Dermatophytid in Tinea Capitis: Rarely Reported Common Phenomenon With Clinical Implications Nancy Cheng, Dakara Rucker Wright

and Bernard A. Cohen Pediatrics 2011;128;e453; originally published online July 4, 2011; DOI: 10.1542/peds.2010-2757

The online version of this article, along with updated information and services, is located on the World Wide Web at:
http://pediatrics.aappublications.org/content/128/2/e453.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2011 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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CASE REPORTS

Dermatophytid in Tinea Capitis: Rarely Reported Common Phenomenon With Clinical Implications
AUTHORS: Nancy Cheng, BA,a Dakara Rucker Wright, MD,a and Bernard A. Cohen, MDa,b
aDivision of Pediatric Dermatology, Department of Dermatology, and bDepartment of Pediatrics, Johns Hopkins University, Baltimore, Maryland

abstract
Tinea capitis may be associated with a dermatophytid, which appears as a disseminated eczematous eruption. This phenomenon may occur before or after initiation of systemic antifungal drug therapy and is not an indication for stopping medication. We present here a series of cases that involve 5 children with tinea capitis who developed a dermatophytid before or during the course of their management. In each child, the eruption resolved despite continuation of oral antifungal therapy. Our experience suggests that dermatophytid secondary to tinea capitis is much more common than reported. Furthermore, parents and clinicians frequently mistake dermatophytid for drug allergy. Recognition of this phenomenon, distinction of dermatophytid from drug allergy, and continuation of systemic treatment is essential for clearing the infection and dermatophytid. Pediatrics 2011;128: e453e457

KEY WORDS dermatology, fungal infections, community pediatrics www.pediatrics.org/cgi/doi/10.1542/peds.2010-2757 doi:10.1542/peds.2010-2757 Accepted for publication Mar 25, 2011 Address correspondence to Bernard A. Cohen, MD, Division of Pediatric Dermatology, Johns Hopkins Childrens Center, 2107 PMOB, 200 N Wolfe St, Baltimore, MD 21287. E-mail: bcohena@ jhmi.edu PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright 2011 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no nancial relationships relevant to this article to disclose.

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Id reactions, also known as autoeczematization, are systemic disseminated eczematous eruptions preceded by acute highly inammatory and/or chronic or subacute localized eczematous eruptions. These reactions are reported most commonly in association with acute dermatitis but have also been associated with many acute and chronic dermatitic processes.15 Dermatophytid represents an id reaction that occurs in the setting of an inammatory dermatophyte infection. Dermatophytids have been commonly described in association with tinea pedis but only rarely with tinea capitis.69 We present here a series of cases that involve 5 children with tinea capitis who developed dermatophytid before or during treatment with oral antifungal medication. Each patient was treated successfully with continued antifungal therapy and symptomatic measures for the dermatophytid. Our experience suggests that id reactions after scalp infection with dermatophyte species are common and must be distinguished from drug-induced allergic reactions. Antifungal agents should be continued through the course of the dermatophytid.

scrapings from 3 patients. All the patients were treated with griseofulvin, and the tinea capitis had improved or cleared in all patients by follow-up 1 to 3 months after starting therapy. Four patients developed dermatophytid reactions after starting therapy, and 1 patient was diagnosed with a dermatophytid at the initial visit before therapy was initiated. Dermatophytid reactions most commonly involved the head and neck, but lesions spread to the trunk and/or extremities in most of the children. All dermatophytid reactions resolved during the course of systemic antifungal therapy.

tinea pedis in adults, which is usually caused by Trichophyton rubrum infection of the foot.1,9 In 1 study, 37 of 213 patients (17%) diagnosed with tinea pedis went on to develop dermatophytid of the hands.9 These patients were observed to develop acute, symmetrical vesicular eruptions at a secondary site, usually the ngers or palms. With tinea pedis, the eruption usually develops 1 to 2 weeks after the primary infection and is thought to represent a delayed-type hypersensitivity to a dermatophyte antigen. The mechanism has been well studied via lymphocyte proliferation and transformation testing, intradermal testing, and patch testing.9 Resolution of the symptoms requires topical or systemic steroid treatment of the id reaction along with an antifungal agent to treat the underlying tinea pedis.1,2,9 To distinguish the primary dermatophyte infection from a dermatophytid, a set of essential diagnostic criteria has been proposed to identify a dermatophytid reaction. First, the host must harbor a proven focus of dermatophyte infection; second, no fungal forms can be recoverable from the lesions of the suspected dermatophytid reaction; and third, dermatophytid symptoms must resolve after eradication of the underlying fungal infection.4 One postulated immunologic mechanism of id reactions involves release of fungal antigens from the site of infection, opsonization by host antibodies, and spread of sensitized T-helper 1 cells and their cytokines to other parts of the body.12 For this reason, id reactions are sometimes described as a type 4 delayed hypersensitivity in the host to a distant focus of infection. Thus, id reactions can occur with any infectious agent that activates the hosts cell-mediated immunity.7,12 Study results have also suggested that

DISCUSSION
Id reactions have been described in a number of dermatitic processes including atopic dermatitis, contact dermatitis, seborrheic dermatitis, scabies, chronic otitis externa, and many dermatophyte infections including tinea pedis, tinea corporis, and tinea cruris.1,2,4,5,7,9 The incidence of dermatophytids may approach 5% of laboratory-conrmed dermatophyte infections.4 Clinical presentation can vary greatly depending on host immunologic response. They are generally characterized by symmetric widespread eczematous eruptions that vary from subtle 1- to 2-mm ne scaly papules to larger papules with surrounding scale and erythema with a predilection for analogous body sites (eg, palms and soles).10 In the most highly sensitized people, disseminated excoriated edematous papules, vesicles, and/or pustules may develop on discrete and conuent red scaly patches and plaques. There have been rare reports of dermatophytids manifesting as migratory thrombophlebitis, erysipelas-like dermatitis of the lower extremities, and erythema annulare centrifugum.11 Dermatophytid has been most commonly reported in association with

METHODS
A cohort of 5 cases, obtained from a chart review in the Johns Hopkins Childrens Center Pediatric Dermatology Clinic, was analyzed for clinical presentation, course of disease, method of treatment, and outcome (Table 1). Approval was obtained from the Johns Hopkins institutional review board to report these cases.

RESULTS
Our patients ranged in age from 4 to 7 years; 2 were boys and 3 were girls, all 5 of them were black, and all of them presented with the typical clinical features of tinea capitis. Trichophyton tonsurans was cultured from scalp
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TABLE 1 Cases of Tinea Capitis With Dermatophytid

Case No. 1 Age, y 3 Gender Male Scalp Culture T tonsurans Clinical Appearance Widespread eczematous eruption, most prominent on chest and back Diffuse eruption of eczematous papules, most severe on face, neck, and ears (Fig 2) Onset of Dermatophytid 2 wk after systemic antifungal treatment 2 wk after systemic antifungal treatment Treatment Griseofulvin 20 mg/kg per d Griseofulvin 20 mg/kg per d; prednisone 1 mg/kg per d Duration of Dermatophytid 10 d Response to Treatment Scalp cleared in 3 mo Scalp cleared in 2 mo

Female

T tonsurans

Male

T tonsurans

Red papules and scaly patches in scalp; widespread scaly pruritic papules on face, neck, chest, and back Pruritic papules on face and neck, spreading to trunk (Figs 1 and 3)

2 wk after systemic antifungal treatment

Griseofulvin 20 mg/kg per d

Female

Results not available

Before antifungal treatment was initiated

Female

Results not available

Pruritic papules on face, trunk, and extremities

1 wk after systemic antifungal treatment

Griseofulvin ultramicrosize 15 mg/kg per d; triamcinolone 0.1% ointment Griseofulvin 20 mg/kg per d; permethrin cream; triamcinolone 0.025%; and 0.1% ointment

Not available, but skin was clear after completion of antifungal therapy Not available, but skin was clear at completion of antifungal therapy 28 d

Scalp cleared in 2 mo

Scalp cleared in 3 mo

30 d

Scalp began to improve in 1 mo

inammatory processes of the skin, including those caused by dermatophyte infection, cause distant skin to be irritated more easily and, thus, facilitate the development of an eczematous reaction.10 Although rarely reported with tinea capitis, our experience suggests that dermatophytid after scalp infection with dermatophyte species is common and must be distinguished from drug-induced allergic reactions to prevent unwarranted withdrawal of medication and persistence or exacerbation of the underlying infection.7 Tinea capitis is a common childhood fungal infection of the hair shaft that classically causes scaling of the scalp and patchy alopecia. It is most commonly seen in black children between the ages of 4 and 7 years.13 Patients often experience scalp pruritis and lymphadenopathy, and some develop red papules and pustules. Patients occasionally may develop an intensely inammatory kerion with boggy tender
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scalp nodules and plaques studded with pustules and exudate.14 Most cases in North America, Europe, Asia, and North Africa are caused by Trichophyton species. With tinea capitis, dermatophytids may occur before or after initiation of systemic antifungal therapy. Dermatophytids from scalp infection are

characterized by diffuse pruritic papules beginning on the scalp, face, and neck and sometimes spreading to the trunk and extremities (Figs 13). Lesions may also appear on the palmar surfaces and interdigital spaces as papules, vesicles, bullae, or pustules.4 After the dermatophytid clears, postinammatory hyperpig-

FIGURE 1
Scalp lesion of tinea capitis with dermatophytid on the forehead.

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Adverse reactions to antifungal agents used for tinea capitis have distinct clinical ndings that are generally easily distinguished from dermatophytids. Hypersensitivity to griseofulvin typically produces an acute onset of urticaria.16 Rarely, griseofulvin can also trigger photosensitivity, a serum sicknesslike reaction with fever, malaise, and a widespread erythematous papular rash, and, extremely rarely, Stevens-Johnson syndrome and toxic epidermal necrolysis.1719
FIGURE 2
Dermatophytid on the face.

Although we only report 5 welldocumented cases in this series, our experience suggests that dermatophytids associated with scalp infection from dermatophyte species is much more common than reported. Although these reactions may be widespread and intensely pruritic, in many cases the astute clinician will observe subtle lesions. Moreover, failure of the clinician to recognize dermatophytids may result in unwarranted withdrawal of the antifungal treatment required to eradicate the underlying infection.7 Until 2008, the preferred Food and Drug Administrationapproved treatment was griseofulvin because of its high cure rate and relatively low cost. However, terbinane granules were approved recently as an alternative treatment, and a number of other new systemic antifungal drugs have also been shown to be safe and effective for tinea capitis.15

Terbinane may rarely trigger acute generalized exanthematous pustulosis (AGEP) or pustular psoriasis. AGEP is characterized by the sudden onset of fever and a widespread erythematous papular eruption that quickly progresses to a ne, nonfollicular, pustular eruption.20 In the pustular psoriasis reaction, rapidly progressive pustules merge to form large areas of pustulation on normal skin and/or red plaques on the trunk and extremities.21

CONCLUSIONS
Lubricants, oral antihistamines, and topical and (occasionally) oral corticosteroids may be necessary to treat dermatophytids and associated pruritus, but these therapies only treat the symptoms; they do not address the underlying infection. As a consequence, clinicians must be able to distinguish dermatophytids from adverse drug reactions and counsel parents accordingly. Antifungal therapy should be continued through the course of a dermatophytid to clear the infection and consequently resolve the eruption.

FIGURE 3
Subtle lesions of dermatophytid on the back.

mentation is common and usually resolves without treatment over a period of months. REFERENCES
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17. Thami GP, Kaur S, Kanwar AJ. Erythema multiforme due to griseofulvin with positive reexposure test. Dermatology. 2001;203(1): 84 85 18. Kawabe Y, Mizuno N, Miwa N, Sakakibara S. Photosensitivity induced by griseofulvin. Photodermatology. 1988;5(6):272274 19. Colton RL, Amir J, Mimouni M, Zeharia A. Serum sickness-like reaction associated with griseofulvin. Ann Pharmacother. 2004; 38(4):609 611 20. Rubegni P, Mandato F, Sbano P, Fimiani M. Terbinane-induced acute generalized exanthematous pustulosis. G Ital Dermatol Venereol. 2008;143(2):151155 21. Tokuyama Y, Senoh A, Setsu N, Iwatsuki K. Pustular psoriasis induced by terbinane: differential diagnosis from acute generalized exanthematous pustulosis. Eur J Dermatol. 2008;18(6):725726

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Dermatophytid in Tinea Capitis: Rarely Reported Common Phenomenon With Clinical Implications Nancy Cheng, Dakara Rucker Wright and Bernard A. Cohen Pediatrics 2011;128;e453; originally published online July 4, 2011; DOI: 10.1542/peds.2010-2757
Updated Information & Services including high resolution figures, can be found at: http://pediatrics.aappublications.org/content/128/2/e453.full.h tml This article cites 19 articles, 2 of which can be accessed free at: http://pediatrics.aappublications.org/content/128/2/e453.full.h tml#ref-list-1 This article has been cited by 2 HighWire-hosted articles: http://pediatrics.aappublications.org/content/128/2/e453.full.h tml#related-urls This article, along with others on similar topics, appears in the following collection(s): Allergy & Dermatology http://pediatrics.aappublications.org/cgi/collection/allergy_an d_dermatology Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pediatrics.aappublications.org/site/misc/Permissions.xht ml Information about ordering reprints can be found online: http://pediatrics.aappublications.org/site/misc/reprints.xhtml

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2011 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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