Clinical review

Tinea capitis in adults

Deirdre A Buckley, specialist registrar,  L Claire Fuller, consultant,  Elisabeth M Higgins, consultant,  Anthony WP du Vivier, consultant. 

Department of Dermatology, King's College Hospital, London SE5 9RS

Correspondence to: D A Buckley, Department of Dermatology, Ealing Hospital, Southall, Middlesex UB1 3HW BillP{at}doctors.org.uk

Tinea capitis (scalp ringworm) is uncommon after puberty. When it occurs in adults the clinical features may be atypical and this may delay the diagnosis.¹ Unless the possibility of dermatophyte infection is considered, unnecessary investigations may be performed and inappropriate treatment prescribed, as illustrated in the four cases described below.

	Case reports

Top Case reports Discussion References

Case 1
A 45 year old Afro-Caribbean woman had had an itchy pustular eruption of the scalp with associated hair loss for several months. Her general practitioner had treated it unsuccessfully with neomycin and gramicidin ointment and oral flucloxacillin and metronidazole. During this period the woman underwent lymph node aspiration and chest radiography because she had an enlarged but painless cervical lymph node. Cytological examination showed a mixed population of lymphocytes, indicating reactive changes; in addition, the surgical house officer observed that the woman had "quite a nasty rash on her scalp."

View larger version (73K): [in this window] [in a new window]   Fig 1.   Circumscribed areas of alopecia on the crown in case 1, with inflammation, pustules, and scaling

Case 2
A 45 year old Afro-Caribbean woman had recurrent scabs and pustules on her scalp for several months. These did not respond to any one of several different antibiotics prescribed by the woman's general practitioner. Other family members were not affected. When the patient was seen in our department, she had an area of alopecia with pustules, crusts, and a boggy mass, which was clinically consistent with a kerion (fig 2). No pathogens were cultured from bacterial swabs, but T tonsurans was isolated from hair samples. The woman's symptoms resolved completely after six weeks' treatment with terbinafine (250 mg daily), and her hair gradually grew again over six months.

View larger version (75K): [in this window] [in a new window]   Fig 2.   Boggy mass on the scalp of patient 2, with overlying alopecia, pustules, and crusts

Case 3
A 35 year old Afro-Caribbean man attending our department with lichen planus of the trunk was noted to have a pustular scalp eruption with scarring alopecia. This condition did not respond to topical steroids and antifungal shampoos prescribed by the patient's general practitioner. A diagnosis of folliculitis decalvans was suspected. Culture of bacterial swabs was negative, but T tonsurans was detected in hair plucks sent for mycology tests. In recent months, his three children (aged 2, 7, and 9 years) had developed scaly patches on the body, and one had recently developed alopecia. The father's scalp condition cleared after one month's treatment with terbinafine (250 mg daily), but he was left with residual scarring. The children responded to oral griseofulvin.

Case 4
A 24 year old Afro-Caribbean man developed alopecia, pustules, and scaly patches on the scalp. These did not respond to treatment with a potent topical steroid and oral flucloxacillin. The patient was referred to the dermatology clinic. Further questioning revealed that his sister's children had been treated for ringworm a few months earlier. T tonsurans was isolated on culture, and the condition cleared completely after a one month course of terbinafine (250 mg daily).

	Discussion

Top Case reports Discussion References

The quantity of fungistatic saturated fatty acids in sebum increases at puberty, and this is thought to explain the rarity of tinea capitis in adults.² Dermatophytic colonisation of the scalp disappears at puberty.^1-3 Colonisation by Pityrosporum orbiculare may interfere with dermatophyte contamination, and the thicker calibre of adult hair may protect against dermatophytic invasion.¹ Tinea capitis in adults generally occurs in patients who are immunosuppressed and those infected with HIV.¹ In immunocompetent adults, the clinical features are often atypical.¹ The disease may resemble bacterial folliculitis, folliculitis decalvans, dissecting cellulitis, or the scarring related to lupus erythematosus. ^{3 4}

In recent years, the incidence of tinea capitis has increased in the United Kingdom, particularly among Afro-Caribbean children living in large cities. ^{5 6} The mean age of patients is 5-6 years, and several siblings may be affected.⁵ The mean prevalence of culture positive tinea capitis in a 1996 school study from south east London was 2.5% (range 0%-12%).⁷ A further 4.9% of these children were asymptomatic carriers (range in classes 0%-47%). Many adults acquire tinea corporis from infected children, but tinea capitis is rare in adult contacts. It is recommended, however, that adult family members should be treated prophylactically with antifungal shampoos as they may be asymptomatic carriers of the dermatophyte.⁸

Between September 1997 and May 1998, we saw four cases of scalp ringworm in Afro-Caribbean adults. The delay in diagnosis was considerable in all these patients. This resulted in disfiguring hair loss, unnecessary invasive investigations, the development of scarring, and the spread of infection to other family members. We wish to alert colleagues to the possibility of tinea capitis in any adult with a patchy, inflammatory scalp disorder and to emphasise that mycological samples should be sent for laboratory analysis in all these patients.

	Acknowledgments

   Contributors: DAB, LCF, EMH, and AWPduV were all involved in treating the patients. DAB wrote the paperl LCF, EMH, and AWPduV revised the paper. DAB and AWPduV are guarantors for the paper.

	Footnotes

Funding: None.

Competing interests: None declared.

	References

Top Case reports Discussion References

1.	Cremer G, Bournerias I, Vandemeleubroucke E, Houin R, Revuz J. Tinea capitis in adults: misdiagnosis or reappearance? Dermatology 1997; 194: 8-11[Medline].
2.	Rothman S, Smiljanic A, Shapiro AL, Weitkamp AW. The spontaneous cure of tinea capitis at puberty. J Invest Dermatol 1947; 8: 81-98.
3.	Pipkin JL. Tinea capitis in the adult and adolescent. Arch Dermatol Syphilol 1952; 66: 9-40.
4.	Sperling LC. Inflammatory tinea capitis (kerion) mimicking dissecting cellulitis. Occurrence in two adolescents. Int J Dermatol 1991; 30: 190-192[Medline].
5.	Buckley DA, Austin G, Armer J, Leeming JG, Moss C. Trichophyton tonsurans infection in Birmingham. Br J Dermatol 1996; 135(supp 47): 21.
6.	Fuller LC, Child FC, Higgins EM. Tinea capitis in south-east London: an outbreak of Trichophyton tonsurans infection. Br J Dermatol 1997; 136: 139[Medline].
7.	Hay RJ, Clayton YM, de Silva N, Midgley G, Rossor E. Tinea capitis in south-east Londona new pattern of infection with public health implications. Br J Dermatol 1996; 135: 955-958[CrossRef][Medline].
8.	Management of scalp ringworm. Drug Therap Bull 1996; 34: 5-6.

(Accepted 7 October 1999)