Dissecting cellulitis of the scalp

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Dissecting cellulitis of the scalp

Andrew J.G. McDonagh

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

Dissecting cellulitis is a rare, chronic, progressive inflammatory disease of the scalp that affects predominantly the vertex and occipital scalp of men, mainly from the second to the fourth decade. Dissecting cellulitis may occur in association with hidradenitis suppurativa and acne conglobata to form the ‘follicular occlusion or retention triad.’ The suggested common pathogenic mechanism includes follicular retention, intense folliculitis, and granulomatous changes, leading to interconnecting sinuses along with abscess formation. Patchy alopecia is associated with extensive fibrosis and scarring, which may become keloidal.

Management strategy

Dissecting cellulitis is characterized by a chronic, progressive course with temporary improvement on treatment followed by relapses when treatment is discontinued. There are no large therapeutic clinical trials, and recommendations for therapy are based on case reports or small series. Inflammatory tinea capitis (kerion) and the very rare case of occult squamous carcinoma should be excluded. Although no specific pathogenetic organisms have been isolated, swabs should be obtained for bacteriology and the antibiotic sensitivity of organisms reviewed.

In mild cases or when disease is limited, improved scalp hygiene and the use of antiseptics, topical antibiotics (based on bacterial culture results), intralesional corticosteroid injections and aspiration of fluctuant lesions may be adequate. At an early stage, systemic antibiotics such as tetracyclines and clindamycin reduce inflammation and can control disease. In more severe cases a combination of systemic antibiotics such as clindamycin with rifampicin with or without corticosteroids may be effective. Isotretinoin has been shown to provide sustained remission if continued for at least 4 months after clinical control is achieved, at a dose of 0.75–1.0 mg/kg daily. Oral zinc sulfate has received anecdotal reports of success when used long term. There are a small number of case reports of success with anti-TNF therapy.

X-ray epilation of affected areas has largely been superseded by laser epilation before the stage of massive inflammation occurs. The most resistant cases may require surgical excision and skin grafting.

Specific investigations

First-line therapies

imageScalp hygiene D
imageTopical antibiotics D
imageSystemic antibiotics D
imageIntralesional corticosteroid injection D
imageIncision and drainage D

Second-line therapies

imageIsotretinoin (oral) D
imageSystemic corticosteroids E

Third-line therapies

imageExcision and grafting D
imageLaser epilation D
imageRadiotherapy epilation D
imageSystemic zinc sulfate E
imageTopical isotretinoin E
imageInfliximab/adalimumab E

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Dissecting cellulitis of the scalp

Andrew J.G. McDonagh

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

Dissecting cellulitis is a rare, chronic, progressive inflammatory disease of the scalp that affects predominantly the vertex and occipital scalp of men, mainly from the second to the fourth decade. Dissecting cellulitis may occur in association with hidradenitis suppurativa and acne conglobata to form the ‘follicular occlusion or retention triad.’ The suggested common pathogenic mechanism includes follicular retention, intense folliculitis, and granulomatous changes, leading to interconnecting sinuses along with abscess formation. Patchy alopecia is associated with extensive fibrosis and scarring, which may become keloidal.

Management strategy

Dissecting cellulitis is characterized by a chronic, progressive course with temporary improvement on treatment followed by relapses when treatment is discontinued. There are no large therapeutic clinical trials, and recommendations for therapy are based on case reports or small series. Inflammatory tinea capitis (kerion) and the very rare case of occult squamous carcinoma should be excluded. Although no specific pathogenetic organisms have been isolated, swabs should be obtained for bacteriology and the antibiotic sensitivity of organisms reviewed.

In mild cases or when disease is limited, improved scalp hygiene and the use of antiseptics, topical antibiotics (based on bacterial culture results), intralesional corticosteroid injections and aspiration of fluctuant lesions may be adequate. At an early stage, systemic antibiotics such as tetracyclines and clindamycin reduce inflammation and can control disease. In more severe cases a combination of systemic antibiotics such as clindamycin with rifampicin with or without corticosteroids may be effective. Isotretinoin has been shown to provide sustained remission if continued for at least 4 months after clinical control is achieved, at a dose of 0.75–1.0 mg/kg daily. Oral zinc sulfate has received anecdotal reports of success when used long term. There are a small number of case reports of success with anti-TNF therapy.

X-ray epilation of affected areas has largely been superseded by laser epilation before the stage of massive inflammation occurs. The most resistant cases may require surgical excision and skin grafting.

Specific investigations

Squamous cell carcinoma arising in dissecting perifolliculitis of the scalp.

Curry SS, Gaither DH, King LE. J Am Acad Dermatol 1981; 4: 673–8.

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