Sir,

Tinea capitis is a dermatophytic infection of the hair shaft and scalp, and it is considered one of the most common dermatoses in pediatric practice. Herein, we present two cases of inflammatory tinea capitis.

CASE 1

A twelve-year-old male patient consulted his pediatrician for a scalp lesion that had progressively enlarged. He was prescribed cefadroxil and sulfur soap; however, due to lack of improvement, he was referred for dermatological evaluation. On examination, there was a localized trichopathy on the scalp characterized by alopecia and honey-colored crusts measuring approximately 4 cm in diameter (Fig. 1). Additional findings included erythematous scaly plaques with hemorrhagic crusts on the forehead and left forearm (Figs. 2a and 2b). There was no significant personal or family history.

	Figure 1: Trichopathy on the scalp characterized by alopecia and honey-colored crusts.
	Figure 2: (a and b) Erythematous scaly plaques with hematic crusts on the forehead and left forearm.

Based on the clinical presentation, a diagnosis of inflammatory tinea capitis was established, and KOH preparation and fungal culture of the hair were requested. The KOH preparation revealed microsporic endothrix hair invasion (Fig. 3a), and Trichophyton tonsurans was isolated on culture (Fig. 3b).

Figure 3: (a) KOH showing a microsporic endothrix hair invasion. (b) Trichophyton tonsurans isolated.

With these findings, the clinical and mycological diagnosis of inflammatory tinea capitis was confirmed. The patient was treated with griseofulvin 250 mg after lunch for six weeks, achieving complete resolution of the lesion (Figs. 4a – 4c).

Figure 4: (a-c) Complete resolution of the lesion after six weeks of treatment.

CASE 2

A six-year-old female patient presented with a scalp lesion of three months’ duration, initially described as persistent “dandruff.” She had been treated by a general practitioner with a topical cream for fifteen days without improvement and was subsequently referred to our clinic. Dermatologic examination revealed localized trichopathy on the scalp consisting of an erythematous, scaly, alopecic plaque with hematic crusts (Fig. 5a). Dermoscopy demonstrated an erythematous, scaly, alopecic plaque (Fig. 5b).

Figure 5: (a) Erythematous, scaly, alopecic plaque with hematic crusts. (b) Dermoscopy demonstrating an erythematous, scaly, alopecic plaque.

A clinical and mycological diagnosis of inflammatory tinea capitis was made. KOH preparation of the hair showed microsporic endothrix invasion (Fig. 6).

Figure 6: KOH preparation of the hair showing a microsporic endothrix invasion.

These findings confirmed the clinical and mycological diagnosis of inflammatory tinea capitis. The patient was treated with one-quarter tablet of griseofulvin after lunch for six weeks, achieving complete remission of the lesion (Fig. 7).

Figure 7: Complete resolution of the lesion after six weeks of treatment.

Inflammatory tinea of the scalp refers to a superficial infection involving the scalp skin and hair shafts. It is mainly caused by dermatophytes of the genera Trichophyton and Microsporum [1]. This condition is characterized by hair invasion with distinct patterns (ecto-endothrix and endothrix) and variable degrees of inflammation, often going unnoticed in its initial stages.

Although primarily considered a childhood mycosis, in recent years, cases have also been described in adults, particularly in immunocompromised individuals [1]. Consequently, it remains a public health issue that predominantly affects children but not exclusively. Notably, there are marked geographic variations: in the Americas, Trichophyton tonsurans predominates, whereas Microsporum canis remains more prevalent in other regions [1–4].

The main causative agents are Trichophyton tonsurans and Microsporum canis [4]. In Latin American countries, there has been a progressive shift toward Trichophyton, displacing Microsporum to a secondary role. This epidemiologic change significantly influences both the course of the disease and the response to treatment [5–6].

Inflammatory tinea of the scalp does not present in a single way; it may appear as erythematous, scaly patches with alopecia, honey-colored or hemorrhagic crusts, black dots, and areas of diffuse hair loss [1,2,4]. Among the variants, kerion deserves special mention, as it presents as an infiltrated, suppurative, alopecic plaque that, if untreated, can lead to scarring alopecia [3].

Dermoscopy and trichoscopy provide very useful diagnostic clues such as comma hairs, corkscrew hairs, and black dots [7].

Diagnosis should combine clinical evaluation with dermoscopy and, most importantly, mycological studies. Direct examination with KOH and fungal culture remain essential tests to confirm the etiological agent [2,3,5]. Dermoscopy also helps differentiate this mycosis from other dermatoses and reveals hair shaft patterns that may not be visible to the naked eye [3,7].

Effective management relies on systemic antifungal therapy, since topical agents alone do not adequately penetrate the hair follicle [5]. Griseofulvin and terbinafine remain the first-line drugs, chosen according to the species identified (Microsporum vs. Trichophyton) [7]. Itraconazole or fluconazole may be used as alternatives in selected situations [5].

Adjunctive use of antifungal shampoos, such as selenium sulfide or ketoconazole, is helpful to reduce fungal load and limit transmission but does not replace systemic treatment. Therapy is typically maintained for 4 to 8 weeks and adjusted based on clinical evolution and mycological results [5,7].

Early treatment shortens disease duration and prevents scarring alopecia [3]. Although inflammatory tinea of the scalp is still more common in children, mycological confirmation and follow-up are equally important in adults to avoid complications and reduce transmission in school and household settings [5]. Hygiene education and early detection of contacts can markedly improve the course and prognosis of the disease [6].

REFERENCES

1.  Hill RC, Gold JAW, Lipner SR. Comprehensive review of tinea capitis in adults:Epidemiology, risk factors, clinical presentations, and management. J Fungi (Basel). 2024;10:357.

2.  Ion A, Popa LG, Porumb-Andrese E, Dorobanţu AM, Tătar R, Giurcăneanu C, et al. A current diagnostic and therapeutic challenge:Tinea capitis. J Clin Med. 2024;13:376.

3.  Shemer A, Lyakhovitsky A, Kaplan B, Kassem R, Daniel R, Caspi T, et al. Diagnostic approach to tinea capitis with kerion:A retrospective study. Pediatr Dermatol. 2022;39:708-12.

4.  Dascalu J, Zaaroura H, Renert-Yuval Y, Khamaysi Z, Avitan-Hersh E, Friedland R. Pediatric tinea capitis:A retrospective cohort study from 2010 to 2021. J Fungi (Basel). 2023;9:366.

5.  StatPearls. Tinea capitis [Internet]. Treasure Island (FL):StatPearls Publishing;2023 [cited 2023]. Available from:https://www.ncbi.nlm.nih.gov/books/NBK536909

6.  Arenas R. Dermatology. 8^th ed. Mexico City:McGraw-Hill Interamericana;2023.

7.  Bolognia JL, Schaffer JV, Cerroni L. Dermatology. 5^th ed. Amsterdam:Elsevier;2024.