Sub-antimicrobial doxycycline (20–40 mg/day) reduces proinflammatory cytokines and has been proposed as a safe long term therapy for chronic inflammatory diseases like DCS.14
Systemic retinoids, isotretinoin (0.5–1.5 mg/kg/day) and acitretin (10–20 mg/day) have considerable evidence in treating recalcitrant DCS; most patients experienced clinical improvement after a three-month course of isotretinoin and two-month course of acitretin that did not relapse in most patients for multiple years. Treatment for six to eleven months allowed lesions to shrink and resulted in prolonged remission.3,7,15,16 The overall efficacy of isotretinoin in treating dissecting cellulitis of the scalp was estimated at 0.9 with a 95% confidence interval (0.81–0.97). Recurrence was seen in 24% (6/25) of patients.17 Oral zinc has also been used as it known to downregulate Nuclear Factor Kappa B (NF-κB) leading to a reduced inflammatory response. Doses of 135–405 mg daily in multiple case reports demonstrated significant improvement in DCS after twelve weeks.18,19 TNF inhibition with adalimumab (40 mg q2weeks) and infliximab (5 mg/kg q8weeks) both resulted in disease remission within eight weeks that lasted well over a year in most cases.20,21 One case report indicated that ten weekly doses of secukinumab 150 mg followed by switching to monthly dosing resulted in a durable response seen only after four weeks.22
Many patients with DCS have limited regions of the scalp affected, which respond well to traditional medical therapies. For severe cases, areas of the affected scalp may require wide local excision and primary closure or coverage with split-thickness
