History

Fact Explanation
The presentation depends upon the site of infection, age of the child and on the strain of fungus Tinea infections of children are superficial dermatophyte fungal infections involving the skin, hair and naisl. There are three causative genera. Genera Trichophyton cause skin, hair and nail infections. Genera Microsporum cause only skin and hair infections. While genera Epidermophyton causes skin and nail infections. The prevalence of tinea infections vary with age. For example Tinea capitis is common among children aged between 3 to 9 years while tinea corporis affects children of all age groups. [1],[2],[3],[4],[5],[6],[10],[11]
Erythematous circular scaly rash Dermatophytes invade into the stratum corneum, and the inflammation they cause is a result of metabolic products of the fungus or delayed hypersensitivity. Usually, anthrophilic fungi cause lesions with minimal inflammation, while zoophilic fungi induce a more intense inflammation. [1],[2],[3],[4],[9],[10]
Patchy alopecia Tinea capitis (scalp ringworm) commonly affects children. Tinea capitis is one of the commonest causes of hair loss in children. [7],[8],[9],[10]
Pruritus Is a common complaint in dermatophyte infections. Infants may present with disturbed sleep and crying. [1],[2],[3],
Contact history Tinea infections are a contagious and communicable fungal infections. Therefore contact history with infected family member, classmate or sharing of clothes, bedlinen, pillows, towels, combs or animal contact may be positive in the history. [1],[2],[3],[9]
History of immunesuppression Protection against fungal infection is mediated by cell mediated immunity [CMI]. Long term steroid therapy, Cushing' syndrome, HIV infection, malnutrition and specific immune deficient conditions are possible risk factors in the history. The incidence of fungal infections is increasing. This increase is related to the growing population of immunocompromised children. This results from the changes in medical practice such as the use of intensive chemotherapy and immunosuppressive drugs. [1],[2],[3],[5],[11]
Common among pre pubertal age group Due to physiological changes that occur with puberty sebum content of skin surface increases. Sebum which is rich in lipids provide a suitable media to growth of causative organisms. [1],[2],[3],[4],[5],[6]
History of living in tropical regions Warmth and humidity provides a suitable environment to pathogenic growth of causative organisms. [1],[2],[3],[4],[5],[6],
More prevalent in the lower socio economic classes Overcrowding and poor social conditions are risk factors, for the spread of disease.
References
  1. WELLER, Richard PJB, HUNTER John AA, SAVIN John A. and DAH Mark V ed. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  2. MARKS Ronald ed. Roxburgh's Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  3. MARKS JR, James G and MILLER Jeffery ed. Lookingbill and Mark's Principals of Dermatology. 4th ed. Elsevier. 2006,125-128.
  4. ADEFEMI SA, ODEIGAH LO, ALABI KM. Prevalence of dermatophytosis among primary school children in Oke-oyi community of Kwara state. Niger J Clin Pract [online] 2011 December [viewed 29 May 2014] Available from: doi:10.4103/1119-3077.79235
  5. PIRES CA, DA CRUZ NF, LOBATO AM, DE SOUSA PO, CARNEIRO FR, MENDES AM. Clinical, epidemiological, and therapeutic profile of dermatophytosis An Bras Dermatol [online] 2014, 89(2):259-265 [viewed 28 May 2014] Available from: doi:10.1590/abd1806-4841.20142569
  6. ADEFEMI SA, ODEIGAH LO, ALABI KM. Prevalence of dermatophytosis among primary school children in Oke-oyi community of Kwara state. Niger J Clin Pract [online] 2011 December [viewed 28 May 2014] Available from: doi:10.4103/1119-3077.79235
  7. AL-REFU KHITAM. Hair loss in children: Common and uncommon causes; clinical and epidemiological study in Jordan. Int J Trichol [online] 2013 December [viewed 29 May 2014] Available from: doi:10.4103/0974-7753.130393
  8. KUNDU D, MANDAL L, SEN G. Prevalence of Tinea capitis in school going children in Kolkata, West Bengal. J Nat Sc Biol Med [online] 2012 December [viewed 29 May 2014] Available from: doi:10.4103/0976-9668.101894
  9. CAROD JEAN-FRANçOIS, RATSITORAHINA MAHERY, RAHERIMANDIMBY HASINA, HINCKY VITRAT VIRGINIE, RAVAOLIMALALA ANDRIANAJA VOLOLOMBOAHANGY, CONTET-AUDONNEAU NELLY. Outbreak of Tinea capitis and corporis in a primary school in Antananarivo, Madagascar. J Infect Dev Ctries [online] 2011 October [viewed 29 May 2014] Available from: doi:10.3855/jidc.1944
  10. MICHAELS BD, DEL ROSSO JQ. Tinea Capitis in Infants: Recognition, Evaluation, and Management Suggestions J Clin Aesthet Dermatol [online] 2012 Feb, 5(2):49-59 [viewed 29 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3315884
  11. JAIN AKANSHA, JAIN SHUBHAM, RAWAT SWATI. Emerging fungal infections among children: A review on its clinical manifestations, diagnosis, and prevention. J Pharm Bioall Sci [online] 2010 December [viewed 29 May 2014] Available from: doi:10.4103/0975-7406.72131

Examination

Fact Explanation
Round, scaling area of alopecia with diffuse scaling on the scalp Dermatophyte infection of the scalp is known as Tinea capitis. This is the commonest tinea infection of children. Anthrophilic organisms cause bald and scaly areas with minimal inflammation. Zoophilic organisms induce an intense inflammation causing red, boggy kerion formation. [1],[2],[3],[4],[5],[6],[7]
Single or numerous erythematous, annular plaques with scaling on the trunk and limbs Tinea infections of the trunk and limbs is Tinea corporis. This is the second commonest tinea infection in children. The lesions expand slowly and the healing center leaves a typical ring like pattern. The erythema is most pronounced at the periphery. [1],[2],[3],[5],[7]
Sharply demarcated area in the groin with elevated, scaling, serpiginous borders Tinea infections involving the groin are known as Tinea cruris. The eruption is unilateral or bilateral and asymmetrical. Can spread to the upper inner thigh. [1],[2],[3],[5]
Interdigital maceration, diffuse scaling on soles and side of the feet Tinea infections of the feet are known as Tinea pedis (athlete's foot). Trichophyton rubrum, Trichophyton mentagrophytes and Epidrmophyton floccosum are the common causative organisms. [1],[2],[3],[5]
Diffuse dry scaling, usually affects only one palm Tinea infections affecting hand are known as Tinea manuum. The characteristic feature is powdery scaling along the creases of the palm. Trichophyton rubrum is the common causative organism. [1],[2],[3],[5]
Slightly scaling, erythematous patches and plaques on the face Tinea infections involving the face is kown as Tinea faciale. The border of the lesion may be not well demarcated. [1],[2],[3],[5]
Subungual debris with separation of the nail bed. Tinea infections of the nail is known as Tinea unguium. The initial changes occur at the free edge of the nail as this becomes yellow and crumbly. [1],[2],[3],[5]
References
  1. WELLER, Richard PJB, HUNTER John AA, SAVIN John A. and DAH Mark V ed. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  2. MARKS Ronald ed. Roxburgh's Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  3. MARKS JR, James G and MILLER Jeffery ed. Lookingbill and Mark's Principals of Dermatology. 4th ed. Elsevier. 2006,125-128.
  4. KUNDU D, MANDAL L, SEN G. Prevalence of Tinea capitis in school going children in Kolkata, West Bengal. J Nat Sc Biol Med [online] 2012 December [viewed 29 May 2014] Available from: doi:10.4103/0976-9668.101894
  5. PIRES CA, DA CRUZ NF, LOBATO AM, DE SOUSA PO, CARNEIRO FR, MENDES AM. Clinical, epidemiological, and therapeutic profile of dermatophytosis An Bras Dermatol [online] 2014, 89(2):259-265 [viewed 28 May 2014] Available from: doi:10.1590/abd1806-4841.20142569
  6. MICHAELS BD, DEL ROSSO JQ. Tinea Capitis in Infants: Recognition, Evaluation, and Management Suggestions J Clin Aesthet Dermatol [online] 2012 Feb, 5(2):49-59 [viewed 29 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3315884
  7. CAROD JEAN-FRANçOIS, RATSITORAHINA MAHERY, RAHERIMANDIMBY HASINA, HINCKY VITRAT VIRGINIE, RAVAOLIMALALA ANDRIANAJA VOLOLOMBOAHANGY, CONTET-AUDONNEAU NELLY. Outbreak of Tinea capitis and corporis in a primary school in Antananarivo, Madagascar. J Infect Dev Ctries [online] 2011 October [viewed 29 May 2014] Available from: doi:10.3855/jidc.1944

Differential Diagnoses

Fact Explanation
Discoid (nummular) eczema This common pattern of eczema classically affects the limbs of middle-aged males. The lesions are multiple, coin shaped, vesicular or crusted highly itchy plaques. [1],[2],[3],[4]
Chronic eczema Eczema is usually itchy and symmetrical. The absence of sharp margin is particularly important feature that separates eczema from most papulosquamous eruptions.[1],[2],[3],[4]
Plaque psoriasis The lesions are well demarcated and range from a few millimeters to many centimeters in diameter. The lesions are pink or red with large centrally adhered silvery white, polygonal scales. Symmetrical sites on elbows,knees, lower back and scalp are sites of predilection. [1],[2],[3],[4]
Pityriasisrosea Most patients develop one plaque before the others, It is larger (2-5 cm diameter) than later lesions, and is rounder, redder and more scaly. After several days many smaller plaques appear, mainly on the trunk, but some also on neck and extremities. [1],[2],[3],[4]
Discoid lupus Erythematosus Plaques show erythema, scaling, scarring and atrophy, telangiectasia, hypopigmentation and peripheral zone of hyperpigmentation. They are well demarcated and lie mostly on sun exposed skin. [1],[3]
Pityriasis versicolor Depigmented macules with fine scaling develop over the skin commonly involving upper trunk. [1],[2]
Seborrhoic dermatitis Erythematous, itchy patches which may become either scaly or exudative and crusted. Commonly involve hair bearing areas such as scalp, forehead, the beard presternal or interscapular areas. [1],[2],[3]
Candidiasis A moist glazed area of erythema and maceration appears in a body fold; the edges show soggy scaling, and outlying satellite papulopustules. These changes are most common under the breasts and the arm pits and groin. [1],[2]
Erythrasma Presents with symptom free macular wrinkled slightly scaly pink, brown or macerated white areas, most often found in armpits or groins or between toes. [1]
Granuloma annulare The lesions of common type of granuloma annulare often lie over the knuckles and are composed of dermal nodules fused in to a rough ring shape. On the hands the lesions are skin colored or slightly pink; elsewhere a purple color may be seen. [1], [2],[3]
Alopecia areata A typical patch is un inflammed, with no scaling, but with empty hair follicles. Pathognomic exclamation mark pattern may be seen. Commonly associated with other immunological disorders. [1],[2],[3],[4]
Paronychia The nail fold become tender and swollen. Pus may be expressed from the space between the nail fold and the nail bed. [1],[2],[3],[4]
References
  1. WELLER, Richard PJB, HUNTER John AA, SAVIN John A. and DAH Mark V ed. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 54-70, 71-72, 97-100,131-134, 221, 252-256, 303, 237, 248-252, 325.
  2. MARKS Ronald ed. Roxburgh's Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 17, 37-43, 114-118,128-142, 241, 265-266, 277.
  3. MARKS JR, James G and MILLER Jeffery ed. Lookingbill and Mark's Principals of Dermatology. 4th ed. Elsevier. 2006,125-128.
  4. KUMAR Parveen and CLARK Michael ed. Kumar & Clark's Clinical Medicine. 8th Ed. Elsevier. 2012,1200-1201, 1236-1240,1240-1243, 1244,1245.

Investigations - for Diagnosis

Fact Explanation
Woods light examination Uses ultraviolet light to observe skin closely. It reveals some of epidermophytes with green fluorescence. Some causative fungi do not fluorescence. [1],[2],[3],[4]
Light microscopic examination Skin scrapings should be taken from the scaly margin of a lesion, with a small curette or a scalpel blade and clippings or scrapings from the most crumbly part of the nail. Broken hair should be plucked with with a tweezers. The specimens are cleared in pottassium hydroxide prior to microscopy. Branching hyphae and spores can easily be seen. [1],[2],[3],[4],[5],[6]
Culture Culture should be carried out in a mycology or bacteriology laboratory. A transport medium is not necessary, and specimens can be sent in folded black paper and dry petri dish. The report may take as long as a month: microscopy is much quicker. [1],[2],[3],[4]
References
  1. WELLER, Richard PJB, HUNTER John AA, SAVIN John A. and DAH Mark V ed. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  2. MARKS Ronald ed. Roxburgh's Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  3. MARKS JR, James G and MILLER Jeffery ed. Lookingbill and Mark's Principals of Dermatology. 4th ed. Elsevier. 2006,125-128.
  4. MICHAELS BD, DEL ROSSO JQ. Tinea Capitis in Infants: Recognition, Evaluation, and Management Suggestions J Clin Aesthet Dermatol [online] 2012 Feb, 5(2):49-59 [viewed 29 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3315884
  5. PIRES CA, DA CRUZ NF, LOBATO AM, DE SOUSA PO, CARNEIRO FR, MENDES AM. Clinical, epidemiological, and therapeutic profile of dermatophytosis An Bras Dermatol [online] 2014, 89(2):259-265 [viewed 28 May 2014] Available from: doi:10.1590/abd1806-4841.20142569
  6. CAROD JEAN-FRANçOIS, RATSITORAHINA MAHERY, RAHERIMANDIMBY HASINA, HINCKY VITRAT VIRGINIE, RAVAOLIMALALA ANDRIANAJA VOLOLOMBOAHANGY, CONTET-AUDONNEAU NELLY. Outbreak of Tinea capitis and corporis in a primary school in Antananarivo, Madagascar. J Infect Dev Ctries [online] 2011 October [viewed 29 May 2014] Available from: doi:10.3855/jidc.1944

Investigations - Followup

Fact Explanation
Follow up visits To see the response to treatment and to assess complications of the disease. Weighing children in follow up visits is important to adjust the dose of systemic therapy.[1],[2],[3],[4].[5]
Periodic monitoring In patients prescribed systemic anti fungals there is a possibility of serious hepatotoxicity and occurrence of other side effects, including thrombocytopenia and derangement of liver enzymes. Periodic monitoring of liver function tests and full blood count is important. [1],[2],[3],[4].
References
  1. WELLER, Richard PJB, HUNTER John AA, SAVIN John A. and DAH Mark V ed. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  2. MARKS Ronald ed. Roxburgh's Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  3. MARKS JR, James G and MILLER Jeffery ed. Lookingbill and Mark's Principals of Dermatology. 4th ed. Elesevier. 2006,2006,125-128.
  4. MICHAELS BD, DEL ROSSO JQ. Tinea Capitis in Infants: Recognition, Evaluation, and Management Suggestions J Clin Aesthet Dermatol [online] 2012 Feb, 5(2):49-59 [viewed 29 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3315884

Management - General Measures

Fact Explanation
Educate parents Inform that Tinea infections are common superficial fungal infection that can be treated successfully. [1],[2],[3],[4]
Advise regarding hygiene Advise families not to share clothes, towels,bedlinen, combs,pillows etc. Advise regarding importance of daily bathing and wearing clean dry clothes to reduce recurrence. After bathing, children should be towel-dried.[1],[2],[3],[4],[5],[6],[7]
Preventive measures for immune compromised children Immune compromised children must advised to practice hand washing as a habit and not to go walk bare-foot in public places, such as shower rooms and swimming pools. Selenium sulphide shampoo and topical antifungals can be used prophylactically. [1],[2],[3],[4],[5],[6],[7]
Advise to treat infected family members/pets Tinea infections are contagious and communicable fungal infections, treating infected family members and infected pets prevents infection of the children. [1],[2],[5]
References
  1. WELLER, Richard PJB, HUNTER John AA, SAVIN John A. and DAH Mark V ed. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  2. MARKS Ronald ed. Roxburgh's Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  3. MARKS JR, James G and MILLER Jeffery ed. Lookingbill and Mark's Principals of Dermatology. 4th ed. Elsevier. 2006,125-128.
  4. MICHAELS BD, DEL ROSSO JQ. Tinea Capitis in Infants: Recognition, Evaluation, and Management Suggestions J Clin Aesthet Dermatol [online] 2012 Feb, 5(2):49-59 [viewed 29 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3315884
  5. CAROD JEAN-FRANçOIS, RATSITORAHINA MAHERY, RAHERIMANDIMBY HASINA, HINCKY VITRAT VIRGINIE, RAVAOLIMALALA ANDRIANAJA VOLOLOMBOAHANGY, CONTET-AUDONNEAU NELLY. Outbreak of Tinea capitis and corporis in a primary school in Antananarivo, Madagascar. J Infect Dev Ctries [online] 2011 October [viewed 29 May 2014] Available from: doi:10.3855/jidc.1944
  6. ADEFEMI SA, ODEIGAH LO, ALABI KM. Prevalence of dermatophytosis among primary school children in Oke-oyi community of Kwara state. Niger J Clin Pract [online] 2011 December [viewed 29 May 2014] Available from: doi:10.4103/1119-3077.79235
  7. JAIN AKANSHA, JAIN SHUBHAM, RAWAT SWATI. Emerging fungal infections among children: A review on its clinical manifestations, diagnosis, and prevention. J Pharm Bioall Sci [online] 2010 December [viewed 29 May 2014] Available from: doi:10.4103/0975-7406.72131

Management - Specific Treatments

Fact Explanation
Local imidazole preparations An imidazole containing preparation (such as miconazole, econazole and clotrimazole) used twice daily for 3-4 week period is usually adequate. Imidazoles interfere with fungal oxidative enzymes to cause lethal accumulation of hydrogen peroxide. They also reduce the formation of ergosterol, an important constituent of fungal cell wall which thus becomes permeable to intracellular constituents. When topical treatment has failed systemic drugs needs to be considered. Systemic therapy given according to the body weight of the child. When prescribing systemic therapy must refer BNF for Childrens' for dosing according to body weight. [1],[2],[3],[4],[5],[6],[7]
Topical nail preparations Children may refuse systemic treatment. For nail infections a nail lacquer containing amorolfine is worth a trial. Ciclopirox is a alternative available in the USA. [1],[2]
Terbinafin Has now largely superseded griseofulvin. It acts by inhibiting fungal squalane epoxidase and does not interact with cytochrome p-450 system. It is fungicidal and so cures chronic dermatophyte infections more quickly and more reliably than griseofulvin. [1],[2],[3],[4],[5],[6],[7]
Griseofulvin Was for many years drug of choice for chronic dermatophyte infections, but is now largely reserved for treatment of tinea capitis. Griseofulvin prevents fungal growth by inhibiting mitosis. The therapeutic efficacy of griseofulvin depends on its capacity to bind to keratin. [1],[2],[3],[4],[5],[6],[7]
Itraconazole Is now preferred to Ketoconazole, which occasionally damages the liver, and is a reasonable alternative to terbinafin if this is contraindicated. Fungistactic rather than fungicidal, it interfere with cytochrome P-450 system, so a review of any other medication being taken is needed before a prescription is issued. [1],[2],[3],[4],[5],[6],[7]
Ketoconazole This drug should be reserved for patients with severe and resistant disease because of the possibility of serious hepatotoxicity and occurrence of other side effects, including rashes, thrombocytopenia and gastrointestinal disturbances . [1],[2],[3],[4],[5],[6]
References
  1. WELLER, Richard PJB, HUNTER John AA, SAVIN John A. and DAH Mark V ed. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  2. MARKS Ronald ed. Roxburgh's Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  3. MARKS JR, James G and MILLER Jeffery ed. Lookingbill and Mark's Principals of Dermatology. 4th ed. Elsevier. 2006,125-128.
  4. BENNET, P.N. and BROWN, M.J. CLINICAL PHARMACOLOGY. 9th Ed. CHURCHILL LIVINGSTONE. 2003, 263-267.
  5. KATZUNG, Bertram G. MASTERS, Susan B. and TREVOR, Anthony J. Basic and Clinical Pharmacology. 12th Ed. Tata McGraw-Hill. 2012, 849-860.
  6. PIRES CA, DA CRUZ NF, LOBATO AM, DE SOUSA PO, CARNEIRO FR, MENDES AM. Clinical, epidemiological, and therapeutic profile of dermatophytosis An Bras Dermatol [online] 2014, 89(2):259-265 [viewed 28 May 2014] Available from: doi:10.1590/abd1806-4841.20142569
  7. MICHAELS BD, DEL ROSSO JQ. Tinea Capitis in Infants: Recognition, Evaluation, and Management Suggestions J Clin Aesthet Dermatol [online] 2012 Feb, 5(2):49-59 [viewed 29 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3315884