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Bald patch, dandruff, pustules on head, redness on scalp. Diagnosed follicutis and alopecia areata. Advice?

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My 16 year old daughter developed dandruff about 10 months ago, and I thought nothing of it, she began using T-Gel (UK) to help, but recently told me that she discovered a small bald patch on the back of her head(Not readily visible as she has long hair, and it is underneath) she has no idea how long the bald patch(with occasional long hairs in it) has been there. I took her to the GP and she said it was probably a fungal infection and prescribed Nizoral shampoo(ketoconazole) this really helped her itchiness. However when I bought - over the counter Nizoral (at the pharmacy) it did not have the same effect. We went back to another GP, and this time she noticed pustules in the hair. She diagnosed folliculitis and alopecia areata - which as you can imagine has frightened my daughter terribly - she has been prescribed Teralysal antibiotic and dermovate for the bald patch. It has now been two weeks, and the pustules have gone, but she is still left with a lot of red patches on her head, and the dermovate has had no effect as of yet.

I was wondering whether this was in fact ringworm? (My son has recently developed athletes's foot) She was sleeping with wet hair on a wet towel, and did do this for months, also a few months ago she had an outer ear infection - itchiness - which she managed to pass to me - both our ears were clear after using fucidin cream for 5 days.

She also suffers from acne on her face, and back, and a little in her front hairline.

I find it too coincidental that she has had an itchy scalp with dandruff, then pustules, a lot of redness on her scalp, and then this patch of baldness at the nape of her neck at the same time - could they not all be related to each other? The bald patch is roughly 4cm x 3cm, and next to it is a scaly lesion.

I would be most grateful for your advice. XXXXXXX XXXXXXX

Posted Fri, 4 May 2012 in Skin Hair and Nails
Answered by Dr. Bharat Chawda 4 hours later

Thank you for posting the query,

You have provided with good information regarding your daughters skin problem and it is a very good description. I appreciate it.
I also understood your problem however it would be good if you can answer few of my queries:
1) When you had first noticed the bald patch ,was the area smooth or did you observe scaling and roughness within the patch.
2) Was the bald patch itchy that time.
3) How many such patches does she have.
4) After application of dermovate cream did she observe any improvement(any hair growth).
5) Is her menstrual periods regular in cycle .
6) Is she over weight/obese .
7) Does she have facial hair too(hirsutism).
8) What is the exact location of her pimples on face (is jaw line & chin involved).
9) Does she feel aggravation of pimples 2 days prior to her menstrual periods.

I would appreciate if you can send me a close up picture of the bald patch & the face which shows her distribution of acne.
You have a feature to upload the reports / image by yourself at the right side of the query page, please utilize that so that I can answer your queries better.

However , I shall address your concern based on your current given information.

Dandruff should not be taken as a disease , until unless it is very excessive.Dandruff is nothing but a combination of sebum(oil) secreted from the sebum glands present in the hair follicles & the peeling of skin.Use of ketoconazole shampoo would definitely reduce it .

As far as the bald patch is concerned it is very important to differentiate between fungal infection & Alopecia Areata. These are two completely different condition ,but mimic clinically ,and both show a bald patch.But a experienced dermatologist would surely differentiate the two.The treatment is completely contrasting in the two.If its a fungal infection (as was diagnosed by your first physician) ,then application of dermovate (steroid) would aggravate the problem.One would require a purely anti fungal medicine in treating a fungal infection.

If it is alopecia areata then drug of choice is injectable steroids along with demovate cream.

Alopecia areta and fungal infection have nothing related to hormones.

But yes ,acne can be due to hormonal disturbances (but not in all cases).If acne is due to hormonal imbalance then one might also observe weight gain ,irregular menstrual periods, facial hair ,scalp hair loss etc.So we should rule out Polycistic ovary disease(PCOD) in such a case.Hormonal imbalance can also lead to oily skin (due to increase sebum production) in scalp & face.Its important to differentiate hormonal and non-hormonal cause here for her acne ,which would help her decide her treatment option too.

Her dandruff ,pustules & acne could be related to hormones ,but not the bald patch.

I think you should consult a competent dermatologist for complete physical examination, evaluation and to get her treated properly (a GP might not be the right choice here).

However if you can reply me with the answers & the picture I would be able to help you further on this.

Awaiting for your reply.

Dr.Bharat chawda
Above answer was peer-reviewed by
Follow-up: Bald patch, dandruff, pustules on head, redness on scalp. Diagnosed follicutis and alopecia areata. Advice? 4 hours later
Many thanks for your prompt reply. I have uploaded pictures of her hair.

She has one main bald patch at the nape of her neck - on photo's and I think she now has a small circle showing on the crown of her head. She refuses to let me take pictures of her face, but her acne is widespread, notablly on her forehead and chin area.
I am however most concerned about her hair loss, is there anything other than AA that can be causing this?

With kindest regards.
Answered by Dr. Bharat Chawda 6 hours later

Thank you for the reply and the pictures.

I have carefully gone through all the image links that you have provided.
The possibilities still remain the same. At this moment it does look like Alopecia Areata (AA), since the patch is shiny with no visible scaling.

If this is what she had in the beginning also with no itching over the patch or scaling, then I am sure that it’s AA. If she had itching and scaling then there is a possibility of it being Tinea Capitis (fungal infection).

Both these conditions are common in children. AA is more related to stress, while tinea capitis to unhygienic condition.
The drug of choice in Tinea capitis is oral anti fungal, while in AA its intra-lesional steroid injection (injections over the bald patch) along with topical lotions.

Since a prompt treatment is required in both the conditions, I would advise you to consult a competent dermatologist for proper treatment as soon as possible.

As far as acne is concerned, there are various treatment options, but this would depend upon the cause of it. In mild cases we prefer oral antibiotics, while in severe resistant cases we prefer oral retinoids. But if acne is due to hormonal imbalance then probably hormonal medicines.

Hope I have answered your query, should you have additional concern regarding the same, I would be happy to address it. Please accept my answer in case you do not have further queries.

Dr.Bharat chawda XXXXXXX specialist, Dermatology.
Above answer was peer-reviewed by
Follow-up: Bald patch, dandruff, pustules on head, redness on scalp. Diagnosed follicutis and alopecia areata. Advice? 5 hours later
Once again many thanks for your prompt reply. Can you advise why the tetralysal has worked on the spots on her back, and the pustules on her head, but has made no difference to the spots of her face?

If AA is an auto immune disease, where may I find clinical research studies on it, so that I can do my best to help my daughter.

With kindest regards
Answered by Dr. Bharat Chawda 6 hours later

Thank you for writing back,

If I am not wrong tetralysal is tetracyclin antibiotic ,has no role to play on AA,but yes it can cure pustules and acne both.Tetracyclin is an obsolete in treatment of acne ,in fact there are lot of reports of bacteria being resistant to it.It has been replaced by minocyclin or azithromycin now.And if acne is very sever then oral retinoids are preferred.

AA is an autoimmune disorder and hence one should also look for other autoimmune conditions in body like thyroid status or anemia.

The treatment of choice in AA is intralesional steroid injection .Other than this one should also be put on topical steroid and minoxidil solution for topical application.Rarely oral steroids are given in resistant cases.

You can follow this link below to read in detail about the same.
WWW.WWWW.WW You would find many things written about AA in net ,but this link is very authentic.

Since AA is a chronic condition ,I would advise you to consult a competent dermatologist for proper treatment and follow up.

I thank you again for submitting your question. I hope you found my response to be helpful and informative. If you have any additional concerns I would be happy to address them.

“ Wish you Good Health”

Dr.Bharat chawda XXXXXXX specialist, Dermatology.
Above answer was peer-reviewed by
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