Erosive pustular dermatosis of the scalp occurring after partial thickness skin graft for squamous cell carcinoma
2004; Elsevier BV; Volume: 57; Issue: 8 Linguagem: Inglês
10.1016/j.bjps.2004.06.019
ISSN1465-3087
Autores Tópico(s)Dermatological and Skeletal Disorders
ResumoA 91-year-old man had a shave biopsy of a lesion on his scalp under local anaesthetic in April 2002. The histology showed a well differentiated squamous cell carcinoma (SCC)—complete excision was not guaranteed. He had a wide excision and split thickness skin graft from his left upper arm in August 2002. Repeat histology showed no evidence of residual carcinoma. He had evidence of intermittent superinfection in the graft on several occasions, which responded poorly to treatment with topical antibiotics. Only 20% of the graft to the scalp had taken. The patient was offered regrafting during numerous follow-up appointments, but had refused. His graft site posed a long-term dressing problem and caused significant morbidity. He has remained under follow-up by the plastic surgeons and was referred to the dermatology department in June 2003. Physical examination of the scalp revealed numerous pustules and crusted erosions overlying superficially ulcerated skin. Erosive pustular dermatosis of the scalp (EPDS) was diagnosed. The scalp responded well to topical clobetasol propionate 0.05%, neomycin sulphate 0.5%, nystatin 100,000 units/g cream (Dermovate-NN) and the patient was weaned successfully on to less potent steroid creams. Figure 1 shows the patients scalp before treatment. Figure 2 shows the patients scalp after topical application of Dermovate-NN for 1 week (Figure 1, Figure 2) .Figure 2Significant improvement after 1 week of topical treatment with Dermovate-NN.View Large Image Figure ViewerDownload (PPT) EPDS is a rare inflammatory disease of unknown aetiology that usually occurs in the elderly. It is characterised by sterile pustules, chronic crusted erosions, cicatricial alopecia and areas of atrophied scalp. Rarely EPDS occurs on the legs. Pye et al. first described EPDS in 1979. It is found more commonly in middle aged and elderly Caucasian women compared to men. Initially a small area of the scalp becomes red and moist with an eroded surface. Crusted lesions and superficial sterile pustulation occur on the overlying skin. As the condition extends, areas of activity coexist with areas of cicatricial alopecia. SCC has been known to develop in the scars.1.Rook, Wilkinson, Ebling. Erosive pustular dermatosis of the scalp. Disorders of hair. In: Dawber RPR, Berker D, Wojnarowska F, editors. Textbook of dermatology, vol. 4, 6th ed, p. 2938, chapter 66.Google Scholar The aetiology of EPDS is obscure. An infectious aetiology appears to be excluded since the microorganisms found in the lesions fail to respond to systemic antibiotics and antimycotic preparations suggesting secondary rather than primary colonisation. Chemical or physical traumatic insults to the scalp (including skin flaps and grafts), radiotherapy, 5 fluorouracil (5-FU) application, viral infection with herpes zoster, or actinic keratoses in bald patients secondary to prolonged UV exposure may play a role in the evolution of EPDS. In some subjects, trauma precedes the onset of the condition by many years. The list of differential diagnoses is wide. Some examples include: pustular psoriasis of the scalp, cicatricial pemphigoid, irritated solar keratosis, SCC, bacterial folliculitis, kerion, lupus erythematosus, pemphigus, eczema, histiocytosis X, dissecting cellulitus of the scalp.4.Martin F.J. Herrera A. Rios J.J. Moreno J.C. Camacho F. Erosive pustular dermatosis of the scalp after skin grafting.Dermatol Surg. 2001; 27: 766-767Google Scholar Response to therapy is variable. Potent topical steroids and oral isotretinoin have been beneficial in some cases. Many patients have responded poorly to topical and systemic antibiotics. Sun protection is generally advised to maintain remission. Oral zinc sulphate can be used as an adjuvant therapy. The kind of skin graft used does not appear to play a role in the course of EPDS according to a report of three cases in Italy.3.Ena P. Lissia M. Doneddu G.M.E. Campus G.V. Erosive pustular dermatosis of the scalp in skin grafts: report of three cases.Dermatology. 1997; 194: 80-84Google Scholar Recurrence of EPDS has been reported even after placement of skin grafts to treat this condition. This is the sixth reported case of EPDS secondary to plastic surgery. Previously published cases are secondary to BCC,4.Martin F.J. Herrera A. Rios J.J. Moreno J.C. Camacho F. Erosive pustular dermatosis of the scalp after skin grafting.Dermatol Surg. 2001; 27: 766-767Google Scholar avulsive trauma,3.Ena P. Lissia M. Doneddu G.M.E. Campus G.V. Erosive pustular dermatosis of the scalp in skin grafts: report of three cases.Dermatology. 1997; 194: 80-84Google Scholar SCC,3.Ena P. Lissia M. Doneddu G.M.E. Campus G.V. Erosive pustular dermatosis of the scalp in skin grafts: report of three cases.Dermatology. 1997; 194: 80-84Google Scholar BCC,3.Ena P. Lissia M. Doneddu G.M.E. Campus G.V. Erosive pustular dermatosis of the scalp in skin grafts: report of three cases.Dermatology. 1997; 194: 80-84Google Scholar neurosurgery.2.Layton A.M. Cunliffe W.J. Erosive pustular dermatosis of the scalp following surgery.Br J Dermatol. 1995; 132: 472-473Google Scholar This is the second reported case of EPDS secondary to SCC. Many cases of EPDS may go undiagnosed. This rare condition should be suspected by surgeons when pustular erosions develop on a failed skin graft site. It is important to be aware of EPDS as there is a possibility of SCC developing in scar tissue.
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