Tinea capitis (Scalp Ringworm)
You see a 9-year-old male who presents with a white, scaly patch on the back of his head. There is some alopecia in the area with hair breakage noted at the scalp.
Tinea capitis (Scalp Ringworm)
Based on the information provided in this case study, I believe that this child may be suffering from Tinea capitis (Scalp Ringworm). Tinea capitis is a common infection of the scalp caused by dermatophyte fungi and occurring mainly in children between five and ten years (Rayala BZ & Morrell DS, 2017). It is a highly contagious fungal infection of the scalp, with extension to the eyebrows and eyelashes. The clinical manifestations of tinea capitis range from as mild scaling with little hair loss to extensive alopecia, patchy hair loss, scaling, or scalp inflammation with positive direct microscopic examination and positive culture. The lesion spreads, forming numerous papules in a typical ring form. Ring-shaped lesions may coalesce with other infected areas (Fuller LC, Barton RC, Mohd Mustapa MF, et al., 2014). The area affected is usually limited, but occasionally, a large confluent may involve much of the scalp.
Differential Diagnosis
- Alopecia Areata: Alopecia areata is a recurrent non-scarring type of hair loss that can affect any hair-bearing area and can manifest in many different patterns. Even though it is a benign condition and most patients are asymptomatic, it can cause emotional and psychosocial distress (Darwin E, Hirt PA, Fertig R, Doliner B, Delcanto G, Jimenez JJ, 2018). Signs and symptoms most often are asymptomatic, but some patients experience a burning sensation or pruritus in the affected area. It can affect any hair-bearing area, and more than one area can be affected at once. Frequency of involvement at sites is the scalp, beard, and eyebrows.
- Atopic Dermatitis: Atopic dermatitis is a chronic, pruritic inflammatory skin disease of unknown origin that usually starts in early infancy, but also affects a substantial number of adults. It is commonly associated with elevated levels of immunoglobulin E (IgE). It is the first disease to present in a series of allergic diseases, including food allergy, asthma, and allergic rhinitis (Carlsten C, Dimich-Ward H, et al., 2013). Signs and symptoms are incessant pruritus and early age of onset.
- Plaque Psoriasis: Psoriasis, which manifests most often as plaque psoriasis, is a chronic, relapsing, inflammatory skin disorder with a strong genetic basis. Plaque psoriasis is rarely life-threatening, but it usually is intractable to treatment (Lowes R, 2014). Its signs and symptoms include red patches of skin covered with thick, silvery scales, small scaling spots, dry, cracked skin, itching, burning or soreness, swollen and stiff joints. It is mostly located on the scalp, trunk, and limbs, with a preference for extensor surfaces, such as the elbows and knees.
I think that Tinea capitis is the possible diagnosis because of the white, scaly patch on the back of the patient’s head, and some scalp alopecia.
Treatment
After microscopic or culture confirmation, medical therapy should be initiated. Griseofulvin has been the traditional treatment of choice in all ringworm infections of the scalp. Griseofulvin remains an effective therapy for tinea capitis. Dosing in the pediatric population is weight based. Recommended dosing is 20-25 mg/kg/day in single or two divided doses for microsized griseofulvin or 15-20 mg/kg/day in a single dose or two divided doses for ultramicrosized griseofulvin for 4-6 weeks (Shemer A, Plotnik IB, Davidovici B, et al., 2013). Therapeutic progress is monitored by regular clinical examination with the aid of a wood lamp for fluorescent species such as M audouinii and M canis. Adverse effects include nausea and rashes. Topical treatment alone usually is ineffective and is not recommended for the management of tinea capitis. Newer antifungal medications, such as itraconazole, terbinafine, and fluconazole, have been reported as effective alternative therapeutic agents for tinea capitis. Griseofulvin accumulates in the keratin of the horny layer, hair, and nails, rendering them resistant to invasion by the fungus. Treatment must continue long enough for infected keratin to be replaced by resistant keratin, usually 4-6 weeks. Selenium sulfide shampoo may reduce the risk of spreading the infection early in the course of therapy by reducing the number of viable spores that are shed.
Patient Education
Patient and parents would be educated not to share personal items, like clothing, towels, hairbrushes, or to borrow such items from other children. According to the American Academy of Pediatrics, children receiving treatment for tinea capitis might attend school, and haircuts, shaving of the head, wearing a cap during treatment are not necessary. Parents to make sure that the child washes his or her hands frequently to avoid the spread of infection. Keep common or shared areas clean, especially in schools, child care centers, gyms, and locker rooms. And to be sure to wash the child’s scalp regularly using shampoo, especially after haircuts.
Reference
Carlsten C1, Dimich-Ward H, Ferguson A, Watson W, Rousseau R, Dybuncio A, Becker A,
Chan-Yeung, M. (2013). Atopic dermatitis in a high-risk cohort: natural history, associated allergic outcomes, and risk factors. Ann Allergy Asthma Immunol, 110(1):24-8. doi: 10.1016/j.anai.2012.10.005.
Darwin E, Hirt PA, Fertig R, Doliner B, Delcanto G, Jimenez JJ. (2018). Alopecia Areata:
Review of Epidemiology, Clinical Features, Pathogenesis, and New Treatment Options. Int J Trichology, 10 (2):51-60.
Fuller LC1, Barton RC, Mohd Mustapa MF, Proudfoot LE, Punjabi SP, Higgins EM. (2014).
British Association of Dermatologists’ guidelines for the management of tinea capitis. Br J Dermatol;171(3):454-63. doi: 10.1111/bjd.13196.
Lowes, R. (2014). FDA approves apremilast (Otezla) for plaque psoriasis. Medscape Medical
News.
Rayala BZ, Morrell DS. (2017). Common Skin Conditions in Children: Skin Infections. FP
Essent, 453:26-32.
Shemer A, Plotnik IB, Davidovici B, Grunwald MH, Magun R, Amichai B. (2013). Treatment of
tinea capitis – griseofulvin versus fluconazole – a comparative study. J Dtsch Dermatol Ges.