Erosive pustular dermatosis

Published on 16/03/2015 by admin

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Erosive pustular dermatosis

Bhavnit K. Bhatia and Jenny E. Murase

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Erosive pustular dermatosis of the scalp (EPDS) is a rare condition characterized by pustular, erosive, and crusted lesions in areas of alopecia that tend to be atrophic, actinically damaged, or both. The condition primarily affects the elderly, and has been documented to follow trauma to the scalp. EPDS lesions tend to be chronic, progressive, and difficult to treat. Laboratory and histopathological findings are not diagnostic.

Management strategy

Traditionally, potent topical corticosteroids have been used in EPDS with a generally positive but variable response within a few months of use. Due to steroid-related cutaneous atrophy, tacrolimus 0.1% ointment, calcipotriol cream, oral zinc, and photodynamic therapy have been introduced as alternative therapies. A recent series has shown dapsone 5% gel to be effective in resolving EPDS. Oral dapsone was shown in one case report to result in initial improvement, but the patient had problems with recurrence. Retinoids and oral corticosteroids have also shown some promise when used in conjunction with other topical antibiotics, topical corticosteroids, topical tacrolimus, oral dapsone, and oral zinc therapy. Topical and systemic antibiotics and antifungals are essentially ineffective.

First-line therapy

image High-potency topical corticosteroids D

Three series and 13 case reports exist for high potency topical cortisones in the literature.

Second-line therapies

image Topical 5% dapsone gel E
image Topical 0.1% tacrolimus ointment E

Nine case reports exist for topical tacrolimus ointment in the literature.

Erosive pustular dermatosis of the scalp: a review with a focus on dapsone therapy.

Broussard KC, Berger TG, Rosenblum M, Murase JE. J Am Acad Dermatol 2012; 66: 680–6.

In the first of four cases, a patient had previously failed clobetasol foam, fluocinonide solution, topical salicylic acid, and UV phototherapy. Seventeen weeks of topical dapsone therapy achieved resolution. In the second patient, 3 months of fluocinolone solution yielded no results, but switching to dapsone 5% gel for 3 months achieved full resolution. In the third patient, topical dapsone applied twice daily resolved crusting within 3 months. The last patient had failed courses of oral prednisone, cephalexin, minocycline, doxycycline, silver sulfadiazine cream, topical tacrolimus, topical betamethasone dipropionate, intralesional triamcinolone, and wound care with silver-impregnated dressings. A side-by-side trial of clobetasol ointment and topical 5% dapsone gel determined dapsone to be more efficacious, resolving all lesions in just over 4 weeks.

Third-line therapies

image Oral dapsone E
image Oral steroids E
image Oral zinc E
image Photodynamic therapy E
image Retinoids E
image Topical calcipotriol cream E

Two cases for photodynamic therapy exist in the literature. Three cases for oral zinc exist, two in combination with oral and topical steroids. Four cases for oral steroids have been reported, two in combination with zinc and topical steroids. Four cases for retinoids are in the literature, one with worsening of erosions and three with good results when combined with combinations of the following: zinc, topical steroids, tacrolimus, antibiotics, topical antiseptics, oral dapsone.

[/level-membership-for-dermatology-category][not-level-membership-for-dermatology-category]

Erosive pustular dermatosis

Bhavnit K. Bhatia and Jenny E. Murase

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Erosive pustular dermatosis of the scalp (EPDS) is a rare condition characterized by pustular, erosive, and crusted lesions in areas of alopecia that tend to be atrophic, actinically damaged, or both. The condition primarily affects the elderly, and has been documented to follow trauma to the scalp. EPDS lesions tend to be chronic, progressive, and difficult to treat. Laboratory and histopathological findings are not diagnostic.

Management strategy

Traditionally, potent topical corticosteroids have been used in EPDS with a generally positive but variable response within a few months of use. Due to steroid-related cutaneous atrophy, tacrolimus 0.1% ointment, calcipotriol cream, oral zinc, and photodynamic therapy have been introduced as alternative therapies. A recent series has shown dapsone 5% gel to be effective in resolving EPDS. Oral dapsone was shown in one case report to result in initial improvement, but the patient had problems with recurrence. Retinoids and oral corticosteroids have also shown some promise when used in conjunction with other topical antibiotics, topical corticosteroids, topical tacrolimus, oral dapsone, and oral zinc therapy. Topical and systemic antibiotics and antifungals are essentially ineffective.

First-line therapy

image High-potency topical corticosteroids D

Three series and 13 case reports exist for high potency topical cortisones in the literature.

Second-line therapies

image Topical 5% dapsone gel E
image Topical 0.1% tacrolimus ointment E

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