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Year : 2022  |  Volume : 14  |  Issue : 5  |  Page : 178-180  

Erosive pustular dermatosis of the scalp: Report of three cases

Department of Dermatology and Venereology, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India

Date of Submission24-Oct-2021
Date of Decision09-Mar-2022
Date of Acceptance11-Mar-2022
Date of Web Publication07-Oct-2022

Correspondence Address:
Sowmya S Aithal
4753/A, Sindhoora, Opposite Jyothi IVF Centre, Dattagalli 3rd Stage, Mysore - 570 022, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijt.ijt_105_21

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Erosive pustular dermatosis of the scalp is a chronic cutaneous condition presenting with areas of erosions and pustules, healing with scarring and alopecia. We report three such cases presenting with pus-filled lesions of the scalp with nonspecific pathological changes. This condition is often misdiagnosed and shows a poor response to antibiotics. Clinical suspicion is of primary importance for early diagnosis and proper treatment.

Keywords: Cicatricial alopecia, erosive pustular dermatosis of the scalp, pustular disorders

How to cite this article:
Aithal SS, Shilpa K, Revathi T N. Erosive pustular dermatosis of the scalp: Report of three cases. Int J Trichol 2022;14:178-80

How to cite this URL:
Aithal SS, Shilpa K, Revathi T N. Erosive pustular dermatosis of the scalp: Report of three cases. Int J Trichol [serial online] 2022 [cited 2023 Feb 4];14:178-80. Available from: https://www.ijtrichology.com/text.asp?2022/14/5/178/358098

   Introduction Top

Erosive pustular dermatosis of the scalp (EPDS) is a rare disease initially described by Burton in 1977 and later in 1979 by Pye et al. It is characterized by pustules, erosions, and crusting on the scalp resulting in cicatricial alopecia. It has a chronic course, slowly progressing to involve large areas of the scalp within months or years. Pustules are generally sterile and it poorly responds to treatment.

   Case Reports Top

Case 1

A 50-year-old man presented to our department with pus-filled lesions on the scalp and loss of hair for 3 years. He had a history of trauma by fox bite 9 years ago, for which grafting was done from his right thigh. He was treated with topical antibiotics previously with not much improvement. He was a farmer by occupation for 30 years. Clinical examination revealed atrophic depigmented patches crusted lesions in the right frontoparietal region of the scalp with cicatricial alopecia [Figure 1]. Gram stain and KOH were negative. Histopathological examination showed skin with intraepidermal neutrophil aggregates with marked spongiosis and ulceration. Dermis showed dense lymphocytic infiltrate [Figure 2]. The patient was treated with topical corticosteroids but noncompliance led to recurrences.
Figure 1: Clinical pi]cture of the scalp of the first case showing areas of alopecia with crusting and depigmented patches

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Figure 2: Histopathological examination showed intraepidermal neutrophil aggregates with marked spongiosis and ulceration. Dermis showed dense lymphocytic infiltrate

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Case 2

A 72-year-old male patient presented with scarring alopecia of the scalp for 11 months, initially started as pus-filled lesions later progressed to leave scars. The patient did not respond to any of the topical or systemic antimicrobial agents. On examination, atrophic areas of alopecia and a few crusted lesions were noted [Figure 3]a. Histopathology revealed atrophic epidermis and lymphocytic infiltrate in the dermis. The culture was sterile. The patient was prescribed steroids (mometasone furoate 0.1% cream) and showed mild improvement [Figure 3]b.
Figure 3: (a) Second case showing atrophic areas of alopecia, erosions, and a few crusted lesions (b) Mild improvement with the healing of erosions seen after topical steroid application

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Case 3

An 80-year-old male patient presented with itchy lesions of the scalp filled with pus and scarred areas of hair loss for 9 months [Figure 4]. Examination showed areas of depigmentation, diffuse alopecia, and crusted lesions over the scalp. Histopathology showed epidermis with hyperkeratosis, parakeratosis, spongiosis, and neutrophilic transcytosis. Culture revealed growth of Staphylococcus aureus Scientific Name Search  but subsequent cultures were sterile. The patient responded to topical antibiotics with steroid combination.
Figure 4: Third case showing areas of depigmentation, diffuse alopecia, and crusted lesions over the scalp

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   Discussion Top

EPDS is an underrecognized chronic cutaneous disease, usually occurring on sun-damaged skin of the scalp in elderly individuals. Clinically, it presents with areas of crusting and pustules eventually producing eroded areas healing with scarring and alopecia.[1]

It is commonly seen in women. In postmenopausal women, estrogen loss may accompany skin atrophy and delayed wound healing.

Predisposing factors include past trauma, skin grafting, actinic damaged by long-term exposure to sunlight, and autoimmune diseases.

The pustules present in this condition are usually sterile with cultures revealing only normal flora. Even when pathogens such as S. aureus or Candida are isolated, respective treatment provides only little improvement suggesting that they represent secondary colonization rather than primary infection. Other organisms that have been isolated include Staphylococcus epidermidis, Pseudomonas aeruginosa, Coagulase-negative staphylococci, Proteus mirabilis, diphtheroid, fungi like Candida albicans, Candida parapsilosis, and Aspergillus ochraceus.[2]

The occurrence of EPDS on skin grafts is likely because of the tendency to occur on the sites of trauma. Areas of tissue damage caused by herpes zoster or iatrogenic insult by electrosurgery, excisional surgery, laser therapy, and radiotherapy also predispose to the development of this condition.[3]

Inflammation plays an important role in the pathophysiology of the disease, which explains its response to anti-inflammatory therapy. Autoimmune diseases such as rheumatoid arthritis are also associated with the condition. Cutaneous atrophy which is caused by sun damage is said to be the major predisposing factor.[4]

The differential diagnosis for the condition includes actinic keratoses, chronic bacterial, fungal infection, pemphigus foliaceus, pyoderma gangrenosum, kerion, folliculitis decalvans, dissecting cellulitis of the scalp, and squamous cell carcinoma.

Histopathology shows atrophy or eroded epidermis, parakeratosis, inflammatory infiltrate of lymphocytes intermingled with neutrophils, plasma cells, and occasional foreign body giant cells. In later stages, atrophy of the hair follicles and fibrosis of the dermis are seen. PAS and Gram stain are generally negative. Direct immunofluorescence is usually negative for immunoglobulins and complement.[5]

Trichoscopy of bald areas shows an absence of follicular ostia with marked skin atrophy with evident dermal blood vessels and perifollicular serous or serosanguinous crusting. Visualization of hair bulbs, coiled, and tortuous hair shafts can also be observed.[6]

Different therapeutic options have been proposed which include topical and systemic drugs. A good response is noted with high-potency topical steroids like clobetasol 0.05%. Since steroids may worsen atrophy, topical tacrolimus is a better alternative. Oral zinc sulfate, oral isotretinoin,[5] photodynamic therapy, topical calcipotriol cream, and topical dapsone 5% gel[7] can be used for treatment. Topical and systemic antibiotics have only a little effect.

   Conclusion Top

EPDS is an underdiagnosed disease and hence high index of suspicion is required when diagnosing a case of chronic, nonhealing erosions occurring on actinically damaged atrophic skin. The histology suggests chronic inflammation. The condition responds to high-potency topical steroids.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Pye RJ, Peachey RD, Burton JL. Erosive pustular dermatosis of the scalp. Br J Dermatol 1979;100:559-66.  Back to cited text no. 1
Caputo R, Veraldi S. Erosive pustular dermatosis of the scalp. J Am Acad Dermatol 1993;28:96-8.  Back to cited text no. 2
Grattan CE, Peachey RD, Boon A. Evidence for a role of local trauma in the pathogenesis of erosive pustular dermatosis of the scalp. Clin Exp Dermatol 1988;13:7-10.  Back to cited text no. 3
Patton D, Lynch PJ, Fung MA, Fazel N. Chronic atrophic erosive dermatosis of the scalp and extremities: A recharacterization of erosive pustular dermatosis. J Am Acad Dermatol 2007;57:421-7.  Back to cited text no. 4
Mastroianni A, Cota C, Ardigò M, Minutilli E, Berardesca E. Erosive pustular dermatosis of the scalp: A case report and review of the literature. Dermatology 2005;211:273-6.  Back to cited text no. 5
Starace M, Loi C, Bruni F, Alessandrini A, Misciali C, Patrizi A, et al. Erosive pustular dermatosis of the scalp: Clinical, trichoscopic, and histopathologic features of 20 cases. J Am Acad Dermatol 2017;76:1109-14.e2.  Back to cited text no. 6
Broussard KC, Berger TG, Rosenblum M, Murase JE. Erosive pustular dermatosis of the scalp: A review with a focus on dapsone therapy. J Am Acad Dermatol 2012;66:680-6.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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