Case report
A 75-year-old female presented with a three-month history of pruritic purulent and crusted lesions over the scalp. She had been treated with multiple oral antibiotics and a topical cream consisting of clobetasol and salicylic acid for one month without any improvement. The patient had no medical history other than hypertension. She was in a good general condition and had not received any immunosuppressant drug. There was not any similar disease in other family members. Physical examination showed multiple erythemato-edemathous papules and plaques with yellow crust, pustule formation, and hair loss involving the vertex and occipital area of the scalp (Fig 1). There were no other lesions in any other parts of the skin, nails and mucosa. Values of serum blood chemistry were in the normal range. The patient’s immune profile was normal. The direct exam with 20% KOH showed an endothrix infection and the mycological culture showed the growth of Trichophyton Violaceum . Bacterial culture was negative. Skin biopsy of the scalp lesions showed an acute superficial and deep folliculitis with intrafollicular mycelial fungal infection consistent with tinea capitis (endothrix), on hematoxylin and eosin staining (Fig 2A & 2B). PAS-stained slides showed endothrix septate hyphae invading the hair shafts (Fig 2C). Fluorescent microscopy showed endothrix infection by green fluorescent, septate hyphae and spores (Fig 2D). The patient was treated with prednisolone 15mg daily for one month and oral itraconazole 400 mg daily, which was gradually tapered to 100 mg daily at the last two months. Also, the patient and all family members were treated with 2.5% selenium sulfide shampoo. There was complete clearance of the lesions and acceptable hair regrowth (Fig 3).