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
References:
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 Emedicine.com chapter
The optimum treatment of this case is to start a combination of systemic steroids 25 mg daily for 1 month and isotretinoin 40 mg per day for 1 year
ReplyDeleteIn my openion,this a varient of sever cystic acne similar to apocrine acne.I see few cases a year and treat them as acne mainly by using oral sulaphamaxisol( seprin)oral pednisolone 5mg/day,topical dalacin c 1% solution and oral isotretinoinThere is no need for excision at all.Intralesional steroid injection might be tried.
ReplyDeletekhalifa sharquie, Baghdad
I've had some success with prolonged courses of rifampicin / clindamycin (300 mg bd for each drug x 6 months).
ReplyDeleteJust a thought-- I was recently working alongside a visiting dermatologist from Brazil and she reported some success using finasteride to treat recalcitrant hidradenitis suppurativa-- I looked into this and there are indeed some reports in the literature supporting this. Could finasteride possibly play a role in pt's with dissecting cellulitis of the scalp?
ReplyDeleteWe did recenly a study where we found that spironolactone was much more effective than finasteride in treatment of acne.Accordingly we recommend to use spironolactone in mangement of acne,apocrine acne,and dissecting cellulitis.
ReplyDeletekhalifa sharquie
in my opinion treatment should be
ReplyDeletedoxycycline 100 mg twice daily + rifampicin 300 mg twice daily + prednisolone in a low dose + oral isotretinoin
intralesional triamcinolone could also be tried in active or resistant lesions.
Salman Ahmad Ch.(pakistan)
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