A 70-year-old man is referred to dermatology for evaluation of a scalp rash that has been present for months. Complaining bitterly of the itching in his scalp, he gives a history that includes treatment attempts with a number of medications, including prescription ketoconazole shampoo, oral antibiotics (eg, minocycline), and a course of oral terbinafine (250 mg/d for three weeks)—none of which has had a positive impact on the problem.
His wife, who is with him, at first denies and then finally admits to having an itchy scalp as well. Neither has a history of prior skin problems.
The patient’s history is significant for type 2 diabetes and for well-controlled hypertension. He has been retired for many years and lives at home with his wife.
EXAMINATION
The patient appears disheveled, confused, and dirty. He is grossly oriented as to time and place, but hard of hearing and difficult to communicate with as a result.
His hair is greasy and dirty, as well as matted down in places. On closer inspection, scabs are noted in his scalp; they are widely distributed but especially heavy in the occipital and supra-auricular scalp. Many flakes of dandruff (some quite large) can also be seen.
Raising the thick hair over his nuchal scalp reveals a whitish sheen. Under 10x magnification, multiple tiny white papules are observed attached to each hair shaft, which accounts for the sheen. When examined under the microscope, the papules are clearly identified as nits. No adult lice are noted.
Significant tender adenopathy is elicited on palpation of the posterior neck area.
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