What’s Causing Scalp Lesions and Hair Loss in a Pair of Young Patients?
In case 1, a 16-year-old, otherwise healthy African American adolescent presented to the emergency department (ED) with her grandmother. The girl had noted a large, circular area of alopecia with areas of pink excoriations on her scalp earlier that day, after the removal of her sewn-in braids. The grandmother, who has systemic lupus erythematosus (SLE), attributed this hair loss to a similar diagnosis. The patient stated that the braids might have been sewn too tightly onto her scalp. She denied pain at the site of alopecia, similar rashes elsewhere, joint pain, a personal or family history of recurrent skin infections, fever, chills, nausea, vomiting, constipation, and diarrhea.
On physical examination, the patient was afebrile with stable vital signs and without signs of acute distress. External inspection of the scalp showed a large, circular, bald area with bogginess, crusting, and pus-like discharge in the parietal region of her scalp (Figure 1).
No other hyperpigmented or hypopigmented lesions or rashes were noted upon examination of her body. The remainder of the physical examination findings were unremarkable.
In a second, unrelated case, an 8-year-old, otherwise healthy African American boy presented to the ED with his mother, who had noted increasing swelling and drainage of a lesion on the boy’s right scalp, with associated alopecia, pruritus, and pain. The lesion initially had started as a small bump 3 weeks ago, at which time the patient was seen in an urgent care medical center, was diagnosed with ringworm of the scalp, and was started on topical ketoconazole shampoo without improvement. His primary care physician subsequently prescribed topical ketoconazole cream, as well as griseofulvin twice daily and topical hydrocortisone cream, 1%, twice daily. The patient presented to the ED for lack of improvement, the lesion turning yellow, and discharge coming from it.
On physical examination, the patient was afebrile, in no acute distress, with stable vital signs. He was noted to have a large, circular, boggy, alopecic lesion on right parietal scalp (Figure 2), which showed no signs of active discharge. The boy’s face and ears, including the external auditory canals, showed diffuse, mildly excoriated papules (Figures 3 and 4); multiple papules also were present on his head and neck. The patient denied any fevers, chills, nausea, vomiting, or other complaints. The rest of the physical examination findings were unremarkable.
What's Your Diagnosis?
A. Scalp cellulitis and abscess
B. Tinea kerion
C. Contact dermatitis
Answer: Tinea kerion
In approaching skin complaints, it is important to keep a wide array of differentials in mind. Many skin conditions can be quickly diagnosed with visual inspection; however, a thorough history and physical examination is most important in the inclusion or exclusion of many systemic diseases that can present with cutaneous manifestations. A basic assessment includes palpation for texture, morphology, size, color, location, and distribution of the lesion.1 Erosions, excoriations, fissures, and crusting are suggestive of a compromised dermal layer, increasing the risk of a secondary infectious process.1 History of atopy (eczema), lesions in a malar distribution on the face (SLE), lesions on flexor surfaces (psoriasis), and tender, erythematous nodules on the lower extremities (inflammatory bowel disease) are some of the most common pediatric diagnoses that present with cutaneous manifestations.
Further testing to consider includes skin biopsy, examination using a Wood lamp (helpful in evaluating hypopigmented and certain fungal lesions), potassium hydroxide (KOH) preparation to evaluate possible fungal and dermatophytic lesions, a Tzanck smear for viral (herpetic) lesions, and immunofluorescence studies to evaluate for deposition antibodies that can be present in some immunologic conditions.1
Tinea capitis is a dermatophyte infection of the hair follicle and dermis that often presents in otherwise healthy and immunocompetent children. Our patients had a tinea kerion, which is an inflammatory response to a tinea capitis infection producing an “elevated, boggy granulomatous mass … often studded by pustules.”1 Symptoms can include pruritus, fever, local lymphadenopathy, and alopecia. With tinea kerion in particular, it is important to consider the presence of secondary bacterial infections so that appropriate treatment can be initiated early in the infectious process.
Diagnosis. The diagnosis often can be made based solely on the history and physical examination findings. KOH preparation can be used to confirm the diagnosis, with the most common organisms being Trichophyton tonsurans and Microsporum canis.
Treatment. While long-term oral therapy with griseofulvin is the standard of care, topical therapy can be as used an adjunct to prevent shedding and further spread of spores.1 Sporicidal shampoos containing selenium sulfide or ketoconazole can be used to treat the patient and close family contacts. Oral and intralesional corticosteroids plus oral antifungals have shown only mild improvement in discomfort caused by the lesions, with no improvement in the cure rate.2,3
Due to the lesions’ boggy appearance, many patients are admitted for antibiotic therapy with concern for secondary bacterial infection. However, studies largely have shown that most cases are without a bacterial source and often can be managed in an outpatient setting with close and frequent follow-up.4
The first patient (Figure 1) was instructed to use ketoconazole shampoo and was placed on a 6-week course of oral griseofulvin and a 2- week course of oral corticosteroids. Without signs of secondary infection or other systemic symptoms, antibiotic therapy was not initiated. Over the course of 2 months, the patient had significant improvement in the overall appearance of the scalp, including decreased bogginess, decreased pruritus, and hair regrowth. The girl’s mother was counseled on appropriate scalp hygiene and avoidance of tight hair weaves until the girl’s symptoms resolved.
For the second patient (Figures 2-4), a consultant dermatologist recommended adding oral prednisone for 2 weeks to the regimen. The patient was instructed to continue using the ketoconazole shampoo and the oral griseofulvin.
At his follow-up appointment, the patient was noted to have posterior cervical lymphadenopathy and a right parietal kerion. Cultures were sent, and the patient was advised to continue oral griseofulvin and ketoconazole shampoo. The patient was also noted to have fine, flesh-colored papules on the face, ears, neck, chest, abdomen, back, and upper and lower extremities, identified as a reaction to the fungus. He was started on topical desonide to his body twice daily, as well as hydrocortisone ointment, 2.5%, to his face twice daily. At his 6-week follow-up appointment, his skin lesions demonstrated moderate improvement.
Jennifer Rabjohns, MS-IV, is a medical student in the class of 2016 at the Case Western Reserve University School of Medicine in Cleveland, Ohio.
Aditi Jayanth, MD, is a pediatrics emergency medicine fellow at SUNY Downstate Medical Center/Kings County Hospital in Brooklyn, New York.
David Effron, MD, is an assistant professor of emergency medicine at Case Western Reserve University and an attending physician in the Department of Emergency Medicine at MetroHealth Medical Center in Cleveland, Ohio.
References:
- Morelli JG. Cutaneous fungal infections. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, PA: Elsevier Saunders; 2007:chap 665.
- Hussain I, Muzaffar F, Rashid T, Ahmad TJ, Jahangir M, Haroon TS. A randomized, comparative trial of treatment of kerion celsi with griseofulvin plus oral prednisolone vs. griseofulvin alone. Med Mycol. 1999;37(2):97-99.
- Ginsburg CM, Gan VN, Petruska M. Randomized controlled trial of intralesional corticosteroid and griseofulvin vs. griseofulvin alone for treatment of kerion. Pediatr Infect Dis J. 1987;6(12):1084-1087.
- Pomeranz AJ, Fairley JA. Management errors leading to unnecessary hospitalization for kerion. Pediatrics. 1994;93(6 pt 1):986-988.