The Course of Untreated Tinea Capitis in Negro Children

THE COURSE OF UNTREATED TI NEA CAPITI S

IN NEGRO CHILDRENt LORRAINE FRIEDMAN, PH.D.,t VINCENT J. DERBES, M.D.t ANI) ELIZABETH P. HODGES, M.T.t

Virtually all of the tinea capitis seen among indigent Negro children of this area is caused either by Trichophyton tonsurans or Iluicrosporum

by T. tonsurans, though not as rare as that caused

by ill. audoulni, is not common (e.g. 7 and 8). To explain the paucity of adult infections, Seale

audoulni with the latter predominating. The and Richardson (9) suggested that the adult great majority of these patients are children 6 scalp may develop an immunity to T. tonsurans to 8 years of age. Until the advent of griseofulvin they were treated by prescription of a variety of

compounds and therapeutic regimens. At the time, it was generally assumed that the various medications effected the cures, for otherwise all of the infected children would have remained infected until adulthood, or in the case of It!. audouini infections, at least until puberty. There is also the possibility, however, that their infections not infrequently cleared spontaneously. While it is generally accepted that tinea capitis caused by M. canis tends to heal spontaneously,

spontaneous cures in lit. audouini infections before the age of puberty are considered uncommon, cxcept when the lesions are inflammatory (e.g. 1, 2, 3, 4). In variance with this common view rcgarding the persistence of 111. audouini infections, Kligman (5) has referred to non-pubescent spontaneous termination of 31. audouini tinea capitis of even the non-inflammatory type prior to puberty and implied that such clearance is not uncommon. Also, Lewis, et al. (6), in their textbook on medical mycology mentioned that many patients get well after the infection has been present only several months. They further state that in any case the disease will never last longer than 2 to 5 years, the latter being the outside limit that hairs remain in the growing stage. Tinea capitis caused by T. tonsurans is con-

sidered even more persistent than that of Ji!. audouini origin and these infections are often classified as among those that do not regress at puberty. Nevertheless, adult tinea capitis caused * From the Department of Microbiology and

Division of Dermatology, Tulane University

School of Medicine, New Orleans, Louisiana. This investigation was supported by a research

grant, E1225, from the National Institute of

Allergy arid Infectious Diseases, Public Health Service.

in conjunction with puberty, as has been thought to be the case in microsporum infections. For the report herein 39 children with naturally

acquired tinea capitis caused by 111. audouini were given placebos and the course of their infections observed. Also reported are 8 cases of untreated tinea capitis, the etiologic agent of which was T. tonsurans. METHODS

M. audoulni studies. Diagnoses were made by the finding of ectothrix hairs which fluoresced

under Wood's light, and by obtaining positive cultures from plucked hairs. When fluorescence disappeared and the scalp seemed normal, specimens for culture were taken by vigorous scraping

of the scalp with a scalpel, not only of the previously infected sites but by sampling the entire scalp in order not to miss possible sites of new infection.

An attempt was made to observe and culture

all patients monthly until at least 2 negative

cultures had been obtained. Some, however, as shown in Table I, were not observed with such regularity. The attempt was made, also, to follow patients after cure. Initially 45 indigent patients were selected, primarily on the basis of assessed cooperativeness, but 6 were lost to the study after 2 to 6 months. Thirty-nine were followed until cure; or they are still under observation. Placebos were administered throughout the study. Materials most frequently used were: (A) topical—(1) Plastibase ointment,* (2) white

petroleum jelly scented with imitation oil of bergamot,f (3) variously colored (with food color-

ing) lots of glycerinized water (approximately 2 percent, to give substance); (B) oral—U) variously colored capsules of beta-lactose and (2)

milk sugar tablets usually recommended for * E.

R. Squibb and Sons, New York, N. Y. t Oil of bergamot produced by Magnus, Mabee and Reynard, Inc., New York, N. Y. McCormick and Co., Inc., Baltimore, Md. § Approved Pharmaceutical Corp., Syracuse,

N.Y.

Received for publication February 13, 1963. 237

TABLE I Observations on thirty-nine patients with tinea capitis caused by Microsporum audoulni Period of Clinic Observation, Nearest Month

•

Sex &

History, Previous Duration

0Z 2

4 7

5M 7M

3 11 11 M 4 5

6 7 8

8 5 9 3 4

Until regrown

Measurements

Until first negative culture

After first negative culture

1

13 5 1

8 18 19

multiple 5 cm2 patches multiple 5 cm2 patches inapparent, few fluorescent hairs

3 3 6 1 3

3 3 6 1 3

10 3 2 14 2

3cm2patch

2 10 25 4 2 3

2 10 27 5 2 3

10

multiple 5 cm2 patches multiple 5 cm2 patches extensive

Until nonfluorescent

months

years 1

.

Maximum Severity, ApproKimate

9M 5M 9M

3F

4M

1

9

? 12 3 1

<1

4

10 5

(none lost) 3 3 8 6

notfol-

6

5

multiple 5 cm2 patches multiple 5 cm2 patches

2ocm2patch extensive

lowed

9 10 11

12 13 14

4 2

4M 3M

6

7M

7 10 M

4 SF 8

5

5 4 5 3

8 M possible

2 8 25 7 2—lot 3

6 14 12 2 12

20cm2patch 20cm2patch slight scaliness

previous infec15 16 17

2 6 3

2M 6M

4M

18

9 10 M

19

7

20 21 22 23

9 12 M

7M

6

7M

2 2

3M

3F 4F

25

3 4

26

9

M

24

7

27

28 <1

M

tion <1 2 3 2—3

1 6 1

<1 ?

3 6

M

2—5

2—5

1

10 9 l—8t

3—st

3—S

9

l—7

1—7

2*

1—8

1-8

1—8

1—8

0 0 0 0

multiple 3—10 cm2 patches

1—st

7

extensive

25 4—lot 10

<1

25—34

25—34t 4—10

4—10

8

extensive multiple 1—10 cm2 patches 10 cm2 patch

12

8 16

11*

inapparent grossly, multiple

lost) 8

14

15

17

18

18

multiple 3-10 cm2 patches extensive

(none

5 cm2 fluorescence

followed only 19 mo., only 1 colony then

l—7t

not followed

inapparent, 3 mm2 uluores-

2

2

not followed

cence few 3 cm2 patches

(none

9

16 mo. observation; continues

(none

M unknown

multiple patches multiple 3 cm2 patches extensive

2—St

lost) lost)

inapparent, 5 cm2 fluorescence

to have 5—20 col-

onies 29

3

F

<1

8

6

16 mo. observation; continues

20 cm2 patch

to have 5—20 col-

onies

4

30

F

4

5

2

7 mo. observation; continues to

few <5 cm2 patches

have 3—15 colonies * On

one occasion after second negative culture, had <5 colonies, attributable to contamination

from infected sibling. t Not seen for interval >1 month; time of conversion could not be stated more precisely. 238

UNTREATED TINEA CAPITIS IN NEGRO CHILDREN

239

TABLE I—Concluded Age at

Period of Clinic Observation, Nearest Month

First

0 .0

Ct

o

Sex

Maximum Severity, Approximate Measurements

Duration

V

regwwn

71

months

years

3

31

History, Previous

M

2

?

1—lot 22 inn, observation; continues

3 cm2 patch

to have 3—S colo-

nies

6

32

F

none

regrowmg but after 29 months still

20 cm2 patch

has few fluorescent hairs

2

33

F

<1

34

5

F

2—3 years

35

10

M

none

25

4 (none

lost) 36

10

M

7

37

5

M

1

38 39

5 3

F F

<1 <1

11—21

for 2j years has had few fluorescent hairs for 2 years has had scattered fluorescent hairs for 3 years continues to have few fluorescent hairs

for 2 years has had scat-

tered fluorescent hairs after 27 months observation, beginning to show improvement 13 12

12

8—llt

12 12

10 9

10 cm2 patches

extensive

inapparent; few fluorescent hairs extensive extensive

extensive, inflammatory multiple areas, inflammatory

narcotic withdrawal therapy. Oilaturn soaps and Lowilla emo1lient were issued on one occasion to patients 1 and 22; and 20, respectively. Iriadvertently, Fostex** ointment or shampoo (con-

stated the "medication" (placebo) issued through the study had "worked", usually within a month, and thus the child had not been brought back to

during a 4—6 week period to patients 22, 23, 24, 30,

offered a refund of the cost entailed by them had resort to other medication been necessary. They were told this procedure was in keeping with a

taining 2 percent salicylic acid) was issued for use

arid 32. Patients 33, 34, and 35 were given Fostex preparations for use during more than 1 monthly interval.

Patients 38 and 39 developed inflammatory

reactions and were advised to shampoo with Dial soap.

In the case of apparent infections, especially

those who caine voluntarily to the clinic for treat-

ment, various "home'' medications had been tried previously. Patients 35, 11, and 34 had received prescriptions in another clinic for daily application for 2 months of Bynainid ointment (Cutter), Quinolor (Squibb) and 2 percent salicylic acid ointments, and Quinadoine ointment (I )oine Chemicals, Inc.), respectively. In the case of patients 15—20, who were not under

observation at the time of cure, the parents were questioned in an effort to determine if the cure could have been attributable to army other medica

tion used during the lapse of observation. Each

the clinic as scheduled. In an extreme effort to

obtain truthful reports, several parents were guarantee by the manufacturer of the ''drug'' (placebo) issued through the study. Not one ac cepted a refund.

'P. tonsurans. No effort was made to select a group of children; those reported represent case histories removed from the files of other studies in progress. Diagnoses of tinea capitis was iimade

by the finding of endothrix hairs; the identity

of the etiologic agent was determined by culture. The management was essentially the same as that described above except that time placebos issued

were never other than the sugar tablets or capsules, petrolatum, Plastibase, or glycerinized water. None received Fostex. OBSERVATIONS

ill. audonini. Table I shows that of the 39 individuals studied, 1—24 became clinical]y well;

¶ Containing polysaturated vegetable oils, their hairs lost fluorescence, and converted to negative culture. Three of the latter group, fraction, Westwood Pharmaceuticals, Buffalo, patients 22—24, had, however, used Fostex soap N.Y. ** Stiefel Laboratories, Inc., Oak Hill, N. Y. II Containing a dewaxed keratin moisturizing Westwood Pharmaceuticals, Buffalo, N. Y.

for a single 4—6 week interva]; 7 patients (15—

240

THE JOURNAL OF INVESTIGATIVE DERMATOLOGY

TABLE II

21) were defaulters who were found to be clear

when they finally returned to the clinic.

Probable duration of infection among twenty-four

Among the remaining 15 patients, numbers 25—

patients with non-i nfiarnmatory tinea capitis

27 were followed only through loss of fluores-

caused by Microsporurn audouini, from estimated onset until culturally negative

cence. Four patients, 28—31, lost fluorescence of

their hair and their scalps became normal but

they continued to have, though erratically,

Duration

cultures showing a few to moderate number of dermatophyte colonies. These four patients came from families having other infected children. Six patients (32—37) have remained fluorescent through 2 to 3 years and are still under observation. Most of these, however, have only a few scattered infected hairs but this residual has been unchanged for 1 to 2 years. An example is patient 34 who had had extensive involvement for 2 or 3 years prior to admission to the study and

months

Number of Patients

1

1 (11)

2

1(3)

3

1(8) (2)

4 5

,

6

1(4) 1(5)

7

3(9,4,4)

for 1 year afterward, but for the past 2 years has had only long fluorescent hairs distributed

8

1(3)

rather widely over the head. The case of patient 35 is similar, except that to our knowledge he never had grossly apparent lesions. Two of the 39 (38 and 39) developed inflammatory reactions prior to cure. Calculating from the first clinic visit, the time

9 10 11 14 15 16

of the above described changes occurred as follows: 10 patients became non-fluorescent

18

2(5,7) 2(9,3) 1(3) 1(4)

31

1(10)

within 3 months, 6 within 6 months, 7 within 9 months, 6 within 12 months, and 4 within 12 to 24 months. (The date of conversion to nonfluorescence was conservatively accepted as the first time the patient was observed in the clinic without fluorescence, regardless of the time that had elapsed since the last observation. As an example, patient 16 was not seen between the third month, when his scalp fluoresced, and the eighth month, when it was not fluorescent; for these totals, his conversion time was estimated as the eighth month.) As stated previously, 6 (patients 32 through 37) of the 39 patients have not lost fluorescence through 2 to 3 years' observation although the number of infected hairs are sparse. In summary, 29 of the 39 patients lost fluorescence within 1 year after their first clinic visit.

(7) (10)

(6)

(4) (7)

1(7) 1

1

(12) L

40

Age of patient (years) at time of negative culture. Italicized figures = females.

t

Conversion

to negative culture occurred

sometime during period so indicated.

were not followed beyond conversion to nonfluorescence.

The 6 patients (32—37) who remained fluores-

cent were also, of course, culturally positive. Five patients (25, 28—31), who lost fluorescence, have remained culturally positive but only weakly

so, as shown ii Table I. In summary, 24 of 39 patients became culturally negative during the course of this study, 21 within 1 year after their first clinic visit and 3 others approximateJy 1

year later. Calculated on the same basis, i.e., from the In Table II can be seen the probable duration first clinic visit, patients had the first of 2 con- of infection, i.e., from the estimated date of secutively negative cultures as follows: 8 within onset until negative culture, of the 24 patients 3 months, 4 within 6 months, S within 9 months,

2 within 12 months, 3 within 18 months, and 2 did not become culturally negative for greater than 2 years. Two of the 39 patients (26 and 27)

who were observed to become culturally negative. This was calculated by combining the months of

previous duration according to history (shown in Table I), with the interval of time, from ad-

241

UNTREATED TINEA CAPITIS IN NEGRO CHILDREN

TABLE III Observations on eight patients with non-inflammatory tinea capitis caused by Trichophyton tonsurans Age at First Patient

Period of Observation Sex

Observatlon culture

History, Previous Duration

Until scalp grossly normal

months

years

WV

2

3

M

JP

6

7

M

Until first negative culture

After first negative culture

Comments

12

Seborrheic; irregular areas of slight scaliness. Detected by culture in

24

Seborrheic; irregular areas of slight scaliness. Detected by culture in

months

2

epidemiologic survey. 2

4

epidemiologic survey. Subsequently

developed M. audouini infection, CB

6

7

M

1

treated with griseofulvin. 9

8

48

Patchy alopecia; patient brought to clinic with ''ringworm''. When last seen 5 years later, slight thinning of hair still observed at site.

AF

7

7

M

<1

1—5

1—5

MV

7

8

M

<1

2—10

2—10

PN

10

10

M

1?

LD

11

DV

4

12 9

2

19

Patchy alopecia; patient brought to clinic with ''ringworm''. Seborrheic; multiple scaly areas recognized by nmther as ringworm. Entirely normal when observed on tenth month. Seborrheic; irregular areas of slight

scaliness. Detected by culture in

12

12

13

M

F

2

4—9

1—9

15

4—9

1_9*

U

epidemiologic survey. Patchy alopecia; had history of having

had ringworm 3 years previously, treated by a dermatologist and discharged after return to normal and 3 negative cultures. "Sehorrhea". Detected by culture in epidemiologic survey. Scalp normal when observed at the ninth month.

* <5 colonies on two subsequent cultures, possibility of contamination from infected sibling.

mission to the study until culturally negative duration, the calculated probable duration of (also shown in Table I). A review of Table II infection would be less than 1 year. The patients shows that 16 of these 24 patients (3, 5—9, 12— with eborrhea-hke infections cleared in a similar 19, 21, and 22) had negative cultures within 12 period of time. From 1 of these (DV) a few months of estimated onset; 6 patients (1, 2, 4, colonies were isolated on sporadic occasions sub10, 23, and 24) converted to negative cultures sequent to loss of symptoms and before the first within 12 to 18 months; and 2 patients (11 and 20)

did not lose their fungus in less than 31 months. T. tonsurans. Since most of these patients did not have classical ringworm and were not aware

of 2 consecutively negative cultures. This patient was a member of a large family, many of whom had active infections. Further observations on the T. tonsurans patients are detailed in Table

that they were infected, pertinent histories III. usually were not obtainable. Three, however, with areas of alopecia were culturally negative within 9 months after admission to the study and,

since they had histories of 1—2 months prior

COMMENTS

In the strictest sense it is difficult to classify but few of the ill. audouini patients as untreated

242

THE JOURNAL OF INVESTIGATIVE DERMATOLOGY

for most had tried "home" medication before coming to the clinic. In exception were the 5 inapparently infected children, detected by us in family studies, or those that had been brought to the ringworm clinic immediately after detection by the mother inasmuch as other members of the family were being "treated" in the clinic. it is reasonably certain, however, that none had received griseofulvin because they were closely

questioned as to whether they had ever taken "pills for ringworm" and because they were for the most part indigent patients who could hardly

nism other than pubescent changes or longevity of

the hairs is operative. The observations concerning T. tonsvrans infections are derived from a sampling too small to permit any conclusions except that spontaneous cures do occur. A further study is in progress to determine the frequency. SUMMARY

Thirty-nine patients with tinea capitis caused by Iliicrosporurn audouini were observed virtually

without medication. Two developed inflamma-

have afforded griseofulvin, especially at its tory reactions and cleared. The others remained early market price. As for those who had had non-inflammatory. Sixteen were culturally nega"home" medication prior to admission to the tive in less than 12 months from estimated onstudy, it seems rather safe to assume it was not set, 6 in 12—is months, and 2 in 30—40 months, curative for even the 3 patients (ii, 34, and 35) all well before puberty. Six patients became who had tried topical remedies prescribed by a clinically well but retained scattered fluorescent dermatologist prior to admission to the study hairs for 2—4 years. The status of the other 7 apparently experienced little or no benefit. patients is described.

Patient 11 remained infected 2 years after 2 months of applying salicylic acid and Quinolor; patient 34, who applied Quinadorne daily for 2

months, was still infected after 3 years; and

patient 35, who had only a few fluorescent hairs

at the time of daily Bynamid application for 2 months, remained infected for nearly 3 years. Similarly, there may be some doubt that cures observed in patients 22, 23, and 24 were spontane-

ous but may have resulted, rather, from the use

Eight patients with T. tonsurans infections, mostly mild or inapparent, also healed without medication.

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