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Chapter 30: Skin Diseases of the Scalp

Maria K. Hordinsky

INTRODUCTION TO CHAPTER

The scalp is characterized by a high density of sweat glands and pilosebaceous units consisting of hair follicles, sebaceous glands, and arrector pili muscles. It is estimated that there are some 100,000 follicles on the scalp so this also means that there are about 100,000 sebaceous glands and associated arrector pili muscles.

Skin diseases involving the scalp can be broadly classified into inflammatory dermatoses, infections, and neoplastic (see Table 30-1). Hair on the scalp protects the skin from ultraviolet light and if absent or decreased, predisposes balding individuals to sunburns, photodamage, and photosensitivity. Likewise, the presence of hair may make cleaning the scalp surface with shampoos challenging permitting the development of scalp conditions such as dandruff and seborrheic dermatitis related to colonization of commensal Malassezia yeasts.

Table 30-1.Differential diagnosis for skin diseases of the scalp.
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Table 30-1. Differential diagnosis for skin diseases of the scalp.
Disease Epidemiology History Physical Examination
Inflammatory
Allergic contact dermatitis

Common

F > M

Any age

 Pruritic. Onset is within hours or days after contact with the allergen Usually presents with erythema, edema, and pruritus of the forehead, eyelids, ears, and rarely the scalp
Atopic dermatitis

Common

M ≥ F

 Pruritic Scalp involvement more commonly seen in infants
Cicatricial alopecias

Relatively uncommon

Prevalence is reported to range from 3.2% to 7.3% of all the alopecia conditions

Most common include discoid lupus erythematosus, lichen planopilaris, and central centrifugal alopecia

 Hair loss may be acute or chronic and associated with itching, burning, pain, redness, and/or drainage Visible loss of follicular ostia, evidence for scalp inflammation with erythema, scaling, pustules, and scalp bogginess (Figures 19-8, 10, 11)
Psoriasis

Common

M > F

Any age

 Asymptomatic to pruritic Red papules and plaques with silvery, thick, adherent scale can be present (Figure 9-3)
Seborrheic dermatitis

Common

M > F

Age: bimodal; peaks in infancy and adulthood

 The patient typically complains of a dry, scaly, and itchy scalp

Infants usually present with "cradle cap," pink to yellow macules and patches with white greasy scales on the scalp

Commonly presents in adults with "dandruff," white flakes with no erythema (Figure 9-7). Moderate to severe seborrheic dermatitis is characterized by erythematous plaques with white greasy scales
Infectious/infestations
Dissecting cellulitis

Uncommon

M > F

Age: 18-40

Drainage, pruritus, and pain may all be present

Considered by some to be part of the follicular triad that includes acne conglobata and hidradenitis suppurativa

 Recurrent pustules, scarring alopecia, and boggy plaques with sinus tract formation are present (Figure 19-13). Staphylococcus aureus is commonly isolated
Folliculitis

Common

M:F dependent upon etiology that may include occlusion, heat, humidity, immunosuppression, medications, disease such as diabetes, and medications

 May be pruritic Characterized by follicular 1-3 mm pustules and/or inflammatory papules
Head lice

Common

F > M

Age: 3-11, especially girls with long hair; black children are less commonly affected

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