An 8-year-old girl is brought to the office by her mother due to hair loss on her scalp. The mother first noticed a patch of hair loss a week ago, and the affected area is now slightly larger in diameter. The area is flaking and very pruritic. She also mentions, "My son had a similar rash on his arm but I didn't want to use his cream on her without an evaluation." The patient has had no fever, and there is no oozing, warmth, or edema of the scalp. She has no medical conditions and takes no medications. Immunizations are up to date. Physical examination shows a well-appearing girl who is scratching her scalp. Examination of the area of hair loss is shown below. Mildly tender posterior cervical lymphadenopathy is present. Which of the following is the most appropriate treatment for this patient's condition?

Question

An 8-year-old girl is brought to the office by her mother due to hair loss on her scalp.  The mother first noticed a patch of hair loss a week ago, and the affected area is now slightly larger in diameter.  The area is flaking and very pruritic.  She also mentions, "My son had a similar rash on his arm but I didn't want to use his cream on her without an evaluation."  The patient has had no fever, and there is no oozing, warmth, or edema of the scalp.  She has no medical conditions and takes no medications.  Immunizations are up to date.  Physical examination shows a well-appearing girl who is scratching her scalp.  Examination of the area of hair loss is shown below.  Mildly tender posterior cervical lymphadenopathy is present.  Which of the following is the most appropriate treatment for this patient's condition?

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Explanation: 11ec2b69_be8f_5e94_8f63_3df640b45c3b_MD0005_00 Tinea capitis is a superficial dermatophyte (eg, Trichophyton) infection of the scalp. It classically presents as pruritic, scaly, erythematous patches that grow centrifugally and have hair loss. Proximal hair shafts may be visualized as small dots in the area of hair loss, and cervical lymphadenopathy may be present. Transmission occurs via direct contact with an infected individual or fomite (eg, shared hats or combs). Diagnosis is often clinical but can be confirmed with potassium hydroxide (KOH) examination of the hair shaft. First-line treatment for tinea capitis is a systemic antifungal, either oral griseofulvin or oral terbinafine. An oral agent must be used in the treatment of tinea capitis to penetrate hair follicles. Adjunctive treatments, such as ketoconazole shampoo, can also be used to help prevent spread of disease but are insufficient as monotherapy. (Choices A and C) Alopecia areata, an immune-mediated disease, is characterized by smooth areas of hair loss and is treated with topical or intralesional corticosteroids (eg, triamcinolone). Scaling and erythema are not seen, and pruritus is uncommon. Topical corticosteroids (eg, hydrocortisone) are also indicated in the treatment of eczema, which presents with dry, pruritic, erythematous patches. Distribution can involve the scalp in infants, but eczema typically affects flexural areas (eg, antecubital fossa) in older children and is not associated with hair loss. Alopecia areata (Choice D) Topical permethrin is the treatment for lice (Pediculus humanus capitis) infestation. Although lice can also spread by fomites and present with pruritus and lymphadenopathy, nits or live lice are visualized on examination and alopecia is not typical. live lice (Choice E) Topical terbinafine is effective against dermatophyte infections of the skin (eg, tinea corporis). An oral agent must be used in the treatment of tinea capitis to penetrate hair follicles. Educational objective: Tinea capitis is a dermatophytosis that causes scaly, erythematous patches of the scalp with hair loss. First-line treatment is oral griseofulvin or oral terbinafine. References: Management of tinea capitis in childhood. (http://www.ncbi.nlm.nih.gov/pubmed/21437064) Tinea capitis: current status. (http://www.ncbi.nlm.nih.gov/pubmed/27599708)

An 8-Year-Old Girl Is Brought to the Office by Her