skin grafting. Multiple reports indicate that surgery achieved both disease remission and excellent aesthetic outcomes in patients who chose this option, however permanent alopecia results in the affected areas.6,23 Aside from surgery, treatment with ND: Yag lasers, ablative lasers, and photodynamic therapy with 5-aminolevulinic acid have all been reported with varying levels of success, however, each modality currently has very little evidence to support treating DCS.7
Each case of DCS is distinct and individualized treatment depends on severity, and more importantly a patient’s willingness to treat with combination therapies given what is required to achieve improvement based on the literature. Before considering treatment options, patients' motivation to take oral pills, injections, lasers, and surgery should be assessed. Given there are no FDA approved therapies for DCS, initially recommending zinc, prescribing topical benzoyl peroxide and clindamycin, and oral antibiotics are pragmatic with the consideration of the increased administrative effort required to start oral retinoids or injectable monoclonal antibodies. In addition, some severe DCS patients can benefit from oral steroids initially as a bridge treatment while preparing to start isotretinoin/acitretin and or adalimumab/infliximab. Clinicians and patients should be mindful of antibiotic usage and switch to longer term options like zinc, oral retinoids, or monoclonal antibodies when appropriate. Surgery should be reserved for severe cases and surgical patients should ideally remain on some medical therapy as well. Ultimately, while numerous options exist for DCS and the other members of the follicular occlusion tetrad, further research and clinical trials are needed to supplement the existing evidence.
Disclosure
The authors declare no conflicts of interest.
References
1. Spitzer L. Dermatitis follicularis et parifollicularis conglobata. Dermatol Ztschr. 1903;10:109.
2. Chicarilli ZN. Follicular occlusion triad: Hidradenitis suppurativa, acne conglobata, and dissecting cellulitis of the scalp. Ann Plast Surg. 1987;18:230–7.
3. Scheinfeld N. Dissecting cellulitis (Perifolliculitis Capitis Abscedens et Suffodiens): a comprehensive review focusing on new treatments and findings of the last decade with commentary comparing the therapies and causes of dissecting cellulitis to hidradenitis suppurativa. Dermatol Online J. 2014;20(5):22692.
4. Curry SS, Gaither DH, King LE Jr. Squamous cell carcinoma arising in dissecting perifolliculitis of the scalp. A case report and review of secondary squamous cell carcinomas. J Am Acad Dermatol. 1981;4(6):673-678.
5. Jemec GB, Heidenheim M, Nielsen NH. The prevalence of hidradenitis suppurativa and its potential precursor lesions. J Am Acad Dermatol. 1996;35(2 Pt 1):191-194.
6. Cuellar TA, Roh DS, Sampson CE. dissecting cellulitis of the scalp: a review and case studies of surgical reconstruction. Plast Reconstr Surg Glob Open. 2020;8(8):e3015. Published 2020 Aug 18.
7. Thomas J, Aguh C. Approach to treatment of refractory dissecting cellulitis of the scalp: a systematic review. J Dermatolog Treat. 2021;32(2):144-149.
8. Nesbitt E, Clements S, Driscoll M. A concise clinician's guide to therapy for hidradenitis suppurativa. Int J Womens Dermatol. 2019;6(2):80-84. Published 2019 Dec 27.
9. Georgala S, Korfitis C, Ioannidou D, Alestas T, Kylafis G, Georgala C. Dissecting cellulitis of the scalp treated with rifampicin and isotretinoin: case reports. Cutis. 2008;82(3):195-198.
10. Garelli V, Didona D, Paolino G, Didona B, Calvieri S, Rossi A. Dissecting cellulitis: responding to topical steroid and oral clindamycin. G Ital Dermatol Venereol. 2017;152(3):324-325.
11. Ochi H, Tan LC, Oon HH. The effect of oral clindamycin and rifampicin combination therapy in patients with hidradenitis suppurativa in Singapore. Clin Cosmet Investig Dermatol. 2018;11:37-39. Published 2018 Jan 18.
12. Yao Y, Jørgensen AR, Ring HC, Thomsen SF. Effectiveness of clindamycin and rifampicin combination therapy in hidradenitis suppurativa: a 6-month prospective study. Br J Dermatol. 2021;184(3):552-553.
13. Domonkos A. Perifolliculitis capitis abscedens and suffodiens. Arch Dermatol. 1969;99:369–370.
14. Di Caprio R, Lembo S, Di Costanzo L, Balato A, Monfrecola G. Antiinflammatory properties of low and high doxycycline doses: an in vitro study. Mediators Inflamm. 2015;2015:329418.
15. Scerri L, Williams HC, Allen BR. Dissecting cellulitis of the scalp: response to isotretinoin. Br J Dermatol. 1996;134:1105–8
16. Jacobs F, Metzler G, Kubiak J, et al. New approach in combined therapy of perifolliculitis capitis abscedens et suffodiens. Acta Derm Venereol. 2011;91:726–727.
17. Guo W, Zhu C, Stevens G, Silverstein D. Analyzing the Efficacy of Isotretinoin in Treating Dissecting Cellulitis: A Literature Review and Meta-Analysis. Drugs R D. 2021;21(1):29-37.
18. Berne B, Venge P, Ohman S. Perifolliculitis capitis abscedens et suffodiens (Hoffman). Complete healing associated with oral zinc therapy. Arch Dermatol. 1985;121:1028–1030.
19. Kobayashi H, Aiba S, Tagami H. Successful treatment of dissecting cellulitis and acne conglobata with oral zinc [2] [Letter]. Br J Dermatol. 1999;141:1137–1138.
20. Navarini AA, Trüeb RM. 3 cases of dissecting cellulitis of the scalp treated with adalimumab: control of inflammation within residual structural disease. Arch Dermatol. 2010;146(5):517–520.
21. Martin-García RF, Rullán JM. Refractory dissecting Cellulitis of the Scalp Successfully controlled with Adalimumab. P R Health Sci J. 2015;34(2):102-104.
22. De Bedout V, Harper H, Miteva M, Lev-Tov H. Treatment dissecting cellulitis of the scalp with secukinumab. J Drugs Dermatol. 2021;20(7):776-777.
23. Hintze JM, Howard BE, Donald CB, Hayden RE. Surgical management and reconstruction of Hoffman's disease (dissecting cellulitis of the scalp). Case Rep Surg. 2016;2016:2123037.
Each case of DCS is distinct and individualized treatment depends on severity, and more importantly a patient’s willingness to treat with combination therapies given what is required to achieve improvement based on the literature. Before considering treatment options, patients' motivation to take oral pills, injections, lasers, and surgery should be assessed. Given there are no FDA approved therapies for DCS, initially recommending zinc, prescribing topical benzoyl peroxide and clindamycin, and oral antibiotics are pragmatic with the consideration of the increased administrative effort required to start oral retinoids or injectable monoclonal antibodies. In addition, some severe DCS patients can benefit from oral steroids initially as a bridge treatment while preparing to start isotretinoin/acitretin and or adalimumab/infliximab. Clinicians and patients should be mindful of antibiotic usage and switch to longer term options like zinc, oral retinoids, or monoclonal antibodies when appropriate. Surgery should be reserved for severe cases and surgical patients should ideally remain on some medical therapy as well. Ultimately, while numerous options exist for DCS and the other members of the follicular occlusion tetrad, further research and clinical trials are needed to supplement the existing evidence.
Disclosure
The authors declare no conflicts of interest.
References
1. Spitzer L. Dermatitis follicularis et parifollicularis conglobata. Dermatol Ztschr. 1903;10:109.
2. Chicarilli ZN. Follicular occlusion triad: Hidradenitis suppurativa, acne conglobata, and dissecting cellulitis of the scalp. Ann Plast Surg. 1987;18:230–7.
3. Scheinfeld N. Dissecting cellulitis (Perifolliculitis Capitis Abscedens et Suffodiens): a comprehensive review focusing on new treatments and findings of the last decade with commentary comparing the therapies and causes of dissecting cellulitis to hidradenitis suppurativa. Dermatol Online J. 2014;20(5):22692.
4. Curry SS, Gaither DH, King LE Jr. Squamous cell carcinoma arising in dissecting perifolliculitis of the scalp. A case report and review of secondary squamous cell carcinomas. J Am Acad Dermatol. 1981;4(6):673-678.
5. Jemec GB, Heidenheim M, Nielsen NH. The prevalence of hidradenitis suppurativa and its potential precursor lesions. J Am Acad Dermatol. 1996;35(2 Pt 1):191-194.
6. Cuellar TA, Roh DS, Sampson CE. dissecting cellulitis of the scalp: a review and case studies of surgical reconstruction. Plast Reconstr Surg Glob Open. 2020;8(8):e3015. Published 2020 Aug 18.
7. Thomas J, Aguh C. Approach to treatment of refractory dissecting cellulitis of the scalp: a systematic review. J Dermatolog Treat. 2021;32(2):144-149.
8. Nesbitt E, Clements S, Driscoll M. A concise clinician's guide to therapy for hidradenitis suppurativa. Int J Womens Dermatol. 2019;6(2):80-84. Published 2019 Dec 27.
9. Georgala S, Korfitis C, Ioannidou D, Alestas T, Kylafis G, Georgala C. Dissecting cellulitis of the scalp treated with rifampicin and isotretinoin: case reports. Cutis. 2008;82(3):195-198.
10. Garelli V, Didona D, Paolino G, Didona B, Calvieri S, Rossi A. Dissecting cellulitis: responding to topical steroid and oral clindamycin. G Ital Dermatol Venereol. 2017;152(3):324-325.
11. Ochi H, Tan LC, Oon HH. The effect of oral clindamycin and rifampicin combination therapy in patients with hidradenitis suppurativa in Singapore. Clin Cosmet Investig Dermatol. 2018;11:37-39. Published 2018 Jan 18.
12. Yao Y, Jørgensen AR, Ring HC, Thomsen SF. Effectiveness of clindamycin and rifampicin combination therapy in hidradenitis suppurativa: a 6-month prospective study. Br J Dermatol. 2021;184(3):552-553.
13. Domonkos A. Perifolliculitis capitis abscedens and suffodiens. Arch Dermatol. 1969;99:369–370.
14. Di Caprio R, Lembo S, Di Costanzo L, Balato A, Monfrecola G. Antiinflammatory properties of low and high doxycycline doses: an in vitro study. Mediators Inflamm. 2015;2015:329418.
15. Scerri L, Williams HC, Allen BR. Dissecting cellulitis of the scalp: response to isotretinoin. Br J Dermatol. 1996;134:1105–8
16. Jacobs F, Metzler G, Kubiak J, et al. New approach in combined therapy of perifolliculitis capitis abscedens et suffodiens. Acta Derm Venereol. 2011;91:726–727.
17. Guo W, Zhu C, Stevens G, Silverstein D. Analyzing the Efficacy of Isotretinoin in Treating Dissecting Cellulitis: A Literature Review and Meta-Analysis. Drugs R D. 2021;21(1):29-37.
18. Berne B, Venge P, Ohman S. Perifolliculitis capitis abscedens et suffodiens (Hoffman). Complete healing associated with oral zinc therapy. Arch Dermatol. 1985;121:1028–1030.
19. Kobayashi H, Aiba S, Tagami H. Successful treatment of dissecting cellulitis and acne conglobata with oral zinc [2] [Letter]. Br J Dermatol. 1999;141:1137–1138.
20. Navarini AA, Trüeb RM. 3 cases of dissecting cellulitis of the scalp treated with adalimumab: control of inflammation within residual structural disease. Arch Dermatol. 2010;146(5):517–520.
21. Martin-García RF, Rullán JM. Refractory dissecting Cellulitis of the Scalp Successfully controlled with Adalimumab. P R Health Sci J. 2015;34(2):102-104.
22. De Bedout V, Harper H, Miteva M, Lev-Tov H. Treatment dissecting cellulitis of the scalp with secukinumab. J Drugs Dermatol. 2021;20(7):776-777.
23. Hintze JM, Howard BE, Donald CB, Hayden RE. Surgical management and reconstruction of Hoffman's disease (dissecting cellulitis of the scalp). Case Rep Surg. 2016;2016:2123037.
AUTHOR CORRESPONDENCE
Adam J. Friedman MD ajfriedman@mfa.gwu.edu
