Favus in an elderly Kashmiri female: A rare occurrence.

Sir,

Tinea capitis, the fungal infection of scalp and hair is uncommon in adults than that in children. Likewise, Favus, a type of tinea capitis, mostly found in endemic areas like Kashmir in India, is most commonly found in children and rarely in adults. We are reporting a case of an elderly Kashmiri female presenting with favus, which is a rare occurrence.

A 60-year-old housewife from rural background was admitted in our department with Steven Johnsen syndrome (SJ syndrome) due to Nimsulide, in May 2012. On cutaneous examination, as an incidental finding, we found scarring alopecia over almost entire scalp and multiple, variable sized, yellow crusted lesions with depressed centers and raised edges over the vertex and occipital region [Figure 1a and b]. On probing, patient revealed that she has 4 years duration of yellowish crusts over the scalp that led to loss of hair. Patient has not taken any treatment for the same. There was nothing significant in the past, family, and drug history. No other family member had such involvement. Her socioeconomic status was below average. She had no features of compromised immune status. Her mucus membrane and nail examination were normal. Her complete blood count revealed increased eosinophil count probably because of drug-induced SJ syndrome. Her liver function tests, kidney function tests, urine analysis, X-ray chest, and electrocardiogram (ECG) were normal. Potassium hydroxide (KOH) examination under microscope showed multiple hyphae [Figure 2]. Skin biopsy of the crusted lesions showed numerous fungal hyphae [Figure 3a and b]. Culture in Sabouraud's dextrose agar showed heaped creamy white colonies of Trichophyton Schoenleinii after 4 weeks of incubation [Figure 4a and b]. Patient was managed for Steven Johnsen syndrome and also put on oral Terbinafine 250 mg once daily. We report this case of adult onset favus as a rare occurrence, though Kashmir is an endemic area for favus in children.

Figure 1

(a and b) Yellow cup-shaped crusts (scutula) and scarring alopecia in patient of favus

Figure 2

KOH wet mount showing fungal hyphae and spores (×40)

Figure 3

(a and b) Histopathological examination of crusted lesions (scutula) showing fungal hyphae (arrows) and inflammatory infiltrate (H and E, ×4 for 3A and ×40 for 3B)

Figure 4

(a and b) Culture in Sabouraud's dextrose agar showing heaped creamy white colonies of Trichophyton Schoenleinii after 4 weeks of incubation and (b) KOH mount from culture under ×40 showing hyphae

Tinea capitis, predominant in preadolescent children, accounts for up to 92.5% of dermatophytosis in children younger than 10 years[1] and 4.9% of tinea capitis occurs in adults.[2] Tinea capitis is uncommon in adults[3] due to many reasons such as fungistatic-saturated fatty acids in sebum that appears at puberty, colonization by malassezia globosa that interferes with dermatophyte contamination and the thicker calibre of adult hair that protects against dermatophytic invasion.[4] Tinea capitis in adults has been reported to occur in patients who are immunosuppressed or HIV-infected.[5] However, there is not enough evidence to support this. Large family size, crowded living conditions, and low socioeconomic status may contribute to an increased chance of tinea capitis. Transmission occurs through infected persons, shed infected hairs, animal vectors, and fomites.[4] Other factors that contribute include contact with affected family members, hormonal differences, composition of sebum, and immunological deficiency.[4] A female predominance in the adult cases has been reported that remains unexplained.[67]

Favus is a type of Tinea capitis, caused by Trichophyton schoenleinii and rarely by T. violaceum and Microsporum gypseum.[89] Favus is relatively common in the countries adjacent to the Mediterranean, south eastern Europe, Southern Asia[9] Greenland, and south Africa.[10] Sporadic cases, however, occur throughout the world, representing importation of the disease.[91112] Favus is a relatively rare disease in most parts of India except Kashmir valley where it occurs in endemic form.[13] Sporadic cases in nonendemic areas have also been reported.[141516] It is characterized by the presence of sulfur-yellow cup-shaped crusts known as “scutula” or “godet” and results in scarring alopecia on healing.[8]

Kashmir valley is an endemic zone for favus in children. We report the case of favus in an elderly Kashmiri female and favus should be considered as a differential diagnosis for cicatricial alopecia even in adults, particularly in endemic areas.