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Tinea capitis: higher rates in low income communities in Ontario

Lower income children in parts of Ontario appear to have high rates of tinea capitis due to Trichophyton tonsurans (T. tonsurans) infection.

According to a group of physicians who practice in a lower income region of Toronto, this condition is not well treated in this population because of the discontinuation of one common drug, griseofulvin.

The therapies that are now covered under Ontario’s drug assistance plans have poor efficacy in this condition. Neither terbinafine nor itraconazole are included for coverage under the Ontario plans.

“In 2010, the production of griseofulvin, which is the main treatment for tinea capitis, was discontinued in Canada,” said Toronto dermatologist Dr. Jonathan Shapero. “Griseofulvin was the primary medication for tinea capitis that had coverage through the Ontario Works Program, as well as the Ontario Disability Support Program, and the Ontario Drug Benefit.”

Effective drugs not available

The drug currently covered by these plans for treating tinea capitis, ketoconazole, is not as effective as griseofulvin at treating one of the pathogens that can cause tinea capitis, T. tonsurans, and also is known to have both androgenic and hepatic side effects, Dr. Shapero said.

“The treatments that would be a reasonable alternative would be terbinafine or itraconazole, but the problem is that they are not covered by the [Ontario] government plans.”

Past studies have shown that individuals living in lower-income and more densely populated neighbourhoods are at higher risk of developing tinea capitis, said Dr. Shapero, who practices

in the Jane-Finch neighbourhood of Toronto. “Our community certainly has these characteristics.”

According to city of Toronto data, the Jane-Finch community had 24 to 28% of the population considered low income families. Additionally, it is a very dense neighbourhood with

approximately 60,000 people living in a relatively small area of the city.

Looking at the low-income patients in the practice he shares with his father, Dr. Howard Shapero, he determined that most of the cases of tinea capitis were due to T. tonsurans.

“We found that a very large proportion of our patients were unable to pay for the cost of treating tinea capitis. The problem with not treating the tinea capitis is that the particular type that tends to occur in black children is caused by the fungus Trichophyton tonsurans. This fungus, when it affects the scalp, has a high likelihood of causing permanent scarring of the

scalp. if left untreated, you can see very large areas of the scalp that will be permanently scarred for the remainder of that child’s life.”

Dr. Shapero and two colleagues surveyed 14 family physicians practicing in the Jane-Finch neighbourhood regarding their experiences treating tinea capitis in that community. Their

“The estimates from the community family physicians revealed a median of 40 to 50 per cent of their patients with tinea capitis struggle to pay for their treatment,” said Dr. Shapero. “To

give this [data] context, each family physician in the Jane-Finch community estimates on average that they see about 30 new cases of tinea capitis per year. Also, they estimate that scarring and kerion formation are seen about 16 times per year per practice.”

A total of 71% of the surveyed physicians said that drug costs were impeding their ability to treat tinea capitis in their practices, and 100% said they thought a limited-use code for oral antifungals would have a positive impact on their patients.

National differences in drug coverage

“We conducted this study to capture real data from the family physicians of the community so that we could assess the need for assistance in these families in paying for the medication,

and advocate for these families for the development of a limited use code, which would allow for coverage of systemic antifungals for children who are on welfare,” said Dr. Shapero.

Coverage of antifungals varies by province. As is the case in Ontario, terbinafine is not covered for tinea capitis by either B.C. Pharmacare or nova Scotia Pharmacare, for example.

In contrast, Dr. Loretta Fiorillo, divisional director of pediatric dermatology at the university of Alberta in Edmonton, said in an email to that her province’s drug plan reimburses for the drug. “Oral [terbinafine] is covered, as are topical antifungals. Inever had a problem with coverage with these products,” she said.

“[Tinea capitis] is a very common problem for the families in our community,” said Dr. Shapero. “Previous studies have shown that the psychosocial impact of scarring alopecia on young children can have a significant impact on that child’s social development, anxiety level, and self-esteem.”

Decisions on drug reimbursement will need to take into account the changing epidemiology of tinea capitis, however.

Speaking at the 2015 Dermatology update in Toronto last September, Dr. Danielle Marcoux

detailed how the types of tinea capitis pathogens encountered in her practice

changed from 2000 to 2015.

“In north America it has been described since the ’90s that the T. tonsurans coming from the south is the major dermatophyte. But in our area, we are seeing more and more M. audouinii in particular, but also some T. soudanense and T. violaceum,” said Dr. Marcoux, a clinical associate professor at the university of Montreal and Chu Sainte-Justine’s department of

pediatrics, division of dermatology.

Specifically, Dr. Marcoux and her colleagues have observed a six-fold increase in the percentage of cases of tinea capitis caused by M. audouinii. while T. tonsurans remains

the most common tinea capitis pathogen, the rise in cases of M. audouinii, mostly among immigrants from Africa, is something physicians should be aware of, she said.

This shift in epidemiology is significant to drug selection due to the differing susceptibility of the fungal types to different drugs. Dr. Marcoux said that 46% of patients with M.

audouinii experienced treatment failure with terbinafine.

“Oral griseofulvin or other oral azole agents are better treatment options for tinea capitis due to these [fungal varieties] or other African species,” said Dr. Marcoux.

Originally posted in The Chronicle of Skin & Allergy (Mar. 2015; 22(2):1,10)

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