Diagnostic Considerations

Also consider the following:

Bacterial folliculitis
Dissecting folliculitis (folliculitis decalvans)
Abscess
Neoplasia
Pyoderma
Secondary syphilis

Seborrheic dermatitis occurs in older children and, unlike tinea capitis, does not cause hair loss. In some cases of tinea capitis, the erythematous scaly lesions closely resemble those seen in seborrheic dermatitis; however, in seborrheic dermatitis, hairs are not broken. Seborrheic dermatitis and psoriasis may cause accumulation of scales in matted masses on the scalp. Scales are more prominent in psoriasis, and hairs are not broken.

Impetigo may be difficult to distinguish from inflammatory tinea capitis, although pain is less severe in tinea capitis, and hairs tend to be seated firmly in impetigo. Alopecia areata also causes circumscribed areas of hair loss similar to tinea capitis, but alopecia areata does not cause scaling. Lesions may have an erythematous border in the early stages of the disease, but this reverses to normal color at later stages. The exclamation mark hairs seen in alopecia areata, in which broken hairs taper from the fractured end toward the skin surface, are pathognomonic.

In secondary syphilis, areas of alopecia have a characteristic moth-eaten appearance or resemble alopecia areata. Serologic testing for the presence of treponemal antibody (rapid plasma reagin and Treponema -specific tests, eg, microhemagglutination– Treponema pallidum test) and testing by special silver impregnation histochemical stain (Warthin-Starry stain) for the demonstration of treponemal organisms aid in the accurate diagnosis of syphilis.

The patient may present with a generalized eruption of itchy papules, particularly around the outer helix of the ear, occurring as a reactive phenomenon (an id response). These symptoms may start with the introduction of systemic treatment for tinea capitis; thus, they be mistaken for a drug reaction.

Differential Diagnoses

Workup

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Media Gallery

Gray-patch ringworm (microsporosis) is an ectothrix infection or prepubertal tinea capitis seen here in an African American male child. Gray patch refers to the scaling with lack of inflammation, as noted in this patient. Hairs in the involved areas assume a characteristic dull, grayish, discolored appearance. Infected hairs are broken and shorter. Papular lesions around hair shafts spread and form typical patches of ring forms, as shown. Culture from the lesional hair grew Microsporum canis.
Typical lesions of kerion celsi on the vertex scalp of a young Chinese boy. Note numerous bright yellow purulent areas on skin surface, surrounded by adjacent edematous, erythematous, alopecic areas. Culture from the lesion grew Trichophyton mentagrophytes. Courtesy of Skin Diseases in Chinese by Yau-Chin Lu, MD. Permission granted by Medicine Today Publishing Co, Taipei, Taiwan, 1981.
Discrete patches of hair loss or alopecia caused by Trichophyton violaceum infection of the vertex scalp of a young Taiwanese boy. Courtesy of Skin Diseases in Chinese by Yau-Chin Lu, MD. Permission granted by Medicine Today Publishing Co, Taipei, Taiwan, 1981.
Photomicrograph depicting an endoectothrix invasion of a hair shaft by Microsporum audouinii. Intrapilary hyphae and spores around the hair shaft are seen (hematoxylin and eosin stain with Periodic acid-Schiff counterstain, magnification X 250).
Fungal hyphae and yeast cells of Trichophyton rubrum seen on the stratum corneum of tinea capitis. Periodic acid-Schiff stain, magnification 250X.
Pronounced inflammatory tissue reaction with follicular pustule formation surrounding a hair follicle seen in a patient with clinical form of infection, termed kerion celsi. No fungal hyphae or spores were identified in the lesion in either tissue sections or culture. Fluorescein-labeled Trichophyton mentagrophytes antiserum cross-reacted with antigens of dermatophyte in the infected hairs within the pustule (hematoxylin and eosin stain, magnification X 75).
Wood lamp examination of a gray-patch area on the scalp. In Microsporum canis infection, scalp hairs emit a diagnostic brilliant green fluorescence. Trichophyton tonsurans does not fluoresce with Wood lamp.
Tinea capitis, presenting as alopecia with scale, in an African American child.

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Author

Marc Zachary Handler, MD Fellow in Mohs Micrographic Surgery, Skin Laser and Surgery Specialists of NY and NJ

Marc Zachary Handler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, European Society for Pediatric Dermatology, International Society of Dermatology, New York Academy of Medicine, Sigma Xi, The Scientific Research Honor Society, Society for Pediatric Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Matthew P Stephany, MD Resident Physician, Department of Dermatology, OU Physicians Dermatology, Oklahoma University Health Sciences Center

Matthew P Stephany, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Professor of Pediatrics, Professor of Medicine, Rutgers New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, Royal College of Physicians of Edinburgh, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Dermatologic/Mohs Surgeon, The Surgery Center at Plano Dermatology

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Paul Krusinski, MD Director of Dermatology, Fletcher Allen Health Care; Professor, Department of Internal Medicine, University of Vermont College of Medicine

Paul Krusinski, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Grace F Kao, MD Clinical Professor of Dermatopathology, Department of Dermatology, University of Maryland School of Medicine and George Washington University Medical School; Director, Dermatopathology Section, Department of Pathology and Laboratory Medicine, Veterans Affairs Maryland Healthcare System, Baltimore, Maryland

Grace F Kao, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, International Society of Dermatopathology

Disclosure: Nothing to disclose.

Franklin Flowers, MD Professor Emeritus, Department of Dermatology, Affiliate Associate Professor of Pathology, University of Florida College of Medicine

Franklin Flowers, MD is a member of the following medical societies: American College of Mohs Surgery

Disclosure: Nothing to disclose.

Tinea Capitis Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

References

Tables

Contributor Information and Disclosures

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