Dissecting cellulitis of the scalp

Management Strategy

Dissecting cellulitis is characterized by a chronic, progressive course with temporary improvement on treatment followed by relapses when treatment is discontinued. There are no large therapeutic clinical trials, and recommendations for therapy are based on case reports or case series. Inflammatory tinea capitis and the very rare complication of squamous cell carcinoma should be excluded. Although no specific pathogenic organisms have been isolated, swabs should be obtained for cultures and the antibiotic sensitivity of organisms reviewed.

In mild cases or when disease is limited, improved scalp hygiene and the use of antiseptics, topical antibiotics, intralesional corticosteroid injections, and aspiration of fluctuant lesions may be adequate. At an early stage, systemic antibiotics such as tetracyclines or azithromycin reduce inflammation and can control disease. In more severe cases a combination of systemic antibiotics, such as clindamycin with rifampicin, may be effective. However, recognition that oral isotretinoin (with or without corticosteroids) can provide sustained remission has led many to now regard it as first-line therapy in DCS. Recent reports highlight success with anti-tumor necrosis factor (TNF) therapy in those unresponsive to standard treatment. Alitretinoin, finasteride, compression therapy and photodynamic therapy are new additions to the therapeutic armamentarium.

In those unresponsive to medical therapy, a surgical approach may be considered. X-ray epilation of affected areas has largely been superseded by laser epilation techniques. The most resistant cases may require surgical excision and skin grafting .