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Table of Contents
Year : 2021  |  Volume : 39  |  Issue : 2  |  Page : 85-86

A case of recalcitrant tinea capitis successfully treated with fluconazole

Department of Dermatology, College of Medicine, Dongguk University Ilsan Hospital, Dongguk University, Goyang, Korea

Date of Submission31-Jul-2020
Date of Decision30-Jan-2021
Date of Acceptance31-Jan-2021
Date of Web Publication23-Jun-2021

Correspondence Address:
Prof. Jong Soo Hong
Department of Dermatology, College of Medicine, Dongguk University Ilsan Hospital, Dongguk University, Goyang
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ds.ds_8_21

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How to cite this article:
Jeong JH, Park YJ, Lee JY, Lee SH, Lee AY, Hong JS. A case of recalcitrant tinea capitis successfully treated with fluconazole. Dermatol Sin 2021;39:85-6

How to cite this URL:
Jeong JH, Park YJ, Lee JY, Lee SH, Lee AY, Hong JS. A case of recalcitrant tinea capitis successfully treated with fluconazole. Dermatol Sin [serial online] 2021 [cited 2023 Mar 21];39:85-6. Available from: https://www.dermsinica.org/text.asp?2021/39/2/85/319157

Dear Editor,

Tinea capitis is a common fungal infection of the scalp in children. The clinical features of this condition range from mild scaling to massive inflammation with extensive alopecia patches, which, if untreated, can progress to permanent hair loss. Various systemic drugs, such as griseofulvin, terbinafine, fluconazole, ketoconazole, and itraconazole, have been used.[1] However, treatment can be interrupted in some cases by factors such as varying dosage schedules according to medications, epidemiological changes, and increasing drug resistance. Here, we present a case of recalcitrant tinea capitis treated successfully with fluconazole.

A 7-year-old girl presented with an itchy alopecia patch on the scalp. She had a cat as a pet. On examination, a round alopecia patch with broken hair shafts and mild scales was observed on the left occipital area [Figure 1]a. Microscopic examination for fungus on the hair revealed the presence of the ectothrix organism and the patient was consequently diagnosed with tinea capitis. We prescribed terbinafine (125 mg/day) and topical isoconazole. Results of a liver function test before terbinafine administration was normal. After 4 days, we observed a small amount of pus on the lesion. We collected skin bacterial and fungal culture samples for examination using a swab on the lesion, and then cefaclor was prescribed. The skin bacterial culture was negative. We switched the treatment from terbinafine to itraconazole because the patient was unresponsive to terbinafine over the course of 5 weeks [Figure 1]b. Isoconazole was also discontinued due to ineffectiveness. However, no significant improvement was noted on the lesion despite 4 weeks of itraconazole treatment (100 mg/day). Microsporum canis was identified on fungus culture. We switched itraconazole to fluconazole syrup (50 mg/day). After 8 weeks of treatment, the patient's lesions and symptoms improved significantly [Figure 1]c. In addition, hair loss was improved with only slight erythema. Considering the patient's young age and compliance, we did not repeat the laboratory tests during the treatment, but no clinical side effects were observed during the entire treatment duration. The patient's lesion improved completely on treatment with the antifungal shampoo for 4 months after discontinuation of oral fluconazole [Figure 1]d.
Figure 1: (a) Before treatment, a scaly alopecia patch was observed on the occipital area (b) After 4 weeks of treatment with terbinafine, a crusted erythematous patch and plaque was observed (c) After 6 weeks of treatment with fluconazole, the lesions improved slightly, leaving erythema (d) 12 weeks after the discontinuation of fluconazole, the lesion had improved completely.

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M. canis is a zoophilic dermatophyte that causes infection after contact with a cat or dog and is generally more acute and has evident inflammatory changes as compared with anthropophlic Trichophyton species. However, tinea capitis by anthropophilic dermatophytes, mostly Trichophyton, is often a chronic condition characterized by relatively mild inflammation. Depending on the fungal species, the therapeutic response may vary. Previous studies[1],[2] showed that griseofulvin was more effective against Microsporum, itraconazole and terbinafine were more effective against Trichophyton, and fluconazole had a similar effect on both. As in this case, previous studies have reported that several cases did not respond to treatment with terbinafine or that patients with tinea capitis caused by M. canis took longer to treat.[3],[4] Therefore, griseofulvin and fluconazole may be used for tinea capitis caused by M. canis. However, griseofulvin is the only fungistatic that leads to a longer treatment period; therefore, the effectiveness of griseofulvin may decline as a result of reduced compliance in children.[5] In addition, griseofulvin is not available in many countries for pediatric use. On the other hand, according to a preceding study,[5] fluconazole has a higher cure rate in treating tinea capitis by M. canis than other oral medications. Fluconazole can also be administered in the form of suppositories, which is considered more favorable for young children. Previous studies showed that itraconazole was effective against both Trichophyton and Microsporum species, but there was no response to itraconazole in our case.

After tinea capitis is confirmed through microscopic examination, the selection of the most appropriate antifungal treatment depends on determining the fungal species through fungal culture. However, because the results of fungal cultures can take several weeks to obtain, it is necessary to use empirical antifungal agents first. Therefore, when choosing an empirical antifungal agent, fluconazole may be a good choice for children presenting with more rapid and evident inflammatory lesions with hair loss, which may lead to suspicion of infection by M. canis. Because the optimal dose and duration of fluconazole in the treatment of tinea capitis have not been clearly established, further studies are required through the examination of additional cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient's parents consent forms. In the form the parents have given the consent for their child's images and other clinical information to be reported in the journal. The parents understand that the name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Grover C, Arora P, Manchanda V. Comparative evaluation of griseofulvin, terbinafine and fluconazole in the treatment of tinea capitis. Int J Dermatol 2012;51:455-8.  Back to cited text no. 1
Kakourou T, Uksal U, European Society for Pediatric Dermatology. Guidelines for the management of tinea capitis in children. Pediatr Dermatol 2010;27:226-8.  Back to cited text no. 2
Baleviciene G, Ceburkovas O, Maciuliene D. Oral terbinafine for tinea capitis due to Microsporum canis in children. Acta Derm Venereol 2001;81:61.  Back to cited text no. 3
Peharda V, Kastelan M, Cabrijan L, Saftic M, Gruber F. Terbinafine in the treatment of tinea capitis. Acta Derm Venereol 1998;7:164-6.  Back to cited text no. 4
Gupta AK, Mays RR, Versteeg SG, Piraccini BM, Shear NH, Piguet V, et al. Tinea capitis in children: A systematic review of management. J Eur Acad Dermatol Venereol 2018;32:2264-74.  Back to cited text no. 5


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