Cicatricial alopecia secondary to neglected favus in a young Kashmiri female: An uncommon occurrence with clinical-dermoscopic correlation

Dear Sir,

Favus or tinea favosa is a type of tinea capitis, a fungal infection that affects the hair and scalp. It is uncommon in adults than children and is native to Kashmir valley in India.^[1] Here, we are describing a case of a young Kashmiri woman with neglected scarring alopecia secondary to favus, a rare occurrence, though endemic in Kashmiri children.

A 28-year-old unmarried girl from a rural area presented in our department with areas of hair loss and thick crusting over her scalp. On enquiring, the patient revealed that she had recurrent episodes of similar lesions over the past 3 years which subsequently healed by hair loss and scarring. Negative history included that the patient had no history of any treatment taken for the same over the years or significant family and drug history. She belonged to a lower socioeconomic status and had no features of immunocompromise. On cutaneous examination, we found scarring alopecia over the frontal, parietal, and partial temporal regions of the scalp. Multiple, cup-shaped yellow-crusted lesions with depressed centers and raised edges of variable size, over the parietal and temporal region [Figure 1]. Dermoscopic examination revealed multiple broken hair shafts, prominent erythema, thin short regrowing hairs, multiple tufts of hair containing less than six hairs, pili torti, and yellowish and hemorrhagic crusts [Figure 2]. She had reactive cervical lymphadenopathy and rest of the examination was normal. Her biochemical parameters including complete blood count, liver function tests, kidney function tests, urine analysis, and chest X-ray were normal. Potassium hydroxide examination under the microscope showed multiple hyphae [Figure 3a]. Culture in Sabouraud’s dextrose agar showed heaped white colonies, of Trichophyton schoenleinii after 4 weeks of incubation [Figure 3b]. The patient was managed as a case favus and put on oral terbinafine 250 mg once daily and topical sertaconazole lotion and ketoconazole shampoo. After 2 and 4 weeks of follow-up, significant improvement was noted [Figure 1].

Close

Figure 1:

Scarring alopecia seen over the frontal, parietal, and partial temporal regions scalp and multiple, variable sized, yellow-crusted lesions with depressed centers and raised edges over the parietal and temporal region. After 2 and 4 weeks of follow-up, significant improvement noted.

Export to PPT

Close

Figure 2:

Dermoscopic examination revealing multiple broken hair shafts, prominent erythema, thin short regrowing hairs, multiple tufts of hair containing less than six hairs, pili torti, and yellowish and hemorrhagic crusts.

Export to PPT

Close

Figure 3:

(a) Potassium hydroxide examination under the microscope showing multiple hyphae. (b) Culture in Sabouraud’s dextrose agar showing heaped up white colonies.

Export to PPT

Favus or tinea favosa is a chronic inflammatory dermatophyte infection, in 95% of the cases, caused by T. schoenleinii. Favus clinically manifests as scutula, yellow saucer-shaped crusts of hyphae and scales surrounding hair follicles, and severe scarring alopecia, resulting from untreated disease. It can lead to major psychological and social issues. It can also affect the nails, glabrous skin, and scalp. Fomites especially disseminate favus-associated dermatophytes. Risk factors include immune system compromise, poor nutrition and hygiene, overcrowding, poverty, and limited access to health care.^[1-3]

Tinea capitis is very uncommon in adults due to a variety of factors, including the development of fungistatic-saturated fatty acids in sebum during puberty, Malassezia globosa colonization, which prevents dermatophyte contamination, and the thicker quality of adult hair. With the exception of Kashmir Valley, where the disease is prevalent, favus is a very uncommon condition in most of India. In addition, sporadic occurrences in nonendemic regions have been documented.^[1,4]

Treatment includes oral griseofulvin, which had been the treatment of choice, but now T. schoenleinii has developed resistance to griseofulvin. Hence, due to decreased efficacy and potentially severe side effects such as carcinogenicity and teratogenicity, newer antifungal drugs such as terbinafine and azoles are recommended. The local treatment includes applying antifungal shampoo twice daily with isoconazole and ketoconazole after removing crusts.^[2,5,6]

In conclusion, the Kashmir Valley is endemic for childhood favus. We present a case of a neglected case of favus with cicatricial alopecia in a young Kashmiri adult female. We detailed the distinctive dermoscopic traits that, to our knowledge, have not been mentioned in literature because of their rarity. We further urge that favus is considered a possible differential diagnosis for cicatricial alopecia in adults, particularly in the endemic areas.