1 The disease may resemble bacterial folliculitis, folliculitis decalvans, dissecting cellulitis, or the scarring related to lupus erythematosus. 1 In immunocompetent adults, the clinical features are often atypical. 1 Tinea capitis in adults generally occurs in patients who are immunosuppressed and those infected with HIV. 1 – 3 Colonisation by Pityrosporum orbiculare may interfere with dermatophyte contamination, and the thicker calibre of adult hair may protect against dermatophytic invasion. 2 Dermatophytic colonisation of the scalp disappears at puberty. The quantity of fungistatic saturated fatty acids in sebum increases at puberty, and this is thought to explain the rarity of tinea capitis in adults. The woman recalled that her 8 year old nephew had shared her bed just before the problem began he had subsequently been treated for ringworm. Four weeks later Trichophyton tonsurans was isolated and she responded well to three months' treatment with terbinafine (250 mg daily). Hair plucks were sent for mycology tests but tinea capitis was considered unlikely and she was treated with isotretinoin (0.5 mg/kg daily). The areas of alopecia enlarged during a three month course of erythromycin (250 mg twice daily), and the patient needed to wear a wig. Culture of bacterial swabs had negative results and a presumptive diagnosis of folliculitis decalvans (an idiopathic inflammatory scarring scalp disorder) was made. Cytological examination showed a mixed population of lymphocytes, indicating reactive changes in addition, the surgical house officer observed that the woman had “quite a nasty rash on her scalp.”Īt the time of her referral to the dermatology clinic she had circumscribed areas of hair loss over the crown, with peripheral inflammation, pustules, and scaling (fig (fig1). During this period the woman underwent lymph node aspiration and chest radiography because she had an enlarged but painless cervical lymph node. Her general practitioner had treated it unsuccessfully with neomycin and gramicidin ointment and oral flucloxacillin and metronidazole. A 45 year old Afro-Caribbean woman had had an itchy pustular eruption of the scalp with associated hair loss for several months.
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