Significance of scraping scalp lesions in adults.

Sir,

A 30 year-old female patient presented to us with pus-filled lesions on the scalp associated with hair loss and pain for the past 2 years. The lesions initially began over the vertex and gradually involved the entire scalp. There was no history of remissions or exacerbations, no history of application of any medications prior to and after the onset of lesions. There was no similar history among family members. On examination, the patient had scarring alopecia over the vertex and occipital area. Multiple pustules and crusted lesions were seen along the margins of the alopecia [Figure 1]. There was no cervical lymphadenopathy. General cutaneous examination, body hair, and nails were normal. A provisional diagnosis of folliculitis decalvans and dissecting cellulitis of the scalp was made. Specimens were collected for biopsy and Gram stain. After two days, the patient presented again with multiple erythematous papules over the forehead, arms, forearms, and back associated with itching. Biopsy showed hyphae and spores within the hair shaft, perifollicular inflammation on periodic acid Schiff staining with destruction of few follicles [Figure 2]. Retrospectively, potassium hydroxide (KOH) examination of the scrapings was done which showed multiple hyphae and spores [Figure 3]. Routine biochemical investigations were normal and enzyme-linked immunosorbent assay for Human Immunedeficiency Virus was nonreactive. The patient was given Tab. griseofulvin 375 mg once daily for 6 weeks along with Tab prednisolone 30 mg OD for 5 days. The lesions began resolving by 3 weeks [Figure 4]. The treatment was continued for 12 weeks.

Figure 1

Multiple inflamed lesions with pustules

Figure 2

Spores and hyphae within the hair on HPE

Figure 3

KOH mount of scrapings showing spores and hyphae

Figure 4

Resolution of the lesions with scarring

Tinea capitis is fungal infection of the scalp and hair which is seen predominantly in preadolescent children. It accounts for up to 92.5% of dermatophytoses in children younger than 10 years.[1] Tinea capitis may be rare in adults due to the fungistatic saturated fatty acids in sebum which appears at puberty. Colonization by Malassezia globosa may interfere with dermatophyte contamination, and the thicker calibre of adult hair may protect against dermatophytic invasion. Tinea capitis in adults generally occurs in patients who are immunosuppressed and those infected with HIV. In immunocompetent adults, the clinical features are often atypical. The disease may resemble bacterial folliculitis, folliculitis decalvans, dissecting cellulitis, or the scarring related to lupus erythematosus.[23] It afflicts women more commonly than men. In urban populations, large family size, crowded living conditions, and low socioeconomic status may contribute to an increased incidence of tinea capitis. Transmission occurs through infected persons, shed infected hairs, animal vectors, and fomites. Infectious organisms may remain viable for many months after being shed from their host. Many adults acquire tinea corporis from infected children, but tinea capitis is rare in adult contacts.[4]

We report a case of tinea capitis in an immunocompetent adult from urban area with features simulating folliculitis decalvans. Biopsy helped us in diagnosing this case. Though there are reports of tinea capitis in adults presenting as pyodermas, folliculitis decalvans, or dissecting cellulitis of the scalp, the diagnosis may be missed by the clinician in a busy out patient department. The differential diagnosis of tinea capitis should be considered in adults with scalp lesions like pustules, alopecia, or scaling. A simple KOH examination will diagnose this condition even in the early stages. Otherwise, the patient may be subjected to unnecessary investigations and treatment. Early diagnosis can be done with high degree of clinical suspicion which will avert further sequelae-like scarring.