Rectal fluconazole for tinea capitis

Abstract

The present report describes a case of tinea capitis in a boy with autistic spectrum disorder and an aversion to oral medications. He refused weekly oral fluconazole and there was a poor response to daily rectal griseofulvin. He tolerated once-weekly rectal fluconazole (10 mg/kg) well and there was an excellent clinical outcome.

CASE PRESENTATION

A five-year-old boy developed scaly scalp lesions associated with alopecia. His older brother had first developed very similar lesions, which, after scraping, were found to be tinea capitis; the lesions resolved after one course of oral griseofulvin. The dermatologist who diagnosed the infection in the brother made the presumptive diagnosis of tinea capitis in the case patient and recommended a course of griseofulvin for him as well.

However, the patient has an autistic spectrum disorder and a significant aversion to oral medications. His mother believed that it would be too difficult to give him a daily oral medication and so he was started on griseofulvin 200 mg per rectum, twice daily. After two months, without significant improvement, his dose was increased to 200 mg per rectum, three times daily. However, his scalp lesions persisted, and he was referred to the Infectious Disease Clinic at the Children’s Hospital of Eastern Ontario, Ottawa, Ontario.

The patient had no constitutional symptoms, other rashes or any other significant medical issues. On examination, he had multiple small circular whitish lesions on his scalp with associated alopecia; the areas of alopecia had a ‘black dot’ appearance, with many broken-off hairs visible. The remaining physical examination was unremarkable.

The patient’s presentation was in keeping with the diagnosis of tinea capitis, and a course of oral weekly fluconazole was recommended. His mother was certain he would refuse a liquid medication, so the tablets were crushed and hidden in his favourite foods. Unfortunately, this strategy failed because he was able to detect the crushed tablet particles even when mixed in ice cream and pudding. Two weeks later, he was seen by a different dermatologist, who suggested stopping the fluconazole and starting oral daily griseofulvin, along with ciclopirox-containing shampoo (1.5%) and topical ketoconazole. Unsurprisingly, the daily oral griseofulvin was not better received than the weekly oral fluconazole, and no improvement resulted. He was seen in the Infectious Disease Clinic one month later for follow-up and, at that point, a course of rectal fluconazole 10 mg/kg (200 mg pulverized tablet in a polyethylene glycol base) once weekly was recommended. The administration of ketoconazole was stopped but antifungal shampoo was continued. He tolerated this regimen well and the lesions steadily improved, with complete resolution after eight weeks of treatment. He was seen four weeks after the end of antifungal therapy, and no recurrence of the infection was detected.

DISCUSSION

Fluconazole has been shown to be an acceptable alternative to griseofulvin or terbinafine for the treatment of tinea capitis, a very common childhood infection. It is important for clinicians to be familiar with this evidence, because griseofulvin is no longer readily available in Canada (it is only marketed now as a veterinary product). A recent Cochrane review (1) showed that both daily fluconazole and daily griseofulvin effected similar complete (clinical plus microbiological) cure rates (total n=140, RR 0.92 [95% CI 0.8 to 1.05]), with fewer side effects in the fluconazole groups; most of the children in the two studies had Trichophyton infections. Another study (2) compared daily fluconazole and daily terbinafine, and found no significant difference in complete cure, although the trend favoured terbinafine (RR 0.87 [95% CI 0.75 to 1.01]). Once-weekly dosing is substantially more convenient, and eight- to 12-week courses have been shown in uncontrolled studies to have a high complete cure rate for unselected tinea capitis (3), although the efficacy has been questioned in known Microsporum infection (4). We suggested trying fluconazole before a course of systemic terbinafine for this particular patient, because his mother believed that he would not tolerate a daily oral medication and because fluconazole has a more favourable side effect profile. It is certainly possible that the topical ciclopirox contributed to the favourable outcome, although no significant response was observed in the four weeks before starting the rectal fluconazole.

Although the popularity of rectally administered medications in unselected paediatric populations is likely to be low, there is a population of children that may prefer rectal dosing to oral dosing. The prevalence of all pervasive developmental disorders is approximately 0.6% (5), and many of these children will have difficulties with pill-swallowing. Some of these children could be trained to take oral medications more readily (6), but many practitioners may not have the time or resources to arrange such training. In these instances, if the child is willing, medication per rectum may be the more expedient course.

Because fluconazole is effective when administered once weekly, it would seem ideally suited for the treatment of dermatophyte infections in such children. To our knowledge, the present case is the first report regarding the use of rectal fluconazole for the treatment of tinea capitis; there are very few reports on the use of rectal fluconazole (7,8). Tinea capitis is a very common problem, and we are certain that this regimen will be the most convenient method of treatment for many.