Erosive pustular dermatosis of the scalp: A neutrophilic folliculitis within the spectrum of neutrophilic dermatoses: A clinicopathologic study of 30 cases

Erosive Pustular Dermatosis of the Scalp Following Hair Transplantation: A Rare Complication

Erosive pustular dermatosis of the scalp (EPDS) is a rare inflammatory condition characterized by sterile pustules, crusts, and skin atrophy, leading to scarring alopecia. While typically affecting the elderly, this report discusses a rare instance in a 31-year-old male who developed EPDS following follicular unit extraction (FUE) for androgenetic alopecia. The diagnosis was confirmed through clinical, dermoscopic, and histopathological examination. Initial treatment with topical steroids showed temporary improvement, but the condition relapsed upon tapering. High-potency topical corticosteroids were ultimately effective. This case underscores the importance of early recognition of EPDS, highlighting the value of clinical, trichoscopic, and histopathologic examination in improving patient outcomes. It also expands the understanding of EPDS by suggesting that surgical trauma may trigger pathergy, potentially initiating the condition in younger individuals without typical risk factors. Given the increasing popularity of hair transplantation, clinicians must remain vigilant about rare complications like EPDS to ensure prompt diagnosis and prevent irreversible alopecia.

Erosive Pustular Dermatosis: Delving into Etiopathogenesis and Management

Erosive pustular dermatosis (EPD) is a chronic inflammatory skin disorder that usually affects mature individuals. It predominantly affects the scalp and can lead to scarring alopecia. Risk factors include actinic damage and androgenetic alopecia. A traumatic insult to the skin is considered a vital trigger of the condition. EPD is a diagnosis of exclusion; thus, several neoplastic, infectious, vesiculobullous, and inflammatory conditions should be ruled out. Biopsy and clinicopathologic correlation are required to differentiate between EPD and these entities. A dysregulated, chronic immune response is considered central to the etiopathogenesis of EPD. We performed an evidence-based systematic review of the management options. There were predominantly studies with level IV and V evidence and only two with level III. Despite the responsiveness of EPD to potent topical steroids, such as clobetasol propionate, recurrence occurs after treatment withdrawal. With the available data, tacrolimus 0.1%, curettage-assisted aminolevulinic acid-photodynamic therapy, and systemic retinoids can be considered second-line options for EPD with a role in maintenance regimens. However, controlled data and more powerful studies are needed to make solid recommendations.

Hidden in plain sight: Considerations for an ulcer of the scalp

BACKGROUND

Pyoderma gangrenosum (PG) is a rare inflammatory skin condition characterized by painful, irregularly shaped skin ulcers mainly affecting the lower extremities. PG rarely affects the head and neck, making the diagnosis of this condition even more challenging. A high index of suspicion is paramount in the diagnosis of PG, especially after surgical procedures.

METHODS

We describe a clinical case of a patient with initially undiagnosed PG of the scalp who underwent surgical excision and full thickness skin graft with subsequent graft necrosis as initial clue for the diagnosis.

RESULTS

Twenty months after initial presentation, this patient healed with a multimodal medical approach of immunosuppressive therapy and wound care.

CONCLUSION

Prompt recognition of PG by physicians assessing any surgical wounds is vital in reducing misdiagnosis and improving patient outcomes.

Erosive Pustular Dermatosis of the Scalp: A Clinicopathologic Study of Fifty Cases

Erosive pustular dermatosis of the scalp (EPDS) is an uncommon, pustular, idiopathic disorder typically occurring on the scalp of the elderly, whose diagnosis requires close clinicopathologic correlations. Recently, the primary histopathologic characteristic of EPDS has been identified in some biopsies from hair-bearing scalp lesions as a sterile, vesiculo-pustule involving the infundibulum of hair follicles. To further delineate the clinicopathologic spectrum of the disease, we led a retrospective study of 50 patients (36 males and 14 females) with a diagnosis of EPDS between 2011 and 2021, reviewing clinical and histopathological data. Androgenetic alopecia was present in 32 patients. Triggering factors were present in 21 patients. The vertex was the most common location; one patient also had leg involvement. Two cases were familial. Disease presentation varied markedly from tiny, erosive, scaly lesions to crusted and hemorrhagic plaques, mimicking pustular pyoderma gangrenosum (PPG). Biopsies of patients with severe androgenetic or total baldness produced specimens showing nonspecific pathologic changes (39/50), while in 11 patients with a hair-bearing scalp histopathologic examination, changes were specific. The clinicopathologic similarities between EPDS and PPG suggest that EPDS should be included in the spectrum of autoinflammatory dermatoses. Clinicians could consider the possibility of associated disorders rather than managing EPDS as a sui generis skin disorder.

Erosive pustular dermatosis of the scalp may not be mutually exclusive with other dermatoses

Erosive pustular dermatosis of the scalp is an uncommon neutrophilic process representing a diagnostic and therapeutic challenge. It often occurs in older patients with prior sun exposure and manifests with hyperkeratosis and crust that may be difficult to distinguish from other inflammatory or neoplastic processes. Although erosive pustular dermatosis of the scalp may respond effectively to high potency topical steroids or other antiinflammatory regimens, caution is advised to avoid overlooking differential diagnoses that may not be mutually exclusive, especially squamous cell carcinoma.

Histologic Patterns and Clues to Autoinflammatory Diseases in Children: What a Cutaneous Biopsy Can Tell Us

Autoinflammation is defined by aberrant, antigen-independent activation of the innate immune signaling pathways. This leads to increased, pro-inflammatory cytokine expression and subsequent inflammation. In contrast, autoimmune and allergic diseases are antigen-directed immune responses from activation of the adaptive immune system. The innate and adaptive immune signaling pathways are closely interconnected. The group of 'complex multigenic diseases' are a result of mutual dysregulation of both the autoinflammatory and autoimmune physiologic components. In contrast, monogenic autoinflammatory syndromes (MAIS) result from single mutations and are exclusively autoinflammatory in their pathogenesis. Studying the clinical and histopathological findings for the various MAIS explains the phenotypical correlates of their specific mutations. This review aims to group the histopathologic clues for autoinflammation into three recognizable patterns. The presence of these histologic patterns in a pediatric patient with recurrent fevers and systemic inflammation should raise suspicion of an autoinflammatory component in MAIS, or, more frequently, in a complex multigenic disease. The three major histopathological patterns seen in autoinflammation are as follows: (i) the 'neutrophilic' pattern, seen in urticarial neutrophilic dermatosis, pustular psoriasis, aseptic neutrophilic folliculitis, and Sweet's syndrome; (ii) the 'vasculitic' pattern seen in small vessel-vasculitis (including hypersensitivity/leukocytoclastic vasculitis, thrombosing microangiopathy and lymphocytic vasculitis), and intermediate-sized vessel vasculitis, mimicking polyarteritis nodosa; and (iii) the 'granulomatous' pattern. Beyond these three patterns, there are additional histopathologic clues, which are detailed below. It is important for a dermatopathologist to recognize the patterns of autoinflammation, so that a diagnosis of MAIS or complex multigenic diseases may be obtained. Finally, careful histopathologic analyses could contribute to a better understanding of the various clinical manifestations of autoinflammation.

Therapeutic options for erosive pustular dermatosis of the scalp: a systematic review

BACKGROUND

Erosive pustular dermatosis of the scalp (EPDS) is a chronic condition characterized by erosive plaques and subsequent scarring alopecia as a result of local trauma or inflammation. A number of therapeutic approaches have been described in the literature but there is no consensus of opinion on optimal treatment of the disease.

OBJECTIVES

To provide evidence-based recommendations for topical and systemic treatment of adult patients with EPDS by performing a systematic review.

METHODS

The MEDLINE, MEDLINE In-Process, Embase and Cochrane databases were searched from inception to 26 June 2019 in accordance with the PRISMA guidelines for studies involving adult patients treated for EPDS with at least one reported response to treatment. The study was registered on PROSPERO. Texts were reviewed independently by two authors. The risk of bias and quality of the studies were assessed using the Quality Appraisal Checklist for Case Series Studies.

RESULTS

In total 75 studies were included, involving 168 patients. Many treatments have been reported in the literature, with varying degrees of therapeutic success. The results were highly heterogeneous and methodological quality was very low. We were unable to perform a meta-analysis on the data.

CONCLUSIONS

The limited available evidence supports use of topical corticosteroids, with or without oral zinc, followed by maintenance therapy with topical calcineurin inhibitors as being effective in managing this condition. Topical photodynamic therapy is also potentially beneficial in the management of EPDS. Prospective, comparative, randomized controlled trials are required in order to provide further evidence to guide treatment.

Erosive pustular dermatosis of the scalp: a multicentre study

BACKGROUND

Erosive pustular dermatosis of the scalp (EPDS) is characterized by crusted erosions or superficial ulcerations that lead to scarring alopecia.

OBJECTIVES AND METHODS

We performed a multicentre retrospective clinical study including 56 patients (29 females and 27 males, mean age 62.7) with a confirmed EPDS in order to describe epidemiology, clinical findings and therapeutic choices of this disease.

RESULTS

Mechanical/chemical trauma was reported in 28.6%, a previous infection in 10.7%, a previous cryotherapy in 5.4% androgenetic alopecia in 48.2% and severe actinic damage in 25%. Trichoscopy showed absence of follicular ostia, tufted and broken hair, crusts, serous exudate, dilated vessels, pustules and hyperkeratosis. Histopathology revealed three different features, depending on the disease duration. The most prescribed therapy was topical steroids (62.5%), followed by the combination of topical steroids and topical tacrolimus (8.9%), systemic steroids (7.1%) and topical tacrolimus (5.4%). A reduction of inflammatory signs was observed in 28 patients (50%) treated with topical steroids and in all three patients treated with topical tacrolimus.

CONCLUSION

The relatively high number of patients collected allowed us to identify a better diagnostic approach, using trichoscopy and a more effective therapeutic strategy, with high-potency steroids or tacrolimus, which should be considered as first-line treatment.

Treatment of erosive pustular dermatosis: a systematic review of the literature

IMPORTANCE

Erosive pustular dermatosis (EPD) is a rare chronic inflammatory condition of the scalp and legs that is often difficult to manage. Currently, there are no treatment guidelines.

OBJECTIVE

To systematically assess the existing literature on various treatment modalities and their efficacies when used in the management of EPD.

EVIDENCE REVIEW

We searched PubMed, Cochrane Libraries, Scopus, and clicnialtrial.gov databases for articles in the English language with no limited time frame. Emphasis was placed on articles that reported on treatment for EPD.

FINDINGS

Of the 168 articles identified by the literature search, 92 met eligibility criteria and were included for qualitative analysis. Efficacious topical treatments included clobetasol, betamethasone, and tacrolimus. Ninety-three and 88% of cases utilizing clobetasol and betamethasone respectively demonstrated improvement or resolution. All 32 cases utilizing tacrolimus reported improvement. Efficacious systemic treatments included oral steroids such as prednisone, methylprednisolone, and dexamethasone. Topical dapsone, photodynamic therapy, systemic steroids, cyclosporine, and oral zinc derivatives were also described with some success.

CONCLUSIONS AND RELEVANCE

According to available data, limited solely to case reports and case series, potent topical steroids are an effective treatment option for EPD. Topical tacrolimus may also be considered in cases that require long-term use or maintenance. Other treatment modalities shown to be successful based on high reported efficacy and low rates of recurrence after treatment include topical dapsone, systemic steroids, zinc derivatives, and cyclosporine. Further studies are needed to compare treatment modalities and to establish treatment protocols.

Erosive pustular dermatosis of the scalp: challenges and solutions

Erosive pustular dermatosis of the scalp is a rare chronic inflammatory disorder defined. It usually affects elderly people and is characterized by extensive pustular lesions, erosions, and crusts located on the scalp. The pathogenesis of this disease is not completely understood, but a known predisposing factor is skin trauma. Autoimmune disorders including rheumatoid arthritis, autoimmune hepatitis, Hashimoto thyroiditis, and Takayasu aortitis are associated diseases reported. The clinical examination reveals erythema, erosions, crusts, follicular pustules, and in advanced stages, scarring alopecia. A scalp biopsy is recommended but not specific, founding epidermal atrophy, focal erosions, and a mixed inflammatory infiltrate consisting of neutrophils, lymphocytes, and plasma cells. Bacterial cultures, fungal and viral stains are not necessary and are usually negative. . Topical high-potency corticosteroids, retinoids, calcipotriol, dapsone, and topical tacrolimus are reported treatments, while photodynamic therapy has been effective in some patients, but has induced the disease in others. All the findings are suggestive but not specific, so it is an excluding diagnosis. The combination of predisposing factors is very important for a correct diagnosis, such as elderly age, sun-damaged skin, presence of androgenetic alopecia, together with clinical manifestations, non-specific histology and laboratory investigations negative for other disease. In our opinion, this scalp disease is a challenge for the dermatologist. We review all the literature to better define the possible solutions in case of suspected erosive pustular dermatosis of the scalp.