Abstract
Introduction
Erosive pustular dermatosis of the scalp (EPDS) is an inflammatory scalp condition that usually affects the elderly, while only few cases have been reported in childhood. In children, it may mimic fungal or bacterial infections, especially kerion.
Case Presentation
We describe the usefulness of trichoscopy as a supportive diagnostic tool in 2 cases of pediatric EPDS.
Discussion
Clinical distinction between EPDS and different types of alopecia in children is difficult, with a significant likelihood of diagnostic errors and delay in therapy. Trichoscopy may provide a noninvasive option that can help avoid invasive diagnostic procedures in children.
Keywords: Trichoscopy, Children, Scalp, Alopecia, Erosive pustular dermatosis of the scalp
Established Facts
Erosive pustular dermatosis of the scalp (EPDS) is a rare condition in children.
Clinical distinction between EPDS and other types of alopecia in children is difficult.
Novel Insights
Branching and dilated vessels represent a trichoscopic clue for the diagnosis of erosive pustular dermatosis in children.
Trichoscopy may provide a noninvasive option that can help avoid invasive diagnostic procedures in children.
Introduction/Literature Review
Erosive pustular dermatosis of the scalp (EPDS) is a chronic inflammatory scalp condition characterized by pustules, erosions, and crusting with a history of a previous event in the affected site. If left untreated, it may progress and result in scarring alopecia [1]. EPDS usually affects the elderly, while only few cases have been reported in childhood [2, 3, 4]. Trichoscopy has proved to be very useful in the diagnosis of EPDS, although a skin biopsy is sometimes necessary. Mimickers of EPDS in children that need to be ruled out include fungal/bacterial infections, especially the inflammatory variant of kerion. Herein, we describe the usefulness of trichoscopy as a supportive diagnostic tool in two histologically proven cases of pediatric EPDS.
Case Report
Case 1
A 4-year-old girl presented with small detectable pustules, inflamed erosions, and more or less thickened yellow-brown crusts. After removing the crusts, an erythematous and edematous alopecic patch (3 × 4 cm) was noticed separated by a thin semicircular band a few millimeters from the normal scalp (shown in Fig. 1a). The lesion had been noted 2 months earlier associated with mild itching. No history of trauma was reported. In addition, no improvement was observed after systemic antibiotic therapy. Skin swabs for bacteria and fungi were performed and proved negative.
Fig. 1.
a Case 1: inflammatory alopecic patch surmounted by pustules and crusts. A thin semicircular band separates the patch from the normal scalp. b Case 1: trichoscopy shows the absence of follicular ostia, round yellow globules, branching dilated vessels, serous exudate, and black crusts on a pink-red background. c Case 2: inflammatory alopecic patch with pustules and sero-hemorrhagic crusts. A thin semicircular band separates the patch from the normal scalp (asterisks). d Case 2: trichoscopy showed round yellow globules together with branching and dilated vessels, yellow crusts, and black dots on a pink-red background. No signs of hair infection are detectable. e Schematic image of the trichoscopic pattern of EPDS.
Case 2
A 3-year-old boy developed a yellow-brown crusted lesion of the vertex 2 weeks after a blunt trauma of the head. On removing the crust, an erythematous area (3 × 3 cm) with detectable pustules and inflamed erosions was observed surrounded by a thin semicircular band of normal scalp (shown in Fig. 1c). Microbiological samples were negative for bacteria or fungi.
In both cases, trichoscopy showed reduced follicular ostia, yellow-brown pustules, and yellow-brown crusts with a pink-red background (shown in Fig. 1b, d). A newly observed entity was widespread branching and dilated vessels in the alopecic area, detected with dermoscopy (×20 magnification).
Based on the clinical, dermoscopic, and microbiological findings, EPDS was suspected. The diagnosis was confirmed by histopathological examination, which highlighted the presence of a mixed inflammatory infiltrate together with a spongiotic pustular superficial reaction and atrophic epidermis. PAS staining did not reveal the presence of fungal hyphae. Treatment with clobetasol propionate 0.05% cream once daily was started, and at 1-month follow-up, the inflammation and pustules were no longer detectable, and initial hair regrowth was observed (shown in Fig. 2).
Fig. 2.
Case 2: initial hair regrowth was observed after 1 month (a), and an almost complete regrowth is evident 6 months after treatment (b).
Discussion
Clinical distinction between EPDS and different types of alopecia, such as bacterial/fungal infection, in children is a challenging task, with a significant likelihood of diagnostic errors and delay in therapy. In recent years, scalp dermoscopy has shown to be a useful auxiliary tool for the recognition of several hair disorders. While some dermoscopic aspects such as scaling, erythema, and pustules are nonspecific and can be found in both EPDS and bacterial/fungal infection, tinea capitis typically displays peculiar dermoscopic features including “comma,” “corkscrew,” “zigzag,” interrupted Morse code-like, “elbow-shaped,” and “question mark” hairs [5, 6, 7, 8]. None of these specific signs were observed in our patients, while in both cases, the affected areas showed reduced follicular ostia, yellow-black crusts, and enlarged and dilated vessels, previously described as the main trichoscopic features of EPDS (Fig. 2) [1, 8]. In particular, branching and dilated vessels may represent a trichoscopic clue for the diagnosis of EPDS in children.
Another possible condition that should be included in the differential diagnosis is folliculitis decalvans. In our cases, this was excluded due to the absence of tufts of hair, the most recognized pathognomonic criterion, the absence of perifollicular erythema, and the different histological appearance.
In conclusion, our cases confirmed how difficult the differential diagnosis of EPDS can be since it shares common clinical features with other cutaneous diseases, such as bacterial/fungal infections that are more frequent in children. In our opinion, trichoscopy may provide a noninvasive option that can help avoid invasive diagnostic procedures in children and guide the clinician toward a prompt diagnosis. This is particularly important because a timely and appropriate therapy for this disease may result in reduced scarring and increased potential for hair regrowth. Further studies on larger groups of patients are needed to confirm our observations.
Statement of Ethics
Ethics approval was not required. Local guidelines do not require Ethics Committee approval for publication of clinical cases. Written informed consent was obtained from patients and their parents for publication of the details of their medical case and accompanying images.
Conflict of Interest Statement
The authors have no conflicts of interest to declare.
Funding Sources
The authors did not receive any funding.
Author Contributions
All the authors discussed the results and significantly contributed to the final manuscript. All the authors read and approved the final version of the manuscript.
Data Availability Statement
Clinical data are available on request.
Funding Statement
The authors did not receive any funding.
References
- 1.Starace M, Iorizzo M, Trüeb RM, Piccolo V, Argenziano G, Camacho FM, et al. Erosive pustular dermatosis of the scalp: a multicentre study. J Eur Acad Dermatol Venereol. 2020 Jun;34((6)):1348–1354. doi: 10.1111/jdv.16211. [DOI] [PubMed] [Google Scholar]
- 2.LaCour M, Allen T, Wilkerson M, Nguyen AV, Gibson BR. A case of erosive pustular dermatosis of the scalp in a pediatric patient. JAAD Case Rep. 2019;5((2)):118–120. doi: 10.1016/j.jdcr.2018.11.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Teng C, Yu J, Taylor J, Rubin AI, Treat JR. Erosive pustular dermatosis of the scalp in an adolescent with near-total hair regrowth: case report and review of the literature. Pediatr Dermatol. 2019;36((5)):697–701. doi: 10.1111/pde.13929. [DOI] [PubMed] [Google Scholar]
- 4.Fertig R, Maddy A, Cadore de Farias D, Simão Corrêa Filho S, Rigatti M, Tosti A. Erosive pustular dermatosis of the scalp after aplasia cutis congenita in a 9-year-old patient: a 5-year follow-up. Pediatr Dermatol. 2017;34((6)):695–696. doi: 10.1111/pde.13252. [DOI] [PubMed] [Google Scholar]
- 5.Waśkiel-Burnat A, Rakowska A, Sikora M, Ciechanowicz P, Olszewska M, Rudnicka L. Trichoscopy of tinea capitis: a systematic review. Dermatol Ther. 2020;10((1)):43–52. doi: 10.1007/s13555-019-00350-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Kumar P, Pandhi D, Bhattacharya SN, Das S. Trichoscopy as a monitoring tool in assessing treatment response in 98 children with tinea capitis: a prospective clinical study. Dermatol Ther. 2021;34((4)):e15010. doi: 10.1111/dth.15010. [DOI] [PubMed] [Google Scholar]
- 7.Yang X, Shi X, Chen W, Zhou Y, Lionakis MS, Kontoyiannis DP, et al. First report of kerion (tinea capitis) caused by combined Trichophyton mentagrophytes and Microsporum canis. Med Mycol Case Rep. 2020 May 19;29:5–7. doi: 10.1016/j.mmcr.2020.05.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Starace M, Loi C, Bruni F, Alessandrini A, Misciali C, Patrizi A, et al. Erosive pustular dermatosis of the scalp: clinical, trichoscopic, and histopathologic features of 20 cases. J Am Acad Dermatol. 2017 Jun;76((6)):1109–14.e2. doi: 10.1016/j.jaad.2016.12.016. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Clinical data are available on request.