An Itchy, Scaly Plaque on the Scalp

CLINICAL

An itchy, scaly plaque on the scalp

Naveen Kumar Kansal, Saurabh Agarwal

Case examination, including external and eczemas are commonly associated A girl, 8 years of age, was referred from the genitalia, oral mucous membranes and with PA. However, the exact paediatrics outpatient department with nails, was within normal limits and did aetiopathogenesis of this disease remains complaints of itching and thick scaling not reveal any evidence of associated unclear. Mucocutaneous examination may on the occipital scalp for the previous 3 mucocutaneous disease. be directed specifically to note: weeks. There were no other cutaneous • classic silvery-white scales, oil-drop or systemic complaints. The patient Question 1 sign and Auspitz’s sign of psoriasis was afebrile and her general physical What is the diagnosis? • greasy-yellow scale of seborrhoeic examination was within normal limits. She dermatitis had a regular vaccination history, and past Question 2 • classic flexural involvement with and family history were not contributory What are the commonly associated extreme itching and scratching of to the complaint. There was no personal or diseases/infections? childhood atopic eczema family history of atopy, allergy or other skin • associated head lice infestation of disease. Her body weight was 23 kg. Question 3 scalp. On examination, a thick, adherent, How should the condition be managed? Abdel-Hamid et al1 found that 83 of 85 ‘asbestos-like’, scaly plaque with matted patients with PA had a Staphylococcal hair was present on the occipital scalp Answer 1 infection, which was confirmed by (Figure 1). There was no associated The diagnosis is pityriasis amiantacea bacterial culture. However, the aetiological hair loss. The rest of the cutaneous (PA), sometimes also known as tinea role of S. aureus in PA is not defined. In or pseudotinea amiantacea. PA is an many patients, however, no associated uncommon but specific reaction pattern or underlying condition was identified. to some of the inflammatory conditions More recently, case reports have been of the scalp. The lesions of PA classically published on the association of PA with consist of thick, adherent, ‘asbestos- Darier’s disease,4,5 and with tumour like’ (amiantaceus) scaling and plaques. necrosis factor (TNF)-α inhibitor therapy These attach to the underlying scalp and for Crohn’s disease,6 tinea capitis7 and piercing hair shafts and result in matting pityriasis rosea.8 Scrapings should of the hair. The condition primarily affects be taken in suspected cases of tinea young adults, although it may occur at any infections for a potassium hydroxide age.1 As in this case, females are more (KOH) microscopic examination of fungal affected by PA than males.1 Temporary elements, as well as for culture/sensitivity alopecia or hair loss is common, and as necessary. Untreated tinea capitis as scarring (cicatricial) alopecia has also been a cause of PA may sometimes lead to reported.2 cicatricial alopecia. Rarely, scalp biopsy may need to be performed to define an Answer 2 unusual, underlying pathology (eg Darier’s Figure 1. Scaly plaque on the scalp with tufting 3 of hair In a number of patients, psoriasis, disease) when PA is atypical, recalcitrant seborrheic dermatitis, atopic dermatitis or poorly responsive to standard therapy.

Answer 3 scalp. A significant improvement was noted 3. Hansted B, Lindskov R. Pityriasis amiantacea At present, there are no specific at the 2-week follow up after treatment. and psoriasis. A follow-up study. Dermatologica 1983;166:314–15. guidelines for the management of PA. 4. Hussain W, Coulson IH, Salman WD. Pityriasis Mid-to-high potency topical corticosteroid Key points amiantacea as the sole manifestation of Darier’s disease. Clin Exp Dermatol 2009;34:554–56. preparations (eg mometasone, • PA is an uncommon, distinctive 5. Udayashankar C, Nath AK, Anuradha P. Extensive halobetasol, clobetasol), combined reaction pattern of the scalp to some Darier’s disease with pityriasis amiantacea, with salicylic acid and tar (sometimes inflammatory conditions resulting in alopecia and congenital facial nerve palsy. Dermatol Online J 2013;19:17. with vegetable or mineral oils) may be thick, adherent, ‘asbestos-like’ scaling 6. Ettler J, Wetter DA, Pittelkow MR. Pityriasis left on the scalp overnight, followed by and plaques, and sometimes alopecia. amiantacea: A distinctive presentation of psoriasis associated with tumour necrosis daily shampooing. This usually results in • The aetiology is unknown. However, factor-α inhibitor therapy. Clin Exp Dermatol loosening of the scales and their removal. some cases are associated with 2012;37:639–41. The steroid preparation needs to be psoriasis, seborrhoeic dermatitis, 7. Ginarte M, Pereiro M Jr, Fernández-Redondo V, Toribio J. Pityriasis amiantacea as manifestation applied to scalp for it to be effective. eczema and, rarely, Darier’s disease, of tinea capitis due to Microsporum canis. As the scales loosen after the morning tinea capitis and pityriasis rosea. Mycoses 2000;43:93–96. shampooing, steroid lotions should be 8. Zawar V. Pityriasis amiantacea-like eruptions in • The condition usually responds well to scalp: A novel manifestation of pityriasis rosea in rubbed directly on the scalp. conservative treatment, but recurrences a child. Int J Trichology 2010;2:113–15. 1 Associated Staphylococcal or are frequent. Patient need proper 7 fungal infections, or other diseases counselling on regular follow-up. (eg Darier’s disease),4,5 may need appropriate treatment or referral to a Authors dermatologist as well. An antidandruff or Naveen Kumar Kansal MD, Assistant Professor, Department of Dermatology and Venereology, tar-based shampoo would be helpful in Government Medical College, Haldwani, Nainital, maintaining remission once the condition Uttarakhand, India. [email protected] is controlled. With appropriate therapy, Saurabh Agarwal MD, Professor and Head, Department of Dermatology and Venereology, hair will regrow in areas of associated Government Medical College, Haldwani, Nainital, hair loss, but the scarring from alopecia is Uttarakhand, India. usually irreversible.2 Competing interests: None. Provenance and peer review: Not commissioned, Patients need appropriate counselling, externally peer reviewed. as PA usually responds well to treatment but may recur promptly when treatment References stops. For our patient, we prescribed 1. Abdel-Hamid IA, Salah AA, Moustafa YM, a topical lotion containing clobetasol El-Labban AM. Pityriasis amiantacea: A clinical and etiopathologic study of 85 patients. Int J propionate (0.05%) with salicylic acid, Dermatol 2003;42:260–64. (6%) to be applied twice a day, and daily 2. Langtry JA, Ive FA. Pityriasis amiantacea, an unrecognized cause of scarring alopecia, shampooing. She was also advised to described in four patients. Acta Derm Venereol apply plain coconut oil liberally on the 1991;71:352–53.