|Year : 2019 | Volume
| Issue : 4 | Page : 332-337
A clinico-epidemiological study of tinea capitis in children attending a Tertiary Care Hospital in Karimnagar
Narendar Gajula, Nishita Vumma, Vontela Rohit, Anusha Kalikota
Department of Dermatology, Venerology and Leprosy, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, Telangana, India
|Date of Web Publication||30-Sep-2019|
Dr Narendar Gajula
Department of Dermatology, Venerology and Leprosy, Chalmeda Anand Rao Institute of Medical Sciences, Bommakal, Karimnagar - 505 001, Telangana
Source of Support: None, Conflict of Interest: None
Background: Tinea capitis is dermatophytic infection of scalp and associated hair. Incidence of the disease remains unknown. It commonly occurs in children between 3-14 yrs of age group. Etiological agents vary from time to time and place to place. Aim: To delineate the various patterns of Tinea capitis observed in Karimnagar district and to assess for any correlation between the clinical, microscopic and microbiologic findings in the patients seen. Also, to identify the common fungal species responsible for producing Tinea capitis. Material and Methods: Clinical morphology and KOH findings were studied in 65 patients who attended DVL OPD at Chalmeda Anand Rao Institute of Medical College, Bommakal, Karimnagar with the suspected diagnosis of Tinea capitis. Fungal culture was performed for all the cases. The epidemiological factors associated with the disease were also assessed. Results: Out of 65 children,36 (55.4%) belonged to 5-10yrs of age with a slight male predominance (1.4:1). Most of the children were living in crowded conditions 52(80%). Hair loss was the commonest symptom in 100% followed by itching in 41(62.9%) of cases. Greypatch variety was the commonest 24 (36.9%) followed by black dot 18(27.7%), kerion 12(18.5%) and agminate folliculitis 11(16.9%). KOH mount was positive in 78.4% and culture in 57.4% of cases. T.violaceum was the commonest 16(37.5%) species isolated followed by T.mentagrophyte 11(25.5%), T.tonsurans 8(18.6%), T.rubrum 6(13.9%) and M.gypseum was the least 2(4.6%). Conclusion: In the present sudy, clinical examination and microscopic findings along with epidemiological factors were considered which attributed that the most common group affectedis the lower socioeconomic population. Though the causative fungi was found to vary between different regions and time, T.violaceum was the most common organisum isolated in our study.
Keywords: Greypatch, tinea capitis, Trichophyton violaceum
|How to cite this article:|
Gajula N, Vumma N, Rohit V, Kalikota A. A clinico-epidemiological study of tinea capitis in children attending a Tertiary Care Hospital in Karimnagar. Indian J Paediatr Dermatol 2019;20:332-7
|How to cite this URL:|
Gajula N, Vumma N, Rohit V, Kalikota A. A clinico-epidemiological study of tinea capitis in children attending a Tertiary Care Hospital in Karimnagar. Indian J Paediatr Dermatol [serial online] 2019 [cited 2021 Mar 2];20:332-7. Available from: https://www.ijpd.in/text.asp?2019/20/4/332/268387
| Introduction|| |
In the recent times, dermatophyte infections are emerging as a serious concern for dermatologists. Apart from the etiological factors, several environmental factors are contributing to the current pandemic. There has been a rise of dermatophyte infection among the pediatric age group. Tinea capitis remains a common childhood infection in many parts of the world.
Tinea capitis describes dermatophyte infection of hair and scalp, typically caused by Trichophyton and Microsporum species, with the exception of Trichophyton concentricum.
It was earlier believed that tinea capitis was rare or nearly absent in India due to the use of vegetable oils by Indians on the scalp regularly. However, it was later observed that tinea capitis was by no means rare. Powell reported dermatophytosis in India. In India, tinea capitis was described by Day and Maplestone in 1935.
Most commonly observed in children between 3 and 14 years of age. The most common cause worldwide is Microsporum canis, whereas in the US, it is Trichophyton tonsurans and Trichophyton violaceum in south India. It is uncommon in adults. Boys outnumbered girls in a ratio of 5:1, but it may be a factor of the past. Beyond this age group, the incidence declines because of the onset of puberty and seborrhea. Tinea capitis is a communicable disease.
Tinea capitis can be classified according to the inflammatory component of clinical presentation namely inflammatory (kerion and favus) and noninflammatory (gray patch and black dot types) or according to the size and the location of the spore, ectothrix (spores outside the hair shaft), and endothrix (spores inside the hair shaft).
Complications of tinea capitis include secondary bacterial infection, tinea in other parts of the body and cicatricial alopecia. Types such as kerion and favus are known to cause cicatricial alopecia which is extremely disfiguring.
A higher rate of the carriage and asymptomatic disease has been reported from South Africa. Most of the studies in our part of the world have shown T. violaceum to be the most common pathogen although other organisms are occasionally found. In recent years, the incidence of tinea capitis has increased in the United Kingdom particularly among the Afro-Caribbean children living in large cities.
The objective of the study is to know the various epidemiological factors contributing for tinea capitis in children and also to know the change in trends of causative fungi responsible for various clinical types of tinea capitis.
| Materials and Methods|| |
The study was conducted at DVL OPD, Chalmeda Anand Rao Institute of Medical Sciences, from April 2016 to 2018 after obtaining the institutional and ethical committee approval. Informed consent was taken from all patients attenders before sampling.
Children aged between 3 and 14 years of age were included in the study were thoroughly examined, and clinically suspected cases of tinea capitis were selected for further study in detail. Children presenting with scalp infection, patchy hair loss, and easy pluckability of hair, with or without any associated inflammatory changes were included in the study. Patients on any oral or topical antifungal therapy for the past 6 weeks were excluded from the study.
A detailed history including epidemiological factors such as socioeconomic status, occupation of parents, overcrowding (>3 members per room) poor hygiene, head bath, type of hair oil used, sharing of combs, history of animal contacts, and family history of dermatophytosis were recorded, woods lamp examination was done and were recorded. Siblings of affected children were also examined to assess for any hair loss. The patients were thoroughly examined to assess for any evidence of tinea corporis, nail involvement, id reaction, or lymphadenopathy.
Examination of the whole scalp was carried out to assess the type and extent of hair loss. The patients were divided into noninflammatory (gray patch and black dot) and inflammatory (kerion and agminate folliculitis).
First, the selected area of scalp was cleaned with spirit. The dull, lusterless, hair, and stubs of hairs including roots of hair were chosen and plucked by sterile surgical forceps and also scraped by the blunt edge of a scalpel. For microscopic examination, the material collected on a slide was immersed in potassium hydroxide (10% KOH) to prepare smears. The slides were assessed under a low-power microscope to look for fungal arthrospores or any hyphae. If the spores were located on the surface of the hair shaft, the infection was classified as ectothrix. If the spores were seen inside the shaft, the infection was classified as endothrix.
After microscopic examination, samples were sent for fungal culture with Sabouraud's Dextrose Agar to which chloramphenicol, cycloheximide was added to suppress any other bacteriological growth and saprophytes, respectively. They were incubated at 26°C–28°C. The cultures were examined weekly for any growth and were discarded after 3 weeks if no growth was detected and the growth was examined by the naked eye and also microscopically and the final organism isolated was reported.
| Results|| |
A total of 65 cases with tinea capitis, involving children between 3 and 14 years of age seen over 2 years' period were enrolled for the study. Majority of the children (53.4%) belong to primary school age group. Of 65 cases, 38 were male children and 27 were female children with a male to female ratio 1.4:1 [Table 1] and [Figure 1]. Children belonging to rural area were 62.6% and urban area were 37.4%. Most of the children were living in crowded conditions (80%) with low-socioeconomic status (80.8%) and poor hygiene (74.4%) [Figure 2]. History of regular head bath (22.6%), intrafamilial contact (26.4%), and contact with animals (28%) was present. Majority of the children shared combs (80%). The number of children with tinea capitis were 56 and 60 (74.4% and 80%) living in poor hygienic and overcrowded conditions, respectively. In spite of regular head bath 17 children (22.6%) had tinea capitis. Almost all children (96%) used coconut oil for hairdressing [Table 2].
|Figure 2: (a) Geographical area of distribution. (b) Socioeconomic status|
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Whereas hair loss was a constant symptom in all 65 children, itching and pain were complained by 52 (69.2%) and 15 (20%) children, respectively.
All the clinical variants of tinea capitis except favus variety were identified in the present study.
KOH was positive for fungus in 51 cases (78.4%) [Figure 3], culture was positive only in 43 (57.4%) cases. Of 51 KOH-positive cases, endothrix was noted in 30 (58.8%) followed by ectothrix in 18 (35.4%) and in 3 cases (5.8%) type of hair invasion could not be determined [Table 3].
|Figure 3: Potassium hydroxide -pictures. (a) Fungal hyphae: Multiple refractile, branched, septate and elongated structures (KOH mount). (b) KOH mount: Ectothrix|
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Of 43 culture-positive cases, T. violaceum was isolated in 16 cases (37.5%) followed by T. Mentagrophytes in 11 cases (25.5%), T. tonsurans 8 cases (18.6%), Trichophyton rubrum in 6 cases (13.9%), and Microsporum gypseum only in 2 cases (4.6%) [Table 4], [Table 5] and [Figure 4], [Figure 5]a, [Figure 5]b and [Figure 6].
|Table 5: Correlation between clinical and microscopic types of tinea capitis|
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|Figure 4: Clinical pictures. (a and b) Gray patch. (c and d) Black dot. (e and f) Kerion. (g and h) Agminate folliculitis|
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|Figure 5: (A) Microscopic morphology features of the dermatophytes seen in the study (a) Trichophyton mentagrophytes - Clustered round microconidia are seen. (b) Trichophyton violaceum - Irregular hyphae with intercalary chlamydoconidia. (c) Trichophyton rubrum- Tear-shaped microconidia and pencil-shaped microconidia are seen. (B) Culture on Sabouraud's Dextrose Agar. (a) Trichophyton mentagrophytes - Creamy white colony with cottony mounded surface. No reverse pigment. (b) Trichophyton tonsurans - Suede-like center with feathery periphery with white to yellow color. (c) Trichophyton violaceum - Waxy and heaped, violet or deep purplish red colony. (d) Trichophyton rubrum - Mounded white center with maroon periphery. Maroon reverse pigment. (e) Microsporum gypseum - Flat and granular with tan to buff pigment, no rivers pigment|
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| Discussion|| |
Majority of the children (70.6%) in the study belonged to 5–10 years of age with a slight male predominance (1.4:1) similar to Grover et al.'s study. This could be because the 5–10 years of age group included school going children who were at a higher risk of transmission of the disease because of close contact with each other. Similar to Kamalam and Thambiah studies who observed that tinea capitis was endemic in school children in Madras.
Some authorities believe that tinea capitis may be common in boys due to shorter hair, frequent visits to village barbers, whose unhygienic practices may be a source of transmission, allowing easy access for circulating spores, while others believe that it may be more common in girls due to tight hair braiding.
Children belonging to rural area were 62.6% and urban area were 37.4%. Whereas 80.8% of children belonged to low-socioeconomic group, 56 (74.4%) children were living in poor hygienic and 60 (80%) children in overcrowded conditions. Similar to studies conducted in Delhi had shown that around 68% of patients were from overcrowded areas with low-socioeconomic and hygienic status. The predominance of the disease in rural children may be due to low standard of living, overcrowding, and poor hygiene which is more in rural areas. The factors of low income, overcrowding, and poor hygiene which go hand in hand under low-socioeconomic status can be attributed as causes of tinea capitis.
Tinea capitis was less common (22.6%) in children having regular head bath. In many cases, we have observed a positive history for other forms tinea in the family and similar complaints among siblings.
It is mentioned in the literature that among vegetable oils only the mustard oil has fungi static property. Hence, it can be understood that coconut oil usage in 96% of the affected children in this study might not have given any protection.
Transmission of infection is increased with decreased personal hygiene, overcrowding, and low-socioeconomic status. Apart from close personal contact, transmission can occur through shared brushes, combs, caps, and bed linen as well. Asymptomatic carriers are common making tinea capitis difficult to eradicate.
During the study, we had observed that in this epidemic era of recurrent superficial fungal infections, tinea is one of the most common dermatoses but tinea capitis is neither as common nor as recurrent as other forms of tinea such as tinea corporis and tinea cruris. After treatment with oral and medications, only two cases have reported recurrence of the infection. These two cases were treated with additional 2–3 weeks with the same treatment following which the lesions have subsided.
Of 65 cases, the most common clinical type was gray patch (36.9%) similar to Bhat et al. and Kund et al. study who had noninflammatory variety more common than inflammatory variables with gray-patch type being the most common. However, another study from Karnataka and some studies from Rajasthan and North India demonstrated the black dot to be the most common variant.,,
The most common etiology was T. violaceum similar to other studies,, followed by T. Mentagrophytes, T. tonsurans, T. rubrum, and M. gypseum. This was relatively different from studies conducted in Jammu and Kashmir with T. tonsurans being the most common organism.
[Table 6] shows Comparison of causative organisms of tinea capitis in various studies, conducted all over India. Two studies conducted in Delhi in 60s and 80s has revealed introduction of T. rubrum and Trichophyton mentagrophytes in 80s in addition to T. violaceum and T. tonsurans already existing in 60s. Thus, it is clear that various species and genera are introduced to the population over a period of time.
|Table 6: Comparison of causative organisms of tinea capitis in various studies|
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The better performance of KOH preparation than culture in identifying the fungus can be due to prior use of topical or systemic antifungal drugs resulting in nonviability of fungus and thus cannot be grown on culture.
| Conclusion|| |
Tinea capitis being more common in people of low-socioeconomic status and unsanitary conditions, there is a need to create awareness on its transmission and preventive measures. Fungal culture gives valuable information with respect to species involved in producing the disease. It is beneficial to do fungal culture in addition to direct microscopy examination to rule out bacterial folliculitis, isolate the species, and get the exact diagnosis to treat accordingly. Early detection and proper management are essential to prevent its spread and complications such as scarring alopecia. Increase surveillance in schools coupled with prompt treatment of cases with antifungal is the best approach to limit the continued spread of infection.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Schieke SM, Garg A. Superfi cial fungal infection In: Wolf K, Lowell A, editors. Gold Smith Fitzpatrick Text Book of Dermatology in General Medicine. 8th
ed., Vol. 188. Tata McGraw Hill: Delhi; 2012. p. 2284-7.
Bose SR. Comments on the rarity of tinea capitis in India. Mycopathol Mycol Appl 1964;22:322-9.
Powell A. Ringworm in Assam. Indian Med Gaz 1900;35:109.
Dey NC, Mapplestone PA, Trichophyton crateriformis in India. Indian Med Gazette 1941;76:410-1.
Elewski BE. Tinea capitis: A current perspective. J Am Acad Dermatol 2000;42:1-20.
Manjunath Shenoy M, Suchitra Shenoy M. Superficial fungal infection. In: Valia RG, Valia AR, editors. IADVL Textbook of Dermatology. 4th
ed., Vol. 15. Mumbai: Bhalani Publishing House; 2015. p. 462-70.
Hay RJ, Moore MK. Mycology. In: Burns T, Breathnach S, Cox N, Griffi ths C, editors. Rook's Textbook of Dermatology. 7th
ed. Massachusetts: Blackwell Publishing; 2004. p. 31.1-31.101.
Buckley DA, Keane FM, Munn SE, Fuller LC, Higgins EM, Du Vivier AW. Recalcitrant viral warts treated by diphencyprone immunotherapy. Br J Dermatol 1999;141:292-6.
Gokhale BB, Padhye AA. Tinea capitis. Indian J Dermatol Venereol 1965;31:1-5.
Mahajan VM, Mohapatra LN. Study of human and animal dermatophytoses in rural areas. II. Mykosen 1968;11:793-8.
Nagabhushanam P, Tirumalarao D, Patnaik R. Dermatomycoses in Hyderabad area. Indian J Dermatol Venereol 1969;35:120-3.
Kamalam A, Thambiah AS. Tinea capitis an endemic disease in madras. Mycopathologia 1980;71:45-51.
Sehgal VN, Saxena AK, Kumari S. Tinea capitis. A clinicoetiologic correlation. Int J Dermatol 1985;24:116-9.
Reddy BS, Swaminathan G, Kanungo R. Clinicomycological study of tinea capitis in Pondicherry. IJDVL 1991;57:180-2.
Kalla G, Begra B, Solanki A, Goyal A, Batra A. Clinicomycological study of tinea capitis in desert district of Rajasthan. Indian J Dermatol Venereol Leprol 1995;61:342-5.
] [Full text]
Jha BN, Garg VK, Agrawal S, Khanal B, Agarwalla A. Tinea capitis in Eastern Nepal. Int J Dermatol 2006;45:100-2.
Singal A, Rawat S, Bhattacharya SN, Mohanty S, Baruah MC. Clinico-myocological profile of tinea capitis in North India and response to griseofulvin. J Dermatol 2001;28:22-6.
Grover C, Arora P, Manchanda V. Tinea capitis in the pediatric population: A study from North India. Indian J Dermatol Venereol Leprol 2010;76:527-32.
] [Full text]
Pai VV, Hanumanthayya K, Tophakhane RS, Nandihal NW, Kikkeri NS. Clinical study of tinea capitis in northern Karnataka: A three-year experience at a single institute. Indian Dermatol Online J 2013;4:22-6.
] [Full text]
Bhat YJ, Zeerak S, Kanth F, Yaseen A, Hassan I, Hakak R. Clinicoepidemiological and mycological study of tinea capitis in the pediatric population of Kashmir valley: A study from a tertiary care centre. Indian Dermatol Online J 2017;8:100-3.
] [Full text]
Kundu D, Mandal L, Sen G. Prevalence of tinea capitis in school going children in Kolkata, West Bengal. J Nat Sci Biol Med 2012;3:152-5.
Friedlander SF, Rueda M, Chen BK, Caceros-Rios HW. Fungal, protozoal and helminthic infections. In: Schachner LA, Hansen RC, editors. Pediatric Dermatology. 3rd ed. London: Mosby; 2003. p. 1093-140.
Chen BK, Friedlander SF. Tinea capitis update: A continuing conflict with an old adversary. Curr Opin Pediatr 2001;13:331-5.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]