Dissecting scalp cellulitis is a form of primary cicatricial alopecia that is often found on the vertex scalp. This form of cellulitis can be seen in all age and racial groups, but most often affecting African American men between the ages of 20-40.
There are many theories about cause including destruction of the hair follicle due to follicular keratinization. Patients will often seek help as a result of painful nodules on the scalp with possible associated drainage or inability to grow hair at the affected areas. On examination of the scalp, a provider will note 1-3 cm nodules on the scalp with interconnecting tracts that may be tender on palpation. These lesions can show signs of scarring alopecia depending on length of time each lesion has been present and with more severe cases.
Goals of treatment should include decreasing inflammation, follicular occlusion, and prevention of secondary infections. Treatment regimens can consist of antibiotics for secondary infection and to decrease inflammation in the scalp, in combination with topical antibiotics. Typically, patients will start out with a regimen including doxycycline, and progress to clindamycin and rifampin if not responsive to doxycycline. If a patient with dissecting scalp cellulitis is not responsive to antibiotics, isotretinoin can also be utilized. Some patients may also benefit from intralesional Kenalog injections into inflamed nodules if there is no infection identified.
The prognosis of dissecting scalp cellulitis is a chronic but remitting/relapsing problem. Complications can include hair loss affecting quality of life, secondary bacterial infections, and rarely, squamous cell carcinoma. Close supervision with a dermatology provider is of high importance to decrease nodules, associated discomfort, scarring alopecia, and risk of squamous cell carcinoma.
Written by Laura Badami, APRN