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Chapter 83: Dissecting Cellulitis

Antara Afrin; Candrice R. Heath

DISSECTING CELLULITIS

Therapeutic Approach

Dissecting cellulitis of the scalp (DCS), also known as perifolliculitis capitis abscendens et suffodiens or Hoffman disease, is a condition that causes pustules and nodules on the scalp that may lead to scarring and hair loss.1 DCS is more likely to affect Black men.2 This condition is part of the follicular occlusion tetrad, which also includes hidradenitis suppurativa, acne conglobata, and pilonidal sinus. Treatment for dissecting cellulitis can be challenging as there is no drug approved by the U.S. Food and Drug Administration for specific treatment of this condition. In the senior author’s experience, first-line treatment options for mild DCS symptoms include benzoyl peroxide, topical clindamycin and oral doxycycline. In the cases of moderate to severe DCS, treatment with a combination of systemic rifampicin and clindamycin can be initiated. For refractory cases, isotretinoin and TNF inhibitors may also be considered. See Table 83-1.

Table 83-1Dissecting Cellulitis Treatment Table
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Table 83-1 Dissecting Cellulitis Treatment Table
MEDICATION NAME INDICATION MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING LEVEL OF EVIDENCE (REFERENCE)
Topical Therapy
Benzoyl peroxide (BPO)a Mild, moderate, severe Anti-microbial 4%-10% wash Hypersensitivity reaction, contact dermatitis None IV3
Chlorhexidine gluconatea Mild, moderate, severe Anti-microbial 4% solution Hypersensitivity reaction, contact dermatitis None IV3
Clindamycina Mild, moderate, severe Anti-microbial 1% gel (use with BPO to decrease risk of resistance) Hypersensitivity reaction, contact dermatitis None IV4
Corticosteroid (clobetasol propionate)a Mild, moderate, severe Anti-inflammatory 0.05% foam QD Skin atrophy, dyspigmentation None IV5,6
Intralesional Therapy
Triamcinolone acetonide injectiona Mild, moderate, severe Anti-inflammatory 5-10 mg/mL injection Skin atrophy, dyspigmentation None IV7,8
Systemic Therapy
Doxycycline Mild, moderate, severe Antimicrobial, anti-inflammatory 100 mg QD Contraindicated in pregnancy and under age 8; GI upset, headache photosensivity, esophagitis None III9
Azithromycin Mild, moderate, Antimicrobial, anti-inflammatory 500 mg TID GI upset None III9
Finasteride severe Antiandrogenic 1 mg QD Birth defects in those of child-bearing potential None III9
Isotretinoina Severe, refractory Sebaceous gland function and keratinization inhibition Dosing variable, 0.25-1 mg/kg/d or 40-80 mg/d; duration of treatment variable, ranging from 3 to 24 mo Teratogenic in those of child-bearing potential, skin dryness, nausea, increased lipids and liver enzymes Baseline CMP and lipid panel, repeat after 2 mo of treatment; pregnancy test prior to starting and monthly in people with child-bearing potential III9–16
TNF inhibitors (adalimumab, infliximab)a Severe, refractory TNF-inhibitor Varies Immunosuppression, infusion reaction, serious infection, injection site reaction, hepatotoxicity, CHF, retrobulbar optic neuritis Baseline TB and hepatitis B testing followed by yearly testing; avoid live vaccines III17,18
Clindamycina Moderate, severe Antimicrobial 300 mg BID; (often combined with oral rifampicin) Pseudomembranous colitis None IV5,9
Corticosteroidsa Moderate, severe Anti-inflammatory Varies; not recommended for long-term treatment; high-dose followed by taper reducing 5 mg per week ...

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