Clinical Challenge: Diffuse Nodularity of the Scalp - MPR

Clinical Challenge: Diffuse Nodularity of the Scalp

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The patient is a 25-year-old black male who seeks medical consultation for a scalp disorder. The condition is of approximately 18 months in duration and is at times painful. He has received treatment at two clinics, consisting of drainage and oral antibiotics with minimal improvement. Examination reveals diffuse nodularity of his scalp, with scarring alopecia. Palpation at several sites elicits moderate tenderness and some purulence. He is afebrile and cervical, and posterior auricular lymph nodes are not enlarged. Routine blood work is unremarkable.

This patient was diagnosed with dissecting cellulitis, also referred to as perifolliculitis capitis abscedens et suffodiens. It is an uncommon chronic inflammatory disorder of the scalp that affects primarily black males 20-40 years of age.1,2 The etiology of dissecting cellulitis is...

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This patient was diagnosed with dissecting cellulitis, also referred to as perifolliculitis capitis abscedens et suffodiens. It is an uncommon chronic inflammatory disorder of the scalp that affects primarily black males 20-40 years of age.1,2 The etiology of dissecting cellulitis is unclear; the pathogenesis may be secondary to an exaggerated inflammatory response to bacteria within hair follicles.3


Dissecting cellulitis typically localizes to the posterior neck and scalp. Lesions begin as a folliculitis or perifolliculitis that progress to painful nodules. Abscesses are often connected by sinus tracks. Active lesions are fluctuant and contain pus, imparting a boggy consistency to the scalp. A culture of the purulent discharge from the lesions may grow bacteria, such as anaerobes Staphylococcus aureus and Pseudomonas aeruginosa.1,4,5 The condition eventuates in scarring alopecia.

Treatment of dissecting cellulitis is difficult, and the response to antibiotics is variable. Intralesional corticosteroids may help minimize abscess duration and size. Some cases respond to oral isotretinoin6-8, which may be preceded by oral rifampin to maximize efficacy.Reports also document remission induced by tumor necrosis factor (TNF) antagonists.10,11

References

  1. Williams CN, Cohen M, Ronan SG, Lewandowski CA. Dissecting cellulitis of the scalp. Plast Reconstr Surg.1986;77(3):378-382.
  2.  Coley MK, Alexis AF. Dermatologic conditions of men of African ancestry. Expert Rev Dermatol. 2009;4(6):595-609.
  3. Chicarilli ZN. Follicular occlusion triad: hidradenitis suppurativa, acne conglobata, and dissecting cellulitis of the scalp. Ann Plast Surg. 1987;18(3):230-237.
  4. Ramesh V. Dissecting cellulitis of the scalp in 2 girls.Dermatologia. 1990;180(1):48-50.
  5. Brook I. Recovery of anaerobic bacteria from a case of dissecting cellulitis. Int J Dermatol. 2006;45(2):168-169.
  6. Scerri L, Williams HC, Allen BR. Dissecting cellulitis of the scalp: response to isotretinoin. Br J Dermatol.1996;134(6):1105-1108.
  7. Taylor AE. Dissecting cellulitis of the scalp: response to isotretinoin. Lancet. 1987;2(8552):225.
  8. Khaled A, Zeglaoui F, Zoghlami A, Fazaa B, Kamoun M. Dissecting cellulitis of the scalp: response to isotretinoin. J Eur Acad Dermatol Venereol. 2007;21(10):1430-1431.
  9. Georgala S, Korfitis C, Ioannidou D, Alestas T, Kylafis G, Georgala C. Dissecting cellulitis of the scalp treated with rifampicin and isotretinoin: case reports. Cutis.2008;82(3):195-198.
  10. Sukhatame SV, Lenzy YM, Gottlieb AB. Refractory dissecting cellulitis of the scalp treated with adalimumab. J Drugs Dermatol. 2008;10(7):981-983.
  11. Brandt HRC, Malheiros APR, Teixeira MG, Machado MCR. Perifolliculitis capitis abscedens et suffodiens successfully controlled with infliximab. Br J Dermatol.2008;159(2):506-507.