, Dermatology OPD, P.O. Box 3232, Tripoli
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpd.IJPD_145_16

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Tinea capitis (TC) is the most prevalent pediatric superficial dermatophyte infection. The culprit species differ across the continents; for instance, Microsporum canis prevails in Europe, whereas Trichophyton tonsurans dominates in North America. Oral medication is always* the main required remedy as TC does not respond well to topical therapy unaided. However, in some countries, griseofulvin is no longer available. Fungal culture should be included in the study of persistent, scalp lesions and trichoscopy can offer a speedy diagnosis by its characteristic findings. Scalp dermoscopy or “trichoscopy” represents a valuable, noninvasive technique for the evaluation of patients with hair loss due to TC. It is simple, quick, and easy to perform.

Keywords: Comma hairs, corkscrew hairs, dermoscopy, scalp infection, tinea capitis, trichoscopy, zigzag

How to cite this article:
Elghblawi E. Tinea capitis in children: A report of four cases trichoscopic with trichoscopic features. Indian J Paediatr Dermatol 2018;19:51-6

How to cite this URL:
Elghblawi E. Tinea capitis in children: A report of four cases trichoscopic with trichoscopic features. Indian J Paediatr Dermatol [serial online] 2018 [cited 2020 Jul 10];19:51-6. Available from: http://www.ijpd.in/text.asp?2018/19/1/51/206074

  Introduction Top

Tinea capitis (TC; fungal infection of the scalp) is a frequent dermatophytosis of childhood. Clinically, it can be divided into its dry which accounts for majority of the cases (90%) or the acute inflammatory form. Diagnosis is easily made by direct 10%–20% potassium hydroxide (KOH) examination of tonsured hair or by isolation of the dermatophyte in Sabouraud agar, which would take weeks to reveal and delays diagnosis and initiation of a proper treatment.

The dermoscopic examination of the hair and scalp is known as trichoscopy. This has been demonstrated to be a very successful and effective means of swift analysis and assessment of various hair disorders, including infectious fungal diseases such as TC. The existence of explicit trichoscopic features permits prompt recognition and enables discrimination between these distinctive entities. In certain skin types, it has certain predilection of findings.

The most commonly reported trichoscopic features in TC patients have been coma hairs and corkscrew hairs (CHs), which have been described as markers of this particular disease.[1],[2] Trichoscope is considered as the stethoscope of a dermatologist.

  Case Reports Top

Case report-1

The male child was originally from Libya where he had had frequent contact with animals and cats with unidentified skin disease. The patient was a white 14-year-old child who presented with slightly pruritic scalp lesions that had appeared 2 months earlier. During the preceding 2 months, he had received treatment with topical corticosteroids for 2 weeks, but his condition had not improved. On the contrary, it had become worse according to his mother. Physical examination revealed an erythematous scaly, partially alopecic plaque on the right parietal region, characterized by superficial crusts [Figure 1]. There were no palpable lymph nodes in the cervical region.
Figure 1: Physical image and woods lamp fluorescence with no trichoscope image©

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Woods lamp elicited green fluorescent hairs. The bacterial culture was not performed as it would take longer to get the results. He was treated successfully with oral griseofulvin at a dosage of 10 mg/kg/day for 8–12 weeks. The clinical picture and symptoms resolved completely with continuous treatment and regular follow-up. At 4 months follow-up, the lesions had cleared completely, and there was no evidence of residual scarring alopecia.

Case report-2

The patient was a white 5-year-old Libyan male child who presented with a crusted plaque on his scalp which had appeared 6 weeks earlier. The distinctive about him is long, light color curly hair. He had received no prior topical or systemic treatment. Physical examination revealed a crusted, nonerythematous, rounded lesion on the parietal area of the head. Words lamp yielded a blue fluorescence. Fungal culture was negative. Trichoscope showed mainly CHs, comma, and zigzag hairs and a possibility of a bar code hair.

The patient was started on griseofulvin 10 mg/day. However, his father discovered it was no longer available in Libya. Therefore, the patient was prescribed antifungal terbinafine (125 mg/day) systematically with antifungal shampoo for 6 weeks and to be followed up. However, the patient did not attend and declined our calls for follow-up.

Contact-type dermoscopic instrument used was DermLite PRO II and connected with iPhone 4S, with alcohol as the interface medium, in combination with magnification power [Figure 2].
Figure 2: Physical image showing the curly hairs, woods lamp fluorescent, and distinctive trichoscope three findings©. Trichoscopy showing comma hairs (thick circle), zigzag hairs (moderate thickness circle), and corkscrew hairs (thin circles). And a possibility of bar code hair (red circle)©

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Case report-3

A male child was originally from Sudan where he had not been in close contact with any animals or with people who had similar lesions.

The patient was a black 8-year-old child skin phototype 5 who presented with a 2-month history of two patches of crusted, noninflammatory lesions on his occipital scalp.

Physical examination revealed fine, whitish scale on the scalp and several plaques of alopecia with marked hair fragility on the hair pull test. There were no palpable lymph nodes on the cervical region.

All the patches showed a characteristic green fluorescence under the Wood's lamp. Mycological examination was not performed as the facility is not available in the center.

Dermoscopic appraisal of the hair structures revealed numerous broken down hairs as well as hairs with a distinguishing comma-like shape (consistent and homogenous thickness and color and marked distal angulation) [Figure 3].
Figure 3: Woods lamp and trichoscope showed mainly comma hairs. Trichoscopy shows mainly comma hairs. Courtesy of Dr. Jameel Sayed

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He was initiated on terbinafine locally and systematically and the symptoms improved slowly.

Trichoscope applied was 3Gen DermLite with Olympus bridge camera with hyper macro.

Case report-4

The fourth case was a white 6-year-old Turkish girl who was brought in, for evaluation of single plaque of alopecia that had been present on the right side of her scalp for 3 weeks and was mildly pruritic. The patient had been in contact with a cat. The hair pull test was positive. Direct examination with KOH was positive, but no fungi culture was requested as fungal cultures often take weeks to obtain results and delay commencing of the medication. On dermoscopic examination, there were multiple hairs with a characteristic comma shape [Figure 4]. The condition resolved completely with 8 weeks treatment of oral ketoconazole at ¼ TSF twice per day.
Figure 4: Physical image and trichoscope showing mainly comma hairs. Trichoscopy showing mainly comma hairs and some zigzag hairs. Courtesy of Dr. Bengu Nisa Akay

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Trichoscope used was DL4 captured with a Nikon camera.

  Discussion Top

These case series show that scalp ringworm in children, which is relatively common and often presents with typical clinical characteristics. Low clinical suspicion can lead to inappropriate empiric treatments that delay diagnosis and complicate the therapeutic response as happened with case number 1.

The four reported cases in this paper were from different locations, background, and geography and mostly presented with the clinical suspicion of TC.

TC is commonly seen in children between the ages of 3 and 7 years. Although the disease was once considered to be unusual in adulthood, a growing number of authors now support the claim that there is an increase in TC among adults, particularly menopausal and elderly women. A possible explanation has been attributed to hormonal changes and hair styling.[3]

In most of the cases in the literature including our own four case series, medical advice is sought late and diagnosis was delayed. This could be explained due to ignorance of the parents and the general lack of awareness of the clinical picture of ringworm infestations.

Although the general trend remains that Microsporum canis is the most common encountered causative agent in TC in Europe (80%), the epidemiology has shifted recently where and now a considerable number of cases are found attributed to Trichophyton mentagrophytes, Trichophyton verrucosum, Trichophyton tonsurans, and Trichophyton rubrum. In Spain, it has been found that T. mentagrophytes constitutes a higher percentage and T. tonsurans constitutes a higher percentage in the UK, Canada, and the USA.[4]

This major trend changes can be logically attributable and claimed to be due to the immigration state from endemic to and across the world which facilitated the contagion flow.[4]

However, in our four cases, no mycological study was done to back up the claim due the unavailability of the service. However, in keeping with what seems to be the current trend change for this disease and its infectivity, the species in our four patients can be speculated as anthropophilic as three of them gave history of a cat close contact with the exception of the Sudanese boy.

It should be noted that mycological culture is essential to confirm the claim and support it with the clinical picture of our four cases. Therefore, any scalp scaly pruritic conditions should be sent for culture as was done in case number 2. However, the result was negative and this could be attributed to laboratory error and the personnel who handled the test wrongly as bacteriological though we sent the request for mycological culture. What made us more suspicious was that we got the result within 2 days, which would not make any sense and in questioning that we did not get a proper explanation. Hence, laboratory error was very probable in case number 2.

Moreover, it should be emphasized that any patients with suspected fungal infections are often referred to a specialist – as case number 1 in this four series was – after receiving 2 weeks treatment with medium potency topical steroids – “mometasone scalp drops.” This had masked the clinical presentation and further modified the patient's response. This does not resolve the process but can affect the sensitivity of diagnostic tests. However, this specialist was well known, but fatal mistakes can happen, and the outcome can be detrimental and unpleasant.

The diversity of the treatments prescribed in these four case series can be explained by the inclinations of the various physicians caring for the four different patients. Although griseofulvin remains, for some authors, the drugs of choice for scalp ringworm in children and adults, recently both terbinafine and itraconazole, are proposed to be acceptable alternatives, especially itraconazole for cases caused by fungi of the genus Trichophyton. Recently, the griseofulvin is no longer available in certain countries including Canada, Greece, and lately not found in Libya.

It should be noted in case number 2, as the case has been seen twice, and obviously no response to the treatment. On asking her mother, it has been found that she gave the treatment only for 5 days and the disease apparent irresponsive to itraconazole – a drug considered effective against TC –may be associated with failure to follow the prescribed regimen strictly.

The different available effective modality of antifungal medications can be summarized as the follows:

The standard treatment is griseofulvin. Itraconazole and terbinafine have in large part replaced griseofulvin in the treatment of TC and in addition to fluconazole and ketoconazole, are evolving treatments for TC.

Griseofulvin is very effective in TC however recently has been withdrawal in certain countries. Griseofulvin builds ups in the keratin of the horny layer, hair, and nails, rendering them resistant to invasion by the fungus. Treatment must continue long enough for infected keratin to be replaced by resistant keratin, usually 4–8 weeks and in some cases up to 12 weeks as was the case with number one.

The other new antifungals have the advantage of shorter treatment durations; however, they may be more expensive.

Itraconazole is an azole with activity against many dermatophytes, Candida species, Malassezia furfur, and some molds. It has a long half-life in the skin and nails, with an affinity for both lipids and keratin, and reaches the skin chiefly through sebum. It has been found that the drug continues to be excreted in sebum for 1 month after therapy has been discontinued.

Itraconazole is available in both tablet and liquid formats. Clinical trials and case series using itraconazole to treat TC have shown it to be effective (90%) for infections caused by either Trichophyton or Microsporum species. Few side effects were seen in most studies using 3 mg/kg/day to 5 mg/kg/day for 4–6 weeks. Although more studies on safety are needed, itraconazole may become a good first-line agent for TC.

Terbinafine is a lipophilic and keratinophilic fungicidal agent, active in vitro against dermatophytes and some molds. It disseminates to keratinocytes from the bloodstream to reach the stratum corneum and hair follicles. It is not metabolized through cytochrome P-450; many of the drug interactions seen with the azoles do not occur with it. Terbinafine is well tolerated, with however some gastrointestinal and skin reactions in barely 2%–7% of patients. Loss of sense of taste has been reported but improves with stoppage. Terbinafine is effective for children with TC at a dose of 62.5–250 mg/day for 4 weeks, and no liquid formulation is available.[5]

Ketoconazole was the first azole evaluated for efficacy in the treatment of resistant superficial fungal infections such as TC. Ketoconazole was found to be equivalent to griseofulvin for such cases in the clinical trials. However, ketoconazole appears to be the least efficacious.[6]

Oral griseofulvin and terbinafine tablets are the least expensive of the antifungal agents; griseofulvin suspension is, however, more luxurious than fluconazole suspension.[5]

However, for the long track record of use, safety, and efficacy, griseofulvin is still considered to be the present traditional drug of choice for TC in children.[6]

Complete cure was achieved in all the three cases with exception to case number 2 who was lost to follow-up despite our calling for them. Moreover, no significant side effects led to the cessation of therapy were recorded. Laboratory investigations were performed before the commencement of the antifungal and were within normal ranges.

In three of the case series, trichoscope was applied and offered free. The main observed findings such as comma hairs and zigzag were found in dermatological examination of all the three patients with TC. However, case number 2 showed all the three described features in the existing literature including multiple corkscrews and one barely seen “Morse code-like hair.” None of any broken or black dots and dystrophic hairs can be seen which represent hair regrowth on dermoscopy. This can be explained to the initial activity of the fungal infection.

Although comma hair has been the first described feature to be a specific dermoscopic trait of TC by Slowinska et al. and Hernández-Bel et al.,[7] according to Lin and Li,[8] it is not always the case. Furthermore, zigzag was reported in TC and suggested to be due to its structural weakness where the fungus M. canis perforates the hair cuticle and causes conidia on the hair surface that bends on the paler part of the infected hairs.[7] Comma hairs have been hypothesized to represent cracking and bending of hyphae-filled hair shafts.[8]

CHs were first described by Hughes et al. as trichoscopy marker for diagnosis of TC in black children. However, in this recently observed case, the same trichoscopic findings were seen in the Libyan white boy (case number 2).

Recently, a new trichoscopic feature surface up with grand magnification application (×150). It is called Morse code like-hairs (bar code-like hairs). This feature coincides with the horizontal white bands, so the infected hair appears as empty bands which are related to localized areas of fungal infection. These horizontal white bands are usually multiple and may cause the hair to bend and break.[9] It denotes that the hair follicle is infected by fungus.[7] However, having said that, case number 2 showed a small one [[Figure 2], red circle].

Dermoscopy in TC shows mainly two typical features, comma and CHs. Hair is slightly curved, and fractured hair shaft is described as a dermsatoscopic marker for TC in white children with M. canis infection. Hughes reported CH as additional feature in children with Trichophyton or Microsporum infection. In addition, broken and dystrophic hairs are seen in TC.[10]

While Hughes et al. had questioned whether CH is a variation of comma hair in the hair types of black patients or is specific to those with Trichophyton soudanense infection, other authors showed that CH is not specific to those with T. soudanense infection and suggested that CH represents a specific trichoscopic finding of dermatophytosis of the scalp in the black race. Moreover, this can be refuted as case number 2 was a Libyan white boy and showed the feature of the CH finding as well.

On the basis of the data reported in the literature, it would therefore seem likely that CH is related to endothrix Trichophyton “black dots” TC in black children. However, the same trichoscopic picture was also observed in the Libyan white boy described herein. Interestingly, our patient had naturally curly hair, a characteristic which is more evident in the black population, whose hair tends to be elliptical (egg-shaped) in cross-section with an erratic thickness along its shaft that resembles a twisted, oval bar.[11]

In our opinion, the trichoscopic finding of CH seems to be a variation of the comma hair of TC as described by Slowinska et al.,[1] suggesting that it is not a peculiar manifestation in black patients but rather a possible manifestation related to curly hair. Further investigation is needed to confirm our assumption.[11]

The distinctive and most prominent features of TC in the case number 3 and 4 were the presence of comma-like structures (comma hairs). These were not accompanied by broken and dystrophic hairs.

Therefore, specific trichoscopic findings are appreciated with TC infection and make diagnosis quickly and easily applicable.

Coming to an end, TC, a dermatophyte infection of the scalp, is still relatively common in routine dermatology practice. It mostly affects children, generally aged between 3 and 7 years, and trichoscopy may therefore be a very useful diagnostic tool in this setting because it is quick, reliable, inexpensive, and noninvasive. In this paper, four different cases series have been described, out of which three had revealed multiple comma hairs as a common characteristic dermoscopic finding.

Diagnosis of TC can be challenging for dermatologists, especially in noninflammatory TC caused by anthropophilic dermatophytes and in black patients, in whom erythema of the scalp is difficult to appreciate. The finding of a typical TC dermoscopic pattern may lead more quickly to a correct diagnosis.

Dermoscopy (surface microscopy) or “trichoscopy” represents a valuable, noninvasive technique allowing rapid and magnified in vivo visualization of the hair and scalp skin, with the visualization of morphologic attributes often indiscernible to the naked eye.

It may be performed with a manual dermoscope (×10 magnification) or a video dermoscopy (up to ×1000 magnification). It is a fast, simple, easy to perform, reliable, and readily accessible test that can be performed at the busy clinic. It also reduces the need for scalp biopsy, is well accepted by patients, and is useful for monitoring treatment and follow-up.[12] The acquaintance and the recognition of these dermoscopic features are simple. Commencing early systemic antifungal therapy is important to combat the disease at its beginning.

Further study is required to illustrate that the presence of the newly described feature “bar/Morse code-like hairs” as an additional reliable finding of fungal infection of the hair follicles to back up the allege.

Doctors should be familiar with the history, epidemiology, and current knowledge of TC, as well as the newer antifungal agents (i.e., itraconazole, fluconazole, and terbinafine) to treat this infection.


This study was conducted on a small number of patients from three geographical and background locations, with no mycological studies to confirm the main culprit and absence of controls.

  Conclusions Top

Comma hairs were observed as a distinctive trichoscopic feature of proposed M. canis-induced TC.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Slowinska M, Rudnicka L, Schwartz RA, Kowalska-Oledzka E, Rakowska A, Sicinska J, et al. Comma hairs: A dermatoscopic marker for tinea capitis: A rapid diagnostic method. J Am Acad Dermatol 2008;59 5 Suppl:S77-9.  Back to cited text no. 1
Mapelli ET, Gualandri L, Cerri A, Menni S. Comma hairs in tinea capitis: A useful dermatoscopic sign for diagnosis of tinea capitis. Pediatr Dermatol 2012;29:223-4.  Back to cited text no. 2
Morell L, Fuente MJ, Boada A, Carrascosa JM, Ferrándiz C. Tinea capitis in elderly women: A report of 4 cases. Actas Dermosifiliogr 2012;103:144-8.  Back to cited text no. 3
Hughes R, Chiaverini C, Bahadoran P, Lacour JP. Corkscrew hair: A new dermoscopic sign for diagnosis of tinea capitis in black children. Arch Dermatol 2011;147:355-6.  Back to cited text no. 4
Antifungal agents for common paediatric infections. Can J Infect Dis Med Microbiol 2008;19:15-8.  Back to cited text no. 5
Bennett ML, Fleischer AB, Loveless JW, Feldman SR. Oral griseofulvin remains the treatment of choice for tinea capitis in children. Pediatr Dermatol 2000;17:304-9.  Back to cited text no. 6
Hernández-Bel P, Malvehy J, Crocker A, Sánchez-Carazo JL, Febrer I, Alegre V. Comma hairs: A new dermoscopic marker for tinea capitis. Actas Dermosifiliogr 2012;103:836-7.  Back to cited text no. 7
Lin Y, Li Y. The dermoscopic comma, zigzag, and bar code-like hairs: Markers of fungal infection of the hair follicles. Dermatol Sinica 2014;32:160-3.  Back to cited text no. 8
Lacarrubba F, Verzì AE, Micali G. Newly described features resulting from high-magnification dermoscopy of tinea capitis. JAMA Dermatol 2015;151:308-10.  Back to cited text no. 9
Miteva M, Tosti A. Trichoscopy in children. Ch. 33. Altas of Trichoscopy. Springer London: Springer; 2012. p. 403-8. Available from: http://www.link.springer.com/chapter/10.1007/978-1-4471-4486-1_33. [Last accessed on 2017 Feb 24].  Back to cited text no. 10
Neri I, Starace M, Patrizi A, Balestri R. Corkscrew hair: A trichoscopy marker of tinea capitis in an adult white patient. JAMA Dermatol 2013;149:990-1.  Back to cited text no. 11
Jáuregui-Aguirre E, Quiñones-Venegas R. Trichoscopy in tinea capitis. Dermatol Rev Mex 2015;59;142-9.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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