SKIN May 2019 Volume 3 Issue 3 Copyright 2018 The National Society for Cutaneous Medicine 180 IN-DEPTH REVIEWS A Review of Treatments for Dissecting Cellulitis of the Scalp Andrew X. Tran BS1, Rebecca M. Sarac BS1, Lisa Prussick BS, MS2, Stella M. Radosta BA, MS1, Andrea Murina MD1* aTulane University School of Medicine, Department of Dermatology New Orleans, LA bTufts University School of Medicine, Department of Dermatology, Boston, Massachusetts The main features of dissecting cellulitis of the scalp (DCS) are pustules, suppurative nodules, draining sinuses, and scars. It can be associated with acne conglobata, hidradenitis suppurativa, and pilonidal cysts which are collectively referred to as the follicular occlusion tetrad12. Although these diseases are specific to different body sites, they are characterized by follicular-based inflammation that leads to tissue scarring. The pathogenesis of DCS is unknown, although it is speculated to be related to follicular occlusion that is secondary to an infection3. However, a specific pathogenic bacterium has yet to be determined4. DCS is also classified as a primary cicatricial alopecia, where the hair follicles are irreparably destroyed and replaced by fibrous tissue5. Patients with dissecting cellulitis may experience psychological distress as a result of the alopecia and scarring. DCS has a higher prevalence in African American males between the ages of 20-406, although there have been reports of this condition occurring in women7 and men of other ethnic origins8, 9. Histologically, there are abscesses, inflammatory infiltrates of neutrophils, dermal fibrosis, and decreased INTRODUCTION Dissecting cellulitis of the scalp (DCS) is a rare and chronic skin disorder that presents with suppurative nodules on the scalp with associated scarring alopecia. The pathogenesis of the disease involves inflammation and destruction of the hair follicle. This makes it clinically and pathologically similar to acne conglobata and hidradenitis suppurativa, which can also occur concomitantly. Many therapies exist to treat DCS, but its refractory nature makes treatment difficult and combination therapies are often needed. The aim of this review is to evaluate the evidence-based medical and surgical treatments for this disease so that clinicians can choose the best treatments according to the disease stage and severity. Knowledge of the clinical endpoints of each treatment modality is important for managing patient expectations and setting treatment goals. There is no standardized method for measurement of clinical improvement in DCS, and each individual treatment can improve one or more aspect of disease activity (such as inflammation or scarring). Topical and oral medications will be reviewed in addition to surgical and laser treatments. ABSTRACT SKIN May 2019 Volume 3 Issue 3 Copyright 2018 The National Society for Cutaneous Medicine 181 density of hair follicles10. Culture of the exudate may reveal the presence of bacteria that is secondary to the follicular occlusion, most commonly Staphylococcal species10. DCS is characterized by the absence of fungi, as tinea capitis can be a mimicker11. Treatment of DCS varies greatly based on the severity of disease. A patient with early stage disease will likely benefit from treatments that are directed against bacterial colonization and inflammation such as oral and topical antibiotics, retinoids, and biologics. Later stage disease requires treatments that address the end-stage scarring and alopecia associated with the disease. These treatments can include intralesional steroids to decrease scar, excision or marsupialization of the diseased skin, or laser treatments to target the hair. Early and late inflammatory stages of DCS are illustrated in Figure 1 and Figure 2. Antibiotics Oral antibiotics have demonstrated success in dissecting cellulitis and are appropriate agents for patients with early limited disease. Oral antibiotics are used for their quick action and anti-inflammatory effect, however relapses can occur when stopped. A retrospective review of 40 patients with DCS showed clinical improvement while on oral antibiotics such as doxycycline, pristinamycin, rifampicin, or a combination of several antibiotics, however all patients relapsed when discontinuing the medication12. A retrospective review of 21 patients with biopsy-proven DCS reported positive outcomes with doxycycline, azithromycin, or a combination rifampicin and clindamycin13. Two case studies demonstrated complete resolution with Figure 1. Early inflammatory stage dissecting cellulitis with sinus tracts and alopecia. Oral antibiotics in combination with adalimumab and intralesional steroids were used in this patient. Figure 2. Late stage dissecting cellulitis with significant scarring alopecia. Oral antibiotics and intralesional steroids were used to treat this patient. ciprofloxacin for 1 month with treatment- refractory DCS14, 15. Oral clindamycin in combination with topical clobetasol was also successful at improving disease burden in a series of three patients17. These findings are summarized in Table 1. TREATMENTS SKIN May 2019 Volume 3 Issue 3 Copyright 2018 The National Society for Cutaneous Medicine 182 Table 1. Treatment of DCS with antibiotics. Author Reference Study Design Method Number of Patients Treatment Duration Disease Symptom Improvements (Yes/No) Hair Regrowth? (Yes/No) Segurado- Miravalles et al. 2017 Retrospective review Doxycycline 100 mg q.d. 5 N/A Yes, 4 of 5 patients N/A Azithromycin 500 mg q.d. three times a week 3 N/A Yes N/A Rifampicin 300 mg b.i.d. and Clindamycin 300 mg b.i.d. 1 10 weeks Yes N/A Garelli et al. 2017 Case series Clindamycin 300 mg b.i.d. 4 1 month Yes N/A Badaoui et al. 2016 Retrospective review Doxycycline, pristinamycin, rifampicin, or combination of antibiotics 40 11 months Yes, but relapse reported after treatment discontinuation N/A Onderdijk and Boer 2010 Case report Ciprofloxacin 500 mg b.i.d. for 1 month then 250 mg b.i.d. for 3 weeks 1 5 months Yes N/A Greenblatt et al. 2008 Case report Ciprofloxacin 250 mg b.i.d. for 1 month then 250 q.d. for 4 months 1 5 months Yes Yes Salim et al. 2003 Case report Trimethoprim 100 mg b.i.d. and clindamycin aqueous solution 1 18 months Yes N/A Table 2. Treatment of DCS with retinoids. Author Reference Study Design Method Number of Patients Treatment Duration Disease Symptom Improvements (Yes/No) Hair Regrowth? (Yes/No) Segurado- Miravalles et al. 2017 Retrospective study Isotretinoin 30 mg q.d. 8 N/A Yes, 7 of 8 patients N/A Marquis et al. 2017 Case report Isotretinoin 20 mg q.d. 1 4 months Yes Yes Badaoui et al. 2016 Retrospective review Isotretinoin 0.5- 0.8 mg/kg q.d. 35 6 months Yes, 33 of 35 patients but relapse reported after treatment discontinuation N/A Acitretin 30 mg q.d. 1 11 months N/A N/A Jacobs et al. 2011 Case report Acitretin 10 mg q.d. 1 6 months Yes N/A SKIN May 2019 Volume 3 Issue 3 Copyright 2018 The National Society for Cutaneous Medicine 183 Georgala et al. 2008 Case series Isotretinoin 0.5 mg/kg q.d. for 3- 4 months 4 7 – 8 months Yes N/A Bolz et al. 2008 Case report Isotretinoin 80 mg q.d for 4 weeks then with dapsone 50 mg b.i.d. for 10 months 1 12 months Yes Yes Khaled et al. 2007 Case report Isotretinoin 0.8 mg/kg q.d. 1 12 months Yes Yes Shaffer et al. 1992 Case report Triamcinolone acetonide (40 mg/mL) intralesional injections and isotretinoin 0.85 - 1.48 mg/kg over x 5 months 1 5 months Yes Yes Table 3. Treatment of DCS with biologic agents. Author Reference Study Design Method Number of Patients Treatment Duration Disease Symptom Improvements (Yes/No) Hair Regrowth? (Yes/No) Badaoui et al. 2016 Retrospective review Infliximab 1 11 months No N/A Mansouri et al. 2016 Case report Adalimumab 80 mg on day 0, 40 mg on day 7, and 40 mg every other week thereafter 1 5 months Yes N/A Infliximab 5 mg/kg at week 0, 2 and 6, followed by 8 week intervals 1 20 months Yes N/A Wollina et al. 2012 Case report Infliximab 5 mg/kg body weight at weeks 0, 2, and 6 1 6 weeks Yes N/A Navarini and Trüeb 2010 Case series Adalimumab 80 mg followed by 40 mg 1 week after and an additional 40 mg every 2 weeks 3 1 – 7 years Yes, but relapse reported within 4 weeks after treatment discontinuation N/A SKIN May 2019 Volume 3 Issue 3 Copyright 2018 The National Society for Cutaneous Medicine 184 Table 4. Procedural therapies. Procedure Authors Study Design Method Time of follow- up DCS recurrence? (Yes/No) Hair Regrowth? (Yes/No) Surgical excision Housewright et al. 2011 Case report Scalpectomy with split thickness skin graft 10 months No No Bellew et al. 2003 Case report 2 months No No Williams et al. 1986 Case report 1 – 4 years No No Badaoui et al. 2016 Retrospective study Surgical treatment (excision or abscess drainage) N/A N/A N/A Meunier et al. 2014 Case report Marsupialization 7 months No No Laser-assisted epilation Krasner et al. 2006 Observational Nd:Yag laser 1 year No Yes, 3 of 4 patients Boyd and Binhlam 2002 Case report 800-nm long- pulsed diode laser 6 months No No Photodynamic therapy (PDT) Liu et al. 2013 Case report ALA PDT 5 months No No X-Ray epilation McMullan and Zeligman 1956 Case series X-Ray 6 months – 1 year No Yes SKIN May 2019 Volume 3 Issue 3 Copyright 2018 The National Society for Cutaneous Medicine 185 Combination therapy with corticosteroids Oral, intralesional or topical corticosteroids can be used in DCS to reduce inflammation and swelling of the scalp, and to minimize scarring. Monotherapy with oral corticosteroids is not recommended due to the risk of relapse and long-term side effects. Salim et al. reported a case of a man with DCS and spondylarthropathy who noted improvement with prednisolone 30mg daily but relapsed when the prednisolone was tapered19 Intralesional triamcinolone and topical steroids can be used alone in patients with limited disease or in combination with systemic treatments. These combination treatments are included in Table 2. Topical corticosteroids have not been studied as monotherapy in DCS. Retinoids Isotretinoin and acitretin are used for the treatment of DCS because they reduce follicular occlusion and decrease sebaceous activity. Isotretinoin can offer good results, particularly when used early in the disease course, because of the possibility of remission within one year of therapy21-24. Patients in a case report and comprehensive review were able to achieve remission on monotherapy with isotretinoin doses from 0.5-1 mg/kg over 4-12 months21, 23, although one case report added dapsone for sustained improvement22. One case report of a 25-year- old man was administered 0.8 mg/kg isotretinoin and achieved significant clinical improvement within 4 months of treatment, with evidence of hair regrowth at 6 months. He was also able to discontinue isotretinoin after 12 months with sustained remission 6 months later21. Shaffer et al. reported successful resolution of DCS in a patient treated with a combination of 5 months of isotretinoin and bimonthly intralesional triamcinolone injections18. A retrospective study conducted at two Dermatology departments in France between 1996-2013 found similar efficacy, with 92% of patients treated with isotretinoin 0.5-0.8 mg/kg achieving remission within 3 months of therapy. However, their data found frequent relapse upon discontinuation, suggesting that longer courses may be required for sustained remission12. Acitretin can be used for patients requiring long-term systemic therapy as well. Jacobs et al., reported a patient treated with prednisolone, topical corticosteroids, topical tacrolimus, and acitretin. The systemic and topical steroids were tapered, and the patient remained stable on acitretin six months later20. Retinoids can be considered as monotherapy in early disease or in combination with other systemic and topical agents in later stage disease. It is important to consider the use of isotretinoin early in the disease course in order to attempt to stop further structural damage to the hair follicle. These findings are summarized in Table 2. Biologics Tumor necrosis factor (TNF) inhibitors have been used in DCS due to its similar pathogenesis to hidradenitis suppurativa. TNF inhibition is effective for suppression of the inflammation of DCS, but studies show that it does not reverse fibrosis. A case series by Navarini and Trueb demonstrated significant symptomatic improvement on adalimumab in three patients with severe clinical disease who had failed isotretinoin therapy25. These patients were subcutaneously administered 80mg at week 0, 40mg at week 1, and 40mg every 2 weeks thereafter. Subjective burden of disease was significantly reduced in all three patients at 8 weeks of treatment, however, relapse SKIN May 2019 Volume 3 Issue 3 Copyright 2018 The National Society for Cutaneous Medicine 186 occurred within 4 weeks of discontinuing therapy25. Other case reports using adalimumab have found similar clinical improvement and reduction in Dermatology Life Quality Index (DLQI) with this dosing regimen26, 27. Higher doses may provide additional efficacy, but no studies have been reported using a weekly dosing regimen. Infliximab may also provide similar improvement to adalimumab. In a recent case report, a patient with a severe suppurative DCS had reduced symptoms and inflammation on infliximab (5 mg/kg at weeks 0, 2, and 6, with 8-week intervals thereafter), but did not have reversal of the fibrosis associated with DCS26. TNF inhibitors like adalimumab and infliximab are useful treatment options for patients with moderate to severe disease with prominent nodules, abscesses and sinus tracts 25. Patients with prominent scarring will likely require combination with other treatments such as intralesional corticosteroids or procedural therapies. These findings are summarized in Table 3. Procedural Therapies For intractable cases of DCS, procedural therapies including X-ray epilation, surgical excision, laser treatment and photodynamic therapy have been reported. X-ray therapy is no longer a primary treatment option due to increased risk of skin cancer28. Surgical procedures that have shown benefit in the treatment of DCS include scalpectomy (excision of the diseased scalp skin) and marsupialization. Treatment with scalpectomy was first reported in 1986 with subsequent publication of successful cases6, 29, 30. More recently, marsupialization was shown to be of benefit in DCS as it is significantly less invasive and can heal remarkably well by secondary intention without the requirement for split-thickness grafting31. However, new lesions can occur in untreated areas and in all reported surgical modalities, hair regrowth was never observed29-31. In patients with longstanding disease and significant scarring, surgical options can be discussed early to provide a targeted reduction in disease burden. Recently, hair follicle ablation with laser treatment has been successfully reported in regard to achieving long-term remission of DCS and can also stimulate hair regrowth. In one case series, four patients were treated with three to seven monthly treatments over one year with the 1,064-nm Nd:YAG laser. Three patients had at least partial hair regrowth at treatment sites32. The use of 5- aminolevulinic acid photodynamic therapy (ALA-PDT) has been reported to be successful in one case with no recurrent disease at 5 months follow up. Laser and light therapies may be preferential to surgery for patients who have failed multiple conventional therapies and seek to retain hair and may be combined with systemic and topical treatments. These findings are summarized in Table 4. The multitude of treatment options for DCS reflects the refractory nature of this chronic skin condition. This makes DCS challenging to treat and places a substantial burden on the quality of life of those afflicted. Due to the progressive nature of the disease, establishing the diagnosis early and providing directed treatments will lead to the best patient outcomes. Treatment selection should account for disease severity and the amount of abscesses, sinus tracts and scar. Combination treatments with both medical and surgical modalities may offer patients DISCUSSION SKIN May 2019 Volume 3 Issue 3 Copyright 2018 The National Society for Cutaneous Medicine 187 with DCS the best results to address both the inflammatory and fibrotic processes of this disease. Conflict of Interest Disclosures: Dr. Murina is a Speaker for Abbvie, Celgene, Janssen and Novartis Funding: None. Corresponding Author: Andrea Murina, MD Department of Dermatology Tulane University School of Medicine New Orleans, LA amurina@tulane.edu References: 1. Chicarilli, Z. N., Follicular occlusion triad: hidradenitis suppurativa, acne conglobata, and dissecting cellulitis of the scalp. Ann Plast Surg 1987, 18 (3), 230-7. 2. Plewig, G.; Kligman, A., In Acne: Morphogenesis and Treatment, Springer-Verlag: Berlin, 1975; pp 192- 3. 3. Mundi, J. P.; Marmon, S.; Fischer, M.; Kamino, H.; Patel, R.; Shapiro, J., Dissecting cellulitis of the scalp. Dermatol Online J 2012, 18 (12), 8. 4. Lebwohl, M., Treatment of skin disease : comprehensive therapeutic strategies. 3rd ed. ed.; Saunders: [Edinburgh?], 2010. 5. Rigopoulos, D.; Stamatios, G.; Ioannides, D., Primary scarring alopecias. Curr Probl Dermatol 2015, 47, 76-86. 6. Williams, C. N.; Cohen, M.; Ronan, S. G.; Lewandowski, C. A., Dissecting cellulitis of the scalp. Plast Reconstr Surg 1986, 77 (3), 378-82. 7. Goldsmith, P. C.; Dowd, P. M., Successful therapy of the follicular occlusion triad in a young woman with high dose oral antiandrogens and minocycline. J R Soc Med 1993, 86 (12), 729-30. 8. Koca, R.; Altinyazar, H. C.; Ozen, O. I.; Tekin, N. S., Dissecting cellulitis in a white male: response to isotretinoin. Int J Dermatol 2002, 41 (8), 509-13. 9. Lim, D. T.; James, N. M.; Hassan, S.; Khan, M. A., Spondyloarthritis associated with acne conglobata, hidradenitis suppurativa and dissecting cellulitis of the scalp: a review with illustrative cases. Curr Rheumatol Rep 2013, 15 (8), 346. 10. Lee CN, Chen W, Hsu CK, Weng TT, Lee JY, Yang CC. Dissecting folliculitis (dissecting cellulitis) of the scalp: a 66- patient case series and proposal ofclassification. J Dtsch Dermatol Ges. 2018 Oct;16(10):1219-1226. 11. Stein, L. L.; Adams, E. G.; Holcomb, K. Z., Inflammatory tinea capitis mimicking dissecting cellulitis in a postpubertal male: a case report and review of the literature. Mycoses 2013, 56 (5), 596- 600. 12. Badaoui, A.; Reygagne, P.; Cavelier- Balloy, B.; Pinquier, L.; Deschamps, L.; Crickx, B.; Descamps, V., Dissecting cellulitis of the scalp: a retrospective study of 51 patients and review of literature. Br J Dermatol 2016, 174 (2), 421-3. 13. Segurado-Miravalles, G.; Camacho- Martínez, F. M.; Arias-Santiago, S.; Serrano-Falcón, C.; Serrano-Ortega, S.; Rodrigues-Barata, R.; Jaén Olasolo, P.; Vañó-Galván, S., Epidemiology, clinical presentation and therapeutic approach in a multicentre series of dissecting cellulitis of the scalp. J Eur Acad Dermatol Venereol 2017, 31 (4), e199- e200. 14. Greenblatt, D. T.; Sheth, N.; Teixeira, F., Dissecting cellulitis of the scalp mailto:amurina@tulane.edu SKIN May 2019 Volume 3 Issue 3 Copyright 2018 The National Society for Cutaneous Medicine 188 responding to oral quinolones. Clin Exp Dermatol 2008, 33 (1), 99-100. 15. Onderdijk, A. J.; Boer, J., Successful treatment of dissecting cellulitis with ciprofloxacin. Clin Exp Dermatol 2010, 35 (4), 440. 16. Georgala, S.; Korfitis, C.; Ioannidou, D.; Alestas, T.; Kylafis, G.; Georgala, C., Dissecting cellulitis of the scalp treated with rifampicin and isotretinoin: case reports. Cutis 2008, 82 (3), 195-8. 17. Garelli, V.; Didona, D.; Paolino, G.; Didona, B.; Calvieri, S.; Rossi, A., Dissecting cellulitis: responding to topical steroid and oral clindamycin. G Ital Dermatol Venereol 2017, 152 (3), 324-325. 18. Shaffer, N.; Billick, R. C.; Srolovitz, H., Perifolliculitis capitis abscedens et suffodiens. Resolution with combination therapy. Arch Dermatol 1992, 128 (10), 1329-31. 19. Salim, A.; David, J.; Holder, J., Dissecting cellulitis of the scalp with associated spondylarthropathy: case report and review. J Eur Acad Dermatol Venereol 2003, 17 (6), 689-91. 20. Jacobs, F.; Metzler, G.; Kubiak, J.; Röcken, M.; Schaller, M., New approach in combined therapy of perifolliculitis capitis abscedens et suffodiens. Acta Derm Venereol 2011, 91 (6), 726-7. 21. Khaled, A.; Zeglaoui, F.; Zoghlami, A.; Fazaa, B.; Kamoun, M. R., Dissecting cellulitis of the scalp: response to isotretinoin. J Eur Acad Dermatol Venereol 2007, 21 (10), 1430-1. 22. Bolz, S.; Jappe, U.; Hartschuh, W., Successful treatment of perifolliculitis capitis abscedens et suffodiens with combined isotretinoin and dapsone. J Dtsch Dermatol Ges 2008, 6 (1), 44-7. 23. Scheinfeld, N., Dissecting cellulitis (Perifolliculitis Capitis Abscedens et Suffodiens): a comprehensive review focusing on new treatments and findings of the last decade with commentary comparing the therapies and causes of dissecting cellulitis to hidradenitis suppurativa. Dermatol Online J 2014, 20 (5), 22692. 24. Marquis, K.; Christensen, L. C.; Rajpara, A., Dissecting Cellulitis of the Scalp with Excellent Response to Isotretinoin. Pediatr Dermatol 2017, 34 (4), e210- e211. 25. Navarini, A. A.; Trüeb, R. M., 3 cases of dissecting cellulitis of the scalp treated with adalimumab: control of inflammation within residual structural disease. Arch Dermatol 2010, 146 (5), 517-20. 26. Mansouri, Y.; Martin-Clavijo, A.; Newsome, P.; Kaur, M. R., Dissecting cellulitis of the scalp treated with tumour necrosis factor-α inhibitors: experience with two agents. Br J Dermatol 2016, 174 (4), 916-8. 27. Wollina, U.; Gemmeke, A.; Koch, A., Dissecting Cellulitis of the Scalp Responding to Intravenous Tumor Necrosis Factor-alpha Antagonist. J Clin Aesthet Dermatol 2012, 5 (4), 36-9. 28. MCMULLAN, F. H.; ZELIGMAN, I., Perifolliculitis capitis abscedens et suffodiens; its successful treatment with x-ray epilation. AMA Arch Derm 1956, 73 (3), 256-63. 29. Bellew, S. G.; Nemerofsky, R.; Schwartz, R. A.; Granick, M. S., Successful treatment of recalcitrant dissecting cellulitis of the scalp with complete scalp excision and split-thickness skin graft. Dermatol Surg 2003, 29 (10), 1068-70. 30. Housewright, C. D.; Rensvold, E.; Tidwell, J.; Lynch, D.; Butler, D. F., Excisional surgery (scalpectomy) for dissecting cellulitis of the scalp. Dermatol Surg 2011, 37 (8), 1189-91. SKIN May 2019 Volume 3 Issue 3 Copyright 2018 The National Society for Cutaneous Medicine 189 31. Meunier, N.; Zaleski, L.; Bloom, D.; Steger, J., Treatment of Dissecting Cellulitis of the Scalp and the Use of Marsupialization: A Review. J Dermatolog Clin Res: 2014; Vol. 2, p 1015. 32. Krasner, B. D.; Hamzavi, F. H.; Murakawa, G. J.; Hamzavi, I. H., Dissecting cellulitis treated with the long-pulsed Nd:YAG laser. Dermatol Surg 2006, 32 (8), 1039-44.