© 2001 by the American Society for Dermatologic Surgery, Inc. • Published by Blackwell Science, Inc.ISSN: 1076-0512/01/$15.00/0 • Dermatol Surg 2001;27:766–767

CASE REPORT

Erosive Pustular Dermatosis of the ScalpAfter Skin Grafting

Francisco J. Martín, MD,* Alberto Herrera, MD, PhD,* Juan J. Ríos, MD,

†

José C. Moreno, MD, PhD,

‡

and Francisco Camacho, MD, PhD*

Departments of *Dermatology and

†

Pathology, Hospital Universitario “Virgen Macarena”, Sevilla, Spain,

and

‡

Hospital Universitario “Reína Sofía”, Córdoba, Spain

Erosive pustular dermatosis of the scalp is a rare condition ofunknown etiology that usually occurs in the elderly and is char-acterized by pustules that appear on the scalp leading to scar-ring alopecia. The histopathology is not specific. Its onset has

been related with previous trauma on the scalp. Only threecases after skin grafting have been reported. We describe a caseof erosive pustular dermatosis of the scalp appearing on a split-thickness skin graft placed after excision of a basal cell carcinoma.

Case Report

A 50-year-old woman presented in 1977 with a bleed-ing, hyperkeratotic, 5 cm tumor located on the midpa-rietal area. It was diagnosed as a basal cell carcinomaand treated with radiotherapy because the patient re-fused surgical treatment. In 1983 the tumor persistedso it was excised and the defect covered with a split-thickness skin graft from the right thigh. The nextyear the patient began suffering from episodes of ery-thematous papules that appeared in the skin graft andevolved into pustules that dried and left an erosive,scarring surface (Figure 1). Several bacterial and fun-gal cultures were performed and all of them yieldednegative results. Repeated biopsies showed chronic,granulomatous, nonspecific inflammation, with noother alterations, ruling out recurrence of the basalcell carcinoma. Direct immunofluorescence was nega-tive. Treatment was started with topical and systemicantibiotics, with disappointing results, and only topi-cal steroids could improve the condition.

Discussion

Erosive pustular dermatosis of the scalp is a rare dis-ease described in 1979 by Pye et al.

1

About 40 caseshave been reported since then, some of them in rela-tion with previous skin grafting, as it is our case.

2,3

Re-

currence of erosive pustular dermatosis of the scalphas been reported even after placement of skin graftsto treat this condition.

4

It is unknown why erosive pustular dermatosis ofthe scalp occurs on skin grafts, but it seems to be re-lated to the tendency of this disease to develop in zonesof trauma.

5–7

Thus it has also been reported after skinflaps,

6

ophthalmic zoster,

8

accidental traumas,

8–10

ra-diotherapy,

11

and 5-fluorouracil (5-FU) application.

5

Erosive pustular dermatosis of the scalp is an exten-sive, chronic state of the scalp that usually presents inthe elderly, causing erosions and cicatricial alopecia.Its etiology is unknown and the histopathology is notspecific, with epidermal atrophy and chronic inflam-matory infiltrate.

12

Squamous cell carcinoma arisingon the scars has also been reported.

13

The conditiondescribed as “pustular ulcerative dermatosis of thescalp,”

14

which affects young African individuals withmalnutrition and parasitic infestations of the bowels,must not be considered as a variant of erosive pustulardermatosis of the scalp, but a pustular condition de-veloped in the surroundings of a cutaneous ulcer dueto high venous pressure.

15

Several drugs have been tried to treat this disease,obtaining temporal improvement but not definitivecure. Potent topical corticosteroids,

4–6,11,16,17

topical orsystemic antibiotics,

4–6

oral isotretinoin,

4,18

and oralzinc sulfate

2

or aspartate

11

have been used. The bestresults have been achieved with topical corticosteroidsor oral isotretinoin, although there is not much experi-ence with the latter.

The nosologic site of this condition has not yet beencleared yet. As the clinical, histologic, and evolutivefindings are rather inaccurate, the use of diagnosticcriteria is perhaps more helpful, as with other diseasessuch as systemic lupus erythematosus. Hence erosive

F. J. Martín, MD, A. Herrera, MD, PhD, J. J. Ríos, MD, J. C.Moreno, MD, PhD, and F. Camacho, MD, PhD have indicated no sig-nificant interest with commercial supporters.Address correspondence and reprint requests to: Francisco J. Martín, MD,Departamento de Dermatología, Hospital Universitario Virgen Maca-rena, Avda. Dr. Fedriani 3, 41071 Sevilla, Spain, or e-mail: camachodp@medynet.com.

Dermatol Surg 27:8:August 2001

martín et al.: pustular dermatosis and skin grafting

767

Figure 1. Scarring and pustules over erythematous papules devel-oped on the skin graft placed to repair the defect secondary tothe excision of basal cell carcinoma.

pustular dermatosis of the scalp can be defined as acondition that fulfills the following criteria:

19

Appears in the elderly on a previously alteredscalp: atrophy, photoaging, or chemical orphysical trauma.

Clinical association of erosions, pustules, scales,and crusts, with no specific histopathology, andwith no infectious agent found responsible forthe condition.

20

Chronic evolution leading to cicatricial alopecia.Resistance to antibiotics and response to topical

steroids and systemic isotretinoin.

These criteria allow the differentiation of erosivepustular dermatosis of the scalp from a number of well-defined entities with similar clinical features: bacterialfolliculitis, kerion, lupus erythematosus, pemphigus,pemphigoid, eczema, histiocytosis X, pustular psoriasisof the scalp, and dissecting cellulitis of the scalp.

18

Although some cases of erosive pustular dermatitishave been described in the legs,

21

their relation witherosive pustular dermatosis of the scalp is uncertain,and it is obvious that restrictive criteria would notconsider it as the same entity as the latter.

References

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