Tinea capitis was thought to be found almost exclusively in children1–4 and most commonly caused by Microsporum audouinii or Microsporum canis.2–7 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.3–7 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 (Table 1). All 4 cases were diagnosed in the dermatology department of our hospital in the past 6 months.

This 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 7.1 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.2–6

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.6,7

In most of the cases that have been reported, including our own case series, diagnosis was delayed.5 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.4,5,8,9 Although M canis remains the most common causative agent of tinea capitis in southern Europe, with a prevalence greater than 80%,3 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,3,10,11 and T rubrum.10 Specifically in Barcelona, T mentagrophytes12 has been highly prevalent, whereas T tonsurans is the species most frequently isolated in the United States, the United Kingdom, and Canada.3,13,14

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.10,11,14 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.15–18

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.

The authors have no conflict of interest to declare.