tinea capitis is a fungal infection of hair and scalp that typically occurs in childhood and equally in both sexes that has recently increased in incidence in adults and the elderly . t. tonsurans infections may not be symptomatic and mostly infects children ; however , it can also cause disease in adults who are close contact with those children . thus , it is difficult to diagnose and it requires a high index of suspicion from the examination physician . tinea capitis has clinical features ranging from a non - inflammatory scaling to a severe pustular eruption with alopecia , known as kerion . t. tonsurans performs an endothrix type of hair invasion , which causes hair to break easily . in addition , it also leads to an inflammatory tinea capitis , which often leads to misdiagnoses . a 38-year - old primary school female teacher presented with a history of symptomless , patchy , slow , progressive hair loss for several years . she had been using over - the - counter ketoconazole shampoo regularly for a long time without any improvement . the patient denied history of animal contact or history of pattern hair loss in her family . bizarre - shaped patches of hair loss with surrounding hair thinning on the vertex were observed ( figure 1 ) . there was no broken hair shaft , exclamation - point hair or significant scalp inflammation surrounding the area of alopecia . potassium hydroxide ( koh ) 10% examination from hair and scalp was negative , and therefore , fungal culture was not performed . the clinician raised the possible diagnosis of this atypical , non - scarring alopecia as alopecia areata with the differential diagnosis of androgenetic alopecia , chronic telogen effluvium , and trichotillomania . betamethasone valerate scalp lotion was prescribed to apply twice daily on the affected scalp area but without any clinical improvement . two 4 mm punch biopsy specimens were taken from the peripheral edge of the alopecia for both vertical and transverse sections to evaluate the cause of non - scarring hair loss in this patient . the histopathology of the scalp biopsy specimens demonstrated an adequate number of terminal hair follicles without evidence of dermal fibrosis . there was minimal superficial perivascular and perifollicular mononuclear cell infiltrate in some of the follicles without definite peribulbar infiltration . numerous fungal hyphae and arthrospores within several hair shafts were demonstrated in both vertical and transverse sections . the epidermis remained intact with orthokeratosis of the keratin and no significant inflammation ( figure 2a and b ) . dermoscopic examination revealed broken hair shafts , comma hair sign and a large number of corkscrew hairs ( figure 3a and b ) . wood lamp s test revealed a non - fluorescent result . a fungal culture from scalp biopsy and hair demonstrated colonies of t. tonsurans . based on clinical presentation , the patient was treated with griseofulvin 500 mg twice daily in combination with ketoconazole shampoo once daily application for eight consecutive weeks . this patient was not in a common age group and partially treated with ketoconazole shampoo . thus , the symptoms could be concealed , resulting in the delay of diagnosis . generally , the diagnosis of tinea capitis must be confirmed by koh preparation of infected hairs and a fungal culture . although scalp biopsy provides high sensitivity , this procedure is invasive and unable to identify the species of pathogen . therefore , the procedure is not in routine clinical use . scalp skin biopsy is performed in order to make a differential diagnosis of unidentified alopecia or another alopecia that is recalcitrant to treatment . due to the obscure clinical presentation of tinea capitis in this patient , the dermoscope , a non - invasive handheld device , could be useful for diagnosis . the appearance of lesional hair under the dermoscope were comma shape and corkscrew hairs , regardless of dermatophyte species . tinea capitis treatment is mainly oral antifungals , but a topical antifungal shampoo is suggested as an adjuvant therapy . this patient used antifungal shampoo for several years that prolonged the disease without complete cured . using of antifungal shampoo probably caused the result to be negative in the first koh examination . additionally , this patient had been prescribed topical steroid medication , which caused a positive result in the following koh examinations . apart from treatment , physicians should consider disease prevention by screening for close - contact individuals and carriers especially in this particular case : the patient was a primary school teacher , who had contact with children . physicians could not make a diagnosis due to the unclear clinical features , until histopathologic exam of the hair shaft showed endothrix fungal infection . the patient had been using over - the - counter ketoconazole shampoo regularly for a long period of time , which caused tinea capitis signs and symptoms unclear and a negative result in the first koh test .