Saturday, May 16, 2009

Dissecting Cellulitis of the Scalp

Abstract: 18 yo man with three year history of cystic lesions scalp, axillae, chin

HPI: This 18 year-old man has had dissecting cellulitis of the scalp for three years. He has been treated with doxycycline 100 mg b.i.d. and excisions of cysts and sinuses by a plastic surgeon. He presented in May of 2009 for another opinion. He has had a few cysts of the axillae and chin. The patient has observed that his scalp is worse after wearing a helmet for football.

O/E: The patient is a healthy, moderately obese African-American teenager. He has painful cysts, nodules and draining sinuses mostly on the occipital portion of the scalp and around the vertex. He has a hypertrophic scar at the site of an excision in the occipital region. He has a few hyperpigmented nodules in the axillae and some small acne cysts on his chin in the bearded area.

Clinical Photos:

Lab: Nil
Path: Nil

Diagnosis: Dissecting Cellulitis of the Scalp in the setting of Follicular Triad Syndrome. An older name for the scalp process is the hard to remember "Perifolliculitis Capitis Abscedens et Suffodiens

Treatment: To date, only doxycycline 100 mg b.i.d. and frequent excisions by a plastic surgeon. I injected some active lesions with triamcinalone acetonide 10 mg/cc and am considering following the rifampicin and isotretinoin protocol reported in the reference below.

Reason Presented: For therapeutic suggestions

1. Georgala S, et al. Dissecting cellulitis of the scalp treated with rifampicin and isotretinoin: case reports. Cutis. 2008 Sep;82(3):195-8.

Dissecting cellulitis of the scalp, or perifolliculitis capitis abscedens et suffodiens, is an uncommon chronic suppurative disease of the scalp manifested by follicular and perifollicular inflammatory nodules that suppurate and undermine, forming intercommunicating sinuses, and leading to scarring alopecia. Treatment generally fails to obtain a permanently successful result; thus, many therapeutic options have been proposed. We report 4 cases of dissecting cellulitis of the scalp successfully treated with oral rifampicin and oral isotretinoin. To our knowledge, this is the first report of oral rifampicin used concomitantly with oral isotretinoin in this disease entity. We also present a brief review of the literature on the topic.

2. Dissecting Cellulitis of the Scalp chapter

Wednesday, May 06, 2009

Teledermatology Rules: Vasculitis

Abstract: 2o yo man with one week history of palpable purpura.
HPI: This 20 yo college student was started on isotretinoin for severe cystic acne a month before he developed a rash on his legs. He also had an upper respiratory infection two weeks before the eruption began. He is away at school (a two hour drive). His mother called the office and spoke to my secretary. Busy week. When I heard that he had a rash, I relayed the message that it was probably the common dermatitis we see with patients on isotretinoin and if worried to send me a photo. Two days later, this photo was sent:

The patient was then emailed and asked to come in the next day. Labs were ordered done before the visit.

O/E: Palpable purpura both L.E. Right ankle swollen and tender. Patient limping.

Lab: CBC normal, UA normal. Pending Labs: Throat culture, ANA, ASOT. (Hep C, Stool for OB, not ordered)

Path: Biopsy performed. Not back

Diagnosis: Leucocytoclastic vasculitis. Etiology: The URI, isotretinoin, idiopathic

Plan: Rest for a few days. No specific therapy at this time except stopping the isotretinoin. If he improves uneventfully without evidence of GI or renal involvement will offer a re-challenge with isotretinoin.

Discussion: A few cases of LCV have been reported with isotretinoin. This patient has severe cystic acne with scarring and it would be a shame to withhold drug if it were not putative for the LCV. I admit I did not pay proper attention to the first telephone call. This illustrates the power of teledermatology which can be almost standard in a few years as cell phone cameras become better and people know how to use them more adroitly.

Questions: What are your thoughts and suggestions?