TINEA BARBAE

EPIDEMIOLOGY.
Tinea barbae, as its name would imply, occurs predominantly in males. The
incidence of tinea barbae has decreased as improved sanitation has reduced
transmission by contaminated barbers razors. Direct exposure to cattle,
horses, or dogs is now the more common mode of acquisition, and this
accounts for a shift in prevalence toward farmers or ranchers in rural settings.

ETIOLOGY.
Tinea barbae is most commonly caused by the zoophilic strains of T.
interdigitale (former T. mentagrophytes var. mentagrophytes), T. verrucosum,
and less commonly M. canis. Among the anthropophilic organisms, T.
schoenleinii, T. violaceum and certain strains of T. rubrum (former T. megninii),
cause tinea barbae in endemic areas.42

CLINICAL FINDINGS.
Tinea barbae affects the face unilaterally and involves the beard area more
often than the moustache or upper lip. Two forms exist.

Superficial Type.
Caused by anthropophiles such as T. violaceum, this form of tinea barbae is
less inflammatory and resembles tinea corporis or bacterial folliculitis. The
active border shows perifollicular papules and pustules accompanied by mild
erythema (Fig. 188- 8A). Alopecia, if present, is reversible.

Inflammatory Type.
Usually caused by T. interdigitale (zoophilic strains) or T. verrucosum,
inflammatory tinea barbae is the most common clinical presentation. It
presents analogously to kerion formation in tinea capitis with boggy-crusted
plaques and a seropurulent discharge (Fig. 188-8B). Hairs are lusterless,
brittle, and easily epilated to demonstrate a purulent mass around the root.
Perifollicular pustules may coalesce and eventuate in abscess-like collections
of pus, sinus tracts, and scarring alopecia.

DIFFERENTIAL DIAGNOSIS OF TINEA BARBAE
Most Likely
Bacterial folliculitis (sycosis vulgaris), pseudofolliculitis barbae, acne vulgaris,
rosacea, contact dermatitis, perioral dermatitis, candidal folliculitis
Rule Out
Herpes simplex, halogenoderma


LABORATORY TESTS AND HISTOPATHOLOGY
Laboratory Test Method Function Findings
Potassium hydroxide
preparation
Scales from the advancing border, subungual
debris, or affected hair removed and place
on a glass slide. KOH 10% dropeed on
specimen and covered with a cover slip. The
undersurface of the glass slide may be gently
heated with a low-lit flame.
KOH solution and gentle
heating softens keratin
and highlights the
dermatophyte.
Ow narrow septated and
brancing hyphae
Culture Sabouroud medium (4% peptone, 1%
glucose, agar, water)
Facilities growth of
dermatophyte
Microscopic morpgology
of microconidia and
macroconidia, along
with culture features
including surface
topography and
pigmentation
Modified Sabouraud medium (addition of
chloramphenicol, cycloheximide, and
gentamicin)
Facilities growth of
dermatophytes and
inhibits growth of non-
candida albicans,
Cryptococcus, prototheca
species, P. werneckii,
scytalidium species,
ochroconis gallopava
Characterization of
fungal colonies.
Common colonies are
characterized in table
188-5.
Dermatophyte test
medium
Scales from advancing border, subungual
debris or affected hair embedded in the
medium.
Medium contains the pH
indicator phenol red.
Dermatophytes utilize
proteins resulting in
excess ammonium ion and
an alkaline environment.
Incubation at room
terperature for 5-14
days results in change in
color of medium from
yellow to bright red in
presence of a
dermatophyte.
Histolopathology
special stains: period
acid-Schiff and
Grocotts
methenamine silver
Tissue may be obtained by skin or nail
biopsy techniques
Stains fungal cell wall
detect fungal elements in
tisuue sections
Pink (PAS) or black
(GMS) fungal elements
noted in the stratum
corneum


TERAPHY
Like tinea capitis, an oral antifungal is usually necessary in the treatment of
tinea barbae. Ultramicronized griseofulvin 500 mg twice daily for 6 weeks,
terbinafine 250 mg daily for 24 weeks, itraconazole 200 mg daily for 24
weeks, and fluconazole 200 mg daily for 46 weeks are regimens that have
been used effectively. Systemic glucocorticoids used for the first week of
therapy are helpful in cases with severe inflammation.

Disease Topical treatment Systemic treatment
Tinea barbae Only as adjuvant topical
antifungal
Griseovulvin 1gr/day (6 weeks)
Terbinafine 250mg/day (2-4 weeks)
Itraconazole 200mg/day (2-4 weeks)
Fluconazole 200mg/day (4-6 weeks)

GRISEOFULVIN.
Griseofulvin along with terbinafine in patients older than 4 years are systemic
treatments for tinea capitis approved by the US Food and Drug
Administration. The previously recommended pediatric dosage was 1020
mg/kg/day in divided doses for 68 weeks taken with a fatty meal to facilitate
absorption.33 However, high failure rates with this regimen resulted in the
current dosage recommendation of griseofulvin 2025 mg/kg/day of the
microsize form, and 15 mg/kg/day in divided doses of the ultramicrosize form
for 8 weeks.68 Although the current recommendation is not based on
outcomes of controlled trials, the collective clinical experience suggests its
high therapeutic efficacy. Disadvantages of griseofulvin include poor
compliance related to length of treatment and its bitter taste in liquid form.
Common side effects include photosensitivity, headache, and gastrointestinal
upset.69 Griseofulvin also is a potent inducer of cytochrome P450 enzymes.

TERBINAFINE.
Doses of 36 mg/kg/day of terbinafine can cure Trichophyton tinea capitis in
24 weeks; however, 48 weeks of treatment may be required for eradication
of Microsporum.68 Two randomized trials confirmed the increased efficacy of
terbinafine (58 mg/kg/day) in the treatment of T. tonsurans infection with
significantly higher cure rates compared to lower dose griseofulvin (1020
mg/kg/day). However, even at this lower dose range, griseofulvin showed
significantly higher cure rates for M. canis infections.70 Further, it is not clear
that terbinafine (58 mg/kg/day) has a therapeutic advantage in curing tinea
capitis over the higher dose regimen of griseofulvin (2025 mg/kg/day).
Terbinafine may cause gastrointestinal upset. As with itraconazole, there are
reports of liver failure in patients using terbinafine. Terbinafine has an
inhibitory effect on the CYP 2D6 subset of the cytochrome P450 system. While
fewer medications are metabolized through this CYP 2D6 subset as than
through the CYP 3A4 subset inhibited by itraconazole and ketoconazole,
notable interactions still exist with -blockers and tricyclic antidepressants.

ITRACONAZOLE.
At doses of 5 mg/kg/day for 24 weeks, itraconazole effectively eradicates
tinea capitis caused by either Microsporum or Trichophyton.68 Pulse therapy
at 5 mg/kg/day for 1 week out of each month for one to three cycles is also
effective. Possible adverse effects of itraconazole include gastrointestinal
upset, diarrhea with the liquid formulation, and peripheral edema, especially
when used in conjunction with calcium channel blockers. Itraconazole is
better absorbed in the presence of food, which results in secretion of gastric
acid and lower gastric pH. On the contrary, antacids such as H2 blockers may
decrease the absorption of itraconazole by increasing the gastric pH. Like with
fluconazole, hepatotoxicity with itraconazole occurs at lower rates than with
ketoconazole.35 Itraconazole has also rarely been linked to congestive heart
failure. Itraconazole is an inhibitor of the CYP 3A4 subset of cytochrome P450
system.

FLUCONAZOLE.
Available as both tablets and a pleasant-tasting liquid, fluconazole at doses of
6 mg/kg/day for 20 days is effective in curing tinea capitis.68 Alternatively,
fluconazole can be administered as a pulse, once weekly, regimen with 6
mg/kg/day for 812 weeks.71 Absorption of fluconazole is not affected by
gastric pH, and gastrointestinal side effects are less common. Hepatitis has
been reported but it occurs less frequently than with ketoconazole.35
Fluconazole is a potent inhibitor of cytochrome P450 enzymes, in particular
CYP 2C9 and 2C19. Since most medications metabolized by the cytochrome
P450 system are through the CYP 3A4 subset, fluconazole has less potential to
interact with medications than other systemic imidazoles.

ADJUVANT THERAPY.
Selenium sulfide (1% and 2.5%), zinc pyrithione (1% and 2%), povidone
iodine (2.5%), and ketoconazole (2%) are shampoo preparations that help
eradicate dermatophytes from the scalp of children. Adjunctive use of these
shampoos is recommended 24 times weekly for 24 weeks.72 The use of
ketoconazole 2% shampoo or selenium sulfide 2.5% three times weekly by all
household members also reduces transmission by decreasing the shedding of
spores.69 Oral glucocorticoids may reduce the incidence of scarring
associated with markedly inflammatory varieties of tinea capitis. Although
there is no consistent evidence for improved cure rates with use of oral
glucocorticoids, they appear to relieve pain
and swelling associated with infections. The usual regimen prednisone is 12
mg/kg each morning during the first week of
therapy.

TOPICAL THERAPY.
In those patients with distal nail involvement and/or contraindication for
systemic treatment, topical therapy should be considered. Ciclopirox 8%
lacquer applied daily for 48 weeks achieved mycologic cure in 29%36% of
cases and clear nails (clinical cure) in 7% of mild to moderate cases of
onychomycosis caused by dermatophytes.77 Despite its much lower efficacy
compared with oral antifungal agents, use of topical ciclopirox avoids risk of
drug interactions. Amorolfine 5% applied twice weekly is another agent
specifically prepared for use as a nail lacquer. It is the first member of a new
class of antifungal drugs, the morpholine derivatives, which show activity
against yeasts, dermatophytes and molds that cause onychomycosis.
Amorolfine may have higher mycologic cure rates (38%54% after 6 months
of treatment) compared to ciclopirox lacquer; however, prospective
controlled trials validating a significant difference are needed.78

SYSTEMIC THERAPY.
An oral antifungal is required for onychomycosis involving the matrix area, or
when a shorter treatment regimen or higher chance for clearance or cure is
desired. Selection of the antifungal agent should be based primarily on the
causative organism, the potential adverse effects, and the risk of drug
interactions in any particular patient. Terbinafine is fungistatic and fungicidal
against dermatophytes, Aspergillus, and less so against Scopulariopsis.
Terbinafine is not recommended for candida onychomycosis since it
demonstrates variable efficacy against Candida species. A course of
terbinafine 250 mg daily for 6 weeks is effective for most fingernail infections,
while a minimum 12-week course1216 is required for toenail infections.
Most adverse effects are gastrointestinal such as diarrhea, nausea, taste
disturbance, and elevation of liver enzymes. Evidence suggests that a 3-month
continuous regimen of terbinafine is the most effective oral treatment for
onychomycosis of the toenails available today.79 Clinical cure rates among
different studies are approximately 50%, although the success rate is lower in
patients over 65 years.80 Itraconazole is fungistatic against dermatophytes,
nondermatophyte molds and yeasts. Safe and effective schedules include
pulse dosing with itraconazole 400 mg daily for 1 week per month or a
continuous dose of 200 mg daily, both of which require 2 months or 2 pulses
of treatment for fingernails and at least 3 months or 3 pulses for toenails.73
Itraconazole is dosed by weight in children at 5 mg/kg/day.81 Elevated liver
enzymes occur in 0.3%5% of patients during therapy and return to normal
within 12 weeks of discontinuation. Although itraconazole has a broader
spectrum of activity than terbinafine, studies have shown a significantly lower
rate of cure (about 25% vs. 50%) and higher relapse rate (about 50% vs.
20%) with itraconazole compared with terbinafine.82,83 Fluconazole is
fungistatic against dermatophytes, some nondermatophyte molds, and
Candida. The usual regimen for fluconazole is 150300 mg once weekly for 3
12 months.73 Griseofulvin is no longer considered standard treatment for
onychomycosis because of its prolonged treatment course, potential for
adverse effects and drug interactions, and its relatively low cure rates.
Combination therapy regimens may have a higher clearance rate than either
oral or topical treatments alone. Oral terbinafine combined with amorolfine
nail lacquer was shown to result in clinical cure and negative mycology in
59% of patients compared to 45% of patients treated with oral terbinafine
alone.84 However, another study failed to show any additional benefit of
combining oral terbinafine with ciclopirox 8% solution.85

In vitro fungicidal activity demonstrated by thymol, camphor, menthol, and oil
of Eucalyptus citriodora86,87 offers the potential for additional therapeutic
strategies to treat onychomycosis. Thymol 4% prepared in ethanol may be
used as drops
applied to the nail plate and hyponychium. The application to nails of
commercially available topical preparations with thymol, such as Vicks
VapoRub, has anecdotally led to success. Final options for refractory cases
include surgical avulsion or chemical removal of the nail with 40% urea
compounds in combination with topical or oral antifungals.