Scalp Hyperkeratosis and Alopecia in Children of Color

May 2011 | Volume 10 | Issue 5 | Original Article | 511 | Copyright © May 2011


Background: Scalp hyperkeratosis and/or alopecia are common pediatric dermatologic findings. In Caucasian children, scalp hyperkeratosis of childhood is most often associated with atopic and seborrheic dermatides. Recent data is lacking on the clinical meaning of scalp hyperkeratosis and alopecia in children of color.
Objective: To determine diagnosis associated with scalp hyperkeratosis and/or alopecia in a predominately Black and Hispanic pediatric patient population.
Methods: A retrospective chart review was conducted for all children (0-17 years of age) seen at our institution who had a scalp fungal culture for the evaluation of scalp hyperkeratosis and/or alopecia from January 2007 to September 2009. Fungal culture was performed using cotton swab technique, plating onto Sabouraud's and Mycosel media. Demographic features, fungal culture results, clinical symptoms, physical findings and final diagnosis were reviewed.
Results: 164 children were identified who were eligible for inclusion in the study, 75 of whom were Black and 56 Hispanic/Latino. Scalp hyperkeratosis was noted in 106 patients and alopecia was noted in 71 subjects. Tinea capitis was the final diagnosis in 50 out of 80 children who had hyperkeratosis without alopecia (60%), 16 of 43 children with alopecia alone (37.2%) and 23 of 28 children with both hyperkeratosis and alopecia (82.1%, P=0.0007). The odds ratio of tinea capitis in the presence of hyperkeratosis with alopecia was 7.49 with a 95 percent confidence limit of 2.19-25.70.
Conclusion: Scalp hyperkeratosis, especially when accompanied by alopecia, is usually associated with tinea capitis in Black and Hispanic children. Fungal culture and empirical anti-fungal therapy are warranted in children of color with scalp hyperkeratosis.

J Drugs Dermatol. 2011;10(5):511-516.


Scalp hyperkeratosis, with or without alopecia, is a common clinical finding seen in pediatric dermatology practices, especially those with children of color. In such cases, fungal cultures are routinely performed to confirm the presence of tinea capitis. However, fungal cultures require weeks to grow and because it is commonplace for children of color to have agents applied to the scalp that may obscure the presenting clinical features and/or alter culture results, it is difficult for clinicians to determine actual diagnosis in an ethnically diverse population of children with scalp hyperkeratosis.1 Therefore, deciding when to treat a patient empirically is of paramount importance in clinical practice.
Scalp hyperkeratosis, also known as scale, can be routinely found in patients suffering from tinea capitis, atopic dermatitis, seborrheic dermatitis and psoriasis.2 Rare reports have also documented scalp hyperkeratosis in Langherhans cell histiocytosis, 3 scabies,4,5 dermatomyositis,6 pityriasis rubra pilaris,7 leukemia cutis8 and pemphigus foliaceous.9 Common etiologies for isolated alopecia include alopecia areata, traumatic alopecia (traction or trichotillomania), or telogen effluvium.10 Alopecia can also be found in conjunction with other symptoms including scalp hyperkeratosis in a host of disorders such as tinea capitis. Due to a diverse array of possible etiologies, it is difficult for clinicians to acutely determine correct diagnosis in a population of children with scalp hyperkeratosis and/or alopecia. This is further complicated when patient populations are not homogenous, and when cultural practices influence clinical findings and diagnoses.
In a study examining common causes of scale in predominantly White pre-pubertal children, Williams et al. demonstrated that seborrheic dermatitis (54.5%) was a leading cause of scalp scaling, followed by atopic dermatitis (24.2%).11 In a population predominantly composed of Black children, Hubbard et al. demonstrated that scale plus adenopathy showed a positive predictive value (PPV) of 97 percent for tinea capitis. In the ab-