A 5-year-old boy was brought by his parents for medical examination to a temporary medical camp in Cape Coast, Ghana. The child presented with multiple pruritic, nonerythematous, scaly patches of hair loss (Figures).The boy’s parents denied a history of trauma or constant scratching of the scalp.
On physical examination, the patient was alert, awake, and oriented. Cardiopulmonary examination findings were unremarkable. Head and neck examination revealed mild cervical lymph adenopathy. Examination of the patient’s trunk and extremities revealed no other lesions or abnormalities. The patient had noticed that the patches of hair loss had been increasing in size over the past few months.
Tinea capitis is caused by a type of dermatophyte—a cutaneous fungal infection—that infects the scalp and associated hair. Tinea capitis is the most common infection of scalp hair and is spread through direct contact with humans, animals, and fomites.1 The condition most commonly presents as singular or multiple patches of scaly, pruritic alopecia. Small black dots representing broken hairs may also be seen on the scalp. Physical examination findings in patients with tinea capitis are frequently significant for mild cervical and suboccipital lymphadenopathy.2 Secondary allergic cutaneous eruptions called dermatophytid reactions can appear elsewhere on the body, as well. These do not result from direct contact with the infected scalp.3
Kerion is a more serious presentation of tinea capitis. Kerion is an abscess caused by an elevated immune response to a fungal infection. On examination, kerions are painful, erythematous plaques with pustules, crust, and drainage on the scalp.2 Favus is another severe presentation of tinea capitis. Favus is a unique lesion defined by the development of cup-shaped yellow crusts called scutula. Multiple scutula often fuse over areas of hair loss and are usually malodorous.4
Trichophyton and Microsporum species of dermatophyte fungi are the most common causes of tinea capitis. However, the cause of tinea capitis varies significantly with geography. In North America and worldwide, the most common cause is Trichophyton tonsurans.5 In Ghana, where we met this patient, and most other countries in West Africa, the primary causes are Microsporum audouinii and Trichophyton soudanense.6
Tinea capitis should be high on the differential diagnosis of patients who are children, who present with cervical lymphadenopathy, and who present with scaly patches of hair loss on the scalp.6 Our patient had all of these findings. Immunocompromised individuals are also at risk of developing tinea capitis.7 A higher index of suspicion is needed to diagnose the infection in healthy adults. If the diagnosis is unclear, a potassium hydroxide (KOH) preparation of scalp hair should be performed. Under KOH preparation, tinea capitis appears as arthrospores (fungal spores) inside the hair shaft.
Treatment options for individuals with tinea capitis include systemic antifungals such as griseofulvin, terbinafine, fluconazole, and itraconazole. Griseofulvin is considered to be the first-line therapy.2 In fact, after griseofulvin was introduced in the late 20th century, the prevalence of tinea capitis was reduced greatly in North America and Europe. The infection continues to be endemic in other countries.1
Alopecia areata is an autoimmune condition that results in hair loss. Classically, alopecia areata occurs on the scalp but may also affect other areas on the body. The patches of hair loss in alopecia are smooth and not scaly. Additionally, alopecia areata is usually asymptomatic.2 These clinical features are not consistent with those present in our patient.
Psoriasis is an inflammatory condition that, unlike alopecia areata, results in erythematous plaques with scales on areas of hair loss. These dermatologic findings are usually on flexor surfaces such as the knees and elbows, not the scalp. Additionally, there are several key systemic findings of psoriasis, including nail pitting, onycholysis, and, sometimes, arthritis.8 Because our patient’s hair loss was limited to the scalp, and because there were no systemic findings consistent with psoriasis, this condition can be ruled out of the diagnosis.
Seborrheic dermatitis results in scaling and pruritus of the scalp. It does not cause alopecia, as was seen in our patient. Telogen effluvium—thinning of hair (usually on the scalp)—can be either temporary or chronic. Usually, less than half of the hair on the scalp is lost. It results from an aberration in the hair growth cycle whereby excessive shedding occurs. While the mechanism of telogen effluvium is not well understood, it is associated with inciting factors such as acute or chronic illness, rapid weight loss, collagenous disorders, and nutritional deficiencies.9 Our patient had patches of hair loss as opposed to diffuse thinning. Also, the patient’s history did not reveal any triggering events for telogen effluvium.
Hair loss can result from a number of pathologic processes, including trauma, immune dysfunction, and infection. Clinicians should be diligent in taking a detailed history and physical examination to develop an accurate differential. Consistent with the diagnosis of tinea capitis, our patient was prescribed griseofulvin.
Ankoor Talwar BS/MBA/MD Student, Union College/Albany Medical College, Albany, New York
Abhinav Talwar BS/MD Student, Northwestern University Feinberg School of Medicine, Chicago, Illinois
Sonia Talwar, MD North Shore University Hospital at Plainview, Plainview, New York
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