Morning Report

Rachel Laarman PGY-3

History
5 yo female presents to clinic with several week history of itchy/ flaking scalp. Mom is embarrassed by all the flaking and has been using grease to keep the scalp moist. She is also concerned that her part seems wider. PMH: UTI as infant, no VUR. Imms UTD FamHx: Negative Social Hx: Lives with Mom, older brother, has two cats at home Meds: None Allergies: None

ROS
Negative for fever, rash elsewhere, N/V, Diarrhea, Pain Positive for itchy scalp, suboccipital lymphadenopathy

Differential Time!

Physical Exam
Vitals: Afebrile. HR 87, BP 95/65 Gen: African-American Female in NAD HEENT: NC/AT. +posterior occipital lymphadenopathy B/L, PERRL, OP clear, Tonsils 2+, no exudate. Scalp: diffuse flaking and scale across scalp with thicker crust along part, area of hair loss along central part, with some broken off hairs seen CV: RRR, normal S1, S2, no murmur, no gallop RESP: CTAB, no wheezes, crackles Abd: Soft, NT, ND. +BS Neuro: Alert, oriented, intact. Moving all extremities equally Skin: Mild rash- erythematous papules scattered across chest/back, no jaundice, pallor.

Differential Time!

Labs/Imaging
SCALP CULTURE: + for Trichophyton Tonsurans
Send for Fungus.
Takes 4-6 weeks to come back. Very important for treatment

Tinea Capitis
Caused by Trichophyton tonsurans, Microsporum, Epidermophyton Dermatophyte infection: feast on keratin, invade the stratum corneum Spread by spores Direct human contact, Zoophilic infection

Tinea Capitis
Most common in children less than 10 years old
Thought to be related to change in fatty acids in postpubertal sebum 3-7 years typical

Epidermal inflammation related to immunologic response to fungi varies ID reaction: rash on face, trunk, neck from immune response to fungus, can present after starting medication not drug allergy
Resolves spontaneously

 Figure 8. Tinea capitis characterized by thick white crusting of scalp. Note hair loss with widening of hair part and compare with normal hair part in front of the braid.

Treatment: Systemic
Griseofulvin 20-25 mg/kg/day once daily or BID
8 week course at minimum Absorption improved with fatty food intake

Itraconazole Fluconazole
4-6 week course Need to check LFTs

Terbinafine
2-4 week course Need to check LFTs

Treatment: Topical
Ketoconazole 2% shampoo/ Selenium sulfide
Lather and leave on for 5 minutes 2-3 times per week for 3-4 weeks Families like this, and it is a good adjunct

Summary
If suspecting Tinea: get a culture. Treat with Griseofulvin: Cheap.
Dosing is 20-25 mg/kg/day QD or BID for 8 weeks

See back in clinic monthly

References
Shy, R. Tinea Coporis and Tinea Capitis. Pediatrics in Review 2007; 28: 164-173. Kakourou, T and Uksal, U. Guidelines for the management of Tinea Capitis in Children. Pediatric Dermatology 2010; 27: 226-228.

Board question
An 8 year old girl presents with localized hair loss of 2 months duration. Physical exam reveals a patch of nearly complete hair loss in the parietal scalp. The scalp is smooth without redness, scaling, or broken hairs. Of the following, the MOST likely explanation for these findings is
A. alopecia areata B. telogen effluvium C. tinea capitis D. traction alopecia E. trichotillomania

A. Alopecia Areata
AA usually occurs on frontal or parietal scalp. They may loose eyelashes or eyebrows also, total loss of scalp hair is rare. Some may have nail pitting associated. Thought to be immune dysregulation. Most kids 95% will regrow their hair in 1 year. 30% will recur. Telogen effluvium is diffuse rather than localized. Hair loss happens 2-4 months after stress, including a febrile illness. Loss can continue for 3-4 months, then growing hair cycles normally. TC has associated scaling, and black dots of broken hairs. Trichotillomania has irregular areas of alopecia with hair of different lengths.