Pediatric Examination and Board Review (38 page)

(A) teenagers

(B) African Americans

(C) whites

(D) immigrants

(E) boys

6.
A helpful diagnostic test in this patient would be

(A) Wood lamp examination of the scalp

(B) Tzanck smear

(C) hair mount

(D) fungal culture

(E) hair pull test

7.
One year later, the patient returns, again complaining of hair loss. She states that “a clump of hair fell out 2 weeks ago.” She denies any flaking, itching, or soreness within the scalp. She has otherwise been feeling well, but she and her mother are extremely anxious about this new development. On examination, there is a quarter-size round patch of hair loss in the right frontal scalp. The skin in the area is smooth and devoid of all hairs. Hairs are easily pulled out at the periphery of the patch. There is no lymphadenopathy (
Figure 20-1
). The most likely diagnosis is

(A) tinea capitis

(B) trichotillomania

(C) alopecia areata

(D) telogen effluvium

(E) androgenetic alopecia

FIGURE 20-1
.

8.
The family asks if this condition is caused by stress. The most appropriate reply is

(A) yes

(B) no

(C) maybe

(D) yes, and antidepressants are indicated for therapy

(E) no, but the patient must stop straightening her hair

9.
A diagnostic sign to look for to help confirm the diagnosis is

(A) exclamation point hairs

(B) question mark hairs

(C) trichoschisis

(D) bubble hair

(E) hair casts

10.
The best form of treatment to recommend at this stage is

(A) intralesional injections of corticosteroid

(B) topical application of class 1 corticosteroid

(C) observation

(D) hair transplants

(E) topical application of a calcineurin inhibitor

11.
Which of the following tests should be considered in this patient?

(A) CBC

(B) ferritin level

(C) thyroid function test

(D) ANA test

(E) glucose tolerance test

12.
A 10-year-old girl presents with her parents for evaluation of hair loss. The child seems unconcerned. Her parents state that they have noticed an area on the top of the scalp where the hair seems thin and the scalp appears dirty. They have noticed these changes gradually. The child is otherwise healthy and takes no medications.

On examination, there is a widening of the part with decreased hair density and a “spangled” appearance of the hairs in this area. The hairs appear to be of varying length and the hair feels coarse in this area. The scalp demonstrates brownish fine scaling. No hairs are obtained on a gentle pull test. There are no papules or pustules and no lymphadenopathy (
Figure 20-2
). The eyelashes are present but also appear to be of varying lengths. The nails are short and ragged.

What question should be asked?

(A) Do you perm your hair?

(B) Do you color your hair?

(C) Do you use a blow dryer?

(D) Do you pull or twirl your hair?

(E) Do you use a chemical straightener on your hair?

FIGURE 20-2
.

13.
Important workup includes

(A) CBC

(B) thyroid function tests

(C) ferritin level

(D) none of the above

(E) all of the above

14.
Successful treatment may involve

(A) discontinuing all processing practices

(B) styling the hair in looser styles

(C) behavioral modification techniques

(D) topical corticosteroids

(E) topical antifungal cream

15.
Additional treatment options may include

(A) selective serotonin reuptake inhibitors (SSRIs)

(B) intralesional corticosteroid injections

(C) permethrin-containing cream rinse

(D) ivermectin

(E) oral antifungal medication

16.
A 16-year-old girl presents complaining that her hair is thinning. She notices that her ponytail is smaller than previously and that she sees large amounts of hair in the drain and on her pillow.

Upon examination, there are no bald patches on her scalp, the scalp appears normal without erythema or scale, and the amount of hair seems within normal limits. However, 20-30 hairs are easily pulled out. Instruct the patient

(A) it is normal to lose up to 250 hairs a day

(B) to collect the hair she is losing at home and to bring it back for evaluation

(C) she should decrease her frequency of hair washing to once a week

(D) this is early-onset “female pattern” hair loss

(E) to stop feeling stressed

17.
An important blood test to obtain in an otherwise asymptomatic individual is

(A) thyroid-stimulating hormone

(B) ANA

(C) ferritin level

(D) erythrocyte sedimentation rate

(E) C-reactive protein level

18.
Ask the patient if she takes any medications. The most significant medication that she reports is

(A) multivitamin pill

(B) sumatriptan

(C) estrogen and progestin

(D) ibuprofen

(E) loratadine

ANSWERS

1.
(E)
The case is most suggestive of a tinea capitis infection. Such infections are caused by dermatophytes, which are often spread from person to person, possibly via fomites. It is not uncommon to see lesions of tinea corporis in the setting of tinea capitis. The organism most often isolated in cases of tinea capitis in the United States is
Trichophyton tonsurans
. First-line treatment is generally with oral griseofulvin. Terbinafine is also approved for this indication in children 4 years and older. Topical therapies cannot penetrate the hair shafts where the organism is found. Secondary bacterial infection is occasionally present and is treated with oral antibiotics when significant. Patients should be educated regarding the transmission and infectivity of this condition, emphasizing the importance of not sharing hair implements, hats, pillows, and so on. All affected individuals in a family should be treated simultaneously to avoid reinfection.

2.
(B)
The optimal length of treatment of tinea capitis with griseofulvin is 6-8 weeks. Optimal duration of treatment with the newer antifungal agents has not been well documented.

3.
(C)
Tinea capitis in the United States is generally an anthropophilic infection. This organism is preferentially pathogenic for humans and is therefore passed from human to human, rather than from animal to human (zoophilic) or from soil to human (geophilic).

4.
(D)
Tinea capitis due to
T tonsurans
is an endothrix infection. In other words, the hair shaft itself is invaded by the fungus. Some element of the hair follicle is affected in all forms of tinea capitis, and it is for this reason that systemic therapy is necessary for clearance. Topical agents cannot penetrate the hair follicle and shaft adequately.

5.
(B)
Data have shown that tinea capitis infection is more common in African American children than in other ethnic groups in the United States, although it is a worldwide problem affecting all children. One theory to explain this observation is that the shape of the hair shaft in African Americans is such that invasion by the fungus is facilitated. Hair care practices such as styling, frequency of washing, and use of greases have also been the subject of speculation to explain the increasing risk of this infection. Postpubertal individuals appear to be at less risk, possibly because of the antifungal properties of sebum.

6.
(D)
Fungal culture is the gold standard for the documentation of tinea capitis. KOH preparations can be helpful; however, many of these infections are within the hair shaft and may be difficult to visualize, especially if only scale is obtained.
Microsporum canis
is another dermatophyte that may be the cause of tinea capitis, but it is a relatively rare cause in the United States. This organism causes an ectothrix infection (invasion remains outside of the hair shaft) and this organism fluoresces under the Wood lamp. Therefore, positive fluorescence can be helpful, but a negative test will not rule out a
T tonsurans
infection. Tzanck smears are sometimes performed to look for herpes virus infections. Hair pull tests are performed to evaluate cases of global hair loss and to examine the hair shaft microscopically.

7.
(C)
Sudden onset of a discrete area of frank alopecia is most suggestive of alopecia areata. This autoimmune condition is relatively common and can occur at any age. The most common presentation is of round patches of alopecia throughout the scalp. There are generally no associated symptoms and the scalp appears healthy and nonscarred. The finding of surrounding hairs that are easily pulled out suggests the process is still active and the patch may continue to enlarge. Progression to loss of the full scalp hair (alopecia totalis) or loss of all body hair (alopecia universalis) is rare. However the condition tends to wax and wane with new patches occurring periodically. Androgenetic alopecia (male and female pattern hair loss) rarely occurs at such a young age and generally presents as a receding frontal hairline or a widening of the part and thinning over the crown.