She was advised to follow up monthly to assess for recurrence or re-infection. A repeat culture sent at the end of 2 months of this treatment was negative. Due to her poor compliance with treatment and persistence of disease, she was advised terbinafine, 250 mg once daily along with ketoconazole shampoo for 1 month, that was continued for another month on account of persisting lesions. Microscopically, clavate microconidia, without macroconidia were noted along the hyphae. The culture on Sabouraud agar showed white, heaped, velvety colonies with red pigmentation on the reverse side after 3 weeks. A fungal culture was re-sent and revealed growth of Trichophyton rubrum on this occasion. Although she was re-started on griseofulvin, she stopped treatment on her own again after taking treatment for 2 months. At that time, there was some improvement in the itching, pain, and scaling. After 3 weeks, the patient stopped treatment on her own and presented to us after another 2 weeks. She was also given ivermectin weekly for 3 weeks along with oral 1% permethrin scalp lotion weekly for pediculosis capitis. The patient was treated with oral griseofulvin, 250 mg twice a day along with a ketoconazole and salicylic acid combination shampoo. The fungal culture was contaminated with Alternaria species. A diagnosis of black dot tinea capitis presenting with cicatricial alopecia was made. The scalp biopsy showed numerous rounded PAS positive spores within hair shafts in the follicle along with focal perifollicular fibrosis associated with mild chronic inflammation and spongiosis. Potassium hydroxide mount of the hair shaft showed spores in an endothrix pattern. The test done to rule out human immunodeficiency virus(HIV) infection was also normal. She did not have any systemic disease and was not receiving immunosuppressive drugs. She also had multiple nits along the hair shaft. The hairs at the periphery were dull, matted, and easily pluckable. There was an area of alopecia with loss of hair follicles of size 3 × 12 cm present over the vertex with black dots at the periphery. On examination, there were multiple patches of hair loss over the scalp along with areas of gray scales and black dots. She was taking multiple treatments from private practitioners but without much relief. A 20-year-old housewife presented to us with complaints of itching and gradual loss of hair over the scalp for the past 2 years.

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