Favus in a non-endemic area

Favus is a rare form of fungal infection of the scalp caused by Tichophyton schoenleinii and rarely by T. violaceum and Microsporon gypseum.[1][2] It is characterized by the presence of sulphur-yellow cup-shaped crusts known as "scutula" or "godet" and result in scarring alopecia on healing.[2] In India favus is frequently observed in Kashmir valley.[3] Sporadic cases have also been reported from other parts of the country.[4][5] We report a typical case of favus caused by T. violaceum in an elderly female from a village in district Udaipur (Rajasthan).

Case Report

A 60-year-old female, admitted in the medical ward of General hospital, Udaipur for haematemesis was referred to us for extensive lesions on scalp for the past 50 years. Examination of the scalp revealed multiple, varying-sized, yellowish crusted lesions with depressed centres and raised edges. Almost the entire scalp was involved [Figure - 1]. Removal of the crusts revealed a moist, raw base undeneath. Areas of cicatricial alopecia and patchy depigmemation were seen in between these lesions. Some of the nails of the fingers and toes were also involved. They showed brittleness, discoloration, subungual debris and partial destruction of nailplates. No other area of body had evidence of dermatophytosis or other dermatoses.

Microscopic examination (KOH preparation) of the scalp lesions and nails showed abundant hyphae. Culture on Sabourauds agar grew T. violaceum. Histopathological study of skin biopsy from the scalp lesion showed plenty of hyphae in stratum corneum and marked atrophy of the epidermis. The dermis showed moderate lymphohistiocytic infiltrate and sclerosis.

Interestingly, several members in the patient′s family including her son, 2 sisters, mother and grandfather were reported to have similar affection of the scalp.

Her son was available for examination. He showed patchy cicatricial alopecia of the scalp and had history of having similar lesions on the scalp as his mother. The lesions had responded to the treatment that he received some years back. The exact details of the treatment were not available.

The patient was treated with oral griseofulvin in a dose of 500 mg daily. She, however, did not report back for further follow-up.

Discussion

Favus is a relatively rare disease in most parts of India except Kashmir valley where it occurs in endemic form.[3] We could find only 2 case reports of favus occurring in non-endemic areas in India one from Haryana,[4] and the other from south India.[5] The infection is usually transmitted from person to person through close contacts or infected fomites. It is commonly acquired during childhood and can persist throughout the life if untreated.

Our case presented with typical, sulphur-yellow crusts with depressed centres characteristic of favus of the scalp. The diagnosis was confirmed by demonstration of hyphae in KOH preparation and skin histology. The culture grew T. violaceum. There was no history of travel by the patient or any other family members to Kashmir valley or a visit in their family by a person from Kashmir. The infection in our patient was possibly acquired from infected family member(s), several of whom were reported to be affected with similar lesions on scalp.

The occurrence of favus in Udaipur district of Rajasthan, a non-endemic zone for favus suggests that there are possibly some sporadic foci of infection in certain areas. These areas should be identified. Further, a high index of clinical suspicion be kept in order to diagnose such cases in the areas where they have previously been unreported.