Forum for Nordic Dermato-Venereology Nr2,2017 | Page 9

Nicolas Kluger – Erosive Pustular Dermatosis of the Scalp
Trichoscopy of bald areas of the scalp will show marked skin
atrophy with enlarged blood vessels of the dermis, lack of
follicular ostia and reduced number of hairs. Serous or black
follicular crusts are seen (3).
Microscopic findings are non-specific and vary according to
the type of lesions sampled (e.g. pustule, erosion, scar) and
the disease duration. At an early stage histology shows chron-
ic inflammation of the upper dermis, with a focal or diffuse
mixed infiltrate composed of lymphocytes, neutrophils and
plasma cells. Hair density is normal, with an increased number
of catagen follicles. At a more evolved stage, fibrosis of the
dermis, absence of sebaceous glands, diminished number or
complete absence of hair follicles, and atrophy of hair follicles
are observed. Negative direct immunofluorescence will rule out
possible bullous pemphigoid. Gram and periodic acid-Schiff
(PAS) stainings will be negative as well (3).
Treatment
Treatment of EPDS has not been codified. Several treatments
have been tried with varying degrees of success. Local and oral
antibiotics and antiseptics are not efficient in the absence of
an infectious cause. Ultrapotent local corticosteroid ointments
(e.g. clobetasol propionate) are efficient. Efficacy is assessed
on the lack of inflammation, the disappearance of erosions
and crusts. However, dermocorticosteroids have to be applied
for a long time (6 months) before efficacy is evident. Relapses
occur within a year of withdrawal, and usually after a mean
of 3 months. In addition, skin atrophy may be worsened by
corticosteroids. The efficacy of tacrolimus 0.1% once or twice
a day, calcipotriol 0.005% daily, and dapsone 5% gel twice a
day (5) have been reported in anecdotal cases. Tacrolimus can
be used as first- or second-line treatment in case of failure of
corticosteroid treatment. The efficacy of tacrolimus is evalu-
ated after 3 months (3). It can be used also as maintenance
therapy twice a week to prevent recurrences (3). Because of
Forum for Nord Derm Ven 2017, Vol. 22, No. 2
the risk of squamous cell carcinoma, follow-up of the patient
is recommended, especially when tacrolimus is used.
The efficacy of oral zinc has been reported in some cases, even
in the absence of zinc deficiency. Treatment with an initial
combination of oral zinc (zinc gluconate) and local dermo-
corticosteroids, followed by zinc alone, may be efficient. Oral
isotretinoin may result in improvement after some months
(8); however, cutaneous atrophy may be a limiting factor to
the use of oral isotretinoin as a first-line treatment. Treatment
with oral dapsone does not seem to be efficient according
to the few reports in the literature (5). Additional advice for
patients includes using sun protection, avoiding additional
aggravation to the scalp (e.g. using hot hairdryers, combing,
dying, perming or bleaching the hair) (3).
References
1. Burton JL. Case for diagnosis. Pustular dermatosis of scalp. Br J
Dermatol 1977; 97 Suppl 15: 67–69.
2. Pye RJ, Peachey RD, Burton JL. Erosive pustular dermatosis of the
scalp. Br J Dermatol 1979; 100: 559–566.
3. Starace M, Loi C, Bruni F, Alessandrini A, Misciali C, Patrizi A,
Piraccini BM. Erosive pustular dermatosis of the scalp: Clinical,
trichoscopic, and histopathologic features of 20 cases. J Am Acad
Dermatol 2017; 76: 1109–1114.e2.
4. Marzano AV, Ghislanzoni M, Zaghis A, Spinelli D, Crosti C. Local-
ized erosive pustular dermatosis of the scalp at the site of a cochlear
implant: successful treatment with topical tacrolimus. Clin Exp
Dermatol 2008; 34: e157–159.
5. Broussard KC, Berger TG, Rosenblum M, Murase JE. Erosive pustular
dermatosis of the scalp: a review with a focus on dapsone therapy.
J Am Acad Dermatol 2012; 66: 680–686.
6. Lovell CR, Harman RR, Bradfield JW. Cutaneous carcinoma arising
in erosive pustular dermatosis of the scalp. Br J Dermatol 1980;
103: 325–328.
7. Patton D, Lynch PJ, Fung MA, Fazel N. Chronic atrophic erosive
dermatosis of the scalp and extremities: A recharacterization of ero-
sive pustular dermatosis. J Am Acad Dermatol 2007; 57: 421–427.
8. Petersen BO, Bygum A. Erosive pustular dermatosis of the scalp:
a case treated successfully with isotretinoin. Acta Derm Venereol
2008; 88: 300–301.
E ducational R eview
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