- Email: [email protected]
Tinea capitis caused by Trichophyton rubrum in a 67-year-old woman with systemic lupus erythematosus
Journal of the American Academy of Dermatology Volume 29, Number 2, Part I
4. Lever WF, Schaumburg-Lever G. Histopathology of the skin. Philadelphia: JB Lippincott, 1983:369. 5. Welsh LO. Estudio de pacientes con Orf en Monterrey. Memorias del VII Congreso Mexicano de Derrnatologia, 1973:434-40. 6. Wilkinson JD. Orf: a family with unusual complications. Br J Dermatol 1977;97:447-50.
Brief communications
257
7. Shelley WB, Shelley ED. Surgical treatment of farmyard pox: orf, milker's nodules, bovine papular stomatitis pox. Cutis 1983;31:191-2. 8. Hunskaar S. A case of ecthyma contagiosum (human orf) treated with idoxuridine. Dermatologica 1984;168:207.
Tinea capitis caused by Trichophyton rubrum in a 67-year-old woman with systemic lupus erythematosus Matthew J. Stiller, MD, Stanley A. Rosenthal, PhD, and Alan S. Weinstein, MD New York, New York
Trichophyton rubrum is the most common cause of tinea pedis, onychomycosis, tinea manuum, tinea cruris, and tinea corporis in the United States, 1-3 but it rarely causes tinea capitis in this country. l, 4 Tinea capitis caused by T. rubrum seldom invades hair. However, endothrix, ectothrix, and rarely endoectothrix infections can occur." Kerion formation has also been reported.v? Tinea capitis is uncommon in adults.' Dermatophytes causing tinea capitis in adults include Trichophyton tonsurans, Trichophyton violaceum. Trichophyton verrucosum, Microsporum canis, Microsporum gypseum, and rarely Trichophyton rubrum. 5, 8 Secretion of sebum and colonization by Pityrosporum orbiculare help to protect the scalp against invasion by dermatophytes.v!" When tinea capitis does occur in adults, it is most frequent in postmenopausal women.I We report a case of tinea capitis caused by T. rubrum in a 67-year-old woman with systemic lupus erythematosus (SLE). We believe this chronic disease made her a susceptible target for this unusual dermatophytosis. CASE REPORT A 53-year-old black woman with SLE sought treatment in June 1977 for pruritic, scaly, focally erythematous and atrophic plaques on both upper extremities and upper back. Irregular, mottled hyperpigmentation was From The Ronald O. Perelman Department of Dermatology of the New York University School of Medicine. Reprint requests: Matthew J. Stiller, MD, The Ronald O. Perelman Department of Dermatology, 550-560 First Avenue, New York, NY 10016.
J
AM ACAD DERMATOL
1993;29:257-8.
Copyright @ 1993 by the American Academy of Dermatology, Inc. 0190-9622/93 $1.00 + .10
16/54/45410
also present on her face. A 4 mm punch biopsy specimen was diagnostic of discoid lupus erythematosus (DLE). Treatment consisted of intralesional triamcinolone acetonide, 2.5 mg/ml, and mid- to high-potency topical glucocorticosteroids. During the next decade the patient's arthritis and renal disease worsened. When seen in July 1992 she required chronic renal dialysis. She reported slightly pruritic, scaly, gray areas on the left side and crown of the scalp. On physical examination well-marginated patches and plaques with adherent, fine, gray-white scale were noted interspersed with mottled, atrophic, and depigmented foci of DLE. A patchy alopecia with multiple broken hairs and an occasional follicular pustule were also present (Figs. 1 and 2). There were no signs of dermatophytosis elsewhere. Wood's light examination ofthe scalp was negative. A 10% potassium hydroxide (KOH) preparation of scales revealed hyphae and occasional arthroconidia. KOH examination of multiple epilated hairs was negative. A culture of scrapings from the scalp was identified
as T. rubrum. Because of the patient's medical problems her tinea capitis was initially treated with a topical imidazole cream. This was unsuccessful; therefore treatment with oral griseofulvin will be started after consultation with the patient's nephrologist.
DISCUSSION
Tinea capitis caused by T. rubrum is rare in the United States. However, there is considerable variation in the incidence and epidemiology of dermatophytoses in different parts of the world. T. rubrum is the most frequent cause of tinea capitis in Benghazi, Libya,' i and in Bangkok, Thailand, 12 where it accounts for about 25% of cases. As in the United States, tinea capitis caused by T. rubrum is extremely uncommon in Western Europe- ': 14 and the Middle East. is, 16
258 Brief communications
Journal of the American Academy of Dermatology August 1993
from those in areas in which this fungus commonly causes tinea capitis. Our patient was postmenopausal and had severe SLE. This presumably increased her susceptibility to T. rubrurn infection. However, she did not have tinea pedis, tinea manuum, tinea unguium, or tinea corporis. These were present in previously reported adults with tinea capitis caused by T. rubrums- 9,17 There was no evidence that other members of the patient's household had a chronic T. rubrurn infection, another factor commonly present in adults with this rare type of tinea capitis. REFERENCES
Fig. 1. Tinea capitis caused by T. rubrum is visible, as are foci of alopecia and patches of DLE. Fig. 2. Tinea capitis caused by T. rubrum shows fine gray-white scale and patchy alopecia.
There is also considerable temporal variation in the species causing tinea capitis. In the United States during the nineteenth century, tinea capitis was rare and most commonly caused by M. canis. During the first half of the twentieth century Microsporum audouinii became the most frequent cause but was surpassed by T. tonsurans in the 1950s. T. tonsurans continues to be the most common cause of tinea capitis. I, 2 The Medical Mycology Society of the Americas maintains an ongoing survey of the incidence of infection by different species of dermatophytes in the United States. In the most recent survey, T. rubrum was responsible for more than halfthe reported cases of dermatomycoses.' butit is unclear why T. rubrurn, which so frequently infects other body sites, seldom causes scalp infections. Genetic and environmental factors must be considered. In addition, the strains of T. rubrum in the United States may be different
1. Rippon JW. The changing epidemiology and emerging patterns of dermatophyte species. Curr Top Myco11985; I: 208-34. 2. Aly R. Incidence of dermatophytes in the San Francisco Bay area. Dermatologica 1980;161:97-100. 3. Sinski JT, Kelley LM. A survey of dermatophytes from human patients in the United States from 1985 to 1987. Mycopathologia 1991;114:117-26. 4. Sinski JT, Flouras K. A survey of dermatophytes isolated from human patients in the United States from 1979 to 1981 with chronological listings of worldwide incidence of five dermatophytes often isolated in the United States. Mycopathologia 1984;85:97-120. 5. Rippon JW. The pathogenic fungi and the actinomycetes. 3rd ed. In: Medical mycology.Philadelphia: WB Saunders, 1988:186-96. 6. Danby FW. Trichophyton rubrum kerion: Subclinical infection unmasked by trauma? Pediatr Dermatol 1990;7: 324-5. 7. Sanyal M, Basu N, Thammaya A. Trichophyton rubrum as the cause of kerion. Bull Calcutta School Trop Med 1970;18:45-6. 8. Vannini R, Guadagni GM, Palleschi E, et al. Tinea capitis in the adult: two cases. Mycopathologia 1986;96:53-7. 9. Pipkin JL. Tinea capitis in the adult and adolescent. Arch Dermatol Syphilol 1952;66:9-40. 10. Plewig G. Pityrosporum in normal sebaceous follicles, comedones, acneiform eruptions, and dandruff. Mykosen 1987;supply 1:155-63. II. Kanwar AJ, Belhaj MB. Tinea capitis in Benghazi, Libya. Int J Dermatol 1987;26:371-3. 12. Taylor RL, Kotrajaras R, Jotisankasa V. Occurrence of dermatophytes in Bangkok, Thailand. Sabouraudia 1968;6: 307-11. 13. Gentles JC, Scott E. Superficial mycoses in the west of Scotland. Scott Med J 1981;26:328-35. 14. Pereiro Miguens M, Pereira M, Pereiro M Jr. Review of dermatophytoses in Galicia from 1951 to 1987, and comparison with other areas of Spain. Mycopathologia 1991; 113:65-78. 15. Shtayeh MSA, Arada HM. Incidence of dermatophytosis in Jordan with special reference to tinea capitis. Mycopathologia 1985;96:59-62. 16. Evron R, Ganor S, Wax Y, et aI. Epidemiological trends of dermatophytoses and dermatophytes in Jerusalem between 1954 and 1981. Mycopathologia 1985;90:113-20. 17. Lasagni A, Graziani F, Bassi G. Tinea capitis microsporica dell'adulto, G Min Dermato\ 1977;1\2:627-30.
4. Lever WF, Schaumburg-Lever G. Histopathology of the skin. Philadelphia: JB Lippincott, 1983:369. 5. Welsh LO. Estudio de pacientes con Orf en Monterrey. Memorias del VII Congreso Mexicano de Derrnatologia, 1973:434-40. 6. Wilkinson JD. Orf: a family with unusual complications. Br J Dermatol 1977;97:447-50.
Brief communications
257
7. Shelley WB, Shelley ED. Surgical treatment of farmyard pox: orf, milker's nodules, bovine papular stomatitis pox. Cutis 1983;31:191-2. 8. Hunskaar S. A case of ecthyma contagiosum (human orf) treated with idoxuridine. Dermatologica 1984;168:207.
Tinea capitis caused by Trichophyton rubrum in a 67-year-old woman with systemic lupus erythematosus Matthew J. Stiller, MD, Stanley A. Rosenthal, PhD, and Alan S. Weinstein, MD New York, New York
Trichophyton rubrum is the most common cause of tinea pedis, onychomycosis, tinea manuum, tinea cruris, and tinea corporis in the United States, 1-3 but it rarely causes tinea capitis in this country. l, 4 Tinea capitis caused by T. rubrum seldom invades hair. However, endothrix, ectothrix, and rarely endoectothrix infections can occur." Kerion formation has also been reported.v? Tinea capitis is uncommon in adults.' Dermatophytes causing tinea capitis in adults include Trichophyton tonsurans, Trichophyton violaceum. Trichophyton verrucosum, Microsporum canis, Microsporum gypseum, and rarely Trichophyton rubrum. 5, 8 Secretion of sebum and colonization by Pityrosporum orbiculare help to protect the scalp against invasion by dermatophytes.v!" When tinea capitis does occur in adults, it is most frequent in postmenopausal women.I We report a case of tinea capitis caused by T. rubrum in a 67-year-old woman with systemic lupus erythematosus (SLE). We believe this chronic disease made her a susceptible target for this unusual dermatophytosis. CASE REPORT A 53-year-old black woman with SLE sought treatment in June 1977 for pruritic, scaly, focally erythematous and atrophic plaques on both upper extremities and upper back. Irregular, mottled hyperpigmentation was From The Ronald O. Perelman Department of Dermatology of the New York University School of Medicine. Reprint requests: Matthew J. Stiller, MD, The Ronald O. Perelman Department of Dermatology, 550-560 First Avenue, New York, NY 10016.
J
AM ACAD DERMATOL
1993;29:257-8.
Copyright @ 1993 by the American Academy of Dermatology, Inc. 0190-9622/93 $1.00 + .10
16/54/45410
also present on her face. A 4 mm punch biopsy specimen was diagnostic of discoid lupus erythematosus (DLE). Treatment consisted of intralesional triamcinolone acetonide, 2.5 mg/ml, and mid- to high-potency topical glucocorticosteroids. During the next decade the patient's arthritis and renal disease worsened. When seen in July 1992 she required chronic renal dialysis. She reported slightly pruritic, scaly, gray areas on the left side and crown of the scalp. On physical examination well-marginated patches and plaques with adherent, fine, gray-white scale were noted interspersed with mottled, atrophic, and depigmented foci of DLE. A patchy alopecia with multiple broken hairs and an occasional follicular pustule were also present (Figs. 1 and 2). There were no signs of dermatophytosis elsewhere. Wood's light examination ofthe scalp was negative. A 10% potassium hydroxide (KOH) preparation of scales revealed hyphae and occasional arthroconidia. KOH examination of multiple epilated hairs was negative. A culture of scrapings from the scalp was identified
as T. rubrum. Because of the patient's medical problems her tinea capitis was initially treated with a topical imidazole cream. This was unsuccessful; therefore treatment with oral griseofulvin will be started after consultation with the patient's nephrologist.
DISCUSSION
Tinea capitis caused by T. rubrum is rare in the United States. However, there is considerable variation in the incidence and epidemiology of dermatophytoses in different parts of the world. T. rubrum is the most frequent cause of tinea capitis in Benghazi, Libya,' i and in Bangkok, Thailand, 12 where it accounts for about 25% of cases. As in the United States, tinea capitis caused by T. rubrum is extremely uncommon in Western Europe- ': 14 and the Middle East. is, 16
258 Brief communications
Journal of the American Academy of Dermatology August 1993
from those in areas in which this fungus commonly causes tinea capitis. Our patient was postmenopausal and had severe SLE. This presumably increased her susceptibility to T. rubrurn infection. However, she did not have tinea pedis, tinea manuum, tinea unguium, or tinea corporis. These were present in previously reported adults with tinea capitis caused by T. rubrums- 9,17 There was no evidence that other members of the patient's household had a chronic T. rubrurn infection, another factor commonly present in adults with this rare type of tinea capitis. REFERENCES
Fig. 1. Tinea capitis caused by T. rubrum is visible, as are foci of alopecia and patches of DLE. Fig. 2. Tinea capitis caused by T. rubrum shows fine gray-white scale and patchy alopecia.
There is also considerable temporal variation in the species causing tinea capitis. In the United States during the nineteenth century, tinea capitis was rare and most commonly caused by M. canis. During the first half of the twentieth century Microsporum audouinii became the most frequent cause but was surpassed by T. tonsurans in the 1950s. T. tonsurans continues to be the most common cause of tinea capitis. I, 2 The Medical Mycology Society of the Americas maintains an ongoing survey of the incidence of infection by different species of dermatophytes in the United States. In the most recent survey, T. rubrum was responsible for more than halfthe reported cases of dermatomycoses.' butit is unclear why T. rubrurn, which so frequently infects other body sites, seldom causes scalp infections. Genetic and environmental factors must be considered. In addition, the strains of T. rubrum in the United States may be different
1. Rippon JW. The changing epidemiology and emerging patterns of dermatophyte species. Curr Top Myco11985; I: 208-34. 2. Aly R. Incidence of dermatophytes in the San Francisco Bay area. Dermatologica 1980;161:97-100. 3. Sinski JT, Kelley LM. A survey of dermatophytes from human patients in the United States from 1985 to 1987. Mycopathologia 1991;114:117-26. 4. Sinski JT, Flouras K. A survey of dermatophytes isolated from human patients in the United States from 1979 to 1981 with chronological listings of worldwide incidence of five dermatophytes often isolated in the United States. Mycopathologia 1984;85:97-120. 5. Rippon JW. The pathogenic fungi and the actinomycetes. 3rd ed. In: Medical mycology.Philadelphia: WB Saunders, 1988:186-96. 6. Danby FW. Trichophyton rubrum kerion: Subclinical infection unmasked by trauma? Pediatr Dermatol 1990;7: 324-5. 7. Sanyal M, Basu N, Thammaya A. Trichophyton rubrum as the cause of kerion. Bull Calcutta School Trop Med 1970;18:45-6. 8. Vannini R, Guadagni GM, Palleschi E, et al. Tinea capitis in the adult: two cases. Mycopathologia 1986;96:53-7. 9. Pipkin JL. Tinea capitis in the adult and adolescent. Arch Dermatol Syphilol 1952;66:9-40. 10. Plewig G. Pityrosporum in normal sebaceous follicles, comedones, acneiform eruptions, and dandruff. Mykosen 1987;supply 1:155-63. II. Kanwar AJ, Belhaj MB. Tinea capitis in Benghazi, Libya. Int J Dermatol 1987;26:371-3. 12. Taylor RL, Kotrajaras R, Jotisankasa V. Occurrence of dermatophytes in Bangkok, Thailand. Sabouraudia 1968;6: 307-11. 13. Gentles JC, Scott E. Superficial mycoses in the west of Scotland. Scott Med J 1981;26:328-35. 14. Pereiro Miguens M, Pereira M, Pereiro M Jr. Review of dermatophytoses in Galicia from 1951 to 1987, and comparison with other areas of Spain. Mycopathologia 1991; 113:65-78. 15. Shtayeh MSA, Arada HM. Incidence of dermatophytosis in Jordan with special reference to tinea capitis. Mycopathologia 1985;96:59-62. 16. Evron R, Ganor S, Wax Y, et aI. Epidemiological trends of dermatophytoses and dermatophytes in Jerusalem between 1954 and 1981. Mycopathologia 1985;90:113-20. 17. Lasagni A, Graziani F, Bassi G. Tinea capitis microsporica dell'adulto, G Min Dermato\ 1977;1\2:627-30.