AnBrasDermatol.2020;95(3):332---335
Anais
Brasileiros
de
Dermatologia
www.anaisdedermatologia.org.brCASE
REPORT
Tinea
capitis:
dermoscopy
and
calcium
fluorescent
microscopy
as
highly
efficient
and
precise
diagnostic
tools
夽
Hui
Xiao
,
Sushmita
Pradhan
,
Xin
Ran
,
Yuping
Ran
∗DepartmentofDermatovenereology,WestChinaHospital,SichuanUniversity,Chengdu,Sichuan,610041,China Received10November2018;accepted13June2019
Availableonline19March2020
KEYWORDS Dermoscopy; Fluorescentdyes; Microscopy, fluorescent; Tineacapitis
Abstract Tineacapitiscomprisingoftineafavosaandkerionismostlyseeninschool-aged
chil-dren.Sometineacapitisoftenpresentedwithinsignificantfindingsunderthenakedeyesare easilyoverlooked.Theauthorsdescribeanunusualcaseoftineacapitiscausedby Trichophy-tonviolaceum.Thepatientwasan8-year-oldgirl,withahistoryofpruritusonthescalpfor morethanoneyear.Adiagnosisoftineacapitiswasconfirmedbyclinicalexaminationaidedby dermoscopy,calciumfluorescentmicroscopyandculture.Commaandcorkscrewhairsaretwo specificdermoscopicpatternsoftineacapitis.Thepatientwastreatedwithsystemic itracona-zole,topicalapplicationwith1%naftifine0.25%ketoconazolecreamfollowedafterdailyhair washwith2%ketoconazoleshampoofor8weeks.
©2020SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.Thisisan openaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
Introduction
Tineacapitiscomprisingoftineafavosaandkerionismostly seen in school-aged children. The incidence of unusual findingsoftineacapitiscausedbyanthropophilic dermato-phytes,suchasTrichophytonviolaceum,hasgrowninrecent years.Thesefungitendtocausescarceinflammatory
reac-夽 How to cite this article: Xiao H, Pradhan S, Ran X, Ran Y.
Tineacapitis:dermoscopyandcalcium fluorescentmicroscopyas highly efficient and precise diagnostic tools. An BrasDermatol. 2020;95:332---5.
∗Correspondingauthor.
E-mail:[email protected](Y.Ran).
tions,presentedwithinsignificantfindingsunderthenaked eyes are easily overlooked. The diagnosis of less symp-tomaticandatypicalcasesoftineacapitisisbasedonthe resultsofdirectmicroscopicexaminationwithconventional 10% KOHsmear andmycological culturesof skin scrapings and hair debris.The absenceof a rapidand reliable con-firmatory test, coupled with a nonspecific presentation, canleadtodelayed diagnosisor misdiagnosis.Ithasbeen reportedthatcommaandcorkscrewhairsaretwospecific dermoscopic patterns of tinea capitis.1,2 Calcium
fluores-cent microscopycan definitely confirm a diagnosis. Here, we report a case of tinea capitis timely diagnosed with dermoscopy and calciumfluorescent microscopy ashighly efficientandprecisediagnostictools.
https://doi.org/10.1016/j.abd.2019.06.013
0365-0596/©2020SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.ThisisanopenaccessarticleundertheCC BYlicense(http://creativecommons.org/licenses/by/4.0/).
Tineacapitis:dermoscopyandcalciumfluorescentmicroscopyashighlyefficientandprecisediagnostictools 333
Figure1 Clinicalmanifestationoftineacapitis.Asmalllocal
beansizedhairlosspatchandscattered‘‘blackspots’’onthe topofthehead(whitecircles).
Case
report
An8-year-oldChinesegirlweighing21kgpresentedtothe dermatology clinic witha history of pruritus onthe scalp formorethanoneyear.Herpastmedicalhistorywas unre-markable.She hadahistory oftaming acat andadog at home.Dermatologicalexaminationrevealed asmall bean-sized patch hair loss and scattered ‘‘black spots’’on the top of the head (Fig. 1). Numerous short, highly convo-luted, coiled, and twisted corkscrewhairs wereobserved underpolarizeddermoscopy(JD801D;JEDA,China)(Fig.2). Calcium fluorescent (Fungal Fluorescence Detection Kit, JiangsuLifetimeBiologicalTechnologyCo.,Ltd.)microscopy ofthescaleincorkscrewhairrevealedextremelyhigh num-bersof spores (Fig.3). The lush purple colonydeveloped after inoculating the scales in SDA medium at 28◦C for 30days(Fig.4).Calciumfluorescentmicroscopic examina-tionshowedseparatebranchesofmyceliumwithirregular protrusions,and thick-walledsporesof varying sizes after the colony were cultured in PDA medium at 25◦C for 14 days(Fig.5).Thegirlwasdiagnosedwithanunusualcase of tineacapitiscaused byT. violaceumconfirmed by der-moscopy,calciumfluorescentmicroscopicexaminationand culture.Shereceivedsystemictreatmentwithitraconazole (Xian-JanssenPharmaceuticalLtd.),100mgperdaywithfull fattymilk,combinedwithtopicalapplicationof1%naftifine
Figure2 Dermoscopyshowedcorkscrewhairs(whitearrows,
originalmagnification×40).
0.25%ketoconazolecream(ChongqingHuapont Pharmaceu-tical Co., Ltd.) followed after daily hair wash with 2% ketoconazoleshampoo(Triatop,Xian-Janssen Pharmaceuti-calLtd.).Thepatientshoweddrasticimprovementafter8 weeksof treatment with the disappearanceof corkscrew hairs.Therefore,norecurrencewasobservedafteroneyear offollow-up(Fig.6).
Discussion
Theprevious studyspeculated theformationof corkscrew hairsasaresultofacombinationofinternaldamagedueto unsymmetricalhairdegradationbyT.violaceumand exter-nalresistanceduetoscalescoveringthehair.3
Dermoscopyisadiagnostictoolfortheidentificationof finestructuresandcolorsthatcannotbeobservedwiththe naked eye. It can facilitate the diagnosis of tinea capi-tis as a rapid, noninvasive, reliable, and an inexpensive method.Calciumfluorescentmicroscopyiseasytooperate andtimelythat accurately identifiesthefungal infections byspecificstainingofthefungalcellwall.Thus,itcan sig-nificantlyimproveitspositiverate,onspecialpopulations,
Figure3 Calciumfluorescentmicroscopyofscalesshowedextremelyhighnumbersofspores(originallight(A)andfluorescent
334 XiaoHetal.
Figure4 Lushpurplecolonydevelopedafterinoculatingthe
scalesinSDAmediumat28◦Cfor30days.
ofchildren,whocanreceiveearlyandeffectivetreatment aftertherapiddiagnosis.4
Financial
support
Nonedeclared.
Authors’
contributions
Hui Xiao: Statistic analysis; approval of the final version of themanuscript; conception and planningof the study; elaborationandwritingofthemanuscript;obtaining, anal-ysis,andinterpretationofthedata;effectiveparticipation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; criticalreview of the literature; critical review of themanuscript.
Figure5 Calciumfluorescentmicroscopicexaminationofthe
smear ofcolony showedseparate branchesofmyceliumwith irregularprotrusions,andthick-walledsporesofvaryingsizes afterthecolonywereculturedinPDAmediumat25◦Cfor 14 days(originalmagnification×1000).
Figure6 Dermoscopyofpost-treatmentfindingsshowedthe
disappearanceofcorkscrewhairs(originalmagnification×40).
SushmitaPradhan:Statisticanalysis;approvalofthefinal versionofthemanuscript;conception andplanning ofthe study;elaborationandwritingofthemanuscript;obtaining, analysis,andinterpretation ofthe data;effective partici-pationinresearchorientation;intellectualparticipationin thepropaedeuticand/ortherapeuticconductofthestudied cases;criticalreviewoftheliterature;criticalreviewofthe manuscript.
Xin Ran: Elaboration and writing of the manuscript; obtaining,analysis,andinterpretationofthedata;effective participationinresearchorientation;intellectual participa-tioninthepropaedeuticand/ortherapeuticconductofthe studiedcases;criticalreviewofthemanuscript.
YupingRan:Statisticanalysis;approvalofthefinal ver-sion of the manuscript; conception and planning of the study;elaborationandwritingofthemanuscript;obtaining,
Tineacapitis:dermoscopyandcalciumfluorescentmicroscopyashighlyefficientandprecisediagnostictools 335 analysis,andinterpretation ofthedata; effective
partici-pationinresearchorientation;intellectualparticipationin thepropaedeuticand/ortherapeuticconductofthestudied cases;criticalreviewoftheliterature;criticalreviewofthe manuscript.
Conflicts
of
interest
Nonedeclared.
Acknowledgments
Wewouldliketothankthepatient’sparentsforgrantingus permissiontopublishthisarticle.
References
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2.Esteves ALV, Serafini NB, Lemes LR, Melo DF. Circular hairs: nomenclatureandmeanings.AnBrasDermatol.2017;92:874---6.
3.Lu M, Ran Y, Dai Y, Lei S, Zhang C, Zhuang K, et al. An ultrastructural study on corkscrew hairs and cigarette-ash-shapedhairsobservedbydermoscopyoftineacapitis.Scanning. 2016;38:128---32.
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