The patient is a 27-year-old African American man requesting treatment for a chronic scalp condition that has not responded to multiple courses of antibiotics. The disorder is painful and has resulted in hair loss. Noted are scattered nodules and sinus tracks. His face and trunk manifest occasional acneiform papules.
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Perifolliculitis capitis abscedens et suffodiens, also referred to as dissecting cellulitis (DC), is a chronic relapsing suppurative dermatitis of the scalp,1 characterized by relapsing folliculitis and painful fluctuant abscesses of the scalp.2 DC is considered a component of a follicular occlusive tetrad, including acne conglobate, hidradenitis suppurative, and pilonidal cyst.2 DC most commonly manifests in men of African American or African Caribbean descent between the ages of 20 and 40 years.3 Although the etiology is unknown, DC is thought to be a neutrophilic and granulomatous inflammatory response secondary to a follicular blockage from a bacterial infection, most frequently caused by Staphylococcus aureus or Staphylococcus epidermidis.3 As DC advances, multiple tender nodules, pustules, and abscesses form through intercommunicating sinuses of the scalp.1Nodules may present as firm or fluctuant, and may drain pus, blood, or serous fluid.1 Presentation is most commonin the vertex and occipital regions.2 Because of the extensive and wide interconnection between the nodules in the scalp, purulent discharge at a distant site when a nodule is pinched is a pathognomonicfinding of DC.1 Lesions at different stages of developmentmay be present throughout the disease course.4 End-stage lesions will present with irreversible dermal fibrosis with prominent alopecia and keloidal scars.1,4 DC is usually diagnosed clinically. Diagnostic work-up may include bacterial culture and sensitivity.1
Adequate control of DC is challenging. Scalp cleansing with chlorhexidine or benzoyl peroxide is encouraged. Mild or early disease may respond to topical and oral antibiotics.1 For worsening DC, isotretinoin is often considered as first-line treatment, with doses ranging between 0.5 and 1 mg/kg/d for 3 months to 1 year.2 For advanced unremitting disease, laser depilation, tumor necrosis factor alpha blockers, or localized scalp excisions are treatment options.
1. Taylor S, Badreshia-Bansal S, Callender V, Gathers R, Rodriguez D. Treatments for Skin of Color E-Book: Expert Consult-Online and Print. United Kingdom, Elsevier Health Sciences; 2011:236-237.
2. Cataldo-Cerda, K., Wortsman, X. Dissecting cellulitis of the scalp early diagnosed by color Doppler ultrasound. Int J Trichology. 2017; 9(4):147-148.
3. Tchernev, G. Folliculitis et perifolliculitis capitis abscedens et suffodiens controlled with a combination therapy: Systemic antibiosis (metronidazole plus clindamycin), dermatosurgical approach, and high-dose isotretinoin. Indian J Dermatol. 2011;56(3):318-320.
4. Calonje JE, Brenn T, Lazar A, McKee P. McKee’s Pathology of the Skin. United Kingdom: Elsevier Health Sciences; 2011:1027.