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  • Writer's pictureEscuela de alopecia

Alarming Trend: Increase in Fungal Infections

Each time, I see more fungal infections on the scalp that can trigger permanent alopecia in young individuals, besides spreading among them and to their relatives. This has been happening basically over the last three years and has been primarily caused by two factors, or so we suspect. The first, you know, is the hairstyle that everyone is sporting nowadays. All young people have the same faded haircut, similar to that of footballers, which requires continuous grooming every week at the hair salon. This, coupled with a clear change in the epidemiology in Europe of some fungi, mainly due to African immigration, has exposed us to different temperatures and humidities, sometimes confusing the diagnoses.

When we talk about fungal infections on the scalp, we're talking about ringworms, and they are ultra-contagious, very contagious, immensely contagious.

Primarily, the origin can be triple: they can come from other people, what we call anthropophilic fungi; they can come from animals, zoophilic fungi; or from the soil, any inert surface that harbors fungi. The latter are the rarest. Well, in Spain, usually, the fungi found on the scalp, especially in young boys, were fungi that were primarily transmitted more zoophilically. For example, the famous Microsporum canis, which obviously came from dogs, which can also be found in other animals. However, nowadays, we encounter, and this has been a problem in recent years, the so-called Trichophyton tonsurans, which was much rarer. I remember when I started studying this in college, but now that I am a dermatology specialist, there are clearly more publications indicating an increasing prevalence in Spain. The publications began in Andalusia, in Malaga. There has been a very recent one, a very recent publication talking about hairdressing centers where there have been outbreaks of this problem, and it is spreading throughout the rest of the country. What these fungi do is they consume keratin, and in the body, the keratin we have is in the skin, the nails, or the hair. But I'm not going to talk about skin or nail fungi, I'm going to talk about hair, which is what I specialize in, what interests me.

These fungi are highly contagious, and as I said, they can be transmitted from person to person. That is, a friend of yours can have this, lend you their hat, and can infect you. It can be transmitted from animal to person, or from person to animal. For example, if you have a pet, a dog, a cat, whatever, and you touch it, it can transmit it to you, or you to it. They can also be transmitted, of course, through what we call fomites. Fomites are inert things. It doesn't necessarily have to be that your girlfriend has a fungus in her hair and touches you, or you touch her, and she transmits it to you, but also your girlfriend can leave you, as I said before, a comb, a brush, a hat, whatever, the towel, the pillow, the sheets, a sweater, and can transmit it to you through that fomite. This fungus reaches your skin there, with the skin, that fungus is capable of producing a series of proteins that mainly break down keratin. It enters the skin, reaches the hair where it nests, and starts eating it basically. If that feeding, especially if it causes a lot of inflammation, your body with that fungus remains, it ends up producing irreversible scarring, and there is no way to recover that hair ever.

And as I said before, it is much rarer for you to transmit it, for example, in the soil. This, for example, throwing yourself out in the street, the forest, whatever, and being in contact, you can get infected.

The further away the fungus is from the human, the more inflammation it will cause you, and the more scarring, when I refer to distant fungi, they are fungi that are usually not in contact with humans, they are very inflammatory. And this is a problem because the fungi that are currently coming, especially to the peninsula, tend to be fairly anthropophilic fungi, they are easily transmitted among people, and many times they are asymptomatic. And the patient, I'll tell you cases, doesn't realize, doesn't realize that they have a fungus for weeks or months on their scalp, and passes it on to other parts of their body, or to other friends.

These fungi have many ways of infecting hair, as I said Trichophyton and Microsporum, but fundamentally, in practice, there are three. Also, this is medicine, but I'll summarize: it can get inside the shaft, what they call the endotrix, or it can go outside, the ectotrix, or some that I've never seen, this, by the way, I've only seen it in books, which is called favus. They are very easy to diagnose because the image is very clear, with pus. Well, very showy, I don't mean this. I am continuously referring to cases that simulate dermatitis, that simulate eczema, that simulate psoriasis, that simulate alopecia areata when you don't actually have this, but you have a ringworm infection.

I mentioned before that this is more common in young people, especially in young boys or girls. Especially at a prepubertal level. Although it can occur at any age, completely prepubertal, we're not sure. It's curious, I'll tellyou something amusing, we think it's more frequent in children first because they are dirtier, obviously, they touch each other, roll around, suck on things, you know, dirty stuff, they have no hygiene whatsoever. Second, their sebum is not mature in our scalp, it's more sebaceous to help protect us, and in fact, there are some medium-chain and short-chain fatty acids in our scalp fat that protect us from infections by other fungi. And third, Malassezia, also called Pityrosporum, is a fungus related to dandruff, with seborrheic dermatitis. Interestingly, this, you know, which starts from adolescence onwards, it faces and hinders other fungi from infecting the scalp. It says, "no, no, this is mine, I produce dandruff, but I don't want this human to have another type of infection," it's something very curious. But I insist, it can also affect adults, it's just a bit rarer. In fact, lately, when it infects adults, it's not uncommon for their child to be infected, right? Or the grandchild, or a friend, etc.

Currently, due to my particular idiosyncrasy, unfortunately or fortunately, I have a waiting list. I don't usually see acute cases of fungal infection in my practice because if you obviously take months to get to my office, someone else has seen you in between, let's say. But what I do see in consultations are subclinical infections, that is, that you haven't noticed, or other doctors haven't realized you had a fungal infection, and it's not really dermatitis, nor psoriasis, nor an eczema patch. You have to think, above all, that there are usual areas, especially the occipital area or the temporal area, I insist, usually the faded one. In which, if you have any patch of eczema, scaling, itching, be careful, be careful, be careful, especially if you see black dots or lose density, that's it, you have to rush to the doctor because you might have a fungal infection, which, I insist, can be completely irreversible. And if you also have a swollen lymph node, it's more likely to be of infectious origin, and you should schedule an appointment with the doctor immediately.

And I mentioned before that it's becoming a bit of a problem in Spain because many of these are asymptomatic, it seems like a bit of dermatitis only in the first few weeks or months, and many times, maybe you go to your doctor and they recommend a corticosteroid. The corticosteroid can reduce the symptoms a bit, but the fungus will grow even more afterwards, and then we have a problem. This, coupled with the fact that the patient will continue to go to the hair salon, will continue to have their hair cut, will continue to infect other clients of the hair salon. There are many hair salons that take very seriously, as it should be, the regulations to do things properly, and well, a minimum of cleanliness and a minimum of sanitary conditions in the hair salon, with disposables, etc. But be careful, not all hair salons, especially some that I don't know if they are bad hair salons or almost, almost already, somewhat peculiar centers, do not have these minimal hygiene measures that are many.

In fact, this is the reason why many good hair salons get upset when cases of this type of fungal infections associated with hair salons appear because it tarnishes a trade when they do things right. In fact, I believe that if you are a hairdresser and you see that your client has a very, very localized dermatitis patch, first ask if they know what that is, if a doctor has seen it, because if not, maybe you can cut their hair, but the material you use to cut the hair, you have to sterilize it afterwards. The diagnosis, if suspected, is easy, usually with clinical evidence, then trichoscopy in the consultation usually shows evidence of a fungal infection, and if there are doubts, a culture can be taken, or even a scraping to see the diagnosis. As for treatment, it always, always, always requires, generally, pills. Fundamentally, we use pills called terbinafine for several weeks. This usually, with fungi of the Trichophyton genus, and griseofulvin, generally for Microsporum, which was the one we used to have more prevalence in Spain, and currently there is less prevalence because Trichophyton is replacing this, it is competing with the old one we had in Spain. And it's something very important, and something that I always do is treat patients and their family members with antifungal shampoos, like ketoconazole or ciclopirox, for at least a month, to prevent, let's say, those infections between them. Be careful with ketoconazole, obviously, it's not recommended in pills, risk of hepatotoxicity. But however, for example, clotrimazole, which I like more, if you know me, if you are my patients, you have seen me say this sometime, I like it much more to treat these cases. Also be careful with animals, okay, you can pass it to the animal, an animal to you, and in the case that there is suspicion that the animal is infected, it is advisable, apart from taking your treatment, to take your little dog, cat, cow, guinea pig, whatever, to the veterinarian to rule it out. It is true that the veterinarian has to have, they all have it, because they have very good training. But they have to have training in dermatology, obviously animal, to make the diagnosis. I have seen not many, but I remember a case, that the veterinarian said no, but then I remember that the little dog developed a patch of alopecia afterwards because, I insist, sometimes they are very non-inflammatory ringworms and it seems like it's just dandruff.

Simply, I give you these small notions about this increasingly larger problem of fungal infections, asymptomatic, very symptomatic, that spread throughout the family. I recommend that you go to the doctor because if not, it can leave permanent sequelae, apart from the fact that, obviously, nobody wants to have a fungus infecting their hair for months. Many people don't mind having it for years in their nails, which almost everyone has, or in their toenails, which I think is disgusting, but hey, they know. But in the hair, they like it less.

Alarming Trend: Increase in Fungal Infections on the Scalp Among Young People

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