Inflammatory masses on boy’s scalp

Dx: Tinea capitis and erythema nodosum

The patient was given a diagnosis of tinea capitis (ringworm of the scalp) based on the clinical presentation. (The patient’s brother and sister were told that they had tinea corporis and tinea faciei, which our patient also had on his face.) Our patient’s diagnosis was confirmed when he rapidly responded to treatment with the antifungal fluconazole. After the first week of this treatment, he complained of tender, erythematous nodules on the anterior surface of his lower legs, which we diagnosed as erythema nodosum (FIGURE 2).

Oral antifungal agents such as griseofulvin, itraconazole, terbinafine, and fluconazole are all effective treatments for tinea capitis.

Tinea capitis is a fungal infection of the scalp that usually starts as flaky and crusty patches of skin, broken-off hair, erythema, scaling, and pustules on the scalp. This can quickly deteriorate into a boggy and pruritic mass of inflamed tissue known as a kerion. The kerion can become severely inflamed and develop regional lymphadenopathy. Hypersensitive and highly inflammatory reactions that look similar to a bacterial infection may be found when the infection is caused by a zoophilic dermatophyte.¹

Tinea capitis primarily affects children younger than age 10 years, with a peak incidence among African American boys.² Because US public health agencies no longer require physicians to report cases of tinea capitis, its true incidence in the United States is unknown, but it is believed to be increasing.²