A 4-year-old girl with scalp lesion

Issue: February 2010

A 4-year-old girl was admitted to the hospital for evaluation and treatment of a scalp lesion.

The history of the chief complaint revealed that she had been diagnosed three weeks earlier by her primary provider with tinea capitis and treatment was started with griseofulvin. She was seen the next day in the emergency room, where the diagnosis of a kerion with early secondary infection was made, and oral cephalexin was added to her therapy. During the ensuing three weeks, the scalp lesion persisted and began to get larger. During this time, she also had some dental work done (caps on several teeth). She had no other complaints related to this lesion.

James H. Brien, DO

Pediatric Infectious Disease, Scott and White's Children's Health Center and Associate Professor of Pediatrics,
Texas A&M University, College of Medicine, Temple, Texas.
e-mail:jhbrien@aol.com

Her immunizations are up to date.

Her past medical history is remarkable for being autistic and very difficult to control. This has caused a great deal of difficulty for the mother to perform basic hygiene, as the child would not let her wash her hair, especially since the onset of this problem due to the discomfort associated with the lesion.

A 4-year-old girl was admitted to the hospital for evaluation and treatment of a scalp lesion.

Examination revealed normal vital signs, and there has been no history of fever. Her scalp had a large, 6-cm x 8-cm, boggy, painful, foul-smelling lesion, with much of her hair matted together with old blood and exudate, as shown in figure 1, which had to be washed to see the lesion. Because of the matting, hair loss was difficult to appreciate, but there appeared to be no loss of hair. In fact, the hair had to be shaved to see the lesion, as shown in figure 2. In the process of cleaning the area, the top of the lesion sloughed off a full- thickness piece of skin, as shown in figure 3, with the release of a large amount of purulent, foul-smelling material.

Lab teded a normal CBC with fungal and bacterial cultures of the drainage and dermatophyte culture of her hair are pending. A skin biopsy was sent for pathology, which revealed chronic dermal inflammation without fungal elements seen.

Figure 1: The patient’s scalp had a large, 6-cm x 8-cm, boggy, painful, foul-smelling lesion with much of her hair matted together with old blood and exudate.

The patient’s scalp had a large, 6-cm x 8-cm, boggy, painful, foul-smelling lesion with much of her hair matted together with old blood and exudate. All photos courtesy of James H. Brien and Brian Ellis, MD.

Hair loss was difficult to appreciate, but there appeared to be no loss of hair. In fact, the hair had to be shaved to see the lesion.

Figure 3: While cleaning the area, the top of the lesion sloughed off a full-thickness piece of skin with the release of a large amount of purulent, foul-smelling material.

While cleaning the area, the top of the lesion sloughed off a full-thickness piece of skin with the release of a large amount of purulent, foul-smelling material.

What’s Your Diagnosis?

Scalp abscess
Self mutilation
Kerion with abscess
ID reaction

Case Discussion

If you are confused, don’t worry.

The answer is not a sure thing, but in my opinion, this patient had a scalp abscess (A), probably secondary to poor hygiene, aggravated by autism with chronic control problems and untreated folliculitis.

However, this case was confusing to some of her providers, even after discharge, because a dermatophyte culture of some hair grew two colonies of a Trichophyton species, one of the main causes of tinea capitis. That culture also grew a few colonies of Fusarium species. The exudate grew a large amount of Enterobacter cloacae, a gram-negative, facultatively anaerobic rod. She was empirically treated with intravenous clindamycin and a third-generation cephalosporin (ceftriaxone) pending the culture and sensitivity results, and then adjusted to oral cefdinir when she was well enough to be discharged home. On the advice of the consulting dermatologist, who felt like this was most likely a kerion, she was also treated with griseofulvin before and after discharge, and also treated with terbinafin (Lamisil) as an outpatient in the Dermatology clinic.

The debate against a kerion: Kerions are occasionally confused with bacterial pyodermas. They both present as soft, sometimes exudative masses. The factors that support this being a scalp abscess are (1) the fact that a bacteria grew from this foul-smelling lesion (kerion discharges are usually sterile), (2) the biopsy failed to confirm any fungal elements, (3) the dermatophyte culture was a bit scant on its growth and was mixed with another fungus, and (4) there was no appreciable hair loss, a hallmark of tinea capitis and kerions (figure 4, courtesy of the Jim Bass Collection).

Tinea capitis and kerions are usually accompanied by hair loss, as shown above.

Is it possible that this was an atypical kerion that got secondarily infected? Anything is possible, but I’m inclined to believe the most likely rather than the very unlikely.


A patient with “ringworm” lesions, and a generalized rash.

An ID reaction (dermatophytid reaction) is a papulovesicular reaction to repeated exposure to an antigen, particularly dermatophytes. There may be a “ringworm” lesion found on the feet, body or head with the more generalized rash as seen in figures 5 and 6.

Self-injury is often seen in patients similar to this, but the type of injury to the head would most likely be pulling out the hair (trichotillomania), but certainly other forms of self-injury may have contributed to the condition. There was some old blood matting the hair, but the appearance after cleaning up the lesion failed to reveal evidence of external injury on examination. Also, there were no other areas of her body that had evidence of injury.

So, I’m sticking with my original opinion that she had a complicated scalp abscess. You may disagree without an argument from me, but after several months of follow-up in dermatology, a kerion was never confirmed.

Columnist comments

I would like to credit and thank Brian Ellis, MD, an outstanding pediatrician in Norman, Okla., for taking the pictures of the patient presented in this case when he was a resident here at Scott and White.

I would like to just provide another reminder about the 44th Annual Uniformed Services Pediatric Seminar, which is just around the corner in San Diego, March 7 – 10. It will be a fun and educational way to pick up 25.5 hours of CME. To review the brochure, please go to the following site: www.aap.org/sectionsuniformedservices2010USPSBrochure.pdf.

Unfortunately, I will be unable to attend this year due to other speaking commitments. But it is one of the best general pediatric meetings available and is AAP-sponsored, plus San Diego is not a bad place to visit. My personal favorite site to see is the USS Midway aircraft carrier, which is now a museum and well worth the $18. Please visit the USS Midway Web site to learn more about it. Of course, you can always see the pandas at the zoo if you don’t have anything else to do.