British A ssociation of D ermatologists' guidelines for the management of tinea capitis 2014

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Abstract

The overall objective of this guideline is to provide up-to-date, evidence-based recommendations for the management of tinea capitis. This document aims to update and expand on the previous guidelines by (i) offering an appraisal of all relevant literature since January 1999, focusing on any key developments; (ii) addressing important, practical clinical questions relating to the primary guideline objective, i.e. accurate diagnosis and identification of cases; suitable treatment to minimize duration of disease, discomfort and scarring; and limiting spread among other members of the community; (iii) providing guideline recommendations and, where appropriate, some health economic implications (tinea capitis is a common problem in resource-poor settings and therefore treatments that are more easily and cheaply available and applicable to these settings have been factored in); and (iv) discussing potential developments and future directions. This guideline is presented as a detailed review with highlighted recommendations for practical use in the clinic (see Section 12), in addition to the production of a patient information leaflet [available on the British Association of Dermatologists' (BAD) website, http://www.bad.org.uk]. The guideline development group consisted of consultant, specialist registrar and associate specialist dermatologists, and a mycologist. The draft document was circulated to the BAD membership, British Dermatological Nursing Group (BDNG) and Primary Care Dermatological Society (PCDS) for comments, and was peer reviewed by the Clinical Standards Unit of the BAD (made up of the Therapy & Guidelines Subcommittee) prior to publication. This set of guidelines has been developed using the BAD's recommended methodology1 and with reference to the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument (www.agreetrust.org).2 Recommendations were developed for implementation in the National Health Service (NHS) using a process of considered judgement based on the evidence. The PubMed, Medline and Embase databases were searched for meta-analyses, randomized and nonrandomized controlled clinical trials, case series, case reports and open studies involving tinea capitis published in the English language from January 1999 to March 2014; search terms and strategies are detailed in the Supporting Information (see Table S1). Working in pairs, the authors screened the identified titles, and those relevant for first-round inclusion were selected for further scrutiny. The abstracts for the shortlisted references were then reviewed and the full papers of relevant material were obtained; disagreements in the final selections were resolved by discussion among the entire development group. Additional relevant references were also isolated from citations in shortlisted and reviewed literature, as well as (independent) targeted searches carried out by the coauthors. The structure of the 2000 guidelines was then discussed and re-evaluated, and different coauthors were allocated separate subsections. Each coauthor then performed a detailed appraisal of the selected literature with discussions with the entire development group to resolve any issues, for example with the quality of evidence and making the appropriate recommendations. All subsections were subsequently collated and edited to produce the final guideline. This document has been prepared on behalf of the BAD and is based on the best data available when the document was prepared. It is recognized that under certain conditions it may be necessary to deviate from the guidelines and that the results of future studies may require some of the recommendations herein to be changed. Failure to adhere to these guidelines should not necessarily be considered negligent, nor should adherence to these recommendations constitute a defence against a claim of negligence. Limiting the review to English language references was a pragmatic decision, but the authors recognize this may exclude some important information published in other languages. The proposed revision for this set of recommendations is scheduled for 2019; where necessary, important interim changes will be updated on the BAD website. Tinea capitis is an infection of scalp hair follicles and the surrounding skin, caused by dermatophyte fungi, usually species in the genera Microsporum and Trichophyton. Tinea capitis continues to be predominantly a disorder of prepubertal children, common in inner-city cosmopolitan communities, with no sign of a reduction in incidence. Although across Europe Microsporum canis remains the most commonly involved organism, in the U.K., a shift towards anthropophilic species continues to be observed.3 Trichophyton tonsurans is reported to account for 50–90% of dermatophyte scalp isolates in the U.K.3 This rise in anthropophilic dermatophyte infections is attributed to immigration and travel patterns. An accurate diagnosis remains a vital component of management. Clinicians unfamiliar with this condition often misdiagnose tinea capitis, especially inflammatory variants such as boggy kerions, leading to delays in diagnosis and inappropriate management.4, 5 Tinea capitis predominates in healthy preadolescent children; infants are less frequently affected.6, 7 The incidence in adults is generally low, but it is more commonly seen in the immune compromised, where the presentation may be atypical.8, 9 The clinical appearance of tinea capitis is highly variable, depending on the causative organism, type of hair invasion and degree of host inflammatory response. Common features are patchy hair loss with varying degrees of scaling and erythema. However, the clinical signs may be subtle and diagnosis can be challenging. A number of clinical patterns exist. Grey patch Small-spored, ectothrix Microsporum infection typically produces characteristic fine scaling with patchy circular alopecia, dull grey in colour due to arthrospores coating the affected hairs. Inflammation may be minimal with anthropophilic fungi (e.g. M. audouinii, M. ferrugineum); however, zoophilic or geophilic species (e.g. M. canis, M. gypseum) typically demonstrate more intense inflammatory response. Black dot Endothrix infection with Trichophyton species (e.g. T. tonsurans, T. violaceum, T. soudanense) produces relatively noninflammatory patches of alopecia with fine scale, classically studded with broken-off, swollen hair stubs, resulting in a ‘black dot’ appearance. Patches may be multiple. Diffuse scale In some cases, alopecia is minimal or absent and infection presents as generalized, diffuse scaling of the scalp, resembling dandruff. Diffuse pustular In more inflammatory variants, a diffuse, patchy alopecia may coexist with scattered pustules or low-grade folliculitis. This may be associated with painful regional lymphadenopathy. Kerion Also known as ‘kerion celsi’, this is the term given to tinea capitis presenting as a painful, boggy, inflammatory mass with associated alopecia. Plaques may be solitary or multiple, studded with pustules and matted with thick crust. Regional lymphadenopathy is common. This variant represents a delayed host inflammatory response to the causative dermatophyte. Misdiagnosis as bacterial abscess is not uncommon; however, secondary bacterial infection should not be overlooked. Kerion is commonly seen with zoophilic, large-spore ectothrix species (e.g. T. Mentagrophytes, T. verrucosum); however, this has been superseded in recent years by endothrix infections with either T. tonsurans or T. violaceum, particularly in urban areas.10 Favus A chronic, inflammatory tinea capitis typically seen in T. schoenleinii infection, this variant is most commonly encountered in the Middle East and North Africa. Favus is characterized by yellow, crusted, cup-shaped lesions (‘scutula’) composed of hyphae and keratin debris, which develop around follicular openings. Favus may result in cicatricial alopecia. Favus infections fluoresce under Wood's lamp. A pruritic, papular ‘id’ eruption, also known as ‘dermatophytid’, particularly around the outer helix of the ear, may accompany treatment initiation, but should not be confused with a drug reaction.11, 12 These eruptions represent a cell-mediated host response to the dermatophyte after effective therapy has been initiated and do not warrant cessation of systemic antimycotic therapy. Topical (or occasionally, if very severe, oral) corticosteroids may provide symptomatic relief. Ectothrix Microsporum species demonstrate bright green fluorescence of infected hairs under Wood's lamp examination. This may aid clinical distinction from nonfluorescent Trichophyton infection (exception: T. schoenleinii can fluoresce dull green), although the value of this investigation is limited given the current predominance of nonfluorescing species of Trichophyton. The presence of regional lymphadenopathy in combination with alopecia and/or scale in a child suspected of having tinea capitis is an important diagnostic clue and should encourage appropriate investigation with fungal culture.13, 14 Although the authors have no personal experience of this technique, dermoscopy is being recommended as a useful adjunctive tool in diagnosing tinea capitis. Black dot hair stubs may be visualized more clearly. ‘Comma-shaped’ hairs have been described in white children with ectothrix infection, whereas corkscrew hairs have been reported in Afro-Caribbean children with tinea capitis.15 The differential diagnosis of tinea capitis is extensive, encompassing any condition causing patchy hair loss, scaling or scalp inflammation. Scalp psoriasis, seborrhoeic dermatitis and atopic dermatitis may be difficult to differentiate from noninflammatory tinea capitis, although these conditions are usually more diffuse, and there may be characteristic signs elsewhere. Alopecia areata is generally nonscaly but may occasionally demonstrate erythema. Exclamation-mark hairs must be distinguished from the broken hairs of tinea capitis. Lupus erythematosus, lichen planopilaris and trichotillomania should also be considered, although they are relatively rare. Inflammatory tinea capitis variants may be misdiagnosed as bacterial folliculitis, folliculitis decalvans or abscesses. Regional lymphadenopathy may be associated with inflammatory variants of tinea capitis. Although the clinical diagnosis of tinea capitis is often relatively accurate, when considered, laboratory investigations to confirm the diagnosis are advisable to isolate the causal organism and direct the choice of systemic therapy.13, 14 Post-treatment samples should be sent to ensure clearance. Suspected tinea capitis lesions should be sampled either by plucking hairs, using a blunt scalpel to remove hair and scalp scale, or by taking scalp brushings. In cases of tinea capitis caused by M. canis, affected hairs identified by fluorescence under a Wood's lamp may be plucked and constitute an appropriate specimen. Specimens should be collected in paper or card packs. Bonifaz et al.16 have shown that the cytobrush improves both sensitivity and time to positive culture. Furthermore, this is available as a sterile device and its soft bristles may cause less discomfort to children. (Strength of recommendation D; level of evidence 3; see Appendixes 1 and 2 for explanations of these measures.) A disadvantage of brush sampling is that it does not enable the laboratory to examine the specimen microscopically and permits only culture. Friedlander et al.17 have demonstrated that gauze swabs make an equally effective and often more convenient sampling method. A comparison of sampling methods for the detection of dermatophytes in asymptomatic carriage has been described.18, 19 This suggests that multiple sampling methods, such as a scalp scraping and a brush, are likely to lead to an increased yield of dermatophyte fungus from infected scalps.20 (Strength of recommendation D; level of evidence 3.) It is considered that sampling the edge of scalp lesions may provide higher yields of causal fungus. Sampling of kerions may be problematic, and culture is often negative. A swab of the lesion may provide the most appropriate specimen. Scalp lesions in suspected cases of tinea capitis should be sampled by scalpel scraping, hair pluck, brush or swab as appropriate to the lesion. (Strength of recommendation D; level of evidence 3.) Microscopy should be carried out on all scalp scrapings and plucked hairs, by mounting in 10–30% potassium hydroxide with or without calcofluor, and examination by light or fluorescence microscopy. The presence of hyphae and/or arthroconidia should be reported. The sensitivity of microscopy is not high.21 (Strength of recommendation D; level of evidence 3.) Where possible it should be determined whether the arrangement of arthroconidia is endothrix or ectothrix, but this is often difficult. All specimens should be cultured on Sabouraud agar with at least one agar plate containing cycloheximide to inhibit nondermatophyte mould growth. Plates should be incubated for at least 2 weeks. Where exposure to cattle is documented and an infection caused by T. verrucosum is suspected, plates should be incubated for up to 3 weeks and examined very carefully at the end of this period for the presence of the slow-growing and inconspicuous colonies of this species. Any dermatophytes growing should be identified and reported. (Strength of recommendation D; level of evidence 4.) There is no routine indication to test dermatophytes for susceptibility to antifungal agents, as many studies have shown little evidence for the development of (Strength of recommendation D; level of evidence 3.) All specimens from cases of tinea capitis should be for microscopy and culture where and the causal identified where is not (Strength of recommendation D; level of evidence 4.) The primary objective of this guideline is to tinea capitis in the The aims of treatment are of the organism, resulting in both a clinical and as and as of of and reduction of to therapy is generally to these (Strength of recommendation level of evidence one should for of the presence of either by microscopy at the patient or for culture. However, in results culture results may weeks to be and may further in the presence of a or when the diagnosis of a fungal infection is suspected based on the presence of very features of lymphadenopathy or alopecia, it is to therapy as these are for tinea 14 (Strength of recommendation level of evidence Although a of may with therapy is not recommended for the management of tinea (Strength of recommendation level of evidence However, are to of and and have all shown in this (Strength of recommendation level of evidence It is to treatment on the of one or more (Strength of recommendation level of evidence evidence has to that the treatment to the dermatophyte involved should therefore and be based on the most likely (Strength of recommendation level of evidence A or a of may be in cases of treatment (see Section or if an fungus is identified on culture. Although in the U.K., remains the only treatment for tinea capitis in children, evidence that antifungal have higher response and are and more This is in recent changes to the and of antifungal in of Europe and the that the of in the may the of to are well in most and the of evidence this guideline should clinical is a drug that at and of the There is years of experience in the use of the and it remains the only for use in the treatment of tinea capitis in children in the It is available in and but the has and not The is no a in the U.K., and are no available in some having been superseded by other The treatment for those 1 is 1 in children or in or for weeks if the drug with may and recommendations to the type of and easily it is It may be necessary to use up to for more in A of that response are highly depending on the species for Microsporum species with for Trichophyton species. A recent of randomized controlled suggests that weeks of treatment is more effective weeks of in Microsporum There is no evidence of to in but evidence suggests that the drug is less effective against Trichophyton species in the clinical and higher for may be in Trichophyton in of cases, in and The drug is in and are against a child for after for use in children in the more to children and more accurate treatment with potential to erythematosus, and the is an that on the and is It against all but has higher against Trichophyton species higher is more effective against M. canis but no and treatment does not In this is for M. canis infection, the for to some can the reported in to treatment is not in the or of prepubertal children, and be the hair in children, does not the scalp where the arthroconidia are in Microsporum for its In of that weeks of is at least as effective as weeks of in T. tonsurans may be considered the when and are Although treatment and has a it remains for use in children in the However, its use is in the of in recent of the British National for Although not available in in the U.K., a of in or to be on has been for use in children years of in the and higher at higher However, it is not available or in the studies of that children require to the drug for in However, there is no of any in children with well in and in and very are to treatment potential to no in provide a not for treatment of children in the is by and increased by both and depending on the of the other its primary of is of which with of for or 5 for weeks have with or (Strength of recommendation level of evidence is the in the of and has against both and Trichophyton The drug is well (Strength of recommendation level of evidence and has been shown to be for use in the of (Strength of recommendation D; level of evidence 3.) are and may be Although in the drug is not for the treatment of tinea capitis in children in the 12 years and treatment available in has for use in children 12 not in the for children 12 years with tinea capitis. of some and of with and has been in the treatment of tinea and has been as an to but its use has been relatively limited of and it no (Strength of recommendation level of evidence with in a of and in of T. violaceum, T. verrucosum and M. canis has been shown with but due its and limited remains the treatment of choice in many of the (Strength of recommendation level of evidence is not for the treatment of tinea in children years in the however, it is for use in all children for Furthermore, the drug is for treatment of tinea in children 1 in have been and well (Strength of recommendation level of evidence is more against dermatophyte isolates or but and its current (Strength of recommendation level of evidence Although the of in tinea capitis at of has been demonstrated in the and it has shown with of and the is the of that was from use in and Europe in Although the potential of of infection to has some to from most this and that children appropriate systemic and adjunctive therapy should be to or of recommendation level of evidence cases due to the anthropophilic T. tonsurans are highly of members may be often with Failure to the will result in (Strength of recommendation level of evidence of all members and those have been isolated from and all anthropophilic these should be with (Strength of recommendation D; level of evidence 4.) This has implications for to ensure that appropriate are to are no but or a of containing are suitable (Strength of recommendation D; level of evidence 3.) The use of corticosteroids and for inflammatory of tinea capitis (e.g. and may and but is were to but studies with antifungal therapy they do not the time to and therefore no are not (Strength of recommendation level of evidence is in T. tonsurans infection, and hair usually after effective antifungal therapy are not at The for this (i) of especially in treatment (ii) of (iii) of the and (iv) fungi can be isolated at the end of but the clinical signs have it is to therapy for a further weeks. However, if there has been no clinical it is to ensure that the antifungal therapy is appropriate for the causal organism identified on culture. the then are (i) to the or duration of the or (ii) to to an for example M. T. or T. The management of asymptomatic those without clinical infection are culture is but current management on the carriage is in of with T. tonsurans but can in M. as In asymptomatic with a therapy is usually the is low, carriage may be with treatment but is with to ensure that treatment has been the of asymptomatic the and of to be and However, although guidelines have been tinea capitis is not considered a health in the at is and of recommendation level of evidence The end for treatment must be clinical response. with sampling is recommended at the end of the treatment period and then is (Strength of D; level of evidence 4.) should therefore be to patient to response. to at the and of tinea capitis across Europe and the of the and may recommendations in the are likely to with However, diagnostic do to be that enable the laboratory diagnosis to be more which will treatment making in the The future for laboratory diagnosis of fungal infections is likely to be a and diagnosis of tinea capitis is to be an and for dermatophyte have generally performed well on clinical specimens hair from with tinea A for the detection of T. tonsurans from has also been studies of microscopy and culture are to whether detection of dermatophytes will the diagnosis of tinea capitis. The recommendation of cases is to in the results due to a and to different However, to this recommendation may to all cases seen in the 12 of evidence are given in the and in Table Tinea capitis is a common scalp infection, seen predominantly in The clinical presentation is highly and on the causative The condition is most commonly due to Microsporum and Trichophyton dermatophyte with T. tonsurans for the of scalp isolates in the are very to and Information as well as the and The is not for the or of any information by the Any should be to the for the

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