Inflammatory variants of tinea capitis in children and adolescents: scoping review protocol

Lucas Ferreira de Godoi Bueno¹, Laís Fumincelli², Maria Paula Barbieri D'Elia³, Sheyla Ribeiro Rocha⁴

^1,2,3,4Federal University of São Carlos. São Carlos (SP), Brazil.

Introduction

Tinea capitis, a dermatophytosis caused by keratinophilic fungi belonging to the genera Microsporum and Trichophyton,^1-2 ranks  among the most prevalent dermatological infections in childhood, primarily affecting children aged 4-7 years, with lower incidence in adolescence and uncommon in adults.^1-5 It proves notably rare before 2 years of age, with scarce cases documented in the literature. Consequently, its epidemiological and clinical features remain largely unknown.⁶

The epidemiology of tinea capitis varies worldwide, showing higher prevalence in developing countries.⁵ It can manifest sporadically or epidemically and, over recent decades, both rising incidence and shifts in affected populations have emerged, linked to migratory patterns, socioeconomic conditions, climate variations, among other factors.^7-8 Tinea capitis, currently considered a public health problem, receives description as a “modern epidemic”,^8-9 featuring frequent outbreak reports in daycare centers and schools.

Clinical presentations of tinea capitis stem from interactions among the pathogen, its virulence, and the host immune response, classifying into non-inflammatory and inflammatory variants.^3,5,7,10-12

In the non-inflammatory variant (“tonsurant ringworm”), tinea capitis appears as an erythematous-scaly plaque, typically pruritic, featuring broken hairs and often linked to cervical lymphadenopathy.^2,4 This clinical form generally responds favorably to treatment without scarring the scalp.⁴

Kerion Celsi represents one inflammatory presentation of tinea capitis, deemed its gravest variant.⁷ Zoophilic or geophilic dermatophytes usually cause it, including M. canis (found in dogs, cats, rodents), T. mentagrophytes (found in horses), and T. verrucosum (found in cattle).^2,4 It manifests as a raised erythematous inflammatory plaque, typically solitary, painful, sharply demarcated, accompanied by pustules and microabscesses, plus regional lymphadenopathy'.^2,4

Kerion Celsi often receives mistaken diagnosis as bacterial abscesses (particularly impetigo) or folliculitis, resulting in delayed appropriate therapy and leading to scarring alopecia in children.^3-5,7,11-13

Tinea favosa (favus), another inflammatory variant caused by T. schoenleinii, targets the hair follicle directly and carries scarring alopecia risk.² Its typical form involves small crater-like lesions surrounding the follicular ostium, termed “favic cup”, a pathognomonic sign. Yet, alternative forms may highlight the scaly element (“pityroid favus”) or suppurative-crusted element (“impetigoid favus”).²

Inflammatory variants of tinea capitis thus qualify as the infection's severest manifestations due to scarring alopecia risk, which produces substantial psychological, social, and aesthetic effects. Such outcomes impair patients' quality of life, potentially causing social activity limitations and diminished school performance, alongside further ramifications. Scarring alopecia, inherently stigmatizing, worsens with delayed appropriate therapy onset, underscoring the imperative to equip health professionals for prompt diagnosis and management of this condition.^3-5,7,11-13

Despite the topic's clinical importance, a preliminary search across JBI Evidence Synthesis, Cochrane Library, PubMed, Epistemonikos, PROSPERO, Campbell Collaboration, Embase, Scopus, Web of Science, and the CAPES Periodicals portal uncovered no prior or ongoing scoping reviews on the matter. Given this void, a scoping review was selected to chart existing evidence, gauge knowledge scope, and pinpoint investigation needs.

The scoping review constitutes a method that, besides contributing to clinical, programmatic, and policy decision-making, enables identification and mapping of the breadth, variety, and nature of the evidence base, especially when reviews on the subject have not yet been published, thereby guiding the formulation of more specific questions to be addressed in the future in a manner more valuable for scientific development in the field in question.^14-15

The aim consists therefore of mapping factors linked to development of inflammatory variants of tinea capitis in children and adolescents.

Method

This study follows the JBI Scoping Review protocol.¹⁶ The Scoping Review aims to identify and map systematically the breadth, variety, and nature of available evidence on a given research topic, enabling identification of existing knowledge as well as gaps, thereby guiding the formulation of more specific questions to be addressed in the future.¹⁵

As recommended by JBI, the PRISMA-ScR checklist and flow diagram (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) will be used, an adaptation of the standard PRISMA employed for systematic reviews, which will guide the main items and concepts to be addressed and the search and selection process of this review.¹⁶ As recommended by JBI, this protocol was registered on the OSF Registries platform under the registration DOI 10.17605/OSF.IO/QWNHX. 

Review question

What factors are associated with the development of inflammatory variants of tinea capitis in children and adolescents?

Other underlying questions include: 1. What key concepts and definitions does the literature use to indicate the clinical presentations of inflammatory variants of tinea capitis? 2. How are studies on tinea capitis being conducted? What knowledge gaps exist regarding inflammatory variants of tinea capitis?

Inclusion criteria

Population

For the “population” criterion, this scoping review will consider studies across various types of literature that include children and adolescents, encompassing the age range from zero to 20 years incomplete.¹⁷

Concept

The “concept” to be examined and analyzed in this scoping review refers to tinea capitis in its inflammatory variants. A prior search was conducted and, according to the results, studies addressing the following forms of tinea capitis described as “inflammatory” in the literature will be considered (Table 1):

Table 1 - Concepts referring to inflammatory variants of ‘tinea capitis’ included in the review and their respective descriptions. São Carlos (SP), Brazil, 2024.

Nº	Concept	Description
1.	Kerion celsi	Form of tinea tonsurante defined by the presence of intense inflammatory reaction associated with pustules and microabscesses that may culminate in scarring alopecia.2-4
2.	Tinea favosa (or “Favo”)	Distinct presentation in the form of crateriform scaly and/or suppurative-crusty lesions, also associated with the risk of scarring alopecia.2

Additionally, considering the possibility that studies may not necessarily cite the terms usually employed in the literature to describe inflammatory variants, studies addressing presentations and situations that in their essence denote the severity of the condition will be considered, for example those that include terms such as: “internment” or “hospitalization”, “emergencies”, “inflammation”, “exacerbation”, “severity”, among other similar terms.

Context

To ensure the breadth of diverse scenarios involving contact with individuals presenting inflammatory variants of tinea capitis, the proposed “context” for this scoping review covers settings where children and adolescents usually are present, such as health services, considering primary care, secondary and outpatient care, and tertiary care, as well as other institutions commonly associated with the pediatric population, including schools, daycare centers, and long-term care facilities.

Types of evidence sources

Publications in any language will be included and, when necessary, automatic translators (“machine translations”) will be used. Studies published using various methodologies will be considered, including randomized and non-randomized clinical trials, bibliographic studies, documentary studies, experimental studies, field studies, case studies, review studies, reflective or theoretical studies; with qualitative, quantitative, or mixed approaches, primary and secondary studies (reviews/reflective-theoretical studies), and data triangulation studies.

Texts occasionally available in grey literature will also be included, encompassing documents produced by government, academic, industrial, or commercial sectors, which generally are not intended for traditional commercial publication and therefore are not indexed in major databases.^18-20 This category covers unpublished research, theses and dissertations, congress and conference proceedings, research reports — technical or governmental —, patents, preprints, e-prints, and other relevant materials available in various repositories.^18-19,21 Although heterogeneous, searching grey literature remains an important step to ensure validity and reliability of both the research process and the data found.²⁰ 

Exclusion criteria

Publications for which the full article cannot be obtained will be excluded.

Search strategy

To find the maximum number of published and unpublished articles, studies will be selected from consultation of various databases.

Initially, an exploratory search was conducted in three databases selected for this review: Excerpta Medica Database (Embase), PubMed, and Scientific Electronic Library Online (SciELO). The descriptors presented in Table 2 were used, whose combinations were structured through the Boolean operators AND and OR.

Table 2 - Descriptors initially used for elaboration of the search expression. São Carlos (SP), Brazil, 2024.

Population	Concept	Context
-Child -Children -Infant -Preschool -Adolescent -Teens -Teenagers	-Tinea capitis -Tinea capitis profunda -Trichophytia profunda capitis -Kerion celsi -Tinea favosa -Favo -Favus	-Health services -Primary health care -Secondary health care -Ambulatory care -Hospital care

From these, analysis proceeded of titles, abstracts, and keywords of the main articles selected, which enabled definition and addition of other descriptors (Table 3), to elaborate a search expression as comprehensive as possible (Appendix I).

Table 3 – Final descriptors used in the search expression. São Carlos (SP), Brazil, 2024.

Population	Concept	Context
-Adolescent -Adolescents -Boy -Boys -Child -Childhood -Children -Girl -Girls -Infant -Infants -Minor -Minors -Neonatal -Newborn -Newborns -Premature -Prematures -Preschool -Preterm -School child -Teen -Teens -Teenager -Teenagers	-Extensive tinea capitis -Favo -Favus -Inflammatory tinea capitis -Kerion celsi -Kerions -Scalp pyoderma -Severe kerion -Tinea capitis -Tinea capitis favosa -Tinea capitis profunda -Tinea favosa -Trichophytia profunda capitis	-Academic medical center -Adolescent dermatology -Ambulatory care -Ambulatory care facilities -Children day care -Day-care center -Dermatology center -Dermatology clinic -Emergency care -Health promotion -Health service -Health services -Hospital -Hospital care -Hospitals -Infant care -Intensive care unit -Intensive care units -Neonatal care -Orphanage -Orphanages -Pediatric dermatology -Pediatric hospital -Pediatric nursing -Pediatrics -Primary health care -Primary school -Secondary health care -Secondary school -Specialty care -Student -Students -Tertiary care center -Tertiary health care

Based on results from the previous stage, the search expression will be adapted and applied in other databases, according to the specificities of each, namely: the Virtual Health Library (BVS), operated by the Latin American and Caribbean Center on Health Sciences Information (BIREME); the Cochrane Database of Systematic Reviews; the Cumulative Index to Nursing and Allied Health Literature (CINAHL); the Excerpta Medica Database (Embase); the Medical Literature Analysis and Retrieval System Online (MedLine) / PubMed, via National Library of Medicine and also MedLine OVID; the International Prospective Register of Systematic Reviews (PROSPERO); the Scientific Electronic Library Online (SciELO); the multidisciplinary Scopus database; and the Web of Science Core Collection.

A search will be conducted for publications available in grey literature in the CAPES Thesis and Dissertation Bank; in Google Scholar; in The National Library of Australia’s Trove, in Academic Archive Online (DIVA), in DART-Europe E-Theses Portal, and in Electronic Theses Online Service (EThOS).

Finally, references found in articles selected in previous stages will be searched and analyzed, aiming to identify additional sources.

Study selection

To ensure scientific rigor, the study search and selection process will be conducted by two reviewers, from the same databases and on pre-defined days. In case of disagreement between selections, a third reviewer will be consulted. All studies found will be presented on the Rayyan platform and duplicates will be removed.

Following PRISMA-ScR guidelines, study selection will proceed in successive stages, based on inclusion criteria and the review question. Initially, duplicate studies will be removed; next, titles and abstracts will be read; subsequently, the full texts of potentially eligible articles will be read. Any exclusions at this stage will be adequately justified by the reviewers. Included studies’ reference lists will also be analyzed to identify other potentially relevant sources. At each stage, preliminary tests will be conducted between reviewers by selecting a sample of identified studies, as dictated by the number of results obtained, to refine selection criteria and align evaluators’ perspectives.

The search and selection process will be depicted using the PRISMA-ScR flow diagram, adapted for Scoping Reviews.¹⁶

Data extraction

From included studies, data extraction will be performed according to population-concept-context criteria of the review, using an extraction tool (Appendix II) developed by the authors, covering extraction details and article identification (extraction date, title, authors, source, and year of publication) and research-relevant characteristics (period and location, methodology, descriptors identified per population-concept-context dimensions, identified inflammatory variants of tinea capitis, associated factors, gaps, limitations, and references of interest).

Similarly, a preliminary test with at least five selected articles will be conducted. After discussion, modifications to the extraction tool may be made if deemed pertinent.

If necessary, authors of selected studies may be directly contacted for missing or additional information.

Data analysis and presentation

Data will be characterized and visually arranged in tables and graphs, as deemed necessary by the authors, considering the guiding question and the research’s general and specific objectives, besides extracted data during the process.¹⁶ To standardize selection, characterization, evidence source evaluation, result synthesis, and discussion, the PRISMA-ScR checklist will be used.¹⁶ Therefore, data analysis and presentation will broadly follow elements from Appendix II.

Firstly, global aspects related to general parameters in the field of inflammatory variants of tinea capitis research will be shown, such as number of publications; publication year or period; countries, regions or continents where studies were conducted and/or published; methodologies used; studied population (neonates, infants, preschoolers, schoolchildren, adolescents). Specifically, results may be presented via simple lists or tabulations, graphs (line, sector, column, bar, etc.), among others.

Furthermore, concepts, definitions, and variants of tinea capitis considered “severe” in the literature will be presented and their statistics discussed, e.g., via simple lists, word clouds illustrating term frequency, graphs, among other possibilities.

Complementing visual elements, a narrative summary will discuss main information and results, relating them to the research objective and guiding question. In addition, identified limitations and knowledge gaps will be analyzed. 

Results

A thorough and systematic literature search is expected to reveal studies that expand knowledge on severe forms of tinea capitis and predisposing and associated factors, contributing to advancement in this field of knowledge and, indeed, to enhancement of care provided to pediatric patients. 

Authors’ Contributions

Study conception: Lucas Ferreira de Godoi Bueno, Laís Fumincelli, Maria Paula Barbieri D'Elia, Sheyla Ribeiro Rocha. Data collection: Lucas Ferreira de Godoi Bueno, Sheyla Ribeiro Rocha. Data analysis and interpretation: Lucas Ferreira de Godoi Bueno, Laís Fumincelli, Maria Paula Barbieri D'Elia, Sheyla Ribeiro Rocha. Manuscript writing: Lucas Ferreira de Godoi Bueno, Critical review of the manuscript:  Lucas Ferreira de Godoi Bueno, Laís Fumincelli, Maria Paula Barbieri D'Elia, Sheyla Ribeiro Rocha. Approval of the final version of the text: Lucas Ferreira de Godoi Bueno, Laís Fumincelli, Maria Paula Barbieri D'Elia, Sheyla Ribeiro Rocha. 

Conflict of interest

The authors declare no conflicts of interest. 

Funding

National Council for Scientific and Technological Development - CNPq. 

References

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Appendix I  - Search expression performed in the Embase Database on 07/03/2024

Nº	Expression	Results
1	(favo) OR (favus) OR (“kerion celsi”) OR (“tinea capitis”) OR (“tinea capitis favosa”) OR (“tinea capitis profunda”) OR (“tinea favosa”) OR (“trichophytia profunda capitis”)	4,866
2	(‘1’ OR (“extensive tinea capitis”) OR (“inflammatory tinea capitis”) OR (kerions) OR (“scalp pyoderma”) OR (“severe kerion”))	4,878
3	(adolescent) OR (adolescents) OR (child) OR (children) OR (infant) OR (infants) OR (preschool) OR (teen) OR (teens) OR (teenager) OR (teenagers)	5,729,437
4	(‘3’ OR (minor) OR (minors) OR (newborn) OR (newborns) OR (neonatal) OR (premature) OR (prematures) OR (preterm) OR (boy) OR (boys) OR (girl) OR (girls) OR (childhood) OR (school child))	6,449,026
5	(ambulatory care) OR (health service) OR (health services) OR (hospital care) OR (primary health care) OR (secondary care) OR (tertiary care)	9,130,081
6	(‘6’ OR (“academic medical center”) OR (health promotion) OR (hospital) OR (hospitals) OR (intensive care unit) OR (intensive care units) OR (pediatric nursing) OR (tertiary care center) OR (“adolescent dermatology”) OR (ambulatory care facility) OR (ambulatory care facilities) OR (dermatology center) OR (dermatology clinic) OR (pediatric dermatology) OR (pediatrics) OR (specialty care) OR (emergency care) OR (neonatal care) OR (pediatric hospital) OR (children day care) OR (day-care center) OR (infant care) OR (orphanage) OR (orphanages) OR (primary school) OR (secondary school) OR (student) OR (students))	17,126,477
7	‘2’ AND ‘4’	2,527
8	‘7’ AND ‘6’	1,666

 Appendix II - Data extraction tool.

Extraction details
Reviewer initials
Extraction date
Article identification
Title
Primary author
Associated author(s)
Journal / publication source
Year of publication
Citation
Article details and characteristics
Study period (If applicable)
Country of origin or where the study was conducted/published (If applicable)
Methodology(ies)
Identified population(s)
Identified concept(s)
Identified context(s)
Main keywords / descriptors
What terms were used to describe inflammatory variants of tinea capitis?
What factors were identified for inflammatory variants of tinea capitis?
Did the authors identify/describe an unfavorable prognosis/outcome?
Did the authors develop any form of intervention/suggestion in relation to semiology, diagnosis and/or treatment of tinea capitis?
Limitations stated by the authors themselves
Gaps identified by the reviewer
Titles of references of potential interest
Additional notes

Corresponding Author

Name: Lucas Ferreira de Godoi Bueno

E-mail: lucasbueno@estudante.ufscar.br

© The Author(s) 2025. This work is licensed under Creative Commons Attribution 4.0 International. License text for use: https://creativecommons.org/licenses/by/4.0/