In some cases, especially in those ill nourished and scrofulous, the inflammation may be of a higher grade, resulting in the production of discrete or grouped pustules, terminating in crusting; or the disease may assume the condition known as tinea kerion. This latter is seen most commonly in scrofulous subjects. Beginning ordinarily as a simple patch of ringworm, the affected area soon becomes inflamed, swollen, oedematous, elevated, red, shining and boggy, covered with a mucoid secretion which is poured out from the openings of the hair-follicles. The stubby hairs soon fall out, leaving the patch more or less bald. The surface is uneven and studded with the foramina, or small cavities, containing the mucoid or sero-purulent secretion, corresponding to the dilated hair-follicles. It bears resemblance to abscess and carbuncle. An analogous condition is not uncommon in tinea sycosis. It may occur with the usual form of tinea tonsurans or alone. Occasionally the disease cures itself in this way. It may, however, be chronic. Its causes are not understood: it may be due to the presence of the fungus in the deeper portions of the hair-follicles, or at times to over-treatment. It is a rare manifestation.

Other unusual forms of the disease are occasionally noted. The spots may in the early stages be merely scaly, with or without inflammatory symptoms, and the hairs long and firmly seated, resembling eczema or seborrhoea. Later, however, the hairs break and the characteristic stumps are the result. As ringworm becomes chronic (its usual course) the clinical features become different. The disease exists in irregular areas—as a rule, non-inflammatory and more or less scaly, especially about the follicles. The hairs are short, stubby, and broken off near the skin or in the apertures of the follicles; in the latter case the skin has a punctate or dotted appearance. This condition is noted especially in brunettes; in blondes the hairs are somewhat longer and apt to drop out insidiously. Or, the disease may be disseminated, involving here and there over the scalp small groups of follicles, the hairs being short, the follicles slightly enlarged, with a tendency to scaliness; in these cases the disease may be easily overlooked.

Ringworm of the scalp is a common affection, and is observed among the rich as well as the poor, but is most frequent in those suffering from malnutrition. It may be communicated by means of caps, combs, brushes, and the like. It is frequently seen in schools and children's asylums, sometimes affecting a large proportion of the inmates. The fungus (trichophyton) invades the epidermis, hair-follicle, bulb, and shaft. The follicle becomes distended and raised; the hairs are permeated with the fungus (spores markedly predominating), are disintegrated, and destroyed. The perifollicular tissue may, in severe cases, be invaded. The spores are present in great abundance, the mycelium existing scantily.

As a rule, there is no difficulty in recognizing the disease. The presence of stumps of hair having a gnawed or nibbled look, the prominent follicles, more or less baldness, and slight or decided scaliness, together with the history and course, constitute a clinical picture that is scarcely mistakable. If necessary, microscopical examination of the hair will give positive information. For this purpose one or two of the short, stubby hairs should be selected, placed upon a slide, a drop of liquor potassæ added, allowed to stand a few minutes, and then examined with a power of two to five hundred diameters; the hairs will be found full of spores, the shafts being completely disintegrated. If a few drops of chloroform are poured upon a patch of ringworm of the scalp and allowed to evaporate, the hairs and follicular openings affected become whitish or light-yellow, which, according to Duckworth, is pathognomonic. It is to be differentiated from squamous eczema, seborrhoea, psoriasis, and alopecia areata. The history of eczema is different: it rarely begins as circular spots, spreading peripherally; the margins are always more or less irregular; the hairs are not involved, but remain seated firmly in the follicles; the itching is marked, whereas in ringworm it is usually slight. Seborrhoea is non-inflammatory; the scales are greasy; the hairs are not broken off; and the margins of the patch are ill defined. In psoriasis the scaling is a marked feature; the hairs are not involved; and the disease is usually to be found typically expressed on other parts of the body. From alopecia areata ringworm may be differentiated by its clinical features; in the former disease the baldness is usually complete, the skin devoid of scales, non-inflamed, smooth, shining, and the follicles, as a rule, less prominent than normal; the absence of the characteristic stumps of ringworm may also be noted. In obscure cases the microscope is to be employed.

An opinion regarding the length of time required to cure ringworm of the scalp should always be guarded; while some cases respond in several weeks, in others several months or more may be required. Relapses are liable to occur. External remedies are, as a rule, alone required. In chronic cases, however, where a condition of malnutrition exists, proper food, fresh air, and suitable internal remedies, as cod-liver oil, iron, and arsenic, are to be advised; cleanliness is of importance. The patches should be washed frequently with warm water and castile soap or sapo viridis, the frequency depending upon the scaling and the amount of disease, and also somewhat upon the remedies employed. Occasional washing of the entire scalp is also to be advised. Remedial applications should be, as a rule, made twice daily. In acute or recent cases, in which the fungus has not penetrated deeply into the hair-follicles, it often yields to the ordinary parasiticides, without the necessity of epilation. In cases commonly encountered, however, the disease has already lasted some length of time, and epilation becomes essential. The main difficulty in the treatment of tinea tonsurans is to bring the remedy in contact with the fungus; otherwise the affection would be as easily curable as that occurring on the general surface. To a great extent epilation aids in overcoming this difficulty, as the parasiticide is then able to permeate the emptied follicle; and in addition to this advantage the extracted hairs take with them the fungus contained within their structures. The hair within and around the affected areas should be clipped short, or, if the patches are numerous, the hair of the entire scalp should be cut, or, what is preferable in many cases, shaved. If the scalp is shaved, a few days elapse before epilation is possible. On a shaved head there is no chance for any diseased area, however small, to escape observation; in the treatment of the disease as met with in institutions this procedure is almost essential. In epilation the loose hairs on the patches and about the borders should first receive attention. For this purpose a small, broad-bladed, short forceps may be employed, a few hairs at a time being seized. A portion of the diseased area should be carefully gone over each day until all are removed. After each epilation the parasiticide is to be applied.

Corrosive sublimate, two to four grains to the ounce of alcohol or water, is a reliable remedy; also oleate of mercury, in the form preferably of a 25 per cent. ointment. An ointment such as the following is serviceable in many cases:

Rx. Ugt. picis liquidæ,
Ugt. hydrarg. nitrat., aa.		 drachm ij;
Ugt. sulphuris, drachm iv.
M. Ft. ugt.

Or, in place of the tar ointment in the formula, carbolic acid in the same or less quantity may be substituted. The officinal tar, sulphur, and ammoniated mercury ointments may also be referred to as useful. In small disseminated patches carbolic acid in glycerin, one to three drachms of the former with enough of the latter to make an ounce, will often prove serviceable. Thymol sometimes proves of value, and may be prescribed as advised by Malcolm Morris:

Rx.Thymolis,drachm ss;
Chloroformis,drachm ij;
Olei olivæ,drachm vj. M.

Coster's paste is also serviceable: