Jurnal RSMH Palembang Vol 1 Issue 1 2020

Jurnal RSMH Palembang

Journal Homepage: http://jurnalrsmh.com/index.php/JRP

Black Dot Type Capitis Tinea Appreciates Bacterial Foliculitis

Radema Maradong Ayu Pranata1, Rusmawardiana1, Fifa Argentina1
1Department of Dermatology and Venereology, Faculty of Medicine, Sriwijaya University, Palembang

ARTICLE INFO ABSTRACT

Keywords: Tinea capitis is a superficial fungal infection of the scalp and hair, which is seen
Black dot predominantly in children. In adults, it is usually related to immunocompromised
Bacterial Folliculitis patients and have an atypical features. In patients with end stage renal disease (ESRD),
Tinea Capitis uremia is associated with immune suppression due to the impact of uremic milieu. All
specimens of tinea capitis should be examined for microscopy, wood’s lamp and
Corresponding author: culture. Reported a case of 50–year-old male, animal husbandry, presented with itchy
Radema Maradong Ayu Pranata papules, pustules, patch alopecia and a hair loss for 6 months. Dermatologic features
showed papules, pustules, patch alopecia and black dot. The patient treated with
E-mail address: ketoconazole shampoo for 3 weeks without any improvement. He had an ESRD for 2
radema.pranata@gmail.com years. Gram stain examination and culture showed no bacteri. Wood’s lamp
examination showed no fluorescent. Potassium hydroxide (KOH) 10% from scalp
All authors have reviewed and scrapings and KOH 20% from hair showed a fungal elements, which support diagnosis
approved the final version of the of black dot tinea capitis. The patient treated with griseofulvin tablet 500 mg twice a
manuscript. day for 8 weeks, cetirizine tablet 10 mg once daily and 3x/week of ketoconazole
shampoo 2% showed improvement in clinical features and microscopic evaluation.
https://doi.org/10.37275/JRP.v1i1.3

1. Introduction caused by Tricophyton and Microsporum species with

Tinea capitis is a superficial fungal infection of the clinical features of inflammatory, non-inflammatory,
scalp and hair, especially in children aged 3-14 favus, and black dot types.2
years.1,2 The fungistatic effect of fatty acids in sebum Inflammatory type tinea capitis is usually caused by
may explain the decreased incidence of tinea capitis zoophilic or geophilic ectothrix pathogens, such as M.
after puberty.2,3 Tinea capitis in adults most occur in canis, M. gypseum and T. verrucosum. Pathogens M.
immunocompromised patients.1 For example, in gypseum and T. verrucosum did not fluoresce on Wood's
patients with end-stage chronic kidney disease (CKD) lamp examination, but M. canis would fluoresce green
that is associated with decreased immunity due to yellow. The non-inflammatory type is often caused by
uremia.4 ectothrix anthrophopilic pathogens such as M.
The classification of superficial fungi according to audouinii or M. ferrugineum. The clinical presentation of
habitat consists of anthrophopilic, zoophilic and the non-inflammatory type is a gray patch with
geophilic. The classification provides information about yellowish green fluorescence. T. schoenleinii is the most
the source of infection. Anthrophopilic disease is common type of favus, although it can also be caused
transmitted by direct contact of infected skin or hair. by T. violaceum and M. gypseum. The clinical features
For example cloth, comb, socks and towels. Zoophilic of the favus type are perifollicular erythema patches
transmitted from animals, such as cats, dogs, horses, with yellow crust (scutula) and smell like cheese or
birds or cows. Geophilics cause sporadic infections due mousy odor. Tinea favus will fluoresce blue-gray if
to direct contact with the soil. Tinea capitis is often caused by T. schoenleinii. Black dot type tinea capitis is

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usually caused by the antrophophilic endothrix complained of erythematous papules, pustules,
pathogens T. tonsurans and T. violaceum. Broken hair alopecia patches with black dot and hair loss since 6
on the scalp causes alopecia patches with a black dot months ago (Figure 1). The patient has been using
appearance. Black dot type tinea capitis tends to have ketoconazole shampoo for 3 weeks, but there is no
minimal inflammation, can form follicular pustules, improvement. The patient had a 2-year history of CKD
nodules, furuncles or in rare cases kerion. This type of and had undergone hemodialysis. No other family
tinea capitis does not have fluorescence.2,5 members have had similar lesions. Wood's lamp
All specimens from cases of tinea capitis should be examination showed no fluorescence. KOH
subjected to microscopic examination and culture examination of 10% of scalp scrapings revealed hyphae
whenever possible.6 The study by Gupta et al. (2014) and arthrospores (Figure 2a). KOH examination of 20%
reported a high sensitivity (73.33%) on KOH of the hair showed endothrix spores with magnification
examination, so that KOH can be used as the definitive of 10x (Figure 2b) and 40x (Figure 2c). Culture with
procedure for screening and diagnosis of dermatophyte Saboroud dextrose agar was negative.
infections.7 The KOH test results can give false negative Patients were treated with 2x500 mg of griseofulvin
results in about 15% of cases, so patients who have a tablets, 2% ketoconazole shampoo used 3 times / week
clinical picture of dermatophytosis must still be treated and 1x10 mg cetirizin tablets. Treatment was carried
even though the KOH test results are negative.2,8 out for 8 weeks and clinical improvement was obtained
(Figure 3). Both clinical and microscopic follow-up
2. CASE REPORT observations with KOH examination showed
A 50 year old man working as a farm employee improvement
.

Figure 1. Baseline clinical manifestations of papules, pustules, black dots, patches of alopecia

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 A B

Figure 2. (a) Scalp scrapings (b) endothrix spores at 10x magnification (c) endothrix spores at 40x magnification

Figure 3. Clinical manifestations after 8 weeks of therapy

3. Discussion that resembled folliculitis was reported. Tinea capitis is

In this case, a man with black dot type tinea capitis a rare dermatophytosis in adults (range 3-11% of all

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cases). Most cases occur in immunocompromised support the diagnosis of black dot type tinea capitis.
patients.9 The comorbid factor in these patients is end- In this case report, the patient was treated with
stage CKD, which affects the immune system. Research 2x500 mg griseofulvin tablets, 2% ketoconazole
by Narain et al (2016) on patients with end-stage CKD shampoo 3 days / week, and 1x10 mg cetirizine tablet.
there are a range of 2.2% of 150 patients suffering from Treatment was carried out for 8 weeks and showed both
tinea capitis. In CKD, uremia occurs due to uremic clinical and microscopic improvement.
milieu, resulting in a decrease in the immune system.4 One type of drug that can be used to treat tinea
The features of the lesions in this patient were capitis is griseofulvin. Griseofulvin is a fungistatic drug
erythematous papules, alopecia patches with black dot that inhibits nucleic acid synthesis, blocks cell division
and pustules that resembled bacterial folliculitis. The at metaphase and impairs cell wall synthesis.
results of Gram stain did not show the presence of Griseofulvin is known as the gold standard therapy for
Gram positive or negative bacteria. Wood's lamp tinea capitis.12 A randomized controlled trial (RCT) by
examination showed no fluorescence. KOH Gupta et al. (2013) reported that 8 weeks of griseofulvin
examination of 20% of hair specimens revealed fungal treatment showed significant improvement over
elements in the hair shaft. KOH examination of 10% of terbinafine.13 Evidence of resistance to griseofulvin in
scalp scrapings revealed fungal hyphae and vitro is not available. A higher dose of griseofulvin and
arthrospores. The fungal culture in this patient was a longer period (12-18 weeks) may be required in
negative. infections caused by Trichophyton. Griseofulvin
In adults, tinea capitis caused by ectothrix or contraindications include severe liver disease, lupus
endothrix fungal pathogens can produce atypical erythematosus and porphyria.
features such as alopecia and dermatitis that mimic
bacterial folliculitis. Therefore, further tests are needed 4. Conclusion
such as examining Wood's lamp, KOH and culture. Tinea capitis is more common in children. In adults,
Examination of Wood's lamp (365 nm) can show it is often associated with immunocompromised
pteridine fluorescence in hair infected with ectothrix conditions, one of which is CKD and presents a picture
fungal pathogens. The fluorescent hair was then of atypical lesions. The lesion in this patient resembled
removed for KOH examination and culture. The results bacterial folliculitis, but KOH examination of 20% of the
of the 20% KOH examination had a specificity value of hair specimen revealed hyphae and endothrix
91% and a sensitivity of 91.9%. Therefore, doctors can arthrospores. This result is very important because it
start treatment with just 20% KOH examination results has a specificity value of 91% and a sensitivity of
without having to do culture.10,11 In some superficial 91.9%, so that therapy can be given without doing
mycoses, the microscopic image of fungal elements is culture. The therapy in this case was griseofulvin
very distinctive so that culture is not required to build tablets because it was considered safe for CKD patients
a diagnosis.5 Research by Kadhim et al (2018) reported and was the gold standard therapy. Other therapies
10.5% of 200 dermatophytosis patients having negative include ketoconazole shampoo and cetirizine tablets.
fungal culture results. This occurs because of Both clinical and microscopic improvements occurred
differences in staff skills and the quality of sampling.10 within 8 weeks after treatment.
Another examination that can be done is a biopsy for
histopathological examination. Skin biopsy is not 5. References
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