Answer to Photo Quiz: Facial rash and alopecia in a patient with systemic lupus erythematosus

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DIAGNOSIS

Endothrix and hyphae were found on microscopic examination of the hair (figure 2A) and skin scrapings (figure 2B). Cultures of the hair and the scrapings of skin grew Trichophyton tonsurans. A diagnosis of tinea capitis and tinea faciei was made. She achieved clinical and mycological clearance after being treated with oral terbinafine 250 mg/day for six weeks. 
Tinea capitis is one of the common causes of hair loss in children; it is rare in adults.¹ However, tinea capitis is far from unusual in immunocompromised adults.^2,3 Hair loss is a common cutaneous adnexal manifestation in systemic lupus erythematosus patients (20-60%).⁴ It may be correlated with the disease activity index in systemic lupus erythematosus,⁵ therefore tinea capitis should be carefully differentiated from primary hair loss in patients with systemic lupus erythematosus using immunosuppressive drugs. Tinea faciei may be atypical in immunocompromised individuals.4 The lesions of tinea faciei should be differentiated from the cutaneous lesions of lupus.


REFERENCES

1. Patel GA, Schwartz RA. Tinea capitis: still an unsolved problem? Mycoses. 2011;54:183-8. 
2. Yu J, Chen W, Wan Z, Li RY. Adult tinea capitis due to Trichophyton violaceum in China. Mycopathologia. 2004;157:49-52. 
3. Lova-Navarro M, Gomez-Moyano E, Martinez Pilar L, et al. Tinea capitis in adults in southern Spain. A 17-year epidemiological study. Rev Iberoam Micol. 2016;33:110-3. 
4. Ramos-e-Silva M, Pirmez R. Red face revisited: Disorders of hair growth and the pilosebaceous unit. Clin Dermatol. 2014;32:784-99. 
5. Sato JO, Corrente JE, Saad-Magalhaes C. Chronic active disease pattern predicts early damage in juvenile systemic lupus erythematosus. Lupus. 2015;24:1421-8.