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Inflammatory masses on boy’s scalp

An 8-year-old boy was brought to his family medicine clinic for treatment of 2 pruritic, inflammatory masses on his scalp that he’d had for one month. The edematous lesions were ulcerated with a crust, and had a diameter of approximately 6 cm and 4 cm on the frontal and occipital scalp, respectively. They hadn’t responded to an unknown treatment administered at a health center in Afghanistan. The boy also had a well-demarcated, erythematous macule with scales on his face. His brother and sister also complained of pruritic, erythematous papules on their arms and faces.

What’s your diagnosis?


 

The patient was given a diagnosis of tinea capitis (ringworm of the scalp) based on the clinical presentation. (His brother and sister were told that they had tinea corporis and tinea faciei, which our patient also had on his face.)

Tinea capitis is a fungal infection of the scalp that usually starts as flaky and crusty patches of skin, broken-off hair, erythema, scaling, and pustules on the scalp. This can quickly deteriorate into a boggy and pruritic mass of inflamed tissue known as a kerion, which can become severely inflamed and develop regional lymphadenopathy. Hypersensitive and highly inflammatory reactions that look similar to a bacterial infection may be found when the infection is caused by a zoophilic dermatophyte.

Tinea capitis primarily affects children younger than 10 years of age, with a peak incidence among African American boys. Because US public health agencies no longer require physicians to report cases of tinea capitis, its true incidence in the United States is unknown, but it is believed to be increasing.

Tinea capitis is treated with systemic antifungal medication. Oral antifungal agents, such as griseofulvin, itraconazole, terbinafine, and fluconazole, are effective. Oral fluconazole is typically administered at a dosage of 5 to 6 mg/kg/d for 3 to 6 weeks; an alternative regimen, 8 mg/kg once weekly for 8 to 12 weeks, is safe, effective, and associated with high compliance. Short-duration therapy with fluconazole 6 mg/kg/d for 2 weeks is also effective.

This patient was treated with oral fluconazole 50 mg/d for 2 weeks and showed rapid improvement. Fluconazole was continued at 150 mg weekly for another 2 weeks, and at 6 weeks, his scalp lesions had completely resolved. The patient’s siblings were initially treated with topical itraconazole, without effect. They were switched to oral fluconazole 50 mg/d and improved.

Adapted from: Kim K. Inflammatory masses on boy’s scalp. J Fam Pract. 2015;64:367-369

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