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Erosive pustular dermatosis


Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports

Erosive pustular dermatosis (EPD) is a rare condition characterized by pustular, erosive, and crusted lesions in areas of alopecia that tend to be atrophic, actinically damaged, or subject to local iatrogenic or external trauma. The condition primarily affects the elderly and is located on the scalp but has also been documented to occur on the legs. EPD lesions tend to be chronic, progressive, and difficult to treat. Laboratory and histopathologic findings are not diagnostic.

Management Strategy

Traditionally, potent topical corticosteroids have been used in EPD with a generally positive but variable response within a few months of use. Due to steroid-related cutaneous atrophy and residual scarring , tacrolimus 0.1% ointment, calcipotriol cream, oral and topical zinc, topical dapsone, and photodynamic therapy (PDT) have been introduced as alternative therapies. Retinoids and oral corticosteroids have also shown some promise when used in conjunction with topical antibiotics, topical corticosteroids, topical tacrolimus, oral dapsone, and oral zinc therapy. Individual case reports exist for other immunosuppressants , silicone gel , and fractional 2940-nm laser. Topical and systemic antibiotics and antifungals are essentially ineffective.

First-Line Therapy

  • High-potency topical corticosteroids

  • D

Erosive pustular dermatosis of the scalp: clinical, trichoscopic, and histopathologic features of 20 cases

Starace M, Loi C, Bruni F, et al. J Am Acad Dermatol 2017; 76(6): 1109–14.

Fourteen of 17 patients responded to clobetasol 0.05% ointment. Two responded to prednisone 25 mg daily tapered over 20 days. All three patients treated with topical tacrolimus responded. Mean duration of treatment before clinical efficacy was 5 months.

Erosive pustular dermatosis of the scalp

Pye RJ, Peachey RD, Burton JL. Br J Dermatol 1979; 100: 559–66.

Six cases are presented in the first description of erosive pustular dermatosis of the scalp (EPDS) in the literature. Five of the six cases resolved after potent topical steroids, often used with neomycin or nystatin.

Second-Line Therapies

  • Photodynamic therapy

  • D

  • Topical 25% powdered zinc oxide

  • D

  • Topical 5% dapsone gel

  • E

  • Topical 0.1% tacrolimus ointment

  • E

Aminolevulinic acid photodynamic therapy in the treatment of erosive pustular dermatosis of the scalp: a case series

Yang CS, Kuhn H, Cohen LM, et al. JAMA Dermatol 2016; 152: 694–7.

Eight patients with EPDS underwent curettage followed by aminolevulinic acid photodynamic therapy 1–2 weeks later, with complete resolution of lesions in six patients. The remaining two patients had complete resolution after a second cycle of curettage and PDT.

Although this case series shows good results after PDT, the literature also notes that PDT is a risk factor for developing EPD.

Topical zinc oxide: an effective treatment option for erosive pustular dermatosis of the leg

Di Altobrando A, Patrizi A, Vara G, et al. Br J Dermatol 2020; 182(2): 495–7.

In 51 patients with leg EPD, 23 patients were treated with topical corticosteroids alone, compared with 28 patients treated with topical corticosteroids for 10 days and transitioned to 25% powdered zinc oxide. Treatment was successful in all patients; however, 10/23 patients in the corticosteroid-only group relapsed, compared with 4/28 in the latter group.

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