Innovative Management of Recalcitrant Dissecting Cellulitis

Home , Acne conglobata, Hidradenitis, Hidradenitis suppurativa, Scarring hair loss

Letters

4. Magro CM, Crowson AN. The clinical and histomorphological features of was hesitant to try isotretinoin. Most of the lesions improved pityriasis rubra pilaris: a comparative analysis with psoriasis. J Cutan Pathol. with medical treatment except for a persistent, large (5 × 4- 1997;24(7):416-424. cm), dome-shaped, boggy nodule (Figure, A), for which inci- 5. Chowdhary M, Davila U, Cohen DJ. Ustekinumab as an alternative treatment sion and drainage was contemplated. option for chronic pityriasis rubra pilaris. Case Rep Dermatol. 2015;7(1):46-50. Because there was some spontaneous drainage from the 6. Strober B, Sigurgeirsson B, Popp G, et al. Secukinumab improves patient-reported psoriasis symptoms of itching, pain, and scaling: results of two nodule, treatment with a pressure dressing was attempted. The phase 3, randomized, placebo-controlled clinical trials. Int J Dermatol. 2016;55 patient, who is an engineer, applied manual pressure to the (4):401-407. nodule several times each day and devised a dressing of gauze, an eye patch (to hide the gauze; a pirate eyepatch costume ac- Innovative Management of Recalcitrant Dissecting cessory, readily available online and in stores), and a head- Cellulitis With Compression Therapy band (also readily available) that he wore under a cap. He folded Dissecting cellulitis of the scalp, also known as perifolliculitis the 2 × 2-inch gauze in quarters, applied it to the portion of the capitis abscedens et suffodiens, is a chronic, relapsing, inflam- lesion with maximal drainage, and held it in place with 2 head- matory disease that often results in scarring alopecia.1 Man- bands. After 1 month, the lesion was smaller, flatter, and less agement of this condition includes medical and sometimes sur- tender, and after 4 months, it exhibited regrowth of terminal gical treatments, but disease control can be challenging, and hair (Figure, B). therapies are often ineffective or only temporarily effective.2 Medical therapies include oral isotretinoin, which many Discussion | Dissecting cellulitis is a rare form of scalp follicu- consider to be the treatment of choice1,3,4; antiseptics; topi- litis. It has a higher prevalence in black men in their second to cal, intralesional, and systemic steroids; topical and oral an- fourth decades.1 It is one of the follicular occlusion triad that tibiotics; dapsone; colchicine; oral zinc sulfate; and tumor ne- also includes acne conglobata and hidradenitis suppurativa.1 crosis factor inhibitors.1-5 Surgical therapies, reserved for only This association suggests a common pathogenic mechanism severe, recalcitrant cases, include incision and drainage, lo- in which hair follicles are blocked with keratin, resulting in in- cal or complete excision with split-thickness skin grafting, la- flammation and follicular destruction. Long-standing dis- ser hair removal, photodynamic therapy, and irradiation.4,5 We ease results in scarring, and secondary bacterial infection may report use of an innovative technique in the management of occur.1,2 this condition. The histopathologic features vary according to the disease stage. Early lesions are characterized by deep perifollicu- Report of a Case | A 44-year-old African American man pre- lar and interfollicular mixed neutrophilic and lymphoplasma- sented with recurrent fluctuant nodules on his right parietal cytic inflammation. Sinus tracts, partly lined with squamous scalp with associated serosanguinous purulent drainage and epithelium and surrounded by dense fibrosis, characterize late scarring hair loss. Biopsy showed granulation tissue, dermal stages.6 Important differential diagnoses include folliculitis de- fibrosis, and deep inflammation of neutrophils, lympho- calvans, a ruptured follicular cyst, acne keloidalis, bacterial fol- cytes, and plasma cells. Based on the clinical and histopatho- liculitis, tinea capitis, and other infections.1,2,5 logic findings, a diagnosis of dissecting cellulitis of the scalp Dissecting cellulitis tends to be recurrent and challenging was made. to treat, conferring substantial limitations on quality of life.4 Over the course of 5 years, he was treated sequentially with Our patient had a large, resistant fluctuant nodule that did not topical clindamycin, oral minocycline, and levofloxacin, as well respond to repeated intralesional steroid injections. We hy- as periodic aspiration and intralesional steroid injections. He pothesize that sustained pressure on the lesion accelerated

Figure. Clinical Appearance of Dissecting Cellulitis Lesion Before and After Compression Therapy

A Before pressure treatment B After pressure treatment

A, A large, fluctuant lesion is present on the scalp before therapy. B, Complete resolution is present after 4 months of compression therapy.

1280 JAMA Dermatology November 2016 Volume 152, Number 11 (Reprinted) jamadermatology.com

Downloaded From: https://jamanetwork.com/ on 09/28/2021 Letters

drainage and caused closure of potential space, preventing con- 6. Brănişteanu DE, Molodoi A, Ciobanu D, et al. The importance of tinued inflammation and allowing the hair to regrow. While histopathologic aspects in the diagnosis of dissecting cellulitis of the scalp. Rom J Morphol Embryol. 2009;50(4):719-724. we realize that not all patients could create and maintain such an effective dressing, and that if more lesions were present, the task would be more problematic, we suggest that com- Chemotherapy With CMF for Triple-Negative Breast pression bandaging may be an effective therapy for dissect- Cancer With Carcinoma Erysipelatoides ing cellulitis in select, motivated patients. An obese woman with underlying triple-negative breast cancer (TNBC) was diagnosed as having carcinoma erysipelatoi- Eseosa Asemota, MD, MPH des (CE) and was treated successfully with cyclophospha- Yunyoung Claire Chang, MD mide, methotrexate, and fluorouracil combination Lynne J. Goldberg, MD chemotherapy (CMF). To our knowledge, there have been no other cases of TNBC with CE responding to CMF. Author Affiliations: Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts. Corresponding Author: Lynne J. Goldberg, MD, Department of Dermatology, Report of a Case | A woman in her 30s had a history of right breast Boston University School of Medicine, 609 Albany St, Boston, MA 02118 cancer, stage IIIa (cT2N2M0), with negative immunohisto- ([email protected]). chemical findings for estrogen receptor (ER), progesterone re- Published Online: August 10, 2016. doi:10.1001/jamadermatol.2016.2743. ceptor (PR), and human epidermal growth factor receptor 2 Conflict of Interest Disclosures: None reported. (HER2). She was initially administered neoadjuvant chemo- Additional Contributions: We thank the patient for granting permission to therapy with 4 cycles of docetaxel (75 mg/m2) and cisplatin (60 publish this information. mg/m2) followed by 4 cycles of combination chemotherapy 1. Mundi JP, Marmon S, Fischer M, Kamino H, Patel R, Shapiro J. Dissecting with cyclophosphamide (500 mg/m2), liposomal doxorubi- cellulitis of the scalp. Dermatol Online J. 2012;18(12):8. cin (40 mg/m2), and fluorouracil (500 mg/m2) and subse- 2. Badaoui A, Reygagne P, Cavelier-Balloy B, et al. Dissecting cellulitis of the quently underwent right modified radical mastectomy. Post- scalp: a retrospective study of 51 patients and review of literature. Br J Dermatol. 2016;174(2):421-423. operative radiotherapy was administered as 28 fractions (total, 3. Vasanth V, Chandrashekar BS. Follicular occlusion tetrad. Indian Dermatol 5040 cGy) to the right chest wall and 5 booster fractions (total, Online J. 2014;5(4):491-493. 1000 cGy) to the right axilla in a span of 6 weeks. After under- 4. Scheinfeld N. Dissecting cellulitis (Perifolliculitis Capitis Abscedens et going postoperative radiotherapy, the patient noticed a pru- Suffodiens): a comprehensive review focusing on new treatments and findings ritic erythema lesion with multiple nodules over the opera- of the last decade with commentary comparing the therapies and causes of tion site of the right breast. The lesion was initially treated as dissecting cellulitis to hidradenitis suppurativa. Dermatol Online J. 2014;20(5): 22692. postradiotherapy dermatitis with a combination of topical be- 5. Jerome MA, Laub DR. Dissecting cellulitis of the scalp: case discussion, tamethasone valerate and fradiomycin sulfate, but there was unique considerations, and treatment options. Eplasty. 2014;14:ic17. no response to these topical treatments.

Figure. Postmastectomy Clinical Images of a Patient With Triple-Negative Breast Cancer With Carcinoma Erysipelatoides Before and After CMF Treatment

A Before treatment B After 5 cycles of CMF chemotherapy

A, Right mastectomy scar with a large, well-defined area of erythema and multiple, scattered small nodules. B, Nearly complete remission of skin lesions after 5 cycles of cyclophosphamide, methotrexate, and fluorouracil combination chemotherapy (CMF).

jamadermatology.com (Reprinted) JAMA Dermatology November 2016 Volume 152, Number 11 1281

Downloaded From: https://jamanetwork.com/ on 09/28/2021