Post‐traumatic erosive dermatosis of the scalp: A hypergranulated variant

Abstract

Erosive pustular dermatosis of the scalp is a slowly progressive chronic inflammatory disease that predominantly affects elderly male patients with marked actinic damage. The clinical evolution consists firstly of keratotic and erosive plaques surmounted by yellow-brown crusts and non-follicular pustules; later, the active crusting lesions regress in number and the scarring process causes diffuse cutaneous thinning and loss of hair follicles. However, manifestations may be atypical, leading to frequent misdiagnosis. We present a case series of post-traumatic erosive pustular dermatosis on the scalp of 4 elderly patients. The characterising feature was the presence of erosion consisting of abundant hypergranulation tissue, with an almost total lack of crusts and pustules. Dermoscopy showed a unique pattern of stretched and dilated linear, telangiectatic and polymorphous on-focus vessels, milky-red areas and white scarring areas. This clinical entity is rarely reported in the literature. The majority of reported cases were located on the legs.

<p>Erosive pustular dermatosis of the scalp: challenges and solutions</p>

“…Trichoscopic examination shows different patterns that are non-specific of EPDS, such as follicular keratotic plugging, milky red areas, white patches, hair shaft tortuosity, tapering hair, and absence of follicular openings (Figure 4). In regard to the trichoscopic findings, follicular keratotic plugging and absence of follicular openings are common in scarring alopecia 18. Milky red areas and white patches are thought to reflect inflammation and scarring of the scalp.…”

“…A recent article pointed out a unique dermoscopic pattern typical of the hypergranulation variant of EPDS consisting of different types of vessels: linearly stretched and dilated, telangiectatic and polymorphous on focus vessels, confluent vessels, milky red and white areas (Figure 7). 18

Figure 5Active phase of the disease with red and milky areas, absence of follicular opening, and several hair shafts broken.

Figure 6Trichoscopy of chronic EPDS where there is evident marked atrophic skin, lack of follicular ostia, and follicular yellow thick exudate. Abbreviation: EPDS, erosive pustular dermatosis of the scalp.

Figure 7The hypergranulation variant of EPDS showing different types of vessels at trichoscopy. Abbreviation: EPDS, erosive pustular dermatosis of the scalp.

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Dermoscopy of lymphoplasmacellular erosive dermatitis of the scalp reveals striking similarities to lymphoplasmacellular balanitis of Zoon

“…Instead, a predominant lymphoplasmacellular infiltrate is not a classic histopathological feature of EPDS, but biopsy timing as well as local and systemic immunological factors could play a role in determining this appearance. On dermoscopy, EPDS shows serum-hematic crusts, loss of follicular ostia and hair tufting, enlargement of dermal vessels and visualization of hair bulbs through a thinned skin [3], milky-red and white areas, linear but also polymorphous vessels [1]. Instead, in our cases we observed a remarkable orange structureless background with focused linear vessels.…”

“…Our case series underlines that differential diagnosis of eroded lesions and crusts on the scalp can be sometimes troublesome: neoplastic diseases should be primarily excluded, but LEDS should be considered among other entities (Table 1) [1,2]. LEDS seems to share many aspects with erosive pustular dermatosis of the scalp (EPDS), such as advanced age, actinic damage, history of previous trauma/surgery [3,4].…”

“…Basal cell carcinoma Presence of typical signs such as on-focus arborizing vessels, blue-grey ovoid nests and globules/dots, brown spoke wheel or leaf like areas, ulcerations or erosions, shine white streaks, structureless white to red areas [2] Relatively frequent on scalp presenting actinic damage; diagnosis can be more easily assessed focusing on non-ulcerated areas [2] Squamous cell carcinoma Red structureless areas with polymorphous vessels (linear, hairpin or glomerular vessels), ulcerations, white halos surrounding vascular structures, white-yellow to light brown structureless areas (keratin), targetoid-appearing hair follicles (white circles) [2] Relatively frequent on scalp presenting actinic damage; differential diagnosis may be difficult, in particular with poorly differentiated squamous cell carcinoma [2] Merkel cell carcinoma Milky-red and shiny white areas, pink or purple hue, polymorphous vessels (often linear irregular, dotted, arborizing or glomerular vessels), ulcerations [1] Very rapid growth [1] Amelanotic melanoma Pigment remnants, milky red areas, more than one shade of pink, white structures, polymorphous vessels (more often linear irregular and dotted, but also hairpin vessel), ulcerations [2] Often shows pigment remnants that can be a very useful diagnostic clue [2] Atypical fibroxanthoma Pink-red and white structureless areas, linear irregular vessels, white lines, ulcerations [1] Rapid growth [1] Inflammatory diseases Classic erosive pustular dermatosis of the scalp Crusts, erosions, milky red areas, on-focus polymorphous vessels, hair tufting, skin atrophy (visualization of dermal vessels and hair bulbs) [1,3] Shares many clinical and dermoscopic features with lymphoplasmacellular erosive dermatitis of the scalp [1,3] Bullous diseases such as localized cicatricial bullous pemphigoid (Brunsting Perry disease) and pemphigus vulgaris Erosions and scarring alopecia; acantholytic hair casts in pemphigus vulgaris [1] Subepidermal blisters (Bursting Perry disease) or intraepidermal blisters (pemphigus vulgaris). Direct immunofluorescence and circulating antibody tests are useful.…”