Abstract
Introduction
Dissecting cellulitis of the scalp (DCS) is a neutrophilic scarring alopecia typically presenting with pustules and fluctuant nodules, followed by suppuration and sinus tract formation. DCS is often associated with other diseases, such as hidradenitis suppurativa (HS) and conglobate acne (CA) which share similar pathogenetic mechanisms.
Case Presentation
The authors report the case of a patient affected by a severe form of DCS, HS, and CA of the face. Previous treatments with isotretinoin, antibiotics, and adalimumab did not have a considerable efficacy. Off-label treatment with secukinumab showed a gradual improvement in the clinical presentation bringing to a reduction in the number of HS lesions and to an almost complete resolution of the inflammatory manifestations of DCS.
Conclusion
Management of DCS is challenging and is typically based on retinoids which are considered the first line of treatment. The efficacy of biologic drugs, especially TNFα inhibitors, in severe and relapsing forms of DCS has been reported in recent literature. To our knowledge, only one case of isolated DCS treated with secukinumab is reported. No cases of concomitant DCS and HS, treated with this type of IL-17 inhibitor, have been described.
Keywords: Acne, Cicatricial alopecia, Hidradenitis suppurativa, Secukinumab
Established Facts
Dissecting cellulitis of the scalp is a neutrophilic scarring alopecia with a challenging management.
It is often associated with hidradenitis suppurativa and conglobate acne as it shares similar pathogenetic mechanisms leading to hyperkeratosis and dysregulation of inflammatory pathway.
All these conditions may lead to severe quality of life impairment.
Novel Insights
Secukinumab showed a rapid efficacy on concomitant dissecting cellulitis of the scalp and hidradenitis suppurativa.
Therapeutic approach of dissecting cellulitis of the scalp could be revolutionized in the future by the use of biologics as IL-17 inhibitors.
Introduction
Dissecting cellulitis of the scalp (DCS) is a neutrophilic scarring alopecia typically presenting with pustules and fluctuant nodules, especially at the vertex and occipital areas. These lesions may lead to suppuration and sinus tract formation. DCS is often associated with hidradenitis suppurativa (HS), conglobate acne, and pilonidal cyst forming the follicular occlusion tetrad. These conditions share similar pathogenetic mechanisms leading to hyperkeratosis and dysregulation of inflammatory pathways [1]. Some authors consider DCS and HS as different localizations of the same disorders due to overlapping clinical and histopathological features [2].
Case Report
We present the case of a 24-year-old patient affected by DCS, HS involving axillary, inguinal, and pubic areas, and conglobate acne. At the age of 16, as acne was the manifestation with the highest clinical severity and impact on quality of life, therapy with oral isotretinoin was started. The treatment led to partial clinical remission of facial lesions but did not have considerable efficacy on HS and DCS. Repeated courses of antibiotics (tetracycline, rifampicin, and clindamycin) led to no improvement. Due to the gradual worsening of HS, at the age of 19, adalimumab was started. After 15 months of therapy, no clinical response was achieved. Treatment with dapsone was proposed, but the glucose-6-phosphate dehydrogenase deficiency contraindicated the drug. Meanwhile, clinical picture further deteriorated. The patient presented with a severe form of HS with numerous nodules and draining fistulae at the axillae, groins, and pubic region (Fig. 1a). Lesions were located also on the temporo-occipital regions of the scalp and on the cheeks (Fig. 1b, c). Hurley stage was III, and IHS4 was equal to 30. In December 2020, off-label treatment with secukinumab was started. The loading dose of 5 weekly injections of 300 mg was later followed by a maintenance dose of 300 mg every 4 weeks. Gradual improvement, especially from an inflammatory point of view, was reported after 4 months of therapy. In the meantime, monthly intralesional injections of triamcinolone acetate (10 mg/mL) were performed, especially on the residual cicatricial areas. Currently, the patient shows less HS lesions than before the treatment, with an IHS4 score of 9. DCS also had considerable improvement with an almost complete resolution of the inflammatory manifestations, as well as acne, although some scars persist (Fig. 2a–c). Most notably, the patient reports a considerable decrease in pain levels, with a reduction of the numeric rating scale for pain from 8 to 2. A decrease in terms of amount of purulent discharge was also observed. These two factors combined brought to a considerable improvement in the patient’s quality of life.
Fig. 1.
Clinical presentation of nodules, abscesses, and sinus tracts on axillae (a), temporal areas (b), and cheeks (c) before therapy with secukinumab.
Fig. 2.
Clinical presentation of axillae (a), temporal areas (b), and cheeks (c) 1 year after starting therapy with secukinumab.
Discussion
Management of DCS is challenging and is typically based on retinoids which are considered the first line of treatment [3]. Antibiotics and steroids can be taken into consideration, but seem to work only in milder cases. Other possible therapeutic approaches include photodynamic therapy, X-ray epilation, and surgery [4]. The efficacy of biologic drugs, especially TNFα inhibitors, in severe and relapsing forms of DCS has been reported in recent literature [5, 6]. To our knowledge, as of right now, only one case of isolated DCS successfully treated with secukinumab is reported in literature [7]. No cases of concomitant DCS and HS treated with IL-17 inhibitors have been described so far. Real-life experiences on secukinumab in HS have already been reported showing a positive impact on signs and symptoms of the disease [8]. Two cases of syndromic HS also had a good response to the same treatment [9, 10]. The aim of this case report was to highlight the efficacy of secukinumab in the treatment of concomitant DCS and HS which are often associated as they share similar pathogenetic pathways with potential consequences for the therapeutic approach.
Statement of Ethics
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Ethical approval is not required for this study in accordance with local or national guidelines.
Conflict of Interest Statement
The authors declare they have no conflicts of interest.
Funding Sources
The authors declare that no funds, grants, or other support was received during the preparation of this manuscript.
Author Contributions
The authors confirm contribution to the paper as follows: study conception – Natale Schettini and Vincenzo Bettoli; data collection – Elisa Marzola, Lucrezia Pacetti, and Simone Cavaliere; draft manuscript preparation – Natale Schettini and Lucrezia Pacetti. Natale Schettini, Elisa Marzola, Lucrezia Pacetti, Simone Cavaliere, and Vincenzo Bettoli approved the final version of the manuscript.
Funding Statement
The authors declare that no funds, grants, or other support was received during the preparation of this manuscript.
Data Availability Statement
All data generated or analyzed during this case report are included in this article. Further inquiries can be directed to the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data generated or analyzed during this case report are included in this article. Further inquiries can be directed to the corresponding author.