An 18-year-old black woman with
cerebral palsy was admitted for evaluation of an intrathecal
baclofen pump site
infection. The dermatology service was consulted for treatment suggestions of a presumed diagnosis of chronic
tinea capitis. Three courses of oral
griseofulvin during the past 2 years failed to resolve the patient's chronic
scalp dermatosis. Scalp lesions first began about 2 years earlier after hospitalization for placement of an intrathecal
baclofen pump. The patient was unable to care for her scalp due to her
cerebral palsy, and her mother interpreted the scalp condition as infectious. No routine shampoo care, scalp care, or topical treatment was performed for more than 1 1/2 years. The mother felt that touching the patient's scalp might cause
pain and noted that the majority of her time was spent concentrating on more critical medical issues. Physical examination revealed coalescing hyperkeratotic plaques extending dorsally from the anterior hairline to the occipital scalp with small flecks of keratinous debris throughout the remaining hair (Figure 1). The plate-like plaques were devoid of hair, except at a few fissures where a few tufts of hair emerged. No cervical lymph nodes were appreciated on palpation. Treatment was initiated with compresses consisting of large warm water-soaked towels 4 times daily. Three times a day, a nursing staff applied 5%
salicylic acid in
olive oil to the scalp under a shower cap for approximately 1 hour. Over the following 2 days, a significant reduction in keratinous debris was appreciated. Within 2 weeks, the bulk of the plaques had been removed (Figure 2). At 6-week follow-up, the underlying scalp showed areas of
fibrosis and possible
scarring with a few emerging tufts of hair. On the basis of history and response to treatment with
salicylic acid and routine scalp care, the patient was diagnosed with an unusually severe case of
dermatosis neglecta.