Case Letter
Phthiriasis capitis ab initio. Use of entodermoscopy for quick differentiation between Phthirus pubis and Pediculus capitis nits
Gaetano Scanni
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Service of Medicine, Azienda Sanitaria Locale Della Província di Bari, Bari, Italy
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Entodermoscopia para pronta diferenciação entre lêndeas de <span class="elsevierStyleItalic">Phthirus pubis</span> e <span class="elsevierStyleItalic">Pediculus capitis</span>" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "777" "paginaFinal" => "779" ] ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 896 "Ancho" => 1250 "Tamanyo" => 240370 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Entodermoscopia da lêndea do <span class="elsevierStyleItalic">Phthirus pubis</span> no couro cabeludo sem interface líquida (30<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>). 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Use of entodermoscopy for quick differentiation between <span class="elsevierStyleItalic">Phthirus pubis</span> and <span class="elsevierStyleItalic">Pediculus capitis</span> nits" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "777" "paginaFinal" => "779" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Gaetano Scanni" "autores" => array:1 [ 0 => array:4 [ "nombre" => "Gaetano" "apellidos" => "Scanni" "email" => array:1 [ 0 => "g.scanni@entodermoscopy.net" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Service of Medicine, Azienda Sanitaria Locale Della Província di Bari, Bari, Italy" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 896 "Ancho" => 1250 "Tamanyo" => 240370 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Entodermoscopy of <span class="elsevierStyleItalic">Phthirus pubis</span> nit on scalp without liquid interface (×30). (A), conically shaped operculum; (B), short and thick sleeve fixing to hair shaft; (C), nit without operculum.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Phthiriasis pubis</span> (<span class="elsevierStyleItalic">crab louse infestation</span>) is an ectoparasitosis transmitted mostly by skin to skin contact, primarily located in the genital areas and secondly, if treated late, expanding towards the armpits or other parts of the adult body with thick hair. In children before sexual maturation, the affected sites can include the eyelashes or head hair, usually after contact with an adult who has been sexually infected. Commonly, diagnosis is easy and requires finding eggs (nits) and/or insects, generally firmly hooked to hair shaft base. Because phthiriasis is included in sexually transmitted diseases, it is recommended to expand investigation to other venereal diseases.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Recent reports about <span class="elsevierStyleItalic">Phthirus pubis</span> seem to suggest a change of its usual behavior, favoring a primary scalp location without genital involvement, as already described by some authors and observed in a personal unpublished series.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Although fomites can carry parasites anywhere, cases considered in this letter refer to adults or school age children whose infestation was neither transmitted through objects or sexual intercourse, nor by non-sexual touching (i.e., when children sleep with a parent). A careful anamnestic reconstruction was only suggestive for a head-to-head direct contact modality.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">This scenario, not yet fully investigated, could be partially explained with some hypotheses. One of the most probable could be related to the very popular practice of pubis and underarm trichotomy or laser epilation of any part of the body that eliminates the parasite’s natural habitat. Another suggestive hypothesis could regard some connection between terrestrial climatic changes and different receptivity of human skin to <span class="elsevierStyleItalic">P. pubis</span>. Anyway, in such unusual conditions, crabs appear to skip genital targets and going directly towards cephalic areas.</p><p id="par0025" class="elsevierStylePara elsevierViewall">If crab lice develop in specific context such as schools, where physical contacts are very common among children, there is a risk of misdiagnosis because school is the place where <span class="elsevierStyleItalic">Pediculus capitis</span> is normally expected as main cause of morbidity and head itch. Unfortunately, scalp itch and nits alone are not sufficient to formulate a correct differentiation with naked eye between <span class="elsevierStyleItalic">P. capitis</span> and <span class="elsevierStyleItalic">P. pubis</span>; on the contrary, it possible by entodermoscopy, which is dermatoscopy with an entomological focus. In fact, the nits of these two different species of parasite, although similar at first glance, have two pathognomonic parts that help to distinguish them: the operculum and the fixing sleeve to the hair shaft.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleItalic">P. capitis</span> nits are closed on top by a dome drilled cover (operculum + aeropyles) and glued to hair shaft by a long, thin, tubular sleeve (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). <span class="elsevierStyleItalic">P. pubis</span> nits instead have a conically shaped operculum and a short, thick sleeve (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). These morphological features can be seen through a 10× magnification hand-held dermatoscope or much better with a 30–50× digital/video dermatoscope. While operculum is relevant for diagnosis in unhatched nits (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>A), the fixing sleeve becomes more important to recognize nits when they lose the operculum because the nymph has hatched (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In the future, it may be observed an increase in the diagnostic of primitive scalp infestations by <span class="elsevierStyleItalic">P. pubis</span>, until now underestimated, because symptoms and macroscopic affinity with the more common <span class="elsevierStyleItalic">P. capitis</span>. What makes cases considered in this letter interesting is that <span class="elsevierStyleItalic">P. pubis</span> can exhibit, when needed, primary interest not only for the usual biological niche of <span class="elsevierStyleItalic">P. capitis</span>, but also for the same modality of transmission (head-to-head).</p><p id="par0035" class="elsevierStylePara elsevierViewall">On the occasion of scalp pruritus either in children or adults, the author recommends an extemporaneous dermoscopic examination of nits to differentiate what kind of pediculosis is really involved. This procedure is able to return the same anatomical structures observable by an optical microscope, but in an easier and faster way. Regarding therapy, it follows the currently guidelines for <span class="elsevierStyleItalic">P. capitis</span>, although the management of contacts can be more complex because of the possibility of sexual abuse in children, which must be ruled out.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, when phthiriasis is diagnosed only on the head without any other site involved and without any type of sexual or non-sexual physical contact, the pathogen of this <span class="elsevierStyleItalic">ab initio</span> condition could be dubbed with the more appropriate name of <span class="elsevierStyleItalic">Phthirus capitis</span> rather <span class="elsevierStyleItalic">pubis</span>, as already proposed by some authors.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Lastly, although a mere opinion of the author, this original pediculus behavior could represent matter of speculation for entomologists and dermatologists because the possibility that a human obliged pathogen changes due to an evolutionary pressure by society’s habits and customs, and perhaps also by the impact of climate changes. Thus, entodermoscopy shows still to be a suitable tool for diagnosing an ectoparasitosis even when it is located on unexpected body sites.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors' contributions</span><p id="par0050" class="elsevierStylePara elsevierViewall">Gaetano Scanni: Approval of the final version of the manuscript; design and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors' contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-03-12" "fechaAceptado" => "2020-03-14" "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "⋆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Scanni G. Phthiriasis capitis <span class="elsevierStyleItalic">ab initio</span>. Use of entodermoscopy for quick differentiation between <span class="elsevierStyleItalic">Phthirus pubis</span> and <span class="elsevierStyleItalic">Pediculus capitis</span> nits. An Bras Dermatol. 2020;95. <span class="elsevierStyleInterRef" id="intr0001" href="https://doi.org/10.1016/j.abd.2020.03.019">https://doi.org/10.1016/j.abd.2020.03.019</span></p>" ] 1 => array:2 [ "etiqueta" => "⋆⋆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Service of Medicine, Poliambulatorio Distretto Unico, Azienda Sanitaria Locale Della Província di Bari, Bari, Italy.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 895 "Ancho" => 1250 "Tamanyo" => 137634 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Entodermoscopy of pediculus capitis nit on scalp without liquid interface (×30). (A), dome-shaped operculum; (B), long and tubular fixing sleeve; (C), nit without operculum.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 896 "Ancho" => 1250 "Tamanyo" => 240370 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Entodermoscopy of <span class="elsevierStyleItalic">Phthirus pubis</span> nit on scalp without liquid interface (×30). (A), conically shaped operculum; (B), short and thick sleeve fixing to hair shaft; (C), nit without operculum.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pthiriasis capitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.A. Witkowski" 1 => "L.C. 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| 2022 Outubro | 74 | 59 | 133 |
| 2022 Setembro | 36 | 65 | 101 |
| 2022 Agosto | 41 | 56 | 97 |
| 2022 Julho | 38 | 58 | 96 |
| 2022 Junho | 47 | 58 | 105 |
| 2022 Maio | 27 | 34 | 61 |
| 2022 Abril | 48 | 68 | 116 |
| 2022 Março | 39 | 72 | 111 |
| 2022 Fevereiro | 24 | 41 | 65 |
| 2022 Janeiro | 41 | 79 | 120 |
| 2021 Dezembro | 35 | 60 | 95 |
| 2021 Novembro | 40 | 64 | 104 |
| 2021 Outubro | 51 | 83 | 134 |
| 2021 Setembro | 35 | 55 | 90 |
| 2021 Agosto | 64 | 62 | 126 |
| 2021 Julho | 44 | 45 | 89 |
| 2021 Junho | 33 | 33 | 66 |
| 2021 Maio | 43 | 65 | 108 |
| 2021 Abril | 204 | 191 | 395 |
| 2021 Março | 92 | 94 | 186 |
| 2021 Fevereiro | 49 | 21 | 70 |
| 2021 Janeiro | 43 | 22 | 65 |
| 2020 Dezembro | 39 | 22 | 61 |
| 2020 Novembro | 20 | 18 | 38 |
| 2020 Outubro | 9 | 11 | 20 |
| 2020 Setembro | 6 | 58 | 64 |
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