Tinea Capitis, Pediculosis Capitis, Seborrhoeic Dermatitis

Review
Common skin conditionsaffectingthe scalp:
Tinea Capitis,PediculosisCapitis, SeborrhoeicDermatitis, Dandruff,
Psoriasis
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Introduction
-fhe
structure of the skin anrl its firnction r,aries in the diII'erent regions o1'the lxrrh'. The scalp urth its higl <lcnsin'
<lf large hair fbllicles :urd :rbunclanceo1'sebaceousglanclsrunstitutes ir unirlue ar-ea. The sca$ is apparetrtll' less
conclitions of'the scalll will be tliscusse<l: clermatophltic inf'eclion
l)rone to inllarnmation. Sonre <lernrat<>logical
(tinca capitis) :rs a common inl'ectious process allbcting lloth thc skin ancl hair; pe<lictrlosiscapitis, the trnitlue
parasitic infbstati<xr;an<l inflarnmatory rliseases,seborrhocic dernratitis, danclrtdf ancl psoriasis.
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Clinical picture (Figures 1-4)
The clinical picture of tinea capitis
varies greatly and dependsmainly on
Epidemiology
the
type ofoffending agent. In general,
Tinea capitis is causedby a variety of
zoophilic
speciesproduce much more
genera
Microspodermatophytesin the
inflammation
than those which
severe
rum andTrichophyton.In SouthAfrica
(anthropohumans
are
confined
to
it is causedmainly by Microsporum
philic).
In
cases,
the
inflammation
some
canis(white children) and Trichophyton
canbe minimal with delicatescalingand
violaceum(black children).
Tineacapitisaffectsmostly children i n a p p r e c i a b l eh a i r l o s s r e s e m b l i n g
of primary school age. The increased s e b o r r h o e i cd e r m a t i t i s o r a t o p i c
incidenceof tinea among prepubertal dermatitis. In some individuals an
childrenhas beenattributedto reduced asymptomaticcarrier stateoccurs. Most
fungistaticpropertiesof the child's often scalp dermatophytic infection
sebum. However, comparisonstudies manifestsa characteristicloss of hair
o f s e b u m i n p r e p u b e r t a l v e r s u s with "black dots" which reflectsthe
postpubertalchildren failed to reveal hair shafts broken within follicular
real fungistatic diffcrences. Children c a n a l s ( m a i n l y i n T r i c h o p h y t o n
contaminateeach other with combs, violaceum infection). Microsporum
caniscancausemore severelyinflamed
hats,hair care items and the spreadof
lesions with pustules - kerion. This
s o m e a n t h r o p o p h i l i cs p e c i e sl i k e
represents
an immune reaction to a
Trichophytonviolaceumin this way is
and is not a sign of
zoophilic
fungus
more commonin African children. An
superinfection.
infectedcat or dog usuallyservesasthe bacterial
sourceof infection with Microsporum
Di fferen ti al di agn o si s
canis in white children. In family
o u t b r e a k so f t h i s z o o p h i l i c s p e c i e s T h e d i f f e r e n t i a l d i a g n o s i so f t i n e a
p o s t p u b e r t a l i n d i v i d u a l s a r e a l s o capitisincludesseborrhoeicdermatitis,
pityriasis capitis, atopic dermatitis,
occasionallyaffected. Tinea capitis in
adults is rare. It must. however,be psoriasis,furunculosis,alopeciaareata
consideredwhen patientspresentwith
and trichotillomania.
a t y p i c a ls c a l p l e s i o n s . T h i s i s o f
particular significance in the elderly. Diagnosis
The diagnosisof tinea capitis is based
Whether this increasein frequencyin
the elderly is secondaryto differences on typical clinical picture - patchy
in the sebumis soeculative.
alopecia,brokenhairs,scaling,cervical
TINEA
CAPITIS
adenopathy. Confirmation of tinea
capitis may be made by direct microscopic examinationof an infectedhair
and by fungal culture. Only culture
identifiesthe species.
Treatment
Tinea capitis needs to be treated with
an oral agent becausethe antifungal
remedy has to penetrateinto the hair
follicle. Sole therapywith topical
antimycoticagentsis usually ineffective.
Griseofulvin taken orally at a dose
of 15-25mglkgldayis still thetreatment
of choice for tinea capitis. As a fatty
meal enhancesgriseofulvin absorption
it should be taken during a meal or
directly after food. Treatment for 6-8
weeks usually suffices but it is
recommendedto perfom culturesevery
few weeksand to continuethe treatment
u n t i l t h ec u l t u r ei s n e g a t i v e .
The main cause of tinea capitis in
South African white children, Microsporum canis, appearsto be highly
sensitiveto griseofulvin. Griseofulvin
is a safe medication and the routine
monitoringof hepaticandhaemopoietic
parametersis rarely necessaryin healthy
children.
Itraconazole(Sporanox@)has been
found to be very effective in tinea
capitis. Itraconazoleshould be dosed
accordingto body weight at about 3 to
5 mgkglday. A continuoustherapywith
itraconazole( l00mg/day) for 4-6 weeks
SA liarn Plact 2(X)3;trri(ll)
has been reported as very effective.r'2
Availability of itraconazolein a liquid
formula (Sporanox@oral solution)
permits the administration of a more
precisedosethanusing the non divisible
capsules.Guptaet a1.3
usedintermittent
pulse therapy, Smglkglday; each pulse
lastedoneweek,with two weeksoff the
drug betweenthe first and secondpulses
and threeweeks off betweenthe second
and third pulses. The third pulse was
not necessaryin every patient. In this
study, itraconazole was found to be
effective and resulted in both clinical
and mycologic cure. In itraconazole
pulse therapy the drug is largely
eliminated from the plasma within 7 to
l0 days,therebyreducingthe potential
for adverseeffects. Itraconazoleshould
not be used with terfenadine or other
nonsedatingantihistaminesowing to
potentialcombinedcardiactoxicity.
Fluconazole (Diflucan@), another
azole antifungal, was also found to be a
promising drug for tinea capitis.a A
continuoustreatmentwith a dose of 5
mglkglday for 4 weeks was found
effectivein casesoftinea capitiscaused
by Trichophytonspecies. Availability
of fluconazole in oral suspension
(Diflucan@ susp.)makes it a useful
alternativein paediatricpatients.
Terbinafine(Lamisil@),a memberof
the allylamine family, is also a useful
agentin tineacapitis. It appearsvery
effective in infections with Trichophyton violaceum. The dose of 62,5-250
mglk{day for 4-6 weeks,dependingon
body weight, is usually required in
infections causedby this fungus.
Microsporum canis usually requires
higher dosesand a longer period of
administration, l0 to l2 weeks.
Terbinafine,initially consideredfree of
any side-effectpotential,lost a bit ofits
imocuous image since with wide use
several unwanted effects have been
reported(most often blood dyscrasisias
and hepatotoxicity). It is nevertheless
a safe drug and there do not seemto be
any absolutecontraindications.
PEDICULOSIS
(HEAD LICE)
CAPITIS
Headlice (Pediculosishumanuscapitis)
aretransmittedamongpersonsliving in
unhealthy, crowded conditions and
SA l'am Pmtt 2003:45(ll)
sharinghats,brushesand combs. Long
hair andelaboratestylesofhairdressing
which prevent frequent washing
increasethe susceptibility.Head lice is
most common in children but no age is
immune. The eggs are attachedto the
hair andwhen they hatch,numerousnits,
resembling dandruff, are left behind.
These are seen mainly in the occipital
and postauricular regions. Pruritus is
the most characteristicmanifestation.
Scratchingoften leads to secondary
infectionand the occipitallymph nodes
are frequently enlarged. The diagnosis
is often missedwhen the possibility is
not considered. Nits firmly attachedto
the hair shaftsare not easilypulled off.
This differentiates them from dandruff
scales.
The treatmentof choice is to apply
Permethrin lo/o cream rinse. Application of Permethrinshould be preceded
by a regular shampooingand towel
drying. Permethrinhas to be applied to
the hair and scalp for l0 minutes and
then rinsed off with water. A single
treatment is usually sufficient.
Permethrin is safe for children over 2
yearsofage.
An alternative therapy is to apply
10% Crotamiton cream (Eurax). It is
left on the scalp for 24 hours and then
shampooed. This treatment can be
repeatedin 7-10 days,if necessary.
presenceof Pityrosporum ovale may
well be a secondaryand not primary
event.
Clinically seborrhoeicdermatitisof
the scalp presentsas areasof erythema
covered by yellow, greasy scales.
Lesions often extend beyond the
margins of the hair onto the forehead
and behind the ears. Seborrhoeic
dermatitis may be associatedwith
transientalopecia.
Tteatment
T h e s e b o r r h o e i cs t a t e i s p r o b a b l y
genetically determinedand eradication
(completepreventionofrelapses)in the
predisposedindividuals is rather
unlikely. What can be done is to reduce
both scaling and the inflammation.
The scalp should be shampooed
frequently, daily or every other day in
severeacutephase,lessoften later on.
There are severalmedicatedshampoosto choosefrom: seleniumsulfide
(Selsun@),tar (Polytar@,Alphosyl@),
(Nizshampoo@).
ketoconazole
Altemating different types of medicated
their efficacy.
shampoosoftenincreases
Shampoosshould be rubbed into the
scalp and left for 5-10 minutesbefore
rinsed out. The length of time the
shampoostayson the scalpappearsless
important than the frequency of
shampooing. In more resistantcases,
t o p i c a l c o r t i c o s t e r o i d sa r e r e c o m SEBORRHOEIC
mended (Procutane@lotion, BetnoDERMA'TITIS
OF THE SCALP
vate@ scalp application, Diprolene@
scalp lotion, Elocon@ lotion and
(FTGURES 5 AND 6)
others). The degreeof scalp inflammaSeborrhoeicdermatitisis a common tion will dictate the potency of the
i n f l a m m a t o r yc o n d i t i o np r e s e n t i n g topical corlicosteroidused.
The treatment of seborrhoeic
clinically as erythematous,scaling
e r u p t i o n , l o c a l i z e d t o t h e s c a l p , dermatitis of the scalp in people of
eyebrows, postauricular areas, central African descent will differ from the
abovegeneralrecommendation.Daily
face,centralchestandback and flexural
areas,the so-calledseborrhoeicareas. shampooingis too drying for black
Although theselesionsarecommon and people hair and rather impractical for
are clinically quite distinctive the cause many African femaleswith hot-pressed
of seborrhoeic dermatitis remains hair. The medicatedshampooshould
elusive. The seborrhoeicstateis asso- be appliedlessoften, once a week,but
ciated with increasedsusceptibility to
for a longertime, 20 to 30 minutes.This
pyogenic infections and invasion by
shampooshould be followed by a
Pityrosporum ovale. Whether Pityrononmedicatedshampooand the usual
s p o r u m o v a l e c a u s e s s e b o r r h o e i c moisturizersor conditioners.Whenthe
dermatitis is not clear. Scalp scales scalp is considerablyinflamed or there
produced by seborrhoeic dermatitis is no responseto the shampoostopical
provide a good nutrient for the growth
steroidsshouldbe applied. Often more
of this lipophilic yeast and increased fatty vehiclesshouldbeused,ointments
ratherthanlotionsandgels,particularly the entirescalp.Frequentlythepsoriatic
lesionsextendbeyondthehairline,rnost
in f-emales
with hot-pressed
hair.
ofien to tho forchead and into
postauricular
regions. flair loss is not
DANDRUFF (PITYRIASIS
common but does occur cspeciallyin
CAPITIS)
s e v e r ee r y t h r o d e r m i ca n d p u s t u l a r
p s o r i a s i s .I t i s u s u a l l yt r a n s i c n a
Is
In dandruif there is desquamationof
small, flaky scalesf}om an otherwise resultingfiom increasedsheddingof
normalscalp.The aetiologyof dandruff t e l o g e nh a i r s . l f t h e r e a r e n o p s o r i a t i c
i s n o t c l e a r a n d t h e l i t e r a t u r e i s l e s i o n s e l s e w h e r e i, t m a y b e v e r y
confusing.5It is usuallyacceptedthat difficult to distinguishpsoriasisfrom
dandrutf and seborrhoeicdermatitis seborrhoeicdennatitis.Takinga biopsy
r e p r e s e n t st w o e n d s o f a d i s e a s c doesnot help.
spectrum.Similarremedies,
medicated
shampoos,
werefbundequallyeftbctive
in thetreatmentof bothconditions.As
i n s e b o r r h o e i cd e r m a t i t i ss h a m p o o s
containingtar, salicylicacid, selenium
sr"rlfide and ketoconazole are
recommended.Usually twice weekly
usagecontrolsthe scaling.
PSORIASIS OF THE SCALP
(FTGURES 7 AND 8)
Psoriasisaffectsapproximately2%oof
t h e w o r l d p o p u l a t i o na n d s c a l p i s
involvedin about50% ofall psoriatics.
Usually there are psoriaticlesions
elsewhere
but the diseasecanbe limited
to the scalp.
Psoriasisof the scalppresentsaswell
d e m a r c a t e de r y t h e m a t o - s q u a m o u s
plaquescoveredby thick silveryscales.
In severeinvolvementtheplaquescover
or tbarnsshouldbe applied. The usual
a p p l i c a t i o ns c h e d u l ec o n s i s t s o f
interrnittentapplications3 to 4 times
wcekly. VitaminD3 analoguecalcipotriol (DovonexO)has a substantial
efl'ect.It is availablein a
antipsoriatic
lotion fbrrnulationfor the treatmentof
the scalplesions. It hasto be notedthat
maximumefficacyof calcipotriollotion
is reachedafter8 weeks,whereasmaximal efticacy of a topical corticosteroid
is reachedafler 2 to 3 weekstreatment.
Calcipotriol can be combinedwith a
topical corticosteroidformulation,after
d e s c a l i n g ,a p p e a r sa t t h e m o m e n t ,
Treatmenf
p s o r i a s i s optimal therapeuticapproachfor scalp
l n a p a t i e n tw i t h e x t e n s i v e
D
i n v o l v i n g s e v e r a l o t h e r t h a n s c a l p psoriasis.
regionssystemictreatmentwith wellestablishedmodalities.i.e. methotre- References
l. LegendreR. Esola-MacreJ. Itracouazolein
xate, cyclosporine,acitretin,leadsto
the trcatrnentol tinea capitis. J An ,4cucl
clearance
of the scalplesionsas well.
D e r n u r t o l 1 9 9 0 "2 3 : 5 5 9 - 5 6 0 .
Local treatmentincludesusageof
2. Greer DL. Treatrnentof tinea capitis with
m e d i c a t e ds h a m p o o sc o n t a i n i n gt a r .
itraconazole. J An ,lccrd Dermarol 1996.
3 5 : 6 37 - 6 38 .
in lotions
salicylicacid,corlicosteroids
l. Gupta AK. Adam P. Dc Doncker P. ltracoor gelsand Vit. D analogr-res.
nazolepulsetherapytirr tineacapitis: A new
Firstly, the excessof scaleshas to
treatmcnt schcdule.Peclialrit Dernlalol
be removed. Salicylicacid 5 to l0%
1998. l5:225-228.
exerts a good keratolytic eff'ect. lt is 4 . M e r c u l i c oM G . S i l v e r na, n R A . E l e w s k iB E .
Tinea capitis: Fluconazolein Trichophyton
fonnulated in an ointrnentthat can be
t o n s u r a n si n t t c t i o n . P e d i u t r i c D e r m u t o l
washedoffeasily. Patientsshouldapply
1998. 15:229-232.
the formulation overnight, preferably 5. ShusterS. The aetiologyofdandruffand the
m o d e o f a c t i o n o f t h e r a p e u t i ca g e n t s .B / i / J
under a bathing or shower cap to enD e n n u t o l 1 9 8 , + I. I l : 2 3 5 - 2 4 2 .
hancethe absorptionof the medication.
6. Van de Kerkhof PC, FranssenME. Psoriasis
After the removal of the scales
o f t h e s c a l p . D i a g n o s i sa n d m a n a g c m e n t .
in lotions,gels
topical corticosteroids
A m J ( ; l i n D e m n t o l 2 0 0 1 ,2 : 1 5 9 - 1 6 5 .
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Figures l-4: Various clinical presentationsof tinea
Figure 1: Mildly inflamed, loss of
hair, follicular accentuation.
Infection causedby Trichophyton
species.
Figure 2: Small patch of alopecia
with scaling causedby
Microsporum canis.
Figure 5: Seborrhoeic dermatitis.
Small. fine scales.no infiltration.
Figure 3: Numerous more inflamed
lesionscausedby Microsporum
canis.
Figure 4: Kerion (Microsporum
canis)
Figure 8: Psoriasis. Lesions extend
beyond the hair line.
Figure 6: Seborrhoeic dermatitis.
Severe involvement, pyogenic
superinfection.
SA Farn Pract2003:45(U)
Figure 7: Psoriasis. Clearly defined
infiltrated patches with white
scales.