A Newborn With Scaly Scalp Lesions

Manjusha Abraham, MD; Douglas Swanson, MD; and Philip Abraham, MD

A 16-day-old girl’s parents brought her to an urgent care clinic out of concern for lesions on the newborn’s scalp. The lesions had appeared 2 days ago on her forehead and had spread to her scalp and cheeks.

On physical examination, multiple annular, erythematosquamous patches were noted. Each lesion measured between 0.5 cm and 1.5 cm in diameter.

The mother reported that the pregnancy and delivery had been uncomplicated.

No fever or any other symptoms were noted in the infant. She was being breastfed and was otherwise thriving. There had been no exposure to any animals, and no other family member had similar lesions. The family had immigrated from Eritrea 4 years ago, and the girl had been born in the United States.

What’s causing this neonate’s erythematous, scaly lesions?



Answer: Tinea capitis

Tinea capitis is a common dermatophytosis in children, but it is very rare in neonates. Still, based on our clinical suspicion for tinea capitis, our patient was treated with clotrimazole 2% topical ointment. The diagnosis of tinea capitis was confirmed with fungal culture results, which identified the culprit as Microsporum ferrugineum.

The girl was seen for follow-up visits 3, 7, and 14 days later; her scalp eruptions had shown some improvement by the end of 2 weeks of topical antifungal therapy. The lesions had resolved completely within 4 weeks of treatment.

Tinea capitis, a fungal infection of the scalp, is common among children, with an estimated prevalence of 3% to 8%,1 but it rare in infants younger than 1 year of age.2 Tinea capitis is caused by 3 main genera of dermatophytes: Trichophyton, Microsporum, and Epidermophyton.3 Risk factors that can increase a person’s susceptibility to these fungal infections include high ambient humidity, broad-spectrum antibiotic use, trauma such as from indwelling catheters and tape, epidermal immaturity, and immunosuppression.

Transmission of the dermatophytes can occur via person-to-person contact, and health care workers unknowingly may spread the disease, or it can be transmitted from an infected animal to a person.4,5 Snider and colleagues reported 6 cases of neonates with nosocomial dermatophyte infections in Houston, Texas; further investigation identified a nurse as the common source for transmission in all cases.7

A large majority of cases of reported infant infections have been among immigrant families.1,5,6 Possible explanations for this are crowded living conditions; hair grooming practices such as the use of pomades and braiding, especially in the African American population; lower socioeconomic status; and limited access to health care.1 Among the African American population, the most common causes of tinea capitis are Trichophyton tonsurans and Microsporum canis. The latter is more frequently acquired from cats and rabbits.5,6 Our patient was from an immigrant family with relatively low socioeconomic status. Although she had had no contact with any pets, and no family members had reported similar lesions, there is a chance that family members are unknowing carriers of M ferrugineum.

Controversy exists about the management of tinea capitis in neonates. Some authors have advocated for systemic treatment,8-10 whereas others have reported the efficacy of topical treatments owing to neonates’ increased skin permeability due to an immature epidermis.11,12

This case illustrates the importance of including infection with a dermatophyte, although rare among neonates, as part of the differential diagnosis of multiple annular lesions in a newborn. We also report the effective treatment of neonatal tinea capitis due to M ferrugineum with topical treatment, thereby avoiding the potential adverse effects of an oral regimen, which has not been well studied in neonates.n


Manjusha Abraham, MD, is a resident in the Department of Pediatrics at the University of Kansas Medical Center.


Douglas Swanson, MD, is an associate professor in the Department of Pediatric Infectious Diseases at Children’s Mercy Hospitals and Clinics in Kansas City, Missouri.


Philip Abraham, MD, is an assistant professor in the Department of Pediatrics at the University of Kansas Medical Center in Kansas City, Kansas.


Kirk Barber, MD, FRCPC—Series Editor, is a consultant dermatologist at Alberta Children’s Hospital and clinical associate professor of medicine and community health sciences at the University of Calgary in Alberta.


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