Problems in Family Practice Dermatoses of the Scalp Lamar S

Problems in Family Practice Dermatoses of the Scalp Lamar S. Osment, MD Birmingham, Alabama By judicious consideration of the clinical appearance, by direct examination with magnification, and by culture results, skin biopsy, and other laboratory results, the clinician is able to diagnose most pathological conditions of the scalp. The scalp participates in many systemic disorders and frequently is the chief site of involvement. Similarly, many generalized disor ders limited to the skin exhibit their most typical manifesta tions in the scalp. Whenever a diagnosis eludes the inves tigator, more than likely he or she has not considered all of the etiological possibilities or has not pursued an adequate labora tory investigation. A few scalp diseases initially present nonspecific clinical pictures. By utilizing follow-up examinations at appropriate intervals, the diagnosis can eventually be made. Once a diagnosis is made, appropriate treatment will gener ally produce satisfactory improvement or cure. Nevertheless, a few generally rare conditions will defy the physician’s most enlightened and aggressive therapy. The scalp is subject to numerous inflammatory paper. These would include systemic diseases lesions. Most scalp conditions encountered by the with major scalp pathology, such as der- practitioner reflect local manifestations of general matomyositis or progressive systemic sclerosis. ized inflammatory dermatoses. However, in these Tumors of the scalp will not be covered in this conditions at any given time the scalp may be the paper (Table 1). An excellent discussion of the sole site of involvement. Secondly, the scalp can alopecias was recently presented in this Journal be involved with localized microbial infections. In and therefore will be omitted here.1 many instances these microbial infections also in volve areas other than the scalp, but often the Generalized Inflammatory Dermatoses scalp alone is involved. An example of this type of with Prominent Scalp Involvement disorder is tinea capitis. Thirdly, there are inflam mations involving chiefly the scalp. In such in Seborrheic Dermatitis stances there may be no lesions or very few le sions elsewhere on the body. An example of this The scalp possesses numerous hair follicles and type of condition is chronic discoid lupus. Condi sebaceous glands. Lesions may appear and remain tions of the scalp not included in the above schema unnoticed for considerable periods of time. There are numerous but are beyond the scope of this is little need for the practitioner to become in volved in the argument as to whether seborrheic Requests for reprints should be addressed to Dr. Lamar S. dermatitis and dandruff are the same condition. osment, 2661 Tenth Avenue, South, Birmingham, AL 35205. Some authors separate the two based on differen- 0094-3509/79/061217-07S01.75 ® 1979 Appleton-Century-Crofts the JOURNAL OF FAMILY PRACTICE, VOL. 8, NO. 6: 1217-1223, 1979 1217 DERMATOSES OF SCALP Table 1. Scalp Disease2 5 1. Generalized Inflammatory Dermatoses with Prominent Scalp Involvement 4. Systemic Disease with Major Scalp Pathology Seborrheic dermatitis Systemic lupus Localized neurodermatitis Exfoliative dermatitis Contact dermatitis Dermatomyositis Psoriasis Scleroderma Lichen planus (lichen planopilaris) Syphilis Pemphigus Lupus vulgaris Pemphigoid Leprosy Dermatitis herpetiformis Sarcoidosis Necrobiosis lipoidica 2. Localized Microbial Infections and Infestations 5. Mechanical Problems Zoster Factitial dermatitis Pyoderma and folliculitis Flot comb alopecia Tinea and kerion Traumatic alopecia Infestations Traction alopecia 3. Inflammations Involving Chiefly the Scalp 6. Tumors Alopecia areata Pseudopelade Folliculitis decalvans Graham-Little disease Alopecia mucinosa Acne necrotica miliaris Perifolliculitis Keloidal acne Discoid lupus Morphea tial microbiology and the inflammation present in seborrheic dermatitis, but they may be considered the same for purposes of treatment. The yellowish scales of seborrheic dermatitis and dandruff are shed very slowly due to their adherence to the hair shafts. Seborrheic dermatitis in its most severe form is accompanied by erythematous greasy scaly lesions of the midline and flexural parts of the body and extremities and the butterfly area of the face (Figure 1). Such full-blown cases are not the rule. Some scalp hair may be lost in severe seborrheic dermatitis but return is complete once the condition is corrected. Organisms such as Pityrosporum ovale, gram-negative cocci, and Corynebacterium acnes are frequently recovered from the scalp in seborrheic dermatitis. These or ganisms are not thought to be causative but appear due to their attraction to the milieu. The patient with seborrheic dermatitis of the scalp or dandruff Figure 1. Seborrheic dermatitis. Scaling and should wash his/her hair daily. Nonmedicated erythema of frontal hairline bland shampoos may be tried initially. If these fail, 1218 THE JOURNAL OF FAMILY PRACTICE, VOL. 8, NO. 6, 1979 DERMATOSES OF SCALP selenium sulfide shampoo (Selsun, Exsel) may be effectively used by substituting it for the regular shampoo twice weekly. Pruritis and inflammation may be treated with topical steroid preparations (Synalar solution applied with the fingertips once daily). If a preparation for the face is needed, one percent hydrocortisone cream is adequate. Localized Neurodermatitis This condition is also called lichen simplex chronicus and is characterized by localized pruritis with lichenification. It may occur on var ious parts of the body including the elbows, wrists, ankles, and the neck. One of the more common locations is on the occipital scalp, frequently at the site of a flat angiomatous birthmark. Women are especially susceptible. Localized neurodermatitis is the result of a habit analogous to fingernail biting Figure 2. Psoriasis. Scaly plaque or cigarette smoking. Presumably such habits are tension release mechanisms. A non-messy topical tact dermatitis of the scalp requires decrease in steroid such as Synalar solution may be used ef physical activity, compresses with plain water in fectively in the treatment of this disorder. Occa thick turkish towels, topical steroids (Topsyn sionally, the oral administration of low doses of cream, Synalar solution), mild sedatives or anti benzodiazepines augment successful therapy. Re pruritics (Periactin, Temaril), and antibiotics if sec currences are frequent. ondary infection is present. Only in the allergic Contact Dermatitis contact dermatitis of the scalp are systemic cor ticosteroids of any great help. Whenever systemic While contact dermatitis is a common disorder steroids are used for this purpose, they must be affecting many different parts of the body, the continued for a period of no less than two weeks. scalp is frequently spared in the involvement. Even in mild allergic contact dermatitis due to hair Psoriasis dyes, the scalp is less severely inflamed than the Psoriasis of the scalp frequently masquerades surrounding forehead, ears, and nuchal skin. for many years as persistent seborrheic dermatitis. The primary lesions of contact dermatitis, At this stage it is characterized by mild erythema whether of the allergic variety or the primary irri and moderate scaliness. As the manifestations be tant variety, are vesicles. Chronic contact der come more obvious the scaliness increases and the matitis is characterized by the same type of lesions become more circumscribed (Figure 2). lichenification and scaliness seen in localized When fully developed, the lesions have a thick neurodermatitis. white scale and are identical to those on other The most frequent type of contact dermatitis of parts of the body. Psoriasis may be generalized but the scalp seen by the practitioner is the primary the scalp, knee, elbow, penis, and nails are the irritant variety caused by either excessive expo predominant sites of involvement. The scalp is sure to permanent wave solutions, their neutral more regularly involved than any of the other izers, or to bleaches. This sort of scalp dermatitis areas. Itching is usually only mild. Proper treat is characterized by bogginess, erythema, and se ment consists of daily shampoos. Tar shampoos, vere blistering. Usually there is a small amount of such as Pentrax, have been found useful. secondary infection with pus. In addition to the great discomfort of the patient, there is usually Lichen Planus concern for permanent hair loss, which is rarely a Lichen planus is a chronic disease char problem. The satisfactory treatment of severe con- acterized by itchy, purplish papules. The disorder THE JOURNAL OF FAMILY PRACTICE, VOL. 8, NO. 6, 1979 1219 DERMATOSES OF SCALP is frequently generalized, and mucous membranes die and pelvic girdle areas as well as the knees and are typically involved. Follicular lichen planus is elbows. The disorder is characterized by intense called lichen planopilaris, and may occur in the pruritis. There is usually an associated asympto scalp where scarring alopecia may result. It is dif matic, gluten-sensitive enteropathy. The histopa ficult to diagnose lichen planus by inspection of thology is characteristic in that the blisters form the scalp unless typical lesions are present below the epidermis and there is an increased num elsewhere. The histopathology, however, is quite ber of eosinophils in the dermis. Anti-IgA im characteristic. munofluorescence is noteworthy at the dermal- epidermal junction. Generalized Bullous Disorders: Pemphigus, Both pemphigus and pemphigoid

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