Clinical Evaluation of Superficial Fungal Infections in Children
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Superficial fungal infections; dermatophytes and yeasts. Distribution of dermatophytes; country and geographical area, lifestyle, climatic conditions and migration varies depending on various reasons (1-3). Common fungal infections in children and adolescents; tinea capitis, tinea corporis, tinea pedis, mucocutaneous candidiasis, onychomycosis and pityriasis versicolor. Risk factors include being an infected family member or immunosuppressive factors such as human immunodeficiency virus (HIV) infection, chemotherapeutic use, long-term antibiotic and systemic corticosteroid use. Fungal infections in children are usually similar to adults, but are sometimes atypical and may cause difficulty in diagnosis. Fungal infections in children can be confused with many diseases such as seborrheic dermatitis, psoriasis, alopecia areata and trichotillomania. In immunocompromised people, systemic treatment is preferred over treatment instead of topical, and systemic treatment is also required for tinea capitis and onychomycosis (4).
This work; The aim of this study was to determine the prevalence, distribution, clinical variants, frequency and treatment approaches of superficial mycoses in children and adolescents with dermatophyte infection.
methods
Fifty-one patients diagnosed with superficial fungal infection in the pediatric dermatology outpatient clinic of Erciyes University, Faculty of Medicine, Department of Dermatology within the last year, who were diagnosed with the diagnosis, clinical appearance, direct microscopy, and in some cases, confirmed by fungal cultures. were evaluated retrospectively.
Records of all patients including age, sex, complaints, family history, concomitant diseases, duration of disease, clinical location and type of lesions, and treatment information were reviewed. Data were analyzed by Student's t-test and Chi-square test.
Results
Of the patients with superficial fungal infection, 33 (64.7%) were male and 18 (35.3%) were female. The mean age was 6.24 ± 4.4 (4 months-17 years) (Table 1).
Eighteen patients (35.3%) had scalp, five (9.8%) trunk, four (7.8%) tongue, four (7.8%) toenail, three (5.9%) both hands Fungal infection was observed in both the toenail and two (3.9%) hand nails. In others; three (5.9%) patients in the face area, three (5.9%) patients in the genital area, one (2%) patient in the upper extremity, two (3.9%) in the foot area and two (3.9%) in the dorsal area patients (Table 2). One patient had trunk and upper extremity involvement, the other had trunk and face involvement, and another had face, tongue, trunk and nail involvement.
In 10 patients with tinea capitis profunda (19.6%), tinea capitis superficialis eight (15.8%), tinea versicolor eight (15.8%), candidiasis eight (15.8%), tinea unguium eight (15.8%) ), tinea corporis two (3.9%), tinea pedis two (3.9%), tinea facial two (3.9%), tinea cruris one (2%) and tinea incognito in one (2%) (Table 3). Tinea incognitive patient was found to be the site of involvement. One of the children had tinea pedis and tinea unguium together. In this study, tinea capitis (35.3%) was found to be the most common clinical type of dermatophytosis.
In the family history of the patients, superficial fungal infection was found in 10 (19.6%) near first degree and two (3.9%) near second degree. The remaining 39 (76.5%) patients did not have a family history.
The most common symptom was pruritus. Concomitant diseases; Pulmonary tuberculosis, extrofia vesica, ectodermal dysplasia, epilepsy, growth retardation, hypospadias, obesity, diabetes, pachyonychia congenita, prematurity, rhinosinusitis, tinea amiantecea and telogen effluvium.
Twenty-one patients received systemic antimycotic treatment (terbinafine or itraconazole) and 30 patients received topical treatment in the whole patient group. Four of the patients in the systemic treatment group were tinea unguium and fourteen were tinea capitis. The other three patients who received systemic treatment were diagnosed as; Candidiasis, tinea incognito and tinea corporis were confirmed nail involvement confirmed by direct mycosis examination. Four were onychomycosis and four were tinea capitis (Table 3).
Four (44.4%) of nine patients with nail involvement were treated topically and five (56.6%) were treated with systemic antimycotics. All patients receiving topical treatment resulted in complete recovery, while four of the five patients receiving systemic treatment had complete recovery. One of them did not come to the controls. It was found that all patients with superficial tinea capitis superficialis received systemic antimycotic treatment, while four of the patients diagnosed with tinea capitis profunda received topical antimycotic treatment (Table 3). While the mean disease duration of the patients receiving systemic treatment at the time of admission to the outpatient clinic was 5881 days, the mean disease duration of those who preferred local treatment was 1738 days.
Discussion
Skin infections caused by dermatophytes and yeasts have become an important problem affecting children and adolescents over the years (3). Most of the patients were male patients aged 5-7 years. In the literature, it has been reported that tinea capitis infection is more common in men. In this study, tinea capitis was found in 13 patients in men and five patients in women, in line with previous information. In previous studies, tinea pedis and tinea unguium were reported to be more common in men than in women, whereas in our study two of the three children with tinea pedis were found to be women (5). This finding may be due to the insufficiency of the number of patients and suggests that more comprehensive studies are needed.
In our study, a history of superficial fungal infection and concomitant immunosuppression in a family of risk factors was also evaluated. It is known that prematurity increases both fungal infections and also predisposes to other infections and increases the use of antibiotics and leads to immunosuppression (6,7). The prevalence of opportunistic superficial fungal infections such as candida is increasing in diseases such as obesity and diabetes. In addition, superficial fungal infections are the most common skin infections detected in patients with diabetes. Fungal infections have been reported to occur in 10-60% of patients with diabetes (8). In epilepsy patients, the use of antibiotics is much higher in this population due to infections frequently accused in the etiology (9). In our patients, it was seen that there were concomitant diseases such as pulmonary tuberculosis, extrofia vesica, ectodermal dysplasia, epilepsy, growth retardation, hypospadias, obesity, diabetes, pachyonis congenita, prematurity and rhinosinusitis. Although none of the patients in our study had concomitant immunosuppressive diseases such as hereditary immunosuppressive disease or chemotherapy, frequent antibiotic use secondary to concomitant diseases was found to be a risk factor for the disease.
In this study, tinea capitis was found to be the most common type of superficial fungal infections in Kayseri. Similarly in the literature, tinea capitis infection is the most common fungal infection in the world in children and adolescents (4,10). The clinical types of tinea capitis and the distribution of agents vary from region to region in the world and in our country. Turkey's Aegean and Mediterranean regions in the western part of tinea capitis superficialis more frequent, although in Kayseri in central Anatolia, East Anatolia, we observed similar to the tinea capitis profunda more often. The reason for this is that the distribution of tinea capitis agents in Central Anatolia is similar to that of Eastern Anatolia (11). Because previous studies have shown that Trichophyton verrucosum is the most isolated agent from patients with tinea capitis in both Central and Eastern Anatolia (12,13).
Unlike adults, many previous studies have reported that onychomycosis is rare in children (14). In various studies conducted in different parts of the world, rates ranging from 0% to 2.6% have been found in children. In parallel with the study conducted by Lange et al. (15) in 2006, it was observed that onychomycosis was not as low as expected in children and adolescents. In our study, onychomycosis was found to be 15.8% of superficial mycoses diagnosed in children under 17 years of age. Therefore, when nail disorder is detected in children, it should be emphasized that onychomycosis should be considered at the forefront of diagnosis. In our study, because of the presence of superficial fungal infection in the family of 12 out of 51 patients, it was seen that family transmission was important in pediatric patients. If superficial fungal infection is detected in children and adolescents, we think that relapse can be prevented by questioning the presence of fungal infection in the family and providing appropriate treatment to family members with fungal infection.
Although the first treatment of superficial fungal infections is topical antifungals, systemic antifungal drugs should be preferred when severe or chronic. Terbinafine, itraconazole and fluconazole are oral antifungals that are effective in the treatment of superficial fungal infections (16). General strategy for the management of superficial fungal infections in children; the most appropriate treatment option, including systemic treatment, without considering the profit / loss ratio and avoiding systemic antifungals as much as possible, but without hesitation in the presence of appropriate indications. In children, drug transfer is easier because nail plate has a thinner structure than adults (17). In this study, 30 patients in the pediatric age group were treated with topical antifungal and 21 patients with systemic antifungals such as terbinafine or itraconazole. In addition to the diagnostic difficulties experienced by primary and secondary care physicians, systemic treatment is preferred in children due to unconfirmed use, possible systemic side effects and difficulty in use in children. it was thought that this could cause the disease duration to be much longer.
Result
Tinea capitis is the most common clinical type of superficial fungal infection in children and adolescents. Superficial dermatophyte infections are more common in male sex. We also believe that onychomycosis should be kept in mind in the differential diagnosis of nail disorder in children due to the high rate of onychomycosis in our patient group. In the majority of patients with onychomycosis, only topical treatment was sufficient. It is stated that family history is an important risk factor in superficial fungal infections, which is often missed by physicians. In the treatment approach, especially the experience of the physician and the correct determination of the predisposing factors such as additional disease are the guiding factors in choosing the most appropriate treatment for tinea capitis, tinea unguium and other superficial fungal infections.
Author Contributions
Ethics Committee Approval: Approval was obtained from Erciyes University Faculty of Medicine Ethics Committee, Informed Consent Form was obtained from all patients included in our study, Concept: Retrospective study, Design: Ragıp Ertaş, Demet Kartal, Serap Utaş, Data Collection and Processing : Ragıp Ertaş, Analysis or Interpretation: Serap Utaş, Ragıp Ertaş, Demet Kartal, Literature Search: Demet Kartal, Written by: Ragıp Ertaş, Referee Assessment: Reviewed by the editors' board, Conflict of Interest: No conflict of interest was declared by the authors. Financial Support: No financial support was received from any institution or person for our study.
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