By Gary M. White, MD
Erosive pustular dermatosis (EPD) is a not-uncommon occurrence in the scalp of older, balding patients in which parts of the skin become covered with mounds of crust.
The patient develops one to several erosive, crusted, and pustular areas on the scalp. It is common for mounds of dried crust to form, often with a greenish hue. Removing the crust often reveals a lake of (green) pus. Staphylococcus is usually cultured, but Pseudomonas may be found. Lesions may be small to very large, e.g., 10 cm. It is not uncommon to see it form during the healing phase after C&D.
A variant occurring on the face after cosmetic resurfacing has been described [JAMA Derm 2017;153;1021]. Three woman develop erosions, crusting, and brightly erythematous patches weeks to months after postoperative healing. The forehead and lateral cheeks were preferentially affected. It is noted that the common trigger for EPD is trauma in areas of chronic actinic damage.
The crust should be removed if possible in the office. Put on gloves and gently remove. If there is much hair, it may need to be trimmed. Culture the underlying pus but prescribe an oral antibiotic before the results are back, e.g., cephalexin, in anticipation of growing Staphylococcus. The patient must be counseled to shampoo/clean daily with sufficient effort to remove and prevent the formation of any crust. Soaking the area overnight with mineral oil or Vaseline may be helpful. After a few days of the antibiotic, a potent topical steroid, e.g. clobetasol ointment, may be applied. Have the patient come back in a week to verify compliance and improvement. At that time, carefully examine the area to exclude basal cell carcinoma or squamous cell carcinoma. Perform a biopsy if needed.
Alternatively, removing all crust and then topical 0.1% tacrolimus ointment BID in combination with topical mupirocin ointment cleared one man's lesions within a month [JEADV 2016;30;380]. Curettage followed by aminolevulinic acid PDT successfully cleared 8 patients with EPD [JAMA Derm 2016;152;694].
Solitary lesion that formed on the scalp of an 80-year-old man after C&D of a basal cell carcinoma.
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