Pediatric Annals

CME 

A 21-Day-Old Boy with an Annular Eruption

Adam Berry, BS; Gil Abramovici, MD; Sarah L. Chamlin, MD

Abstract

A healthy 21-day-old black male was referred to pediatric dermatology for evaluation of a facial and scalp eruption that had been present for less than 1 week. The child’s parents had applied a topical corticosteroid cream for several days without any improvement noted. The child was otherwise well and thriving. Review of systems was negative. Family history was unremarkable for autoimmune or infectious skin diseases.

On physical examination the patient was alert, active, and vigorous. He had multiple 1 to 2.5-cm erythematous annular, scaly plaques with pustules on the periphery on his upper cheeks, forehead, and anterior scalp. No alopecia was noted. Occipital and neck lymph nodes were not palpable. A potassium hydroxide skin preparation was negative for fungal elements and a fungal culture was performed. Serum laboratory testing was also performed.

Abstract

A healthy 21-day-old black male was referred to pediatric dermatology for evaluation of a facial and scalp eruption that had been present for less than 1 week. The child’s parents had applied a topical corticosteroid cream for several days without any improvement noted. The child was otherwise well and thriving. Review of systems was negative. Family history was unremarkable for autoimmune or infectious skin diseases.

On physical examination the patient was alert, active, and vigorous. He had multiple 1 to 2.5-cm erythematous annular, scaly plaques with pustules on the periphery on his upper cheeks, forehead, and anterior scalp. No alopecia was noted. Occipital and neck lymph nodes were not palpable. A potassium hydroxide skin preparation was negative for fungal elements and a fungal culture was performed. Serum laboratory testing was also performed.

Figure 1.

 

Figure 2.

 

A healthy 21-day-old black male was referred to pediatric dermatology for evaluation of a facial and scalp eruption that had been present for less than 1 week. The child’s parents had applied a topical corticosteroid cream for several days without any improvement noted. The child was otherwise well and thriving. Review of systems was negative. Family history was unremarkable for autoimmune or infectious skin diseases.

On physical examination the patient was alert, active, and vigorous. He had multiple 1 to 2.5-cm erythematous annular, scaly plaques with pustules on the periphery on his upper cheeks, forehead, and anterior scalp ( Figures 12 ). No alopecia was noted. Occipital and neck lymph nodes were not palpable. A potassium hydroxide skin preparation was negative for fungal elements and a fungal culture was performed. Serum laboratory testing was also performed.

Diagnosis:

Tinea Faciei / Tinea Capitis

Discussion

This patient was evaluated for neonatal lupus erythematosus at his initial visit due to his cutaneous findings of annular skin lesions, and all studies were negative. Prior to his follow-up with pediatric dermatology, his scalp and facial fungal cultures grew Trichophyton tonsurans , confirming the diagnosis of tinea faciei and tinea capitis. He was treated with griseofulvin for 6 weeks with clearing of lesions.

Annular eruptions in young infants are not common. Diagnostic considerations when seeing annular lesions in neonates include neonatal lupus erythematosus, tinea infections, nummular dermatitis, psoriasis, seborrheic dermatitis, erythema annular centrifigum, urticaria, and annular erythema of infancy. The scale, pustules, and erythema in this case were consistent with a tinea infection, but the potassium hydroxide (KOH) office examination was negative. A negative KOH examination is not uncommon when topical steroids have been applied to a fungal infection. Of note, topical steroid application to fungal infections can cause a complication called Majocchi’s granuloma, a deeper follicular fungal infection that requires treatment with a systemic antifungal.

Tinea capitis and tinea faciei are fungal infections of the scalp and face, respectively, caused by dermatophyte species, particularly Trichophyton species . 1,2 The clinical presentation of tinea capitis can vary considerably, especially in infants. 3 Scalp findings may include scaly papules and plaques, pustules, alopecia, broken hairs, and even a boggy mass, or a kerion. 3,4T. tonsurans is the causative organism in more than 90% of tinea capitis in the U.S. This organism invades the hair shaft — an endothrix infection — creating chains of arthrospores that render a diagnostic Wood’s lamp examination unhelpful. 3 Microsporum canis infection, a less common cause of tinea capitis, causes an ectothrix infection, which fluoresces green with Wood’s lamp examination because the spores are on the exterior of the hair shaft. Tinea faciei or tinea corporis can be caused by infection from adjacent infected scalp areas, as was likely in this infant. Of note, tinea faciei, like tinea capitis, often requires systemic therapy to completely clear the lesions. 4

Dermatophytes are most commonly spread by close person-to-person contact, anthropophilic spread, with organisms such as T. tonsurans . 3,4 Dermatophytes can also spread from animals, known as zoophilic spread, with an organism such as M. canis . Tinea capitis infections occur most commonly in children ages 3 to 7 years old, and black and Afro-Caribbean children are the most susceptible. 1,3 Of note, tinea infections are rare in infants, and relatively few cases have been reported. 3,5,6 Nonetheless, it has been described as early as the second day of life and should be kept in mind in all neonates who present with scaly or annular lesions. 5,6

KOH examination and fungal cultures can be performed to confirm the diagnosis of cutaneous tinea infections. 4 One study suggests that a KOH examination of skin scrapings and individual hair strands is the most sensitive test to determine the diagnosis (73.3% versus 41.7% compared to fungal culture). 7 However, KOH office examination is not practical for all practitioners, and treatment is often based on clinical findings alone. Despite this, it is prudent to send a fungal culture prior to therapy for tinea capitis and, if positive, organism identification can guide oral antifungal choices.

Oral antifungal therapy is the treatment of choice in tinea capitis, as poor response and inadequate eradication of the dermatophyte is seen with topical therapy. 3,4 Historically, oral griseofulvin therapy has been the gold standard. 2,3 Most experts recommended 20 mg/kg/day to 25mg/kg/day of microsize griseofulvin for 6 to 8 weeks. Griseofulvin’s safety and efficacy in older children has been demonstrated over many decades; 3 however, no expert consensus on the necessity of laboratory monitoring in younger infants has been established. CBC and serum transaminase testing can be considered. 3 Oral terbinafine in the granule formulation has been approved for treatment of tinea capitis in children older than 4 years of age, and a recent meta-analysis comparing terbinafine and griseofulvin in the treatment of tinea capitis showed similar efficacy. 8 Terbinafine dosing is weight-based, and therapy is suggested for 4 weeks. Other oral treatment options include itraconazole or fluconazole. Itraconazole or high-dose griseofulvin should be considered for M. canis infection.

Cleaning of the environment and of combs and brushes is also warranted for tinea capitis infections. Adjuvant therapy with an antifungal shampoo such as ketoconazole is often suggested for the infected child and their household contacts, and infected children should avoid sharing hats or hooded sweatshirts. Importantly, most school systems do not prevent school attendance for infected children. Household contacts should be examined if a child is not responding as expected or has a recurrent infection after adequate therapy.

References

  1. Abdel-Rahman SM, Farrand N, Schuenemann E, et al. The prevalence of infections with Trichophyton tonsurans in schoolchildren: the CAPITIS study. Pediatrics . 2010;125(5):966–973. doi:10.1542/peds.2009-2522 [CrossRef]
  2. Atanasovski M, El Tal AK, Hamzavi F, Mehregan DA. Neonatal dermatophytosis: report of a case and review of the literature. Pediatr Dermatol . 2011;28(2):185–188. doi:10.1111/j.1525-1470.2010.01318.x [CrossRef]
  3. Michaels BD, Del Rosso JQ. Tinea capitis in infants: recognition, evaluation, and management suggestions. J Clin Aesthet Dermatol . 2012;5(2):49–59.
  4. Paller A, Mancini AJ. Hurwitz Clinical Pediatric Dermatology .4th ed. New York, NY: Elsevier Saunders; 2011:390–395. doi:10.1016/B978-1-4377-0412-9.00017-4 [CrossRef]
  5. Fu M, Ge Y, Chen W, et al. Tinea faciei in a newborn due to Trichophyton tonsurans. J Biomed Res . 2013;27(1):71–74. doi:10.7555/JBR.27.20120102 [CrossRef]
  6. Metkar A, Joshi A, Vishalakshi V, Miskeen AK, Torsekar RG. Extensive neonatal dermatophytoses. Pediatr Dermatol . 2010;27(2):189–191. doi:10.1111/j.1525-1470.2009.00941.x [CrossRef]
  7. Levitt JO, Levitt BH, Akhavan A, Yanofsky H. The sensitivity and specificity of potassium hydroxide smear and fungal culture relative to clinical assessment in the evaluation of tinea pedis: a pooled analysis. Dermatol Res Pract . 2010;2010:764843.
  8. Gupta AK, Drummond-Main C. Meta-analysis of randomized, controlled trials comparing particular doses of griseofulvin and terbinafine for the treatment of tinea capitis. Pediatr Dermatol . 2013;30(1):1–6. doi:10.1111/j.1525-1470.2012.01866.x [CrossRef]
Authors

Adam Berry, BS, is a Clinical Research Fellow, Division of Dermatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine. Gil Abramovici, MD, is a Clinical Research Fellow, Division of Dermatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine. Sarah L. Chamlin, MD, is Associate Professor of Pediatrics and Dermatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine.

Address correspondence to: Sarah L. Chamlin, MD, Division of Dermatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 East Chicago Avenue, Chicago, IL 60611; email: schamlin@luriechildrens.org.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00904481-20131223-12

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