Journal of Symptoms and Signs    2014; Volume 3, Number 5 

Expert Opinion

Tinea capitis in adults

Laura Atzori, Nicola Aste, Monica Pau

Dermatology Clinic, Department of Medical Science “M.Aresu”, University of Cagliari, Italy.

Abstract
Background Tinea capitis is a rare infections occurring in adults, as after puberty the fungistatic sebum activity and the thicker hair caliber protect
from scalp dermatophytes colonization. Several predisposing factors have been suggested, mainly hormonal variations in menopausal women and
immunosuppression, especially HIV related. Besides, a recent alarming increase has been reported in young immunocompetent adult, due to more
resistant dermatophytes strains, able to survive and parasites the post-pubertal scalp, such as Trycophyton tonsurans. Changes in epidemiology due
to globalization and migration fluxes favor the diffusion of African and Caribbean species in the Western countries.
Methods Critical revision on current knowledge and published literature.
Results Clinical presentation is usually atypical in adult’s tinea capitis, mimicking any scalp dermatitis, from mild to severe inflammatory conditions,
with ill-defined hairloss patches, normal appearing hairs mixed with black dots or irregularly broken hairs, variable scaling and pustules. More severe
cases have scarring and atrophic evolution, simulating decalvans folliculitis, dissecting cellulitis. Responsible dermatophytes are the same of children’s
tinea capitis. Contagion from asymptomatic dermatophyte carriers or tinea capitis affected children in the household should be considered. Agro-
pastoral environment and close contact with domestic animals might be relevant in some patients.
Conclusions Medical awareness of this rare entity is mandatory to avoid diagnostic delay, unnecessary investigations and possible inappropriate
treatment. Mycological samples should be sent to reference laboratory whenever a patchy hair loss occurs in adults, especially when previous treat-
ment for common dermatitis have been disappointing.

Keywords: adult’s tinea capitis; scalp ringworm; dermatophyte infections; tinea capitis in adults; scalp infections.

Received: March 21, 2014; Accepted: May 29, 2014; Published: December 16, 2014

Corresponding Author: Laura Atzori, Clinica Dermatologica, Via Ospedale 54, 09124, Cagliari, Italy.
E-mail: atzoril@unica.it.

Introduction tinea capitis in immunocompetent adults range from < 1%

to up 5% [10‒15]. Disease duration at time of diagnosis
Tinea capitis (TC) or scalp ringworm of the Anglo-
varies from 1 week to 5 years [6‒13], and the delay
Saxon literature is a common and worldwide distribut-
increases in older patients and very severe cases [5, 6].
ed dermatophyte infection, which is mostly age related,
Women are preferentially affected in all case series
being characteristic of pre-pubertal children and ex-
(from 66% to 94%), and post-menopausal condition is
tremely rare in adults [1‒15]. The reported frequency of

392                                                                                                            http://www.intermedcentral.hk/                        

 Tinea capitis
common, but age varies greatly (from 17 to 76 year-
old), with not conclusive average esteem [6, 7, 13]. The
TC epidemiological profile differs from country to
country, and among different geographical areas in the
same country, being conditioned from climate and natu-
ral dermatophytes selection along centuries [15, 16].
Adult’s tinea capitis was mainly reported in Italy,
France, Tunisia, Greece, China and Taiwan [3‒7, 11‒
15]. Besides, last few decades migration fluxes, espe-
cially from Africa to Western countries, have diffused
worldwide very resistant strains, able to survive on the
adult scalp. Especially Tricophyton tonsurans has been
increasingly reported in the United Kingdom, United
States, Brazil [7‒10, 16]. Alerting physician and per-
forming more mycological examinations should avoid
under-estimation of the disease, especially in those pa-
tients with long-standing mild scaling dermatitis of the
scalp, not responding to current medications. Misdiag-
nosis and inappropriate treatment prolong illness and
might induce more inflammatory patterns, with pus-
tules and erosive features, eventually causing scarring
alopecia.
Ethiology and Transmission
The epidemiology of adult’s TC reflects children’s dis-
ease, with isolates over the years variations due to in-
creased sanitation, and personal hygiene, but also envi-
ronmental changes, especially after antifungals intro-
duction. M.audouini and T.schoenleinii infections have
disappeared worldwide after the advent of griseofulvin.
Actually, the majority of adult’s TC series report preva-
lence of Tricophyton (T) species, followed by Micro-
sporum canis [1, 7‒15]. Our personal experience sup-
port a major role of M.canis [6], but the datum simply
reflects the predominance (82%) of this dermatophyte
as cause of tinea capitis in Sardinian children [18], a
major island of the Mediterranean Basin. Isolation,
warm climate and an ancient agro-pastoral tradition
might be responsible of such peculiar epidemiology,
which is also consistent with the frequent isolation of
other zoophile strains on our adults, T.mentagrophytes
and T.verrucosum [6]. Close contacts with domestic
animals, especially kittens, but also dog, rabbit, cows
have been documented in our cases. T.violaceum has
become exceptional in Sardinia, while it remains
among the most frequent isolates in Tunisia, Taiwan,
China, South Africa, Eastern Europe [2, 12‒15, 17].
 http://www.intermedcentral.hk/                                                                                                          393
Tricophyton tonsurans, which has strong phenotype
and genotype similarity to T. violaceum [19], has been
responsible of a dramatic TC increase in UK and USA
[7-10, 17], affecting primarily children and then young
African and Caribbean adults. The control of this pecu-
liar strain contagion is difficult, as fomites resists on
various material surfaces for extensive periods of time
[10]. Contact with shed hairs, brushes, personal items,
dolls, but also class-room surfaces and rent car have
been implicating in the soaring American incidence.
Despite that, inter-human transmission remains the
principle source of infection in adults, taking cares of
affected children or living in shelter with children [10].
A familial history of TC is reported in 10% of Tunisian
cases [15]. Contagion from affected children is also
relevant in Microsporum canis infection, because con-
tacts with pets is less frequent in adults, while the nurs-
ing and child assistant role is common, especially for
grandparents. Asymptomatic carriers have been report-
ed among adults taking cares of tinea capitis affected
children [20‒23], and the condition is probably more
diffused than expected. Concomitant tinea corporis [6]
and/or autoinoculation from pre-existing onychomyco-
sis have been reported [19].
Dermatophytes are direct human pathogen, having
adapted to subside on keratin degradation, but to para-
sites the adult’s scalp there must be some predisposing
conditions, usually being the host defenses very effec-
tive.
Protective Factors
The pubertal increase in sebum secretion, rich of fungi-
static saturated fatty acids is a main factor protecting
the scalp from dermatophytes parasitism [24]. Some
Trycophyton species might be less sensitive, being able
to perforate the hair external sheet (endothrix parasit-
ism), and safely shelter from sebum cap. Malassezia
spp competitive colonization of the scalp might inter-
fere with dermatophytes growth, while another natural
barrier to fungal invasion is the increased caliber and
thickness of adult’s hairs [12].
Favoring Factors
The majority of adults affected with tinea capitis are
postmenopausal women, ranging from 20% to 75‒90%
of the reported cases [3‒15]. Sebaceous glands involu-
 
 Tinea capitis
tion parallel the decreased estrogen levels, and various
degree alterations of hormonal patterns were docu-
mented in a previous experience of our Institute [6].
Other factors influencing transmission in adults are
overcrowding, low socioeconomic status, and underly-
ing conditions such as anemia, and diabetes [15]. An-
other major risk factor is immune suppression, which
may be due to HIV infection [19, 25, 26], but also sec-
ondary to drug administration, as in renal transplant
recipients [27], and in advanced breast cancer under
trastuzumab treatment [28]. Systemic administration of
corticosteroids for autoimmune diseases has been re-
ported [15].
Hair care practices might favor dermatophytes infec-
tion: less shampooing, typical of dry hairs in menopau-
sal woman and any age African Americans [10], might
reduce removal of spores, while styling (dyeing, perm,
traction) might impair hair shaft integrity [29].
Clinical Manifestations
Adults might present with sharply circumscribed patchy
tinea capitis (Figure 1), but more often the features are
atypical (tinea atypica), simulating more common af-
fections [30]. Pruritus and hairloss are the main patients’
complaints, leading to several visits and sometimes
inconclusive treatment, before the infection is sought.
Clinical examination often reveals ill-defined hair loss
areas, with mixed truncated and normal appearing hairs
(Figure 1), variable seborrhea and scaling (Figure 2)
and isolate inflammatory lesions, from pustules to nod-
ules. Black-dots features are frequently reported in
T.Tonsurans infection, but lacking in other cases.
Franck kerion celsi is extremely rare in adult [31−33],
but severe, with very painful pustules and nodules
(Figure 3), tending to patches coalescence, discharging
pus mixed with hairs follicle debris, and a risk of scar-
ring alopecia.
Very inflammatory infections might depends on the
type of dermatophytes, being zoophile species more
aggressive, but evolution from a misdiagnosed tinea
capitis treated with incongruous topical medication is
another possibility.
Polymorphic presentation leads to diagnostic delay,
mimicking more common scalp pathologies. Minimal
to mild inflammatory infections are confused with seb-
orrheic dermatitis, alopecia areata, trichotillomania,
psoriasis, secondary syphilis. Diffuse or stratified ad-
394                                                                                                            http://www.intermedcentral.hk/
herent scaling on a more erythematous base might sim-
ulate psoriasis, chronic lupus erythematosus, and lichen
planus, especially when minimal atrophic and scarring
changes appears. Pustular infections require differentia-
tion from bacterial folliculitis, decalvans folliculitis,
and dissecting cellulitis [34].
Diagnosis
Examination of the hair and skin scraping after 10−20%
potassium hydroxide (KOH) clarification is the sim-
plest and rapid diagnostic tool, showing hyaline fungal
hyphae and arthrospores on hair root and scales. The
type of hair shaft invasion under the microscope (Fig-
ure 4) is suggestive of the causative dermatophytes
specie:
‐ A- Ectothrix infection: hyphae and arthroconidia
cover the outside of the hair shaft, with cuticle de-
struction, but remaining confined to the hair sur-
face. This kind of parasitism is characteristic of
Microsporum Canis, but also T.verrucosum might
be involved.
‐ B- Endothrix parasitism: the hairs shaft is filled
with hyphae ans arthroconida, like a “walnuts bag”.
The main responsible fungi are T.violaceum and
T.tonsurans, which are able to internalize into the
hair cell.
Samples culture on Sabouraud media is necessary to
further identify the isolates by colonies and conidia
morphology, but require expertise and shipment to ref-
erence laboratory is advisable. The use of colorimetric
media (Dermatophyte Test Medium; DTM) might be
easy to read in a general office, and have the advantage
of room temperature storage, but it is quite expensive.
Wood’s lamp examination might be useful in M.canis
infections (characteristic green fluorescence). False
negative results in T.tonsurans infection have been pos-
tulated to cause a certain diagnostic delay and have
favored the recent epidemics in American children and
young women [10].
Very unusual and severe cases might require a scalp
biopsy and histological examination to exclude major
diseases or super-infections [34]. It is important to ad-
vise the pathologist of the clinical suspect, to perform
periodic acid-Schiff (PAS) or other additional stains.
                       
 Tinea cap
pitis

Figgure 1. Examples of typical annular pseudo-alopecic patchess of tinea capitiss in adults

Figure 2. SSeveral examples of adult’s tinea capitis with iill-defined hair loss areas, mixeed truncated annd normal appeaaring hairs, varia-
ble scalingg and seborrhoeeic crusting.

 http://ww
ww.intermed
dcentral.hk/                                                                                                          39
95 
 
 Tinea cap
pitis

Figure 3. Examples
E of moore extensive innvolvement, mim micking female androgenetic alopecia
a and/or psoriasis and eeventual evolution
to very inflaammatory infecctions, from locaalized kerion to generalized eroosive and pustular dermatitis.

Figure 4. DDermatophyte tyypes of hair parrasitism under tthe microscope:: native hair preeparations after 20% KOH clarification (Magniffi-
cation: uppper 10 × and boottom 40 ×)

396                                                                                                            http://w

www.intermedcentral.hkk/                        
 
 Tinea capitis
Therapy and Evolution
A recent meta-analysis comparing tinea capitis golden
standard griseofulvin with terbinafine has confirmed
species-specific differences in treatment efficacy [35],
with griseofulvin superiority in Microsporum spp. in-
fections, and terbinafine advantage for Trichophyton
spp. infection. Giseofulvin suggested dosage in adult’s
tinea capitis is 20‒25 mg/kg/d for 6‒8 weeks [6, 15].
Considering that the majority of adult’s TC are caused
by Trichophyton strains, terbinafine 250 mg/d is a good
option, showing a good sebum and hairs penetration,
and higher compliance towards griseofulvin in adults
[35]. Besides, HIV patients might not respond or devel-
op adverse reactions to both griseofulvin and terbinaf-
ine [19, 36]. Itraconazole 400 mg/d prolonged treat-
ment (16 months) was effective in 2 very problematic
HIV patients [19].
Topical treatment with one of the many different
antifungal (imidazole, allylamine, ciclopirox olamine)
is also very important, because patches are less defined
in respect to children, and real extension of the infec-
tion is difficult to be evaluated. Relapses are more fre-
quent than in children, especially in HIV patients [19].
Bacterial super-infection and scary alopecia are main
possible complications.
Conclusion
Dermathophytes have survived along millennia for their
ability to many different conditions adaptation, from
soil dependency to animals and finally humans. Natural
selection actually favours species able to hide itself,
simulating more common dermatologic conditions, thus
maintaining illness along times. Adult’s tinea capitis is
a rare condition, but a rising incidence has been report-
ed worldwide and it is likely to further escalate, consid-
ering the migration fluxes of globalization, and diffu-
sion of very resistant strains, such as T. Tonsurans.
Asymptomatic carriers are probably more frequent than
believed, and might sustain environmental diffusion.
Physician’s should be regularly trained to recognised
minimal signs and suspect dermatophytes scalp infec-
tions, especially when dealing with erythematous scal-
ing dermatitis, and irregular patches hairloss, present
for long periods of time and when previous therapies
have proved to be ineffective. Misdiagnosis and incon-
gruous therapy further prolong illness, favour progres-
 http://www.intermedcentral.hk/                                                                                                          397
sion to severe inflammatory pustular and erosive forms,
with the risk of scary alopecia, which might be over-
come through a higher use of mycological tests.
Disclosure
There are no conflicts of interest.
References
1. Pipkin JL. Tinea capitis in adults and adolescents. Arch Der-
matol Syph. 1952; 66: 940.
2. Barlow D, Saxe N. Tinea capitis in adults. Int J Dermatol. 1988;
27(6): 388-390.
3. El Euch D, Mokni M, Sellami A, Cherif F, Alzaiz MI, Ben
Osman Dahari A. Les teignes du cuir chevelu observèès à Tu-
nis del 1985 à 1998: a propos de 1222 cas. J Mycol Med. 2001;
11: 87-91.
4. Terragni L, Lasagni A, Oriani A. Tinea capitis in adults. My-
coses. 1989; 32: 482-486.
5. Gianni C, Betti R, Perotta E, Crosti C. Tinea capitis in adults.
Mycoses. 1995; 38: 329-331.
6. Aste N, Pau M, Biggio P. Tinea capitis in adults. Mycoses.
1996; 39: 299-301.
7. Buckley D, Fuller LC, Higgins EM, du vivier A. Tinea capitis
in adults. Brit Med J. 2000; 320: 1389-1390.
8. Fuller LC, Child FC, Higgins EM. Tinea capitis in south-east
London: an outbreak of Trichophyton tonsurans infection. Br J
Dermatol. 1997; 136(1): 139.
9. Bronson DM, Desai DR, Barsky S, Foley SM. An epidemic of
infection with Trichophyton tonsurans revealed in a 20-year
survey of fungal infections in Chicago. J Am Acad Dermatol.
10.
1983; 8(3): 322-330.
Silverberg NB, Weinberg JM, DeLeo VA. Tinea capitis: focus
on African American women. J Am Acad Dermatol. 2002;
46(2 Suppl Understanding): S120-124.
11. Vidimos AT, Camisa C, Tomecki KJ. Tinea capitis in three
adults. Int J Dermatol. 1991; 30 (3): 206-208.
12. Cremer G, Bournerias I, Vandemeleubroucke E, Houin R,
Revuz J. Tinea capitis in adults: misdiagnosis or reappearance?
Dermatology. 1997; 194(1): 8-11.
13. Yu J, Li R, Bulmer G. Current topics of tinea capitis in China.
Nippon Ishinkin Gakkai Zasshi 2005; 46: 61-55.
14. Lee JY, Hsu ML. Tinea capitis in adults in southern Taiwan.
Int J Dermatol. 1991; 30(8): 572-575.
15. Mebazaa A, Oumari KE, Ghariani N, Mili AF, Belajouza C,
Nouira R, Denguezli M, Ben Said M. Tinea capitis in adults in
Tunisia. Int J Dermatol. 2010; 49(5): 513-516.
16. Ajello L. The Medical Mycological Iceberg. HSMHA Heath
Reports. 1971; 86(5): 437-448.
17. Aly R, Hay RJ, Del Palacio A, Galimberti R. Epidemiology of
tinea capitis. Med Mycol. 2000; 38 Suppl 1: 183-188.
18. Aste N, Pau M, Biggio P. Tinea capitis in children in the dis-
trict of Cagliari, Italy. Mycoses. 1997; 40(5-6): 231-233.
19. Bournerias I, De Chauvin MF, Datry A, Chambrette I, Carriere
J, Devidas A, Blanc F. Unusual Microsporum canis infections
in adult HIV patients. J Am Acad Dermatol. 1996; 35(5 Pt 2):
808-810.
20. Bergson CL, Fernandes NC. Tinea capitis: study of asympto-
matic carriers and sick adolescents, adults and elderly who live
with children with the disease. Rev Inst Med Trop Sao Paulo.
2001; 43(2): 87-91.
 
 Tinea capitis
21. Pomeranz AJ, Sabnis SS, McGrath GJ, Esterly NB. Asympto-
matic dermatophytes carriers in the households of children
with tinea capitis. Arch Pediatr Adolesc Med. 1999; 153(5):
483-486.
22. Dessinioti C, Papadogeorgaki E, Athanasopoulou V, Antoniou
C, Stratigos AJ. Screening for asymptomatic scalp carriage in
household contacts of patients with tinea capitis during 1997-
2011: a retrospective hospital-based study. Mycoses. 2014;
57(6): 366-370.
23. Hirose N, Tamura M, Suganami M, Ogawa YS, Hiruma M.
The results of Trichophyton tonsurans screening examinations
and infection management in University Judo Federation of
Tokyo athletes over a 4-year period. Med Mycol J. 2012; 53(4):
267-271.
24. Rothman S, Smiljanic A, Shapiro AL, Weitkamp AW. The
spontaneous cure of tinea capitis in puberty. J Invest Dermatol.
1947; 8: 81-98.
25. Narang K, Pahwa M, Ramesh V. Tinea capitis in the form of
concentric rings in an HIV positive adult on antiretroviral
treatment. Indian J Dermatol. 2012; 57(4): 288-290.
26. Lateur N, André J, De Maubeuge J, Poncin M, Song M. Tinea
capitis in two black african adults with HIV infection. Br J
Dermatol. 1999; 140(4): 722-724.
27. Virgili A, Zampino MR. Relapsing tinea capitis by Micro-
sporum canis in an adult female renal transplant recipient.
Nephron. 1998; 80(1): 61-62.
28. Mansur AT, Artunkal S, Ener B. Tinea capitis in an adult pa-
tient under treatment with trastuzumab. Mycoses. 2011; 54(5):
e609-610.
29. Sharma V, Silverberg NB, Howard R, Tran CT, Laude TA,
Frieden IJ. Do hair care practices affect the acquisition of tinea
398                                                                                                            http://www.intermedcentral.hk/
capitis? A case-control study. Arch Pediatr Adolesc Med.
2001l; 155(7): 818-821.
30. Atzori L, Pau M, Aste N. Tinea atypica. G Ital Dermatol Vene-
reol. 2013; 148(6): 593-601.
31. Hassan I, Rather PA, Sajad P. Favus in an elderly Kashmiri
female: A rare occurrence. Ind J Dermatol. 2013; 58(5): 411.
32. Tanuma H, Doi M, Abe M, Kume H, Nishiyama S, Katsuoka
K. Case report. Kerion Celsi effectively treated with terbinaf-
ine. Characteristics of kerion Celsi in the elderly in Japan. My-
coses. 1999; 42(9-10): 581-585.
33. Aste N, Pau M, Biggio P. Trichophyton mentagrophytes kerion
in a woman. Br J Dermatol. 1996; 135(6): 1010-1011.
34. Miletta NR, Schwartz C, Sperling L. Tinea capitis mimicking
dissecting cellulitis of the scalp: a histopathologic pitfall when
evaluating alopecia in the post-pubertal patient. J Cutan Pathol.
2014; 41(1): 2-4.
35. Gupta AK, Drummond-Main C. Meta-analysis of randomized,
controlled trials comparing particular doses of griseofulvin and
terbinafine for the treatment of tinea capitis. Pediatr Dermatol.
2013; 30(1): 1-6.
36. Rustin MH, Bunker CB, Dowd PM, Robinson TW. Erythema
multiforme due to griseofulvin. Br J Dermatol. 1989; 120(3):
455-458.
Copyright: 2014 © Laura Atzori, et al. This is an Open Access arti-
cle distributed under the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduc-
tion in any medium, provided the original work is properly cited.