A kerion is a boggy plaque found on occasion in tinea capitis that results from a massive immune inflammatory response to the causative fungal agent. The fungi most likely to cause this reaction are in the zoophilic class. The kerion often appears as a large, inflamed, boggy-feeling plaque with alopecia. Serous drainage and crusting are also present. These plaques are very tender to palpation, and children complain of pain even when the lesions are not manipulated. Alopecia overlies the plaque, and if it is severe, a kerion can lead to permanent scarring alopecia. Posterior occipital and cervical adenopathy is present and tender to palpation. The kerion often become impetiginized with bacteria, especially Staphylococcus species. Treatment is based on the use of systemic oral antifungals in association with an oral corticosteroid to decrease the massive inflammatory response. Any bacterial coinfections must be treated at the same time. Scarring alopecia may be permanent and may lead to morbidity for the child.
Tinea unguium, or onychomycosis, is clinically recognized by thick, dystrophic, crumbling nails. One or all the nails on a foot or hand may be involved. Toenail infection is much more common than infection of the fingernails. Most patients start with tinea pedis, after which the fungus spreads to infect the nail plate. This results in thickening and yellowing of the nail. Over time, the nail becomes thickened with subungual debris that is easily removed with a blunt instrument such as a curette. The nail may become onycholytic and fall off the nail bed. Patients are most frequently asymptomatic, but some complain of discomfort and difficulty clipping their nails. Diabetic patients and those with peripheral vascular disease are at risk for bacterial cellulitis. The dystrophic nails serve as a nidus for infection with various bacteria. Nail disease requires the use of systemic oral medications to get the best therapeutic response. Topical agents have shown some benefit, but only for very mild nail involvement. A deep green discoloration under the nail is an indication of Pseudomonas nail colonization. The bacteria make a bright green pigment that is easily visible. Soaks in acetic acid (vinegar) diluted 1 : 4 in water are effective in clearing up the secondary Pseudomonas.
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