Report
Tinea Capitis in tIte United Arab Emirates Gilles G, Lestringant, M,D,, Khalil Qayed, M,D,, and Benedict Blayney, M,R,C,G,P,
Abstract: The authors reviewed the causative agents for tinea capitis in United Arab Emirates nationals attending Tawam Hospital, Al Ain, between 1981 and 1988. Microsporum canis was the most prevalent organism isolated. Oral griseofuivin remained the treatment of choice. The addition of isotretinoin appeared promising in the chronic intlammatory forms.
The aim of this work is to give an approximation of the fungal flora in the district of Al Ain, United Arab Emirates, The causative dermatophytes identified by culture in 234 cases of tinea capitis treated at Tawam Hospital, Al Ain, between March, 1981 and December, 1988 were reviewed. Microsporum canis was the most prevalent organism isolated (68,8%), followed by Trichophyton mentagrophytes (9,4%) and T. violaceum (6.4%). Clinically, there was a high incidence of deep inflammatory forms. Very good results were obtained in the treatment of Majocchi's granuloma and perifolliculitis capitis abscedens et suffodiens Hoffmann using a combination of isotretinoin and griseofulvin. The available data concerning dermatophytic flora of the Arabian Gulf countries are summarized. The United Arab Emirates lies in a hot, arid climate zone on the southeastern coast of the Arabian Gulf. Al Ain is a recently built garden city of 70,000 inhabitants in the Emirate of Abu Dhabi; it is situated in the desert on the edge of Buraimi Oasis, at the eastern end of the Empty Quarter, There are many surrounding villages and farms where people'tend camels, goats, sheep, and cattle. Tawam University Hospital provides free health care for UAE nationals. It is a 300-bed tertiary care institution situated in Al Ain. Health care is up to Western standards. Tinea capitis is a common disease of children in theDistrictof Al Ain.
From the Department of Dermatology, Tawam University Hospital, Al Ain, Abu Dhabi, United Arab Emirates, Address correspondence to: Gilles G, Lestringant, 1V1,D,, Tawam University Hospital, P,O, Box 15258, Al Ain, Abu Dhabi, United Arab Emirates, February 1991, Vol. 30, No. 2
Materials and Methods • The files of 234 UAE citizens presenting with tinea capitis who attended Tawam Hospital between March, 1981 and December, 1988 were reviewed. The recruitment of patients into the study was based on their having positive scalp cultures. Specimens sent for fungal studies consisted either of (1) curetted scales and hair, (2) swabs taken with a cotton wool probe previously dampened in the transport medium, (3) pus, and (4) skin biopsies. Specimens were inoculated onto agar slants of Sabouraud's dextrose agar and mycosel agar, incubated at 25C for 4 weeks and examined twice weekly. Fungus isolates, if any, were then subcultured onto Sabouraud's, mycosel and potato dextrose agars in Petri dishes. The isolates were examined macroscopically and microscopically in lactophenol cottoh blue, Trichophyton vitamin agar and urea dextrose agar were used for the differentiation of some Trichophyton species.
Results and Discussion Our results are summarized in Table 1. The 234 cases reviewed do not reflect the total number of patients with tinea capitis seen at Tawam Table 1. Causative Dermatophytes Isolated in 234 Patients with Tinea Capitis
Species
Total
Ad. cani.s
161 (68,8%)
M. aitdoitinii M. ferriigineum Ad. gypseum M. species* Total genus Adicrosporum T. mentagrophyte.s T. violacetim T. verrucosum T. rubrum T. tonsurans T. schocnk'inii T. soudanense T, species* Total genus Trichophyion Gross total
2
2 1 2
168(71,8%) 22 (9,4%) 15(6,4%) 7 (3%) 5 5 2 1 9
66 (28,2%) 234(100%)
' No futlher details available.
127
128
International Journal of Dermatology • February 1991
Figure I. Giant form of Majocchi granuloma: trichophytie pseudoblastoma (7'. ton.surans).
Hospital during the period ofthe survey. In many instances, patients were treated after elinical assessment only. Furthermore, in the majority of cases of family epidemics, only one member ofthe family had a sample taken for culture. Specimens were easier to obtain from the traditionally shaven scalps of the boys than from the girls with their long hair. Thus, the sex ratio of tinea capitis in the population cannot be deduced from the survey. For similar reasons, the age distribution of the disease cannot be determined. The youngest patients were two 1-month-old boys infected with M. canis and T. menlagrophytes, respectively. A 2-month-oId girl had a kerion secondary to M. canis. The oldest patients reviewed were a 15-yearold girl with a perifolliculitis abscedens et suifodiens dermatophytica of 3 years' duration due to M. ferrugineum and a 16-year-old boy with a lesion caused by T. soudanense. M. canis was by far the most common organism
Vol. 30
isolated (68.8%). It is probably even more prevalent in the community than our study shows, as our mode of recruitment, as previously stated, did not take account of family epidemics. T. mentagrophyles was the next most common organism found (22 isolates, 9.4%); another zoophilic species, T. verrucosum, (7 isolates, 3%) was isolated during the years 1983 to 1985 only. Cats are common in the locality; dogs, for religious reasons, are not approved of as domestic animals, and strays are regularly impounded by the Public Health Authorities. In a significant number of our patients, pet rabbits would appear to have been the source of M canis infection. Many ofthe inhabitants ofthe Al Ain district keep camels which are valued for their milk and for racing purposes. Camels may be a reservoir for some zoophilic species. T. violaceum (15 isolates, 6.4%) was rare before 1986 but was frequently isolated during the last 2 years ofthe survey. T. violaceum is the most common causative agent of tinea capitis in India (54.7%),' (67.6%),^ and in Egypt (52%).^ There are close links (trading, family) between the UAE and these two countries and there are large expatriate Indian and Egyptian communities in the UAE. T. schoenleinii, however, which was the next most common agent of tinea capitis (23%) in 1980 in India' and Egypt,-^ was isolated only twice in our series. From a clinical standpoint, the number of deep inflammatory forms observed was surprisingly high. We noted 40 kerion eelsi, 22 of which were secondary to M. canis and three to T. rubrum, two Majocchi's granulomas (Fig. 1), and seven cases of Perifollieulitis abscedens et suffodiens dermatophytica Hoffmann (PASD).
Table 2. Epidemiology of Tinea Capitis in some of the Arabian Gulf Countries Author and Country
Date of Study
Rahim'' Iraq Karaoui, Selim, Mousa' Kuwait Kolemen et al.^ Eastern Province Saudi Arabia Kubec, Selim, Al Ghareer' Kuwait Al Sogair, Al Humaidan, Moawad'" Eastern Province Saudi Arabia Present study Al Ain, UAE
1948-1964
1141
6 mo 1978
96 (tinea capitis only) 38
Nov 82-May 83 1980-1984
No. of Isolates
1984-1987
373 (tinea capitis only) 447
1981-1988
234
Main Causative
Dermatophytes Isolated
T. schoenleinii 74% M. canis 77% M. canis 55.3% M. canis 64.3% M. canis 56.6%
T. violaceum 23% T. violaceum 10.4% T. verrucosum 15.8% T. violaceum 22.5% T. violaceum 30.7%
M. canis 68.8%
T. mentagrophytes 9.4%
No. 2
Tinea Capitis in the UAE • Lesfringant, Qayed, and Biayney
A 6- to 8-week course of oral griseofulvin (15-25 mg/kg/d) was always effective and retnains our treatment of choice. In nonsuppurative forms, it was given together with a once- or twice-daily application of a topical imidazole derivative or, more recently, naftifine. When treating kerion celsi, an oral antibiotic, normally erythromycin, was added during thefirst10 days of treatment. We found that twice daily applications of a 10% benzoyl peroxide gel were of some help in shortening the inflammatory stage ofthe lesions. We have always been reluctant to use systemic corticosteroids or radiotherapy in the chronic devastating Majocchi's granuloma or PASD, and ketoconazoie did not prove to be any more effective than griseofulvin. One of US'* has already reported the promising results obtained in the treatment of chronic forms with a combination of griseofulvin in the usual dosage, and isotretinoin (0,6-1 mg/kg/d). There are little data available concerning the dermatophytic flora ofthe Arabian Gulf countries,^ Table 2 summarizes the information we have been able to
129
References 1, Khosa RK, Girgla HS, Hajini GH, et al. Study of dermatomycoses(in India), Int J Dermatol, 1981;20;130-132 2, Sehgal VN, Saxena AK, Kumari S, Tinea eapitis: a elinieoaetiologie correlation, Int J Dermatol, 1985;24:116-119 3, Amer M, Taha M, Tosson Z, et al. The frequency of causative dermalophytes in Egypt, Int J Dermatol, 1981;20:431-434, 4, Lestringant GG, The use of isotretinoin in the treatment of ehronic deep dermatophyte infeetions (letter), J Dermatol Treat, 1990;l;169, 5, Binazzi M, Papini M, Simonetti S, Skin myeoses: geographie distribution and present-day pathomorphosis, Int J Dermatol, 1983;22:92-97, 6, Rahim GF, A survey of fungi causing tinea eapitis in Iraq, Br J Dermatol, 1966;78:213-218, 7, Karaoui R, Selim M, Mousa A, Ineidenee of dermatophytosis in Kuwait, Sabouraudia, 1979; 17:131-137, 8, Kolemen F, Gawad AA, Anter S, et al, Dermatophytie flora of the Eastern Provinee in Saudi Arabia, The King Faisal Specialist Hospital Medieal Journal, 1984;4:313-316, 9, Kubee K, Selim M, Al Ghareer H, Epidemiology ofthe myeotie flora in Kuwait, Mykosen, 1986;29(February):71-75, 10, Al Sogair SM, Al Humaidan YM, Moawad MK, Sealp fungus infeetions in the Eastern Provinee of Saudi Arabia, Annals of Saudi Medicine, 1989;9;259-262,
Sunscreens Sunscreens are classified as chemical or physical depending on whether they absorb specific wavelength bands of radiation or reflect and scatter. When chemical sunscreens are applied fo the skin, they usually do not modify the appearance of the skin. When physical sunscreens are applied to the skin, they can be seen on fhe skin's surface because fhey reflect and scatter light (1, 3), Because physical sunscreens are not wavelength selective, they are recognized as effective ingredients in sunscreen products contributing broad spectral protection. Greater emphasis is being put on use of physical sunscreens because of regulatory and safety concerns. In Japan, fhe amount of chemical sunscreen agents that can be used in a product is limited by law. If sunscreen products are to be highly effective, an adequate amount of physical sunscreen must also be employed. At the present time there is no limitation on the amount of physical sunscreen that can be used in a product. Presumably there is no risk to the user from physical sunscreens. In the United States the OTC drug review examined the safefy and efficacy of each sunscreen agent separately, setting maximum allowable concentrations in products. The maximum allowable concentration was determined on fhe basis of the concentrations that had been used in marketed formulations and that were supported by safety testing for those concentrations. The current policy allows use of combinations of approved agents up to the maximum concentration limits for each agent. At the time of the OTC review only titanium dioxide was submitted as a physical sunscreen agent for use in sunscreen products. Titanium dioxide, therefore, appears to be fhe only acceptable physical sunscreen for use in sunscreen products in the United States. In the past several years, the availability of physical sunscreens and their quality has increased. The range ot particle sizes, especially smaller sizes, has been extended dramatically. Today there are many additional choices of possible physical sunscreen agents. Moreover, we now know better how to design acceptable products incorporating physical sunscreens. According to Pathak, "Physical sunscreens are usually opaque formulafions and contain ingredients that are particulate in nature and do not selectively absorb UVR, but when applied as a film, they primarily reflect and scatter UVR and visible radiation because of the size of the particles and thickness of fhe fiim." Also in 1986, Kollias et al,, while establishing the optical specifications for a new spectrophotometer, examined the reflectance characteristics of titanium dioxide, showing that titanium dioxide exhibited a strong absorption edge characteristic of semiconductors at wavelengths just shorter than 400 nm. This observation provided the inspiration for this examination of the definition of physical sunscreens,—Sayre R, Kollias N, Roberts R, Bager A, Sadiq I. Physical sunscreens. J Soc Cosmet Chem 1990;41:103-109.
Tinea Capitis in tIte United Arab Emirates Gilles G, Lestringant, M,D,, Khalil Qayed, M,D,, and Benedict Blayney, M,R,C,G,P,
Abstract: The authors reviewed the causative agents for tinea capitis in United Arab Emirates nationals attending Tawam Hospital, Al Ain, between 1981 and 1988. Microsporum canis was the most prevalent organism isolated. Oral griseofuivin remained the treatment of choice. The addition of isotretinoin appeared promising in the chronic intlammatory forms.
The aim of this work is to give an approximation of the fungal flora in the district of Al Ain, United Arab Emirates, The causative dermatophytes identified by culture in 234 cases of tinea capitis treated at Tawam Hospital, Al Ain, between March, 1981 and December, 1988 were reviewed. Microsporum canis was the most prevalent organism isolated (68,8%), followed by Trichophyton mentagrophytes (9,4%) and T. violaceum (6.4%). Clinically, there was a high incidence of deep inflammatory forms. Very good results were obtained in the treatment of Majocchi's granuloma and perifolliculitis capitis abscedens et suffodiens Hoffmann using a combination of isotretinoin and griseofulvin. The available data concerning dermatophytic flora of the Arabian Gulf countries are summarized. The United Arab Emirates lies in a hot, arid climate zone on the southeastern coast of the Arabian Gulf. Al Ain is a recently built garden city of 70,000 inhabitants in the Emirate of Abu Dhabi; it is situated in the desert on the edge of Buraimi Oasis, at the eastern end of the Empty Quarter, There are many surrounding villages and farms where people'tend camels, goats, sheep, and cattle. Tawam University Hospital provides free health care for UAE nationals. It is a 300-bed tertiary care institution situated in Al Ain. Health care is up to Western standards. Tinea capitis is a common disease of children in theDistrictof Al Ain.
From the Department of Dermatology, Tawam University Hospital, Al Ain, Abu Dhabi, United Arab Emirates, Address correspondence to: Gilles G, Lestringant, 1V1,D,, Tawam University Hospital, P,O, Box 15258, Al Ain, Abu Dhabi, United Arab Emirates, February 1991, Vol. 30, No. 2
Materials and Methods • The files of 234 UAE citizens presenting with tinea capitis who attended Tawam Hospital between March, 1981 and December, 1988 were reviewed. The recruitment of patients into the study was based on their having positive scalp cultures. Specimens sent for fungal studies consisted either of (1) curetted scales and hair, (2) swabs taken with a cotton wool probe previously dampened in the transport medium, (3) pus, and (4) skin biopsies. Specimens were inoculated onto agar slants of Sabouraud's dextrose agar and mycosel agar, incubated at 25C for 4 weeks and examined twice weekly. Fungus isolates, if any, were then subcultured onto Sabouraud's, mycosel and potato dextrose agars in Petri dishes. The isolates were examined macroscopically and microscopically in lactophenol cottoh blue, Trichophyton vitamin agar and urea dextrose agar were used for the differentiation of some Trichophyton species.
Results and Discussion Our results are summarized in Table 1. The 234 cases reviewed do not reflect the total number of patients with tinea capitis seen at Tawam Table 1. Causative Dermatophytes Isolated in 234 Patients with Tinea Capitis
Species
Total
Ad. cani.s
161 (68,8%)
M. aitdoitinii M. ferriigineum Ad. gypseum M. species* Total genus Adicrosporum T. mentagrophyte.s T. violacetim T. verrucosum T. rubrum T. tonsurans T. schocnk'inii T. soudanense T, species* Total genus Trichophyion Gross total
2
2 1 2
168(71,8%) 22 (9,4%) 15(6,4%) 7 (3%) 5 5 2 1 9
66 (28,2%) 234(100%)
' No futlher details available.
127
128
International Journal of Dermatology • February 1991
Figure I. Giant form of Majocchi granuloma: trichophytie pseudoblastoma (7'. ton.surans).
Hospital during the period ofthe survey. In many instances, patients were treated after elinical assessment only. Furthermore, in the majority of cases of family epidemics, only one member ofthe family had a sample taken for culture. Specimens were easier to obtain from the traditionally shaven scalps of the boys than from the girls with their long hair. Thus, the sex ratio of tinea capitis in the population cannot be deduced from the survey. For similar reasons, the age distribution of the disease cannot be determined. The youngest patients were two 1-month-old boys infected with M. canis and T. menlagrophytes, respectively. A 2-month-oId girl had a kerion secondary to M. canis. The oldest patients reviewed were a 15-yearold girl with a perifolliculitis abscedens et suifodiens dermatophytica of 3 years' duration due to M. ferrugineum and a 16-year-old boy with a lesion caused by T. soudanense. M. canis was by far the most common organism
Vol. 30
isolated (68.8%). It is probably even more prevalent in the community than our study shows, as our mode of recruitment, as previously stated, did not take account of family epidemics. T. mentagrophyles was the next most common organism found (22 isolates, 9.4%); another zoophilic species, T. verrucosum, (7 isolates, 3%) was isolated during the years 1983 to 1985 only. Cats are common in the locality; dogs, for religious reasons, are not approved of as domestic animals, and strays are regularly impounded by the Public Health Authorities. In a significant number of our patients, pet rabbits would appear to have been the source of M canis infection. Many ofthe inhabitants ofthe Al Ain district keep camels which are valued for their milk and for racing purposes. Camels may be a reservoir for some zoophilic species. T. violaceum (15 isolates, 6.4%) was rare before 1986 but was frequently isolated during the last 2 years ofthe survey. T. violaceum is the most common causative agent of tinea capitis in India (54.7%),' (67.6%),^ and in Egypt (52%).^ There are close links (trading, family) between the UAE and these two countries and there are large expatriate Indian and Egyptian communities in the UAE. T. schoenleinii, however, which was the next most common agent of tinea capitis (23%) in 1980 in India' and Egypt,-^ was isolated only twice in our series. From a clinical standpoint, the number of deep inflammatory forms observed was surprisingly high. We noted 40 kerion eelsi, 22 of which were secondary to M. canis and three to T. rubrum, two Majocchi's granulomas (Fig. 1), and seven cases of Perifollieulitis abscedens et suffodiens dermatophytica Hoffmann (PASD).
Table 2. Epidemiology of Tinea Capitis in some of the Arabian Gulf Countries Author and Country
Date of Study
Rahim'' Iraq Karaoui, Selim, Mousa' Kuwait Kolemen et al.^ Eastern Province Saudi Arabia Kubec, Selim, Al Ghareer' Kuwait Al Sogair, Al Humaidan, Moawad'" Eastern Province Saudi Arabia Present study Al Ain, UAE
1948-1964
1141
6 mo 1978
96 (tinea capitis only) 38
Nov 82-May 83 1980-1984
No. of Isolates
1984-1987
373 (tinea capitis only) 447
1981-1988
234
Main Causative
Dermatophytes Isolated
T. schoenleinii 74% M. canis 77% M. canis 55.3% M. canis 64.3% M. canis 56.6%
T. violaceum 23% T. violaceum 10.4% T. verrucosum 15.8% T. violaceum 22.5% T. violaceum 30.7%
M. canis 68.8%
T. mentagrophytes 9.4%
No. 2
Tinea Capitis in the UAE • Lesfringant, Qayed, and Biayney
A 6- to 8-week course of oral griseofulvin (15-25 mg/kg/d) was always effective and retnains our treatment of choice. In nonsuppurative forms, it was given together with a once- or twice-daily application of a topical imidazole derivative or, more recently, naftifine. When treating kerion celsi, an oral antibiotic, normally erythromycin, was added during thefirst10 days of treatment. We found that twice daily applications of a 10% benzoyl peroxide gel were of some help in shortening the inflammatory stage ofthe lesions. We have always been reluctant to use systemic corticosteroids or radiotherapy in the chronic devastating Majocchi's granuloma or PASD, and ketoconazoie did not prove to be any more effective than griseofulvin. One of US'* has already reported the promising results obtained in the treatment of chronic forms with a combination of griseofulvin in the usual dosage, and isotretinoin (0,6-1 mg/kg/d). There are little data available concerning the dermatophytic flora ofthe Arabian Gulf countries,^ Table 2 summarizes the information we have been able to
129
References 1, Khosa RK, Girgla HS, Hajini GH, et al. Study of dermatomycoses(in India), Int J Dermatol, 1981;20;130-132 2, Sehgal VN, Saxena AK, Kumari S, Tinea eapitis: a elinieoaetiologie correlation, Int J Dermatol, 1985;24:116-119 3, Amer M, Taha M, Tosson Z, et al. The frequency of causative dermalophytes in Egypt, Int J Dermatol, 1981;20:431-434, 4, Lestringant GG, The use of isotretinoin in the treatment of ehronic deep dermatophyte infeetions (letter), J Dermatol Treat, 1990;l;169, 5, Binazzi M, Papini M, Simonetti S, Skin myeoses: geographie distribution and present-day pathomorphosis, Int J Dermatol, 1983;22:92-97, 6, Rahim GF, A survey of fungi causing tinea eapitis in Iraq, Br J Dermatol, 1966;78:213-218, 7, Karaoui R, Selim M, Mousa A, Ineidenee of dermatophytosis in Kuwait, Sabouraudia, 1979; 17:131-137, 8, Kolemen F, Gawad AA, Anter S, et al, Dermatophytie flora of the Eastern Provinee in Saudi Arabia, The King Faisal Specialist Hospital Medieal Journal, 1984;4:313-316, 9, Kubee K, Selim M, Al Ghareer H, Epidemiology ofthe myeotie flora in Kuwait, Mykosen, 1986;29(February):71-75, 10, Al Sogair SM, Al Humaidan YM, Moawad MK, Sealp fungus infeetions in the Eastern Provinee of Saudi Arabia, Annals of Saudi Medicine, 1989;9;259-262,
Sunscreens Sunscreens are classified as chemical or physical depending on whether they absorb specific wavelength bands of radiation or reflect and scatter. When chemical sunscreens are applied fo the skin, they usually do not modify the appearance of the skin. When physical sunscreens are applied to the skin, they can be seen on fhe skin's surface because fhey reflect and scatter light (1, 3), Because physical sunscreens are not wavelength selective, they are recognized as effective ingredients in sunscreen products contributing broad spectral protection. Greater emphasis is being put on use of physical sunscreens because of regulatory and safety concerns. In Japan, fhe amount of chemical sunscreen agents that can be used in a product is limited by law. If sunscreen products are to be highly effective, an adequate amount of physical sunscreen must also be employed. At the present time there is no limitation on the amount of physical sunscreen that can be used in a product. Presumably there is no risk to the user from physical sunscreens. In the United States the OTC drug review examined the safefy and efficacy of each sunscreen agent separately, setting maximum allowable concentrations in products. The maximum allowable concentration was determined on fhe basis of the concentrations that had been used in marketed formulations and that were supported by safety testing for those concentrations. The current policy allows use of combinations of approved agents up to the maximum concentration limits for each agent. At the time of the OTC review only titanium dioxide was submitted as a physical sunscreen agent for use in sunscreen products. Titanium dioxide, therefore, appears to be fhe only acceptable physical sunscreen for use in sunscreen products in the United States. In the past several years, the availability of physical sunscreens and their quality has increased. The range ot particle sizes, especially smaller sizes, has been extended dramatically. Today there are many additional choices of possible physical sunscreen agents. Moreover, we now know better how to design acceptable products incorporating physical sunscreens. According to Pathak, "Physical sunscreens are usually opaque formulafions and contain ingredients that are particulate in nature and do not selectively absorb UVR, but when applied as a film, they primarily reflect and scatter UVR and visible radiation because of the size of the particles and thickness of fhe fiim." Also in 1986, Kollias et al,, while establishing the optical specifications for a new spectrophotometer, examined the reflectance characteristics of titanium dioxide, showing that titanium dioxide exhibited a strong absorption edge characteristic of semiconductors at wavelengths just shorter than 400 nm. This observation provided the inspiration for this examination of the definition of physical sunscreens,—Sayre R, Kollias N, Roberts R, Bager A, Sadiq I. Physical sunscreens. J Soc Cosmet Chem 1990;41:103-109.
