Nursing in Practice March/April 2019 (issue 107) - Page 42 March/April 2019 This 17-year-old has presented as she is fed up with the appearance of her skin. It has been like this for a few months and is itchy. You notice that she also has scaling and redness around her nose. She tells you she has just found out that her previous partner cheated on her and she has never been tested for sexually transmitted infections – could you arrange a sexual health screen? 2 3 4 This 10-year-old boy was brought in by his mother who had noticed for some time that his hair and scalp were scaly. Gradually he has started to lose hair and now has a scaly bald patch, which is causing him discomfort. His younger brother is starting to develop the same problem. Answers 1 Kerion A condition where hair follicles discharge blood and sometimes pus due to a fungal infection (tinea capitis). Clinically it feels like a boggy swelling. Treatment is with an antifungal such as terbinafine or griseofulvin, which is often needed for several months. It is not uncommon for another sibling in the family to have the same fungal scalp infection. 2 Traction alopecia Hair loss has been gradual because of the boy pulling on his hair. This is likely to be linked to the stress of the bereavement. Compulsive pulling of hair is called trichotillomania and the commonest age of onset is 12-13. Treatment is usually with talking therapies to address the underlying cause. 3 Psoriasis The photo shows the classic pink lesions with silvery surface scale. The diagnosis is clear from the appearance and the location, psoriasis being common around the hairline and the extensor surfaces of the knees and elbows. Psoriasis is a systemic disease, associated in some patients with severe arthritis that can occur before the rash. Treatment can range from topical steroids and vitamin D analogues to potent systemic drugs such as methotrexate. 4 Seborrhoeic dermatitis Chronic inflammatory condition that causes redness and scaling. The adult form usually presents in the teens and can affect the face and hair, including facial hair in men. A new diagnosis of seborrhoeic dermatitis should prompt consideration of an HIV test as it is associated with immunodeficiency. Treatment is usually with topical steroids and antifungals. A 41-year-old woman has come to see you as she is concerned about this rash, which is on her scalp and the extensor surfaces of her elbows. It is very itchy and she finds it unsightly. Before you can look at the scalp, she says that she hopes you don’t mind but she has another problem – her joints have been very achy lately – could you look at them too? 1 You know this 12-year-old boy well as you have been supporting the family after a sudden bereavement. Mum has brought him in today as she is concerned about this hair loss. She has noticed him fiddling with his hair and wonders if the two things might be connected. Can you identify the cause and management of these skin presentations? Answers in the box below Common presentations on the scalp and hairline 42 CLINICAL