An itchy scalp - medical case study

DAY 1

Mrs K brings her eight-year-old son Sam into a busy London general practice. The boy is suffering from an itchy circular rash on his cheek and is examined by Dr R. The GP makes a diagnosis of ringworm and prescribes Daktacort cream – an antifungal/anti-inflammatory agent.

DAY 6

Mrs K brings Sam back into the surgery, now with a red and itchy scalp. Sam is seen this time by locum Dr B who examines the boy and records a diagnosis of seborrhea capitis. He prescribes Betnovate – a steroid lotion – to be applied once daily and coal tar shampoo to be used every second day.

DAY 17

Sam comes back into the surgery with his mother complaining that his scalp is even more raw and itchy. He is seen by a different GP – Dr S. The doctor examines Sam and records in the notes “periorbital oedema and itchy scalp ++”. The GP also notes flakiness on the scalp which he records as being consistent with a reaction to the previous treatment. He prescribes an antihistamine and Capasal shampoo. He tells Mrs K to bring Sam back if the symptoms do not resolve.

DAY 20

Dr R sees Sam again for an emergency appointment. The boy has developed a scalp abscess which has burst, discharging a considerable amount of pus. Dr R re-examines the scalp and finds it tender/boggy. He prescribes amoxicillin and arranges for a review in two days.

DAY 22

Sam returns to the surgery for review and Dr R sees no improvement in the boy’s condition. The GP makes an emergency referral for that same day. Sam is seen by a paediatric dermatologist who makes the diagnosis of a probable kerion – a reaction to ringworm in the scalp. The boy is admitted to hospital and laboratory investigations confirm a fungal infection. He is given both fungal and antibiotic treatment and is in hospital for 10 days.

32 DAYS AND BEYOND

Sam suffers complications during and after his period in hospital including a possible adverse reaction to an antifungal drug. There is significant hair loss in the worst affected areas of the scalp with re-growth of hair in these areas poor. Two years later Sam undergoes plastic surgery with excision of scalp skin in the areas affected by alopecia but there is still patchy hair loss and scarring. The boy is taunted and bullied at primary and secondary school because of his condition and his education suffers due to absenteeism.

THREE years after Sam first presented with his infection a letter is received by the surgery from solicitors acting on behalf of the patient, alleging negligence in the diagnosis and management of his tinea capitis. All three GPs are named in the action.

MDDUS is contacted by the practice. An adviser commissions an expert medical report on the case. Documents including a statement of the allegations, the patient records and written accounts by each GP are examined by a primary care expert.

Commenting on the case the expert first questions why Dr B did not seem to consider the possibility of tinea capitis at the second consultation when Sam presented with an itchy inflamed scalp – especially considering the recent diagnosis of ringworm on the boy’s cheek. This error was further compounded by the prescription of Betnovate lotion which contains the potent steroid betamethasone. Such steroids can suppress immunity and are contraindicated in suspected infection.

The expert offers no criticism of Dr S’s actions in the third consultation. Seborrheic dermatitis/cradle cap are clinical features compatible with a possible adverse reaction to the earlier treatment and would have made diagnosis of the underlying condition difficult. His prescription of an antihistamine and medicated shampoo is judged reasonable in the circumstances. But another expert commenting on the case disagrees, taking the view that this consultation was a missed opportunity to reassess the diagnosis.

In considering the prescription of an antibiotic and the further two-day delay in making an emergency referral, the expert is supportive of Dr R’s action in that pus is usually the result of bacterial rather than fungal infection. Amoxicillin is the standard antibiotic used for such infections. A two-day review to assess the response to therapy suggests an adequate degree of concern.

Given the expert’s criticism of Dr B’s failure to consider tinea capitis and the later missed opportunity to reassess the diagnosis, MDDUS advisers and lawyers judge that the best course of action is to pursue an early settlement of the case with no admission of liability. The practice agrees.

KEY POINTS

• Keep clear notes justifying diagnoses/ treatment plans.

• Diagnoses and management plans can and should always be questioned.