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DISSECTING CELLULITIS
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Scalp Dissecting Cellulitis
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Kendall Lane MD, LT, MC, USN
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A 27 year-old Caucasian male presented with tender progressing fluctuant nodules and
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alopecia on his scalp for seven years. The lesions often oozed a serosanguinous
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discharge and bled occasionally. All cultures of the discharge were negative.
He had
been treated with courses of doxycycline, isotretinoin, and intralesional kenalog without
significant improvement.
A trial of oral steroids relieved the tenderness and reduced the
discharge temporarily. Past medical history was significant for scarring acne on the face,
multiple pilonidal cysts, and hidradenitis suppurativa. Family history was negative for
any similar skin conditions.
He was not taking any medications or supplements.
On examination, flesh-colored tender fluctuant nodules with scarring alopecia were noted
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on the scalp (Figure 1). The nodules formed intercommunicating sinuses that expressed
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a serosanguinous discharge when palpated.
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Deep pitting scars were seen on the face.
Scars were noted in bilateral axillae and adjacent to the gluteal cleft from prior surgical
incisions.
Lymphadenopathy was absent. The remainder of the physical exam was
unremarkable.
Figure 1
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Diagnosis
Dissecting cellulitis as part of the follicular occlusion tetrad
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About the condition
Dissecting cellulitis, also referred to as perifolliculitis capitis abscedens et suffodiens
(PCAS) or Hoffman Disease, is a progressive chronic suppurative condition most
commonly affecting African American males between the ages of 18 and 40 years old.1
Although less common, females and children can be affected.2, 3 The specific etiology of
this uncommon condition is unknown, but the mechanism is thought to be due to
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follicular blockage or occlusion.1 Sebaceous material accumulates and causes dilation
and rupture of the follicle resulting in a localized neutrophilic and granulomatous
response.
Secondary bacterial infection can occur, but it is not the primary cause.
The condition begins with simple folliculitis on the scalp progressing to perifollicular
pustules, fluctuant nodules, and sinus tract formation. Alopecia initially begins as telogen
Staphylococcus
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effluvium secondary to inflammation and then progresses to patchy scarring alopecia.
Regional lymphadenopathy is characteristically absent, unless a secondary infection is
present. Serosanguinous or seropurulent fluid may be expressed from the nodules.
Culture of the discharge is typically negative.
Although spondyloarthorpathy has been reported, most patients do not have systemic
symptoms or disease. Osteomyelitis of the skull and squamous cell carcinoma can rarely
Folliculitis
occur in patients with dissecting cellulitis.
Folliculitis
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occur in patients with dissecting cellulitis.
On histological examination, early lesions will show dense neutrophilic, lymphocytic,
histiocytic, and plasma cell infiltrates. Abscesses may be seen in the dermis and
subcutaneous tissue. Granulomas, foreign body giant cells, scarring, and fibrosis may be
seen later in the disease process.
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Dissecting cellulitis is considered to be a part of a follicular occlusion tetrad. Patients
with the tetrad present with scarring acne conblogata, pilonidal cysts, hidradenitis
suppurativa, and dissecting cellulitis. This patient had all four components of the tetrad.
Clinically, dissecting cellulitis can mimic acne keloidalis nuchae, pseudopelade of Brocq,
tinea capitis, tufted folliculitis, and discoid lupus erythematous. Table 1 lists the
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differential diagnosis for dissecting cellulitis with the defining clinical characteristics and
treatments included.
Condition
Characteristics
Treatment
Dissecting cellulitis Tender nodules and sinus tracts on scalp Isotretinoin
Folliculitis
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Serosanguinous drainage
Antibiotics
LAD absent
Oral steroids
KOH negative
Surgery
Culture negative for bacterial or fungal
Laser
Elements
May be seen as part of follicular
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occlusion
tetrad
Tinea Capitis
Tender nodules with drainage
Kerion
KOH positive
Oral antifungals
Culture positive fungal elements
LAD present
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Fever? Elevated WBC?
Folliculitis
Pustules involving hair follicle with
Oral antibiotics
Surrounding erythema
Acne keloidalis
Papules and nodules on nape of neck
Oral antibiotics
nuchae
Secondary to acne
Topical retinoids
Young black males
Discoid lupus
Flat-topped firm scaly plaques
Sunscreen
erythematosus
Follicular plugging
Topical or
females
Intralesional kenalog
antimalarials
Immunosupressive
agents
Pseudopelade of
Scarring alopecia
Brocq
Minimal inflammation
No treatment
Dermal atrophy causing "footprints in
the snow” sign
mild erythema and slight perifollicular
scaling
Tufted hair
Rare progressive scarring alopecia
Tar shampoo
folliculitis
10-15 hairs emerging from a single
Oral antibiotics
follicular opening
Table 1: Differential Diagnosis
Dissecting cellulitis is a difficult condition to treat.
Medical therapies include antibiotic
soaps (chlorohexidine and benzoyl peroxide), dapsone, intralesional kenalog, zinc
supplements,8 topical and oral isotretinoin, oral antibiotics (tetracycline and doxycycline),
and oral steroids.1,4 Of these, an extended course of oral isotretinoin appears to be the
most effective therapy.1
CO2, 800nm, long-pulse non-Q-switched ruby, and long-
pulsed Nd:YAG lasers have been used with variable success.9-12 Although reported as
being effective, x-ray therapy is not routinely used because of undesirable side effects
including skin cancer.1,4 However, in 2005, Chinnaiyan et al reported the use of modern
external beam radiation to successfully treat refractory dissecting cellulitis without long-
external beam radiation to successfully treat refractory dissecting cellulitis without longterm complications.13 More commonly, surgical methods are used for severe and
intractable cases.
Simple incision and drainage and wide excision with split-thickness
skin grafting have been used to treat severe cases.
Medical therapy is usually used
first. If not responsive, the patient may benefit from more aggressive destructive or
surgical therapies. Patients with dissecting cellulitis typically benefit from early
dermatology consultation.
The patient described above is currently awaiting dermatology evaluation for surgical
treatment. He has failed multiple medical therapies.
In addition to sending these patients to dermatology, the primary care provider should
evaluate the lesions for secondary bacterial or fungal infections with culture and KOH
preparation.
Although rare, if osteomyelitis is suspected, a CT scan should be
considered. A careful skin examination of the affected site should be preformed to
identify squamous cell carcinomas, especially if previously treated with x-ray therapy.
Bibliography
Skibinska M, Schwartz R. Perifolliculitis capitis abscedens et suffodiens.
Accessed July 16, 2007 at: http://www.emedicine.com/derm/topic625.htm.
Ramesh V. Dissecting cellulitis of the scalp in 2 girls. Dermatologica 1990;180:48-50.
Unal S, Unal S, Kuyucu S, Kuyucu N. Dissecting cellulitis of the scalp: A case
report.
International Pediatrics 2004;19(2):203-5.
Scheinfeld NS. A case of dissecting cellulitis and a review of the literature. Dermatol
Online J 2003;9(1):8.
Salim A, David J, Holder J. Dissecting cellulitis of the scalp with associated
spondylarthropathy: case report and review. J Eur Acad Dermatol Venereol
2003;17(6):689–691.
Ramasastry ss, Granick MS, Boyd JB, Furrell JW. Severe perifolliculitis capitis with
osteomyelitis. Ann Plat Surg 1987;18:241-244.
Curry SS, Gaither DH, King EL. Squamous cell carcinoma arising in dissecting cellulitis of
the scalp: a case report and review of secondary squamous cell carcinomas. J Am Acad
Dermatol 1981;4:673-678.
Kobayashi H, Aiba S, Tagami H. Successful treatment of dissecting cellulitis and acne
conglobata with oral zinc. Br J Dermatol 1999;141:1137-8.
Glass LF, Berman B, Laub D. Treatment of perifolliculitis capitis abscedens et suffodiens
with the carbon dioxide laser. J Dermatol Surg Oncol 1989; 15:673-676.
Boyd A, Binhlam J. Use of an 800-nm pulsed-diode laser in the treatment recalcitrant
dissecting cellulitis of the scalp. Arch Dermatol 2002;138(10):1291-3.
Chui CT, Berger TG, Price VH, Zachary CB. Recalcitrant scarring follicular disorders
treated by laser-assisted hair removal: a preliminary report. Dermatol Surg
1999;25(1):34-7.
Krasner B, Hamzavi F, Murakawa G, Hamzavi I. Dissecting cellulitis
treated with the long-pulsed Nd:YAG laser. Dermatol Surg
2006;32(8):1039–44.
Chinnaiyan P, Tena L, Brenner M, Welsh J. Modern external beam radiation therapy for
refractory dissecting cellulitis of the scalp. Br J of Dermatol 2005:152(4):777-9.
Callen J. Lupus Erythematosus, discoid. Accessed July 21, 2007 at:
http://www.emedicine.com/DERM/topic247.htm.
Sperling L. Pseudopelade, Brocq. Accessed July 21, 2007 at:
http://www.emedicine.com/derm/topic357.htm.
Hughes C. Tufted hair follicultis. Accessed July 21, 2007 at:
http://www.emedicine.com/derm/topic439.htm.
Affiliations:
LT Lane is a physician in the United States Navy.
The views expressed in this article are those of the author and do not reflect the official
policy or position of the Department of the Navy, Department of Defense, or the United
States Government.
Copyright ©Priory Lodge Education Limited 2007
First Published August 2007
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