DISCUSSION RESPONSE

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.

Superficial fungal infections are usually caused by dermatophytes or yeast organisms; dermatophytes infest the skin and nails and thrive in stratum corneum of the skin, hair, and nails (Buttaro et al., 2017). The inflammatory reaction caused by dermatophytes differs depending on what body area is affected and the type of organism (DermNet, 2014). Dermatophyte infections are most common in the scalp hair and body surfaces during childhood (Buttaro et al., 2017).

Differential Diagnosis

Tinea Capitis – is the most likely diagnosis and is the most common dermatophyte infection in childhood, typically from the ages of 2-10, and is more common in boys (Burns et al., 2017). Physical examination usually reveals scaling, erythema, or crusting, bald patches or areas of broken hairs, and most often caused by M. canis hair is broken and lusterless with a gray scale on the scalp (Burns et al., 2017)

Psoriasis Vulgaris – psoriasis is an immune-mediated skin disorder with a genetic predisposition that causes keratinocyte proliferation and dermal vascular abnormalities (Burns et al., 2017). Infections, local trauma, stress and drugs can trigger the disease and childhood-onset occurs in 30% of cases (Burns et al., 2017). Plaque psoriasis is a well-marginated rash that becomes popular with silver scales; psoriasis vulgaris produces erythematous plaques with thick, silvery-white scales concentrated on elbows, knees, scalp, and hairline (Burns et al., 2017). Fungal infection should be ruled out prior to diagnosis (Burns et al., 2017).

Seborrheic dermatitis – also known as cradle cap or dandruff, commonly presents as dry, flaky, scales on the scalp and is caused by sebaceous gland secretion and the presence of Malassezia yeast (Burns et al., 2017). Seborrheic dermatitis may resemble dermatophytosis, eczema, psoriasis, etc. but will be more “yellowish in color” and only cause hair loss if complicated by a secondary staphylococcal infection (DermNet, 2014).

Treatment and Management Plan

Medication –

Griseofulvin ultramicrosize 10-15mg/kg/day or griseofulvin microsize 20-25 mg/kg/day taken with fatty foods to enhance absorption until two weeks after a negative culture (Burns et al., 2017). Side effects may include GI disturbances, photosensitivity, skin eruptions, and headache (Burns et al., 2017).

Shampoo with selenium sulfide 2.5% or econazole, or ketoconazole 2% two to three times a week for four weeks (Burns et al., 2017)

Prednisone 1 to 2 mg/kg/day for 5 to 14 days if kerion with severe inflammation is present (Burns et al., 2017).

Education

Family and pets should be checked for infection and treated to prevent transmission and reinfection, asymptomatic carriers are common (Burns et al., 2017).

Hair regrowth is slow, possibly taking up to a year and maybe permanent (Burns et al, 2017)

Sheets and clothes should be washed in hot water and dried on hot cycle, increase vacuuming (Burns et al., 2017)

Hair traction, greasy pomades, and infrequent shampooing may increase risk of infection (Burns et al, 2017).

Follow-up

2 weeks to evaluate treatment, then every 2 to 4 weeks until new hair growth (Burns et al, 2017).

Reference

Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G., & Garzon, D. L. (Eds.). (2017). Pediatric primary care (6th ed.). St. Louis, Missouri: Elsevier.

Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice (5th ed.). St. Louis, MO: Elsevier.

DermNet New Zealand Trust. (2014). DermNet NZ. Retrieved from http://www.dermnetnz.org/