Scalp Perifolliculitis: Please help my Dad!

[trigirl]

I'm posting with the hope that someone will be able to offer advice for a worsening problem my father has had for the past year and a half. Attached is a jpg picture of his scalp. As you can see, it is red and inflammed and he finds it very itchy and painful. It is having a huge impact on his quality of life: he's prone to depression as it is and he has somehow convinced himself that this is cancerous!

The dermatologist performed a skin punch biopsy which yielded a diagnosis of perifollicular fibrosis. However, the pathologist noted that the sample was crushed and that a repeat biopsy would be appropriate. This is where things get difficult. My dad lives in Canada where because of the health care system it is extremely difficult to get a referral to a specialist -- this is the only dermatologist who will see him and not only did he think a repeat biopsy was unnecessary but he doesn't think the scalp condition looks "that bad." The dermatologist prescribed Minocin 100mg/day and offered Accutane which my dad refuses to take (another long story....) So, at this point, my dad has been taking antibiotics for over 6 months with no improvement.

Any suggestions would be much appreciated: 1) does this look like a folliculitis to you?; 2) what other treatment could be initiatied? 3) is there any way I could bring my dad to the US for treatment? (I just finished my first year of medical school in New York.)

Sorry for the length of the post -- hope someone can help. Thanks!

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[omarsaleh66]

Dear trigirl

Im just a second year med student. My only experience with dermatology is that i did some research on psoriasis and i know that gives me no credibility, but I looked up 2 articles on ur dad's condition on pubmed and here are 2 cases: one case i think talks about treating the condition with some sort of plastic surgery. The other case talks about treatment with prednisone, a corticosteroid. Read below in case u havent seen this before and maybe there's some hope for ur dad.

later
Omar




Ann Plast Surg. 1987 Mar;18(3):241-4. Related Articles, Links


Severe perifolliculitis capitis with osteomyelitis.

Ramasastry SS, Granick MS, Boyd JB, Futrell JW.

This report describes a severe case of perifolliculitis capitis with the rare complication of skull osteomyelitis, a combination not previously reported. The patient demonstrated the typical features of perifolliculitis capitis, namely, rubbery, hard, elevated nodules involving almost the entire scalp with multiple deep-seated abscesses. Bone was exposed in two areas and the diagnosis of skull osteomyelitis was confirmed by skull x-ray films and bone biopsy specimens, which grew Staphylococcus aureus. The patient was treated with enteral hyperalimentation, intravenous antibiotics, and multiple debridements of the scalp, including the involved periosteum and outer cortex of the exposed bone, followed by reconstruction with split-thickness skin grafts. A complete eradication of the disease with closure of all open wounds and clearance of osteomyelitis of the skull was achieved.




Ann Plast Surg. 1980 Feb;4(2):166-9. Related Articles, Links


Perifolliculitis capitis: successful control with alternate-day corticosteroids.

Adrian RM, Arndt KA.

A case of perifolliculitis capitis is reported in which the patient was initially treated with high-dose intravnous antibiotics and topical antibacterial agents without success. Systemic corticosteroids were instituted, with rapid subsidence of disease activity. One year later, the patient remains on 5 mg of prednisone on alternate days, and is free of disease activity. In view of other more aggressive treatments reported in the literature for this disease, high-dosage prednisone with rapid change to alternate-day dosage is a reasonable initial course of action.

 

[trigirl]

Thanks Omar. Credible or not, I appreciate the response I'm beginning to think a surgical approach is the way to go. Anyone else have any thoughts?

 

[dermpa02]

<<Any suggestions would be much appreciated: 1) does this look like a folliculitis to you?; 2) what other treatment could be initiatied? 3) is there any way I could bring my dad to the US for treatment? (I just finished my first year of medical school in New York.)>>

Hello trigirl,

I cannot tell from your photo if there are pustules, or if the lack of hair is due to scarring or just plain falling out (possibly leaving behind broken stumps), or if the lumps are hard or boggy. Therefore I will mention a few things off the top of my head for you to consider.
Folliculitis decalvans, pseudopelade (of Brocq, I think), discoid lupus, lichen planus, etc. If there is no scarring, then must consider a deep-seated fungal infection.

If the hair follicles are scarred over, then it will be almost impossible to get them to regrow. Many, if not most, of the diseases causing the scarring alopecias have no cure, and you are lucky if you can just maintain control. The antibiotics don't help because most of these problems are due to processes gone haywire in the hair follicle, and any bacterial presence is a secondary effect. If the follicles aren't scarred over, but there are signs of bacterial infection such as pustules/abcesses, then must consider drug-resistant staph (MRSA), which won't be affected by the minocycline. Hopefully someone has done a culture.

Surgical intervention might possibly help if one could excise the whole area of involvement, but I don't know if that would even be possible for such a large area such as your dad's. IOW, that would be one helluva skin graft.

As for other treatments - if this is indeed some kind of scarring alopecia (again, can't tell from the pic), then intralesional steroids might help.

Do you know if the biopsy specimen was sent to a general lab, or to a dermatopathologist? I might possibly consider taking several specimens and sending them off to someone who specializes is dermatopath.

It's getting late - don't hold any speling errers against me. Let us know what transpires....

hth,
Phil