Tinea amiantacea

Tinea amiantacea

Abstract:  17 yo girl with 10 year history of thick adherent scales over scalp

HPI:  The patient is a 17 yo girl who has suffered with wide-spread thick adherent scaly concretions over the scalp.  She has been bullied and teased at school for many years, often being called “lice girl” and similar epithets. She has tried many tar shampoos, ketoconazole shampoo, olive oil, and P&S liquid; all without effect.  There is no personal or family history of psoriasis or atopy.

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.

Photo:

Laboratory: 

CBC, Chemistries normal.

Fungal Culture:Negative at 1 month

Bacterial Culture: 3+ Coag positive Staph aureus (sensitivities pending)

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: Tinea amiantacea, aka Pityriasis amiantace.  In this case, the cause of T. aminatacea was most likley psoriasis.

Discussion:  This 17 yo girl has suffered with what appears to be tinea aminatacea for a decade.  It appears unlikely that this is psoriasis. Tinea capitis has not been ruled out.  I have found KOH preps from the scalp difficult, so did a fungal culture.  Her bacterial culture showed 3+ S. aureus but I suspect this is a secondary invader.  My plan at this time is to treat with two weeks of an antibiotic based on sensitivities, and start on terbinafine pending fungal culture.  If culture negative and if these approaches are not helpful, I may recommend isotretinoin.  The use of this has not been reported for T. aminatacea; but it makes some sense.  The other question I have is whether a scalp biopsy may be helpful.

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. Pityriasis amiantacea: a clinical and etiopathologic study of 85 patients.

Abdel-Hamid IA. Int J Dermatol. 2003 Apr;42(4):260-4.

Abstract

RESULTS: A total of 85 PA patients were collected and studied. Pathological diagnosis of scalp psoriasis was confirmed in 35.3% of cases. Eczematous features suggesting a diagnosis of seborrheic and atopic dermatitis were detected in 34.2%. Diagnosis of tinea capitis, diagnosed by potassium hydroxide preparation, fungal culture, and periodic-acid Schiff staining, was detected in 12.9% of the PA patients. Staphylococcus isolates were detected in 96.5% of the PA patients compared with 15% in healthy persons as the control (P > 0.00001).

CONCLUSIONS: Pityriasis amiantacea represents a particular reaction pattern of the scalp to various inflammatory scalp diseases. The most frequent skin diseases associated with PA are psoriasis and seborrheic dermatitis. It is important to keep the diagnosis of tinea capitis in mind when evaluating PA patients. Staphylococci on the scalp could participate in the pathogenesis of PA.

2. Tinea capitis favosa misdiagnosed as tinea amiantacea.

Anane S, Chtourou O. Med Mycol Case Rep. 2012 Dec 28;2:29-3