Tinea and fungal skin infection — branching viva

Branching viva from a five-year-old with a scaly bald scalp patch and broken hair stubs, through the recognition of tinea capitis, the oral-therapy rule, the species-guided choice of terbinafine versus griseofulvin and household carrier screening, with a pivot to a four-year-old with a painful boggy kerion after contact with a kitten and a question on tinea incognito from a steroid-containing cream.

branching clinical structured oral3 min readVerification in progress

Prompt

You are the paediatric registrar in the outpatient clinic. The examiner asks you to work through a five-year-old with an itchy scaly bald scalp patch and broken hair stubs, and later a four-year-old with a painful boggy purulent scalp mass after the family acquired a kitten, and a parent using a steroid-containing cream on an annular forearm rash. Information is released in stages.

Opening — framing the problem

The examiner begins: a five-year-old has a three-week history of an itchy, scaly bald patch on the scalp with broken hair stubs, black dots flush with the skin and an enlarged occipital node. Talk me through your approach. [1]

I would frame this as tinea capitis. The broken hair stubs and black dots are hair broken flush with the scalp surface, which is the endothrix pattern of Trichophyton tonsurans, and the enlarged occipital node favours a fungal scalp infection over a non-infectious dermatosis. I would confirm with potassium hydroxide microscopy of a plucked hair looking for branching septate hyphae and arthroconidia, and send fungal culture to identify the species. [1]

Paediatrics Fellowship Pro

You have read the opening of this viva. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References6Show ledger

[1]Gupta AK, Polla Ravi S, Wang T, et al. An update on tinea capitis in children. Pediatr Dermatol, 2024.PMID 39113245
[2]Fuller LC, Barton RC, Mohd Mustapa MF, et al. British Association of Dermatologists' guidelines for the management of tinea capitis 2014. Br J Dermatol, 2014.PMID 25234064
[4]Tey HL, Tan AS, Chan YC Meta-analysis of randomized, controlled trials comparing griseofulvin and terbinafine in the treatment of tinea capitis. J Am Acad Dermatol, 2011.PMID 21334096
[5]Gupta AK, Drummond-Main C Meta-analysis of randomized, controlled trials comparing particular doses of griseofulvin and terbinafine for the treatment of tinea capitis. Pediatr Dermatol, 2013.PMID 22994156
[6]Leung AK, Lam JM, Leong KF, et al. Tinea corporis: an updated review. Drugs Context, 2020.PMID 32742295
[10]Dessinioti C, Papadogeorgaki E, Athanasopoulou V, et al. Screening for asymptomatic scalp carriage in household contacts of patients with tinea capitis during 1997-2011: a retrospective hospital-based study. Mycoses, 2014.PMID 24372570