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Chapter 35: 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.

Hair on the scalp protects the skin from ultraviolet light and if absent or decreased, predisposes balding individuals to sunburns, photo damage, 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.

APPROACH TO DIAGNOSIS

Skin diseases involving the scalp can be broadly classified into the following categories (Table 35-1).

  • Inflammatory dermatoses

  • Cicatricial alopecias

  • Infections/infestations

  • Neoplasia

Table 35-1.Skin Diseases of the Scalp.
View Table||Download (.pdf)
Table 35-1. Skin Diseases of the Scalp.
Disease Features
Inflammatory Dermatoses

Allergic contact dermatitis

image

Epidemiology:

 Uncommon.

 F > M

 Any age.

History:

 Pruritic. Onset is within hours or days after contact with the allergen.

Physical Exam:

 Usually presents with erythema, edema and pruritus of the forehead, eyelids, ears, and less so, the scalp.

 (See chapter 8)

Atopic dermatitis

image

Epidemiology:

 Common.

 M > F.

 More common in infants.

History:

 Pruritic.

Physical Exam:

 Scalp involvement more commonly seen in infants. Usually presents as scaly erythematous plaques with crust and excoriations.

 (See chapter 8)

Psoriasis

image

Epidemiology:

 Common.

 M > F.

History:

 Asymptomatic to pruritic.

Physical Exam:

 Red papules and plaques with silvery, thick, adherent scale can be present.

 (See chapter 9)

Seborrheic dermatitis

image

Epidemiology:

 Common.

 M > F.

History:

 Dry, scaly, and itchy scalp.

Physical Exam:

 Presents with "dandruff", white flakes with no erythema. Moderate to severe seborrheic dermatitis is characterized by erythematous plaques with white greasy scales.

 (See chapter 9)
Cicatricial Alopecias

Acne keloidalis nuchae

image

Epidemiology:

 Common.

 M > F.

 Black men with Afro-textured hair are the predominate population at risk.

History:

 May be associated with scalp injury.

Physical Exam:

 Presents with inflamed papules or pustules and keloid-like scarring on the posterior lower scalp and nape of the neck.

 (See chapter 10)

Central centrifugal cicatricial alopecia

image

Epidemiology:

 Uncommon.

 Predominantly affects middle-aged women of African ancestry.

 F > M with prevalence reported to range from 2.7% to 5.6%.

History:

 Usually presents with asymptomatic hair loss over the crown of the scalp, sometimes symptomatic and with signs of inflammation.

Physical Exam:

 Hair thinning on the vertex region followed by progressive hair loss that extends peripherally in a centrifugal, symmetric manner; perifollicular erythema, and scale are found at the periphery of areas of alopecia.

 (See chapter 30)

Discoid lupus erythematosus

image

Epidemiology:

 Uncommon.

 F > M.

 15–30% of patients with systemic lupus erythematosus (SLE) develop discoid lupus erythematosus (DLE). Five to 28% of patients with DLE may develop ...

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