Update on the Treatment of Kerion Celsi

Dermatophytid reactions are secondary eruptions in response to dermatophytosis. Only a few cases demonstrating an association between dermatophytid reactions and tinea capitis have been reported. Dermatophytid reactions were evaluated in patients diagnosed with kerion celsi. Patients admitted to the dermatology clinic of Van Regional Training and Research Hospital between November 22, 2012, and July 1, 2013, diagnosed with kerion celsi were evaluated for dermatophytid reactions. Six girls (32%) and 13 boys (68%) were included in this study. Dermatophytid reactions were detected in 13 of the 19 patients (68%). Seven patients (36.84%) had eczematous patches or plaques and three (15.8%) had papules. Eczematous lesions, papules, and pustules were noted in two patients (10.5%) and one (5.3%) had signs of an angioedema-like reaction. Dermatophytid reactions in all patients were observed before the initiation of therapy. According to our clinical experiences, dermatophytid reactions in patients with kerion celsi were more common than reported. Eczematous scaly patches or plaques were the most frequently seen forms of dermatophytid in patients with kerion celsi. Dermatophytid reactions may occur before or after initiation of systemic antifungal therapy. Recognition of this reaction is important so that dermatophytids can be distinguished from drug reactions and the decision can be made whether to continue or to stop the systemic antifungal treatment.

A 75-year-old non-working male living in Sagamihara, Kanagawa Prefecture, had erythematous plaques with scales associated with follicular pustules in the head area extending from the occipital to right temporal regions about 1 month prior to his initial visit, when hair loss increased. The diagnosis was kerion Celsi. Trichophyton rubrum was isolated from scales and tissues taken from lesions in the head. Histopathological examinations showed irregular epidermal thickening with dense cell infiltration from the dermis to subcutaneous adipose tissues. Granulomatous reactions involving neutrophils, histiocytes and giant cells were seen mainly in the hair follicles. Periodic acid-Schiff (PAS) and Grocott-positive microbial elements were detected in the horny layer, and inside and outside the hair follicles. Pustules disappeared 1 week after starting the oral treatment with terbinafine (125 mg day-1). A cure was achieved 2 weeks after starting the treatment, with only slight scales remaining. No recurrence has been observed to date. Terbinafine was thought to be very effective and safe for kerion Celsi. We reviewed 27 cases of kerion Celsi reported in patients, aged at least 70 years, in Japan and found that the major characteristics of this disease in Japan include the following: (1) female cases outnumber male cases; (2) the causative organism was T. rubrum in 14 of 27 patients (51.9%); and (3) topical application of steroids often induces this disease in patients with superficial tinea capitis.

Kerion Celsi is an acute inflammatory reaction that develops in response to the penetration of dermatophytes into hair follicles and is accompanied by a secondary bacterial infection and a reaction of the lymph nodes. The incidence of kerion in mycosis of this localization can vary from 15% to 57%. Despite the widespread distribution of dermatophytes in the pediatric population, studies in the field of etiology and diagnostics of kerion Celsi are limited and contradictory. The aim of this study is to analyze to analyze the clinical and laboratory features of kerion Celsi caused by Trichophyton tonsurans. The article describes a case of kerion Celsi caused by the anthropophilic fungus T. tonsurans . The patient received complex treatment in the conditions of the daily dermatovenereology hospital of the Moscow Scientific and Practical Center of Dermatovenereology and Cosmetology of Moscow Health Department. The development of kerion Celsi was caused by incorrect long-term use of topical glucocorticosteroids, and was also delayed due to incorrect diagnostic tactics in the outpatient setting. During the laboratory examination of the pathological material obtained from the patient, the growth of the T. tonsurans culture was not obtained. The etiological diagnosis was made based on the results of direct microscopy and PCR. Direct microscopy of the hair revealed the location of the spores as endothrix . After hospitalization in the pediatric dermatovenereology department, the patient quickly responded to treatment with oral antimycotics and antibiotics. Kerion Celsi is a difficult-to-treat form of scalp mycosis that negatively affects the quality of life of the child and family. The international and domestic experience in diagnosing kerion Celsi demonstrated in the article indicates the need to refer children with rashes on the scalp to a dermatovenereologist for timely diagnosis of mycosis and prevention of serious complications.

Rationale:Kerion Celsi, a severe form of tinea capitis, is generally caused by zoophilic and geophilic fungi. This is the first report of an unusual case of kerion Celsi caused by Microsporum gypseum in a 6-year-old boy.Patient concerns:A 6-year-old boy presented to the dermatology clinic with the complaint of multiple pustules, edematous plaques over the scalp with hair loss for 1 month.Diagnosis:Clinical and laboratory investigations, including reverse transcriptase-quantitative polymerase chain reaction, confirmed M gypseum causing kerion Celsi.Interventions:Upon combination therapy using oral itraconazole and oral prednisolone along with the topical terbinafine, kerion Celsi remitted in the patient.Outcome:New hair growth was noted during the 4-month follow-up.Lesson:We presented the first case of kerion Celsi infection secondary to M gypseum that was probably transmitted from a guinea pig.

Kerion Celsi is an inflammatory, deep fungal infection of the scalp. It is rare in neonates but gets more common in children about 3 years and older. It represents with swelling, boggy lesions, pain, alopecia and purulent secretions. Secondary bacterial infection is not unusual after maceration. Extracutaneous manifestations include regional lymphadenopathy, fever and very rare fungemia. Id-reactions can occur. Diagnosis is based on clinical suspicion, clinical examination and medical history. Diagnosis should be confirmed by microscopy, fungal culture and molecular procedures. The most common isolated fungal species are anthropophilic Trichophyton (T.) tonsurans and zoophilic Microsporum (M.) canis, while geophilic species and moulds rarely cause Kerion Celsi. Treatment is medical with systemic and topical antifungals supplemented by systemic antibiotics when necessary, while surgery needs to be avoided. Early and sufficient treatment prevents scarring alopecia. The most important differential diagnosis is bacterial skin and soft tissue infections.

The actual case is interesting for two reasons: the appearance of a self-healing micro-pustular eruption immediately after the beginning of therapy and the onset of psoriasis in the same site of kerion after a few months. The incidence of allergic reactions to fungal antigens varies widely according to the different Authors and the different criteria adopted for the diagnosis (2). For the diagnosis of dermatophytide the following criteria should be met: a- causal fungal infection demonstrated with mycological examination, especially when unilateral (for example of a single foot in the case of pompholix of the hands secondary to tinea pedis); b- secondary lesions morphologically of various type but bilateral and symmetrical (for example of both palmar regions in case of pompholix) with negative mycological examination and positive cutaneous allergological tests to fungal antigens; c- spontaneous resolution of lesions when causal infection stops. From the morphological point of view the causal lesions are characterized by intense inflammation; not by chance the first dermatophytide was described by Jadassohn in a kerion. The secondary lesions can be of various type, but mainly eczematous, papular and pustular (2); they may occur before starting therapy or immediately after starting treatment. The ides of the second case are probably linked to the massive destruction of fungi and are reminiscent of what happens in syphilis with the Jarisch-Herxheimer reaction or in onchocerchiasis and other parasitoses after treatment with albendazole or ivermectin with the Mazzotti reaction (1). The knowledge of the ide reactions that arise after the beginning of the therapy is important from the practical point of view because the suspicion of an allergic reaction to griseofulvin could lead to drug withdrawal. When the drug, for example griseofulvin, has never been taken before and the ide reaction occurs within 5-6 days from the beginning of the therapy, it is possible to exclude an immune mediated reaction to the drug because the minimum time for a first sensitization to be realized is 7 days. Also interesting in the current case is the appearance of psoriasis on previous kerion that recalls the phenomenon of Koebner and occurred in a subject with positive biparental family history for psoriasis.

Kerion celsi represents the inflammatory extreme of tinea capitis, as a delayed hypersensitivity reaction to the causative dermatophyte. Data regarding prevalence, trends in pathogens, and risk factors for scarring are limited. The main objective of the study is to assess clinical and epidemiologic features of children with kerion celsi and risk factors for scarring. We reviewed medical records of pediatric patients with kerion celsi treated between January 2006 and July 2020. Among 80 patients, the prevalence of permanent alopecia was 27.5%. Patients with remaining alopecia presented to our clinic at a mean 1.3months earlier than those with complete response to treatment (2.2±2.1 and 3.4±4.8, respectively; p<.05). Patients of Ethiopian ethnicity were more represented than in the general population; however, scarring was observed in only 11% (p=0.08). Outcomes did not differ by pathogen, antifungal treatment prescribed, duration of treatment, or the use of prednisone or antibiotics. Scarring alopecia is a common complication of kerion celsi. Host innate immune response, pathogen virulence, and treatment timeline should be considered as possible variables affecting risk of scarring in the future studies.

Kerion celsi (KC), known as scalp ringworm, is the most common dermatophytosis in children. In Mexico, it ranks fourth among dermatophytoses, with a frequency of 4%-10%. KC is the inflammatory variety of tinea capitis (TC), with the most common causative agents being Microsporum canis and Trichophyton mentagrophytes. We present the clinical case of a six-year-old male diagnosed with KC. Direct examination stained with chlorazol black and cultures were performed, yielding negative results. Histopathological study revealed spores and short hyphae within and surrounding the hair shaft. Treatment with itraconazole was initiated based on suspicion of Microsporum spp. from the trichoscopy findings. We propose a diagnostic and therapeutic algorithm for kerion celsi.

Oral griseofulvin is considered the 'gold standard' therapy for patients with kerion because it can interfere with the synthesis of proteins, cell walls and nucleic acids in growing dermatophytes including Trichophyton, Microsporum and Epidermophyton. Although cure rates of griseofulvin for Microsporum canis infections are significantly better than for terbinafine, the longer therapeutic course of griseofulvin causes poor compliance among infected children. We report a 2-yearold Chinese girl with kerion caused by M canis. She exhibited good clinical responses to 7 weeks of treatment with oral terbinafine (4 mg/kg per day) without any obvious adverse events. During 6 months of follow-up, her scalp lesion cleared completely with new hair regrowth and the laboratory evaluation of hematology and biochemistry study including liver transaminases was normal.

Kerion Celsi is an inflammatory variant of tinea capitis and is usually caused by Microsporum canis. Griseofulvin is the gold standard treatment, but FDA approves its use only for children up to two years. Even though it is rare in children younger than three years, tinea capitis can still occur, as in the case of the one-year-old child who was successfully treated with photodynamic therapy combined with curcumin, resulting in total remission.

Tinea capitis is seen world-wide among children up to 12years. The most severe type is Kerion Celsi with painful abscesses and lymphadenopathy. We report on an 11-year-old boy with Kerion Celsi, who was initially treated using antibiotics under the common misdiagnosis of abacterial infection. Mycological investigations could identify Microsporum canis. The patient was treated orally with griseofulvin, which resulted in complete mycological remission after 8weeks. Cicatrical alopecia, however, could not be prevented. Purulent infections of the scalp should lead to early mycological diagnostics in children.

Kerion Celsi is a markedly inflammatory presentation of tinea capitis, usually caused by Microsporum and Trichophyton infections. Rapid introduction of aggressive systemic antifungal therapy is pivotal in the treatment. Erythema nodosum is a hypersensitivity reaction characterized by red, tender, nodular lesions usually on the pretibial surfaces; the most common etiologic causes in childhood are infections. Erythema nodosum is an “id” or dermatophytid reaction in kerion Celsi; the hypersensitivity reaction is the consequence of vast amount of fungal antigens. There are only a few case reports in the literature on the common occurrence of kerion Celsi and erythema nodosum in children, the authors find their case worthy of presentation because of this rare constellation.

Kerion caused by Microsporum audouinii in a child

Tufted folliculitis is an uncommon folliculitis of the scalp that resolves with patches of scarring alopecia within which multiple hair tufts emerge from dilated follicular orifices. The clinicohistological data from a group of 15 patients with tufted folliculitis were reviewed and compared with those of seven patients with folliculitis decalvans, five with acne keloidalis nuchae, four with dissecting cellulitis of the scalp, three with kerion celsi and 20 with follicular lichen planus. It was found that tufted folliculitis could be differentiated from folliculitis decalvans only by finding several hair tufts scattered within patches of scarring alopecia. Histologically, a single tuft consisted of peculiar clustering of adjacent follicular units opening at the bottom of an epidermal depression. Conversely, the presence of keloidal plaques in acne keloidalis nuchae, coalescing nodules discharging purulent material in dissecting cellulitis of the scalp, erythematous plaques covered by pustules replete with fungal elements in kerion celsi, and the absence of follicular pustules in follicular lichen planus distinguished these diseases from tufted folliculitis. On the basis of these findings, it is suggested that tufted folliculitis should be considered as a distinctive clinicohistological variant of folliculitis decalvans. Tufting of hair is caused by clustering of adjacent follicular units due to a fibrosing process and to retention of telogen hairs within the involved follicular units.

269 10 year experience of pediatric kerion celsi in Costa Rica