Treatment Outcomes for Tinea Capitis in a Skin of Color Population

July 2012 | Volume 11 | Issue 7 | Original Article | 852 | Copyright © July 2012

Dhaval Bhanusali MD, Marcelyn Coley MD, Jonathan I. Silverberg MD MPH PhD, Andrew Alexis MD MPH and Nanette B. Silverberg MD

Abstract
Background: Tinea capitis periodically undergoes demographic shifts in causative dermatophyte and therapeutic response to oral anti-fungal therapy.
Objective: To determine prevalent fungal species and response to standard antifungal therapy in inner-city children of color.
Methods: An IRB-approved chart review of demographic, clinical, diagnostic, and therapeutic data was conducted for children and young adults (0 to 18 years of age) who had scalp fungal culture performed for scalp hyperkeratosis and/or alopecia over a 2.5 year time-period. Supplemental parental phone interview was performed for missing data points.
Results: A total of 84 patients with final diagnosis of tinea capitis were identified—52% male, 60.6% African-American, 28.2% Hispanic, and 9.9% Caucasian. Complete resolution at 4 weeks was uncommon in all demographic groups (Hispanic: 11.7%, African-American: 41.3%). The Hispanic group and the youngest patients (aged less than 4 years) were less likely to respond to initial therapy, but the results were not significant. Of the 80 tinea capitis patients initially treated with griseofulvin, 41 out of 54 children (76%) had complete response to micronized suspension +/- crushed tablet (33% required shift to tablets from suspension) and 20 out of 26 (76.9%) cleared on crushed tablets alone. Of the 19 griseofulvin failures, 5 cleared on fluconazole suspension, 7 on terbinafine sprinkles, 3 on itraconazole therapy, and 4 were lost to follow-up. Of the 47 patients who could be evaluated long-term after a single course of oral griseofulvin at 6 weeks or greater, 38 had documented long-term mycological cure (80.8%) and 42 had long-term clinical cure (89%). Trichophyton tonsurans (n=40) was the most prevalent causative species identified on culture, followed by Alternaria species (n=10) and Microsporum canis (n=1).
Limitations: Retrospective chart review: patient population has a high rate of usage of over-the-counter antifungal creams and shampoos, affecting culture results.
Conclusions: Tinea capitis is still the most common cause of Trichophyton tonsurans in New York City. Response rates to griseofulvin are similar to rates seen in the 1970s, but require higher dosing and conversion to crushed tablets in partial responders. Usage of crushed ultramicronized griseofulvin, terbinafine sprinkles, itraconazole, and fluconazole are alternative regimens for those children whose tinea capitis does not clear on griseofulvin suspension.

J Drugs Dermatol. 2012;11(7):852-856.

INTRODUCTION

Tinea capitis (TC) is a dermatophyte infection of the hair shaft and surrounding skin of the scalp, which usually presents with hyperkeratosis and alopecia (annular, diffuse or black dot). Worldwide, TC is the most common pediatric dermatophyte infection1,2 with peak incidence ranging from 3 to 7 years of age.3,4 The prevalence of TC varies by geographically. The prevalence of TC in Europe is 1.5%, whereas in the United States, estimates range from 3% to 8% of the pediatric population.5,6
Since the 1960s, Trichophyton tonsurans has emerged as the main causative organism of TC, now accounting for more than 95% of positive cultures in the United States.7,8,9,10 While T tonsurans represents 60% to 90% of TC infections in the USA, UK, Jamaica, and Brazil, Microsporum canis is still the most common causative agent in much of Central and Southern Europe and Saudi Arabia. 11-14 In 2007, a study described T soudanense and T violacerum as potential causes of TC in a Baltimore hospital.15 There are many proposed theories as to why various causative organisms are inherent to certain parts of the world, including climate, pathogenhost exposure, access to health care, and immigration patterns of humans.16 The latter is an important consideration in a clinic such as ours based in New York City, a metropolis that serves as a melting pot for a variety of immigrant groups.
Since FDA-approval of griseofulvin liquid suspension 40 years ago, dosing of this medication has changed. Most sources agree that the original dosage of 5 mg to 10 mg/kg/day is inadequate 7,17 and that children require 20 mg to 25 mg/kg/day for at least 6 weeks.18 Additionally, some cases do not respond to griseofulvin suspension and need alternative forms of the medication.18 These two concepts, dosing and formulation, suggest that fungal species of TC in the United States are becoming relatively resistant to griseofulvin.
The present study addresses specific response of cases of TC to oral antifungals. We look to further 1) define the causative organisms in this diverse New York City population, 2) assess the response to traditional and non-traditional treatments for