BJD

G E N E R A L D E R M A TO L O GY British Journal of Dermatology

A single typical trichoscopic feature is predictive of tinea

capitis: a prospective multicentre study
bert,4
F. Dhaille iD ,1 A.-S. Dillies,1 F. Dessirier,1 P. Reygagne,2 M. Diouf,3 T. Baltazard,1 F. Lombart,1 V. He
5 5 6 6 1 1
M. Chopinaud, L. Verneuil, C. Becquart, E. Delaporte, C. Lok and G. Chaby iD
1
Department of Dermatology and 3Biostatistics Department, Clinical Research and Innovation Directorate, Amiens University Medical Center, Amiens, France
2
Centre Sabouraud, H^opital Saint Louis, Paris, France
4
Department of Dermatology, Rouen University Medical Center, Rouen, France
5
Department of Dermatology, Caen University Medical Center, Caen, France
6
Department of Dermatology, Lille University Medical Center, Lille, France

Summary

Correspondence Background Specific trichoscopic signs of tinea capitis (TC) were first described in
Florie Dhaille. 2008. The accuracy of this diagnostic tool has not been evaluated.
E-mail: floriedhaille@gmail.com. Objectives To assess the diagnostic accuracy of trichoscopy.
Methods A prospective, multicentre study was done between March 2015 and
Accepted for publication
March 2017 at the dermatology departments of four French university medical
4 March 2019
centres. Patients with a presumed diagnosis of TC were included. Trichoscopy
Funding sources was considered to be positive if at least one specific trichoscopic sign was
Grant from PHYTO laboratory. observed. Trichoscopy results were compared with the gold standard for diagno-
sis of TC (mycological culture).
Conflicts of interest Results One hundred patients were included. Culture was positive for 53
None declared.
patients and negative for 47. The sensitivity of trichoscopy was 94% [95%
DOI 10.1111/bjd.17866 confidence interval (CI) 88–100], specificity was 83% (95% CI 72–94), posi-
tive predictive value was 92% and negative predictive value was 86%. Comma
hairs, corkscrew hairs, zigzag hairs, Morse-code-like hairs and whitish sheath
were significantly more frequent in patients with a positive mycological cul-
ture (P < 0
001). Comma hairs were more frequent in patients with Trichophy-
ton TC (P = 0
026), and zigzag hairs were more frequent in patients with
Microsporum TC (P < 0
001). Morse-code-like hair was not observed in any
patients with Trichophyton TC and therefore appears to be highly specific for
Microsporum TC.
Conclusions The presence of a single trichoscopic finding is predictive of TC. Tri-
choscopy is a useful, rapid, painless, highly sensitive tool for the diagnosis of TC
– even for dermoscopists with little experience of trichoscopy. It enhances physi-
cians’ ability to make treatment decisions.

What’s already known about this topic?

• Tinea capitis (TC) must be confirmed by a mycological culture that may take up to
6 weeks, delaying treatment.
• Specific trichoscopic signs of TC were first described in 2008, but the accuracy of
trichoscopy for diagnosing TC has not previously been evaluated.

What does this study add?

• The present series is the largest yet on the use of trichoscopy in the diagnosis of
TC.
• Our results demonstrated that the presence of a single feature (comma hair, cork-
screw hair, zigzag hair, Morse-code-like hair or whitish sheath) is predictive of TC.

© 2019 British Association of Dermatologists British Journal of Dermatology (2019) 1

2 Single typical trichoscopic feature predictive of tinea capitis, F. Dhaille et al.
• Trichoscopy is painless and highly sensitive.
• Morse-code-like hair appears to be highly specific for Microsporum TC.
Tinea capitis (TC) is a common, contagious, dermatophyte
infection of the scalp that occurs predominantly in children.1
The diagnosis of TC is based on a clinical assessment and a
Wood lamp examination.2 However, this diagnosis must be
confirmed by a mycological culture before systemic treatment
is initiated. The culture may take up to 6 weeks – delaying
treatment initiation and increasing the risk of contagion.3
Specific trichoscopic signs of noninflammatory TC were first
described in 2008, mostly with video-dermoscopy.4–12 Tri-
choscopy (dermoscopy of hair and scalp) with a pocket der-
moscope may be a useful, rapid, painless tool for diagnosing
TC. However, the accuracy of trichoscopy for diagnosing TC
has not previously been evaluated. We therefore conducted a
prospective, nonrandomized, multicentre, noninferiority study
to compare the accuracy of trichoscopy with that of the gold-
standard method (mycological culture) for the diagnosis of
TC.
Patients and methods
Design overview
The study was performed between March 2015 and March
2017 at the dermatology departments of four university medi-
cal centres in France. The protocol was approved by the local
institutional review board (CPP Nord Ouest II, Amiens,
France) and registered at ClinicalTrials.gov (NCT 02550496).
Patients were included after they had provided verbal and
written consent. For patients < 18 years of age, written,
informed consent was obtained from one of the parents or
legal guardians.
Setting and participants
The study population consisted of consecutive ambulatory
patients treated at or referred to one of the four investigating
centres for suspected TC. Included patients had one or more
signs of TC: dandruff, scales with pruritus or scaling alopecia.
There was no age restriction on inclusion. Patients having
taken systemic antifungal medications in the 2 weeks prior to
observation were excluded, as were patients with inflamma-
tory TC (e.g. patients with kerions, in whom a trichoscopy
assessment tends only to reveal old crusts, suppuration or
pustules).
Study procedures
During a consultation with a dermatology resident, standard
clinical data were recorded: the patient’s age and hair type
British Journal of Dermatology (2019)
(African, Asian or Caucasian), and any international travel in the
previous 6 months. A Wood lamp examination was performed.
The trichoscopy assessment was performed by dermatology res-
idents who had no previous training in trichoscopy or the iden-
tification of trichoscopic signs of TC, and had only been shown
the trichoscopic aspects of TC described in the literature: photos
or drawings of comma hairs, corkscrew hairs, zigzag hairs,
Morse-code-like hairs and whitish sheath. Trichoscopy was per-
formed at a magnification of 910 with a handheld, nonpolar-
ized light dermoscope (Deltaâ 20; HEINE Optotechnik,
Herrsching, Germany), in the absence of immersion liquid. The
dermoscope was cleaned after each assessment with a quater-
nary ammonium surface disinfectant. Photographs of the tricho-
scopic features were taken directly through the dermoscope
with a smartphone, and embedded in an electronic case report
form (eCRF). All the trichoscopic features highlighted during
the examination were reported on the eCRF.
A dermatologist with expertise in hair disorders (referred to
hereafter as the expert) and training in the identification of
TC-specific signs reviewed the photographs and reported the
findings on the eCRF. The expert was blinded to the culture
results and the dermatologist’s assessment of the scalp. The tri-
choscopy assessment was considered to be positive by the resi-
dent and the expert if at least one TC-specific sign described
in the literature was present on at least two hairs.
The sample for mycological culture (skin scales and plucked
hairs) was collected by the dermatologist or a mycologist after
the trichoscopy assessment. The latter assessment sometimes
guided the practitioner’s choice of areas to be sampled. Myco-
logical examination (direct microscopic observation with 40%
potassium hydroxide, and culture in mycobiotic agar incu-
bated at 24°C) was performed in all patients. TC was con-
firmed if the mycological culture was positive.
Outcomes and measurements
The primary outcome measures were the sensitivity, speci-
ficity, positive predictive value (PPV) and negative predictive
value (NPV) of the trichoscopy procedure (on the basis of the
resident’s data and those of the expert). The trichoscopy
results were compared with the gold standard for the diagno-
sis of TC (mycological culture).
The secondary outcome measures included the correlation
between the trichoscopic aspects of TC with the type of hair
or the dermatophyte species (based on the expert analysis),
the degree of concordance between the resident and the
expert, the sensitivity and specificity of the direct mycological
examination, and (for Microsporum TC) the sensitivity and speci-
ficity of the Wood lamp assessment.
© 2019 British Association of Dermatologists

Statistical analysis
Quantitative variables were expressed as the mean  SD and
the median. The sensitivity, specificity, PPV and NPV were
presented as the percentage [95% binomial confidence interval
(CI)]. Qualitative data were analysed with a v2-test or Fisher’s
exact test. Cohen’s kappa was calculated for the concordance
analysis. All statistical analyses were performed with SAS (ver-
sion 9
4; SAS Institute, Cary, NC, U.S.A.).
Results
Baseline characteristics
One hundred and four patients were included. Four patients
were then excluded as a result of missing data (n = 2), double
inclusion (n = 1) or a diagnosis of kerion (n = 1). We anal-
ysed data for the remaining 100 patients; there were 53 indi-
viduals in the ‘positive culture’ (PC) group, and 47
individuals in the ‘negative culture’ (NC) group (Fig. 1).
The mean  SD age of the study population was 13  19
years (range 1–83; median 5). There were 53 female patients
(53%) and 47 males (47%). The PC group comprised 20
women (38%) and 33 men (62%), and the mean  SD age
was 6
24  9 (range 1–57). Of the nine patients who travelled
outside France in the past 6 months, six had a PC (Senegal, n =
2; Afghanistan, Spain, Morocco and Tunisia, n = 1 each).
Of the 53 patients in the PC group, 27 had Caucasian hair
and 26 had African hair. None of the study participants had
Asian hair. Thirty-one patients had clinical features suggestive
of Microsporum infection (one large lesion of alopecia, with short
hairs) and 22 had clinical features suggestive of Trichophyton
infection (several small patches of alopecia). The most frequent
Four paents excluded
(two due to loss of data, one to
kerion, one to double inclusion)
Posive culture
n = 53
Posive trichoscopy Negave trichoscopy
n = 50
Fig 1. Flowchart of included patients. TC, tinea capitis.
© 2019 British Association of Dermatologists
Single typical trichoscopic feature predictive of tinea capitis, F. Dhaille et al. 3
dermatophyte was Microsporum canis (n = 22, including 20 with
Caucasian hair), followed by Trichophyton tonsurans (n = 13,
including 12 with African hair); Microsporum audouinii (n = 5);
Trichophyton soudanense (n = 4); Trichophyton mentagrophytes (n = 2);
Trichophyton rubrum (n = 2); Trichophyton rivalieri (n = 2); Microsporum
gypseum (n = 2); Trichophyton violaceum (n = 1). The mean  SD
turnaround time for a PC was 32 10 days.
Definitive diagnoses were made for 37 of 47 patients in the
NC group: pityriasis amiantacea (n = 14); seborrhoeic dermati-
tis (n = 8); alopecia areata (n = 5); trichotillomania (n = 3);
psoriasis (n = 3); lichen planopilaris (n = 2); folliculitis decal-
vans (n = 1); eczema (n = 1). In the remaining 10 cases, a lack
of data ruled out a firm diagnosis (n = 10).
Specificity and sensitivity of the trichoscopy assessment
The trichoscopy assessment was positive (based on the
expert’s interpretation of the photographs) for 58 patients (50
in the PC group and eight in the NC group). The sensitivity
of the trichoscopy assessment was 94% (95% CI 88–100), the
specificity was 83% (95% CI 72–94), the PPV was 92% and
NPV was 86%. Regarding the interpretation of in vivo tri-
choscopy by the dermatology residents, sensitivity was 89%
(95% CI 80–97), specificity was 77% (95% CI 64–89), PPV
was 81% and NPV was 86%.
Specificity and sensitivity of each specific sign
Comma hairs, corkscrew hairs, zigzag hairs, Morse-code-like
hairs and whitish sheath were significantly more frequent in
the PC group (Fig. 2, Table 1). The sensitivity and specificity
of each specific sign of TC are summarized in Table 2.
Paents with clinical
suspicion of TC
n = 104
Cases analysed
n = 100
Negave culture
n = 47
Posive trichoscopy Negave trichoscopy
n=3 n=8 n = 39
British Journal of Dermatology (2019)
4 Single typical trichoscopic feature predictive of tinea capitis, F. Dhaille et al.

(a) (b)

(c) (d)

Fig 2. Trichoscopic images of tinea capitis (TC) acquired with a handheld dermoscope (magnification 910). (a) TC caused by Microsporum canis:
zigzag hair (grey arrows) and whitish sheath (red arrows). (b) TC caused by Trichophyton tonsurans: corkscrew hair (circles). (c) TC caused by M.
canis: Morse-code-like hair (black arrows) and whitish sheath (red arrows). (d) TC caused by T. tonsurans: comma hair (squares).

(positive or negative) noted by the resident who included the

Correlation between the trichoscopic aspects of tinea
patients with the results noted by the expert. The correlation
capitis and the type of hair and dermatophyte species
coefficient for concordance was high (0
67, 95% CI 0
52–
For patients who had a positive mycological culture, the speci- 0
82). We also calculated level of agreement between the resi-
fic trichoscopic features of TC were analysed according to the dent and the expert for each individual sign: the correlation
type of hair (Caucasian or African). Morse-code-like hairs and coefficient was high for comma hair (0
67, 95% CI 0
51–
zigzag hairs were observed more frequently in specimens of 0
83), corkscrew hair (0
63, 95% CI 0
42–0
84), Morse-
Caucasian hair (P = 0
004 and P = 0
039, respectively), and code-like hair (0
61, 95% CI 0
39–0
83) and whitish sheath
comma hairs were observed more frequently in specimens of (0
78, 95% CI 0
66–0
90), and very high for zigzag hair
African hair (P = 0
008). (0
81, 95% CI 0
68–0
93).
For the 53 patients in the PC group, the specific trichoscopic
signs of TC were analysed according the type of dermatophyte
Specificity and sensitivity of the Wood lamp examination
involved (Microsporum or Trichophyton). The difference was statisti-
and the direct mycological examination
cally significant for zigzag and Morse-code-like hairs, which
were more frequently observed in cases of Microsporum TC (P = A Wood lamp examination was not performed for 31 of the
0
002 and P < 0
001, respectively). The difference was also sig- 100 patients in the study (owing to a lack of time in 27 cases
nificant for comma hairs, which were more frequently observed
in cases of Trichophyton TC (P = 0
026).
Specific trichoscopic signs of TC in the PC group were analysed Table 1 Distribution of the trichoscopic signs of tinea capitis as a
according to the type of arthrospore (endothrix or ectothrix); we function of the results of the mycological culture
found 33 cases with ectothrix-type dermatophytes and 20 cases
with endothrix-type dermatophytes. There were significantly Positive Negative
higher proportions of comma hairs and corkscrew hairs in the Total culture culture
endothrix group, and significantly higher proportions of Morse- (n = 100) (n = 53) (n = 47) P-value
code-like hairs and zigzag hairs in the ectothrix group. Comma hairs 34 29 5 < 0
001
Corkscrew hairs 14 12 2 0
008
Zigzag hairs 29 26 3 < 0
001
Concordance analysis Morse-code hairs 16 16 0 < 0
001
The reproducibility of this trichoscopy assessment was evalu- Whitish sheaths 50 44 6 < 0
001
ated by comparing the results of the trichoscopy examination

British Journal of Dermatology (2019) © 2019 British Association of Dermatologists

 Single typical trichoscopic feature predictive of tinea capitis, F. Dhaille et al. 5
Table 2 Sensitivity and specificity of each specific sign of tinea capitis
Sensitivity (%)
Comma hair 54
7 (41
5–67
3)
Corkscrew hair 22
6 (13
5–35
5)
Zigzag hair 49
1 (36
1–62
1)
Morse-code-like hair 30
2 (19
5–43
5)
Whitish sheath 83 (70
8–90
8)
Data in parentheses are the 95% confidence interval. PPV, positive predictive value; NPV, negative predictive value.
and lack of equipment in four cases). The technique’s sensitiv-
ity and specificity (calculated after excluding cases of Trichophy-
ton TC) were, respectively, 70
8% and 90
3%.
Of the 53 patients with a PC, 26 were also positive in the
direct examination. The sensitivity of direct examination was
49
1% (95% CI 36
1–62
1) and the specificity was 97
9%
(95% CI 88
9–99
6%).
Discussion
The primary objective of this prospective study was to evalu-
ate the accuracy of trichoscopy for diagnosing TC. We com-
pared the results of the trichoscopy examination with those of
the gold-standard technique (i.e. mycological culture); the
sensitivity and specificity were, respectively, 94% and 83% for
the expert, and 89% and 77% for the residents who included
the patients. The correlation coefficient for concordance was
high between the resident and the expert, even when calcu-
lated for each individual sign; this value indicates that tri-
choscopy is reproducible. We found that the presence of a
single trichoscopic finding (comma, corkscrew, zigzag or
Morse-code-like hair or whitish sheath) was predictive of TC.
The accuracy of trichoscopy assessment had not previously
been evaluated.
The clinical and demographic characteristics of our study
population were similar to those reported in the literature;
our population mainly comprised children < 13 years of age
(with a median age of 6
24 years for the patients in the PC
group). In the literature, 80% of cases of TC are said to occur
in children < 10 years of age, with around half of these in
children < 5 years of age.13,14 In the PC group, we did not
observe the female predominance mentioned in some litera-
ture studies; on the contrary, 62% of the cases occurred in
males.13,15 As recently described in the literature, we noted
the predominance of anthropophilic dermatophytes (51%,
mainly T. tonsurans) and zoophilic dermatophytes (45%, mainly
M. canis).13 We found only one similar study in the literature:
a prospective study of 50 children with a possible diagnosis of
TC.16 However, the researchers used a video-dermoscope
(magnification 940–9400), which is not widely available in
routine clinical practice. The mycological culture was positive
for 38 of the 50 patients. The researchers found very few
specific signs, and concluded that the association of perifollic-
ular scaling with any type of dystrophic hair or with broken
© 2019 British Association of Dermatologists
Specificity (%) PPV (%) NPV (%)
89
4 (77
4–95
4) 85
3 63
6
95
7 (85
8–98
8) 85
7 52
3
93
6 (82
8–97
8) 89
7 62
100 (92
4–100) 100 56
87
2 (74
8–94) 88 82
hairs might represent a specific trichoscopic pattern for TC.
Their finding might have been due to a lack of power in a
study with a sample size half that of the present work.
The 2008 report by Slowinska et al. on two patients was the
first to state that comma hair was a distinctive marker for TC.4
Since then, several studies have described other specific signs:
corkscrew hairs,8,9,17 zigzag hairs,11,18 horizontal white bands
(referred to as ‘Morse-code-like hairs’),12 and weak-looking
whitish or translucent hairs. These white hairs may result from
fungal invasion of the whole hair shaft.18–20 Short broken
hairs, black dots or dystrophic hairs are frequently described
but are not specific for TC.21
In the literature, some researchers have sought to establish a
correlation between specific signs on the one hand and the
type of hair or the type of parasite on the other hand. How-
ever, the sample sizes were too small to enable statistically sig-
nificant conclusions to be drawn. Indeed, comma hairs have
been mostly described in cases of ectothrix infection.4,7,20,21
Corkscrew hairs were described for the first time by Hughes
et al. in 2011 in six children, although the researchers could
not link this sign to the type of hair (African) or the incrimi-
nated dermatophyte (T. soudanense).7 Corkscrew hairs seem to
be short comma-shaped hairs with a more exaggerated coiled
appearance, resulting from cracking and bending of the hair
shaft filled with the hyphae.4 Indeed, Lu et al. described a
direct microscopic examination with a 10% potassium hydrox-
ide smear of corkscrew hair, which revealed that curved hairs
were filled with extremely high numbers of endothrix spores
(TC caused by T. violaceum).22 Zigzag hairs have been described
in cases of ectothrix infection.18,23 Lastly, Morse-code-like hair
is mostly frequently described as a dermoscopic finding in the
setting of an ectothrix infection.12,18,23
In the present study, comma hair was more frequently
observed in the subset of patients with African-type hair than
in the subset with Caucasian-type hair. Comma hair and cork-
screw hair were more frequently observed in the ‘endothrix
TC’ subgroup. Zigzag hair and Morse-code-like hair were
more frequently observed in the subset of patients with Cau-
casian-type hair, and in the ‘ectothrix TC’ subgroup. Morse-
code-like hair was not observed in any patients with Trichophy-
ton TC, and so this feature appears to be highly specific for
Microsporum TC. In cases of infection by an endothrix-type para-
site, the hair breaks close to the scalp (comma and corkscrew
hair). In contrast, the hair breaks further from the scalp in
British Journal of Dermatology (2019)
6 Single typical trichoscopic feature predictive of tinea capitis, F. Dhaille et al.
cases of infection by an ectothrix-type parasite, and thus may
be have a zigzag shape or a Morse-code-like aspect. Hence,
the results of the trichoscopy assessment may give the physi-
cian an idea of the type of dermatophyte present. The present
study is the first to have highlighted these factors, which may
have value in routine dermatological practice. Nevertheless,
mycological assessments and cultures remain essential for con-
firming the diagnosis and identifying the disease-causing
pathogen.
A Wood lamp examination was not performed on 31% of
the patients, mainly due to a lack of time. For the tested
patients, the relatively low sensitivity and specificity (70
8%
and 90
3%, respectively, after the exclusion of cases of Tri-
chophyton TC) highlighted the limitations of this examination.
The sensitivity of direct examination was 49
1% (95% CI
36
1–62
1) and the specificity was 97
9% (95% CI 88
9–
99
6). The value of trichoscopy in diagnosing TC is further
highlighted by the low sensitivity of direct examination and
the long turnaround time required for a PC.
One limitation of our study relates to the representativeness
of the study population; all study participants had consulted a
dermatology department at a university hospital. Furthermore,
a second mycological examination was not performed if the
initial examination was negative. The power of the statistical
analysis in the trichoscopic subgroups was limited by the
small sample sizes. Nevertheless, it is important to note that
the present series is the largest yet analysed.
In conclusion, trichoscopy is a very useful tool for the diag-
nosis of TC; the technique is rapid, painless and highly sensi-
tive – even for dermoscopists inexperienced in trichoscopy.
Our results demonstrated that the presence of a single feature
(comma hair, corkscrew hair, zigzag hair, Morse-code-like
hair or whitish sheath) is predictive of TC. Morse-code-like
hair appears to be highly specific for Microsporum TC. The use
of trichoscopy greatly enhances the physician’s ability to make
treatment decisions. In the event of doubt, a mycological cul-
ture is still required.
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© 2019 British Association of Dermatologists