Dissecting Cellulitis of the Scalp

By BALAJI YEGNESWARAN, MD and ALEJANDRO HERRERA, MD
Drexel University College of Medicine/Saint Peter’s University Hospital, New Brunswick, NJ
VISHAL JAIN, MD, MRCP
Penn State University, Hershey, Pa | May 5, 2010

For the past 7 years, a 32-year-old African American man had multiple nonpruritic scalp abscesses. He also reported intermittent fever and joint pain. The abscesses had been drained on many occasions, and he had received several antibiotics, although no organisms had been isolated. Collagen(Drug information on collagen) vascular disease, SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, osteitis), discoid lupus, and cutaneous sarcoid had been ruled out. During the past 7 years, he had been treated with prednisone(Drug information on prednisone), methotrexate(Drug information on methotrexate), and hydroxychloroquine(Drug information on hydroxychloroquine) without any response.

Fungal cultures were negative for tinea capitis, and no nuchal lymph nodes were palpable.¹ Folliculotropic mycosis fungoides with large-cell transformation² was unlikely because the patient did not have any other systemic symptoms. Fluid from incision and abscess drainage revealed abundant neutrophils and red blood cells with no evidence of malignancy. Cultures and stains were negative for bacterial and fungal infection. The diagnosis of exclusion was dissecting cellulitis of the scalp.

The differential diagnosis of this condition includes acne keloid,³ which is associated with chronic, scarring folliculitis that affects mostly African American patients and is located on the back of the neck of young adults. The course is progressive and leads to hypertrophic scarring, chronic abscesses, and hair loss. Pseudopelade of Brocq,⁴ characterized by its lack of atrophy and "footprints in the snow" alopecia morphology, is another condition in the differential that generally occurs in white patients.

Dissecting cellulitis is difficult to treat. Medical therapies include antibiotic soap (chlorhexidine and benzoyl peroxide(Drug information on benzoyl peroxide)), dapsone(Drug information on dapsone), intralesional triamcinolone(Drug information on triamcinolone), zinc supplements, topical and oral isotretinoin(Drug information on isotretinoin), oral antibiotics (tetracycline and doxycycline(Drug information on doxycycline)), and oral corticosteroids. Simple incision and drainage and wide excision with split-thickness skin grafting have been used to treat severe cases when medical therapy has failed.

by Anne Carlisle | May 31, 2011 5:05 PM EDT

I have had only two of these cases in 15 yrs and both were in the early stages and both responded well to isotretinion. Sad he had this for seven years without any effective course of tx.

by Robert Weiss | June 06, 2010 8:25 PM EDT

Was the possibility of lymphedema of the scalp considered in the differential diagnosis? Had this patient had any head, neck or facial surgery or radiation which might have caused blockage of the lymphatic drainage from the scalp to the venous arch? Was manual lymph drainage considered as a treatment protocol? Robert Weiss, M.S. Lymphedema Patient Advocate National Lymphedema Network

by Bradley Powers | May 24, 2010 4:45 PM EDT

This seems like a rare condition. I suspect if I ever saw something that looked like this I would send him to a Dermatologist. Would any dermatologist know what this is? or would it require a tertiary center, teaching hospital faculty to get to the bottom of this problem (no pun intended).

In my opinion, showing a couple other pictures which are typical of some of the other differentials that are more common would also be helpful.

by Khalid Iqbal Butt | May 20, 2010 4:41 PM EDT

oral isotretinoin was tried ?

REFERENCES:
1. Padilha-Gonçalves A. Inflammatory tinea capitis (kerion) mimicking dissecting cellulitis. Int J Dermatol. 1992;31:66.
2. Gilliam AC, Lessin SR, Wilson DM, Salhany KE. Folliculotropic mycosis fungoides with large-cell transformation presenting as dissecting cellulitis of the scalp. J Cutan Pathol. 1997;24:169-175.
3. Luz Ramos M, Muñoz-Pérez MA, Pons A, et al. Acne keloidalis nuchae and tufted hair folliculitis. Dermatology. 1997;194:71-73.
4. Collier PM, James MP. Pseudopelade of Brocq occurring in two brothers in childhood. Clin Exp Dermatol. 1994;19:61-64.

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Dissecting Cellulitis of the Scalp

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