The Journal of Dermatology Vol.

30: 898903, 2003

Tinea Barbae (Tinea Sycosis): Experience with Nine Cases

Alexandro Bonifaz, Teresa Ramrez-Tamayo and Amado Sal
Abstract Tinea barbae is a rare dermatophytosis that affects the hair and hair follicles of the beard and mustache. This paper presents 9 cases of tinea barbae observed over an 18-year period of time and classified as follows: 1 was superficial and 8 were deep (6 folliculitis-like and 2 kerion-like). Most of the cases (4) were associated with topical steroid therapy, others with pet contact (3 cases) and one with diabetes. The causal agents isolated were: Trichophyton rubrum in 3; Microsporum canis in 3; Trichophyton mentagrophytes in 2; and Trichophyton tonsurans in one. The involvement of the hair was observed and classified in all cases. The trichophytin skin reaction was positive in all 9 patients. All the patients were treated with systemic antimycotics, 3 cases with griseofulvin, 1 with ketoconazole, 3 with itraconazole, and 2 with terbinafine. Clinical and mycologic cures were achieved at 6 to 8 weeks of treatment at the usual doses. Key words: dermatophytes; folliculitis; kerion; tinea barbae; tinea sycosis

Introduction Tinea barbae, also called tinea sycosis, is a mycosis usually caused by zoophilic and anthropophilic dermatophytes. The infection is more common in rural areas, and usually involves the hair and hair follicles of the beard and mustache. It is an exceptional tinea, limited only to adult males, and occurs in two modalities: mild superficial, very similar to the common tinea, and deep, which typically causes pustular folliculitis or severe kerion-like inflammation (13). This paper reports our clinical, mycologic and therapeutic experience with nine cases. Materials and Methods
The study included cases of clinically and mycologically proven tinea barbae who presented
Received January 30, 2003; accepted for publication August 5, 2003. Dermatology Service and Micology Department, General Hospital of Mexico, Dr. Balmis 148, col Doctores CP 06720, Mxico D.F., Mexico. Reprint requests to: Dr. A. Bonifaz, Zempoala 60101, Narvarte, CP 03020, Mxico D.F., Mexico.

at the Dermatology Service, General Hospital of Mexico during the period from January 1983 to December 2001. A mycologic work-up of the hair and skin scales was performed in all patients, and consisted of: direct KOH examinations to observe fungal elements and classify the type of hair parasite; cultures in the usual Sabouraud dextrose agar (SDA) and Mycosel agar; fluorescence detection with Woods light, biopsies (H & E and PAS stains) and skin reaction to trichophytin. The latter was performed using the same criteria as PPD, that is, reading was done at 48 hours; the test was positive when induration and erythema were >0.5 cm and was considered as hyperergic in cases >2 cm. Once tinea barbae was proven, treatment with systemic antifungal agents was instituted. Patients were seen periodically for follow-up and mycologic tests until treatment was completed; a final follow-up visit was scheduled two months after completion of treatment.

Results The study included 9 cases. Table 1 summarizes most of demographic data, clinical patterns and predisposing factors. Clinically,

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Table 1.Demographic data Age range Mean age Clinical variety 19 to 57 years 38.8 years Folliculitis-like (tinea sycosis) Kerion-like Superficial Beard Beard + Mustache Steroid treatment Animal contact (2 due to cats and 1 by rabbit) Tinea capitis of son Diabetes None 6 cases 2 cases 1 case 6 cases 2 cases (only 1 bilateral) 4 cases 3 cases 1 case 1 case 1 case

Clinical topography

Predisposing factor

Table 2.Mycologic and immunological data Etiology Trichophyton rubrum Trichophyton mentagrophytes Trichophyton tonsurans Microsporum canis Microsporia (M. canis) Microide (T. mentagrophytes) Endothrix: (T. tonsurans) Endothrix: hyphae + few spores (T. rubrum) Green fluorescence (M. canis) Hiperergic response. Indurations >2 cm (strongly positive) Normergic response. Indurations 0.5 to 1 cm (positive) Acute inflamatory granulomatous process 3 cases 2 cases 1 case 3 cases 3 cases 2 cases 1 case 3 cases 3 cases 2 cases 7 cases 1 case

Hair involvement

Woods light Trichophytin (Skin test) Biopsy

8/9 cases were unilateral; in 6 of them the disease involved only the beard area and in 2 it also affected the mustache. Symptoms were itching and pain in 6 cases and only itching, in 2; one case did not report any symptoms. As to the probable predisposing factors, the irregular use of topical steroids was proven in 4 cases. Three cases reported constant contact with pets, in which the causal agent was also isolated: 2 cats (Microsporum canis) and one rabbit (Trichophyton mentagrophytes); in these cases, the etiologic agents were isolated respectively from the pets. One case was also associated with the

use of topical steroids. One more case was associated with tinea capitis from his own child, caused by Trichophyton tonsurans . In two patients the same causal agent was isolated (Trichophyton rubrum) as the cause of both the tinea pedis and onychomycosis. Skin biopsy was performed in only one case of the folliculitis-like variety; the report was the following: Acute inflammatory granulomatous process with parakeratosis, perivascular lymphocytic infiltrate in superficial dermis, perifolliculitis and numerous giant cells. PAS stain showed hairs with numerous mycotic elements (spores and/or fila-

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Fig. 1. Pustular folliculitis (kerion-type) due to T. rubrum

Fig. 2. Tinea barbae (affecting beard and mustache) due to M. canis

ments). As to the etiology, T. rubrum and M. canis were isolated in 3 cases; T. mentagrophytes in 2 cases; and T. tonsurans in one case. In all cases, the type of hair infection was classified by direct examination (KOH), which showed three types of hair invasion: microsporia with small spores; microide with large spores and few hyphae, and one endothrix with hyphae and small spores. The correlation with causal agents is illustrated in Table 2. Response to skin reaction with trichophytin was positive in 7/9 patients; it was normergic (positive) in 5 cases, and hyperergic (strongly positive) in others cases. The latter corresponded to the inflammatory varieties of the kerion-type, one caused by M. canis and another one by T. mentagrophytes (Figs. 1 and 2). As for treatment, only systemic antifungal varieties agents were administered as follows: 3 cases were treated with griseofulvin; 1 case with ketoconazole; 3 cases with itraconazole; and 2 with terbinafine. The following treatment schedules were used: griseofulvin 500 mg/day for 8 weeks; ketoconazole 200 mg/day for 8 weeks; itraconazole 200 mg/day for 6 weeks, and terbinafine 250 mg/day for 6 weeks. A systemic analgesic (ibuprofen) was added in only one case. All the patients had clinical

and mycologic cure. A follow-up visit was scheduled two months after completion of treatment. Discussion Tinea barbae, tinea sycosis or, as it is commonly known, barbers itch, is an exceptional dermatophytosis. A little over 150 cases had been reported in the literature by 1990 (4, 5). The low frequency of this disease may be explained by its similarity to tinea capitis, in the sense that only a few cases occur after puberty, due to the protection that fatty acids provide to the hair and hair follicle. The disease became most frequent in the 60s, probably due to the increased use of topical steroids. Most reports in the literature are isolated cases or small case series over long periods of time. The Portuguese report by De Lacerda et al. (6) is interesting, because the authors report a series of 42 cases over a seven-year period. They included a diversity of clinical varieties, causal agents, and treatment approaches. This is undoubtedly the report comprising the largest number of cases. Tinea barbae may occur as two clinical presentations. The mild superficial one, which is pruriginous, is characterized by an erythemo-squamous plaque with active bor-

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ders and is indistinguishable from tinea of the face. However, it is important to stress that the latter always involves hair and hair follicles. The second variety, deep tinea, is folliculitis-like, characterized by erythematous plaques with marked pustular folliculitis and, in some cases, nodules and abscesses. There are some extraordinarily inflammatory cases that mimic tumors (7). Deep tinea barbae should be clinically differentiated from a series of clinical pictures that include the following major ones: folliculitis due to Staphylococcus aureus, carbuncle, furuncles, acne vulgaris, pseudofolliculitis, contact dermatitis and Candida folliculitis (1, 4, 8, 9). It is important to mention tinea barbae is an exceptional entity in Mexico; cases are rarely seen (1013) and this is the largest series reported. We ignore what causes such few cases but believe this can be due to the fact that our population is less bearded than Europeans and that sheep breeding and shearing is limited in our country. Regarding etiology, tinea barbae is thought to be caused by various dermatophytes. T. rubrum is predominant among the anthropophilic species. Even though this organism has little affinity for the hairy areas, it may invade the hair, especially in cortisone-related cases (13). Of the zoophilic species, one of the most frequently isolated fungi is Trichophyton verrucosum, especially in patients from rural areas. Other reported species include T. mentagrophytes and M. canis (14). Other dermatophytes reported include: Trichophyton megninii, Trichophyton violaceum, Trichophyton shoenleinii, Microsporum gypseum, and Epidermophyton floccosum (1, 6, 7, 12, 1519). In Mxico as in most other Latin-American countries (10, 11) where cases have been reported, the main etiologic factor is T. rubrum, never the less in this paper M. canis was the most seen, related to pet contact and use of steroids; likely, it is important to emphasize the case by T. tonsurans, very rarely reported in the literature (1, 14, 17). This was a direct father-son transmission where the father had a tinea

capitis caused by this dermatophyte. Tinea barbae is usually associated with various predisposing factors, among which the constant use of topical steroids is outstanding. In our study, 4/9 cases were associated with cortisone treatment. Many cases reported in the literature were individuals who workerd as farmers, shearers, shepherds, etc. As a result of this, zoophilic dermatophytes like T. verrucosum were detected, particularly in individuals who milk cows (6, 8). Pet contact may also produce infection. In our study, the causal agents were isolated from pets in three cases: one rabbit (T. mentagrophytes) and two cats (M. canis). It was surprising to see that these animals had no apparent clinical lesions, but Rippon (1) has already reported that these dermatophytes may be part of the usual flora. There was one case of T. tonsurans infection that was also isolated from a patients child with tinea; this probably occurred through inoculation. Similar cases have been reported in the literature by various authors, including Kick et al. (15). The disease is also thought to also be caused by a focus of tinea pedis and/or tinea unguium, especially in T. rubrum cases (16). This paper contributes the following valuable information: clinically speaking, it is important to emphasize the main clinical variant is the folliculitis type, that resembles bacterial folliculitis, a much more frequent disease with which differential diagnosis must be made; regarding predisposing factors, most cases are associated with the use of topical steroids, and contact with pets; this has not been frequently reported in the literature. A thorough mycologic work-up is the best way to make the diagnosis, especially through the observation and classification of hair involvement, because this allows us to simply and quickly confirm the diagnosis. Fluorescence detection with Woods lamp is not very useful, it is only possible in cases of infestation by microsporia (M. canis), and most cases are of endothrix invasion (1). It is important to mention that in some cases

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Fig. 3. Tinea barbae due to T. mentagrophytes. a) Baseline, b) After treatment with terbinafine

the diagnosis is histopathological, as in our case in which skin biopsy reported an acute granulomatous process with numerous giant cells, with a highlight of mycological elements (spores and filaments) seen in the PAS stain. It is important to note this histological image is almost indistinguishable from inflammatory tinea capitis (kerionlike) and that it is similar to both clinical variants of tinea barbae (foliculitis-like and kerion-like). The assignment of drug therapy differed chronologically, that is, the first cases were treated with griseofulvin (1, 6, 13, 17, 18), the following ones with ketoconazole, and the last ones with itraconazole (4) and terbinafine (5). Each of these drugs was used in several cases. Because the infection occurs at the level of the hair follicles, systemic therapy is always necessary (Fig. 3). Treatment with the most recent drugs is only one-month long, since both are considered as reservoir drugs, which means that minimum inhibitory dose remains for some time after the drug has been discontinued. We have not had any experience with flu-

conazole; however, its use has been reported at 200 mg/week doses for 6 to 12 weeks (8), or at 50 mg/day (15) for 6 weeks. Both regimens showed good therapeutic responses. This paper reports the use and experience of most oral antimycotic drugs (except fluconazole), although in a subjective manner, since all cases were seen in different periods of time; we saw the best clinical response was seen with itraconazole and terbinafine. In summary, we think that tinea barbae is an entity that, although rare, should be borne in mind, because frequent conditions like folliculitis, pseudofolliculitis and other diseases may present with clinically identical symptoms. In order to make the diagnosis, a mycologic study (KOH and cultures) is important, together with biopsies. Treatment should always consist of a systemic antifungal agent, preferably a triazole derivative (itraconazole and fluconazole) or an allylamine (terbinafine). References
1) Rippon JW: Tinea barbae, in: Medical Mycology, The Pathogenic Fungi and the Pathogenic Actino-

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mycetes, 3th ed, WB Saunders Co, Philadelphia, 1992, p 215. Drake LA, Dinehart SM, Farmer ER, et al: GuideLines of care superficial infections of the skin: tinea capitis and tinea barbae, J Am Acad Dermatol, 34: 290294, 1996. Greer DL: Dermatophytosis, in Jacobs PH, Nall L (eds): Antifungal Drug Therapy, A Complete Guide for the Practitioner, Marcel Dekker Co, New York, 1990, p 5. Yamamoto T, Sano T, Kato T, et al: A case of tinea barbae successfully treated with itraconazole, Jpn J Clin Dermatol, 44: 813815, 1990. Tanuma H, Doi M, Nishiyama S, et al: A case of tinea barbae treated with terbinafine, Mycoses, 41: 7781, 1998. De Lacerda MH, Caldeira JB, Delfino JP, et al: Sicose por fungos dermatofitos (tnha da barba). Anlise de 42 casos, Med Cut Ibero Lat Am, 9: 161 178, 1981. Borgo G, Sivolella S: Description of a severe and rare case of tinea barbae in the mental region, Minerva Stomatol, 48: 294298, 1999. Sabota J, Brodell R, Rutecki GW, et al: Severe tinea barbae due to Trichophyton verrucosum infection in dairy farmers, Clin Infect Dis, 23: 1008 1010, 1996. Kapdagli H, Ozturk G, Dereli T, et al: Candida follicullitis mimicking tinea barbae, Int J Dermatol, 36: 295297, 1997. Arenas R: Dermatofitosis, in: Micologa Mdica

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