DISSECTING CELLULITIS OF THE SCALP

By Gary M. White, MD


Dissecting Cellulitis of the Scalp


Dissecting cellulitis (DC) of the scalp (also known as perifolliculitis capitis absedens et suffodiens) is a chronic inflammatory condition of the scalp that often leads to significant scarring. Strictly speaking, this condition is not infectious, however, in practice, secondary infection by e.g. Staphylococcus is common. DC may be associated with two other diseases that altogether make up the follicular occlusion triad (hidradenitis superativa and acne conglobata). Alopecia-associated pseudocyst of the scalp may be a precursor.

Clinical

A spreading alopetic area with peripheral pustules occurring more commonly in a man is characteristic. Crust, pus and inflammatory, draining nodules are typical. Over time, significant hair loss may occur. The grouping of hairs out of one follicle (tufted folliculitis) is common.

In a review of 51 patients [BJD 2016;174;421], 50 were men with a mean age of onset of 27 years. 33/35 obtained complete remission with isotretinoin after 3 months, but with frequent relapse after discontinuation.

Treatment

Inquiry should be made about oil exposure, e.g. at work as this can trigger. One study found going to a gym and anabolic steroid use can trigger DC [JEADV 2017;31;e199].

Combination Therapy

Combination therapy is the rule utilizing oral antibiotics, intralesional steroids, marsupialization of sinus tracts at times and if needed oral isotretinoin.

Oral Antibiotics

Pus should be routinely cultured and any bacterial infection should be treated until cultures become negative. Whether cultures are positive or not, an oral tetracycline, e.g. doxycycline 100 mg twice a day is commonly given. In one study, oral rifampicin 300 mg BID and oral clindamycin 300 mg BID both for 10 weeks was very effective. Occasionally, a second or even third course was needed. Azithromycin (e.g. 500 mg 3/week) was helpful in one study.

Intralesional Steroids

Often, larger cysts need to be injected with triamcinolone 5-10 mg/cc.

Isotretinoin

A course of isotretinoin is often needed for resistant disease. It is highly effective, inducing remission within 3 months in 92% [BJD 2016;174;421]. However, recurrence after cessation is common. Long term, low dose therapy may be considered.

Adalimumab

Adalimumab has been found very helpful in treatment-resistant disease [Arch Dermatol. 2010;146:517-20].

Additional Pictures

Dissecting Cellulitis of the Scalp

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