Surgical Intervention Combined With Photodynamic Therapy for Treatment of Perifolliculitis Capitis Abscedens et Suffodiens

Summary:

Perifolliculitis capitis abscedens et suffodiens (PCAS) is a chronic recurrent disease. Single treatment modalities are commonly ineffective. A surgical intervention combined with photodynamic therapy (PDT) may be an effective treatment strategy. Herein, we present the case of a 21-year-old man with a 2-month history of PCAS treated with such a treatment. PDT may directly eradicate sebaceous glands and reduce follicular hyperkeratosis, and the surgical procedure can eliminate septic and decayed tissue. The surgical intervention combined with PDT was effective in relieving the patient’s pain, and we believe it provides an option for the treatment of PCAS.

Perifolliculitis capitis abscedens et suffodiens (PCAS) is a rare chronic purulent and inflammatory disease of the scalp. Patients commonly present deep follicular occlusions, keloid formations, patchy alopecia on the scalp, and a history of fluctuating scalp nodules and abscesses, which drain pus. The pathogenesis and pathophysiology of PCAS remain incompletely elucidated due to a lack of relevant studies.¹ The primary etiology has been associated with disrupted keratinization at hair follicles. The accompanying blockage of the pilosebaceous units and release of accumulated keratin and bacteria result in a neutrophilic and granulomatous inflammatory response, abscess formation, and the development of sinus tracts and fibrosis. Current treatments include systemic antibiotics, oral isotretinoin, biologics, and topical treatments. However, long-term (3–12 mo) antibiotic therapy may lead to bacterial resistance;² the adverse effects associated with isotretinoin use are common (particularly dryness-related manifestations), and the cost of biologics is high. Thus, the treatment of PCAS remains a challenge with unsatisfactory outcomes and a high relapse rate. Here, we report the use of a surgical intervention combined with photodynamic therapy (PDT) to satisfactorily treat a patient with PCAS.

CASE REPORT

We present the case of a 21-year-old man with a 2-month history of inadequate PCAS treatment involving oral doxycycline, oral herbal medicine, and topical chloramphenicol (Fig. 1). The patient had no obvious cause for recurrent abscess and rupture of the head, and hair loss was caused by repeated infection. The main manifestations of the patient were swelling mass, hard texture, sinus forming inside the skin, and purulent discharge when pressed. The patient expressed intolerable pain and psychological stress, prompting us to perform a surgical incision and drainage along with subcutaneous tissue debridement to excise the abscesses and necrotic tissues, thereby alleviating his discomfort. One day after the operation, the patient underwent PDT. A 5% aminolevulinic acid (ALA) solution was applied for 1 hour; then the surface drug was wiped off, and the skin lesions were illuminated as a whole with an energy of 60–120 J/cm² and a power of 40–100 mW/cm². The next treatment could be performed after the last irradiation reaction subsided, and the interval was generally 1–2 weeks. Depending on the patient’s recovery, sutures can be performed when the skin is dry, and there is no significant exudation. In this case, the symptoms were relieved after 3 weekly sessions, and then surgical suture was performed. At the 1-year follow-up, the patient expressed satisfaction with the treatment outcomes (Fig. 2).

Fig. 1.

Preoperative photographs of the patient. (A and B) Photographs of the patient’s scalp during the initial examination revealing the presence of multiple subcutaneous nodules, fistulas, and alopecia areas.

Fig. 2.

A, Photograph showing intraoperative visualization of subcutaneous gelatinous necrotic tissue in the scalp. B, Patient’s photograph 1 year postoperatively showing flattened abscess sites on the scalp.

DISCUSSION

ALA-PDT provides a safe and effective alternative to antibiotics, isotretinoin, and biologics. ALA-PDT can directly eradicate sebaceous glands and reduce follicular hyperkeratosis by generating reactive oxygen species (ROS).³ The speed of ROS formation is key to the efficacy of ALA-PDT. Fire needles and lasers promote ROS generation in target tissues by increasing the penetration and accumulation of ALA-PDT in proliferating cells.

A linear incision was made where the fluctuation of the abscess was most obvious. Subcutaneous curettage was performed from the incision to both sides to remove the decomposed tissue and sinus tract. Vaseline gauze was inserted to stop bleeding, and the linear incision was simply sutured. PDT was performed after waiting for exudation to decrease.

Surgical PCAS treatment has been reported to be up to 95% effective, making it superior to other therapies such as the administration of tumor necrosis factor inhibitors (87% efficacy), isotretinoin (54% efficacy), or phototherapy (80% efficacy).⁴ Surgical treatment is necessary for patients with refractory and intractable PCAS.⁴ The surgeon can remove nodules and sinus tracts that cannot be eliminated by medication alone, through a quick incision and drainage. Additionally, flipping the flap during the operation can enhance ROS generation, thereby improving the effectiveness of the ALA-PDT.^5,6

Previous studies have shown that the healing rate of infected wounds is often lower than that of surgical wounds.⁷ PDT can maintain a minimum level of bacteria on the wound bed, thus reducing the probability of disease recurrence and recurrence interval.⁸ This reduces the production of purulent exudates and maintains a normal moist healing environment after filling with oily gauze. Adjuvant PDT therapy can improve the healing management of chronic diseases and is a new protocol to promote the healing of inflammatory skin diseases on the basis of surgery.⁹ Combined photodynamic treatment of PCAS can reduce the risk of readmission within 30 days after plastic surgery intervention, reduce the medical burden, and assist in the management of the entire course of the disease.¹⁰

In the case of our patient with severe PCAS, the combination treatment was effective. However, our experience with a single patient cannot be used to demonstrate the efficacy of the proposed treatment strategy for other cases. We will try to locate other cases for future studies.

DISCLOSURES

The authors have no financial interest to declare in relation to the content of this article. This study was supported by the Taishan Scholar Project Special Fund (No. tsqn202312371), the Shandong Provincial Clinical Research Center for Dermatovenerology, and the Medical Health Science and Technology Project of Shandong Province (Grant No. 202320001137).

PATIENT CONSENT

Informed consent was obtained from the patient before the study.

ETHICAL APPROVAL

The institutional review board of the Hospital for Skin Diseases at the Shandong First Medical University approved this study, which was conducted in accordance with the Declaration of Helsinki guidelines.