History Taking · Foundation · Dermatology

Scalp Scaling and Hair Loss in a Child

Practise this PLAB 2 history taking station on Tinea Capitis. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. You see Arjun, a seven-year-old boy, brought by his mother who is concerned about persistent scaling on his scalp and some hair loss over the past four weeks. Please take a focused history and discuss your management plan with the parent.

Background notes: PMH: Generally healthy, previous chicken pox age 4

What this station tests

  • Oral antifungal is mandatory for tinea capitis: topical treatment alone is inadequate because it does not penetrate the hair follicle
  • Distinguishing from alopecia areata: scaling with broken hairs (tinea) versus smooth non-scaly patches with exclamation mark hairs (alopecia areata)
  • Pet source identification: recently adopted dog as a potential Microsporum canis source, vet check recommended
  • Kerion as a complication: swollen, boggy, painful scalp patch requiring urgent additional treatment
  • Infection control: no sharing combs, brushes, hats; antifungal shampoo to reduce spore shedding

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Scalp scaling with hair loss in a child requires the candidate to distinguish tinea capitis from other causes (alopecia areata, seborrhoeic dermatitis) and recognise that oral antifungal treatment is mandatory (topical treatment alone is inadequate). Arjun is 7, brought by his mother Nisha with 4 weeks of scalp scaling and hair loss. Open with: 'Nisha, tell me about what you have noticed on Arjun's scalp and when it started.'

Core approach

Characterise the lesion. Scaling, erythematous patch on the scalp with hair loss in the affected area. Hairs are broken off at the surface (not pulled out cleanly as in alopecia areata). The patch has expanded over 4 weeks. Baby shampoo has not helped. No pain but mild itching. He is otherwise well, no fever.

Identify the source. Ask about pets: they have a cat (2 years) and a recently adopted dog (6 months ago). Microsporum canis from cats and dogs is a common cause. Ask about school contacts: any other children with similar scalp problems? Trichophyton tonsurans is spread person-to-person and is increasingly common.

Distinguish from differentials. Alopecia areata: smooth, non-scaly patches with exclamation mark hairs (absent here, the scaling is the key difference). Seborrhoeic dermatitis: diffuse scaling without hair loss. Psoriasis: well-demarcated plaques with silvery scale (different morphology). Tinea capitis: scaling with broken hairs and patch expansion is the pattern.

Confirm diagnosis: send hair and scale samples for microscopy and culture (plucked hairs with roots, not cut). Culture is the gold standard. Wood's lamp may show fluorescence if Microsporum species (but not all species fluoresce).

Closing and safety netting

Treatment: oral antifungal is mandatory. Topical treatment alone does not penetrate the hair follicle and is inadequate for tinea capitis. Griseofulvin is first-line for children (or terbinafine as alternative depending on species). Duration: typically 6 to 8 weeks. Adjunctive: antifungal shampoo (ketoconazole or selenium sulphide) twice weekly to reduce spore shedding.

Address the mother's concerns. Contagious: yes, but with treatment he can return to school. Scarring: unlikely if treated promptly, hair regrows once infection clears. Pets: the dog (recent adoption) may be the source and should be checked by a vet. Siblings: examine for similar lesions. Infection control: do not share combs, brushes, hats, or pillows.

Safety net: 'If the patch becomes very swollen, boggy, and painful (kerion), come back urgently as this is a severe inflammatory reaction that needs additional treatment.' Follow-up in 4 weeks to assess response. Repeat culture after treatment to confirm clearance.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for tinea capitis. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Tinea pattern identified (scaling, broken hairs, expanding patch). Pet history obtained. School contacts checked. Differentials distinguished (alopecia areata, seborrhoeic dermatitis). Samples sent for culture.

Costs marks: Not identifying scaling pattern. Not asking about pets. Not distinguishing from alopecia areata. No culture sent.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Oral antifungal prescribed (not topical alone). Adjunctive antifungal shampoo. Vet check for pets. Infection control advice. Kerion safety netting. Follow-up with repeat culture.

Costs marks: Topical only. No shampoo adjunct. Not mentioning pets. No kerion warning.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Addressing mother's contagion concern. Reassuring about hair regrowth. School return advice. Practical infection control she can implement immediately.

Costs marks: Not addressing contagion. Not reassuring about prognosis. Not advising about school.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Prescribing topical antifungal alone. Tinea capitis requires oral treatment because topical agents do not penetrate the hair follicle. This is a commonly tested point: candidates who prescribe cream or shampoo alone provide inadequate treatment.
  2. Not asking about pets. A recently adopted dog is a plausible source of Microsporum canis. Candidates who do not ask about animals miss the source and the opportunity to prevent reinfection.
  3. Not warning about kerion. A severe inflammatory response to tinea capitis can cause a kerion (boggy, painful swelling) which may be mistaken for bacterial abscess. Candidates who do not mention this miss a complication that needs urgent management.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How should I structure the tinea capitis history in this PLAB 2 station?

Scalp scaling with hair loss in a child requires the candidate to distinguish tinea capitis from other causes (alopecia areata, seborrhoeic dermatitis) and recognise that oral antifungal treatment is mandatory (topical treatment alone is inadequate). Arjun is 7, brought by his mother Nisha with 4 weeks of scalp scaling and hair loss.

What are examiners marking in this tinea capitis station?

Marks are won for: Tinea pattern identified (scaling, broken hairs, expanding patch). Pet history obtained. School contacts checked. Differentials distinguished (alopecia areata, seborrhoeic dermatitis). Marks are lost for: Not identifying scaling pattern. Not asking about pets. Not distinguishing from alopecia areata. No culture sent.

What is the most common mistake candidates make in this tinea capitis station?

Prescribing topical antifungal alone. Tinea capitis requires oral treatment because topical agents do not penetrate the hair follicle. This is a commonly tested point: candidates who prescribe cream or shampoo alone provide inadequate treatment.

How do I prepare for this station if I have not managed tinea capitis in clinical practice?

Structure beats experience here. Focus on distinguishing from alopecia areata: scaling with broken hairs (tinea) versus smooth non-scaly patches with exclamation mark hairs (alopecia areata). Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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