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Chapter 41: Scalp Acne

Raquel de Melo Carvalho; Bianca Maria Piraccini

SUMMARY

SUMMARY

  • Scalp Acne is a skin disorder of the pilosebaceous unit and is the result of multiple factors.

  • We still cling to the four major pathogenic factors: follicular hyper-keratinization, excess sebum, inflammation, and Cutibacterium acnes (C. acnes), also called Propionibacterium acnes (P. acnes).

  • It can present as inflammatory papules, pustules, and nodules.

TIPS FOR DIAGNOSIS

  • Use trichoscopy to your advantage.

  • Cytology, culture, antibiogram, and histopathology can help in difficult cases.

  • Search for relevant history such as occlusion by chemical or mechanical means, and other risk factors.

TIPS FOR TREATMENT

  • Treating scalp acne is not much different than treating acne on the rest of body; the most significant barrier is hair.

  • Most conditions tend to improve with anti-seborrheic and antiseptic shampoos.

DON’T FORGET

  • Acne is an immune-mediated chronic inflammatory disease.

  • It is not a cosmetic condition.

  • When it is necessary, treat it aggressively.

PITFALLS AND CAUTIONS

  • Differential diagnosis from acne: superficial pustular folliculitis (SPF), folliculitis barbae and sycosis barbae, perifolliculitis capitis abscedens et suffodiens, folliculitis keloidalis nuchae, actinic folliculitis, eosinophilic pustular folliculitis (EPF), malassezia folliculitis, epidermal growth factor receptor (EGFR) inhibitor-induced papulopustular eruption, lichen planopilaris, and scalp rosacea.

EXPERT PEARLS

  • Keep differential diagnoses in mind, be wary of scalp acne that does not improve, and is associated with other symptoms

  • Scalp acne is generally not associated with hair loss, in some cases it may have a temporary focal atrichia around the inflammation.

PATIENT EDUCATION POINTS

  • Wash hair soon after exercise.

  • Avoid using too many hair products, such as hairsprays and gels.

  • Avoid squeezing, picking, or popping a pimple on the scalp.

  • Avoid prolonged use of caps and hairstyles that occlude the scalp.

INTRODUCTION

Acne is a disease unique to humans and is associated with sebaceous glands that are found at high density on the scalp, forehead, and face.5

It is a skin disorder of the pilosebaceous unit and is the result of multiple factors.1 The pilosebaceous unit consists of the hair shaft, the hair follicle, the sebaceous gland, and the erector pili muscle5 (Fig. 41.1).

FIGURE 41.1

Structure of the pilosebaceous unit. APM, arrector pili muscle; HF, hair follicle; HS, hair shaft; JZ, junctional zone; SG, sebaceous gland.

An illustration depicts the pilosebaceous unit with 4 layers and constituents. The pilosebaceous unit is classified into four layers. From top to bottom, the layers are as follows: infundibulum, isthmus, supra bulbar region, and bulbar region. The top thin region of the hair visible outside is labeled hair shaft. The hair region labeled sebum lies in the infundibulum. The middle region of the hair in the layer of the isthmus is labeled the junctional zone. An irregularly-shaped organ labeled sebaceous gland descends from the infundibulum to the supra bulbar region. A muscle structure labeled arrector pili muscle extends from the bottom of the hair follicle in the supra bulbar region to the infundibulum. The bottom of the hair in the bulbar region is labeled hair follicle.
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The pilosebaceous units of large terminal hairs, such as those located on the scalp, are only rarely involved in acne as the terminal hair is stiff, thick, and long. The diameter of the hair is wide enough to occupy almost the entire lumen of the canal.5 The hair acts as a wig and allows the sebum to drain and does not block the pores.6 Sebaceous glands are present in the highest density on the scalp, forehead, and face ...

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