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FIGURE 88.24 Nonscarring alopecia on the scalp of a child characteristic of alopecia areata Tinea Cruris Tinea cruris begins as a small, red, scaling rash in the groin that spreads peripherally and clears centrally The edges are sharply marginated and scalloped, extending down the thighs Generally, the scrotum is not noticeably involved Other conditions to consider are seborrheic dermatitis (which usually can be differentiated by involvement of other areas of the body such as the ears, scalp, and eyelids), intertrigo (generally secondary to friction and maceration), contact dermatitis, candidiasis (which usually involves the inner thigh and causes the scrotum to appear bright red), and erythrasma (which will fluoresce under Wood lamp) The clinician should always check the feet to ensure there is no fungal involvement in that area as well In general, this condition affects only postpubertal children Diagnosis is made by KOH preparation Nonspecific measures for treatment include loose-fitting clothing, reducing the amount of perspiration Clotrimazole, miconazole, tolnaftate, and econazole are useful as topical antifungal agents Rarely, oral griseofulvin may be needed in severe cases Tinea Pedis Tinea pedis is generally caused by Trichophyton rubrum or Trichophyton mentagrophytes It occurs most commonly in postpubertal children The cracking and peeling of the skin suggestive of tinea pedis in prepubertal children more often indicates the presence of atopic eczema or hyperhidrosis KOH preparation will demonstrate hyphae, especially when samples are taken from between the fourth and fifth interspaces of the toes Clinically, the skin has a dry, white, hazy appearance and is often pruritic When secondary bacterial infection is present, an odor occurs At times, an inflammatory lesion (caused by T mentagrophytes ) causes blistering The presence of an id reaction indicates dissemination of antigen to other parts of the body, especially the hands The differential diagnosis of tinea pedis includes simple maceration, contact dermatitis, and atopic eczema Treatment consists of drying the feet thoroughly after washing; wearing dry, clean socks; avoiding caffeine-containing foods to decrease sweating; keeping shoes off as much as possible; and walking barefoot or in sandals Topical antifungal agents and/or oral griseofulvin are used to treat this condition Tinea Versicolor Tinea versicolor refers to a superficial infection of the skin caused by Malassezia , which produces color changes of the skin, hypopigmentation, hyperpigmentation, and sometimes a salmon-colored redness ( Figs 88.17 and 88.25 ) Wood light examination usually shows yellowish-brown fluorescence Because moisture promotes growth of the organism, exacerbations occur in warm weather or in athletes who sweat excessively The infection is difficult to eradicate and recurs frequently A KOH preparation shows short, stubby hyphae and large clusters of spores, often referred to as “spaghetti and meatballs.” Treatment consists of lathering the entire body with selenium sulfide shampoo (2.5% concentration) or ketoconazole shampoo after wetting the skin surface in a shower The lather is left on for to 10 minutes and is then showered off This procedure is carried out daily during the first week, with decreasing frequency over the ensuing weeks Maintenance therapy once weekly throughout the summer or warmer seasons is advisable because of the high incidence of recurrence Localized areas of involvement can be treated with topical antifungal agents (e.g., econazole, ketoconazole topically) Adolescents can be treated with 150 mg of fluconazole given once or at monthly intervals during the warm summer months or during a sports season when the patient sweats frequently Because tinea versicolor tends to be a recurrent problem, retreatment in subsequent years may be necessary FIGURE 88.25 Scaly hyperpigmented patches consistent with tinea versicolor PAPULOSQUAMOUS ERUPTIONS/SCALY RED PATCHES AND PLAQUES Papulosquamous eruptions are discussed in Chapter 70 Rash: Papulosquamous Eruptions and Viral Exanthems These are conditions that are a mixture of papules or plaques with scale They are often red but can be more pink or purple in color as in lichen planus Conditions That Lack Pruritus Pityriasis Rosea For more information about pityriasis rosea, see Chapter 70 Rash: Papulosquamous Eruptions and Viral Exanthems This is a harmless skin condition that generally occurs in preadolescents to adults and contains scaly pink or red plaques often in a “Christmas tree” distribution on the back ( Fig 88.18 ) There are atypical variants that are more papular and scaly and include the head and neck One should consider secondary syphilis in the differential of pityriasis rosea ( Fig 88.20 ) Guttate psoriasis should also be included in the differential Secondary Syphilis Please see previous discussion in this chapter Pruritic Papulosquamous Disorders Lichen Planus Lichen planus is seen occasionally in pediatric patients as a chronic, pruritic, reddish-blue (violaceous) to purplish eruption Two percent to 3% of cases occur in patients younger than 20 years of age FIGURE 88.26 Purple polygonal papules consistent with lichen planus The eruption generally involves the flexors of the wrist, forearms, and legs, especially the dorsum of the foot and ankles The highly pruritic lesions appear as small, violaceous, shiny, flat-topped, polygonal papules ( Fig 88.26 ) These qualities may be recalled with the alliterative mnemonic of the five p’ s: p ruritic, p urplish, p lanar, p olygonal, p apules Some add a sixth p indicating a predilection for so-called “private” areas such as penis or vulva The surface of these papules may have white cross-hatching, called Wickham striae Lesions may occur in sites of trauma or injury (Koebner phenomenon) The scalp may be involved, often resulting in a scarring alopecia, called lichen planopilaris It is important to examine the buccal mucous membranes and the genital areas for a reticulated or lace-like pattern of white papules or streaks This finding is characteristic for lichen planus The nails are often pitted, dystrophic, or ridged (pterygium nails) The lesions in lichen planus can be vesicular or bullous Hypertrophic and linear lesions occur but are less common Persistent, severe, postinflammatory hyperpigmentation is common in African Americans In twothirds of patients, the lesions clear within to 15 months The cause of the disorder is unknown Topical therapy with steroids can be helpful, and treatment with oral steroids may be necessary for extremely symptomatic patients For ... this chapter Pruritic Papulosquamous Disorders Lichen Planus Lichen planus is seen occasionally in pediatric patients as a chronic, pruritic, reddish-blue (violaceous) to purplish eruption Two percent