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Dissecting cellulitis of the scalp: A review on clinical characteristics and management options in a series of 14 patients

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Dermatologic Therapy
Authors:
Marta Gamissans
Marta Gamissans
Marta Gamissans
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Jorge Romaní at Granollers General Hospital
Jorge Romaní
Cristina López-Llunell at Corporació Sanitària Parc Taulí
Cristina López-Llunell
Núria Riera‐Martí
Núria Riera‐Martí
Núria Riera‐Martí
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LETTER
Dissecting cellulitis of the scalp: A review on clinical
characteristics and management options in a series of
14 patients
Dear Editor,
Dissecting cellulitis of the scalp (DCS) is a rare neutrophilic dermatosis
related to hidradenitis suppurativa (HS). Its management is generally
difficult.
1,2
Our objective was to describe clinical presentation and ther-
apeutic options in patients with DCS. A retrospective observational
single-center study was performed. DCS disease severity was assessed
according to Lee's classification. Complete response (CR) was defined
as the complete recovery of hair loss or global absence of a bald area.
Partial response (PR) as the partial recovery with noticeable bald areas
and no response (NR) as no improvement or enlarging hairless areas.
Recurrence rate was defined as a relapse of inflammation or nodules
after a CR or the disappearance of improvement in those who achieved
a PR. Response and recurrence were evaluated 3 and 6 months, respec-
tively after the beginning of the treatment.
3
Fourteen patients, 100% (14/14) men with a median age of
39.6 ± 9.8 years, a median of body mass index of 28.5 kg/m
2
and a
high rate of smoking habit (64%) (9/14) were included. 86% (12/14)
had also HS in other areas, which was controlled with topical treat-
ment, in only 14% (2/14) of the patients DCS was an isolated finding.
Acne history was present in 64% (9/14) of the patients. About 79%
(11/14) of them showed II or III SDC stage and lesions predominated
on the vertex 100% (14/14) and occipital area 50% (7/14).
A linear regression model where DCS was the dependent vari-
able proved there was statistically significant association with
acne (p< 0.01), Hurley stage (p=0.02) and male sex (p=0.04)
(Table S1).
They all received a combined treatment for SDC, either sequen-
tially or in parallel. Initial management included topical or oral antibi-
otics, or intralesional steroid injection. In 86% (12/14) of them, the
treatment was scaled up to isotretinoin, dapsone, surgery, or TNF-
alpha antagonists. Treatment response rates, duration, recurrence
rates and adverse effects are summarized in Table 1and Table S2.
TABLE 1 Treatment outcome and adverse effects
Treatment Patients %
CR
(complete
response) %
PR (partial
response) %
NR (no
response) %
Mean duration of
the treatment ±
standard deviation
(DE) months
RR
(recurrence
rate) % Adverse effects
Topical
antibiotics
78.6% (11/14) 0% (0/11) 27.3% (3/11) 72.7% (8/11) 5.09 ± 1.56 100% (3/3) Pruritus or erythema
36.3% (4/11)
Systemic
antibiotics
a
71.4% (10/14) 10% (1/10) 90% (9/10) 0% (0/10) 2.5 ± 0.83 90% (9/10) Abdominal intolerance
40% (4/10)
Isotretinoin
b
28.6% (4/14) 25% (1/4) 50% (2/4) 25% (1/4) 3.5 ± 1.8 33.3% (1/3) Dry eyes, itching 75%
(3/ 4)
Surgical
treatment
21.4% (3/14) 100% (3/3) 0% (0/3) 0% (0/3) –0% (0/3) None reported
Dapsone
c
28.6% (4/14) 50% (2/4) 50% (2/4) 0% (0/4) 9.25 ± 5.06 0% (0/4) None reported
Anti-tumor
necrosis
factor
(TNF)
d
21.4% (3/14) 75% (2/3) 25% (1/3) 0% (0/3) 9.33 ± 3.77 0% (0/3) Infusion reaction, that
forced treatment
withdrawal 33% (1/3)
Intralesional
steroid
injection
7.1% (1/14) 0% (0/1) 100% (1/1) 0% (0/1) –0% (0/1) Discrete skin atrophy
Abbreviations: CR, complete response; NR, no response; PR, partial response; RR, recurrence rate.
a
Systemic antibiotics: 60% (6/10) doxycycline 200 mg/24 h 3 months, 40% (4/10) rifampicin and clindamycin 300 mg/12 h 3 months.
b
Isotretinoin 0.5 mg/kg/day.
c
Dapsone: 50% (2/4) 50 mg/day, 50% (2/5) 100 mg/day.
d
Anti-tumor necrosis factor (TNF): 66.6% (2/3) adalimumab 80 mg/2 weeks, infliximab 33.3% (1/3) 0.5 mg/kg/month.
Received: 28 March 2022 Revised: 30 May 2022 Accepted: 6 June 2022
DOI: 10.1111/dth.15626
Dermatologic Therapy. 2022;35:e15626. wileyonlinelibrary.com/journal/dth © 2022 Wiley Periodicals LLC. 1of2
https://doi.org/10.1111/dth.15626
... Gamissans et al.'s retrospective cohort study reported a partial response in 3 out of 11 patients treated with topical antibiotics. Pruritus or erythema was reported to occur in 4 out of 11 treated patients [8]. One case report noted improvement with a isotretinoin gel and clindamycin gel combination treatment in a 20-year-old male [9]. ...
... Overall, complete recovery of alopecia was seen in 3 patients, and 11 exhibited a partial response. Four of the patients had gastrointestinal (GI) distress [8]. Melo et al.'s retrospective cohort study demonstrated improvement in nine out of ten patients on lymecycline 300 mg (mg) per day for 3 months [13]. ...
... Another retrospective cohort study described a partial or complete response in three out of four patients who received isotretinoin. One out of three patients with a reported response had a recurrence [8]. Adverse effects reported with isotretinoin across all studies included xerosis, dry eyes, erosive skin lesions, pruritus, epistaxis, and hyperlipidemia. ...
Treatments for Dissecting Cellulitis of the Scalp: A Systematic Review and Treatment Algorithm
Article
Full-text available
  • Sep 2023
Dissecting cellulitis of the scalp (DCS) is a chronic inflammatory skin condition characterized by abscesses, nodules, fistulas, and scarring alopecia. Management of this oftentimes debilitating dermatosis can be challenging due to its recalcitrant nature. There is limited data regarding the efficacy of treatment options for DCS. The aim of this study was to conduct a systematic review of the literature to explore the efficacy and safety of reported DCS treatments. In October 2022, MEDLINE and EMBASE databases were searched for articles on treatments for DCS. Studies that contained outcome efficacy data for DCS treatments were included. Reviews, conference abstracts, meta-analyses, commentaries, non-relevant articles, and articles with no full-text available were excluded. Data extraction was performed by two independent reviewers. A total of 110 relevant articles with 417 patients were identified. A majority of studies (86.4%) were case reports or series. Treatment options included systemic antibiotics, oral retinoids, biologics, procedural treatments, combination agents, and topical treatments. Oral retinoids and photodynamic therapy were the most extensively studied medical and procedural interventions, respectively. Overall, randomized controlled trials are needed to evaluate various treatment regimens for DCS and provide patients with a robust, evidence-based approach to therapy.
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... 1 Treatments for DCS include antibiotics, retinoids, tumor necrosis factor-alpha (TNF-a) inhibitors and surgical modalities. 2 Apremilast, a phosphodiesterase-4 inhibitor, has shown some efficacy in HS, suggesting it may be effective in DCS. 3 We present a case of a patient with longstanding, refractory DCS successfully managed with apremilast. ...
... Tetracyclines commonly used first-line, though clindamycin, trimethoprimsulfamethoxazole and dapsone are frequently used as well, among others. 2,4 Isotretinoin is another commonly prescribed therapy for patients with DCS with moderate to severe disease activity; a meta-analysis by Guo et al 5 showed that DCS patients with DCS on isotretinoin had significant improvement in their disease. However, recurrence was noted in 24% (6/25) of cases. ...
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The Role of Sex and Gender in Dermatology - From Pathogenesis to Clinical Implications
Article
Full-text available
  • Jul 2023
  • J CUTAN MED SURG
Background: Sex and gender have increasingly been recognized as significant risk factors for many diseases, including dermatological conditions. Historically, sex and gender have often been grouped together as a single risk factor in the scientific literature. However, both may have a distinct impact on disease incidence, prevalence, clinical presentation, severity, therapeutic response, and associated psychological distress. Objectives and project description: The mechanisms that underlie differences in skin diseases between males, females, men, and women remain largely unknown. The specific objectives of this review paper are:To highlight the biological differences between males and females (sex), as well as the sociocultural differences between men and women (gender) and how they impact the integumentary system.To perform a literature review to identify important sex- and gender-related epidemiological and clinical differences for various skin conditions belonging to a range of disease categories and to discuss possible biological and sociocultural factors that could explain the observed differences.To discuss dermatological skin conditions and gender-affirming treatments within the transgender community, a population of individuals who have a gender identity which is different than the gender identity they were assigned at birth. Future impact: With the rising number of individuals that identify as non-binary or transgender within our increasingly diverse communities, it is imperative to recognize gender identity, gender, and sex as distinct entities. By doing so, clinicians will be able to better risk-stratify their patients and select treatments that are most aligned with their values. To our knowledge, very few studies have separated sex and gender as two distinct risk factors within the dermatology literature. Our article also has the potential to help guide future prevention strategies that are patient-tailored rather than using a universal approach.
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Dapsone in hidradenitis suppurativa: A case series of 56 patients
Article
Full-text available
Background Hidradenitis suppurativa (HS) is a chronic inflammatory disease with a challenging treatment. Current guidelines reserve dapsone as a third line agent for patients with mild to moderate HS. To our knowledge, only four small case series have been reported. Objective To assess the effectiveness and safety of dapsone in our clinical practice. Methods A retrospective observational single-center study of 56 HS patients who underwent treatment with dapsone from May 1, 2015, to June 1, 2021, was performed. The Hidradenitis Suppurativa Clinical Response (HiSCR) scale was used to evaluate the response to treatment. Results 56 patients were included, 66% of which were men, with a median age of 33 years. Most of them had mild or moderate disease and belonged to LC2 follicular phenotype. All patients had been refractory to first-line treatments. Dapsone was prescribed at doses of 50-150 mg/day. 62.5% of the patients achieved HiSCR after 12 weeks of treatment. No serious adverse reactions were detected. The median duration of treatment was 8 months. After multivariate analysis, an association was found between the presence of fistulous tracts and the risk of non-response to the drug. In four of the dapsone responders, oral retinoids were added to achieve a sustained response. Limitations Retrospective and non-controlled nature of this study. Conclusions Dapsone is an effective and well-tolerated option for long-term HS treatment, and in this series, it was mainly chosen for patients with LC2 phenotype. It would be interesting to study combination with retinoids and other management options. This article is protected by copyright. All rights reserved.
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The role of biologic treatment in special scenarios in hidradenitis suppurativa: Facial and nape phenotype, dissecting cellulitis of the scalp, and lymphedema
Article
Full-text available
Background: Hidradenitis suppurativa (HS) is a chronic inflammatory disorder affecting the hair follicle which typically affects the axilla, inguinal, sub-mammary and perianal areas. Atypical HS, such as facial HS, dissecting cellulitis of the scalp (DCS), nape HS and HS lymphedema has also been described. There is scarce evidence about the treatment of atypical HS. Aims: To describe the efficacy of biologic drugs and adjuvant therapeutic interventions used in patients with atypical HS who had an inadequate response to systemic antibiotics. Methods: Prospective case series study of patients with atypical HS (facial HS, DCS, nape HS and HS lymphedema) treated with biologic drugs in a HS Clinic setting. Disease activity indexes, socio-demographic, clinical and safety variables were collected. Results: Two patients met criteria for Facial HS, three met criteria for DCS / nape HS and three patients met criteria for HS lymphedema. Patients with facial HS achieved rapid improvement without requiring other therapies. Patients with DCS, nape HS and HS lymphedema showed variable response, with decrease of activity indexes, and requiring adjuvant treatments. Conclusions: Biologic drugs are useful in the management of special HS locations. In the case of facial HS, biologic therapy seems to be quite effective as monotherapy. In the cases of DCS, HS lymphedema and nape HS, treatment combination or intensification may be needed. This article is protected by copyright. All rights reserved.
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Analyzing the Efficacy of Isotretinoin in Treating Dissecting Cellulitis: A Literature Review and Meta-Analysis
Article
Full-text available
  • Jan 2021
Background and Objective Dissecting cellulitis of the scalp is a primary scarring alopecia. Isotretinoin is commonly referenced in the literature as a treatment for dissecting cellulitis. The objective of this article was to conduct a review and meta-analysis to assess the efficacy of isotretinoin for treating dissecting cellulitis of the scalp.Methods The following databases were searched for articles prior to 23 June, 2019: PubMed, Embase, Cochrane Central, CINAHL, and Web of Science. Multi-patient studies (more than three) that reported on the administration of isotretinoin for dissecting cellulitis were included. A pooled meta-analysis for improvement of disease burden after isotretinoin administration in patients with dissecting cellulitis of the scalp was performed. A fixed-effects model was used.ResultsFive articles were ultimately used for the quantitative meta-analysis. The overall efficacy rate of isotretinoin in treating dissecting cellulitis of the scalp was estimated to be 0.9 with a 95% confidence interval (0.81–0.97). The sensitivity analysis suggested that the overall efficacy is still very high, with a range of 0.83–0.94. Recurrence was seen in 24% (6/25) of patients. Common associated diseases amongst patients with dissecting cellulitis of the scalp were acne conglobata 20% (30/151) and hidradenitis suppurativa 19% (11/72).Conclusions Isotretinoin is an effective treatment for improving symptoms of dissecting cellulitis of the scalp. Disease recurrence is a common finding for those who undergo successful treatment.
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Dissecting Cellulitis of the Scalp: A Review and Case Studies of Surgical Reconstruction
Article
Full-text available
  • Aug 2020
Dissecting cellulitis of the scalp (DCS) is a part of the follicular occlusion tetrad (hidradenitis, acne conglobata, and pilonidal disease). It is a spectrum disorder that can be severe and refractory to medical management. The authors describe 3 such cases successfully treated with surgical resection and reconstruction and present a scoring system for timely referral of such patients to a reconstructive surgical team. Methods: A literature review of all available cases of DCS was undertaken, and the treatments and outcomes were reviewed. Our institution has had 3 recent cases that demonstrated delayed presentation common in the severe spectrum of this condition. All underwent radical surgical resection and reconstruction with skin grafting that was very positively received by all the patients. Results: Three cases of DCS were treated with radical scalpectomy, and split-thickness skin grafting was done with a good cosmetic outcome and a high degree of subjective patient satisfaction. All would have received timely referral if the presented scoring system had been applied earlier. Conclusions: DCS is a rare but debilitating condition that may progress to a medically refractory condition requiring surgical intervention. Surgical resection and skin grafting offer a durable cure, but delayed presentations are common. Use of a scoring system may reduce the time to surgical referral for refractory cases.
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Approach to Treatment of Refractory Dissecting Cellulitis of the Scalp - A Systematic Review
Article
  • Jul 2019
Background: Dissecting cellulitis is a chronic inflammatory dermatosis that results in disfiguring and painful, purulent lesions. Treatment of patients with disease resistant to standard therapies, including intralesional or topical steroids or antibiotics, can be a dilemma for clinicians. Methods: We performed a systematic review of the literature on November 2018 to find articles which presented treatment options and outcomes of patients who failed prior treatment with standard therapies. Results: We identified 57 articles of interest, with 53 being case studies or series. Isotretinoin was the most often reported, but response was limited. Biologics and laser therapy were used less often but demonstrated a better chance of remission. X-ray epilation and surgical excision demonstrated the best remission rates but can be complicated by serious morbidity. Conclusion: We propose a regimen for the treatment of recalcitrant cases of dissecting cellulitis. In the future, more robust studies including randomized control trials are needed to identify the preferred treatment options for refractory dissecting cellulitis.
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Dissecting folliculitis (dissecting cellulitis) of the scalp: a 66‐patient case series and proposal of classification
Article
  • Aug 2018
Background and Objectives Dissecting folliculitis (DF) or dissecting cellulitis of the scalp is regarded as a rare disease with disfiguring scarring alopecia. This study aimed to analyze the features of DF and to propose a classification to define its severity. Patients and Methods A hospital‐based retrospective study was conducted. Patients with a histopathological diagnosis or clinical features leading to diagnosis of DF were included and classified into three stages. Results Among the 66 patients recruited (63 men / 3 women, mean age 24.9 years), multiple interconnected alopecic nodules involving the vertex scalp were the main feature. Histopathology showed an extensive inflamed granulation abscess forming a dissection plane in the lower dermis/subcutis in the acute stage. Lymphocytic infiltration was predominant in seven of 21 histology specimens. Overweight and obesity were noted in 29 of 45 patients examined. No association with smoking was found. There was comorbidity with acne conglobata in 15 of 66 patients, two of whom had acne inversa. Longer disease duration and greater number of nodules were associated with higher severity of DF (p < 0.05). A complete remission rate of 25 % was achieved by any treatment, and a rate of 37.5 % was achieved with oral isotretinoin alone. Conclusions DF is not uncommon in Taiwan. An association with obesity needs to be clarified.
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Epidemiology, clinical presentation and therapeutic approach in a multicenter series of dissecting cellulitis of the scalp
Article
  • Aug 2016
Dissecting cellulitis of the scalp (DCS) is a rare disorder in which inflammatory nodules, abscesses and sinuses may progress to scarring alopecia.1 Along with hidradenitis suppurativa (HS), acne conglobate (AC) and pilonidal cyst, DCS forms the follicular occlusion tetrad.2 These disorders share a similar etiology, in relation to hyperkeratosis, follicular occlusion and subsequent inflammation.3 Although HS is a well-known entity, there are very few studies about the epidemiology, clinical profile and treatment of patients diagnosed with DCS. The objective of our study was to describe the epidemiology, clinical presentation and therapeutic options in a multicenter series of patients diagnosed with DCS. This article is protected by copyright. All rights reserved.
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Dissecting cellulitis of the scalp: A retrospective study of 51 patients and review of literature
Article
  • Jul 2015
  • BRIT J DERMATOL
Dissecting Cellulitis of the Scalp (DCS), also known as perifolliculitis capitis abscedens et suffodiens or Hoffmann disease, is a rare and unknown etiology of primary neutrophilic cicatricial alopecia. DCS has been considered as being part of the "follicular occlusion tetrad" along with Hidradenitis Suppurativa, Acne conglobata and pilonidal cyst, suggesting a common pathogenic mechanism: deep follicular occlusion, follicular rupture, then follicular infection.(1-3) Since the first description, only 72 patients suffering from DCS have been published. Several treatments have been tried, among them, only systemic retinoids permitted to achieve complete remission. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
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