Evaluation of Impact of Tinea Capitis on Quality of Life in Pediatric Patients Using Children's Dermatology Life Quality Index and Its Correlation with Disease Duration.

INTRODUCTION: The superficial fungal infection of the scalp caused by dermatophytes is called tinea capitis. It has a predilection for the pediatric age group. In developing countries like India factors such as overcrowding, inadequate hygiene, and low literacy rate contribute to its high incidence. AIMS AND
OBJECTIVE: This study aimed at identifying and grading the psychosocial impact of tinea capitis in children and correlating it with disease duration and socioeconomic status of patient's family.
MATERIALS AND METHODS: This was a cross-sectional study conducted in our skin outpatient department involving children aged 6-16 years with clinical diagnosis of tinea capitis. We used the children's dermatology life quality index (CDLQI) instrument to observe the psychological implications in these children.
RESULTS: The study included 134 patients, with a mean CDLQI score of 6.01 ± 4.17. There was a male preponderance in our study with 112 (68.3%) male patients and 52 (31.7%) female patients. The age group affected most commonly was 6-8 years (37.8%). The domains affected most severely were symptoms and feelings (Q1 and Q2) followed by sleep (Q 9). The psychological implications were higher in patients suffering from kerion, older children, and female patients. There was a statistically significant correlation between the impact on quality of life (QOL) and disease duration as well as disease severity; however, no correlation could be made between QOL and socioeconomic strata of family.
CONCLUSION: The study brings into question the overlooked psychological implications of tinea capitis which are often overlooked by the dermatologist and parents as a mere dermatological disease. Instead a holistic approach including a complete psychological evaluation of children and appropriate counseling of both patients and their parents must be done. Copyright:

INTRODUCTION

Cutaneous fungal infections are an ever rising entity. In developing countries, with the majority of people falling under low socioeconomic strata, factors such as overcrowding, inadequate hygiene, and low literacy contribute to these fungal infections.[1] Among the approximately 40 species of dermatophytes, around 6 are commonly attributed to tinea capitis.[2] The incidence of Tinea capitis in India varies from 0.5% to 10%[345] with Trichophyton tonsurans attributed to be the most common causative organism.[6]

Tinea capitis can have varied presentations ranging from a noninflammatory, scaly, subclinical variants like gray patch and black dot to inflammatory variants such as kerion and favus.[7] The unsightly appearance of this disease could have uncalled for psychological impact on children's quality of life (QOL).[891011]

Although various studies in the past have evaluated the clinicoepidemiological patterns and prevalence of tinea capitis in India,[71213] none so far have attempted to assess the impact of this ailment on the QOL and psychological implications on the tender mind of the children suffering from it in our country. This study aimed at identifying and grading the psychosocial impact of tinea capitis in children and correlating it with socioeconomic status of the patient's family.

MATERIALS AND METHODS

Ethical approvals

This study was initiated after taking a formal permission from Professor Andrew Y Finlay, Department of Dermatology, Cardiff University School of Medicine, Heath Park, Cardiff, UK, to use the validated Hindi version of Child DLQI questionnaire. In addition, the study was approved by the Institutional Ethical Committee. A written informed consent from the patients' parents and assent from the children was taken before enrolling them into the study.

Patients

This prospective, cross-section, noninterventional study was conducted in our skin-out patient department between September 2018 and September 2019. The study included 164 children age 6–16 years, clinically diagnosed with tinea capitis. The cases were diagnosed on the basis of the presence of scalp lesion including scales, crusts, follicular inflammation with erythema, with/without alopecia. All new cases clinically diagnosed with tinea capitis such as kerion, favus, black dot, and gray patch were included. In addition, confirmation of diagnosis was done by KOH examination, mycological culture, and dermoscopic analysis. Immunocompromised patients and those with concurrent dermatophytic infection of any site apart from scalp were excluded from the study.

The evaluation of disease severity was done on the basis of following clinical parameters: pruritus, erythema, presence of pustules, crusts, and scales on a 4-point scale: 0 = absent, 1 = mild, 2 = moderate, and 3 = severe. The sum total of all the parameters was averaged to grade the severity of disease.

A thorough history taking in the form of age, sex, involved sites, type of lesions, and severity of disease was done.

Children's dermatology life quality index questionnaire

The children's dermatology life quality index (CDLQI) questionnaire was interviewer-administered which consisted of 10 questions. Each question had a maximum score of 3. The following possible scores existed for each question: 0 - not at all or not relevant or unanswered, 1 - a little, 2 - a lot, and 3 - very much or prevented work or studying. The maximum score for DLQI was 30, denoting the maximum negative impact on skin-related QOL. The following severity bands for CDLQI scores were considered: 0–5 “no psychosocial impact,” while those scoring ≥6 were considered to have a “psychosocial impact.”[14] This psychological impact was further categorized as mild (6–10), moderate (11–20), and severe (21–30). The patients responded to each of the 10 questions administered by the interviewer under parents' assistance. The questions were divided into the following subgroups: Q 1–2 symptoms and feelings; Q 4,5,6-leisure; Q 7 school; Q 3 and Q 8 personal relationships; Q 9 sleep; and Q 10 treatment.

Statistical analysis

The statistical analysis of the data was done using SPSS version 20.0, Armonk, NY: IBM Corp. Mean and standard deviation were calculated to find the distribution of the continuous numbers while proportion or percentages were used for qualitative variables. R value was calculated wherever required and P < 0.05 was considered statistically significant.

RESULTS

A total of 164 children aged 6–16 years with a clinical diagnosis of tinea capitis completed the study. Various patterns of tinea capitis seen were: black dot (54.3%; n = 89) [Figure 1a], gray patch (32.3%; n = 53) [Figure 2a], and kerion (13.4%; n = 22) [Figure 3a]. Apart from clinical diagnosis, other confirmatory methods of diagnosis included culture (positive in 32.9%; n = 54) [Figures 1b, 2b and 3b] KOH (positive in 40.8%; n = 67) [Figures 1d, 2d and 3d], and peculiar dermoscopic findings (seen in 56.7%; n = 93) [Figures 1c, 2c and 3c]. However, none of the patients showed fluorescence on woods lamp examination.

Figure 1

Black dot tinea capitis (a) clinical image, (b) positive culture, (c) characteristic dermoscopy showing black dots (red arrow) and short broken hair (yellow arrow), (d) KOH mount showing endothrix

Figure 2

Gray patch tinea capitis (a) clinical image, (b) positive culture, (c) characteristic dermoscopy showing comma hair (green arrow) and cork screw hair (red arrow) along with some perifollicular and interfollicular scaling, (d) KOH mount showing ectothrix

Figure 3

Kerion inflammatory tinea (a) clinical image with secondary infection, (b) positive culture, (c) dermoscopy showing perifollicular scaling, hemorrhage, and diffuse yellowish structure-less area depicting pustular lesions, (d) KOH mount showing branch like tubular fungal hyphae

The mean age of patients was 7.4 ± 5.4 years. There was a male preponderance in our study with 112 (68.3%) male patients and 52 (31.7%) female patients. The age group affected most commonly was 6–8 years (37.8%, n = 62), followed by 10–12 years (34.8%, n = 57) [Figure 4].

Figure 4

Age distribution of the study participants

The average duration of illness was 2.6 ± 1.9 months (range 2 weeks–8 months).

The mean CDLQI score of the study subjects was 6.01 ± 4.17 implying a mild impact on QOL. While 85 (51.8%) children had a score between 0 and 5 (no impact), 79 (48.2%) had a score of ≥6 in CDLQI. These 79 pupils were identified as having a psychological impact on QOL. This impact was further graded as mild in 59.5% (n = 47), moderate in 35.4% (n = 28), and severe in 5.1% (n = 4) patients [Table 1 and Figure 5].

Table 1

Children dermatology life quality index distribution of study subjects

CDLQI score	Impact on QOL	Number of patients (%) (n=164; 100%)
0-5	No effect	85 (51.8)
6-10	Mild	47 (28.7)
11-20	Moderate	28 (17.1)
21-30	Severe	4 (2.4)

CDLQI – Children dermatology life quality index; QOL – Quality of life

Figure 5

Age distribution of patients having impact on QOL due to tinea capitis

In our study, female pupil showed a higher impact on QOL (59.6%; n = 31 out of 52 females) than male pupil (42.9%; n = 48 out of 112 males) (P = 0.043) [Table 2]. Furthermore, female children suffering from tinea capitis were 2.04 times more likely to have psychological impact than male children (odds ratio 2.04; confidence interval of 95% between 1.04 and 3.98). Meanwhile, older children had a higher impact on QOL compared to younger ones (Y2 value = 8.94; P = 0.03). Of the 79 patients who had a negative impact on their QOL, while comparing the 3 different morphological types, we found that patients suffering from kerion had a significantly higher DLQI score (14.1 ± 7.4) compared to black dot (10.1 ± 4.1) and grey patch (10.3 ± 3.9) (kerion vs. black dot, P = 0.02; kerion vs. grey patch, P = 0.04).

Table 2

Differences in children dermatology life quality index score according to gender

Gender	Number of patients (%)
	CDLQI score <6 (no impact)	CLDQI score ≥6 (impact on QOL)
Male (n=112), n (%)	64 (57.1)	48 (42.9)
Female (n=52), n (%)	21 (40.4)	31 (59.6)

CDLQI – Children dermatology life quality index; QOL – Quality of life

There was a positive correlation between disease severity and impact on QOL. The mean CDLQI of patients with mild, moderate, and severe disease was 4.32 ± 3.65, 5.97 ± 4.73, and 8.82 ± 9.37, respectively [Table 3 and Figure 6].

Table 3

Correlation between disease severity and impact on quality of life

Disease severity (number of patients)	Total number of patients	Mean CDLQI±SD	Patients with CLDQI score ≥6 (impact on QOL)	Mean CDLQI±SD
Mild (59)	59	4.32±3.65	30	8.37±4.17
Moderate (71)	71	5.97±4.73	35	11.91±5.38
Severe (34)	34	8.82±9.37	14	13.35±8.14

CDLQI – Children dermatology life quality index; QOL – Quality of life; SD – Standard deviation

Figure 6

Correlation graph between disease severity and children's dermatology life quality index score

The domain affected most severely was of symptoms and feelings (Q 1 and Q 2) followed by the domain of sleep (Q 9) [Table 4]. There was a strongly positive correlation between the duration of illness and CDLQI score (r = 0.34; P = 0.0017) [Figure 7].

Table 4

Mean dermatology life quality index score per domain

Domains	DLQI score (mean±SD)
Symptoms and feelings (question 1 and 2)	2.65±1.78
Leisure (question 4, 5 and 6)	0.76±1.97
School time (question 7)	0.91±0.44
Relations with friends and being teased/bullied (question 3 and 8)	0.68±1.36
Child’s sleep (question 9)	0.97±0.52
Burden of treatment (question 10)	0.04±0.17
Total score	6.01±4.17

DLQI – Dermatology life quality index; SD – Standard deviation

Figure 7

Correlation graph of disease duration with children's dermatology life quality index score (presence of a positive linear correlation depicted by the red line; r = 0.34; P = 0.0017

Majority of affected children belonged to rural background (62.2%; n = 102). Of all the cases, more than half (53.1%, n = 87) belonged to lowest two strata of socioeconomic scale (SES) [Table 5]. However, on statistical analysis, there was no correlation between CDLQI score and SES (r = 0.06, P = 0.43).

Table 5

Socioeconomic distribution of patients’ families

Socioeconomic class	Rural; n=102 (modified BG Prasad SES 2019)[15]	Socioeconomic class	Urban; n=62 (modified Kuppuswamy’s SES 2019)[16]
Upper	5	Upper	11
Upper middle	21	Upper middle	12
Middle	19	Lower middle	19
Lower middle	34	Upper lower	8
Lower	23	Lower	12

SES – Socioeconomic status

DISCUSSION

In our study, around half of the pupils (48.2%) had a score of ≥6 in CDLQI and as an extrapolation, a psychological impact on QOL owing to tinea capitis. Our findings were in agreement with the two studies conducted on the same subject in Nigeria by Fienemika and Okeafor[17] and Akinboro et al.[18] Contrary to the study conducted by Fienemika and Okeafor[17] we found a significant correlation between the age of the child and the presence of a psychosocial impact with older children having a higher impact on QOL.

Such high psychological impact on children could also be attributed in part to the westernization which overstates the importance of external physical features. In fact, this could also explain a higher impact on QOL in older age group of children as they experience greater exposure to westernized media and live under peer pressure. Therefore, children affected with tinea capitis may feel ashamed and abashed owing to the unsightly appearance of their scalp.

Another interesting finding of our study, the presence of psychological upset with a female preponderance, was similar to the observation of various other studies.[1718] These findings are pretty obvious since both female children and adults tend to be more concerned about the appearance of their bodies. In our society, most females are taught from a very young age to keep their hair long. Since tinea capitis could also result in alopecia or sometimes require trimming of hair in inflammatory cases, this might be unacceptable to the child.[1718] We also observed that patients with the inflammatory variant kerion had a higher impact on QOL compared to the noninflammatory variants (gray patch and black dot).

On a detailed analysis of the CDLQI score, we observed that the children were affected the most due to the itching and pain (in case of inflammation). The second most adversely affected was the domain of sleep. The affected children also agreed to being truant from school more often (77 children), avoiding daily outdoor activities (82 children), and feeling like social out casts at times (16 children). There was a positive correlation between disease severity and impact on QOL [Table 3].

Children with a longer duration on illness or those with recurrent or inflamed tinea capitis had a much higher impact on QOL [Figure 7]. Factors contributing to this were not seeking medical treatment on time, incomplete treatment, inappropriate application of topical irritants (in 14 patients), and reinfection, to name a few. Other factors which may contribute to chronicity in tinea capitis are drug resistance, poor compliance and steroid abuse. In the past, various studies have described psychological disturbances in children affected with dermatological diseases, ranging from anxiety and depression to antisocial behavior and delinquent tendencies.[19] The pruritus, alopecia, scaling, and oozing in infected cases could account for the unsightly appearance and lead to social stigmatization for the child.[9]

In addition, some of the parents also admitted that they would not let the child's siblings/cousins play or sleep with the affected child as they were afraid the disease would get transmitted to other kids. The results of our study, coupled with those of the other similar studies mentioned above, call on the necessity to ensure the psychological wellbeing of children affected with tinea capitis.

Dermatophytes causing fluorescence on Wood's lamp are usually members of the Microsporum genus and only one member of the Trichophyton genus, namely Trichphyton schoenleinii. However, the most prevalent species responsible for black dot, grey patch aswell as favus in our side of the country are Trichophyton violaceous, Trichophyton rubrum, and Trichophyton metagrophytes, all nonfluorescent species.[202122232425] The absence of Wood's lamp fluorescence observed in our patients could be attributed to this geographic variation in species' distribution. In addition, most cases of kerion are also nonflourescence owing to the fact that secondary inflammation obscured the fungus.

Some of the limitations of our study were a small sample size, the absence of a disease-specific QOL indexing and, absence of a control group to assess the differences in psychological status of children unaffected with tinea capitis. Another limitation of our study was exclusion of children presenting with other dermatophytic infections. There is still a dearth of clinical data on the psychological implications of dermatophytic infections in pediatric population and we suggest that larger controlled studies are needed to explore the same.

CONCLUSION

This study brings into question the overlooked psychological implications of tinea capitis, especially in chronic and inadequately treated cases, which is often overlooked by the dermatologist and parents as a mere dermatological disease. The management of such children must, therefore, not be limited simply to the management of skin ailment. Instead, a holistic approach including a complete psychological evaluation of children and appropriate counseling of both patients and their parents must be done.[262728]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.