TINEA CAPITIS IN AN ADULT AFTER LOCAL CORTICOTHERAPY - Folha Médica 1995;110(1):73-76

Marcia Ramos-e-Silva, MD, PhD
Beatriz Moritz Trope, MD
Maria Julieta Caiuby, MD
Tania Ludmila de Assis, MD, PhD
Absalom Lima Filgueira, MD, PhD

From the Section of Dermatology - HUCFF
Universidade Federal do Rio de Janeiro
Brazil

ABSTRACT
A case of Tinea Capitis in an adult caused by Trichophyton tonsurans is described. The patient had no signs of systemic immunossupression but was using topical corticosteroid at the site of the infection. The lesion resembled seborrheic dermatitis. Trichophyton tonsurans seems to be increasing as a cause of tinea capitis specially in adults in Rio de Janeiro, Brazil. Its clinics and epidemiology are discussed.

KEYWORDS: Dermatology, Epidemiology, Tinea capitis, Trichophyton tonsurans.

TINEA CAPITIS IN AN ADULT AFTER LOCAL CORTICOTHERAPY
Tinea Capitis is incomum after puberty unless accompanied by severe systemic immunosuppression. We had the opportunity to diagnose and treat a 22-year-old white female patient who developed the disease on the occipital region. The lesion resembled seborrheic dermatitis which the patient had chronically and for which persistent local use of a corticosteroid solution was being perfomed. The mycologic examination showed that Trichophyton tonsurans was responsible for the infection. The patient and her sister had previously Tinea Corporis caused by the same fungus.

CASE REPORT
A 22-years-old white woman, nurse student, born and living in the urban area of Rio de Janeiro, complained of hair loss for the past two weeks. The patient referred scaling and itching on the occipital region which appeared a few days before she noted a patchy area of hair loss. On her general physical examination, there were no abnormalities except for two enlarged lymphnodes on the right cervical region.

On dermatological examination, a single dry, descamative patch with diffuse and very discrete alopecia was found (Fig. 1). Few hairs were broken off just below the scalp surface giving the appearance of "black dots", although most of them seemed normal. At the border of the patch, there were some very tiny pustules. The lesion had approximately 5 cm., it was located at the occipital region and did not show fluorescence with the Wood's lamp.

The patient also presented three erythematous and scaly patches with circinated borders and a tendency to central healing, varying from 1.5 to 4 cm. located on the right arm (2 lesions) and trunk (1 lesion).

There was a past clinical history of seborrheic dermatitis of the scalp and face being treated with topical corticosteroid solution (halcinonide) and her sister had previously tinea corporis caused by Trichophyton tonsurans.

The diagnostic hypothesis for the scalp lesion were:
1. exacerbation of the seborrheic dermatitis with hair loss;
2. tinea capitis facilitated by the local corticotherapy used for the presumed seborrheic dermatitis.

The trunk and right arm lesions were clinically compatible with tinea corporis.

The mycological examination revealed, on direct exam of the scales taken from the trunk lesion, septated hyphae and arthrospores (Fig. 2) and, from the hair fragments taken from the scalp lesion, large spored endotrix parasitisme (Fig. 3).

The culture in Sabouraud's Agar obtained from the scales of the trunk lesion and from the hair fragments of the scalp lesion was characterized, macroscopically, by velvety colonies with short aerial hyphae. They were gray to sulfur yellow in color and the surface pattern showed some folds with a raised tuft at the center of the colonies (Fig. 4). The reverse side of the colonies had a yellow brown color.

On the optic microscope, the cultured fungus presented septated hyphae and clavated or tear-shaped microconidia that grew laterally in clusters from multiple branched thickened terminal hyphae or on simple conidiophores. (Fig. 5).

The conclusion was Trichophyton tonsurans and, with this diagnosis of tinea capitis and tinea corporis confirmed, the patient started oral griseofulvin at a dosage of 500mg daily during forty days and the use of halcinomide solution was suspended. There was total recovery with complete hair growth 30 days after the therapy was initiated.

DISCUSSION
Tinea capitis is common in children affecting boys more than girls probably because short hairs help implantation of spores1. Although very rare after puberty, when it occurs, it is often associated with the infection simultaneously at another site (tinea corporis, tinea cruris, etc.) which is not so frequent in children2.

In adults it affects mostly women3 and the area of choice is the occiput. There is usually a trigger factor such as diabetes mellitus, pulmonary tuberculosis, immunodefficiency, malnutrition, drugs or some other factor that causes immunossupression2. It is not infrequent in transplanted patients or in those with systemic lupus erythematosus4.

The increase in the production of saturated fatty acids with fungistatic activity in the sebum by the action of androgenics hormones could be responsible for the spontaneous cure of tinea capitis which occurs right after puberty5, although Kligman6,7 thinks that the infection simply undergoes spontaneous resolution at any age. Prepubertal infections by T. tonsurans do not resolve at puberty as do the infections by Microsporum3 and Kamalam2 supposes that sebum is not of much value against the Trichophyton species.
T. tonsurans is an anthropophilic organism, transmitted from one person to another8. It produces large spores9. It is one of the fungus responsible for the so-called endotrix parasitisme where the organism grows into the hair follicle, penetrates the hair shaft and grows downward inside the hair. Destruction of keratin makes the hair so fragile that it breaks at or below the surface. The "black dots" describe the appearance of the broken hair tips which are often curled or deformed at the mouth of the follicles10. As the lesion extends centrifugally, central areas may recover and the hair may regrow8.

The clinical manifestation of T. tonsurans' tinea capitis is not specific and frequently appears in the form of an irregular alopecia with scaling or as a seborrheic dermatitis-like scaling without loss of hair11, which is easily confused with dandruff 1. This 'black dot ringworm' or endotrix tinea capitis sometimes presents great difficulty for its clinical differentiation from seborrheic dermatitis. Other differential diagnosis are psoriasis, folliculitis and chronic lupus erythematosus12. The hairs infected by T. tonsurans do not fluoresce under the Wood's lamp which also makes the diagnosis more difficult 8,13.

The geographic distribution and prevalence of dermatophytes are not static but change under the influence of various forces such as climate, migration of peoples and developments in prophylaxis and therapy14. T. capitis has declined dramatically in the USA and most industrialized nations since the introduction of griseofulvin in the late 1950's 15.

T. tonsurans is now the major cause of tinea capitis in the USA8,15,16 but until some years ago it was Microsporum canis and M. audouinii8,16. This fungus has been the major cause of tinea capitis in Chicago over the past 20 years3; in New York where it predominantly infects black children (30 cases out of 31)11 and in Philadelphia since 197917.

The incidence of the dermatophytes causing tinea capitis varies greatly. In Western Australia its major cause is M. canis18 as it is in Umbria, Italy19 and Uruguai20; in Madras, India, it is T. violaceum2; in Tel Aviv, Israel, T. schoenleinii21; in Ile-Ife, Nigeria, M. audouinii22 and in South Africa, T. violaceum4.

Garcia-Perez & Moreno-Gimenez23, reviewing the literature on tinea capitis in adults, found 39,59% of the cases caused by T. tonsurans. In Japan only a few cases of T. tonsurans have been reported9 and in Israel among 1000 cases of dermatophytosis, Alteras & Lehrer21 could not find a single case of tinea capitis produced by T. tonsurans.

Furtado, Ihara & Maroja24, in Manaus, State of Amazon, found among 115 cases of tinea capitis, 91,7% caused by T. tonsurans, 13,9% in adults and 52,2% in women. In Rio de Janeiro, Brazil, some cases of tinea capitis in adults due to M. canis and T. tonsurans have been reported25,26,27.

In Brazil the most common fungus found as causative agent of tinea capitis is Microsporum canis which is ectotrix and zoophilic. Trichophyton violaceum is also found28. The endotrix and anthropophilic Trichophyton tonsurans was not very common among us in Rio de Janeiro but it seems to be increasing as the cause of the urban cases of non-inflammatory tinea capitis specially in adults.

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Fig. 1: Aspect of the lesion on the occipital region: a single dry, descamative patch with diffuse and very discrete alopecia.
Fig. 2: Direct mycological exam of the scales from the trunk lesion: septated hyphae and arthrospores.
Fig. 3: Direct mycological exam of a hair fragment: endotrix type of parasitisme with the large spores.
Fig. 4: Macroscopy of the colony: velvety surface, short aerial hyphae, gray to yellow color and raised central tuft.
Fig. 5: Microscopy of the colony: septated hyphae and characteristic clavated or tear-shaped microconidia that can grow to various sizes laterally in clusters from the hyphae.