Low utilization of confirmatory testing for tinea capitis by pediatricians at an academic center in New York, United States, 2005–2021

We retrospectively reviewed physician diagnostic and treatment practices for pediatric tinea capitis at an academic institution over 16 years, in assessing adherence with published guidelines. We demonstrate the need to increase utilization of confirmatory testing and systemic therapy, and call for directed pediatrician education towards these goals.

Low utilization of confirmatory testing for tinea capitis by pediatricians at an academic center in New York, United States, 2005-2021 Introduction Tinea capitis (TC), a fungal scalp infection, is the most common childhood dermatophytosis worldwide (1).TC primarily affects children aged 3-14 years, particularly Black males, and is most often caused by Microsporum and Trichophyton species.In the United States, T. tonsurans is the most common causative species (2).American Academy of Dermatology guidelines (1996, most recent year) and the American Academy of Pediatrics Committee on Infectious Disease (2021 Red Book, most recent year) emphasize confirmatory testing of suspected TC and treatment with systemic antifungals (3,4).Confirmatory testing is important given possibility of misdiagnosis, ineffectiveness of topicals against TC, and need for antifungal stewardship in an era of emerging antifungal-resistant dermatophytes (5).Because data on guideline adherence are lacking, we aimed to capture TC diagnostic and treatment practices.

Discussion
In this 16-year retrospective review of TC patients at Weill Cornell Medicine, virtually all dermatologists, but only one-fifth Cases deemed not diagnostic after testing resulted are excluded from this section, as prescribed treatments were discontinued.c Three encounters in which patients were seen by emergency medicine physicians (all prescribed systemic griseofulvin only without confirmatory testing) were included in total count, but excluded from p-value calculations.^P-values were calculated using chi-square tests comparing dermatologists vs. pediatricians. of pediatricians, performed confirmatory testing.In a national commercial database study of 3.9 million pediatric TC encounters, confirmatory testing was infrequent (21.9%), with dermatologists testing more often than pediatricians (51.0% vs. 16.4%,p < 0.01), suggesting similar testing practices between academic and community pediatricians (6).KOH preparations were documented in approximately two-thirds of dermatologist encounters and in no pediatric encounters.Low testing rates by pediatricians may be due to lack of recognition of importance of diagnostic confirmation emphasized by American Academy of Dermatology guidelines and American Academy of Pediatrics Red Book recommendations, long fungal culture turnaround times competing with prompt treatment initiation, and lack of training or required Clinical Laboratory Improvement Amendments certification for KOH examinations (3,4,6).Consistent with TC treatment guidelines, most patients were prescribed systemic antifungals (92.6%).Using topical antifungals (creams, shampoos) alone is discouraged, due to lack of hair follicle root penetration.However, 11.4% of pediatricians prescribed topical therapy only, similar to the aforementioned commercial database study reporting a 10.1% rate for pediatricians, emphasizing the need for directed education (6).For systemic therapies, a systematic review of 38 TC clinical trials reported overall 92% and 72% complete cure rates for terbinafine and griseofulvin, respectively, terbinafine being more effective for Trichophyton and griseofulvin more effective for Microsporum species (7).Terbinafine is regarded as first-line treatment in the US, given vast predominance of Trichophyton TC and shorter treatment course (6-8 weeks) (7).However, since terbinafine was infrequently prescribed by pediatricians (1.6%), directed education is necessary.
Limitations include single-center design and small sample size.However, our study may accurately reflect US practices, given congruence with the commercial database study (5).
We highlight opportunities to increase utilization of confirmatory testing and systemic therapy, and call for directed pediatrician education towards these goals.

TABLE 1
Diagnosing physician specialty and demographics of patients with tinea capitis diagnoses from 2005 to 2021.

TABLE 2
Diagnostic and treatment practices for patients with tinea capitis diagnoses from 2005 to 2021.
a No encounters utilized polymerase chain reaction testing or antifungal susceptibility testing.b