Approach to treatment of refractory dissecting cellulitis of the scalp: a systematic review

Surgery combined with photodynamic therapy for the case of perifolliculitis capitis abscedens et suffodiens: A case report

Perifolliculitis capitis abscedens et suffodiens, also known as dissecting cellulitis of the scalp, is a rare, chronic suppurative, inflammatory head hair follicle disease, which seriously affects the patient's quality of life. Clearly, clinical treatment varies widely and is somewhat challenging. We report a case of a 19-year-old male patient who had good results through surgery combined with photodynamic therapy. Surgery combined with photodynamic therapy for perifolliculitis capitis abscedens et suffodiens is effective and safe, especially for patients with poor responses to previous traditional treatments.

A Case of Dissecting Cellulitis of the Scalp, Hidradenitis Suppurativa, and Conglobate Acne Successfully Treated with Secukinumab

Introduction

Dissecting cellulitis of the scalp (DCS) is a neutrophilic scarring alopecia typically presenting with pustules and fluctuant nodules, followed by suppuration and sinus tract formation. DCS is often associated with other diseases, such as hidradenitis suppurativa (HS) and conglobate acne (CA) which share similar pathogenetic mechanisms.

Case Presentation

The authors report the case of a patient affected by a severe form of DCS, HS, and CA of the face. Previous treatments with isotretinoin, antibiotics, and adalimumab did not have a considerable efficacy. Off-label treatment with secukinumab showed a gradual improvement in the clinical presentation bringing to a reduction in the number of HS lesions and to an almost complete resolution of the inflammatory manifestations of DCS.

Conclusion

Management of DCS is challenging and is typically based on retinoids which are considered the first line of treatment. The efficacy of biologic drugs, especially TNFα inhibitors, in severe and relapsing forms of DCS has been reported in recent literature. To our knowledge, only one case of isolated DCS treated with secukinumab is reported. No cases of concomitant DCS and HS, treated with this type of IL-17 inhibitor, have been described.

Improvement of Recalcitrant Dissecting Cellulitis of the Scalp After a Trial of Upadacitinib

Dissecting cellulitis of the scalp (DCS) is a rare condition characterized by painful inflammatory nodules and abscesses on the scalp, often leading to sinus tracts and scarring alopecia. We present a case of DCS in a 26-year-old male who experienced significant clinical improvement following a short course of upadacitinib, a Janus kinase (JAK) inhibitor. The patient received multiple standard treatments such as topical antimicrobials, oral antibiotics, corticosteroids, and intralesional triamcinolone injections, with limited success. However, following the initiation of upadacitinib, the patient reported reduced pain, pustular draining, and bleeding, with significantly improved quality of life. To our knowledge, there is currently a paucity of literature documenting the use of JAK inhibitors for DCS. This case aims to highlight the potential of JAK inhibitors as a therapy for refractory DCS, a condition with limited treatment options.

Hidradenitis suppurativa and follicular occlusion syndrome: Where is the pathogenetic link?

The follicular occlusion tetrad complex encompasses several entities (hidradenitis suppurativa, acne conglobata, dissecting cellulitis of the scalp, and pilonidal cyst) that share common clinical features, risk factors, and pathophysiology. Follicular occlusion is a crucial triggering mechanism in the etiology in each of these disorders, leading to development of distinctive skin lesions such as deep-seated nodules, abscesses, comedones, and draining sinuses, often with accompanying scarring. Despite the fact that the follicular occlusion tetrad components manifest multiple similarities, they also exhibit many differences among themselves and require individual approaches and treatment.

Oral Isotretinoin and Its Uses in Dermatology: A Review

In 1982, the Food and Drug Administration (FDA) of the United States of America approved isotretinoin (13-cis-retinoic acid), a retinoid derivative of vitamin A, to treat severe recalcitrant acne vulgaris. Apart from its prescribed use for severe acne, evidence suggests that isotretinoin is commonly used off-label to treat mild-to-moderate acne, inflammatory skin conditions, genodermatoses, skin cancer, and other skin disorders. This is due to its anti-inflammatory, immunomodulatory, and antineoplastic properties. Some "off-label" use is successful, while others are ineffective. Therefore, this information is essential to clinicians for deciding on the appropriate use of isotretinoin. In this article, we aim to review the most updated evidence-based data about the use of oral isotretinoin in dermatology.

Scarring Alopecia

African hair shaft and pigmented scalp have unique features that challenge diagnosis in scarring alopecia. In addition, Black patients may associate 2 or more types of hair disorders. Therefore, it is imperative to understand their findings thoroughly to establish a good diagnosis. Differential diagnosis on the frontal scalp includes traction alopecia and frontal fibrosing alopecia. Disorders such as central centrifugal cicatricial alopecia, fibrosing alopecia in a pattern distribution, discoid lupus erythematosus, and lichen planopilaris usually affect the middle scalp. Folliculitis decalvans, dissecting cellulitis, and acne keloidalis nuchae are the main differential diagnosis of the posterior scalp.

Recent Advances in Understanding of the Etiopathogenesis, Diagnosis, and Management of Hair Loss Diseases

Hair-loss diseases comprise heterogenous conditions with respective pathophysiology and clinicopathological characteristics. Major breakthroughs in hair follicle biology and immunology have led to the elucidation of etiopathogenesis of non-scarring alopecia (e.g., alopecia areata, AA) and cicatricial alopecia (e.g., lichen planopilaris, LPP). High-throughput genetic analyses revealed molecular mechanism underlying the disease susceptibility of hair loss conditions, such as androgenetic alopecia (AGA) and female pattern hair loss (FPHL). Hair loss attracted public interest during the COVID-19 pandemic. The knowledge of hair loss diseases is robustly expanding and thus requires timely updates. In this review, the diagnostic and measurement methodologies applied to hair loss diseases are updated. Of note, novel criteria and classification/scoring systems published in the last decade are reviewed, highlighting their advantages over conventional ones. Emerging diagnostic techniques are itemized with clinical pearls enabling efficient utilization. Recent advances in understanding the etiopathogenesis and management for representative hair diseases, namely AGA, FPHL, AA, and major primary cicatricial alopecia, including LPP, are comprehensively summarized, focusing on causative factors, genetic predisposition, new disease entity, and novel therapeutic options. Lastly, the association between COVID-19 and hair loss is discussed to delineate telogen effluvium as the predominating pathomechanism accounting for this sequela.

Perifolliculitis capitis abscedens et suffodiens treatment with tumor necrosis factor inhibitors and baricitinib: A case report and literature review

Rationale

Perifolliculitis capitis abscedens et suffodiens (PCAS), also known as dissecting cellulitis of the scalp (DCS), is a part of the “follicular occlusion tetrad” that also includes acne conglobate (AC), hidradenitis suppurativa (HS), and pilonidal sinus, which share the same pathogenic mechanism, such as follicular occlusions, follicular ruptures, and follicular infections.

Patient concerns

A 15-year-old boy had multiple rashes on the scalp accompanied by pain.

Diagnosis

The patient was diagnosed with PCAS or DCS based on the clinical manifestations and laboratory examinations.

Interventions

The patient was initially administered adalimumab 40 mg biweekly and oral isotretinoin 30 mg daily for 5 months. Because the initial results were insufficient, the interval between adalimumab injections was extended to 4 weeks, and isotretinoin was changed to baricitinib 4 mg daily for 2 months. When the condition became more stable, adalimumab 40 mg and baricitinib 4 mg were administered every 20 and 3 days, respectively, for two more months until now.

Outcomes

After 9 months of treatment and follow-up, the original skin lesions of the patient were almost cured, and most inflammatory alopecia patches disappeared.

Conclusion

Our literature review did not find any previous reports on treating PCAS with TNF-α inhibitors and baricitinib. Accordingly, we presented the first successful treatment of PCAS with this regimen.

Demodicosis in Different Age Groups and Alternative Treatment Options-A Review

Infestation with Demodex mites is a common occurrence, especially in adults and the elderly. More recent attention has been paid to the presence of Demodex spp. mites in children, even ones without comorbidities. It causes both dermatological and ophthalmological problems. The presence of Demodex spp. is often asymptomatic, thus it is suggested to include parasitological investigation tests in dermatological diagnostics, in addition to bacteriological analysis. Literature reports show that Demodex spp. are related to the pathogenesis of numerous dermatoses, including rosacea or demodicosis gravis, and common eye pathologies reported by patients such as dry eye syndrome or ocular surface inflammatory conditions, such as blepharitis, chalazia, Meibomian gland dysfunction, and keratitis. Treatment of patients is a challenge and is usually prolonged, therefore it is important to carefully diagnose and properly select the therapy regimen for the treatment to be successful, and with minimal side effects, especially for young patients. Apart from the use of essential oils, research is ongoing for new alternative preparations active against Demodex sp. Our review was focused on the analysis of the current literature data on the available agents in the treatment of demodicosis in adults and children.

20% ALA-PDT pretreated by fire needle in patients with dissecting cellulitis of the scalp: An interim analysis

BACKGROUND

Dissecting cellulitis of the scalp (DCS) is a rare but distinctive, chronic suppurative condition, and the treatment is a therapeutic challenge. Recently, treatment of DCS with 5-aminolaevulinic acid photodynamic therapy (ALA-PDT) has been considered as a potential option.

OBJECTIVE

To evaluate the efficacy and safety of 20% ALA-PDT pretreated by fire needle in the treatment of DCS.

MATERIALS AND METHODS

Topical 20% ALA-PDT with fire needle intervention as a pretreatment, was applied to six patients with DCS. All patients completed three sessions treatment at an interval of ten days. They were assessed for the efficacy at the baseline and on ten days after each treatment. According to the reduction of lesions and the improvements of patients' symptoms after each session, the objective assessment of therapeutic effect was divided into four grades. The adverse effects were recorded.

RESULTS

A total of six male patients were enrolled in our study. After three sessions of ALA-PDT, among them, three patients recovered, two patients achieved significant improvement and one patient achieved partial response.Patient 4 (Pt.4) relapsed at 6-month follow-up. Pt.1 and Pt.6. maintained complete response after one year follow-up. We also found that the clearance rate of the popular/nodular and cyst/abscess was much higher than sinus.

CONCLUSION

20% ALA-PDT pretreated by fire needle could be an effective, minimally-invasive, safe method for DCS patients. Lesion in the early stages have a better response than sinus.

A Case of Dissecting Cellulitis which Was Initially Suspected to Be a Trichilemmal Cyst

We treat infected cysts on a daily basis, but it is difficult to diagnose similar lesions produced by inflammatory conditions that are not primarily caused by bacteria. Dissecting cellulitis of the scalp (DCS) is a chronic inflammatory disease that results in disfiguring, painful, and purulent lesions. It often takes a long time to diagnose. The pathophysiology of DCS remains unclear. Various treatments for DCS have been proposed, depending on the severity of the disease. However, none of these treatments are clearly superior to the others. If DCS spreads to the entire occipital region, aggressive surgical treatment may be beneficial in terms of the patient's quality of life. However, surgical interventions, such as drainage, are not effective at preventing the progression of the disease. Herein, we report the case of a young female patient who developed a cyst in the occipital region. We initially suspected that the lesion was a normal infected trichilemmal cyst. However, DCS was subsequently suspected because the lesion exhibited an unusual course after drainage and debridement. We consider that we made a diagnosis relatively early, but if we had sufficient knowledge about DCS we could have made a diagnosis even earlier by performing debridement sooner. Minocycline was administered for 5 months, which caused the lesion to disappear. After 2 years, no recurrence had been observed.

Scarring Alopecia: Diagnosis and New Treatment Options

This article focuses on the assessment and treatment of patients with primary cicatricial alopecia and provides new information regarding the genetics and pathophysiology of this group of diseases.

Topical Treatment for Scarring and Non-Scarring Alopecia: An Overview of the Current Evidence

Alopecia is a clinical condition related to hair loss that can significantly affect both male and female adults' quality of life. Despite the high market demand, only few drugs are currently approved for alopecia treatment. Topical formulations still bring drawbacks, such as scalp irritation with frequent use, and low drug absorption to the site of action, which limits the efficacy. The most recent research points out that different formulation technology could circumvent the aforementioned flaws. Such technology includes incorporation of drugs in rigid or deformable nanoparticles, strategies involving physical, energetical and mechanical techniques, such as iontophoresis, sonophoresis, microneedling, and the use of solid effervescent granules to be hydrated at the moment of application in the scalp. In this paper, the progress of current research on topical formulations dedicated to the treatment of alopecia is reviewed and discussed.

Recalcitrant Dissecting Cellulitis of the Scalp Treated Successfully with Adalimumab with Hair Regrowth: A Case Report

Dissecting cellulitis (DC) of the scalp or perifolliculitis capitis abscedens et suffodiens is a rare chronic inflammatory condition of the scalp manifested by perifollicular pustules, nodules, abscesses and sinuses that result into scarring alopecia. Treatment of DC is challenging and often disappointing. We report a 38-year-old male patient with DC for 5 years, and multiple topical and systemic therapies had shown poor effect. This patient achieved excellent response to adalimumab with hair regrowth.

Consensus on the use of oral isotretinoin in dermatology - Brazilian Society of Dermatology

BACKGROUND

Isotretinoin is a synthetic retinoid, derived from vitamin A, with multiple mechanisms of action and highly effective in the treatment of acne, despite common adverse events, manageable and dose-dependent. Dose-independent teratogenicity is the most serious. Therefore, off-label prescriptions require strict criteria.

OBJECTIVE

To communicate the experience and recommendation of Brazilian dermatologists on oral use of the drug in dermatology.

METHODS

Eight experts from five universities were appointed by the Brazilian Society of Dermatology to develop a consensus on indications for this drug. Through the adapted DELPHI methodology, relevant elements were listed and an extensive analysis of the literature was carried out. The consensus was defined with the approval of at least 70% of the experts.

RESULTS

With 100% approval from the authors, there was no doubt about the efficacy of oral isotretinoin in the treatment of acne, including as an adjunct in the correction of scars. Common and manageable common adverse events are mucocutaneous in nature. Others, such as growth retardation, abnormal healing, depression, and inflammatory bowel disease have been thoroughly investigated, and there is no evidence of a causal association; they are rare, individual, and should not contraindicate the use of the drug. Regarding unapproved indications, it may represent an option in cases of refractory rosacea, severe seborrheic dermatitis, stabilization of field cancerization with advanced photoaging and, although incipient, frontal fibrosing alopecia. For keratinization disorders, acitretin performs better. In the opinion of the authors, indications for purely esthetic purposes or oil control are not recommended, particularly for women of childbearing age.

CONCLUSIONS

Approved and non-approved indications, efficacy and adverse effects of oral isotretinoin in dermatology were presented and critically evaluated.