Published on 18/03/2015 by admin
Filed under Dermatology
Last modified 22/04/2025
This article have been viewed 2640 times
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
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.
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X-ray epilation of affected areas has largely been superseded by laser epilation before the stage of massive inflammation occurs.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.
Swabs for bacteriology
Scrapings and plucked hair roots for mycology
Scalp biopsy for histology and fungal culture
Twersky JM, Sheth AP. Int J Dermatol 2005; 44: 412–14.
Sperling LC, Major MC. Int J Dermatol 1991; 30: 190–2.
Two cases of highly inflammatory tinea capitis resulting in scarring alopecia. In any case of inflammatory alopecia in adults, tinea capitis should be excluded. If scalp scrapings and plucked hair roots do not show spores, and superficial fungal culture gives negative results, a biopsy for histology and fungal culture should be performed.
Ramesh V. Dermatologica 1990; 180: 48–50.
Two girls with dissecting cellulitis, in one of whom Pseudomonas aeruginosa was isolated from a sinus discharge. The role of infection in perpetuating the condition is highlighted.
Curry SS, Gaither DH, King LE. J Am Acad Dermatol 1981; 4: 673–8.
A case of squamous cell carcinoma arising in dissecting folliculitis of the scalp that was fatally aggressive. Early diagnosis and treatment are essential.
Gillam AC, Lessin SR, Wilson DM, Salhany KE. J Cutan Pathol 1997; 24: 169–75.
Follicular mycosis fungoides presenting in a manner similar to dissecting cellulitis of the scalp with non-healing, draining nodular lesions.
Harries MJ, Sinclair RD, MacDonald-Hull S, Whiting DA, Griffiths CE, Paus R. Br J Dermatol 2008; 159: 1–22.
An extensive review and summary of reported treatments for disorders including dissecting cellulitis.
Moyer DG, Williams RM. Arch Dermatol 1962; 85: 118–24.
A report of six cases treated with systemic antibiotics.
Jolliffe DS, Sarkany I. Clin Exp Dermatol 1977; 2: 291.
A discussion of the therapeutic difficulties inherent in this disorder, and report of a mild case of dissecting folliculitis responding well to oral oxytetracycline 1 g daily for 2 months.
Greenblatt DT, Sheth N, Teixeira F. Clin Exp Dermatol 2008; 33: 99–100.
Case report of rapid improvement in refractory dissecting cellulitis with oral ciprofloxacin 500 mg twice daily for 1 month then reduced to 250 mg twice daily.
Scerri L, Williams HC, Allen BR. Br J Dermatol 1996; 134: 1105–8.
Three patients showed a sustained response. The authors recommended that isotretinoin should be given initially at 1 mg/kg daily and maintained at a dose not less than 0.75 mg/kg daily for at least 4 months after clinical remission is achieved. Long-term post-treatment follow-up of two of the patients showed sustained benefit.
Adrian RM, Arndt KA. Ann Plast Surg 1980; 4: 166–9.
The authors initially used high-dose oral prednisolone after intravenous antibiotics had failed. Maintenance with 5 mg prednisolone on alternate days for 2 years is reported.
Williams CN, Cohen M, Ronan SG, Lewandowski CA. Plast Reconstruct Surg 1986; 77: 378–82.
Four patients with extensive scalp disease responded to wide excision and split-thickness skin grafting.
Krasner BD, Hamzavi FH, Murakawa GJ, Hamzavi IH. Dermatol Surg 2006; 32: 1039–44.
Four patients achieved sustained improvement at 1 year, with some regrowth of hair at treated sites.
Boyd AS, Binhlam JQ. Arch Dermatol 2002; 138: 1291–3.
Complete clearance of disease poorly responsive to multiple drugs after four treatments at monthly intervals, with remission maintained 6 months after laser epilation.
Glass LF, Berman B, Laub D. J Dermatol Surg Oncol 1989; 15: 673–6.
Chinnalayan P, Tena LB, Brenner MJ, Welsh JS. Br J Dermatol 2005; 152: 777–9.
Rapid improvement in four cases treated with electron beam therapy.
Kobayashi H, Aiba S, Tagami H. Br J Dermatol 1999; 141: 1136–8.
A patient with dissecting cellulitis and acne conglobata responding to oral zinc sulfate 135 mg three times a day for 12 weeks. The dose was reduced to 260 mg daily for 7 weeks, with no recurrence, but 1 week after stopping zinc therapy the scalp nodules recurred. Zinc was resumed and the scalp lesions diminished within 8 weeks. Afterwards, disease was well controlled for 1 year on zinc sulfate 135 mg daily.
Karpouzis A, Giatromanolaki A, Sivridis E, Kouskoukis C. Eur J Dermatol 2003; 13: 192–5.
Dissecting cellulitis in an 18-year-old white patient was controlled with topical isotretinoin.
Brandt HRC, Malheiros APR, Teixeira MG, Machado MCR. Br J Dermatol 2008; 159: 506–7.
Response to infliximab 8-weekly for 12 months in a case refractory to oral antibiotics and isotretinoin.
Navarini AA, Trüeb RM. Arch Dermatol 2010; 146: 517–20.
Rapid improvement with adalimumab within a few weeks but relapse likely on stopping treatment where structural abnormalities have developed.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
WhatsApp us
Scalp hygiene
Topical antibiotics
Systemic antibiotics
Intralesional corticosteroid injection
Incision and drainage
Isotretinoin (oral)
Systemic corticosteroids
Excision and grafting
Laser epilation
Radiotherapy epilation
Systemic zinc sulfate
Topical isotretinoin
Infliximab/adalimumab
