Erosive pustulosis of the scalp

Published in Dermatology

Journal Scan / Review · August 05, 2019

Erosive Pustular Dermatosis of the Scalp

Dermatology (Basel, Switzerland)

Abstract 

Erosive pustular dermatosis of the scalp (EPDS) is an uncommon disease and primarily affects older men who have photo-damaged bald scalp, as was confirmed by our case series. EPDS is probably an overlooked disease, whose diagnosis is often missed because of a higher incidence of other cutaneous diseases affecting the same area and usually secondary to chronic actinic damage, such as actinic keratosis, basal cell carcinoma, and squamous cell carcinoma. For the first time, we report a case series of misdiagnosed EPDS with the aim of understanding why a diagnosis of EPDS was initially missed and try to give some tips to avoid future diagnostic delay.

Written by

 

 

Vincenzo Piccolo MD

In this paper, we investigated all the patients in whom the diagnosis of erosive pustular dermatosis of the scalp (EPDS) was missed. EPDS is a rare cutaneous disorder usually affecting the photo-damaged bald scalp of the elderly. It can be considered a great masquerader, as it mimics different common and uncommon skin conditions, including inflammatory, infectious, and neoplastic, the latter also secondary to chronic actinic damage, such as actinic keratosis, basal cell carcinoma, and squamous cell carcinoma.

EPDS is probably an overlooked disease, the diagnosis of which is often missed by clinicians because of its protean clinical presentation and its similarity to a large variety of more common skin conditions. For the first time, the authors of this paper tried to understand why the diagnosis of EPDS is "forgotten" and provide some tips to avoid future diagnostic delay. Along with clinical features of EPDS (combination of pustules, vegetating erosions, and crusts), recently, trichoscopy of EPDS has been described showing absence of follicular ostia, dilated vessels, and perifollicular serous crusts. The combination of the above-mentioned clinical and dermoscopic findings should lead the clinician to suspect EPDS in the differential diagnosis and take a biopsy when necessary to confirm the suspicion.

TAKE-HOME MESSAGE

• The authors presented a series of 8 patients with histologically proven erosive pustular dermatosis of the scalp (EPDS) who were originally misdiagnosed. The most common misdiagnoses were actinic keratoses (4/8), BCC (3/8), and SCC (1/8). The authors hypothesized that EPDS is often missed because of nonspecific clinical findings, including erosions and crusts, which can orient the diagnosis towards malignancy, as well as the high incidence of other cutaneous diseases affecting the same area. Misdiagnosis can lead to treatment with 5-fluorouracil, cryotherapy, or imiquimod, which worsen the condition. Once diagnosed correctly, all 8 patients in the series responded quickly to high-potency topical corticosteroid treatment.

• EPDS is a commonly misdiagnosed condition. It should be considered in the differential of pustules, erosions, and hemorrhagic/serous crusts on the photo-damaged bald scalp to avoid treatments that will worsen the condition and to initiate topical corticosteroids, which are often rapidly effective.

– Margaret Hammond, MD

Dermatology (Basel, Switzerland)

Erosive Pustular Dermatosis of the Scalp: Why Do We Miss it?

Dermatology (Basel) 2019 Jul 05;[EPub Ahead of Print], V Piccolo, T Russo, S Bianco, A Ronchi, R Alfano, G Argenziano 

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

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