Simple cases

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Case 17

12-year-old girl complains of itching on nape

My scalp, back of the neck and especially behind the ears have been itchy for about a week.

It is wise to start with a neutral question. Here is it very helpful, as this dermatosis favors the nape and retroauricular regions.

No, but my little brother has a few red spots on his neck. The girl I sit next to in school is always scratching her head.

This disorder is transmitted by direct contact. It is most common in children and often epidemics are seen in kindergartens and schools.

No, never.

Good question to exclude chronic scalp dermatoses such as psoriasis and seborrheic dermatitis.


Good question to exclude other causes of more generalized pruritus, such as scabies. Total body inspection important.

I think my mom bought a new bottle.

This question is directed towards a possible allergic contact dermatitis, which can usually be excluded on clinical examination.

Once; 2 days ago.

The history excludes this new shampoo, as the itching was present first.

Choose the right efflorescences:

Correct. No distinct lesion is seen. The main complaint is pruritus and the main finding nits attached to some hairs on the posterior scalp.

Scales, as seen in psoriasis and seborrheic dermatitis, are not present here. Scales can be easily removed from the hair shaft, while nits are firmly attached.

Crusts sometimes occur with this disease following scratching and bleeding, but they are not seen today.

Choose the right diagnosis:

Atopic dermatitis is a common cause of scalp pruritus in children, but other sites should be involved and the history more chronic.

Important differential diagnostic consideration. Seborrheic dermatitis does not have nits, usually also affects anterior scalp and is more chronic.

False. Scabies only involves the scalp in infants. In older children, it usually affects the interdigital spaces, nipples, penis and umbilicus.

Correct. The nits are diagnostic, but the history of itching on the nape ands behind the ears, as well as a classmate with similar itching, is highly suggestive.

Choose the right therapy(ies):

This is for seborrheic dermatitis, not for lice.

Good. This is the standard treatment. In smaller children, wash off after 3 hours. Both lice and nits are killed.

A fine comb helps remove the nits, once they have been killed by lindane or an alternative agent such as permethrin or malathion.

Sometimes used in severe cases, but usually can be avoided.

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