Dermoscopy features on dermatomycosis

Dear Editor, A 7-year-old, otherwise healthy Indian girl presented with asymptomatic sparsening of hair on the sides and posterior scalp of 6 months duration. The parents reported no improvement with oral iron and multivitamin supplements taken for 3–4 months, betamethasone, and 2% minoxidil lotion applied for 2–3 months, and three doses of weekly oral fluconazole 50 mg. Examination revealed numerous coalescing patches of nonscarring alopecia, with the left parieto-occipital scalp being more involved [Figure 1]. There was mild scalp scaling but no visible broken hair shafts or exclamation-point hair. Hair pull test was negative. A 10% potassium hydroxide (KOH) mount preparation of hair shafts from multiple areas was negative for fungal elements. Specimen was also sent for fungal culture. Provisionally, differential diagnoses of noninflammatory tinea capitis (TC), diffuse alopecia areata (AA), and trichotillomania (TTM) were considered. Trichoscopy using a hand-held dermoscope (Heine Delta® 20T) under polarized light (×10) revealed several “comma,” and “corkscrew” hairs in addition to few black dots and focal scale-crust. A dead head louse was also detected incidentally, however, no nits were visualized [Figure 2]. In the absence of defining trichoscopic features of AA or TTM, and the unmissable presence of typical trichoscopic features of TC, the patient was treated with oral terbinafine (125 mg/day) and 2% ketoconazole shampoo. Our diagnosis of TC was reaffirmed when the fungal culture reported growth of Trichophyton violaceum. The child achieved complete clinical cure by the 6th week of treatment initiation. The utility of trichoscopy is being increasingly recognized in the diagnosis of alopecia in children. The dermoscopic features of various causes of alopecia, including AA, TTM and TC are now well-recognized.[1] The trichoscopic features of TC vary in inflammatory and noninflammatory variants. While the typical black-dot tinea is characterized black dots and short broken hair, inflammatory variant shows additional features such as erythema, scaling, pustules and follicular scale-crusts. Though black dots and broken hair are non-specific findings that can also be seen in AA and TTM, presence of comma, corkscrew and zig-zag hairs are specific to TC.[23] “Comma hair,” observed in both endothrix and ectothrix-infections appear as slightly curved hair shafts, fractured close to the scalp surface and result from hyphal invasion of the hair shaft.[23] Corkscrew and zigzag hair represent variations of the comma hair.[23] The trichoscopic hallmarks of AA are exclamation mark hairs and yellow dots,[4] while TTM shows broken hair shafts of uneven length, follicular hemorrhage, trichoptilosis, tulip hair, flame hair, and other specific features, which were absent in our patient.[5]Figure 1: Patchy-to-diffuse hair loss in a 7-year-old girl; more prominent on the left side of the scalpFigure 2: Trichoscopy [Polarized, 10×] showing multiple comma hairs (green arrows), corkscrew hairs (red arrows), in addition to black dots and focal scale crust. A dead head louse was seen incidentally (Yellow circle)The clinical pattern of alopecia was not very typical of TC in our patient, with diffuse nonscarring alopecia, minimal inflammation, and a negative hair pluck test. A negative KOH rendered the diagnosis tricky. Fungal culture, the gold standard of diagnosis of TC, takes approximately 4 weeks for growth of dermatophytes. The correct diagnosis was initially suggested by trichoscopy that showed characteristic comma and corkscrew hairs, which allowed us to start the treatment early. The diagnosis of TC was later confirmed by a positive fungal culture. With this report, we wish to highlight the utility of dermoscopy as a quick, simple and noninvasive technique in the differential diagnosis of nonscarring alopecia in children and as an aid in instituting the optimal treatment without delay. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Tiña de la cabeza: descripción de los hallazgos dermatoscópicos en 37 pacientes

The myriad of coexisting risk factors for tinea capitis (TC) in parts of Africa makes it common among schoolchildren from this region. Diagnosis ideally involves microscopy and culture of scalp scrapings, which is not always feasible in resource-poor settings. Small-scale reports have identified trichoscopy (dermoscopy of hair and surrounding skin) as a cheap, quick, and simple tool for evaluating TC. We sought to describe the trichoscopic features of TC among Nigerian children. A total of 204 children with clinically diagnosed TC had trichoscopy of their scalp lesions and culture of scalp scrapings. Trichoscopic features and culture results were noted. Perifollicular scaling (78.4%), interfollicular scaling (69.1%), and black dots (44.1%) were the commonest trichoscopic features. Others include regrowing hairs (18.6%), comma hairs (14.7%), broken hairs (13.2%), corkscrew hairs (3.4%), zigzag hairs (2.5%), and peripilar casts (2.0%). All children with comma, corkscrew, and zigzag hairs, as well as most with black dots (88.9%), broken hairs (88.9%), and regrowing hairs (77.5%) had positive cultures, irrespective of the isolated dermatophyte. Comma hairs were specific for Tinea infection with positive culture of dermatophytes. The presence of black dots in combination with individual features like broken hairs, regrowing hairs, perifollicular scaling, or interfollicular scaling also had a high specificity for positive cultures. In the management of children with TC, trichoscopy is useful as a diagnostic tool, especially where access to laboratory evaluation is either not instant or unavailable.

Background: Trichoscopy (hair and scalp dermatoscopy) facilitates the diagnosis of hair and scalp disorders. The aim of this study was to identify the trichoscopic features in diagnosis of Tinea Capitis (TC) and to compare these findings with those of Alopecia Areata (AA).Material and Methods: The current study included 30 patients with TC and 30 patients with AA. They were recruited from Outpatient Clinics of Dermatology and Venereology Department, Tanta University Hospitals. Clinical examination, laboratory investigations (direct microscopic examination with 10% potassium hydroxide and fungal culture) were done to confirm clinical diagnosis and dermoscopically aiming at finding the different dermoscopic features of TC and AA.Results: Short broken hairs, black dots, comma shaped hairs, corkscrew hairs and zigzag shaped hairs were observed in patients with TC. Short vellus hairs, black dots, exclamation marks, white hairs and pig tail re-growing hairs were observed in patients with AA.Conclusion: Comma shaped hairs, zigzag shaped hairs and cork screw were observed only in patients with TC. Yellow dots, exclamation mark hairs and short vellus hairs were observed only in patients with AA. Dermoscopy is rapid and reliable confirmatory test used to differentiate between TC and AA by detecting their characteristic dermoscopic features.

Introduction: Tinea capitis is a common dermatophyte infection of the scalp and hair shaft, most commonly observed in children. Trichoscopy is nonivasive tool which helps in early diagnosis and prompt treatment of tinea capitis. Objectives: This study was carried out with the aim to describe the trichoscopic features of tinea capitis and to find out its different clinical variants with the aid of trichoscopy. Materials and Methods: This is a hospital based cross sectional descriptive study conducted from 1st January 2019 to 31st December 2019. All patients clinically diagnosed with tinea capitis were included in the study. Result: A total of 50 patients with tinea capitis were recruited. The most common age group was found to be 6-10 years (52%) and 27 patients (54%) were female. Majority of the population were students, i.e. 46 patients (92 %). Family history was positive in 38% of cases. The clinical variants seen were black dots in 20 patients (40%), followed by gray patch in 15 patients (30%), kerion in 8 patients (16%) and combined type (both gray patch and black dots) in 4 patients (8%). The most common trichoscopic feature were black dots in 40 (80%), followed by comma hairs in 38 (76%), corkscrew hairs in 33 (66%), and broken hairs in 24 (48%). Conclusion: This study highlighted that the use of trichoscopy as non-invasive tool helped in diagnosing the cases of tinea capitis without the use of wood’s lamp and laboratory investigations.

Trichoscopy (hair and scalp dermatoscopy) facilitates the diagnosis of hair and scalp disorders. The aim of our study was to identify the trichoscopic features in diagnosis of tinea capitis (TC) and to compare these findings with alopecia areata (AA). Our study included 15 children with TC and 10 children with AA as a control group. Affected areas of the scalp on all the cases were analysed under a magnification of 20X and 40X by a digital dermatoscope (MoleMax II). Broken and dystrophic hairs were found in dermatological examination of all the patients with TC. In addition, corkscrew hairs, comma hairs and black dots were observed respectively. Yellow dots, exclamation mark hairs and vellus hair were observed in patients with AA. Broken and dystrophic hairs, corkscrew hairs, comma hairs and black dots were observed only in patients with TC; yellow dots, exclamation mark hairs and vellus hairs were observed only in patients with alopesi areata. Further studies with larger numbers of patients are needed to determine specific trichoscopic findings of TC and to access differential diagnosis.

Superficial Fungal Infections

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PM ObjectivesTinea capitis is a relatively common disease, and the mycological examination is the gold standard for diagnosis. However, the probability of false negative on the KOH test is up to 40% and culture examination takes a long time for diagnosis. The characteristic pattern of dermoscopy not only aids in diagnosis, but also enables early treatment.MethodsWe evaluated six patients who were diagnosed with tinea capitis through clinical and dermoscopic findings. The images of the lesions were taken with a digital camera (Nikon, HB-42) and photographed with dermoscopy (Dermlite Foto 2 Pro) from the patients. The pictures were obtained by taking multiple focal points with dermoscopy. The comma, corkscrew, Morsecode-like, zig-zag, and bent hairs were observed as the main findings.ResultsThe dermoscopic finding was seen with overlapping of various findings in each of the patients. Upon dermoscopy, the most common findings were the corkscrew hair (66%) and the bent hair (66%). The comma hair (33%) and the proximal white shaft hair (33%) were less frequently observed and zigzag hair and Morse-code like hair were not seen in six patients. In the photograph taken with a camera, findings considered to be dermoscopic features such as corkscrew hair or comma hair were not observed.ConclusionIt is important for dermatologists to consider that abnormal findings in dermoscopy can play an important role in diagnosing Tinea capitis. And it will help in early treatment and prevent the progression of complications. Here in, we report specific dermoscopic findings which can narrow down the differential diagnosis.

Background:Tinea capitis is the most common pediatric dermatophyte infection. Trichoscopy aids in the rapid diagnosis and allows prompt treatment, preventing horizontal transmission.Objectives:The objective of this study is to document the trichoscopic features of tinea capitis and evaluate its correlation with clinical type, microscopic form, and mycological culture and propose diagnostic trichoscopic criteria.Materials and Methods:Trichoscopy was performed, after taking consent in 98 participants (<18 years) of tinea capitis diagnose by hair root and scalp scraping examination for hyphae positive on potassium hydroxide mount microscopy or culture positive on SDA media. The comparison of observed trichoscopic features, with the clinical type, pattern of invasion, and etiological agent was carried out.Results:The most common clinical variant was black dot, and etiological agent was Trichophyton violaceum. The following trichoscopic features were noted: black dot, comma, short broken, corkscrew, horse-shoe, zigzag hair, and perifollicular scaling. Perifollicular scaling was significantly common in gray-patch variant, whereas comma, black dot, horse-shoe hair, and perifollicular scaling were noted in black-dot variant. Comma, corkscrew, and zig-zag hair were significantly present in endothrix form, whereas perifollicular scaling was evident in ectothrix form. Combining perifollicular scaling with comma hair, short broken, and black dot hair achieved a diagnostic sensitivity of 98.97%.Conclusions:Trichoscopy by evaluating for the combination of perifollicular scaling and 3 dystrophic hair (comma hair, black dot, and short-broken hair) is a good diagnostic tool for tinea capitis. Horse-shoe hair a novel finding, not hitherto reported in the literature requires validation in future studies.

Analysis of trichoscopic signs observed in 24 patients presenting tinea capitis: Hypotheses based on physiopathology and proposed new classification

Specific trichoscopic signs of tinea capitis (TC) were first described in 2008. The accuracy of this diagnostic tool has not been evaluated. To assess the diagnostic accuracy of trichoscopy. A prospective, multicentre study was done between March 2015 and March 2017 at the dermatology departments of four French university medical centres. Patients with a presumed diagnosis of TC were included. Trichoscopy was considered to be positive if at least one specific trichoscopic sign was observed. Trichoscopy results were compared with the gold standard for diagnosis of TC (mycological culture). One hundred patients were included. Culture was positive for 53 patients and negative for 47. The sensitivity of trichoscopy was 94% [95% confidence interval (CI) 88-100], specificity was 83% (95% CI 72-94), positive predictive value was 92% and negative predictive value was 86%. Comma hairs, corkscrew hairs, zigzag hairs, Morse-code-like hairs and whitish sheath were significantly more frequent in patients with a positive mycological culture (P < 0·001). Comma hairs were more frequent in patients with Trichophyton TC (P = 0·026), and zigzag hairs were more frequent in patients with Microsporum TC (P < 0·001). Morse-code-like hair was not observed in any patients with Trichophyton TC and therefore appears to be highly specific for Microsporum TC. The presence of a single trichoscopic finding is predictive of TC. Trichoscopy is a useful, rapid, painless, highly sensitive tool for the diagnosis of TC - even for dermoscopists with little experience of trichoscopy. It enhances physicians' ability to make treatment decisions. What's already known about this topic? Tinea capitis (TC) must be confirmed by a mycological culture that may take up to 6 weeks, delaying treatment. Specific trichoscopic signs of TC were first described in 2008, but the accuracy of trichoscopy for diagnosing TC has not previously been evaluated. What does this study add? The present series is the largest yet on the use of trichoscopy in the diagnosis of TC. Our results demonstrated that the presence of a single feature (comma hair, corkscrew hair, zigzag hair, Morse-code-like hair or whitish sheath) is predictive of TC. Trichoscopy is painless and highly sensitive. Morse-code-like hair appears to be highly specific for Microsporum TC.

Dermoscopy is a noninvasive diagnostic tool that allows the recognition of morphologic structures not visible to the naked eye. Trichoscopy is useful for the diagnosis and follow-up of hair and scalp disorders. The aim of the present study was to evaluate the causes of focal non-cicatricial alopecia in Egyptian children and to assess the importance of the trichoscope in the diagnosis of each disease. This study was done with 200 Egyptian pediatric patients aged from 2 to 18 years who suffered from focal non-cicatricial alopecia. Clinical and dermoscopic evaluations were performed on all patients, and informed consent was obtained from their parents. The most prevalent diagnoses were alopecia areata (42%) and tinea capitis (40.5%), followed by trichotillomania (8%) and tractional alopecia (7%). Congenital triangular alopecia (1.5%) and patchy androgenetic alopecia (1%) were less common. Trichoscopy revealed distinct features in alopecia areata cases, such as short vellus hair, exclamation mark hair, black dots, broken hair, pigtail hair, and upright regrowing hair. The most common trichoscopic features of tinea capitis were comma hair, corkscrew hair, broken hair, bent hair, zigzag hair, morse code hair, perifollicular scaling, and diffuse scaling. These findings contribute to understanding the etiology and clinical presentation of childhood alopecia, facilitating accurate diagnosis and appropriate management. The routine use of trichoscopy in the clinical evaluation of scalp and hair disorders enhances diagnostic capabilities beyond simple clinical inspection. Trichoscopy reveals disease features that contribute to accurate diagnosis and improved management.

Background:Tinea capitis is a fungal infection that affects the scalp. It is caused by a group of fungi known as dermatophytes, which thrive in warm and moist environments. In Somalia, there is a data shortage regarding dermatological conditions, especially in Mogadishu, the most populous city in the country. Tinea capitis has gone unreported despite its high prevalence in Somali dermatology clinics and the Somali diaspora in Western countries. The absence of up-to-date information hampers the capability to diagnose, treat, and prevent Tinea capitis. Therefore, the study aims to evaluate dermoscopic signs about isolated organisms and potassium hydroxide (KOH) examination.Method:A hospital-based cross-sectional study was implemented between January and April 2023 in Mogadishu, Somalia. All eligible Tinea capitis-infected children were included in the study. Microscopically, analysis was conducted by adding 10% of KOH in fungal elements. Data were analyzed using descriptive statistics and the χ2 test at P value less than 0.05.Results:A total of 76 tinea capitis-infected children participated in the study; 56% were age group between 5-9 years old, 68.4% were male, and 92.1% showed KOH positivity. Trichophyton violaceum (65.8%) and Trichophyton sudanense (14.5%) were the most common fungal organisms detected in the culture. comma hairs (93.10%), scales (40.80%), and corkscrews (32.90%) were the most common dermoscopic signs of tinea capitis. The demographical characteristics and dermoscopic signs of tinea capitis significantly associated with the positivity of KOH examination were age, sex, comma hairs, corkscrew hairs, broken hair, Scales, and Zigzag hair.Conclusion:Children in Mogadishu, Somalia, bear a significant burden of Tinea Capitis infections. Trichophyton violaceum and Trichophyton sudanense were the predominant causative agents identified in the cultures. The most common dermoscopic signs of tinea capitis observed in this study were comma hairs, scales, and corkscrew patterns. Hence, early diagnosis of Tinea Capitis infections and timely, effective treatments with contact tracing are highly needed.

Comma and corkscrew hairs are trichoscopic markers of tinea capitis. Although comma hairs have been reported in both black and white patients with tinea capitis, corkscrew hairs were previously hypothesized to manifest exclusively in patients with curly or African hair types. However, we report a significant number of comma and corkscrew hairs in a Hispanic female patient with naturally straight hair and Trichophyton tonsurans tinea capitis. Thus, dermoscopy is a rapid, noninvasive, and cost-effective tool for evaluating tinea capitis and should be used in combination with culture in all patients regardless of hair texture or race.

Pediatric patients often reveal localized alopecic foci on the scalp. The essential point upon approaching a child with localized alopecia is distinguishing the two most common causes, alopecia areata and tinea capitis, as their treatments are entirely different. Although potassium hydroxide examination is the preferred method for their clear distinction, dermatoscopy is also emerging as a rapid diagnostic tool. This study aimed to assess and compare the dermatoscopic findings of alopecia areata and tinea capitis. Enrolled in this study were 34 children with tinea capitis and 21 children with alopecia areata admitted to a single-center outpatient clinic between 2017 and 2021. The authors confirmed all children's diagnoses by an integrative evaluation of clinical features, potassium hydroxide examination results, and treatment response patterns. Clinical features and the variables of interest (dermatoscopic findings) were investigated through the medical records and the baseline dermatoscopic images. The most common dermatoscopic finding within the tinea capitis cohort was comma hairs, detected in 33 (97.1%) of the patients. Other findings of the tinea capitis group included squamation (n=31, 91.2%), broken and dystrophic hairs (n=30, 88.2%), corkscrew hairs (n=24, 70.6%), zigzag hairs (n=18, 52.9%), and pigtail hairs (n=9, 26.5%). The most common dermatoscopic finding within the alopecia areata cohort was exclamation mark hairs (n=13, 61.9%), that was followed by black dots (n=9, 42.9%), yellow dots (n=8, 38.1%), vellus hairs (n=6, 28.6%), and broken and dystrophic hairs (n=5, 23.8%). Among the detailed evaluation of dermatoscopic findings of tinea capitis and alopecia areata patients, the only overlapping feature was dystrophic and broken hairs that could be present in both diseases; but were more common within the TC group than within the AA group (88.2% vs. 23.8%).