Thursday, April 06, 2017

78 yo man with scalp lesions

Abstract:  78 yo man with 1 year history of scalp lesions.

HPI:
May 9,2016:  Cryotherapy 4 keratoses on vertex of scalp
August 11, 2016: Crusted lesions at site of cryotherapy.  Clinical diagnosos of erosive pustular dermatosis of scalp made.  Treated with mupirocin oint and clobeyasol ointment  Initially improved.
Sept 9 2016:  Resolved
10/24/2016: Continued to do well
April 4, 2017: Recurrent lesions on vertex of scalp.  Thick crusted lesions (see photo)  The crusts were brownish and dirty looking, but unfortunately I removed them before taking the photo of April, 2017.

O/E:  What was initially hypertrophic keratosit papules were transformed into ~ 1 cm crusted erosive lesions.

Clinical  Photos:
Note pustule
4.4.17 (after crusts removed)
s/p 1 week Chlorhexidine, 4 days tacrolimus 0.1%

Lab:  August 11, 2016: + Staph aureus from lesion Vx scalp - usual sensitivities

Diagnosis:
This is either erosive pustular dermatosis of the scalp or squamous cell ca.  The rapid worsening since cryotherapy suggests the former.  It appears that biopsy may be necessary.  Not all cases of EPD respond to clobetasol ointment.

Questions:  Is this EPD or are these lesions squamous cell carcinomas.  Patient is reluctant to have a biopsy done. This process appears to have been gtriggered by the trauma of liquid nitrogen and did respond initially to clobetasol.  10 - 20% of EPD cases appear to be non-responders ro clobetasol.

Follow-up.  Marked improvement following chlorhexidine wash daily and topical tacrolimus 0.1% ointment at the suggestion of a colleague.  He recurred after clobetasol ointment.

References:
1. Erosive pustular dermatosis of the scalp: Clinical, trichoscopic, and histopathologic features of 20 cases.  [Current and thorough review]
Starace M, et. al.: J Am Acad Dermatol. 2017 Feb 14.
BACKGROUND: Erosive pustular dermatosis of the scalp is a chronic eruption that leads to scarring alopecia.
OBJECTIVE: The clinical, dermoscopic, and histopathological features and the course of the disease in 20 patients were reviewed and compared with the reports in the literature.
RESULTS:The mean age was 59.4 years. Androgenetic alopecia was present in 12 patients, 6 of whom showed actinic damage. Trauma was reported in 9 patients. Four patients were affected by autoimmune disorders. The vertex was the most common location. In all 20 patients trichoscopy showed an absence of follicular ostia with skin atrophy. Histopathology revealed 3 different features, depending on the disease duration. A reduction of inflammatory signs was observed in 14 patients treated with topical steroids and in all 3 patients treated with topical tacrolimus 0.1%.
CONCLUSIONS: The relatively high number of patients allowed us to identify a better diagnostic approach, using trichoscopy, and a more effective therapeutic strategy, with high-potency steroids or tacrolimus, which should be considered as first-line treatment.

2.  Disseminated Erosive Pustular Dermatosis also Involving the Mucosa: Successful Treatment with Oral Dapsone (Free Full Text)
Jamison D. Feramisco.  Acta Derm Venereol. 2012 Jan; 92(1): 91–92.

3.  Erosive pustular dermatosis of the scalp: a review with a focus on dapsone therapy.
Broussard KC. J Am Acad Dermatol. 2012 Apr;66(4):680-6
Abstract
BACKGROUND: Erosive pustular dermatosis of the scalp (EPDS) is an inflammatory disorder of unknown origin characterized by pustules, erosions, and crusting in areas of alopecia that tend to be atrophic, actinically damaged, or both. The most common treatments reported include antibiotics and topical anti-inflammatories, which can be ineffective. In the search for effective treatment for EPDS, we share our experience with topical dapsone 5% gel.
OBSERVATIONS:We present 4 patients with EPDS, all with classic clinical presentations and histologic findings of EPDS, who had failed a variety of treatments including oral, intralesional, or topical steroids, tacrolimus, and antibiotics. All patients demonstrated rapid improvement or resolution with topical dapsone 5% gel.
CONCLUSION: Our observations demonstrate topical dapsone 5% gel to be a novel, safe, and efficacious therapeutic alternative for mild to moderate EPDS.

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