CASE REPORT TINEA AMIANTACEA

Kepaniteraan Klinik Bidang Ilmu Kesehatan Kuli dan Kelamin RSAL-MINTOHARDJO, JAKARTA

Oleh: Benita putri permata (030.05.050)

Dokter Pembimbing: dr. Suswardana, M.Kes, Sp.KK

Fakultas Kedokteran Universitas Trisakti Jakarta 2013

Fall

08

Fall

08

TINEA AMIANTACEA
Benita Putri Permata

Abstract Tinea amiantacea is a condition in which there is excessive scaling of the scalp. Thick silvery or yellowish scales encircle the hair shafts and may bind down tufts of hair. The scales may resemble asbestos, giving rise to the term amiantacea the French word for asbestos is 'amiante'. Introduction Tinea amiantacea also known as pityriasis amiantacea (PA) presents as tenaciously adherent scales surrounding the base of scalp hairs that can result in hair loss 1. Baron Jean-Louis Alibert of France first described the condition in 1832 as an asbestos-like tinea2 . The exact cause of PA is unclear and may be due to a number of underlying conditions
3,4,5

. It is thought to represent a reaction pattern to inflammatory skin disease

with the most common causes being psoriasis and seborrheic dermatitis6. Case report A 10 year old asian boy present with heavy scale onto the hairs and separate and bind together their proximal portions (fig.1) (fig.2) (fig.3). He was otherwise healty and did not take any medication. There were no other skin manifestations of psoriasis or seborrheic dermatitis. The patient was prescribed with grioseofulvin , the longest standing effective treatment for tinea capitis is griseofulvin given in a dose of 10mg/kg daily for a period of 6-8 weeks.

(fig.1)

(fig.2)

(fig.3)

Discussion Pityriasis amiantacea (PA) is a papulosquamous condition of the scalp that presents with asbestos-like thick scales attached to the hair shaft. Scales are arranged in an overlapping manner like flakes of asbestos, leading to its name amiantaceus 3. The lesions can involve localized areas of the scalp or encompass it entirely. Long-standing inflammatory lesions of PA can lead to scalp fibrosis and result in permanent hair loss 7. Pityriasis amiantacea seems to be more common in females and those of younger age, with a mean age of 23.8 in one of the largest studies of PA patients 6,8 . The condition may be a reaction pattern to a number of inflammatory processes in the scalp. In one of the larger studies of patients with pityriasis amiantacea, scalp biopsies revealed pathologic diagnoses of psoriasis, seborrheic dermatitis, tinea capitis, atopic dermatitis, lichen planus, bacterial infection, and pityriasis rubra pilaris 6 . A recent report also describes PA as a manifestation of Darier disease
9

. Of these conditions, psoriasis

and seborrheic dermatitis appear to be the most common causes for PA. Staphylococcus aureus has been documented to be present in the majority of patients with PA
6,10

. S. aureus isolation likely represents secondary bacterial infection or normal

colonization. In one study, patients with Staphylococcal infection responded well with a combined regimen of systemic and topical antibiotics, topical corticosteroids, and coal tar
11

Our patient was prescribed with grioseofulvin, The longest standing effective treatment for tinea capitis is griseofulvin given in a dose of 10mg/kg daily for a period of 6-8 weeks. Griseofulvin is an orally active compound derived from a Penicillium species
21

. It is

fungistatic in vitro and its mode of action is through the inhibition of the formation of intracellular microtubules. Griseofulvin is active in vitro against dermatophyte fungi but few other organisms respond to the drug. There are both tablet and liquid formulations of griseofulvin. However, in the UK production of the liquid (paediatric) formulation of griseofulvin has been discontinued by the main supplier. Alternative formulations can be imported or some pharmacies suspend crushed tablets of griseofulvin in a suitable liquid base. However neither approach has been approved by a UK licensing authority. In assessing the evidence for its efficacy it is important to recognise that, because griseofulvin was one of the earliest antifungal drugs introduced, there are few comparative clinical trials. However reported experience suggests that for most organisms causing tinea capitis it is effective, although there are some patients with M. canis infections who require longer courses of treatment, e.g. 12 weeks. Since the earliest clinical studies, patients with T. tonsurans infections have been reported to have a variable response to griseofulvin and, again, the duration of therapy may have to be increased. The Infectious Disease Working Group from the American Academy of Pediatrics, for instance, recommend a higher dosage, 20mg/kg/day for T. tonsurans infections. There are no randomised comparative studies of the two doses (10 v 20 mg/kg day).However there are now some clinical trials comparing terbinafine with griseofulvin. In general, there is a paucity of studies regarding the treatment of PA. Effective and timely treatment of PA is critical to avoid scarring alopecia. The treatment should include keratolytic agents and topical corticosteroids
11

. Topical corticosteroids may reduce

11

inflammation decreasing erythema and pruritus. They should be used intermittently, and their safety has not been documented beyond 4 weeks of use other topical medications
12

. Keratolytic agents, like

salicylic acid, help to remove thick, hyperkeratotic scales and improve penetration of . Shampoos containing ketoconazole, ciclopirox, and zinc pyrithione are also useful in treating thick scales.

PA can be difficult to effectively treat with topical medications as several weeks of use may be needed before benefits are seen, and the thick scale will often reaccumulate if not treated regularly. Topical treatments can also be messy and time-consuming, leading to high levels of non-compliance 13 . Systemic agents may be justified for select patients with severe pityriasis amiantacea that has failed to respond to topical treatments. Biologic agents, such as tumor necrosis factoralpha (TNF-) inhibitors, have been increasingly used for a variety of inflammatory dermatologic diseases
14

. Infliximab (Remicade) was used in this case for PA due to

psoriasis. This agent is a chimeric monoclonal antibody against TNF- which leads to a decreased amount of interleukins (IL-1, IL-6) released from inflammatory cells, thus down-regulating inflammation downstream 15. Reference 1. Plewing G, Jansen T. Seborrheic dermatitis. In Freedberg IM, Eisen AZ, Wolff K, et al., editors. Fitzpatrick's dermatology in general medicine, 6th edition. New York: McGraw-Hill; 2003. 1200-1201 2. Alibert JL. La porrigine amiantacea. Monographie des Dermatoses. Paris, France, 1832: 293-5. 3. Knight AG. Pityriasis amiantacea: a clinical and histopathological investigation. Clin Exp Dermatol 1977; 2: 137-142. 4. Hansted B, Lindoskov R. Pityriasis amiantacea and psoriasis: a follow-up study. Derm. 1983; 166: 314-315. 5. Ring DS, Kaplan D. Pityriasis amiantacea: a report of 10 cases. Arch Dermatol 1993; 129: 913-914. 6. Abdel-Hamid IA, Salah AA, Moustafa YM, El-Labban AM. Pityriasis amiantacea: a clinical and etiopathologic study of 85 patients. Int J Dermatol 2003; 42: 260-4.

7. Langtry JAA, Ive FA. Pityriasis amiantacea, an unrecognized cause of scarring alopecia, described in four patients. Acta Derm Venereol. 1991; 71: 352-353.

8. Ring DS, Kaplan D. Pityriasis amiantacea: a report of 10 cases. Arch Dermatol 1993; 129: 913-914. 9. Hussain W, I. Coulson H, Salman WD. Pityriasis Amiantacea as the sole manifestation of Darier's disease. Clin Ex Dermatol 2009; 34:552-558. 10. Shalev RM, Cohen AD, Medvedovsky E, Sashavinsky S, Tchetov T, Vardy DA. Pityriasis amiantacea associated with Staphylococcus aureus super-infection in bedouin patients. Microbial Ecology in Health and Disease 2004; 16-4: 218-221. 11. van der Vleuten CJ, van de Kerkhof PC. Management of scalp psoriasis: guidelines for corticosteroid use in combination treatment. Drugs 2001; 61(11):1593-8. 12. Matsunaga J, Maibach HI, Epstein E. Scalp and Hair, Palms and Soles. In Roenigk HH, Maibach HI. Psoriasis. 3rd edition. New York: Marcel Dekker Inc., 1998. 45-57. 13. Warren RB, Brown BC, Griffiths CE. Topical treatments for scalp psoriasis. Drugs 2008; 68(16):2293-302. 14. Alexis AF, Strober BE. Off-label dermatologic uses of anti-TNF alpha therapies. J Cutan Med Surg 2005; 9(6):296-302. 15. Gupta AK, Skinner AR. A review of the use of infliximab to manage cutaneous dermatoses. J Cutan Med Surg 2004; 8:77-89.