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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 24  |  Issue : 1  |  Page : 20-24

The identification and grading of the psychosocial impact of Tinea capitis in primary school children in a semi-urban area of Rivers State, Nigeria


1 Department of Paediatrics, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
2 Department of Mental Health/Neuropsychiatry, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria

Date of Web Publication9-May-2017

Correspondence Address:
Chukwuma U Okeafor
Department of Mental Health/Neuropsychiatry, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/npmj.npmj_172_16

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  Abstract 

Introduction: Tinea capitis is a fungal skin disease, which is not life-threatening but could affect the psychosocial life of those suffering from it. Thus, this study sought to identify and grade the psychosocial impact related to Tinea capitis in primary school children. Subjects and Methods: This was a cross-sectional study involving primary school children in Emohua Local Government Area of Rivers State. These children had been clinically diagnosed with Tinea capitis. The Children Dermatology Life Quality Index instrument was used to identify the presence of a psychosocial impact, which was graded as none, mild, moderate, and severe. The Statistical Package for Social Sciences version 20 software was used for analysis, and statistical significance was set at P < 0.05. Results: A total of 184 children aged 6–12 years with Tinea capitis participated in the study. The mean age of the children was 9.5 ± 2.9 years. The male-to-female ratio was 2.5:1. More than half of the children (58.2%, n = 127) had mild-to-severe psychosocial impact. The psychosocial impact was significantly higher (P = 0.02) among the female children (61.5%; n = 32) than the male children (41.7%; n = 20). In addition, female children with Tinea capitis were 2.2 times more likely to suffer a psychosocial impact than their male counterparts (odds ratio = 2.2; 95% confidence interval: 1.16–4.32). There were no significant differences in the psychosocial impact across the age categories (P = 0.859). Conclusion: Tinea capitis has a psychosocial impact on the daily lives of school children, with more than half of the children experiencing mild-to-severe grades of psychosocial impact. Collaboration between mental health physicians and pediatric dermatologists is encouraged to address the effect of Tinea capitis on the psychosocial life of school children, especially the female children.

Keywords: Children, Nigeria, psychosocial impact, Tinea capitis


How to cite this article:
Fienemika AE, Okeafor CU. The identification and grading of the psychosocial impact of Tinea capitis in primary school children in a semi-urban area of Rivers State, Nigeria. Niger Postgrad Med J 2017;24:20-4

How to cite this URL:
Fienemika AE, Okeafor CU. The identification and grading of the psychosocial impact of Tinea capitis in primary school children in a semi-urban area of Rivers State, Nigeria. Niger Postgrad Med J [serial online] 2017 [cited 2017 Jun 23];24:20-4. Available from: http://www.npmj.org/text.asp?2017/24/1/20/205972


  Introduction Top


Tinea capitis is a superficial fungal skin infection of the scalp. It is caused mostly by the genera Epidermophyton, Microsporum, and Trichophyton.[1] It is the most common fungal infection among school-aged children[2],[3],[4] and is commonly referred to as “ringworm.” The disease varies from a benign, scaly, noninflammatory, subclinical colonization to an inflammatory disease characterized by the production of a scaly, erythematous lesion, and alopecia.[5] In few cases, the lesion changes abruptly to become boggy and elevated with tender nodules on its surface.[6]

Tinea capitis is unsightly and could have psychosocial implications because of its attached social stigma, ulceration, alopecia, and irritation, which disrupt the pupil’s concentration in class.[7],[8] Pupils with itchy scalp and patchy or total hair loss are frequently ridiculed, isolated, and bullied by classmates or playmates.[7] A disabling scalp lesion could be perceived as a trivial lesion to the observer; however, it may be a source of intense discomfort and stigma to the affected pupil.[9] When the psychosocial well-being of a school-going child is hampered, optimal learning could be threatened leading to poor academic performance.[10]

Noteworthy is the fact that though several studies[11],[12],[13] have focused on identifying the psychosocial impact of other, widespread skin diseases, that of Tinea capitis appears to be understudied. This could arise because of the perception that the disease is not life-threatening, and probably because of the assumption that it is unlikely to affect the psychosocial aspect of those suffering from it, who are mainly children. Furthermore, most of the previous studies[5] conducted in Nigeria determined the burden of this disease in children in terms of the disease prevalence without exploring the psychosocial impact of the disease on the children. This study sought to answer the following research questions: Do primary school children with Tinea capitis suffer a psychosocial impact? What are the grades of psychosocial impact experienced by the affected children? Is there any association between the sociodemographic characteristics of children (age and sex) and the presence of a psychosocial impact in primary school children with Tinea capitis? Hence, this study aimed to identify and grade the psychosocial impact of Tinea capitis in primary school children as well as to determine any relationship between the psychosocial impact and the sociodemographic characteristics based on the age and sex of the children.


  Subjects and Methods Top


Ethical consideration

Ethical approval for this study was obtained from the Research and Ethics Committee of our Tertiary Hospital (Protocol number: UPTH/ADM/90/S.II/VOL.X/314) on 21st August 2013. Permission was obtained from the Rivers State Primary Schools Education Board and the school heads. Consent letters were sent to the parent/guardian of the selected pupil. Written informed consent was obtained from each parent/guardian of the selected children before their inclusion in the study. In addition, assent was obtained from each of the children. The parents/guardians of the children were counseled and given a prescription for topical and oral antifungal medications. They were also referred to the Primary Health Center in the Local Government Area (LGA) to ensure effective follow-up and further management of the children. The study was conducted from 5th May to 30th July 2014.

Study design and location

This was a cross-sectional study conducted in Emohua LGA of Rivers State, Nigeria. Emohua LGA, a semi-urban area, is one of the 23 LGAs in Rivers State. It covers a total of 831 km2 with a total human population of 201,901.[18] The people of Emohua are mostly farmers and traders.

Sample size determination and the selection of the study population

The minimum sample size (179) for this study was calculated based on the formula for cross-sectional studies[19] using an alpha level of 0.05, a beta level of 0.2, 19.5% prevalence of Tinea capitis from a Nigerian study,[15] and a precision of 0.1. The study population comprised primary school children aged 6–12 years with Tinea capitis. Multistage sampling technique was utilized to select the pupils for the study. The list of the schools (51 public and three private schools) in Emohua LGA was obtained from Rivers State Primary Schools Education Board. Eight public schools and one private school were then selected by purposive sampling. Hence, a total of nine schools were selected by the authors, and this was sufficient to attain the minimum sample size. In schools with more than one arm of a class, an arm was selected randomly to represent the others, whereas in schools with only one arm of a class, that arm was chosen. One arm was selected from all six classes (primary one to primary six) in all the selected schools. At least 25 pupils in each of the arms were selected randomly and screened for Tinea capitis. One hundred and eighty-four pupils (out of 1289 pupils screened) were identified as positive for Tinea capitis and were evaluated for psychosocial impact.

Study procedure

A case of Tinea capitis was defined based on the clinical diagnosis (i.e., having a scalp lesion consisting of scales, crusts, follicular inflammation with erythema, and/or alopecia) and/or laboratory diagnosis (i.e., visualization via direct microscopy of branching septate hyphae and arthroconidia in the skin scales, the crusts, and the hair pieces). This case definition was used, because a negative culture does not rule out a dermatophyte infection. Therefore, attention was given to the clinical features of Tinea capitis, which resulted in better diagnostic precision.[16],[20]

The children’s scalps were thoroughly inspected by trained personnel (FAE), and any evidence of scaling, crusting, and follicular inflammation was recorded. Furthermore, the lesions were gently swabbed with 70% ethyl alcohol. The hairs and the scales from the active borders of the lesions were scrapped by gently rubbing the area with a new toothbrush into a clean, labeled envelope and sealed. One toothbrush and a pair of gloves were used per child. Alopecic areas with short hairs were rubbed firmly with water-moistened, tightly woven gauze. Thereafter, each hair was lifted off the gauze with forceps into the labeled envelope. Following specimen collection for each child, proper hand washing technique was observed. The specimens collected were transported to the Microbiology Laboratory of the University Teaching Hospital for laboratory testing. The collected samples (the scales, the crusts, or the dull, lusterless stubs of the hair) were observed under a light microscope. The fragments of the scrapings, the crusts, and the hairs were mounted on a clean slide in a drop of 10–20% potassium hydroxide (KOH) solution and covered with a cover slip. The slide was heated gently for a few seconds over a low flame to digest the keratin and the fungal elements. The slide was then examined under a low and a high lens magnification for the presence of hyphae and arthroconidia and the distribution pattern of the latter on the hair shafts (endothrix or ectothrix invasion).[5],[8]

The questionnaire for assessing the psychosocial impact was extracted from the Children’s Dermatology Life Quality Index (CDLQI) questionnaire[21] and modified to fit Tinea capitis infection. CDLQI is a validated and reliable tool for assessing the psychosocial impact of a dermatological disorder.[21] The questionnaire was interviewer-administered. It consisted of 10 questions, which were answered as “not at all,” “a little,” “a lot,” or “very much” and scored as 0, 1, 2, and 3, respectively. The questionnaire had a maximum score of 30 and a minimum score of 0. Those who scored 5 or less were classified as having “no psychosocial impact,” whereas those who scored 6 and above were classified as having a “psychosocial impact.” Those with a psychosocial impact were further categorized as mild (6–10), moderate (11–20), and severe (>20).[21] The pupils, who had a clinical diagnosis of Tinea capitis, responded to each of the 10 questions administered by the interviewer (FAE).

Statistical analysis

Data analysis was performed using the Statistical Package for Social Sciences version 20 software. The data were presented as frequencies and proportions, and they were summarized using means and standard deviations. Chi-square tests were used to compare differences in the proportions. Odds ratio (OR) and 95% confidence interval (CI) were computed to determine the strength of association. Statistical significance was set at P < 0.05.


  Results Top


A total of 184 pupils aged 6–12 years with a clinical diagnosis of Tinea capitis were recruited in this study. An image of Tinea capitis is shown in [Figure 1].
Figure 1: Image of Tinea capitis

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The mean age of the pupils was 9.3 ± 3.1 years. A higher proportion of the pupils were males (71.7%; n = 137) and belonged to the age category of 10–12 years (52.7%; n = 97), as shown in [Table 1]. Out of the 184 pupils with a clinical diagnosis of Tinea capitis, 127 (69.0%) were positive on laboratory testing.
Table 1: The age and sex distribution of the pupils

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A psychosocial impact was identified in 107 (58.2%) pupils and was graded as mild in 53.3% (n = 57), moderate in 41.1% (n = 44), and severe in 5.6% (n = 6). Seventy-seven (41.8%) of the 184 pupils had no psychosocial impact because of Tinea capitis.

[Table 2] shows the sociodemographic (age and sex) correlates for the psychosocial impact of Tinea capitis in the pupils. The psychosocial impact was significantly higher (P < 0.05) in the female children (61.5%; n = 32) than the male children (41.7%; n = 20). In addition, female children with Tinea capitis were 2.2 times more likely to have a psychosocial impact than their male counterparts (OR = 2.2; 95% CI: 1.16–4.32). There was no significant difference in the frequencies of psychosocial impact across the age groups of the pupils (P > 0.05).
Table 2: Relationship between the presence of psychosocial impact and the demographic characteristics based on the age and sex of the pupils with Tinea capitis

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  Discussion Top


This study showed that more than half of the children had a psychosocial impact because of Tinea capitis infection. The findings of this study corroborate with a similar study by Akinboro et al.[16] in southwestern Nigeria. A study that involved children aged 5–16 years with Tinea capitis found that this non-life-threatening infection markedly affected the psychosocial life of those suffering from it. Another study by Beattie and Lewis-Jones[22] involving children with all types of skin disorders in United Kingdom noted a low quality of life using the CDLQI instrument. These studies along with this study bring to limelight the necessity for psychological care in this group of children.

Contrary to other studies,[16],[22] this study did not find any significant relationship between the age of the child and the presence of a psychosocial impact. These other studies noted that the psychosocial impact was significantly higher in the older children in comparison to the younger children. Noteworthy is the fact that these studies also involved teenagers in their study population. Nonetheless, the findings of this study possibly infer the need to offer psychosocial care to primary school children with Tinea capitis irrespective of their ages.

Although this study was conducted in a semi-urban area, it is possible that the current westernization trend of overemphasis on external appearances being adopted through the influence of foreign mass media[23] may affect the children. Hence, children with Tinea capitis may be embarrassed because of the appearances of their skin lesions. In addition, the findings of significantly higher prevalence of psychosocial impact among female children are in agreement with other studies.[13],[16] This may not be surprising, because girls are more conscious of their body image than boys.[24] Dermatological disorders in female children may result in a negative perception of their body image, poor social acceptance, and the avoidance of some of their daily enjoyable activities.[25] Females love to have grown hairs for plaiting or braiding. Alopecia is a common complication of the diseases. Therefore, Tinea capitis infection may compromise this expectation and impact negatively on their psychosocial state.[16] Psychological problems such as anxiety, depression, self-withdrawal, and delinquent tendencies have been reported in children with dermatological disorders.[26] Tinea capitis, in particular, presents with itching, loss of the hair, and scaly lesions. These symptoms coupled with its unacceptable appearance and stigmatization (avoidance or restrictions faced by those suffering from the disease) have a significant negative impact on social relations, psychological status, and daily activities of the individual.[8],[27] This study, therefore, highlights the need for holistic care of the primary school children with Tinea capitis; thus, the management of these children, which hitherto has been limited to dermatological care alone,[5],[14],[15] should include psychosocial care. This study also challenged the perception that Tinea capitis is merely a disease affecting the skin.


  Limitation of the Study Top


The authors noted that the absence of comparative groups in this study to explore the differences in the psychosocial impact between children with Tinea capitis and children with other dermatological disorders is a limitation in this study. The authors advocate for future studies to investigate the relationship between psychosocial impact and academic performance among the infected children.


  Conclusion Top


Tinea capitis infection has a negative psychosocial impact in school-aged children. Female children were two times more likely to have to a psychosocial impact because of Tinea capitis than their male counterparts. The age of the child was not significantly associated with the psychosocial impact caused by Tinea capitis.


  Recommendation Top


Collaboration between mental health workers and pediatric dermatologists is advocated to address the psychosocial issues that may arise because of Tinea capitis infection in school-aged children.

Acknowledgements

The authors acknowledge the efforts, support, and encouragement by Dr Ibitein N. Okeafor and the staff of Eagles Watch Research Centre and Care during the period of the preparation of the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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