Published on 18/03/2015 by admin
Filed under Dermatology
Last modified 18/03/2015
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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X-ray epilation of affected areas has largely been superseded by laser epilation before the stage of massive inflammation occurs.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.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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