A 68-year-old female was presented to our department with a 3-week history of multiple nodules, plaques and pustules on the scalp. The patient has no serious health history and underlying conditions, but she had been in contact with cats and dogs. Three weeks ago, several nodules and plaques appeared on her scalp, which gradually enlarged with pustules, accompanied by pain and high fever. The patient had been diagnosed as bacterial abscess in the local hospital, and was given intravenous antibiotic for one week with no response. Physical examination showed that diffuse pustular, nodules and plaques on the scalp, studded with patchy alopecia and matted with thick crust, along with postauricular lymphadenopathy (Fig. 1). Potassium hydroxide (KOH) examination revealed that the patient was positive for pus (Fig. 2a). Trichophyton mentagrophyte was isolated on Sabouraud dextrose agar at 27℃ after two weeks (Fig. 2b).
The patient was treated with oral terbinafine (250 mg/d) and prednisone (1 mg/kg/d). Routine surgery drainage was not performed due to no treatment benefit and might contribute to further scarring. However, compression to remove the infected scalp might be useful as an adjunctive approach for patients with inflammatory tinea capitis. The patient received debridement without surgery drainage. The fever disappeared, severe pain relieved and pus decreased after 3 days of treatment. Corticosteroid treatment was discontinued ten days later. Then, the patient continued to receive oral terbinafine and topical povidone–iodine therapy. After one month, she returned to our department with severe ache. The patient still had diffuse thick crusts and pus on the scalp (Fig. 3a). After removing the thick crusts, we found that the scalp was studded with plaques and nodules as before (Fig. 3b). Then, the patient was given prednisone (1 mg/kg/d) for ten days and debridement again, and continued to take oral terbinafine. The thick crusts, pustules, nodules, plaques and pain disappeared, and postauricular lymphadenopathies regressed after 1.5 months of treatment (Fig. 4a), and only patchy alopecia remained 2 months later (Fig. 4b). The 3-month course of oral terbinafine (250 mg/d), repeated debridement and two short-course oral corticosteroids resulted in mycological clearance and successful resolution of symptoms (Fig. 4c). The patient’s liver function was normal throughout the entire treatment plan.
In conclusion, short-course oral corticosteroids can help reduce inflammation and pain, and repeated debridement without surgery can reduce transmission of spores, especially in patients with total scalp involvement of inflammatory tinea capitis. Moreover, it is highly recommended for these patients to take oral terbinafine with adequate dosage and duration. The combination of repeated debridement, terbinafine and short-course steroids can be used as an effective method for the treatment of severe diffuse pustular tinea capitis.