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Clinical Summary

Dissecting cellulitis of the scalp occurs predominately in young males. This condition, along with acne conglobata, hidradenitis suppurativa, and pilonidal cysts, constitutes the “follicular occlusion tetrad.” Multiple, fluctuant abscesses on the scalp vertex and occiput are present. Sinus tracts form between the abscesses, and purulent, foul-smelling discharge may be present. Over time, disfiguring, scarring alopecia can involve the entire scalp.

Management and Disposition

Exclusion of a secondary infection is paramount. In the ED, incision and drainage of new, rapidly forming abscesses may be helpful; obtain cultures if this is attempted. Long-term anti-inflammatory antibiotics may prevent further abscesses. Urgently refer the patient to a dermatologist for further management.

FIGURE 13.45

Dissecting Cellulitis of the Scalp. Many active sinus tracts and alopecia in a young Hispanic man. (Photo contributor: Richard P. Usatine, MD. Used with permission. From Usatine RP, Smith MA, Mayeaux EJ, Chumley HS. The Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw Hill; 2013: Fig. 189-7.)

Pearls

  1. Consider this diagnosis when presented with recurrent scalp abscesses and draining sinus tracts unresponsive to antibiotics.

  2. Early diagnosis and urgent referral can prevent further scarring and alopecia.

  3. Most patients are young to middle-aged males; the psychological impact is significant.

FIGURE 13.46

Dissecting Cellulitis of the Scalp. Inactive but with disfiguring scars on the entire scalp. Early referral to a dermatologist may prevent this stage. (Photo contributor: J. Matthew Hardin, MD.)

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