Clinical and Experimental Dermatology (j^i']) 2, 69.
Brief comtnunications
Ringworm on the scalp due to Epidermophyton floccosum
NAYER NIKPOOR AND BARBARA J. LEPPARD Department of Dermatology, Pahlavi University, Shiraz, Iran
Accepted for publication 6 July 1976
Summary A 9-year-old male is described who had multiple erythematous pustular ringed lesions on the scalp without hair loss. Epidermophytonfloccosumwas grown on culture from scalp brushings.
Epidermophytonfloccosum{E.floccosum)is an anthropophilic fungus which cotnmonly produces tinea of the groins and feet. It does not invade hair and therefore does not usually cause tinea capitis. A boy with an unusual pattern of ringworm on the scalp is described in whom the causative organism was found to be E. floccosum. Case report A 9-year-old boy from Shiraz, in Southern Iran, presented with a i-year history of ringed scaly lesions on the scalp, face and neck. Because of this his hair had been kept closely cropped by his parents. On examination, the patient had multiple erythematous annular lesions involving the whole of the scalp and a few scattered lesions on the forehead, cheeks, neck and right ear (Fig. i). Individual lesions were composed of rings of tiny pustules with an erythematous halo. There was no associated hair loss and the hairs were not pulled out easily. Reprint requests to: Dr B. Leppard, St John's Hospital for Diseases of the Skin, Lisle Street, Leicester Square, London WC2H 7BJ.
70
N. Nikpoor and B.J. Leppard
Figure i. Extensive scaly annular lesions on face and scalp.
Investigations. Wood's light examination of the scalp showed no fluorescence. Direct microscopic examination of plucked hairs was negative for both spores and hyphae. A scalp brushing (Clayton & Midgley, 1968) using a 3 in. plastic massage brush was inoculated into Sabouraud's dextrose agar medium in a standard petri dish. After 2 weeks grey-green colonies with a yellow-tan undersurface characteristic oi E.floccosumhad grown. Microscopic examination of the culture showed the typical blunt, club-shaped, smooth-walled macroconidia of E. fioccosum. After a 6-week course of oral griseofulvin, 0*5 g daily and topical Whitfield's ointment all the lesions had completely disappeared. Eamily history. The parents had no abnormality of the skin, including the skin of the groins and the toe webs. Four younger siblings had had 'ringworm' in the previous year. Two of these were subsequently seen in the clinic and examined. A 6-year-old sister had a few similar red scaly lesions on the scalp and an i8-month-old brother had two lesions of typical tinea corporis on the front of the chest. Cultures of scalp brushings from the sister and skin scales from the brother were both overgrown with contaminants. Both children were treated with griseofulvin and the lesions had cleared after 6 weeks. Comment E.floccosumis a common cause of tinea cruris and has been responsible for several minor epidemics in schools (Meinhof & Jander, 1971), hostels (Rosman, 1962; Lundell, 1974) and public baths (Jung & Koch, 1968). In such cases the causative organism has been found on the floors, benches and toilet seats. A few cases have been reported in the literature in which E. floccosum has involved the scalp, always without hair loss (Sternberg et al., 1959; Dvorak, Otcenasek & Lansky, 1964). Nicolau, Alteras & Negulescu (1962) described a 19-year-old deaf mute male with congenital alopecia who developed warty plaques all over the body including the scalp. It is possible that
Ringworm on the scalp
ji
he also had some immunological abnormality since he had widespread lesions similar to the patient described by Levene (1973) with reticulum cell sarcoma and chronic fungal infection. The patient described here had scalp lesions with the clinical features of tinea corporis. In the prepubertal state the scalp may act in the same way as glabrous skin and may thus be affected by such organisms as E.floccosumwhich do not invade hair. The 'hairbrush diagnosis' (Mackenzie, 1963; Clayton & Midgley, 1968) is effective for culturing the organism and for screening other members of the patient's family. Acknowledgment We thatik Mr M. Buxton for his help with the mycology cultures. References CLAYTON, Y.M. & MIDGLEY, G . (1968) A new approach to the investigation of scalp ringworm in London schoolchildren. 7
Brief comtnunications
Ringworm on the scalp due to Epidermophyton floccosum
NAYER NIKPOOR AND BARBARA J. LEPPARD Department of Dermatology, Pahlavi University, Shiraz, Iran
Accepted for publication 6 July 1976
Summary A 9-year-old male is described who had multiple erythematous pustular ringed lesions on the scalp without hair loss. Epidermophytonfloccosumwas grown on culture from scalp brushings.
Epidermophytonfloccosum{E.floccosum)is an anthropophilic fungus which cotnmonly produces tinea of the groins and feet. It does not invade hair and therefore does not usually cause tinea capitis. A boy with an unusual pattern of ringworm on the scalp is described in whom the causative organism was found to be E. floccosum. Case report A 9-year-old boy from Shiraz, in Southern Iran, presented with a i-year history of ringed scaly lesions on the scalp, face and neck. Because of this his hair had been kept closely cropped by his parents. On examination, the patient had multiple erythematous annular lesions involving the whole of the scalp and a few scattered lesions on the forehead, cheeks, neck and right ear (Fig. i). Individual lesions were composed of rings of tiny pustules with an erythematous halo. There was no associated hair loss and the hairs were not pulled out easily. Reprint requests to: Dr B. Leppard, St John's Hospital for Diseases of the Skin, Lisle Street, Leicester Square, London WC2H 7BJ.
70
N. Nikpoor and B.J. Leppard
Figure i. Extensive scaly annular lesions on face and scalp.
Investigations. Wood's light examination of the scalp showed no fluorescence. Direct microscopic examination of plucked hairs was negative for both spores and hyphae. A scalp brushing (Clayton & Midgley, 1968) using a 3 in. plastic massage brush was inoculated into Sabouraud's dextrose agar medium in a standard petri dish. After 2 weeks grey-green colonies with a yellow-tan undersurface characteristic oi E.floccosumhad grown. Microscopic examination of the culture showed the typical blunt, club-shaped, smooth-walled macroconidia of E. fioccosum. After a 6-week course of oral griseofulvin, 0*5 g daily and topical Whitfield's ointment all the lesions had completely disappeared. Eamily history. The parents had no abnormality of the skin, including the skin of the groins and the toe webs. Four younger siblings had had 'ringworm' in the previous year. Two of these were subsequently seen in the clinic and examined. A 6-year-old sister had a few similar red scaly lesions on the scalp and an i8-month-old brother had two lesions of typical tinea corporis on the front of the chest. Cultures of scalp brushings from the sister and skin scales from the brother were both overgrown with contaminants. Both children were treated with griseofulvin and the lesions had cleared after 6 weeks. Comment E.floccosumis a common cause of tinea cruris and has been responsible for several minor epidemics in schools (Meinhof & Jander, 1971), hostels (Rosman, 1962; Lundell, 1974) and public baths (Jung & Koch, 1968). In such cases the causative organism has been found on the floors, benches and toilet seats. A few cases have been reported in the literature in which E. floccosum has involved the scalp, always without hair loss (Sternberg et al., 1959; Dvorak, Otcenasek & Lansky, 1964). Nicolau, Alteras & Negulescu (1962) described a 19-year-old deaf mute male with congenital alopecia who developed warty plaques all over the body including the scalp. It is possible that
Ringworm on the scalp
ji
he also had some immunological abnormality since he had widespread lesions similar to the patient described by Levene (1973) with reticulum cell sarcoma and chronic fungal infection. The patient described here had scalp lesions with the clinical features of tinea corporis. In the prepubertal state the scalp may act in the same way as glabrous skin and may thus be affected by such organisms as E.floccosumwhich do not invade hair. The 'hairbrush diagnosis' (Mackenzie, 1963; Clayton & Midgley, 1968) is effective for culturing the organism and for screening other members of the patient's family. Acknowledgment We thatik Mr M. Buxton for his help with the mycology cultures. References CLAYTON, Y.M. & MIDGLEY, G . (1968) A new approach to the investigation of scalp ringworm in London schoolchildren. 7
