Dermatology: Practical and Conceptual


Research Letter | Dermatol Pract Concept. 2024;14(3):e2024158 1

Monitoring the Treatment of Tinea Capitis With 
Trichoscopy - Are There Signs of Trichoscopic Cure?

Theodosia Gkentsidi1, Konstantinos Kampouridis2, Katerina Bakirtzi1,  
Angeliki Panagopoulou1, Aimilios Lallas1, Eleni Sotiriou1

1 1st Dermatology Department, Medical School of Aristotle University of Thessaloniki, Hospital of Skin and Venereal Diseases, Thessaloniki, 

Greece

2 Mycological Laboratory,1st Dermatology Department, Medical School of Aristotle University of Thessaloniki, Hospital of Skin and 

Venereal Diseases, Thessaloniki, Greece

Key words: trichoscopy, trichoscopic cure, dermoscopy, treatment, Tinea Capitis

Citation: Gkentsidi T, Kampouridis K, Bakirtzi K, Panagopoulou A, Lallas A, Sotiriou E. Monitoring the Treatment of Tinea Capitis With 
Trichoscopy - Are There Signs of Trichoscopic Cure? Dermatol Pract Concept. 2024;14(3):e2024158. DOI: https://doi.org/10.5826/
dpc.1403a158

Accepted: March 4, 2024; Published: July2024

Copyright: ©2024 Gkentsidi et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, 
distribution, and reproduction in any medium, provided the original authors and source are credited.

Funding: None.

Competing Interests: None.

Authorship: All authors have contributed significantly to this publication.

Corresponding Author: Theodosia Gkentsidi, 124 Delfon Street, Thessaloniki 54643, Greece, tel. 00302313308860,  
Email: tgkentsidi@gmail.com

Introduction

Tinea Capitis (TC) is a dermatophytic infection of the hair 

whose diagnosis is based on clinical examination and di-

rect microscopy and is established with fungal culture [1]. 

Nonetheless,direct microscopy is not always available in 

daily clinical practice and fungal culture is a time-consuming 

process. Several trichoscopic features have been associated 

with TC, such as comma, corkscrew, zig-zag, morse-code and 

broken hairs, black dots and scaling [2-4]. However, scarce 

evidence exists on whether the persistence or disappearance 

of these findings reliably predict the final result of the fungal 

culture in TC treatment monitoring [5,6].

Case Presentation

The aim of this prospective clinical study is to investi-

gate which trichoscopic criteria predict the persistence or 

resolution of TC after treatment and assess whether trichos-

copy can be used to confirm a definite cure, without requir-

ing a culture. Inclusion criteria were the presence of clinical 

and trichoscopic findings of TC and positive direct micros-

copy and fungal culture. Trichoscopic images were captured 

at baseline and in every sequential visit using a camera 

with an attached dermoscopic lens (DermLite photosystem, 

3Gen) at 10-fold magnification (Figure 1). Patients were 

evaluated trichoscopically and mycologically at baseline 

and subsequently every four weeks until negative mycologi-

cal examination was attained. All patients received itracon-

azole or terbinafine and topically isoconazole cream and 

ketoconazole shampoo until negative culture was achieved. 

When clinical presentation was highly suggestive of TC and 

direct microscopy was positive, systematic treatment was 

initiated right away, before the results of the fungal culture. 

The trichoscopic images were evaluated by 2 independent 

investigators, blinded to the result of the culture. A third 



2 Research Letter | Dermatol Pract Concept. 2024;14(3):e2024158

investigator was involved in case of disagreement. The evalu-

ated criteria included comma, corkscrew, zig-zag, morse-code 

and broken hairs, black dots, erythema and scaling. Sensitiv-

ity (%), specificity (%), positive predictive value (PPV; %) 

and negative predictive value-(NPV; %) were calculated for 

each trichoscopic criterion, using the result of the fungal 

culture as reference. Overall, 23 patients with a mean age 

of 14.6 years (range: 5-32) were included in the study. The 

most commonly isolated dermatophyte was Microsporum 

canis (61.0%) followed by Trichophyton mentagrophytes 

(26.0%) and Trichophyton tonsurans (13.0%), optimally 

corresponding to the result of direct examination (61% ec-

toparasitic and 39% endoparasitic infection). The results of 

the dermoscopic examinations at baseline and follow up vis-

its are shown in Figure 2. Table 1 shows the sensitivity, speci-

ficity, PPV and NPV of each dermoscopic criterion to predict 

the result of the fungal culture. The features with the highest 

sensitivity were erythema (95.45%), black dots (93.94%) 

and broken hairs (87.88%), indicating that these features are 

usually present when the culture was positive. Comma, cork-

screw, zig-zag, morse-code and broken hairs had a 100% 

PPV, suggesting that the trichoscopic persistence of these fea-

tures in the follow up during treatment is highly predictive 

of positive fungal culture and should warrant treatment con-

tinuation. The features with the highest NPV were broken 

hairs (89.74%), erythema (88.89%), black dots (88.24%) 

and morse-code hairs (85.19%). Therefore, the gradual reso-

lution of these features is highly suggestive of negative fungal 

culture and disease cure. Moreover, this study indicates that 

the dermatoscopic maintenance of black dots, erythema and 

scaling, because of their low specificity and moderate PPV, 

when observed with no other trichoscopic findings, are not 

sufficient to predict residual disease.

Limitations of our study are the relatively small size, the 

collection of fungal culture under systematic treatment and 

the fact that we included only Caucasian patients, which 

does not allow the generalization of our findings to other 

populations with different skin types.

Conclusions

In conclusion, our results indicate that trichoscopy can fa-

cilitate TC treatment monitoring and a “trichoscopic cure” 

might accurately predict a negative fungal culture.

Acknowledgements

The patients in this manuscript have given written inform 

consent to the publication of their case details.

Figure 1. Trichoscopic image of Tinea Capitis caused by Trichophyton tonsurans. (A) At baseline 

the trichoscopic findings are: black dots (blue arrow), comma and zig-zag hairs (green arrows), 

broken hairs and scaling. (B) At week 8, after two months of systematic treatment with terbinafin, 

direct examination and fungal culture are negative and the remaining trichcoscopic findings are 

black dots (blue errows) and mild scaling. (C) At week 12, one month after discontinuation of treat-

ment, direct examination and fungal culture are negative and trichoscopy reveals only black dots.



Research Letter | Dermatol Pract Concept. 2024;14(3):e2024158 3

References

1. Mayser P, Nenoff P, Reinel D, et al. S1 guidelines: Tinea capi-

tis. J Dtsch Dermatol Ges. 2020;18(2):161-179. DOI: 10.1111 

/ddg.14026. PMID: 32026639.

2. Slowinska M, Rudnicka L, Schwartz R, et al. Comma hairs: 

a dermatoscopic marker for tinea capitis: a rapid diagnos-

tic method. J Am Acad Dermatol. 2008 ;59(5 Suppl):S77-9.  

DOI: 10.1016/j.jaad.2008.07.009. PMID: 19119131.

3. Aqil N, BayBay H, Moustaide K, et al . A prospective study of 

tinea capitis in children: making the diagnosis easier with a der-

moscope. J Med Case Rep. 2018 28;12(1):383. DOI: 10.1186 

/s13256-018-1914-6. PMID: 30591075.

4. Elghblawi E. Idiosyncratic Findings in Trichoscopy of Tinea 

 Capitis: Comma, Zigzag Hairs, Corkscrew, and Morse Code-

like Hair. Int J Trichology. 2016 ;8(4):180-183. DOI: 10.4103/ijt 

.ijt_92_15. PMID: 28442876.

5. Campos S, Brasileiro A, Galhardas C, et al. Follow-up of tinea 

capitis with trichoscopy: a prospective clinical study. J Eur Acad 

Dermatol Venereol. 2017;31(11):e478-e480. DOI: 10.1111 

/jdv.14322. PMID: 28499060.

6. Kumar P, Pandhi D, Bhattacharya S, et al. Trichoscopy as a 

monitoring tool in assessing treatment response in 98 children  

with tinea capitis: A prospective clinical study. Dermatol-

Ther. 2021;34(4):e15010. DOI: 10.1111/dth.15010. PMID: 

34041831.

Figure 2. Results of The Dermoscopic Examinations at Baseline and Follow up Visits. At baseline, 

the percentage of Morse code hairs, typical of ectoparasitic infection (microspora), is higher than 

Corkscrew hairs which are associated with endoparasitic infection (trichophyta), in line with the 

results of the fungal cultures and direct examinations with KOH. Moreover, Morse code hairs seem 

to resolve later than Corkscrew hairs along the treatment timeline, indicating that ectoparasitic 

infections are more persistent. At week 12,when all fungal cultures are negative, the only remaining 

trichoscopic findings are scaling, erythema, and black dots.

Table 1. Statistical Results for Each Trichoscopic Feature After Treatment.

STATISTIC
COMMA 
HAIRS

CORKSCREW 
HAIRS

ZIG-ZAG 
HAIRS

MORSE-
CODE 
HAIRS

BLACK 
DOTS

BROKEN 
HAIRS ERYTHEMA SCALING

SENSITIVITY (%)
(95% CI)

47,62%
(25.71%-
70.22%)

38,46%
(13.86%-
68.42%)

33,33%
(7.49%-
70.07%)

80,95%
(58.09%-
94.55%)

93,94%
(79.77%-
99.26%)

87,88%
(71.80%-
96.60%)

95,45%
(77.16%-
99.88%)

86,67%
(69.28%-
96.24%)

SPECIFICITY (%)
(95% CI)

100%
(85.18%-
100.00%)

100%
(75.29%-
100.00%)

100%
(76.84%-
100.00%)

100%
(85.18%-
100.00%)

42,86%
(26.32%-
60.65%)

100%
(90.00%-
100.00%)

40%
(19.12%-
63.95%)

18,18%
(6.98%-
35.46%)

PPV (%)
(95% CI)

100%
(0.00%-
0.00%)

100%
(0.00%-
0.00%)

100%
(0.00%-
0.00%)

100%
(0.00%-
0.00%)

60,78%
(53.46%-
67.66%)

100%
(0.00%-
0.00%)

63,64%
(54.74%-
71.69%)

49,06%
(43.75%-
54.38%)

NPV (%)
(95% CI)

67,65%
(58.17%-
75.87%)

61,90%
(51.39%-
71.41%)

70%
(59.52%-
78.74%)

85,19%
(70.42%-
93.28%)

88,24%
(64.98%-
96.81%)

89,74%
(77.74%-
95.64%)

88,89%
(52.27%-
98.32%)

60%
(31.88%-
82.78%)

CI = confidence interval; NPV = negative predictive value; PPV = positive predictive value.