Discussion
The amount of fungistatic saturated fatty acids in sebum increases at puberty and therefore dermatophyte colonization of the scalp disappears in this age9. This is thought to explain the rarity of tinea capitis in adults. Although the disease was once thought to be rare in adulthood, studies have been increasingly reporting tinea capitis among adults especially in immunocompromised patients, menopausal and elderly women2 34. Our patient was a 75-year-old menopause female, but not immunocompromised. In most of the reported cases, including our case, the diagnosis was delayed. This delay is probably due to both the rarity of this infection in adults and its atypical clinical presentation. The disease may resemble bacterial folliculitis, folliculitis decalvans, dissecting cellulitis, pityriasis amiantace and its related etiologies, and scaring alopecia like lupus erythematosus10. In many studies the correct diagnoses were established by tissue culture23. Although, for some authors, griseofulvin remains the treatment of choice for tinea capitis in children and adults, both terbinafine and itraconazole are considered acceptable alternatives2 3 4. Due to the numerous reports describing treatment-resistant dermatophytosis, which has emerged as a global public health threat,11 12 1314 we started the treatment with high dose itraconazole as 400 mg daily. Also, we prescribed prednisone 15mg daily at the first month because of the severe inflammation. Our patient responded well to this treatment and there was complete clearance of the lesions with acceptable hair regrowth.
We reviewed tinea capitis case reports in adults indexed in PubMed between 2018 and 2023. To be included in the review, articles had to be available in the English language. Inclusion criteria included patient age ≥18 years, diagnosis of tinea capitis, no history of immunosuppression or receiving any immunosuppressant drugs, no history of other medical conditions or history of other dermatophytosis infection in other parts of the skin, no history of gardening, pet-keeping, contact with domestic animals or other individuals with the same manifestations or dermatophytosis infection and no history of contact with objects containing fomites, including brushes, combs, bedding, clothing, toys, furniture, and telephones (Table 1).
We found a total of 11 cases. Of these cases, the prevalence was higher in women (8/11) and the average age was 48.36. Three cases did not have a mycological culture and didn’t mention the dermatophyte isolated. Trichophyton tonsurans was the most common dermatophyte, followed by Trichophyton violaceum. Most cases were treated with oral terbinafine 250 mg daily. One patient was treated with oral griseofulvin 500 mg every 12 hours and another one with oral itraconazole 200 mg twice daily. Most patients received combination therapy consisting of oral and topical antifungal agents. All patients reported were cured successfully without any side effects. Two cases had disseminated lesions on the face15, extremities and nails1516 years after the scalp manifestations. One case caused by Trichophyton tonsurans suffered subsequent herpes zoster infection, which shows that tinea capitis may be a risk factor for varicella zoster virus reactivation17.