Journal of Dermatology and Clinical Research
Central
Case Report
*Corresponding author
Treatment of Dissecting Cellulitis
of the Scalp and the Use of
Marsupialization: A Review
Dr. Nicole Meunier, General Medical Officer for the 3rd
Radio Battalion, Marine Corps Base Hawaii, USA, Tel:
808-397-7587; Email:
1
2
3
Nicole Meunier *, Lisa Zaleski , David Bloom and James Steger
4
General Medical Officer for the 3rd Radio Battalion, Marine Corps Base Hawaii, USA
Department of Dermatology, Naval Hospital Okinawa, Japan
3
Department of Ear Nose and Throat, Naval Hospital Okinawa, Japan
4
Department of Dermatology, Naval Medical Center San Diego, USA
1
2
Abstract
Submitted: 22 January 2014
Accepted: 13 February 2014
Published: 15 February 2014
Copyright
© 2014 Meunier et al.
OPEN ACCESS
Keywords
•Cellulitis
•Scalp
•Marsupialization
•Follicular occlusion triad
Dissecting cellulitis of the scalp (DCS), or perifolliculitis capitis abscedens et suffodiens, is a
rare, chronic, relapsing and remitting inflammatory disease of the scalp. We present a case of
a patient with severe DCS refractory to medical management on chronic high-dose prednisone.
We describe the procedure of marsupialization under general anesthesia which may be an
effective treatment option for severe cases of DCS.
ABBREVIATIONS
DCS: Dissecting Cellulitis of the Scalp
INTRODUCTION
Dissecting cellulitis of the scalp (DCS), or perifolliculitis
capitis abscedens et suffodiens, is a rare, chronic, relapsing
and remitting inflammatory disease of the scalp. DCS was first
described by Spitzer in 1903 and named perifolliculitis capitis
abscedens et suffodiens by Eric Hoffman in 1908. The condition
is often referred to in the European literature as Hoffman’s
disease and was renamed DCS by Barney in 1931 [1,2]. DCS is
described as one component of the follicular occlusion triad,
along with hidradenitis suppurativa and acne conglobata [3].
DCS most often occurs on the vertex and occipital scalp of African
American males between 20 and 40 years of age [4]. The disease
is characterized by firm or fluctuant subcutaneous nodules and
burrowing abscesses that initially cause a potentially reversible
overlying alopecia but eventually result in dense dermal fibrosis,
chronic sinus tract formation, hypertrophic scarring and scarring
alopecia [5]. Multiple therapeutic modalities have been described
with often disappointing outcomes. We describe a case of severe
DCS refractory to medical management with symptom flares
while on high-dose prednisone. Marsupialization was performed
under general anesthesia on selected areas of the occipital scalp
with significant symptom relief.
CASE PRESENTATION
Patient history
A 29 year old African American male with hidradenitis
suppurativa and cystic acne presented with a five year history of
painful scalp cysts. Of his follicular occlusion triad, the dissecting
cellulitis of the scalp was his primary complaint and the worst
of all of his symptoms. The patient completed multiple courses
of antibiotics including trials of doxycycline, minocycline,
trimethoprim/sulfamethoxazole DS, and clindamycin orally
twice daily. These medications were used in conjunction with
topical clindamycin solution and benzoyl peroxide 10% wash
with no significant change in the patient’s symptoms. Isotretinoin
(13-cis-retinoic acid) 80 mg daily was then attempted but the
patient reported a severe worsening of symptoms and declined
further treatment.
Given the lack of success with multiple antibiotic regimens and
isotretinoin, the patient was started on a trial of the anti-tumornecrosis factor-alfa inhibitor etanercept 25 mg biweekly. There
was mild improvement in the first three weeks, but no sustained
response was observed over a two month period. The patient
was unable to complete a 4 month trial period due to military
travel and the inability to keep the etanercept refrigerated. The
patient refused 1064 nm laser hair removal treatments.
High dose prednisone at 80 mg daily was subsequently
initiated due to constant 8/10 scalp pain. The first sign of
dramatic change occurred after four weeks of prednisone
therapy, but this improvement was transient. Despite high-dose
prednisone of at least 60 mg orally daily over a year timeframe,
the patient continued to experience flares. Combination therapy
was attempted with oral clindamycin and etanercept for 3
months, clindamycin and rifampin for 6 weeks, and dapsone for
3 months. No sustained benefit with any of the above regimens
was observed.
The patient desired a more permanent solution to his
symptoms and consented to a marsupialization of the scalp.
Cite this article: Meunier N, Zaleski L, Bloom D, Steger J (2014) Treatment of Dissecting Cellulitis of the Scalp and the Use of Marsupialization: A Review. J
Dermatolog Clin Res 2(2): 1015.
Meunier et al. (2014)
Email:
Central
Telemedicine consultation with one of the authors (Steger) who
had extensive successful experience using marsupialization of
the scalp resulted in reassurance that this technique had great
promise for this patient. After further discussion with the
patient, he consented to marsupialization of the involved areas
of the scalp.
Procedure
Preoperative pictures were obtained shown in Figure 1. The
patient was placed under general anesthesia in the operating
room. The affected occipital scalp was injected with 10 ml of
1% lidocaine with 1: 100, 000 epinephrine. An open sinus was
identified and a metal eyelet probe was inserted. The Bovie was
used on cutting mode at a setting of 15 to open the entire length
of the sinus tract in both directions. The Bovie was also used to
remove any free skin on the entire roof of the sinus tract. The
base of the tract was curetted to remove the granulation tissue.
A probe was then used to explore the valley created and
identify connections to other areas. These sinus tracts were
marsupialized in the same manner. This method was repeated
until the majority of the most frequently flared regions had been
treated. Approximately 20% of his scalp was marsupialized and
the rest was left for a subsequent marsupialization. Hemostasis
was achieved with electrocautery. Each marsupialized area
was then packed with gelfoam and a compressive dressing was
applied overnight.
Our patient followed up on post operative day 1 appearing
as shown in Figure 2A, B, and C and then followed up weekly
thereafter. The wounds were cleansed with normal saline daily
and then a mixture of aquaphor and silver sulfadiazine was
placed into the wounds. A telfa pad was placed over the wounds
and then wrapped with curlex gauze. Percocet was prescribed
for pain as needed. The patient’s wife is a nurse and was able to
help the patient with bandage changes daily at home.
By post operative day 34 of the first marsupialization
procedure, the wounds were mostly healed as shown in Figures
3A, B, and C. The wounds were completely healed by post
operative day 60 as shown in Figures 4A, B, and C. The patient
has not had any DCS flares in the marsupialized regions that were
widely excised since his surgery. There were 5 areas on the left
scalp where smaller areas of the scalp had been marsupialized.
These regions returned with flares and were treated with a larger
excision during his second marsupialization.
The second marsupialization procedure was completed on
post operative day 90 with the same procedures followed as the
Figure 2 Post operative day 1 from the first marsupialization procedure.
Figure 3 Post operative day 34 from the first marsupialization procedure.
Figure 4 Post operative day 60 from the first marsupialization procedure.
In figure 4A note the recurrence of pus in the regions previously treated with
smaller resections.
Figure 5 Post operative day 4 from the second marsupialization procedure.
prior marsupialization. Figures 5A, B, and C show the patient
on post operative day 4 from the second marsupialization
procedure where larger areas were marsupialized. Figures 6A,
B, and C demonstrate the filling of the surgical defects by post
operative day 34. The same recovery period was seen with the
second procedure with excellent patient satisfaction as shown in
Figures 7A, B, and C. Figures 8A, B, and C show continued wound
healing and no disease recurrence in the treated areas 7 months
after the second marsupialization procedure.
DISCUSSION
Figure 1 Preoperative view of occipital scalp.
J Dermatolog Clin Res 2(2): 1015 (2014)
DCS is a rare, chronic, relapsing and remitting inflammatory
disease. The etiology remains unclear, however the mechanism
appears to be related to follicular hyperkeratosis and occlusion.
2/5
Meunier et al. (2014)
Email:
Central
Figure 6 Post operative day 34 from the second marsupialization procedure.
Figure 7 Post operative day 63 from the second marsupialization procedure.
Figure 8 7 months after the second marsupialization procedure.
Multiple treatment modalities have been described with varying
degrees of success [6]. Nonsurgical therapies include topical and
systemic antibiotics, systemic steroids, and systemic retinoids.
Monotherapy with antibiotics has not been reported with
sustained success. Doxycycline, erythromycin, minocycline
and flucoxacillin are among other antibiotics that have been
unsuccessful in achieving consistent symptom control [7,8].
A case of systemic steroids initiated at a high dose with rapid
transition to alternate-day dosing was described. The patient
remained free of disease activity after 12 months, however
remained on the alternate-day dosing of prednisone [9].
Isotretinoin appears to be the most efficacious among
nonsurgical treatment modalities, with several successful cases
described after prolonged treatment courses of 9 to 11 months.
Two-thirds of the cases reported in one study demonstrated
sustained therapeutic benefit after a nine month course of
isotretinoin at 1 mg/kg/day dosing. One patient had no scalp
disease and complete hair re-growth two and a half years after
treatment [7].
Isotretnoin has also been used in conjunction with rifampin.
In 2 of 4 reported cases, there was no recurrence noted 10
months after treatment. However, biopsies taken along the
edge of the active lesions demonstrated persistent histological
features consistent with dissecting cellulitis [10].
Several cases have also been reported on the use of anti-
J Dermatolog Clin Res 2(2): 1015 (2014)
TNF alpha therapy. With infliximab, one successful case was
reported with complete remission that remained stable for at
least 12 months [11]. Another case demonstrated near complete
remission at a 3 month follow up, but the authors described their
results as palliative rather than curative. In two of three patients
treated with adalimumab, histological evidence of residual
structures including subcutaneous sinus tracts remained.
Symptoms relapsed in one case after the therapeutic agent was
discontinued [12].
X-ray therapy was used in the 1960s, but due to increased
risk of skin cancer it is no longer a primary treatment option [13].
More recently, hair follicle epilation with various lasers including
the 800-nm pulsed-diode laser has been reported with good
results in regards to symptom control. However, the absence of
or minimal hair regrowth is a common result of laser therapy
[14,15].
In one case study, the patient underwent four treatment
sessions at four week intervals using an 800-nm diode laser. At
a six month follow-up the patient’s scalp condition improved but
there was no hair regrowth [14]. The largest study to date using
the pulsed-diode laser included 38 men and women. Patients
were given up to four treatments. There were no reported cases
of infection, textural changes, dyschromia, or scarring, however
fifty-nine percent reported sparse regrowth with hair that tended
to be thinner and lighter in color [15].
The long-pulsed Nd:YAG laser has more recently been utilized
without significant adverse cutaneous side effects. 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 sites. Further, three of
the patients were able to stop or decrease the need for systemic
medications [8].
The most effective surgical interventions to date in the
treatment of DCS is excisional surgery or scalpectomy followed
by split-thickness grafting. Local incision and drainage has
been employed, but at most provides temporary symptom
relief. Treatment with scalpectomy was first reported in 1986
with subsequent publication of successful cases. One case was
reported to have no recurrence at nine months post-operatively
[16-18].
The use of marsupialization in DCS cases has not been widely
published, with only two cases printed of discussions that occurred
during regional dermatology society meetings in 1943 and 1960
[19,20]. In our case the patient failed multiple trials of topical
and oral antibiotics, was unable to tolerate isotretinoin, failed
anti-TNF alpha therapy and multiple combination therapies. The
only significant improvement was transient with the initiation
of high-dose prednisone, but recurrent and severe symptom
flares significantly delayed attempts at a prednisone taper.
The patient declined laser therapy because he was concerned
about the potential for permanent hair loss. Marsupialization
compares favorably to existing treatment options and was
the leading option in this case as it offered a more permanent
outcome for the patient’s severe and recalcitrant symptoms. It
is a significantly less invasive surgery than complete scalpectomy
that can heal remarkably well by secondary intention without the
3/5
Meunier et al. (2014)
Email:
Central
Table 1: Lessons Learned.
-A small amount is enough to provide post-operative hemostasis if the scalp hemorrhage is well controlled with electrocauterization during surgery.
Gel Foam
-A single layer of gel foam cut to the exact size and shape of the surgical wound is optimum.
-If slightly larger, the gel foam can be compacted into the wound.
-it is of tant amount importance to remove all of the sinus tracts connecting into each unroofed abscess or the DCS will
reform in that area and expand to other areas.
-Although larger marsupializations of the scalp may take longer to heal, if performed correctly, application of 1% silver
Sinus tract removal
nitrate (for antimicrobial activity) + 5% balsam of Peru (for accelerated reepithelialization) compounded in Aquaphor
provides an excellent dressing.
-If unavailable, the use of silver containing wound dressing is highly recommended.
-Recurrence in completely marsupialized areas is quite rare [personal experience of Dr. Steger].
-However, new unconnected adjacent tracts may form in these patients because of their personal susceptibility to this
Recurrence of symptoms condition, but these new areas respond to subsequent marsupializations.
-The reason standard surgical approaches fail, short of a more radical scalpectomy, is their inability to identify incoming
sinus tracts intraoperatively.
Despite the extensive wounds seen immediately postoperatively, marsupialization with secondary healing is in reality a
Wound healing
tissue sparing procedure via finding, unroofing, and removing any diseased tissue.
Although perhaps beneficial at times, traditional combination therapies with antibiotics, intralesional or systemic steroids,
Comparison with medical
retinoids, and biologics typically fail sooner or later, but can provide temporary benefit while awaiting more definitive
management
surgical therapies.
requirement for split-thickness grafting. While marsupialization
scars continue to contract and remodel over a year’s time,
diffusely affected areas of the scalp may be difficult to conceal.
In areas of the scalp with less extensive disease, scarring can be
hidden by hair styling.
Our patient tolerated the procedure well with early symptom
relief. He remains symptom free in the treated regions 7 months
post surgery. Despite the patient’s initial concern about hair
loss, he is very satisfied with the significant improvement in his
symptoms and has noticed gradual improvement in his scarring
over the past several months. New lesions on the frontal scalp
have since occurred in areas that have not been treated. Our
patient continues to be on clindamycin 300 mg twice daily and
oral hydrocortisone 40 mg daily due to his groin hidradenitis.
The prednisone had been changed to hydrocortisone due to
endocrinology recommendations for ease of weaning off of oral
steroids. A course of isotretinoin is planned as the next course
of action but has been delayed due to the desire to have another
child. Lessons learned from the case are summarized in Table 1.
In summary, DCS is often difficult and frustrating to treat.
However, marsupialization can be a powerful tool in controlling
and clearing it. It is our hope that this report will increase
awareness of marsupialization as a significant treatment option
for this disfiguring and discouraging scalp affliction.
conglobata, and dissecting cellulitis of the scalp. Ann Plast Surg. 1987;
18: 230-237.
4. Moyer DG, Williams RM. Perifolliculitis capitis abscedens et suffodiens.
A report of six cases. Arch Dermatol. 1962; 85: 378-384.
5. Sperling LC. Scarring alopecia and the dermatopathologist. J Cutan
Pathol. 2001; 28: 333-342.
6. Mundi JP, Marmon S, Fischer M, Kamino H, Patel R, Shapiro J. Dissecting
cellulitis of the scalp. Dermatol Online J. 2012; 18: 8.
7. Scerri L, Williams HC, Allen BR. Dissecting cellulitis of the scalp:
response to isotretinoin. Br J Dermatol. 1996; 134: 1105-1108.
8. Krasner BD, Hamzavi FH, Murakawa GJ, Hamzavi IH. Dissecting
cellulitis treated with the long-pulsed Nd:YAG laser. Dermatol Surg.
2006; 32: 1039-1044.
9. Adrian RM, Arndt KA. Perifolliculitis capitis: successful control with
alternate-day corticosteroids. Ann Plast Surg. 1980; 4: 166-169.
10.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: 195-198.
11.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: 36-39.
DISCLOSURE
12.Navarini AA, Trüeb RM. 3 cases of dissecting cellulitis of the scalp
treated with adalimumab: control of inflammation within residual
structural disease. Arch Dermatol. 2010; 146: 517-520.
The views expressed in this article are those of the authors
and do not reflect the official policy of the Department of the
Navy, Department of Defense, or U.S. Government. This work has
not been published elsewhere.
14.Boyd AS, Binhlam JQ. Use of an 800-nm pulsed-diode laser in the
treatment of recalcitrant dissecting cellulitis of the scalp. Arch
Dermatol. 2002; 138: 1291-1293.
REFERENCES
13.McMullan FH, Zeligman I. Perifolliculitis capitis abscedens et
suffodiens; its successful treatment with x-ray epilation. AMA Arch
Derm. 1956; 73: 256-263.
1. Spitzer L. Dermatitis follicularis et perifollicularis conglobata.
Dermatol Ztschr. 1903; 10: 109.
15.Campos VB, Dierickx CC, Farinelli WA, Lin TY, Manuskiatti W,
Anderson RR. Hair removal with an 800-nm pulsed diode laser. J Am
Acad Dermatol. 2000; 43: 442-447.
3. Chicarilli ZN. Follicular occlusion triad: hidradenitis suppurativa, acne
17.Housewright CD, Rensvold E, Tidwell J, Lynch D, Butler DF. Excisional
2. Barney RE. Dissecting cellulitis of the scalp. Arch Dermatol Syph.
1931; 23: 503.
J Dermatolog Clin Res 2(2): 1015 (2014)
16.Williams CN, Cohen M, Ronan SG, Lewandowski CA. Dissecting
cellulitis of the scalp. Plast Reconstr Surg. 1986; 77: 378-382.
4/5
Meunier et al. (2014)
Email:
Central
surgery (scalpectomy) for dissecting cellulitis of the scalp. Dermatol
Surg. 2011; 37: 1189-1191.
18.Arneja JS, Vashi CN, Gursel E, Lelli JL. Management of fulminant
dissecting cellulitis of the scalp in the pediatric population: Case
report and literature review. Can J Plast Surg. 2007; 15: 211-214.
19.Cannon AB. Perifolliculitis capitis abscedens et suffodiens. Arch
Dermatol. 1944; 49: 67-68.
20.Wolf M. Diagnosis: Perifolliculitis capitis abscedens and suffodiens.
Arch Dermatol. 1960; 81: 1016-1017.
Cite this article
Meunier N, Zaleski L, Bloom D, Steger J (2014) Treatment of Dissecting Cellulitis of the Scalp and the Use of Marsupialization: A Review. J Dermatolog Clin Res
2(2): 1015.
J Dermatolog Clin Res 2(2): 1015 (2014)
5/5