Categorizing hair loss in children depends on many factors, but it is important to rule out an infectious etiology as early as possible, according to Sheila Fallon Friedlander, MD.

“What can Tinea capitis look like? Anything,” she said in a presentation at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

Although T. capitis most often presents in children aged 3-7 years as a pattern of localized hair loss, often with scaling, sometimes with nodules, other possibilities include pustules, boggy masses, and diffuse hair loss, said Dr. Friedlander, professor of pediatrics and dermatology at the University of California, San Diego.

Sometimes the hair loss may be so subtle that families come in complaining of “dandruff” rather than hair loss, she noted. Evaluating the patient for the presence of cervical or occipital lymph nodes is crucial; big nodes are usually a tip-off that infection is present.

Dr. Sheila Fallon Friedlander of Rady Children's Hospital San Diego

Dr. Sheila Fallon Friedlander

The prevalence and etiology of tinea remains a moving target, and T. capitis varies with place and time, Dr. Friedlander observed. Historically, T. capitis has been most common in inner-city communities and developing countries, but “change is in the air,” she said, citing recent epidemiologic data from countries including Egypt, Palestine, Kuwait, Tunisia, and Saudi Arabia showing Microsporum canis overtaking Trichophyton violaceum as the dominant organism causing T. capitis. The upswing in M. canis traces back to family pets, especially cats and dogs, but “don’t forget hamsters,” she said.

Clinicians treating T. capitis should ask about family pets, advised Dr. Friedlander, adding that city dwellers’ conditions may be more likely caused by Trichophyton tonsurans, T. violaceum, or Trichophyton soudanense. Also consider immigration status and family history when evaluating T. capitis, and use a Wood’s lamp for diagnosis if one is available, she advised. M. canis will fluoresce and T. tonsurans will not, she pointed out.

Other strategies to evaluate the condition include KOH, culture, polymerase chain reaction, and trichoscopy.

Other treatment options include terbinafine, itraconazole, and fluconazole, and each have their pros and cons, she said. Terbinafine – which persists for months in the skin, nails, and hair – is the least expensive, and is her first choice for infections caused by T. tonsurans.

Itraconazole is available as a liquid, but costs more, causes diarrhea, and comes with a boxed warning about the potential for cardiac complications; fluconazole is the most expensive, but may be used in infants, she added.

Other high-risk groups for T. capitis include female caretakers of high-risk individuals, such as “grandma”; wrestlers; and Buddhist monks, she said. “Short hair, sharing combs, and unclean barbers” contributed to a documented increased risk of T. capitis according to a recently published study of 60 Buddhist monks whose average age was 11.6 years, she added. (Pediatr Dermatol. 2017 May;34[3]:371-3).

Dr. Friedlander had no relevant financial conflicts to disclose.

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