Inflammatory tinea capitis mimicking dissecting cellulitis in a postpubertal male: a case report and review of the literature

Abstract

Tinea capitis in postpubertal patients is unusual and may be misdiagnosed as dissecting cellulitis. We report a case of a healthy 19-year-old Hispanic male presenting with a 2-month history of a large, painful subcutaneous boggy plaque on the scalp with patchy alopecia, erythematous papules, cysts and pustules. Although initially diagnosed as dissecting cellulitis, potassium hydroxide evaluation (KOH preparation) of the hair from the affected region was positive. A punch biopsy of the scalp demonstrated endothrix consistent with tinea capitis, but with a brisk, deep mixed inflammatory infiltrate as can be seen with chronic dissecting cellulitis. Fungal culture revealed Trichophyton tonsurans, and a diagnosis of inflammatory tinea capitis was made. The patient was treated over the course of 17 months with multiple systemic and topical antifungal medications, with slow, but demonstrable clinical and histopathological improvement. A rare diagnosis in adults, clinicians should have a high index of suspicion for this condition in an adult with an inflammatory scalp disorder not classic for dissecting cellulitis or with a recalcitrant dissecting cellulitis. Prompt, appropriate diagnosis and treatment is necessary to prevent the long-term complications of scarring alopecia.

Tinea capitis mimicking dissecting cellulitis in three children

“…The infection is often misdiagnosed as dissecting cellulitis and unsuccessfully treated with antibiotics. [6][7][8][9][10] Exudative discharge may also prompt misdiagnosis as bacterial infection, but bacterial cultures are negative; fungal cultures are commonly delayed because tinea capitis is not initially suspected.…”

“…When fungal cultures are obtained, T. tonsurans is the most common causal dermatophyte. [7][8][9][10] Dissecting cellulitis-like tinea capitis may resemble other inflammatory types of tinea capitis, such as kerion, but should be recognized as a distinct variant. Whereas kerion typically presents with a localized inflammatory, boggy mass, dissecting cellulitis-like tinea capitis presents with multiple edematous alopecic plaques and nodules across the scalp in an interwoven pattern.…”

“…3 There have been several reported cases of an additional clinical subtype of inflammatory tinea capitis that resembles dissecting cellulitis. [6][7][8][9][10][11][12] Dissecting cellulitis is a noninfectious inflammatory condition of the scalp characterized by painful nodules connected by sinus tracts, with associated scarring. 6,13 Dissecting cellulitis is most common in African American men, with one study reporting a mean age of 26 years.…”

“…13 Cases of dissecting cellulitis-like tinea capitis, in contrast, have been reported in children 9-19 years of age. [6][7][8][9][10][11][12] Reported cases of this variant of tinea capitis describe its presentation as boggy, erythematous, interconnected plaques and nodules with overlying alopecia, [6][7][8][9][10][11][12] but the literature on this rare subtype is limited and it is commonly omitted in reviews of the disease. This subtype of tinea capitis is likely to be misdiagnosed because of a lack of widespread knowledge of it.…”

A Large, Tender Scalp Nodule in an 8-Year-Old Boy

“…6 Many suggest the use of corticosteroids because kerions present with intense inflammation and the use of these corticosteroids may allow quicker recovery and preservation of hair. 6,7 One small study does not support the use of corticosteroids in kerion celsi. 6 Topical keratolytics and gentle soaks can aid in removal of the thick crust that develops on the surface of the kerion.…”