Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Erosive Pustular Dermatosis of the Scalp Following Treatment With Topical Imiquimod for Actinic Keratosis

Erosive Pustular Dermatosis of the Scalp Following Treatment With Topical Imiquimod for Actinic... Erosive pustular dermatosis of the scalp (EPDS) is a rare chronic disease described first in 1977 by Burton1 and then in 1979 by Pye et al.2 It manifests as extensive pustular lesions, erosions, and crusting of the scalp in elderly individuals and leads to scarring alopecia. The cause remains unknown, although local trauma such as that caused by topical treatment of actinic keratosis with fluorouracil, 5%, tretinoin, surgery, cryotherapy, radiotherapy, and photodynamic therapy has been suggested as a trigger in actinically damaged or otherwise atrophic skin.3-5 Report of a Case An 84-year-old man presented with a 2-month history of eroded, pustular, and crusted lesions confined to the scalp that had developed after application of imiquimod cream, 5%, 3 times per week for 8 weeks for the treatment of actinic keratosis. The findings of a general clinical examination were normal, and there was no evidence of any skin disease. The physical examination revealed pustules, erosions, scales, and crusts on his bald and sun-damaged scalp. Detachment of the crust revealed a moist, atrophic surface with prominent telangiectases, erosions exuding a yellowish seropurulent material, and superficial pustulation (Figure). Figure View LargeDownload Atrophic, pustular, erosive, and crusted lesions of the scalp. Histologic examination showed ulcerated atrophic epidermis with subcorneal pustules and a polymorphous dermal infiltrate composed of lymphocytes, macrophages, and neutrophils. Findings of direct immunofluorescence, indirect immunofluorescence, and repeated bacteriologic and mycologic investigations were negative. Laboratory data, including autoimmunity findings, were normal, and no evidence for an underlying systemic disease was found. Clinical and histopathologic features were consistent with a diagnosis of EPDS, a rare form of nonmicrobial pustulosis mainly occurring in elderly patients with atrophic sun-damaged skin. It is characterized by sterile pustules, erosions, crusts, skin atrophy, and scarring alopecia.3-5 Comment Erosive pustular dermatosis of the scalp responds well to high-potency topical steroids. Tacrolimus ointment and calcipotriol cream have also been used successfully to avoid further atrophy. Anecdotal reports have described partial responses with nimesulide, oral isotretinoin, or oral dapsone.3-5 The list of differential diagnoses is wide, including chronic bacterial or fungal infection, irritated solar keratosis, squamous cell carcinoma, pustular psoriasis of the scalp, cicatricial pemphigoid, lupus erythematosus, pemphigus foliaceus, eczema, factitial damage, dissecting cellulites of the scalp, and neutrophilic scarring alopecia. However, the appearance of these skin conditions on the previously altered scalp of an elderly patient; the clinical association of erosions, pustules, and crusts with no specific histopathologic cause indicated and with no infectious agent found; evolution to scarring alopecia; resistance to antibiotics; and response to topical steroids allow the diagnosis of EPDS.3-5 The case presented herein is of interest because, although trauma has been documented to precipitate this condition, to our knowledge topical imiquimod, an active immune response modifier commonly used in dermatology as a treatment for actinic keratosis and superficial basal cell carcinoma, has not previously been reported as a triggering factor. In fact, the previous reported adverse effects of imiquimod cream, 5%, have not included chronic pustules, scale crusts, or nonhealing erosions. In our opinion, EPDS should be considered in any patient developing a chronic inflammatory response or delayed healing after imiquimod treatment. Back to top Article Information Correspondence: Dr Vaccaro, Institute of Dermatology, Policlinico Universitario Via Consolare Valeria, 98125 Messina, Italy (Mario.Vaccaro@unime.it). Financial Disclosure: None reported. References 1. Burton JL Case for diagnosis: pustular dermatosis of scalp. Br J Dermatol 1977;97(suppl 15)67- 69PubMedGoogle ScholarCrossref 2. Pye RJPeachey RDBurton JL Erosive pustular dermatosis of the scalp. Br J Dermatol 1979;100 (5) 559- 566PubMedGoogle ScholarCrossref 3. Mastroianni ACota CArdigo MMinutilli EBerardesca E Erosive pustular dermatosis of the scalp: a case report and review of the literature. Dermatology 2005;211 (3) 273- 276PubMedGoogle ScholarCrossref 4. Patton DLynch PFung MFazel N Chronic atrophic erosive dermatosis of the scalp and extremities: a recharacterization of erosive pustular dermatosis. J Am Acad Dermatol 2007;57 (3) 421- 427PubMedGoogle ScholarCrossref 5. Guarneri CVaccaro M Erosive pustular dermatosis of the scalp following topical methylaminolaevulinate photodynamic therapy. J Am Acad Dermatol 2009;60 (3) 521- 522PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Dermatology American Medical Association

Erosive Pustular Dermatosis of the Scalp Following Treatment With Topical Imiquimod for Actinic Keratosis

Loading next page...
 
/lp/american-medical-association/erosive-pustular-dermatosis-of-the-scalp-following-treatment-with-idxkC2VJmt

References (5)

Publisher
American Medical Association
Copyright
Copyright © 2009 American Medical Association. All Rights Reserved.
ISSN
0003-987X
eISSN
1538-3652
DOI
10.1001/archdermatol.2009.278
Publisher site
See Article on Publisher Site

Abstract

Erosive pustular dermatosis of the scalp (EPDS) is a rare chronic disease described first in 1977 by Burton1 and then in 1979 by Pye et al.2 It manifests as extensive pustular lesions, erosions, and crusting of the scalp in elderly individuals and leads to scarring alopecia. The cause remains unknown, although local trauma such as that caused by topical treatment of actinic keratosis with fluorouracil, 5%, tretinoin, surgery, cryotherapy, radiotherapy, and photodynamic therapy has been suggested as a trigger in actinically damaged or otherwise atrophic skin.3-5 Report of a Case An 84-year-old man presented with a 2-month history of eroded, pustular, and crusted lesions confined to the scalp that had developed after application of imiquimod cream, 5%, 3 times per week for 8 weeks for the treatment of actinic keratosis. The findings of a general clinical examination were normal, and there was no evidence of any skin disease. The physical examination revealed pustules, erosions, scales, and crusts on his bald and sun-damaged scalp. Detachment of the crust revealed a moist, atrophic surface with prominent telangiectases, erosions exuding a yellowish seropurulent material, and superficial pustulation (Figure). Figure View LargeDownload Atrophic, pustular, erosive, and crusted lesions of the scalp. Histologic examination showed ulcerated atrophic epidermis with subcorneal pustules and a polymorphous dermal infiltrate composed of lymphocytes, macrophages, and neutrophils. Findings of direct immunofluorescence, indirect immunofluorescence, and repeated bacteriologic and mycologic investigations were negative. Laboratory data, including autoimmunity findings, were normal, and no evidence for an underlying systemic disease was found. Clinical and histopathologic features were consistent with a diagnosis of EPDS, a rare form of nonmicrobial pustulosis mainly occurring in elderly patients with atrophic sun-damaged skin. It is characterized by sterile pustules, erosions, crusts, skin atrophy, and scarring alopecia.3-5 Comment Erosive pustular dermatosis of the scalp responds well to high-potency topical steroids. Tacrolimus ointment and calcipotriol cream have also been used successfully to avoid further atrophy. Anecdotal reports have described partial responses with nimesulide, oral isotretinoin, or oral dapsone.3-5 The list of differential diagnoses is wide, including chronic bacterial or fungal infection, irritated solar keratosis, squamous cell carcinoma, pustular psoriasis of the scalp, cicatricial pemphigoid, lupus erythematosus, pemphigus foliaceus, eczema, factitial damage, dissecting cellulites of the scalp, and neutrophilic scarring alopecia. However, the appearance of these skin conditions on the previously altered scalp of an elderly patient; the clinical association of erosions, pustules, and crusts with no specific histopathologic cause indicated and with no infectious agent found; evolution to scarring alopecia; resistance to antibiotics; and response to topical steroids allow the diagnosis of EPDS.3-5 The case presented herein is of interest because, although trauma has been documented to precipitate this condition, to our knowledge topical imiquimod, an active immune response modifier commonly used in dermatology as a treatment for actinic keratosis and superficial basal cell carcinoma, has not previously been reported as a triggering factor. In fact, the previous reported adverse effects of imiquimod cream, 5%, have not included chronic pustules, scale crusts, or nonhealing erosions. In our opinion, EPDS should be considered in any patient developing a chronic inflammatory response or delayed healing after imiquimod treatment. Back to top Article Information Correspondence: Dr Vaccaro, Institute of Dermatology, Policlinico Universitario Via Consolare Valeria, 98125 Messina, Italy (Mario.Vaccaro@unime.it). Financial Disclosure: None reported. References 1. Burton JL Case for diagnosis: pustular dermatosis of scalp. Br J Dermatol 1977;97(suppl 15)67- 69PubMedGoogle ScholarCrossref 2. Pye RJPeachey RDBurton JL Erosive pustular dermatosis of the scalp. Br J Dermatol 1979;100 (5) 559- 566PubMedGoogle ScholarCrossref 3. Mastroianni ACota CArdigo MMinutilli EBerardesca E Erosive pustular dermatosis of the scalp: a case report and review of the literature. Dermatology 2005;211 (3) 273- 276PubMedGoogle ScholarCrossref 4. Patton DLynch PFung MFazel N Chronic atrophic erosive dermatosis of the scalp and extremities: a recharacterization of erosive pustular dermatosis. J Am Acad Dermatol 2007;57 (3) 421- 427PubMedGoogle ScholarCrossref 5. Guarneri CVaccaro M Erosive pustular dermatosis of the scalp following topical methylaminolaevulinate photodynamic therapy. J Am Acad Dermatol 2009;60 (3) 521- 522PubMedGoogle ScholarCrossref

Journal

Archives of DermatologyAmerican Medical Association

Published: Nov 1, 2009

Keywords: actinic keratosis,imiquimod

There are no references for this article.