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Chapter 85: Erosive Pustular Dermatosis (Chronic Atrophic Dermatosis of the Scalp and Extremities)

Uwe Wollina

EROSIVE PUSTULAR DERMATOSIS (CHRONIC ATROPHIC DERMATOSIS OF THE SCALP AND EXTREMITIES)

Therapeutic Approach

Erosive pustular dermatosis (EPD) is a rarely reported noninfectious inflammatory disease. It can be caused or aggravated by certain medications and by photodynamic therapy. EPD occurs on the scalp or on the lower legs. It has a female predominance. EPD is more common in elderly but has been reported occasionally in children and adolescents. Choice of treatment is influenced by etiology, age of patients, and localization. If medications are suspected as triggers, these should be stopped or replaced whenever possible. Topical treatment with high potency corticosteroids is the treatment of choice in adults. In case of superinfection, these should be combined with topical antibiotics. We prefer fusidinic acid, since fusidinic acid is not used as a systemic drug in Germany. In other regions of the world oral antibiosis might be more preferable. Second-line treatment consists of oral antibiotics. We prefer tetracycline because of the anti-inflammatory activity. Further options are listed in the table. See Table 85-1.

Table 85-1Erosive Pustular Dermatosis Treatment Table
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Table 85-1 Erosive Pustular Dermatosis Treatment Table
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MEDICATION NAME MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING LEVEL OF EVIDENCE (REFERENCE)
Topical Therapy
Topical corticosteroids Anti-inflammatory 0.05% clobetasol propionate or 0.05% betamethasone diproprionate or 0.1% mometasone fuorate; BID Potential skin atrophy in the long-term use None III1-6
Topical calcipotriol Anti-inflammatory 0.005%, once a day Potential of hyperpigmentation and skin irritation None III1-6
Topical calcineurin inhibitors Anti-inflammatory Tacrolimus 0.1% ointment; BID, pimecrolimus cream 1%; BID Burning sensations None III1-6
Topical dapsone Anti-inflammatory 5% Gel; BID None reported None III2
Topical zinc oxide plus topical corticosteroids Anti-inflammatory 25% powder; 3 time per week (for legs only) None reported None III7
Systemic Therapy
Doxycycline Anti-inflammatory, antimicrobial 200 mg/d Contraindicated in pregnancy, <8 yo; photosensitivity, GI upset, esophagitis, headache None III1-6
Minocycline Anti-inflammatory, antimicrobial 100 mg/d Contraindicated in pregnancy, <8 yo; photosensitivity, GI upset, esophagitis, headache None III1-6
Oral corticosteroids Anti-inflammatory 0.57-1.0 mg/kg body weight; once a day Recurrence may occur after tapering the dose, contraindicated in acute viral or bacterial infections, systemic mycoses, strongyloidiasis, poliomyelitis, tuberculosis Fasting blood sugar, CRP, electrolytes, lipid profile—before treatment and every 4-6 wk III1-6
Dapsone Anti-inflammatory 50 mg BID Met-hemoglobulinemia, hemolysis, agranulocytosis, hypersensitivity syndrome Glucose-6-phosphate dehydrogenosae (before treatment), blood count, transaminases, creatinine, pregnancy test, reticulocytes count—before treatment and every 4-6 wk IB1-6,8
Ciclosporin A Anti-inflammatory 3 mg/kg body weight Hypertension, creatinine increase, GI upset, contraindicated during pregnancy and lactation and phototherapy Blood pressure, blood cell count, creatinine, uric acid, transaminases, lipid panel, pregnancy test—all before treatment—during the first 3 mo blood pressure and creatinine every 2 wk, thereafter once a month; all other parameters—every 4-8 wk III1-6,9
Low-dose retinoids Anti-inflammatory 40 mg or 0.75 mg/kg body weight/d isotretinoin or 50 mg/d acitretin

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