Hidradenitis Suppurativa and Perifolliculitis Capitis
Saturday, January 01, 2011
Perifolliculitis Capitis Abscedens et Suffoidiens/Dissecting
Cellulitis of the Scalp
Hidradenitis suppurativa and perifolliculitis capitis are
chronic inflammatory processes that affect the groin, axilla, and
inframammary areas (hidradenitis suppurativa) and the scalp
(dissecting cellulitis). Progression is often relentless and defies
medical management. Early surgery for local and widespread lesions
is often the best alternative.
- Culture draining sinus tracts or abscesses for aerobic and
- Give full-dose oral antibiotics effective against the isolated
organisms for 1 month. Tetracycline, amoxicillin, penicillin,
dicloxacillin, cephalosporins, and clindamycin have all been used
with variable results.
- Prescribe topical clindamycin solution to be applied to the
affected areas twice daily.
- Incise and drain fluctuant abscesses.
- Inject triamcinolone acetonide 5-10 mg/cc into all nonfluctuant
inflammatory areas. This may be repeated at intervals of 2-4
- Local areas may be totally excised, if small, with good
- Encourage obese patients with disease in the intertriginous
areas to lose weight.
- Oral zinc sulfate 220 mg three times daily may be beneficial.
In one case of perifolliculitis capitis, complete healing
Initial positive response
- Continue oral antibiotics and taper them slowly over 6-12
months. If the disease recurs, reculture and repeat initial
- Because relapse and persistence is the rule, even patients who
have responded well to conservative therapy may be offered more
extensive surgical procedures, especially for axillary disease (see
Initial treatment failure
- Medical treatment a. Systemic corticosteroids (prednisone 0.5-1
mg/kg/day) for several weeks will significantly reduce
inflammation. When combined with appropriate antibiotics,
corticosteroids may also allow the disease to be controlled. b.
Isotretinoin 1-2 mg/kg has been effective in some patients. When
there is no contraindication, a course should be attempted. c. For
severe recalcitrant dissecting disease of the scalp, low-dose x-ray
epilation (Adamson-Keibock technique) will usually at least
temporarily control severe recalcitrant disease.
- Surgical treatment Extensive surgical procedures usually offer
the only hope for the severely affected. a. For axillary disease,
total excision of the affected axillary areas is of only moderate
morbidity and gives excellent results. After their convalescence,
patients are, in general, quite happy with the long-term, usually
permanent remission. b. Genitocrural hidradenitis can also be
totally excised, but often extensive grafting or prolonged healing
is required owing to the large areas of involvement. Despite this,
after convalescence most patients are satisfied. c. Total excision
of the affected scalp in dissecting cellulitis of the scalp is also
effective, and often curative. Patients are usually rendered
permanently bald, so a hairpiece may be required.
- These disease processes are aggressive, and they require
aggressive management to obtain disease control.
- Tetracycline is contraindicated in pregnancy.
- With high-dose zinc sulfate, GI upset is common.
- Patients face a twofold risk of carcinoma in these conditions.
If the disease is chronic, squamous cell carcinomas, which may be
fatal, may occur. In addition, there is an increased risk of
cutaneous carcinoma in the radiation-treated areas, especially in
patients with white skin. Any suspicious nonhealing lesion requires
- Inflammatory bowel disease may cause perirectal and/or genital
sinus tracts and abscesses. These may be misdiagnosed as