Photo Quiz

Swelling and Erythema of the Scalp on a Teenager

 

Am Fam Physician. 2016 Nov 15;94(10):836-842.

A 16-year-old boy presented with swelling and erythema on the scalp that had worsened over the previous four weeks. Three to four months prior to the development of the swelling, he noted a red circular rash on the same area of his scalp. The rash resolved with application of an over-the-counter antifungal cream. After resolution of the rash, the swelling and erythema began, and the area became painful. He did not have a fever or chills, and there was no discharge from the site. The patient was otherwise healthy and active, and was a member of his school's wrestling team.

Examination of the scalp revealed an area of erythema and induration (Figure 1). The scalp was tender to palpation but not fluctuant. There was no cervical or occipital lymphadenopathy. Ultrasonography showed no fluid collection in the lesion.

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Figure 1.


Figure 1.

Question

Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. Id reaction.

B. Kerion.

C. Pustular psoriasis.

D. Staphylococcal abscess.

Discussion

The answer is B: kerion. Kerions are the result of an inflammatory response to an invasive fungal infection of the hair follicles and scalp. The fungus is usually a dermatophyte such as Trichophyton verrucosum or Trichophyton mentagrophytes.1 Presentation ranges from a raised, spongy lesion to an extremely painful indurated lesion.1 Kerions are commonly mistaken for a staphylococcal abscess, but the absence of fever and fluctuance can help to distinguish them from a bacterial infection. The initial rash is red and circular, which is typical of tinea capitis, a Trichophyton infection that often occurs in wrestlers.

If the fungal infection is untreated, alopecia and scarring may develop. The first-line therapy is oral griseofulvin.2 Topical treatment is not effective because of the depth of the fungal infection. Although bacterial infections can occur with kerions, they are uncommon. Fever, chills, and malaise are common signs of a superimposed bacterial infection, and the lesion is typically fluctuant.3 When there is concern for bacterial superinfection, an antibiotic that covers Staphylococcus and Streptococcus should be used in addition to griseofulvin.

An id reaction, also known as disseminated eczema or autoeczematization, is a generalized acute eczematous reaction that can be triggered by a variety of stimuli, including infection or inflammation. It typically presents as an intensely pruritic, symmetric, maculopapular or papulovesicular rash. Widespread follicular pustules are possible. A focal circular lesion without scaling or lichenification would be an unlikely presentation. An id reaction responds to treatment of the underlying cause.4

Pustular psoriasis is a rare form of the autoimmune disease psoriasis, characterized by white pustules surrounded by erythematous skin. It can be generalized or focal, and has a cyclic nature with reddening of the skin followed by pustule eruption.5

A staphylococcal abscess can present on the scalp with redness and induration but would likely have painful fluctuance. Ultrasonography is helpful to identify fluid collection. An abscess is typically associated with fever and other systemic symptoms.3,6

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Summary Table

ConditionCharacteristics

Id reaction

Intensely pruritic, symmetric, maculopapular or papulovesicular rash; can have widespread follicular pustules

Kerion

Raised, spongy lesion that is painful and sometimes indurated; typically associated with tinea capitis

Pustular psoriasis

White pustules surrounded by erythematous skin; autoimmune etiology

Staphylococcal abscess

Area of redness and induration with painful fluctuance; associated with fever and other systemic symptoms

Summary Table

ConditionCharacteristics

Id reaction

Intensely pruritic, symmetric, maculopapular or papulovesicular rash; can have widespread follicular pustules

Kerion

Raised, spongy lesion that is painful and sometimes indurated; typically associated with tinea capitis

Pustular psoriasis

White pustules surrounded by erythematous skin; autoimmune etiology

Staphylococcal abscess

Area of redness and induration with painful fluctuance; associated with fever and other systemic symptoms

Address correspondence to Sommer Aldulaimi, MD, at sommer.aldulaimi@bannerhealth.com. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Fuller LC, Child FJ, Midgley G, Higgins EM. Diagnosis and management of scalp ringworm. BMJ. 2003;326(7388):539–541....

2. Trovato MJ, Schwartz RA, Janniger CK. Tinea capitis: current concepts in clinical practice. Cutis. 2006;77(2):93–99.

3. Cheng AG, DeDent AC, Schneewind O, Missiakas D. A play in four acts: Staphylococcus aureus abscess formation. Trends Microbiol. 2011;19(5):225–232.

4. Evans MP. Id reaction (autoeczematization). Updated August 5, 2016. Medscape. http://www.emedicine.medscape.com/article/1049760-overview. Accessed September 8, 2016.

5. Borges-Costa J, Silva R, Gonçalves L, Filipe P, Soares de Almeida L, Marques Gomes M. Clinical and laboratory features in acute generalized pustular psoriasis: a retrospective study of 34 patients. Am J Clin Dermatol. 2011;12(4):271–276.

6. Kemper AR, Dolor RJ, Fowler VG Jr. Management of skin abscesses by primary care pediatricians. Clin Pediatr (Phila). 2011;50(6):525–528.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Assistant Medical Editor.

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