Photo Rounds
Rash and fever in a 14-month-old girl
A careful examination of this toddler’s rash and a thorough history led us to the correct diagnosis.
Differential diagnosis includes bacterial infections, psoriasis
Bacterial infections can cause abscesses or carbuncles on the scalp with tender and fluctuant changes that can also be accompanied by fever. However, because our patient was afebrile and relatively well, and the scalp lesions were nontender and without pus, a bacterial infection was unlikely.
Scalp psoriasis appears as raised, erythematous, dry and scaly patches, and not as inflammatory boggy masses (as was observed in our patient).
Skin cancer such as squamous cell carcinoma can present as erythematous, crusted, or scaly patches on sun-exposed skin. However, our patient’s lesions were too large to be malignant.4 In addition, skin cancer is rare in children.4
Oral antifungal medications are usually first-line treatment
Tinea capitis is treated with systemic antifungal medication. Oral antifungal agents, such as griseofulvin, itraconazole, terbinafine, and fluconazole, are effective.5-6
Erythema nodosum usually resolves without treatment, but should be observed until the underlying cause is treated.3
Our patient was treated with oral fluconazole 50 mg/d for 2 weeks and showed rapid improvement. After 2 weeks of treatment with oral fluconazole, he had hairless lesions on his scalp (FIGURE 3). The tender, erythematous nodules on his legs resolved spontaneously. Fluconazole was continued at 150 mg weekly for another 2 weeks, and our patient’s scalp lesions completely resolved after 6 weeks.
The patient’s siblings were initially treated with topical itraconazole, without effect. They were switched to oral fluconazole 50 mg/d and improved.
CORRESPONDENCE
Kyoungwoo Kim, MD, Department of Family Medicine, Inje University Seoul Paik Hospital, 9, Mareunnae-ro, Jung-gu, Seoul 100-032, Republic of Korea; kwkimfm@gmail.com
