47-year-old with a severe rash on the head diagnosed with dissecting cellulitis of the scalp
A previously healthy 47-year-old man arrived at the emergency department with a 7-month history of a severe rash on his head that had not gone away despite repeated rounds of oral antibacterial medicines. The vital indicators were all within normal limits. On physical examination, there were several painful, swampy, and erythematous nodules on the vertex of the scalp, with minimal purulent and serosanguinous discharge and underlying baldness. There were no other skin changes. Other laboratory tests, including a fourth-generation human immunodeficiency virus test and a fast plasma reagin test, came up negative. Based on these findings, the patient was diagnosed with dissecting cellulitis of the scalp.
Dissecting cellulitis of the scalp was diagnosed. A chronic inflammatory skin disorder characterised by swampy, suppurative nodules and patchy hair loss is dissecting cellulitis of the scalp. Follicular occlusion causes the condition, which may be accompanied with other follicular occlusive conditions such as acne conglobata, hidradenitis suppurativa, and pilonidal cysts, none of which were present in this case. The patient was started on topical glucocorticoids and oral doxycycline. The scalp leakage and edoema had subsided four weeks later.
Dissecting cellulitis of the scalp – an inflammatory illness
Dissecting cellulitis of the scalp (DCS), also known as perifolliculitis capitis abscedens et suffodiens or Hoffman disease, is a chronic inflammatory illness of the scalp characterised by boggy, suppurative nodules and patchy hair loss. Follicular occlusion may be a critical pathogenic event in the progression of DCS. Other follicular occlusive conditions, such as acne conglobata, hidradenitis suppurativa, and pilonidal cysts, can coexist with DCS. There is a scarcity of information regarding DCS treatment alternatives. The most widely utilised therapies are oral antibiotics and oral isotretinoin.
DCS is a kind of primary cicatricial (scarring) alopecia, a group of inflammatory illnesses that destroy hair follicles and cause irreversible hair loss. Based on pathologic findings, attendees in a 2001 workshop on cicatricial alopecia sponsored by the North American Hair Research Society defined DCS as a neutrophilic variant of primary cicatricial alopecia.
DCS can affect an isolated part of the scalp or the entire calvaria, posing a significant therapeutic problem. A diversity of treatment alternatives frequently suggests a lack of evident superiority of one strategy over another. In the case of DCS, it may also symbolise the disease’s spectrum, which can be severe and socially isolating at one end, and for which surgery is the only treatment that enables long-term disease control without any medical side effects.
DCS’s global influence is unknown
This is not surprising given that the National Institutes of Health classifies DCS as an uncommon condition. On the other hand, HS, which is also classified as an uncommon disease by the National Institutes of Health, has received greater attention and has been linked to poorer socioeconomic position.
DCS is essentially a cicatricial alopecia characterised by numerous inflammatory pustules, abscesses, and the creation of chronic discharge tubes and sinuses. It has been defined as a component of the FO trio, together with acne conglobata, HS or acne inversa, and perifolliculitis capitis abscedens et suffodiens. Pilonidal illness is added by the FO tetrad.Members of this tetrad are often diagnosed independently of one another; nevertheless, there have been occurrences of these disorders affecting individuals concurrently. Although the exact cause of many disorders is yet unknown, a common pathophysiology has been proposed. This comprises aberrant keratinization with blockage of the follicular infundibulum, which leads to rupture in the same way that hidradenitis does.
This rupture causes a severe inflammatory response
Deep sinus tracts develop in the individuals over time, marking the diagnosis about 34 months after the onset of symptoms. The sinuses worsen and finally consolidate to form a persistent suprainfection that can only be treated with antibiotics. Scientific research into the pathophysiology of DCS reflects the disease’s rarity. According to Scheinfeld8, histology reveals lesions with dense neutrophilic, lymphocytic, histiocytic, and plasma cellular infiltrates early on. Granuloma composed of lymphocytes, plasma cells, and foreign-body giant cells will be present in a more chronic lesion.
DCS is most commonly encountered in men of Afro-Caribbean heritage in their early adulthood or middle age, while females and Caucasians have also been known to be affected. The specific cause of DCS is unknown, but it is likely complex. It should be highlighted that if the resection is done well, surgery can provide a long-term cure for this disease. A one-year follow-up after excision with wide (3 cm) margins revealed that the disease had not recurred. This also enables a clinician to recommend this strategy to a patient who prefers it to the cost and compliance requirements of medicinal therapy.
Source: NEJM
