Dissecting Folliculitis of the Scalp

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A synonym for this entity is perifolliculitis capitis abscedens et suffodiens. This disease shows considerable geographical variation and most often appears to affect Afro-Caribbean male patients. It usually starts during early adulthood. It has been described in women and girls [20] as well, and familial occurrence has also been documented [21]. An association with acne is reported in 30% of cases [22]. The disease is however uncommon and only a few cases have been reported in the literature making it difficult to establish reliable arguments for an association [20].

Clinically, dissecting folliculitis of the scalp is characterized by peri-follicular pustules, nodules, abscesses and sinus that progressively evolve into scarring alopecia. The clinical picture is often complicated by a keloid tendency [4, 9, 15, 23]. The course of the disease is chronic and relapsing. Squamous cell carcinoma may arise in chronic relapsing lesions and has a recognized metastasizing potential. Death from metastatic carcinoma has been described in one patient [9].

Treatment is generally not rewarding. Antibiotics are commonly prescribed, and combination therapy using rifampicin and clindamycin has been advocated [24]. Tetracyclines in acne doses are usually not effective, whereas some relief may be gained from anti-staphylococcal medicines such as dicloxacillin in long-term therapy (authors' personal experience). Isotreti-noin is occasionally (rarely) helpful at a dosage between 0.67 and 1.0 mg/kg per day when prescribed for several months [25-29]. Topical isotretinoin has also been reported to be efficient [22]. Alternatives include zinc [30], systemic or intralesional corticosteroids, surgical excision and skin grafting [29]. X-ray therapy is no longer recommended because of its carcinogenic risk. Both CO2 laser [31] and 800-nm lasers [32] have been used in a severe case of dissecting cellulitis of the scalp. More recently, long-pulse non-Q-switched ruby laser has been reported as efficient in three patients [33].

In contrast to acne, the tendency for scarring and the recalcitrant nature of this disease bear clear similarities to HS. In the absence of actual genetic classification, the absence of specific epidemiological data and the relative rarity of the two diseases, however, make actual assessment difficult.

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