Dermatology: Practical and Conceptual Dermatology Practical & Conceptual Letter | Dermatol Pract Concept. 2021; 11(3): e2021042 1 What’s Under the Veil? Michela Starace, Miriam Anna Carpanese, Francesca Bruni, Iria Neri, Bianca Maria Piraccini, Aurora Alessandrini Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy Key words: Phthirus pubis, parasite infestation, scalp involvement, sexually transmitted disease Citation: Starace M, Carpanese MA, Bruni F, Neri I, Piraccini BM, Alessandrini A. What’s under the veil? Dermatol Pract Concept. 2021; 11(3): e2021042. DOI: https://doi.org/10.5826/dpc.1103a42 Accepted: November 12, 2020; Published: July 8, 2021 Copyright: ©2021 Starace et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License BY- NC-4.0, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited Funding: None Competing interests: None declared. Authorship: All authors have contributed significantly to this publication. Corresponding author: Miriam Anna Carpanese MD, Department of Experimental, Diagnostic and Specialty Medicine - Division of Dermatology, University of Bologna, Bologna, Italy, Via Massarenti, 1, 40138 Bologna, Italy. Email: miriam.carpanese@gmail.com Introduction Phthirus pubis is an ectoparasite, whose only host are humans. Phthirus pubis is responsible for the corresponding parasitic infestation that is sexually transmitted and usually affects the genital areas. Despite being rare, scalp involvement is becom- ing increasingly frequent because of the increasing habit of pubic hair removal. We present the case of a pregnant woman with isolated scalp involvement and a diffuse cutaneous rash of the body. Case presentation A 21 year old woman from Pakistan, 22 weeks pregnant, presented with a widespread intensely pruritic cutaneous rash of the body that persisted in the last 1 month. She had been previously examined at the maternity department and at the emergency room without a diagnosis. Dermatological examination revealed reddish and itchy papules surrounded by erythema and scratching lesions over the trunk, the arms, and the back. (Figure 1, A and B). The Patient was asked to remove the veil from her head to facilitate the physical examination. With some resistance and difficulty, the patient finally removed the veil. This was the first time her scalp was examined as no one had ever asked her to do so in the previous examinations. The scalp was com- pletely covered in both live lice and nits. A video of walking lice was also taken (Supplementary Material). (Figure 1C). The presence of crusty and scaly plaques over the patient’s ear and the neck indicated a secondary impetiginisation, due to scratching. No lice were found upon body inspection. When asked about her clinical history the patient confirmed that her husband also presented the same symptoms, especially at the level of the genital area, on pubic hairs. This anamnestic data and the identification of the lice allowed to diagnose a Phthi- rus pubis infestation that was exclusively located on the scalp. Treatment included total hair shaving and successive application of a malathion solution. Conclusion Phthirus pubis is an obligate ectoparasite, it is usually sex- ually transmitted and spreads via the direct contact whit an affected person. Phthirus pubis classically affects pubic, axillary and body hair, but also beard, scalp and eyelash infestation have been described. The scalp involvement is very 2 Letter | Dermatol Pract Concept. 2021; 11(3): e2021042 rare, in these cases it might be the only location affected, as experienced by our patient. The increasing diffusion of pubic hair removal’s habit, destroying the lice’s natural habitat is an effective preventive procedure against Phthirus pubis [1]. Phthirus pubis showed the ability to change its tropism, lead- ing to increasingly frequent atypical infestations in other parts of the body such as scalp, eyebrows, axillae, and trunk. As the atypical patterns of pubic lice infestation are becoming more frequent compared to the past, it is important to recognise Phthirus pubis in cases of resistant pruritus and dermatitis [2]. This reported case highlights the importance of consid- ering an eventual Phthirus pubis infestation in patients pre- senting a lice infestation, exclusively affecting the scalp. This consideration allows for a correct diagnosis and treatment, including the treatment of sexual partners. Finally, another important take-home message is to always perform a full body examination, also in parts where the patient denies the disease. Supplementary Materials The video showing reported live lice on the patient’s head is available at: https://youtu.be/UPlFzRC8NRM References 1. Veraldi S, Schianchi R, Ramoni S, Nazzaro G. Pubic hair removal and Phthirus pubis infestation. Int J STD AIDS. 2018; 29(1):103- 104. DOI: 10.1177/0956462417740292. PMID: 29130406 2. Jimenez-Cauhe J, Fernandez-Nieto D, Ortega-Quijano D, Ramos-Rodriguez D. Characterization of Phthirus pubis With Ex Vivo Dermoscopy. Sex Transm Dis. 2020;47(4):280-281. DOI: 10.1097/OLQ.0000000000001126. PMID: 32004257 Figure 1. (A) Reddish and itchy papules surrounded by erythema and scratching lesions over the trunk, the legs and the arms. (B) over the back. (C) Live lice and nits covering the scalp of the patient.