Tinea Capitis in Elderly Women: A Report of 4 Cases

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Morell, M.J. Fuente, A. Boada, J.M. Carrascosa, C. Ferrándiz" "autores" => array:5 [ 0 => array:4 [ "nombre" => "L." "apellidos" => "Morell" "email" => array:1 [ 0 => "laiamorell@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M.J." "apellidos" => "Fuente" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Boada" ] 3 => array:2 [ "nombre" => "J.M." "apellidos" => "Carrascosa" ] 4 => array:2 [ "nombre" => "C." "apellidos" => "Ferrándiz" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Dermatología, Hospital Universitari Germans Trias i Pujol, Badalona, (Barcelona), Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tinea capitis en mujeres de edad avanzada: descripción de 4 casos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1150 "Ancho" => 1542 "Tamanyo" => 200649 ] ] "descripcion" => array:1 [ "en" => "Case 4. Inflammatory, crusted plaque on the patient's scalp. Fungal culture was positive for Trichophyton mentagrophytes." ] ] ] "textoCompleto" => "IntroductionTinea capitis was thought to be found almost exclusively in children<a class="elsevierStyleCrossRefs" href="#bib0005">1–4</a> and most commonly caused by Microsporum audouinii or Microsporum canis.<a class="elsevierStyleCrossRefs" href="#bib0010">2–7</a> In recent years, however, the epidemiological profile of the disease has changed in terms of both incidence and causative agents, and its prevalence has increased in adult patients, especially elderly women.<a class="elsevierStyleCrossRefs" href="#bib0015">3–7</a> In order to correctly diagnose and manage tinea capitis, physicians need to be familiar with the clinical signs of the disease in elderly patients, as well as the therapeutic responses seen in this age group.We present 4 cases of tinea capitis in elderly women with atypical clinical manifestations and pathogens (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). All 4 cases were diagnosed in the dermatology department of our hospital in the past 6 months.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Case DescriptionsCase Description 1The patient was a 71-year-old woman who presented with hair loss and pruritic lesions on her back and scalp. The symptoms had first appeared 3 months earlier. The patient had been diagnosed with eczema and had received treatment with topical corticosteroids for several months. The pruritus had decreased slightly, but the alopecia had progressively worsened. The patient had not been in contact with animals. Physical examination revealed a scaly, erythematous annular plaque covering the neck and the upper third of the back. A large alopecic plaque with abundant whitish desquamation was present on the scalp (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), and hair fell out easily with traction. Skin-scale and hair samples were collected for direct microscopic examination using the potassium hydroxide technique, which revealed hyphae, and for culture, which was positive for Trichophyton tonsurans. Oral treatment with itraconazole (200mg/day) resulted in marked improvement in the lesions at 1 month. After that, however, improvement slowed, despite the fact that the patient reported taking the drugs correctly. Clinical symptoms persisted and cultures were still positive 7 months after the start of treatment. The treatment was therefore changed to oral terbinafine (250mg/day), which resulted in complete resolution within 1 month.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Case Description 2The patient was a 65-year-old woman who presented with slightly pruritic scalp lesions that had appeared 3 months earlier. During the preceding 3 months, she had received treatment with topical corticosteroids, antibiotics, and ciclopirox olamine shampoo, but her condition had not improved. The patient had not been in contact with animals or with people who had similar lesions. Physical examination revealed an erythematous, partially alopecic plaque on the cranial vertex characterized by superficial crusts and pustules (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Histopathologic examination of the biopsy specimen revealed clear evidence of folliculitis and a granulomatous foreign-body reaction. The bacterial culture was negative and Trichophyton rubrum colonies were isolated in the fungal culture. Oral treatment with itraconazole (200mg/day) was initiated and the clinical and microbiologic symptoms resolved completely after 6 weeks.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Case Description 3The patient was a 69-year-old woman who presented with a crusted tumoral growth on her scalp that had appeared 6 weeks earlier. She had received no prior topical or systemic treatment. Physical examination revealed a crusted lesion on the back of the head. The crust concealed fleshy exophytic granulation tissue. Fungal culture was positive for T tonsurans. Eight weeks after oral treatment with terbinafine (250mg/day) was initiated, there was still some evidence of scarring alopecia but no signs of inflammation, desquamation, or traction hair loss.Case Description 4The patient was a 72-year-old woman who presented with a 3-week history of 2 crusted, inflammatory lesions on her scalp. She had completed a 3-day treatment with topical corticosteroids and oral cloxacillin. The perilesional erythema had resolved but the rest of the lesion had not improved. The patient had no fever or other symptoms. Physical examination revealed one crusted lesion on the left parietal-temporal region of the scalp (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) and another on the forehead. The crust was removed from the lesion on the forehead, revealing an eroded surface with suppuration at various points. Regional lymph nodes were enlarged and palpable.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Although an initial biopsy showed nonspecific changes, a second histologic study revealed the presence of mixed dermal infiltration with numerous eosinophils, as well as spores and filaments inside the follicles. These findings, together with positive culture results, allowed us to establish a diagnosis of Trichophyton mentagrophytes infection. Oral treatment with itraconazole (200mg/day) was initiated. The symptoms improved slowly, resolving completely within 35 days of the start of treatment.DiscussionThis case series shows that scalp ringworm in elderly patients is relatively common and often presents with atypical clinical characteristics. Low clinical suspicion can lead to inappropriate empiric treatments that delay diagnosis and complicate the therapeutic response.Tinea capitis is usually seen in children between the ages of 3 and 7.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Although the disease was once thought to be rare in adulthood, a growing number of authors have reported an increase in tinea capitis among adults, particularly menopausal and elderly women.<a class="elsevierStyleCrossRefs" href="#bib0010">2–6</a>Factors that may favor the development of the disease at this age include hormonal changes, the use of certain hair-care products, and using the services of hair salons, which can be a source of infection.<a class="elsevierStyleCrossRefs" href="#bib0030">6,7</a>In most of the cases that have been reported, including our own case series, diagnosis was delayed.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> This delay is probably due to both the rarity of this infection in adults and its atypical clinical manifestations, which can be confused with inflammatory processes such as seborrheic dermatitis or psoriasis. Atypical manifestations seem to be more common in patients infected with T tonsurans (as in 2 of our cases), who often present either diffuse desquamation with mild alopecia and lesions suggestive of seborrheic dermatitis or pustular inflammatory lesions and associated regional lymphadenopathy, a clinical picture that can lead to an incorrect diagnosis of bacterial infection.<a class="elsevierStyleCrossRefs" href="#bib0020">4,5,8,9</a> Although M canis remains the most common causative agent of tinea capitis in southern Europe, with a prevalence greater than 80%,<a class="elsevierStyleCrossRef" href="#bib0015">3</a> the epidemiology of these infections has changed considerably in recent years. A growing number of cases have been attributed to the following species: T mentagrophytes, Trichophyton verrucosum, T tonsurans,<a class="elsevierStyleCrossRefs" href="#bib0015">3,10,11</a> and T rubrum.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> Specifically in Barcelona, T mentagrophytes<a class="elsevierStyleCrossRef" href="#bib0060">12</a> has been highly prevalent, whereas T tonsurans is the species most frequently isolated in the United States, the United Kingdom, and Canada.<a class="elsevierStyleCrossRefs" href="#bib0015">3,13,14</a>These changes are attributable to many factors, in particular the rise of travel to endemic areas and the migratory flows from the Southern to the Northern hemisphere. In addition to facilitating contagion, migration has also helped to spread species endemic to Africa and Asia–generally anthropophilic fungi–to urban areas in Europe, especially neighborhoods where immigrants make up a high percentage of the population.<a class="elsevierStyleCrossRefs" href="#bib0050">10,11,14</a> In keeping with what seems to be the current trend for this disease, the species found in our 4 patients–all city dwellers–were anthropophilic.It should be noted that fungal culture was essential to either confirming the clinical suspicion or redirecting the diagnosis in all 4 cases. Fungal culture should therefore be used routinely in cases of desquamative conditions of the scalp that involve pruritus or an inflammatory appearance, especially in elderly patients whose symptoms do not respond satisfactorily to the prescribed treatment. It should also be emphasized that patients with fungal infections of the skin are often referred to a specialist–as 3 of the patients in this series were–after receiving treatment with topical corticosteroids, which mask the clinical presentation and further modify the patient's response, or with azole shampoos, which do not resolve the process but can affect the sensitivity of diagnostic tests.The diversity of the treatments prescribed in this series can be explained by the preferences of the various physicians caring for the different patients. Although griseofulvin remains, for some authors, the treatment of choice for scalp ringworm in children and adults, both terbinafine and itraconazole are considered acceptable alternatives (the latter in particular for cases caused by fungi of the genus Trichophyton).It should be noted that the disease's apparent resistance to itraconazole–a drug considered effective against tinea capitis–in the case of the first patient may be associated with failure to follow the prescribed regimen strictly. Moreover, in most of the cases in the literature reporting a good response, the dose recommended is 200mg/day, although some authors recommend a dose of 5mg/kg/day. The recommended dose in the first patient in this series would therefore be between 300 and 400mg/day as the patient weighed approximately 65kg. No resistance to itraconazole has been reported in cases of scalp ringworm caused by T tonsurans. Itraconazole resistance has been reported, however, in cases caused by T mentagrophytes (in Latin America), and cases caused by T tonsurans have shown resistance to fluconazole.<a class="elsevierStyleCrossRefs" href="#bib0075">15–18</a>In conclusion, the differential diagnosis of any scaly and/or inflammatory skin condition in elderly patients, including those with alopecia, should include tinea capitis, and fungal cultures should be performed routinely in cases of suboptimal response to anti-inflammatory treatments.Conflict of InterestThe authors have no conflict of interest to declare." 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However, its epidemiological profile has changed in recent decades, with regard to age at onset and the causative microorganisms. We report the cases of 4 women over 65 years of age diagnosed with tinea capitis. One presented plaques of alopecia with desquamation and the other 3 developed crusted inflammatory lesions. Cultures were positive for Trichophyton tonsurans (2 patients), Trichophyton rubrum, and Trichophyton mentagrophytes.The relative rarity of tinea capitis in the elderly and the frequently atypical presentation in this age group can delay diagnosis, leading to irreversible sequelae and increasing the risk of contagion. Fungal culture should be included in the study of persistent, atypical dermatoses of the scalp, particularly in the elderly." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La tinea capitis se ha considerado clásicamente como un proceso casi exclusivo de la infancia. Sin embargo, en las últimas décadas se han observado algunos cambios en su perfil epidemiológico, tanto en lo que concierne a las edades de presentación como a los agentes responsables.Se describen los casos de 4 mujeres mayores de 65 años diagnosticadas de tinea capitis. Una de ellas presentaba placas alopécicas con descamación, mientras que en las otras tres las lesiones eran inflamatorias y costrosas. Los cultivos fueron positivos para Trichophyton tonsurans (2 pacientes), Trichophyton rubrum y Trichophyton mentagrophytes.La relativa infrecuencia de la tinea capitis en la edad avanzada y, por otra parte, su frecuente atipicidad clínica condicionan un diagnóstico tardío, circunstancia que puede condicionar secuelas irreversibles e incrementa la posibilidad de contagios. El cultivo fúngico debería incorporarse en el estudio de las dermatosis del cuero cabelludo de curso atípico y persistente, especialmente en individuos de edad avanzada." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Morell L, et al. Tinea capitis en mujeres de edad avanzada: descripción de 4 caso. Actas Dermosifiliogr.2012;103:144-148." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1577 "Ancho" => 1587 "Tamanyo" => 209783 ] ] "descripcion" => array:1 [ "en" => "Case 1. Alopecic plaque with desquamation 3 months after onset." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1595 "Ancho" => 1585 "Tamanyo" => 344643 ] ] "descripcion" => array:1 [ "en" => "Case 2. Erythematous, alopecic plaque with crusts and pustules on the cranial vertex. Fungal culture was positive for Trichophyton rubrum." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1150 "Ancho" => 1542 "Tamanyo" => 200649 ] ] "descripcion" => array:1 [ "en" => "Case 4. Inflammatory, crusted plaque on the patient's scalp. Fungal culture was positive for Trichophyton mentagrophytes." ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "DM: diabetes mellitus; HT: hypertension." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Case No. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">History \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Site \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Prior Diagnosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Delay in Diagnosis, mo \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Culture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Clinical Findings \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Clinical Course \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None of interest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Back, neck, and scalp \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Eczema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Trichophyton tonsurans \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Annular plaque, desquamation, and alopecia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Itraconazole (3 months), terbinafine (1 month) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complete remission (16 weeks) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DM, HT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Scalp \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Eczema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Trichophyton rubrum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Erythematous plaque with alopecia on the cranial vertex with pustules and crusts \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Itraconazole \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complete remission (6 weeks) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None of interest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Scalp \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Trichophyton tonsurans \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hyperkeratotic alopecic tumoral growth on the back of the head \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Terbinafine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complete remission (8 weeks) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None of interest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Scalp \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bacterial infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Trichophyton mentagrophytes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hyperkeratotic plaque with suppuration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Itraconazole \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Remission (5 weeks) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab181993.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Summary of the 4 clinical cases." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Micosis superficiales: dermatofitosis, 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Case Report

Tinea Capitis in Elderly Women: A Report of 4 Cases

Tinea capitis en mujeres de edad avanzada: descripción de 4 casos

L. Morell

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laiamorell@hotmail.com

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, M.J. Fuente, A. Boada, J.M. Carrascosa, C. Ferrándiz

Servicio de Dermatología, Hospital Universitari Germans Trias i Pujol, Badalona, (Barcelona), Spain

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    "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>"
    "titulo" => "Tinea Capitis in Elderly Women&#58; A Report of 4 Cases"
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        "autoresLista" => "L&#46; Morell, M&#46;J&#46; Fuente, A&#46; Boada, J&#46;M&#46; Carrascosa, C&#46; Ferr&#225;ndiz"
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        "titulo" => "<span class="elsevierStyleItalic">Tinea capitis</span> en mujeres de edad avanzada&#58; descripci&#243;n de 4 casos"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Case 4&#46; Inflammatory&#44; crusted plaque on the patient&#39;s scalp&#46; Fungal culture was positive for <span class="elsevierStyleItalic">Trichophyton mentagrophytes</span>&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Tinea capitis was thought to be found almost exclusively in children<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> and most commonly caused by <span class="elsevierStyleItalic">Microsporum audouinii</span> or <span class="elsevierStyleItalic">Microsporum canis&#46;</span><a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;7</span></a> In recent years&#44; however&#44; the epidemiological profile of the disease has changed in terms of both incidence and causative agents&#44; and its prevalence has increased in adult patients&#44; especially elderly women&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;7</span></a> In order to correctly diagnose and manage tinea capitis&#44; physicians need to be familiar with the clinical signs of the disease in elderly patients&#44; as well as the therapeutic responses seen in this age group&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present 4 cases of tinea capitis in elderly women with atypical clinical manifestations and pathogens &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; All 4 cases were diagnosed in the dermatology department of our hospital in the past 6 months&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Descriptions</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Description 1</span><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a 71-year-old woman who presented with hair loss and pruritic lesions on her back and scalp&#46; The symptoms had first appeared 3 months earlier&#46; The patient had been diagnosed with eczema and had received treatment with topical corticosteroids for several months&#46; The pruritus had decreased slightly&#44; but the alopecia had progressively worsened&#46; The patient had not been in contact with animals&#46; Physical examination revealed a scaly&#44; erythematous annular plaque covering the neck and the upper third of the back&#46; A large alopecic plaque with abundant whitish desquamation was present on the scalp &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; and hair fell out easily with traction&#46; Skin-scale and hair samples were collected for direct microscopic examination using the potassium hydroxide technique&#44; which revealed hyphae&#44; and for culture&#44; which was positive for <span class="elsevierStyleItalic">Trichophyton tonsurans</span>&#46; Oral treatment with itraconazole &#40;200<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; resulted in marked improvement in the lesions at 1 month&#46; After that&#44; however&#44; improvement slowed&#44; despite the fact that the patient reported taking the drugs correctly&#46; Clinical symptoms persisted and cultures were still positive 7 months after the start of treatment&#46; The treatment was therefore changed to oral terbinafine &#40;250<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#44; which resulted in complete resolution within 1 month&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Description 2</span><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was a 65-year-old woman who presented with slightly pruritic scalp lesions that had appeared 3 months earlier&#46; During the preceding 3 months&#44; she had received treatment with topical corticosteroids&#44; antibiotics&#44; and ciclopirox olamine shampoo&#44; but her condition had not improved&#46; The patient had not been in contact with animals or with people who had similar lesions&#46; Physical examination revealed an erythematous&#44; partially alopecic plaque on the cranial vertex characterized by superficial crusts and pustules &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Histopathologic examination of the biopsy specimen revealed clear evidence of folliculitis and a granulomatous foreign-body reaction&#46; The bacterial culture was negative and <span class="elsevierStyleItalic">Trichophyton rubrum</span> colonies were isolated in the fungal culture&#46; Oral treatment with itraconazole &#40;200<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; was initiated and the clinical and microbiologic symptoms resolved completely after 6 weeks&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Description 3</span><p id="par0025" class="elsevierStylePara elsevierViewall">The patient was a 69-year-old woman who presented with a crusted tumoral growth on her scalp that had appeared 6 weeks earlier&#46; She had received no prior topical or systemic treatment&#46; Physical examination revealed a crusted lesion on the back of the head&#46; The crust concealed fleshy exophytic granulation tissue&#46; Fungal culture was positive for <span class="elsevierStyleItalic">T tonsurans</span>&#46; Eight weeks after oral treatment with terbinafine &#40;250<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; was initiated&#44; there was still some evidence of scarring alopecia but no signs of inflammation&#44; desquamation&#44; or traction hair loss&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Description 4</span><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was a 72-year-old woman who presented with a 3-week history of 2 crusted&#44; inflammatory lesions on her scalp&#46; She had completed a 3-day treatment with topical corticosteroids and oral cloxacillin&#46; The perilesional erythema had resolved but the rest of the lesion had not improved&#46; The patient had no fever or other symptoms&#46; Physical examination revealed one crusted lesion on the left parietal-temporal region of the scalp &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; and another on the forehead&#46; The crust was removed from the lesion on the forehead&#44; revealing an eroded surface with suppuration at various points&#46; Regional lymph nodes were enlarged and palpable&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Although an initial biopsy showed nonspecific changes&#44; a second histologic study revealed the presence of mixed dermal infiltration with numerous eosinophils&#44; as well as spores and filaments inside the follicles&#46; These findings&#44; together with positive culture results&#44; allowed us to establish a diagnosis of <span class="elsevierStyleItalic">Trichophyton mentagrophytes</span> infection&#46; Oral treatment with itraconazole &#40;200<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; was initiated&#46; The symptoms improved slowly&#44; resolving completely within 35 days of the start of treatment&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">This case series shows that scalp ringworm in elderly patients is relatively common and often presents with atypical clinical characteristics&#46; Low clinical suspicion can lead to inappropriate empiric treatments that delay diagnosis and complicate the therapeutic response&#46;Tinea capitis is usually seen in children between the ages of 3 and 7&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Although the disease was once thought to be rare in adulthood&#44; a growing number of authors have reported an increase in tinea capitis among adults&#44; particularly menopausal and elderly women&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Factors that may favor the development of the disease at this age include hormonal changes&#44; the use of certain hair-care products&#44; and using the services of hair salons&#44; which can be a source of infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In most of the cases that have been reported&#44; including our own case series&#44; diagnosis was delayed&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> This delay is probably due to both the rarity of this infection in adults and its atypical clinical manifestations&#44; which can be confused with inflammatory processes such as seborrheic dermatitis or psoriasis&#46; Atypical manifestations seem to be more common in patients infected with <span class="elsevierStyleItalic">T tonsurans</span> &#40;as in 2 of our cases&#41;&#44; who often present either diffuse desquamation with mild alopecia and lesions suggestive of seborrheic dermatitis or pustular inflammatory lesions and associated regional lymphadenopathy&#44; a clinical picture that can lead to an incorrect diagnosis of bacterial infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5&#44;8&#44;9</span></a> Although <span class="elsevierStyleItalic">M canis</span> remains the most common causative agent of tinea capitis in southern Europe&#44; with a prevalence greater than 80&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> the epidemiology of these infections has changed considerably in recent years&#46; A growing number of cases have been attributed to the following species&#58; <span class="elsevierStyleItalic">T mentagrophytes</span>&#44; <span class="elsevierStyleItalic">Trichophyton verrucosum</span>&#44; <span class="elsevierStyleItalic">T tonsurans</span>&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;10&#44;11</span></a> and <span class="elsevierStyleItalic">T rubrum&#46;</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Specifically in Barcelona&#44; <span class="elsevierStyleItalic">T mentagrophytes</span><a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> has been highly prevalent&#44; whereas <span class="elsevierStyleItalic">T tonsurans</span> is the species most frequently isolated in the United States&#44; the United Kingdom&#44; and Canada&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;13&#44;14</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">These changes are attributable to many factors&#44; in particular the rise of travel to endemic areas and the migratory flows from the Southern to the Northern hemisphere&#46; In addition to facilitating contagion&#44; migration has also helped to spread species endemic to Africa and Asia&#8211;generally anthropophilic fungi&#8211;to urban areas in Europe&#44; especially neighborhoods where immigrants make up a high percentage of the population&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11&#44;14</span></a> In keeping with what seems to be the current trend for this disease&#44; the species found in our 4 patients&#8211;all city dwellers&#8211;were anthropophilic&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">It should be noted that fungal culture was essential to either confirming the clinical suspicion or redirecting the diagnosis in all 4 cases&#46; Fungal culture should therefore be used routinely in cases of desquamative conditions of the scalp that involve pruritus or an inflammatory appearance&#44; especially in elderly patients whose symptoms do not respond satisfactorily to the prescribed treatment&#46; It should also be emphasized that patients with fungal infections of the skin are often referred to a specialist&#8211;as 3 of the patients in this series were&#8211;after receiving treatment with topical corticosteroids&#44; which mask the clinical presentation and further modify the patient&#39;s response&#44; or with azole shampoos&#44; which do not resolve the process but can affect the sensitivity of diagnostic tests&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The diversity of the treatments prescribed in this series can be explained by the preferences of the various physicians caring for the different patients&#46; Although griseofulvin remains&#44; for some authors&#44; the treatment of choice for scalp ringworm in children and adults&#44; both terbinafine and itraconazole are considered acceptable alternatives &#40;the latter in particular for cases caused by fungi of the genus <span class="elsevierStyleItalic">Trichophyton</span>&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">It should be noted that the disease&#39;s apparent resistance to itraconazole&#8211;a drug considered effective against tinea capitis&#8211;in the case of the first patient may be associated with failure to follow the prescribed regimen strictly&#46; Moreover&#44; in most of the cases in the literature reporting a good response&#44; the dose recommended is 200<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; although some authors recommend a dose of 5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#46; The recommended dose in the first patient in this series would therefore be between 300 and 400<span class="elsevierStyleHsp" style=""></span>mg&#47;day as the patient weighed approximately 65<span class="elsevierStyleHsp" style=""></span>kg&#46; No resistance to itraconazole has been reported in cases of scalp ringworm caused by <span class="elsevierStyleItalic">T tonsurans</span>&#46; Itraconazole resistance has been reported&#44; however&#44; in cases caused by <span class="elsevierStyleItalic">T mentagrophytes</span> &#40;in Latin America&#41;&#44; and cases caused by <span class="elsevierStyleItalic">T tonsurans</span> have shown resistance to fluconazole&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;18</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In conclusion&#44; the differential diagnosis of any scaly and&#47;or inflammatory skin condition in elderly patients&#44; including those with alopecia&#44; should include tinea capitis&#44; and fungal cultures should be performed routinely in cases of suboptimal response to anti-inflammatory treatments&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of Interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare&#46;</p></span></span>"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Tinea capitis is a condition usually found only in children&#46; However&#44; its epidemiological profile has changed in recent decades&#44; with regard to age at onset and the causative microorganisms&#46; We report the cases of 4 women over 65 years of age diagnosed with tinea capitis&#46; One presented plaques of alopecia with desquamation and the other 3 developed crusted inflammatory lesions&#46; Cultures were positive for <span class="elsevierStyleItalic">Trichophyton tonsurans</span> &#40;2 patients&#41;&#44; <span class="elsevierStyleItalic">Trichophyton rubrum</span>&#44; and <span class="elsevierStyleItalic">Trichophyton mentagrophytes</span>&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The relative rarity of tinea capitis in the elderly and the frequently atypical presentation in this age group can delay diagnosis&#44; leading to irreversible sequelae and increasing the risk of contagion&#46; Fungal culture should be included in the study of persistent&#44; atypical dermatoses of the scalp&#44; particularly in the elderly&#46;</p>"
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        "resumen" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La <span class="elsevierStyleItalic">tinea capitis</span> se ha considerado cl&#225;sicamente como un proceso casi exclusivo de la infancia&#46; Sin embargo&#44; en las &#250;ltimas d&#233;cadas se han observado algunos cambios en su perfil epidemiol&#243;gico&#44; tanto en lo que concierne a las edades de presentaci&#243;n como a los agentes responsables&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Se describen los casos de 4 mujeres mayores de 65 a&#241;os diagnosticadas de <span class="elsevierStyleItalic">tinea capitis</span>&#46; Una de ellas presentaba placas alop&#233;cicas con descamaci&#243;n&#44; mientras que en las otras tres las lesiones eran inflamatorias y costrosas&#46; Los cultivos fueron positivos para <span class="elsevierStyleItalic">Trichophyton tonsurans</span> &#40;2 pacientes&#41;&#44; <span class="elsevierStyleItalic">Trichophyton rubrum</span> y <span class="elsevierStyleItalic">Trichophyton mentagrophytes</span>&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La relativa infrecuencia de la <span class="elsevierStyleItalic">tinea capitis</span> en la edad avanzada y&#44; por otra parte&#44; su frecuente atipicidad cl&#237;nica condicionan un diagn&#243;stico tard&#237;o&#44; circunstancia que puede condicionar secuelas irreversibles e incrementa la posibilidad de contagios&#46; El cultivo f&#250;ngico deber&#237;a incorporarse en el estudio de las dermatosis del cuero cabelludo de curso at&#237;pico y persistente&#44; especialmente en individuos de edad avanzada&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Morell L&#44; et al&#46; <span class="elsevierStyleItalic">Tinea capitis</span> en mujeres de edad avanzada&#58; descripci&#243;n de 4 caso&#46; Actas Dermosifiliogr&#46;2012&#59;103&#58;144-148&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Case No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">History&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Site&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Prior Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Delay in Diagnosis&#44; mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Culture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Clinical Findings&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Clinical Course&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">1</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None of interest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Back&#44; neck&#44; and scalp&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Eczema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Trichophyton tonsurans</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Annular plaque&#44; desquamation&#44; and alopecia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Itraconazole &#40;3 months&#41;&#44; terbinafine &#40;1 month&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete remission &#40;16 weeks&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DM&#44; HT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Scalp&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Eczema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Trichophyton rubrum</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Erythematous plaque with alopecia on the cranial vertex with pustules and crusts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Itraconazole&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete remission &#40;6 weeks&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None of interest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Scalp&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Trichophyton tonsurans</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hyperkeratotic alopecic tumoral growth on the back of the head&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Terbinafine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete remission &#40;8 weeks&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">4</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None of interest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Scalp&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bacterial infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Trichophyton mentagrophytes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hyperkeratotic plaque with suppuration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Itraconazole&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Remission &#40;5 weeks&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab181993.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Summary of the 4 clinical cases&#46;</p>"
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      ]
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:18 [
            0 => array:3 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Micosis superficiales&#58; dermatofitosis&#44; onicomicosis&#44; ti&#241;a negra y piedra"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "S&#46; Verna"
                            1 => "M&#46;P&#46; Heffernan"
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                    0 => array:1 [
                      "LibroEditado" => array:5 [
                        "titulo" => "Fitzpatrick&#39;s Dermatolog&#237;a en Medicina General"
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                        "paginaFinal" => "1821"
                        "edicion" => "7<span class="elsevierStyleSup">th</span> ed&#46;"
                        "serieFecha" => "2008"
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            1 => array:3 [
              "identificador" => "bib0010"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Guidelines for the management of tinea capitis&#46; British Association of Dermatologists"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "E&#46;M&#46; Higgins"
                            1 => "L&#46;C&#46; Fuller"
                            2 => "C&#46;H&#46; Smith"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol"
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                        "paginaInicial" => "53"
                        "paginaFinal" => "58"
                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10886135"
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            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology of tinea capitis in Europe&#58; current state and changing patterns"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "G&#46; Ginter-Hanselmayer"
                            1 => "W&#46; Weger"
                            2 => "M&#46; Ilkit"
                            3 => "J&#46; Smolle"
                          ]
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1439-0507.2007.01424.x"
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                        "tituloSerie" => "Mycoses"
                        "fecha" => "2007"
                        "volumen" => "50"
                        "paginaInicial" => "6"
                        "paginaFinal" => "13"
                        "link" => array:1 [
                          0 => array:2 [
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              "etiqueta" => "4"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiological trends in skin mycoses worldwide"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "B&#46; Havlickova"
                            1 => "V&#46;A&#46; Czaika"
                            2 => "M&#46; Friedrich"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1439-0507.2008.01606.x"
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                        "fecha" => "2008"
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              "etiqueta" => "5"
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                  "contribucion" => array:1 [
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                      "titulo" => "Changing face of tinea capitis in Europe"
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                          "etal" => false
                          "autores" => array:1 [
                            0 => "L&#46;C&#46; Fuller"
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                    0 => array:2 [
                      "doi" => "10.1097/QCO.0b013e3283293d9b"
                      "Revista" => array:6 [
                        "tituloSerie" => "Curr Opin Infect Dis"
                        "fecha" => "2009"
                        "volumen" => "22"
                        "paginaInicial" => "115"
                        "paginaFinal" => "118"
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                          0 => array:2 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ti&#241;a de la cabeza"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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Article information

ISSN: 15782190
Original language: English

DOI:10.1016/j.adengl.2012.03.001

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2023 August	148	23	171
2023 July	188	47	235
2023 June	126	31	157
2023 May	291	34	325
2023 April	329	28	357
2023 March	293	26	319
2023 February	270	21	291
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2022 December	135	52	187
2022 November	90	33	123
2022 October	93	24	117
2022 September	187	36	223
2022 August	79	36	115
2022 July	111	37	148
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2022 May	219	39	258
2022 April	284	50	334
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2021 December	169	52	221
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2020 November	176	36	212
2020 October	206	23	229
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2020 August	79	21	100
2020 July	74	24	98
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2020 May	54	20	74
2020 April	61	21	82
2020 March	50	21	71
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2020 January	0	1	1
2019 December	4	10	14
2019 November	0	3	3
2019 October	0	8	8
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2019 August	3	12	15
2019 July	0	18	18
2019 June	1	26	27
2019 May	1	37	38
2019 April	0	43	43
2019 March	2	8	10
2019 February	0	6	6
2019 January	1	9	10
2018 December	3	7	10
2018 November	1	0	1
2018 October	3	0	3
2018 September	7	4	11
2018 August	0	12	12
2018 July	0	15	15
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2018 May	0	10	10
2018 April	0	4	4
2018 March	0	7	7
2018 February	112	11	123
2018 January	124	19	143
2017 December	141	12	153
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2017 October	80	21	101
2017 September	66	11	77
2017 August	147	18	165
2017 July	115	20	135
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2017 May	108	12	120
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2016 February	9	16	25
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2015 December	6	16	22
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2015 September	5	1	6
2015 August	15	5	20
2015 July	133	16	149
2015 June	81	12	93
2015 May	115	22	137
2015 April	91	13	104
2015 March	93	12	105
2015 February	99	16	115
2015 January	98	17	115
2014 December	106	9	115
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2014 October	89	15	104
2014 September	102	19	121
2014 August	77	9	86
2014 July	84	21	105
2014 June	108	11	119
2014 May	75	13	88
2014 April	54	8	62
2014 March	73	19	92
2014 February	22	13	35
2014 January	29	9	38
2013 December	32	9	41
2013 November	27	9	36
2013 October	20	7	27
2013 September	15	8	23
2013 August	7	5	12
2013 July	9	13	22
2013 June	9	24	33
2013 May	12	11	23
2013 April	16	21	37
2013 March	14	10	24
2013 February	38	1	39
2013 January	34	7	41
2012 December	22	10	32
2012 November	2	6	8
2012 October	2	2	4

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