Wednesday, September 20, 2017

17 year-old girl with 8 year history of scalp dermatitis


The patient is a 17 year-old girl with an 9 year history of thick scales on her scalp.  She has used multiple medications without relief.  The patient has been bullied at school where she has been called “lice girl.”  Socially, this has been traumatic.

O/E:  She is a well-developed and well-nourished 17 yo with thick chestnut colored hair or normal intelligence.  There are no areas of alopecia. Thick, silvery adherent scales are present on the occipital, parietal and temporal scalp.  When these are removed, hair roots come out, too.  The remainder of the cutaneous examination is normal.  No nail dystrophy.
Clinical Images (July 2017)
Lab: Fungal culture negative.  Bacterial culture 3+ Staph aureus.

Failed Treatments (per mother):

"Every single otc dandruff shampoo
Every prescription medicated dandruff shampoo
Scalpicin
Prescribed scalp drops with and without coal tar
Every Tea Tree product you can find otc
Hot oil treatments
P & S Oil
Nutrogena T-gel and T-sal
Olive oil"
Terbinafine 250 mg p.o. x 1 month
Keflex 500 mg b.i.d. x 2 weeks

Scalp Biopsy read by Lynne Goldberg (Boston University Skin Path): was felt to be most compatible with psoriasis.  Seborrhea was in the differential diagnosis but less likely.

Diagnosis:  Working Dx:  Tinea amiantacea secondary to psoriasis.

Discussion: This 17 yo girl has suffered with what appears to be tinea aminatacea for almost a decade.  It appears unlikely that this is psoriasis. Tinea capitis has been ruled out by culture.  Her bacterial culture showed 3+ S. aureus but I suspect this is a secondary invader as she did not improve with cewplanexin.  Since the fungal  culture was negative and these approaches were not helpful, I may recommend isotretinoin.  The use of this has been reported for T. aminatacea only and in a Korean case report.

Dr. Goldberg's rotocol for Scalp Psoriasis, Tinea amiantacea and Related disorders:
1. Wet hair at night
2. Apply Dermasmoothe scalp oil liberally to scalp. Leave on overnight
3. Sleep with this overnight in a shower cap (to protect pillow)
4. Shampoo in the morning with T-Sal or other dandruff shampoo

Do this nightly at first if possible, but after a week or so she will be better and will not need to do it every night.



References:

1. Abdel-Hamid I et al. Pityriasis amiantacea: a clinical and etiopathologic study of 85 patients. Int J Dermatol. 2003 Apr;42(4):260-4.

2. Kwon JI.  Isotretinoin for Tinea amiantacea (A Case Report). Korean J Dermatol 2012;50(11):1002-1005 (In Korean)

3.  Mannino G, McCaughey C, Vanness E. A case of pityriasis amiantacea with rapid response to treatment WMJ. 2014 Jun;113(3):119-20.  Full Free Text.


4. Scalp psoriasis: European consensus on grading and treatment algorithm.  Ortonne J. J Eur Acad Dermatol Venereol. 2009 Dec;23(12):1435-44.

4 comments:

  1. Hi David ,I would agree with bx for histo and culture . I have seen one case where the patient had histiocytosis X involving the scalp and also glue ear . Further blood tests showed diabetes insipidus .There was no body rash . Regards Chris Tyson . .

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  2. Poor girl. I would biopsy. Need to r/o any underlying inflammatory cause. Consider longer antibiotic course (doxycycline or MCN if not allergic) for 1-2 months as anti-inflammatory and potent topical steroid (clobetasol) solution in AM, Derma-Smooth oil with cap qhs, and shampoo out in AM (maybe t-sal to help with scale and alternate with keto shampoo in case of seb Derm overlap). Good luck!!! Kathryn Barlow

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  3. I had same case recently with same culture. I used same oral treatmen. I used a lot of salicylic aicd&urea topically for a lot of scales with significant improvement. My patient was 35-year old healthy women. I consider neglect dermatitis in ddx in otherwise hygienic woman

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  4. David AltmanOctober 28, 2017

    I have found that the topical regimens can't cope with this degree, or the patient can't cope with the intensive enough topical regimen. When that happens I use oral griseofulvin for a couple months and then continue a topical regimen alone.

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